Every finding on record at Pembilier Nursing Center

Based on observation and staff interview, the facility failed to maintain a sanitary kitchen environment for 1 of 1 facility kitchen. Failure to ensure the sanitizer test strips used to test the concentration of sanitizing solution are not expired has the potential for inadequate sanitization and may result in foodborne illness.Findings include:Observation in the kitchen on 04/27/26 at 11:13 a.m. showed a dietary staff member (#4) tested the concentration of a premixed sanitizing solution with test strips that expired October 2025.During an interview on 04/27/26 at 11:25 a.m., a dietary staff member (#4) stated staff should not use expired test strips.

Based on observation, review of facility policy, and staff interview, the facility failed to follow standards of infection control for 4 of 12 sampled residents (Residents #3, #4, #18, and #20) and 1 supplemental resident (Resident #8) observed during cares. Failure to follow infection control standards for hand hygiene and glove use during cares and while performing procedures has the potential to transmit infections to residents, staff, and visitors. Findings include: Review of the facility policy titled Handwashing/Hand Hygiene occurred on 04/29/26. This undated policy stated, . Staff will perform hand hygiene when indicated using proper technique and consistent with accepted standards of practice. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. After handling items potentially contaminated with blood, body fluids, secretions, or excretions . moving from a contaminated body site to a clean body site . Review of the facility policy titled Clean Dressing Change occurred on 04/29/26. This undated policy stated, . Set up clean field on the overbed table with needed supplies for wound cleansing and dressing application: a. If the table is soiled, wipe clean . b. Place a disposable cloth or linen saver on the overbed table . Review of facility policy titled Insulin Pen occurred on 04/29/26. This undated policy stated, . Procedure . Perform hand hygiene . [NAME] gloves . Review of facility policy titled Blood Glucose Monitoring occurred on 04/29/26. This undated policy stated, . The nurse will perform the blood glucose test utilizing the facility's glucometer [A handheld device to check blood sugar] . the nurse will abide by the infection control practices . Procedure . Perform hand hygiene and don gloves . collect blood sample . discard the lancet [disposable needle] in a puncture resistant sharps container. Remove the strip and dispose of it in sharps container. remove and discard gloves and perform hand hygiene. - Observation on 04/27/26 at 9:30 a.m. showed Resident #4 seated in a wheelchair. Two certified nurse aides (CNAs) (#6 and #7) completed hand hygiene, applied gloves, and entered the room. The CNAs assisted Resident #4 to stand with a mechanical sit-to-stand lift. The CNA (#6) completed perineal cares, and without removing the soiled gloves and completing hand hygiene, placed a clean brief on the resident. The CNA (#6) removed the soiled gloves, and without completing hand hygiene, repositioned the resident's pants, and transferred the resident into the wheelchair. Both CNAs completed hand hygiene and exited the room. The CNA (#6) failed to perform hand hygiene after removing soiled gloves and before touching other items. Observation on 04/28/26 at 10:15 a.m. showed a nurse (#3) performed hand hygiene, applied a gown and gloves, and entered Resident #18's room with colostomy supplies. The nurse placed the colostomy supplies on the resident's overbed table without establishing a clean field. The nurse removed the soiled colostomy bag, disposed of the bag, removed the soiled gloves, and without performing hand hygiene, applied clean gloves. The nurse cleansed and dried the stoma with cleansing spray and gauze, removed the soiled gloves, and without performing hand hygiene, applied clean gloves. The nurse cut the colostomy bag seal to size, applied a colostomy barrier seal, applied the new colostomy bag, and without removing the soiled gloves or performing hand hygiene, the nurse sanitized the scissors and overbed table. The nurse removed the soiled gown and gloves, performed hand hygiene and exited the room with the garbage bag. The nurse (#3) failed to establish a clean field before placing the clean ostomy supplies on the table and failed to perform hand hygiene between glove changes and prior to sanitizing medical supplies. - Observation on 04/28/26 at 11:10 a.m. showed a nurse (#3) completed hand hygiene, applied a gown and gloves, and entered Resident #20's room to perform a dressing change. The nurse moved a juice glass and other items to the side of the overbed table. Without sanitizing the overbed table or placing a barrier, the nurse placed the clean dressing supplies on the overbed table and completed the dressing change. The nurse (#3) failed to establish a clean field before placing clean dressing supplies on the overbed table. - Observation on 04/28/26 at 11:41 a.m. showed a nurse (#3) prepared an insulin pen for Resident #8. The nurse performed hand hygiene, and without applying gloves, administered the insulin to Resident #8, returned to the medication cart, and without performing hand hygiene, prepared medication for another resident. The nurse (#3) failed to follow standard infection control protocols while administering insulin and failed to perform hand hygiene prior to preparing medications for another resident. - Observation on 04/28/26 at 5:03 p.m., showed a nurse (#3) entered Resident #20's room, performed hand hygiene, applied gloves, and checked the resident's blood glucose by poking the finger with a lancet. The nurse placed the soiled lancet on the resident's bedside table and obtained a drop of blood on the test strip. The nurse removed the soiled gloves, and with a bare hand, disposed of the lancet and test strip in a sharp's container. The nurse (#3) failed to wear gloves when disposing of a contaminated lancet and test strip and failed to sanitize the resident's overbed table after exposure to the contaminated lancet. - Observation on 04/29/26 at 9:38 a.m. showed CNAs (#6 and #9) performed hand hygiene, applied gowns and gloves and entered Resident #3's room which required enhanced barrier precautions (EBP). The CNAs transferred the resident from the wheelchair to the bed utilizing a mechanical body lift. The CNA (#6) removed the soiled brief, cleansed the resident's rectal area, repositioned the resident, and the CNA (#9) completed perineal care. The CNA (#6) removed the soiled gloves, and without completing hand hygiene or applying clean gloves, placed a clean brief on the resident. The CNA (#9), still wearing soiled gloves, assisted with placing the clean brief then removed the soiled gloves. Both CNAs completed hand hygiene. The CNA (#6), without applying clean gloves, positioned heel boots and blankets on the resident. Both CNAs removed their gowns and completed hand hygiene prior to exiting room. The CNA (#6) failed to perform hand hygiene after removing soiled gloves and before touching other direct care items. The CNA (#9) failed to remove soiled gloves and perform hand hygiene before applying a clean brief. During an interview on 04/29/26 at 5:55 p.m., an administrative staff member (#2) stated she expected staff to follow infection prevention policies and procedures related to infection control.

