Every finding on record at Prairie View Skilled Nursing

Based on observation, interview, and record review, the facility failed to ensure the ice machine drain line maintained a required air gap (empty space that ensures dirty sewer water cannot flow backward into the ice machine and contaminate the ice) to prevent potential contamination. This deficient practice had the potential to affect all residents who consumed ice from the facility ice machine. The facility census was 45. Review of the facility's policy titled, Ice Machine and Ice Storage Chests, revised January 2012, showed:- Ice machines and ice storage/distribution will be used and maintained to assure a safe and sanitary supply of ice;- Ice-making machines, ice storage chests/containers, and ice can all become contaminated by:a. unsanitary manipulation by employees, residents, and visitors;b. waterborne microorganisms naturally occurring in the water source;c. colonization by microorganisms; and/ord. improper storage or handling of ice;- Did not address the air gap required for the ice machine. Observations on 05/26/26 at 9:32 A.M., and 3:36 P.M., 05/27/26 at 8:09 A.M., and 05/28/26 at 9:28 A.M., of the ice machine located in the dining room showed:- A bucket of discolored water placed on the left-side of the floor;- Two silk arrangements with a buildup of dust lay on top;- A round black plastic pipe connected from the back of the ice machine and inserted into a floor drain;- Water dripped from the pipe directly into the floor drain;- The ice machine drain line lacked an air gap to prevent direct contact between the pipe and the floor drain. During an interview on 05/28/26 at 1:46 P.M., the Dietary Manager said the ice machine drain line should have a maintained air gap to prevent backflow contamination and should not have been inserted directly into the floor drain. There should be nothing placed on top of the ice machine unrelated to its use.During an interview on 05/28/26 at 1:53 P.M., the Maintenance Supervisor said the ice machine drain line should have a maintained air gap to prevent contamination from the floor drain. During an interview on 05/28/26 at 2:05 P.M., the Administrator said the ice machine drain line should have a maintained air gap to prevent contamination from the floor drain. There should be nothing placed on top of the ice machine unrelated to its use.

Based on interview and record review, the facility failed to assess and investigate a choking incident that required the Heimlich maneuver (a procedure used to clear a blocked airway in a choking person) and failed to determine whether additional interventions were necessary to reduce a foreseeable risk of recurrent choking for one resident (Resident #2) out of one sampled resident. Following a choking incident that resulted in airway obstruction and required emergency intervention, the facility failed to investigate the cause of the incident, assess the resident's continued choking risk, evaluate the effectiveness of existing interventions, or determine whether revisions to the resident's care plan, diet, supervision, or other interventions were necessary to reduce the risk of recurrence. The facility census was 45.Review of the facility policy titled, Accidents and Incidents, revision date July 2017, showed:- All accidents or incidents involving residents, employees, visitors, etc., occurring on the premises shall be investigated and reported to the administrator;- Reports of accidents and incidents shall be reviewed to identify trends, accident hazards, and individual resident vulnerabilities. 1. Review of Resident #2's quarterly Minimum Data Set (MDS, a federally mandated assessment completed by the facility), dated 04/02/26, showed:- Diagnoses of dementia (general term for a group of neurological conditions that cause a decline in mental abilities that affects daily life), history of stroke, hemiplegia (paralysis on one side of the body), dysphagia (difficulty swallowing), anxiety, hypertension, post-traumatic stress disorder (PTSD), and psychotic disorder;- Partial/moderate assistance with eating;- Mechanically altered diet;- Dependence on staff for activities of daily living and mobility. Review of the resident's physician order sheet (POS), May 2026, showed:- Regular diet with mechanical soft texture, dated 09/17/24;- No bread or peanut butter sandwiches, dated 09/17/24. Review of the resident's care plan, last reviewed 04/16/26, showed:- Mechanical soft diet with small portions;- No bread and no peanut butter sandwiches;- One serving at a time;- Remind the resident to eat slowly and provide small portions to reduce choking risk;- Monitor for chewing and swallowing difficulties and obtain speech therapy evaluation if indicated;- History of choking requiring the Heimlich maneuver on 08/17/24. Review of the resident's nursing documentation, dated 05/24/26, showed:- The resident choked while eating in the dining room;- The resident turned red, could not cough or speak, and was unable to respond to verbal stimuli;- Staff performed the Heimlich maneuver three times before the resident expelled the obstruction and resumed breathing and speaking;- The physician and responsible party were notified. Review of the resident's medical record following the choking incident showed:- No documentation the facility investigated the choking incident;- No documentation staff assessed the cause of the choking episode;- No documentation staff evaluated the effectiveness of the resident's existing choking interventions following the incident;- No documentation staff reviewed whether changes to the resident's diet, supervision, feeding assistance, or care plan were necessary following the incident;- No documentation staff implemented additional interventions to address the resident's choking risk. Observations on 05/26/26, 05/27/26, and 05/28/26 showed Resident #2 continued to receive meals in the dining room. The medical record lacked evidence the facility had evaluated whether existing interventions remained effective following the choking incident requiring the Heimlich maneuver. During an interview on 05/28/26 at 9:40 A.M., the Director of Nursing stated she was unaware Resident #2 required the Heimlich maneuver during the choking incident. She said the resident's diet should have been reviewed following the incident and expected the resident to receive further evaluation after the choking episode. During an interview on 05/28/26 at 9:40 A.M., the Administrator said no investigation had been completed regarding Resident #2's choking incident and was unsure what investigation staff should have conducted. During an interview on 05/28/26 at 9:58 A.M., the Physician said he/she had been notified of the choking incident. He/She would expect further evaluation of speech and swallowing if the resident continued to experience swallowing difficulties.