Based on observation, review of facility policy, and staff interview, the facility failed to promote privacy and confidentiality of the electronic medication administration record (eMAR) on 1 of 1 medication cart. Failure to promote resident privacy and lock computer screens may result in unauthorized viewing of the residents' private health information records by other residents, visitors, or unlicensed staff. Findings include: Review of the facility policy titled Safeguarding of Resident Identifiable Information occurred on 04/29/26. This undated policy stated, . Facility's policy to implement reasonable and appropriate measures to protect and maintain the safety and confidentiality of the resident's identifiable information . Computer screens showing clinical record information may not be left unattended and readily observable or accessible by other residents or visitors. Observation on 04/28/26 at 11:41 a.m. showed a nurse (#3) at the medication cart. The nurse left the medication cart with prepared insulin and removed Resident #8 from the dining room to administer medication in a private area down the hallway. The nurse (#3) failed to lock the unattended cart and computer screen. During that time, two visitors walked in front of the unlocked medication cart with the computer screen and eMAR clearly visible.During an interview on 04/29/26 at 5:55 p.m., an administrative staff member (#2) confirmed staff are expected to lock the computer screen and medication cart when unattended.

Based on observation, record review, review of manufacturer's guidelines, and staff interview, the facility failed to ensure accurate labeling and storage for 1 of 1 resident (Resident #15) observed for eye drop administration. Failure to properly label and dispose of medications may result in residents receiving an incorrect dose of medication, reduced medication efficacy, and has the potential to cause an eye infection.Findings include: Review of prescribing information for Systane Ultra Preservative-Free [PF] single-use vials (eye drops), found at https://systane.myalcon.com/products/systane-complete-preservative-free/, occurred on 04/29/26, and stated . Systane Ultra Preservative-Free [PF] single-use vials. must be discarded after each use . After opening the vial of our Preservative-Free product, the risk of product contamination increases .Observation on 04/29/26 at 8:53 a.m. showed a nurse (#5) administered Systane Ultra PF single-use eye drops, one drop in each eye, to Resident #15. After administration, the nurse (#5) capped the single-use vial, placed it in the medication cart and stated, There is enough medication in there for another use .Review of the electronic medication administration record (eMAR) identified Systane Ultra PF eye drops, one drop into both eyes two times daily. The Systane Ultra PF pharmacy label, stated, Give 2-4 times a day as needed.The nurse failed to ensure the medication label matched the current physician's order and failed to appropriately discard the single use vial after use. During an interview on 04/29/26 at 5:55 p.m., an administrative staff member (#2) confirmed she expected staff to discard single use medication vials and medication labels to match Physician's orders.

Based on record review, review of professional reference, and review of facility policy, the facility failed to provide care and services to maintain the resident's highest level of well-being for 1 of 1 closed record (Resident #83) transferred to the emergency room (ER) for a change in health status. Failure to monitor and assess the resident's condition on a continuing basis resulted in a worsening of symptoms delay in hospitalization , and possible death. Findings include: Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, page 189, stated, . Nurses have responsibilities related to both medical and nursing diagnoses. Nursing diagnoses relate primarily to the nurse's independent functions, that is, the areas of healthcare that are unique to nursing and separate and distinct from medical management. However, the nurse is still responsible for identifying and responding to data that indicate real or potential medical problems. Independent nursing interventions for a collaborative problem focus mainly on monitoring the client's condition and preventing development of the potential complication. Definitive treatment of the condition requires both medical and nursing interventions. Review of the facility policy titled Notification of Changes occurred on [DATE]. This policy, dated, [DATE], stated, Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. Circumstances requiring notification include: . Significant change in the resident's physical, mental or psychosocial condition . Review of the facility policy titled Physician, Physician Assistant, Nurse Practitioner or Clinical Nurse Specialist Lab Notification occurred on [DATE]. This policy, dated, [DATE], stated, The facility must promptly notify the attending physician, physician assistant, nurse practitioner or clinical nurse specialist of lab results that fall outside of clinical reference ranges . Delayed notification may contribute to delays in changing the course of treatment or care plan. Review of Resident #83's medical record occurred on [DATE]-25, 2024. Diagnoses included a history of rheumatoid arthritis, cerebral infarction (stroke) without residual deficits, neoplasm of breast, in remission, and respiratory bronchiolitis/interstitial lung disease. A quarterly Minimum Data Set (MDS), dated [DATE], identified extensive assist with activities of daily living (ADLs) such as bed mobility, transfers, dressing, toileting, hygiene, and bathing, assist with wheelchair mobility, and not ambulating due to progressive rheumatoid arthritis to feet/knees. A document titled, Resuscitation Guidelines signed by Resident #83 on [DATE] and signed by the resident's physician on [DATE], stated, . By signing this part of the form, I am requesting a status of DNR [do not resuscitate] DNR means no CPR [Cardiopulmonary resuscitation]. You call 911 except for a cardiac arrest [stoppage of heart]. Active treatment up to the point of cardiac arrest is given. Review of Resident #83's primary physician's most recent progress note, dated [DATE], stated, Physical exam . lungs clear, heart sinus rhythm in 70's [sic] without murmur [irregular heart sound]. Abdomen scaphoid [inward], no signs of pain with palpation . Assessment and Plan: Rheumatoid Arthritis . history of left lower extremity deep vein thrombosis . Plan: follow up in one month. She has as needed Tramadol 50 mg [milligrams] up to three times a day for pain. Current physician's orders included: * Complete daily and record oxygen level and temperature * Eliquis (an anti-platelet blood thinner) 5 mg twice a day * Methotrexate Sodium (anti-cancer drug) 2.5 mg, 8 tablets once a day on Wednesday * Arthritic strength extended-release Acetaminophen (Tylenol) (pain/fever reducer) 1300 mg three times a day * Tramadol (pain medication) 50 mg three times a day-as needed (PRN) Resident #83's nurses' notes showed the following: * [DATE] 5:08 p.m. is alert & [and] oriented with confusion noted. Speech is clear, able to make her needs known. Limited to extensive assist needed with washing, dressing. Independent, assist as needed with toileting & transfers. No SOB [shortness of breath] noted. No c/o's [complaints of] pain. * [DATE] 10:41 a.m. is a close contact and is not experiencing any COVID symptoms. She tested negative for COVID on ,d+[DATE]. * [DATE] 7:20 a.m. Test for COVID performed on day 3 after exposure. Results negative. No symptoms. * [DATE] 4:13 p.m. Res [resident] c/o of not feeling well. She could not sit on the edge of her bed by herself. VS [vital signs]: T [temperature] 99.8, P [pulse]112, RR [respiratory rate] 20. BP [blood pressure] ,d+[DATE]. O2 [oxygen] sats [saturation] (a measure of oxygen in the blood) 95% R/A. [room air]. Res settled into bed & told to stay in her room for the rest of the day. Res was tested for Covid this AM & was negative. *[DATE] 7:13 p.m. has temp of 99.6 and O2 saturation on [sic] 97% on room air. She is alert but has some confusion. Scheduled Tylenol given tonight with other medication crushed in pudding. Encouraged oral intake while in room. * [DATE] 6:14 a.m. Covid test positive this morning. Resident remains afebrile [without a fever] and on room air. She is alert with confusion at this time. * [DATE] 12:07 p.m. refused both breakfast & lunch. Resident has been resting in bed with c/o's tired/weakness. Extensive assist needed with washing, dressing, toileting & transfers. Temp. 98.6 O,d+[DATE]%. * [DATE] 7:30 p.m. is afebrile and 02 saturation 93% on room air. She has had some confusion noted this evening. has had increased weakness but has improved and is able to pivot transfer to wheelchair and self-propel in room. Scheduled medication given tonight. *[DATE] 12:14 p.m. is more tired and continues to be weak. She is afebrile and 02 saturation 94% on room air. Confusion noted. Denies SOB no c/o pain. Took meds as normal. Has been resting in bed. Has been yelling out for help, rather than use call light. Is confused and not making sense at times. * [DATE] 7:42 p.m. has been hollering out for help this evening. When nurse went to check on resident and she was lying in bed. requested her HS [hour of sleep-bedtime] medication. call-light is within reach. * [DATE] 8:32 p.m. is afebrile, 94% on room air. * [DATE] 5:05 a.m. could be heard hollering out for help in her room. Nurse entered room and resident requested to use bathroom. Call-light was within reach, . confused and didn't use call-light. Resident taken to bathroom, she was very weak and needed a lot of assistance with pivot transferring to wheelchair and toilet. * [DATE] 3:20 p.m. continues to be weak. She is afebrile and 02 saturation 94% on room air. Denies SOB. Took [sic] spooned to her. Has been restless, is yelling out for help rather than use call light does not know what she wants most of the time. Has been back and forth between bed and w/c [wheelchair] several times. Isn't comfortable in either place for long. C/o pain in bilateral l/e [both lower extremities] this afternoon, Tramadol given prn. * [DATE] 12:05 a.m. has been very restless tonight. Hollering out for help constantly. States she is uncomfortable. Scheduled tylenol administered earlier and tramadol given at this time. Different positioning attempted, with no results. Resident does calm down when staff sit and talk with her, but then starts hollering again. Afebrile at 98.9 tympanic [by ear]. 02 sat 91% on RA. Fresh ice water given, will monitor. * [DATE] 12:53 a.m. Checked on resident. She is resting in bed, quietly at this time. * [DATE] 3:24 a.m. Resident continues to holler out all night. When asked what she needs, just states she wants to get up, no other specific needs. When talked to, she calms down for a short while. Afebrile. Respirations even, non-labored. Voices [sic] is very raspy, resident is weak. Oral hydration offered. * [DATE] 7:26 a.m. condition remains same. Continues to yell out help throughout the night. Resident checked on frequently. Unable to voice specific need/concern. Oral fluids encouraged/offered. Voice is raspy. Complains of generalized pain/aches throughout her body. Scheduled tylenol given at the time. * [DATE] 2:25 p.m. condition remains same. She remains confused & continues to call out help periodically T/O [throughout] the day shift. When asked what she needs she is unable to voice specific need/concern. Oral fluids encouraged/offered. Voice is raspy. Complains of generalized pain/aches throughout her body. Scheduled tylenol & PRN Tramadol given for same. * [DATE] 7:48 p.m. is constantly yelling help. Appears very dehydrated. Mucosa dry. Skin turgor delayed. Confused, disoriented. Unable to take medicine/fluids orally. Everything just leaks out the side of her mouth. Called physician on call, [physician name] and received order to send her in for evaluation. Called emergency contact, [family name] and he is ok with the plan as well. * [DATE] 7:56 p.m. Resident is noted to have scant amount of bright red blood around her lips/mouth at this time. Perhaps from dry mouth/constant yelling. Will monitor. * [DATE] 8:04 p.m. Call placed to ambulance at this time. * [DATE] 8:05 p.m. Unable to take BP with our machine at this time, upon several attempts. May attempt a manual later. O2 sats in the 80's on RA. afebrile at 97.7 temporal, [forehead] respirations raspy, 22 rpm [respirations per minute], unable to tell me her name, just hollers help all the time, not able to respond to questions. Pale. * [DATE] 8:19 p.m. resident left facility via ambulance to [facility name]. * [DATE] 5:28 p.m. [Family name] called to inform nurse that resident expired [passed away] @ [at] 1:30 pm @ [facility name]. Resident #83's vital signs and point of care records identified the following: * Intakes: - [DATE]: Fluids: 300 ml (milliliters); Meals: Breakfast: ,d+[DATE]%; Lunch and Dinner: no documentation - [DATE]: Fluids: 120 ml; Meals: Breakfast and Lunch: refused; Dinner: no documentation - [DATE]: Fluids: no documentation; Meals: Breakfast, Lunch, and Dinner: no documentation - [DATE]: Fluids: 180 ml; Meals: Breakfast and Lunch: no documentation; Dinner: None - [DATE]: Fluids: no documentation; Meals: Breakfast, Lunch, and Dinner: no documentation Resident #83's [DATE] medication administration record (MAR) identified the following pain medications administered: * Tylenol 1300 mg PRN administered three times a day from [DATE] to [DATE] and twice a day on [DATE]. * Tramadol 50 mg PRN administered: - [DATE] - 7:06 p.m. - [DATE] - 1:54 a.m. and 8:20 p.m. - [DATE] - 2:56 p.m. and 11:24 p.m. - [DATE] - 11:46 a.m. Documentation before and after Tramadol showed restless, yelling help, and complaints of generalized aches and pains. Facility staff failed to notify the resident's physician of the positive COVID-19 test on [DATE], symptoms of increased pain and confusion, and decreased intakes, until the emergency room transfer on [DATE].