Based on observation, interview, and record review, the facility failed to obtain an order for a catheter (a flexible tube inserted into the bladder to drain urine) and catheter care for one resident (Resident #13) out of three sampled residents. The facility census is 45.Review of the facility's policy titled, Catheter Care, Urinary, revised August 2022, showed: - The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections;- Did not address the need for catheter and catheter care orders. 1. Review of Resident #13's medical record showed:- admission date of 11/26/25;- Diagnosis of reflex neuropathic bladder (the blader does not empty properly due to a neurological condition); - Urology notes, dated 05/06/26, urinary catheter was placed during the visit due to urinary retention related to reflex neuropathic bladder with no additional orders or instructions;- Nurse's note, dated 05/06/26 at 4:20 P.M., the resident returned from the urology appointment. Urinary catheter in place upon arrival. The urinary catheter was requested to remain in place for 30 days as tolerated. No new skin issues noted;- Physician order sheet (POS), dated 05/26/26, with no current physician order for the urinary catheter to be in place or for catheter care; - Treatment administration record (TAR), dated 05/06/26 - 05/26/26, with no documentation of urinary catheter care. During an interview on 05/26/26 at 3:00 P.M., the resident said he/she had a catheter placed by the urologist (physician who specializes in treating diseases of the urinary tract). Staff did not provide his/her urinary catheter care. Observation on 05/28/26 at 1:25 P.M., of the resident's urinary catheter care showed:- Certified Medication Technician (CMT) D and Certified Nurse Assistant (CNA) E provided the resident's urinary catheter care. During an interview 05/28/26 at 2:00 P.M., the Director of Nursing (DON) said there should be documented orders for a urinary catheter and catheter care. During an interview 05/28/26 at 2:30 P.M., Licensed Practical Nurse (LPN) A said there should be documented orders for a urinary catheter and catheter care.

Based on interview and record review, the facility failed to provide a written copy of the notice of transfer or discharge to the resident and/or the resident's responsible party for three residents (Residents #14, #37, and #48) out of six sampled residents. The facility census was 46. Review of the facility's policy titled, Transfer or Discharge, Facility-Initiated, dated October 2022, showed: - Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy; - The resident and representative are notified in writing of the specific need for transfer or discharge; - Notice of transfer is provided to the resident/representative as soon as practicable before the transfer and to the long-term care (LTC) ombudsman when practicable; - Notices are provided in a form and manner that the resident can understand, taking into account the resident's educational level, language, communication barriers, and physical or mental impairments; - Nursing notes will include documentation of appropriate orientation and preparation of the resident prior to transfer or discharge. 1. Review of Resident #14's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - No documentation of the written notification with the reason for the hospital transfer provided to the resident and/or the responsible party. 2. Review of Resident #37's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - No documentation of the written notification with the reason for the hospital transfer provided to the resident and/or the responsible party. 3. Review of Resident #48's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - No documentation of the written notification with the reason for the hospital transfer provided to the resident and/or the responsible party. During an interview on 04/02/25 at 8:59 A.M., the Social Service Director (SSD) said there should be a transfer/discharge notice given to the resident and/or the resident representative when a resident was sent to the hospital. During an interview on 04/02/25 at 9:28 A.M., Licensed Practical Nurse (LPN) A said when a resident was sent to the hospital, he/she verbally told the resident and /or the resident's representative of the reason for the transfer/discharge to the hospital. The SSD completed the transfer/discharge form. During an interview on 04/02/25 at 9:35 A.M., the Director of Nursing (DON) said when a resident was sent to the hospital, he/she verbally told the resident and/or the resident's representative of the reason for the transfer/discharge to the hospital. The SSD completed the transfer/discharge form. During an interview on 04/03/25 at 11:06 A.M., the Administrator said there should be a transfer/discharge notice given to the resident and/or the resident representative when a resident was sent to the hospital.