Based on information from the facility reported incident, record review, review of facility policy, and staff interview, the facility failed to notify the resident's physician and resident's authorized representative of a change in condition for 1 of 1 closed record (Resident #83) who had a positive COVID-19 test. Failure to notify the physician of this change may have prevented the physician from altering the treatment/care provided to the resident and the representative's ability to make informed decisions regarding medical care. Findings include: The survey team determined a deficient practice existed on 05/01/23. The facility implemented corrective action on 05/05/23 and completed nursing education on 05/11/23. Review of the facility policy titled Notification of Changes occurred on 01/23/24. This policy, dated, 10/12/22, stated, Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. Circumstances requiring notification include: . Significant change in the resident's physical, mental or psychosocial condition . Review of the facility policy titled Physician, Physician Assistant, Nurse Practitioner or Clinical Nurse Specialist Lab Notification occurred on 01/23/24. This policy, dated, 10/12/22, stated, The facility must promptly notify the attending physician, physician assistant, nurse practitioner or clinical nurse specialist of lab results that fall outside of clinical reference ranges . Delayed notification may contribute to delays in changing the course of treatment or care plan. Review of Resident #83's medical record occurred on January 24-25, 2024. The progress notes showed the following: * 05/01/23 4:13 p.m. Res [resident] c/o [complained of] of not feeling well. She could not sit on the edge of her bed by herself. VS: [vital signs] T [temperature] 99.8, P [pulse] 112, RR [respiratory rate] 20. BP [blood pressure] 122/77. O2 sats [oxygen saturation] 95% R/A [room air]. Res settled into bed & told to stay in her room for the rest of the day. Res was tested for Covid this AM & was negative. * 05/02/23 6:14 a.m. Covid test positive this morning. Resident remains afebrile [without an elevated temperature] and on room air. The medical record lacked documentation the facility notified Resident #83's physician or authorized representative regarding the positive COVID-19 test. During an interview on 01/25/24 at 10:00 a.m., two administrative staff members (#1 and #3) agreed the facility failed to notify the resident's physician and family of positive Covid result. Based on the following information, non-compliance at F580 is considered past non-compliance. The facility implemented the corrective action for the resident affected by the deficient practice by: * Completing an investigation with interviews of staff who cared for the resident from 05/02/23 to 05/05/23. * Determining the investigation showed staff failed to notify the physician and authorized representative of resident's irregular lab results on 05/02/23. * Reviewing the facility policies regarding notification of physician and authorized representative in place at the time of the incident and finding them to be up to date. * Educating nursing staff of notification policies at a meeting held on 05/11/23 as multiple staff were involved in the communication breakdown. The facility addressed measures put in place and implemented systemic changes to ensure the deficient practice does not recur by: * Adding a quality assurance program titled, Family/Physician Notification - Purpose: Notification to family/physician of resident issues/events is required, including but not limited to: fall events, skin issues, change of condition, change of medication or treatment, appointments, infections. This will be monitored via nurse's notes and reports, notifications must be documented for each occurrence. Facility audits began on 06/01/23 and continued monthly. * Providing education to all nursing staff on 05/11/23. * Implementing new nurse training requirements on 11/01/23 requiring a review of notification of changes, transfer & discharge, and lab notification policies with subsequent written testing.

Based on observation, review of facility policy, and staff interview, the facility failed to ensure safe and secure storage of controlled medications for 1 of 1 medication cart. Failure to store medications securely may result in unauthorized access to medications and/or medication errors. Findings include: Review of the facility policy titled Controlled Substance Administration and Accountability occurred on 01/24/24. This undated policy, stated, . Patient specific controlled substances (e.g. [such as] narcotic/epidural infusions, tablets etc.) are stored under double lock until administered to the patient. Observation of medication pass on 01/24/24 at 8:07 a.m. showed a staff nurse (#4) administered Resident #29's morning medications. The resident received two controlled medications, alprazolam (an antianxiety) and gabapentin (nerve pain medication). Observation showed staff failed to double lock these controlled medications. During an interview on the morning of 01/25/24 an administrative nurse (#1) confirmed staff failed to double lock the controlled medications.

Based on record review and staff interview, the facility failed to ensure resident's records contained the certification of a terminal illness for 1 of 1 sampled resident (Resident #27) receiving hospice services. Failure to have these documents in the resident's records limits staff's ability to ensure coordination of care between the facility and hospice. Findings include: Review of Resident #27's medical record occurred on all days of survey. Resident #27 elected hospice services on 12/15/23. The medical record lacked the physician's certification of a terminal illness. During an interview on 01/24/24 at 4:23 p.m., an administrative nurse (#1) confirmed the medical record lacked the certification of terminal illness related to hospice.

Based on observation, review of facility policy, and staff interview, the facility failed to follow standards of infection control for 2 of 8 sampled residents (Resident #9 and #14) observed during perineal cares. Failure to follow infection control standards during perineal cares has the potential to transmit infections to residents, staff, and visitors. Findings include: Review of the policy/procedure titled Handwashing/Hand Hygiene occurred on 01/25/24. This undated policy stated, Hand hygiene is indicated . After contact with blood, body fluids or contaminated surfaces; d. after touching a resident; e. after touching the resident's environment; . g. immediately after glove removal . - Observations for Resident #14 showed the following: * 01/23/24 at 9:45 a.m., showed two certified nurse aides (CNA) (#5 and #6) assisted Resident #14 onto the toilet using a mechanical lift. After toileting, the CNA (#6) performed perineal care, and without removing her gloves, applied a new brief, pulled up the resident's pants, and straightened the resident's clothes. The CNA (#6) pushed the lift out of the bathroom and lowered the resident into the wheelchair. The CNA (#6) removed her gloves and without performing hand hygiene applied the resident's protective boot, tied up the garbage bag and left the room with the garbage. The CNA (#6) failed to remove gloves and perform hand hygiene before assisting the resident and leaving the room. * 01/24/24 at 10:30 a.m., showed two CNAs (#7 and #8) assisted Resident #14 onto the toilet using a mechanical lift. After toileting, the CNA (#8) performed perineal cares, discarded the perineal wipes in a garbage bag and tied up the bag. The CNA (#8) pulled up the resident's pants, removed her gloves, and held the gloves and garbage bag in her hands while the CNA (#7) pushed the lift out of the bathroom and lowered the resident into the wheelchair. The CNA (#8) still holding the soiled gloves and garbage in her hand, offered the resident a canister with wipes for her hands. The resident took a wipe, and the CNA placed the canister back on the nightstand. The CNA (#8) failed to perform hand hygiene and exited the room with the garbage bag and soiled gloves. - Observation on 01/23/24 at 10:50 a.m. showed two CNAs (#6 and #8) assisted Resident #9 onto the toilet using the mechanical lift. The CNA (#6) donned gloves, performed perineal care, removed the gloves, and without performing hand hygiene, obtained a sweater from the closet and assisted Resident #9 with the sweater, and adjusted the oxygen tubing. The CNA (#6) failed to perform hand hygiene after perineal care and before assisting the resident with other tasks. During an interview on 01/25/24 at 10:05 a.m., an administrative nurse (#1) stated she expected staff to perform hand hygiene after removing gloves. 45873

Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.17), and staff interview, the facility failed to ensure the Minimum Data Set (MDS) accurately reflected the residents' status for 1 of 12 sampled residents (Resident #8). Failure to accurately complete Section N (Medications) of the MDS, may negatively affect the development of a comprehensive care plan, and the care provided to the residents. Findings include: The Long-Term Care Facility RAI Manual, revised October 2019, page N-7, states, . N0410H, Opioid: Record the number of days an opioid medication was received by the resident at any time during the 7-day look-back period. Review of Resident #8's medical record occurred on 01/31/23. The current physician's orders lacked an order for an opioid. A quarterly MDS, dated [DATE], identified staff coded section N for opioid use all seven days of the look-back period. During an interview on the afternoon of 01/31/23, an administrative nurse (#1) confirmed staff coded section N of the MDS incorrectly for Resident #8.

Based on review of the facility reported incident, record review, review of facility policy, review of facility documents, and resident and staff interview, the facility failed to provide adequate assistance for 1 of 2 sampled residents (Resident #32) reviewed for transfers with a full body mechanical lift. Failure to ensure the correct use of transfer devices resulted in an injury for Resident #32, and placed all residents requiring full body mechanical lifts at risk for falls and injury. Findings include: A review of the facility policy titled Safe Resident Handling/Transfers occurred on 02/01/23. This undated policy stated, . Two staff members must be utilized when transferring residents with a mechanical lift. Review of the initial incident report sent to the State Survey Agency (SSA), dated 05/12/22, concerning Resident #32 and a certified nursing assistant (CNA) (#3) on 05/11/22 stated, . Staff member was transferring resident with a hoyer lift [full body mechanical lift]. Lift tilted to side and resident slid out of hoyer canvas and bumped her head on arm of hoyer. TLC [tender loving care] was provided and first aid (ice) provided to resident as a comfort measure only. The facility's plan to protect all residents during the investigation stated, . Staff were brought together at shift change and reviewed policy which states two people with hoyer transfers. During an interview on 01/29/23 at 4:35 p.m., Resident #32 stated No if she had ever fallen, and further stated, A long time ago I slid in that thing [full body mechanical lift] and bumped my head. I had a little goose egg. Review of Resident #32's medical record occurred on 01/31/23 and 02/01/23, and included diagnoses of Alzheimer's disease, and osteoarthritis. The current care plan stated, , , , I need extensive to total assistance with ADLs [activities of daily living] . Transfers - Hoyer lift with staff assist of 2. Review of the facility provided documentation regarding Resident #32's injury with the hoyer lift identified the following: * 06/14/22 Nurse (#2) reported [CNA #3] reported to me last evening that she didn't have the legs set wide enough apart on the lift and that the swinging bars on the hoyer lift swung against a residents [sic] forehead, [resident name]. [Resident #32's name] was laying [sic] in bed with no bruising or any bumps observed to forehead or anywhere. She said it 'Hurt a little' but declined offer of Tylenol. Vitals and neuro [neurological] assessment were normal. I was able to get another set of vitals this morning, which were also normal, and still no bumps or bruises present. Review of the facility's investigation report identified the following: . [CNA #3] was attempting to raise the lift up over the bed to sit [resident name] up but 'did not have the legs open far enough so it started to tip forward. the crossbars were swinging, did not hit her directly in the head but swung across her forehead.' She then stated that she was immediately able to stabilize the lift and [resident name] was laying on the bed, she then called another CNA on the walkie [portable voice system] that came to assist her and [resident name] was transferred safely into her wheelchair. During an interview on the afternoon of 01/31/23, an administrative nurse (#1) stated the facility conducted annual skills validations, which included mechanical lifts, for all staff in July 2022, and further stated the Quality Assurance committee monitored competencies and any risks for falls or injury. Based on the following information, non-compliance at F689 is considered past non-compliance. The facility implemented the corrective action for the resident affected by the deficient practice by: * CNA (#3's) counseling form, dated 06/14/22, stated the following: 1. Observation of employee's conduct: Will monitor proper use of transfers using lifts for minimum of 90 days (and ongoing). * Documentation dated June 14-16, 2022 titled, Electronic Total Lift Competency *Hoyer Lift showed the facility assessed all the CNAs' competency with full body mechanical lifts. * Completed an investigation with interviews of the resident and staff involved during the incident on 05/11/22. * Determined the investigation showed CNA #3 failed to follow the mechanical lift policy, which resulted in minor harm (little goose egg) per the nurse (#2's) assessment. * Provided education to staff following incident regarding the requirement of two staff with all mechanical lift transfers. The facility addressed measures put in place to ensure the deficient practice does not recur by: * Providing competency validation for mechanical lifts with all staff in July 2022. * Providing monitoring by the Quality Assurance committee of staff competence with mechanical lifts.

Based on observation, review of facility policy, and staff interviews, the facility failed to follow standards of infection prevention and control for 1 of 1 sampled resident (Resident #22) observed during nebulizer treatment. Failure to follow infection control standards related to performing aerosol-generating procedures has the potential to transmit infections to other residents, staff, and visitors. Findings Include: Review of the facility policy/procedure titled Coronavirus Preventions and Response occurred on 01/31/2023. This policy, dated October 2022, stated, . consider implementing broader use of respirators and eye protection by HCP [healthcare personnel] during resident care encounters . having HCP use PPE [personal protective equipment] . particulate respirators with N95 filters or higher used for . all aerosol-generating procedures . Observation on 01/30/23 at 10:32 a.m., showed Resident #22's resting in bed receiving a nebulizer [breathing] treatment. The open door lacked signage for aerosol precautions and the staff nurse (#5) administering the treatment failed to wear an N95 mask. During an interview on 02/01/23 at 08:30 a.m., with two administrative staff members (#1 and #4), confirmed staff should follow infection control guidelines.

Based on observation, review of facility policy, and staff interview, the facility failed to follow standards of infection control for 3 of 4 days of survey (September 27-29, 2021). Failure to follow infection control practices related to hand hygiene/glove use (Resident #3, #5, and #7) and properly donning personal protective equipment (staff member #5) has the potential to transmit infections to other residents, staff, and visitors. Findings include: HAND HYGIENE/GLOVE USAGE Review of the facility policy titled Personal Protective Equipment occurred on 9/29/21. This policy, revised 2021, stated, . Wear gloves when direct contact with blood, body fluids . is anticipated. Perform hand hygiene before donning gloves and after removal. Gloves are not a substitute for hand hygiene. Change gloves and perform hand hygiene between clean and dirty tasks, when moving from one body part to another . Observations showed the following: - 9/28/21 at 10:40 a.m., a certified nursing assistant (CNA) (#4) donned gloves, performed perineal care for Resident #7, removed the gloves, assisted an unidentified CNA with a transfer, and exited the room without performing hand hygiene. - 09/28/21 at 11:06 a.m., two CNAs (#9 and #11) assisted Resident #5 to the bathroom utilizing the sit-to-stand lift. The CNA (#9) donned gloves and performed perineal care. Without removing her gloves, the CNA adjusted the resident's clothing, assisted to transfer the resident to her wheelchair, placed a cloth mask on the resident's face, removed the resident's sweater, and grabbed the handles of the resident's wheelchair. The CNA (#9) failed to remove her gloves and perform hand hygiene after perineal care and before completing other tasks. During an interview on 9/30/21 at 9:45 a.m., an administrative nurse (#1) stated she expected staff to perform hand hygiene after glove removal and before exiting the resident's room. MEDICATION ADMINISTRATION Review of the facility policy titled Medication Administration occurred on 09/30/21. This policy, reviewed 2021, stated, . Remove medication from source, taking care not to touch medication with bare hand. Observation on 09/29/21 at 8:29 a.m., showed a nurse (#7) punched out multiple medications from Resident #3's medication cards into a medication cup. The nurse dropped two of the medications on top of the medication cart, picked them up with her bare hands, and placed the medications into the medication cup prior to administering them to the resident. PERSONAL PROTECTIVE EQUIPMENT Review of the Centers for Disease Control and Prevention (CDC) guidance found at: https://www.cdc.gov, updated August 13, 2021, stated, Your Guide To Masks . wear a mask that covers your nose and mouth . How not to wear a mask . under your nose . Observations during survey showed the following: * 09/27/21 at 5:35 p.m. a dietary staff member (#5) checked food temperatures wearing a surgical mask below her nose. * 09/28/21 at 5:25 p.m. a dietary staff member (#5) prepared resident meal trays in the kitchen wearing a surgical mask below her nose. During an interview of the morning of 09/30/21 an administrative staff (#1) stated she expected staff to wear a mask covering their nose and mouth.

Based on observation, record review, review of professional reference, and review of the facility policy, the facility failed to follow professional standards of practice for 1 of 4 residents (Resident #26) observed receiving oral medications. Failure to administer medications as recommended may affect the absorption and efficacy of the medication. Findings include: Review of a professional reference found at https://www.drugs.com/drug-interactions/[MEDICATION(S)].html, updated May 2021, indicated, . [MEDICATION(S)] (a [CONDITION(S)] replacement) oral works best if you take it on an empty stomach, 30 to 60 minutes before breakfast. Certain medicines can make this medicine less effective if taken at the same time. If you use any of the following drugs, avoid taking them within 4 hours before or 4 hours after you take [MEDICATION(S)]: [MEDICATION(S)] [calcium supplement] . [MEDICATION(S)] sulfate [iron supplement] . vitamins . Review of the facility policy titled Medication Administration occurred on 09/30/21. This policy, reviewed 2021, stated, . Medications are administered . as ordered by the physician and in accordance with professional standards of practice . Medications requiring administration on an empty stomach: [MEDICATION(S)] . Review of Resident #26's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] * [MEDICATION(S)] tablet; 200 mcg (micrograms); oral, once a day * [MEDICATION(S)] tablet; 50 mcg; oral, once a day * [MEDICATION(S)] (a calcium-vitamin D3-vitamin K supplement * [MEDICATION(S)] sulfate once a morning Observation on 09/29/21 at 8:44 a.m. showed a nurse (#7) administered to Resident #26 the [MEDICATION(S)], along with other scheduled morning medications which included [MEDICATION(S)] and [MEDICATION(S)] sulfate. The facility failed to administer Resident #26's [MEDICATION(S)] according to the professional recommendations.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide adequate supervision and assistive devices necessary to prevent accidents for 1 of 2 sampled residents (Resident #134) observed during a transfer. Failure to use a gait belt when transferring a resident placed the resident at risk for falls and injury. Findings include: Review of the facility policy titled Use of Gait Belt Policy occurred on 09/29/21. This policy, revised 2021, stated, Policy: It is the policy of this facility to use gait belts with residents that cannot independently ambulate or transfer for the purpose of safety. Review of Resident 134's medical record occurred on all days of survey. The care plan stated, At risk for falls: [Resident #134] needs hands on assist with ambulation and transfers. Transfers - limited to extensive assist of 1. Observation on 09/28/21 at 10:10 a.m. showed two certified nursing assistants (CNAs) (#2 and #3) transferred Resident #134 from the bed to the bath chair. Both CNAs lifted under the resident's arms during the transfer. The CNAs failed to use a gait belt during the transfer. Observation on 09/28/21 at 10:35 a.m. showed a CNA (#2) transferred resident #134 from the bath chair to a standing position and lifted under the resident's arm. The CNA failed to use a gait belt to assist the resident to a standing position. Observation on 09/28/21 at 12:05 p.m. showed a CNA (#2) lifted under Resident #134's arm to transfer the resident from the wheelchair to a dining room chair. The CNA failed to use a gait belt during the transfer. During an interview on 09/30/21 at 9:45 a.m., an administrative nurse (#1) stated she expected staff to use a gait belt when transferring residents.

Based on observation, record review, and review of a professional reference, the facility failed to ensure each resident received food in a form designed to meet the individual resident needs for 1 of 1 sampled resident (Resident #14) with physician's orders for a texture modified diet. Failure to serve food according to physician's orders placed the resident at risk for reduced meal intake, choking, and aspiration pneumonia. Findings include: Review of the facility policy titled Texture and Consistency-Modified Diets occurred on 09/30/21. This undated policy stated, . Nursing staff will notify the director of food and nutrition services of consistency changes ordered by the physician . The food and nutrition services department will be responsible for preparing and serving the diet texture and fluid consistency ordered. Review of Resident #14's medical record occurred on all days of survey and identified the physician ordered a regular diet with ground meats on 06/04/20. The nutritional assessment, dated 08/04/21, the current care plan, and the resident's tray card also identified Resident #14 received a regular diet with ground meat. Observations of Resident #14 included the following: * 09/27/21 at 6:14 p.m., a meal plate containing a whole piece of country style sausage. * 09/28/21 at 12:15 p.m., a CNA (#9) placed to the resident's mouth and encouraged the resident to eat a hamburger in a bun. * 09/29/21 at 12:07 p.m., a CNA (#10) fed the resident bone-in chicken wings cut up into small pieces, and stated, She really doesn't eat the food. She just chews on it for the flavor then spits it out. The facility provided a copy of the ORAL FEEDING RISK RESPONSIBILITY WAIVER. Review of the waiver, dated and signed by Resident #14's power of attorney (POA) on 01/13/21, identified the facility counseled the POA on the risks and health complications associated with oral feedings. The waiver failed to identify the specific diet desired by the POA or that the POA did not want ground meats for Resident #14. The facility staff failed to ensure Resident #14 received ground meats as per physician's orders and care plan.

Based on observation, record review, review of facility policy, resident interview and staff interview, the facility failed to provide documentation, necessary treatment and care for 1 of 1 sampled residents (Resident #6) with skin bruising. Failure to assess, monitor, document, and implement interventions may result in delayed healing or the development of additional skin breakdown. Findings include: Review of the facility policy titled Bumps and Bruises Policy and Procedure occurred on 12/17/19. This undated policy, stated, . Bumps and bruises noticed by staff are reported to the charge nurse as soon as possible . The charge nurse will then observe the area . and record findings in the resident's nurses notes. Review of Resident #6's medical record occurred on all days of survey. The current care plan identified, At Risk for Skin Breakdown . Skin assessments weekly and prn (as needed) . Charge nurse to assess skin upon report and start treatment if necessary . Observe skin with cares and report to nurse any skin concerns - red areas, open areas, bumps/bruising, rash, discoloration, warm areas, blisters, etc. Observation on 12/15/19 at 4:25 p.m., showed Resident #6 with purplish discoloration and a flexible fabric 1 x 3 bandage on his left hand from his knuckles to his wrist. When asked what happened, Resident #6 stated the bruise happened two days ago. Observation on 12/17/19 at 8:37 a.m., showed a CNA (certified nurse assistant) #3 assist Resident #6 with the bedside commode. When asked about the bruise on Resident #6's left hand, the CNA stated she did not know how he got the bruise. During an interview on 12/17/19 at 9:40 a.m., a nurse (#2) when asked about the bruise on Resident #6's left hand, did not know about the bruise. The medical record lacked evidence of documentation, assessment, and monitoring of the resident's bruised left hand. During an interview on 12/17/19 at 11:40 a.m., a supervisory nurse (#4) stated she expected staff to report skin issues to the nurse, the nurse to monitor and record Resident #6's left hand bruising in his medical record.

1. Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide adequate assistive devices necessary to prevent accidents for 2 of 2 sampled residents (Resident #2 and #3) observed during transfer. Failure to ensure proper use of wheelchair foot pedals placed the residents at risk for accidents and injuries. Findings include: Review of the facility policy titled Proper use of wheelchair pedals occurred on 12/17/19. This undated policy, stated, . 3. Wheelchair pedals will be used during staff mobility to promote safety if: . Resident is unable to self-propel wheelchair . Resident is unable to hold feet up during transport and unable to express refusal or consent to wheelchair pedals verbally, due to cognitive deficit. If unable to verbalize choice and resident cannot hold up feet, wheelchair pedals will be used. - Review of Resident 2's medical record occurred on all days of survey and included [DIAGNOSES REDACTED]. The current care plan identified, . Mode of Locomotion - Primarily wheelchair propelled by staff. Observation on 12/16/19 at 8:39 a.m., showed a certified nurse aide CNA (#5) transported Resident #2 in the wheelchair from the dining room, to the bathroom and back to the front lobby. Both of the resident's shoes slid on the floor and made an audible noise. The CNA failed to place foot pedals on Resident #2's wheelchair and/or cue the resident to lift his feet. - Review of Resident #3's medical record occurred on all days of survey. The current care plan identified, . becomes very short of breath with minimal exertion. A quarterly Minimum Data Set ((MDS) dated [DATE] identified extensive assist with wheelchair locomotion on and off the unit. Observations on all days of the survey showed certified nurses aides (CNAs) transported Resident #3 in his wheelchair down the hall to and from his room to the dining room. Both of the residents shoes slid along the surface of the floor and made an audible noise. The CNA's failed to place foot pedals on Resident #3's wheelchair and/or cue the resident to lift his feet. During an interview on 12/17/19 at 11:03 a.m., an administrative nurse (#4) stated she expected staff to use foot pedals for residents who needed assistance when transported. 2. Based on observation and staff interview, the facility failed to ensure the residents environment remained as free of accident hazards as possible for 2 of 2 soiled utility rooms (North and East). Failure to safely store hazardous chemicals placed cognitively impaired/wandering residents at risk for accidents and injury. Findings include: Observation of an ulocked soiled utility room on the north unit the morning of 12/17/19, showed a locked upper cabinet door with the key still in the lock. The cabinet contained the following chemicals: * Stride Citrus cleaner: Label stated, warning. causes serious eye irritation. Avoid contact with eyes, skin and clothing.May cause irritation to mouth, throat and stomach. Wear chemical-splash goggles and chemical-resistant gloves. * Halt cleaner: Label stated, . in case of emergency, call poison control center or doctor for treatment advice. If in eyes: Hold eye open and rinse slowly and gently with water for 15-20 minutes. If on skin: Take off contaminated clothing. Rinse skin immediately with plenty of water for 15-20 minutes. If swallowed: Have person sip a glass of water if able to swallow. Do not induce vomiting unless told to do so by a poison control center or doctor. If inhaled: Move person to fresh air. If person is not breathing, call 911 or an ambulance, then give artificial respiration. DANGER: corrosive. Causes irreversible eye damage and skin burns. Harmful if swallowed or absorbed through the skin. Do not get in eyes, on skin, or on clothing. Wear goggles or face shield and rubber gloves and protective clothing when handled. Observation on the morning of 12/17/19 showed a bottle of Stride Citrus cleaner seating on the shelf in an unlocked soiled utility room on the east unit. During an interview on 12/17/19 at 10:45 a.m., a facility staff member (#1) agreed the chemical stored in the east soiled utility room should be locked up, and the key for the locked cabinet in the north soiled utility room should not be stored in the key lock.

Based on record review, staff interview, review of the facility policy, and review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to complete a significant change in status assessment (SCSA) for 1 of 1 sampled residents (Resident #12) who experienced a significant change in status. Failure to determine the need for and complete a SCSA in response to a resident's decline limited the facility's ability to accurately assess the resident's status, and identify and implement appropriate care approaches. Findings include: Review of the facility policy titled Resident Assessment Instrument occurred on 11/29/18. This undated policy stated, The Assessment Coordinator is responsible for ensuring that the Interdisciplinary Assessment Team conduct timely resident assessment and reviews according to the following schedule: . b. When there has been a significant change in the resident's condition . The Long-Term Care Facility RAI 3.0 User's Manual (Version 1.15), dated (MONTH) (YEAR), page 2-22 stated, . A 'significant change' is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without staff intervention . 2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary review and/or revision of the care plan. and page 2-25 stated, A SCSA is appropriate if there are either two or more areas of decline or two or more areas of improvement. This may include two changes within a particular domain (e.g., (for example) two areas of ADL (Activities of Daily Living) decline or improvement. - Review of Resident #12's medical record occurred on all days of survey. A quarterly Minimum Data Set (MDS), dated [DATE], identified the resident as independent with bed mobility, transfers, toileting, walking in the room and corridor, and locomotion on and off the unit. The medical record identified Resident #12 was hosptalized on [DATE] until 08/21/18. A quarterly MDS, dated [DATE], identified the resident required extensive assistance with bed mobility, toileting, and locomotion on and off the unit. The record lacked rationale for staff failure to complete a SCSA following Resident #12's hospitalization . During an interview on 11/28/18 at 11:50 a.m., an administrative staff member (#2) stated staff was waiting until the (MONTH) MDS to do a SCSA.

Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.15), and staff interview, the facility failed to ensure accurate coding of Minimum Data Sets (MDSs) for 1 of 13 sampled residents (Resident #16) and 1 supplemental resident (Resident #23). Failure to accurately complete Section I (Active Diagnoses) and Section N (Medications) of the MDS does not allow each resident's assessment to reflect their current status/needs, and may affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include: SECTION I: ACTIVE DIAGNOSES The Long-Term Care Facility RAI User's Manual, revised (MONTH) (YEAR), page I-8 stated, . Item I2300 Urinary tract infections [MEDICAL CONDITION]: The UTI has a look-back period of 30 days for active disease . - Review of Resident #16's medical record occurred on all days of survey and identified the resident was hosptalized on [DATE] with a [DIAGNOSES REDACTED]. A quarterly MDS, dated [DATE], identified staff failed to code section I2300 for a UTI in the last 30 days. During an interview on 11/28/18 at 11:20 a.m., an administrative staff nurse (#2) confirmed she failed to code a UTI on Resident #16's MDS dated [DATE]. SECTION N: MEDICATIONS The Long-Term Care Facility RAI Manual, revised (MONTH) (YEAR), page N-7, stated, . N0410E, Anticoagulant (e.g., [MEDICATION NAME], or low- molecular weight [MEDICATION NAME]): Record the number of days an anticoagulant medication was received by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). Do not code antiplatelet medications such as aspirin/extended release, [MEDICATION NAME], or [MEDICATION NAME] here. - Review of Resident #23's medical record occurred on all days of survey. The current physician's orders [REDACTED]. The quarterly MDS, dated [DATE], identified the use of an anticoagulant 7 times during the 7-day look back period. During an interview on 11/28/18 at 11:40 a.m., an administrative staff member (#2) confirmed she incorrectly coded an anticoagulant on Resident #23's 10/11/18 MDS.