Based on interview and record review, the facility failed to inform the resident and the family or legal representative of their bed-hold policy at the time of the transfer to the hospital for three residents (Residents #35, #37, and #48) out of six sampled residents. The facility census was 46. Review of the facility's policy titled, Transfer or Discharge, Facility-Initiated, dated October 2022, showed: - Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy; - The resident and representative are notified in writing of the notice of the facility bed-hold and policies; - Notices are provided in a form and manner that the resident can understand, taking into account the resident's educational level, language, communication barriers, and physical or mental impairments; - Nursing notes will include documentation of the appropriate orientation and preparation of the resident prior to the transfer or discharge. 1. Review of Resident #35's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - No documentation the resident and/or the resident's representative was informed in writing of the facility's bed-hold policy at the time of the transfer on 12/28/24. 2. Review of Resident #37's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - No documentation the resident and/or the resident's representative was informed in writing of the facility's bed-hold policy at the time of the transfer on 01/15/25 and 02/09/25. 3. Review of Resident #48's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - No documentation the resident and/or the resident's representative was informed in writing of the facility's bed-hold policy at the time of the transfer on 01/18/25. During an interview on 04/02/25 at 8:59 A.M., the Social Service Director (SSD) said there should be a bed-hold policy notice given to the resident and/or the resident representative when a resident was sent to the hospital. During an interview on 04/02/25 at 9:32 A.M., Licensed Practical Nurse (LPN) A said when a resident was sent to the hospital, he/she verbally told the resident and/or the resident's representative of the bed-hold policy. The SSD completed the bed-hold policy form. During an interview on 04/02/25 at 9:35 A.M., the Director of Nursing (DON) said when a resident was sent to the hospital, he/she verbally told the resident and/or the resident's representative of the bed-hold policy. The SSD completed the bed-hold policy form. During an interview on 04/03/25 at 11:06 A.M., the Administrator said there should be a bed-hold policy notice given to the resident and/or the resident representative when a resident was sent to the hospital.

Based on interview and record review, the facility failed to identify, assess, and provide supportive interventions for one resident (Resident #35) with a diagnosis of post traumatic stress disorder (PTSD - a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event) out of one sampled resident. The facility's census was 46. Review of the facility's policy titled, Behavioral Health Services, dated February 2019, showed: - The facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practical physical, mental, or psychosocial well-being in accordance with comprehensive assessment and plan of care; - Behavioral health services are provided to residents as needed as part of the interdisciplinary (involving two or more departments or professions), person-centered approach to care; - Residents who exhibit signs of emotional/psychosocial distress receive services and support that address their individual needs and goals for care; - Residents who do not display symptoms of, or have not been diagnosed with, mental, psychiatric, psychosocial adjustment, substance abuse or PTSD will not develop behavioral disturbances that cannot be attributed to a specific clinical condition that makes the pattern unavoidable; - Staff training regarding behavioral health services includes, but is not limited to: a. Recognizing changes in behavior that indicates psychological distress; b. Implementing care plan interventions that are relevant to the resident's diagnosis and appropriate to his/her needs; c. Monitoring care plan interventions and reporting changes in condition; d. Protocols and guidelines related to the treatment of mental disorders, psychosocial adjustment difficulties, and history of PTSD. 1. Review of Resident #35's medical record showed: - admitted on [DATE]; - Diagnoses of PTSD, major depressive disorder (MDD - long-term loss of pleasure or interest in life), and anxiety (persistent worry and fear about everyday situations) disorder. Review of the resident's March and April 2025 Physician's Order Sheets (POS), showed: - An order for risperidone (an antipsychotic medication - a medication used to treat psychosis, a collection of symptoms that affect your ability to tell what is real and what is not) 0.25 milligram (mg) by mouth two times a day related to PTSD for 14 days, dated 03/13/25 and completed on 03/27/25; - An order for fluoxetine (an antidepressant medication) 40 mg two capsules by mouth in the morning related to depression, dated 03/13/25; - An order for clonazepam (an antianxiety medication) 0.5 mg by mouth two times a day related to anxiety disorder, dated 11/14/24. Review of the resident's Preadmission Screening and Resident Review (PASARR - a federal program to prevent inappropriate admission and retention of people with mental disabilities in nursing facilities), dated 10/22/24, showed: - Diagnoses of PTSD and MDD; - No behaviors and triggers documented. Review of the resident's behavioral note charting, dated 10/19/24 - 02/08/25, showed: - Anger and hostility; - Yelling and profanity; - Refusal of medications; - Threatening behavior toward staff. Review of the resident's Trauma Screening Questionnaire (TSQ), undated, showed: - Difficulty falling or staying asleep; - Irritability or outbursts of anger; - Being jumpy or being startled at something unexpected; - No documentation of when or who completed the questionnaire. Review of the resident's care plan, revised 11/07/24, showed: - Takes an antidepressant related to PTSD; - No documentation the resident had past trauma or any triggers that would cause the resident to have behaviors. During an interview on 03/31/25 at 11:55 A.M., the resident said he/she had PTSD due to being in combat during the Vietnam War and witnessed people killed. Loud sounds, noises, and closed-in spaces made him/her upset and irritable. He/She did not like to eat in the dining room because of the closed-in space and preferred to eat in his/her room. During an interview on 04/03/25 at 9:58 A.M., the Minimum Data Set (MDS - a federally mandated assessment instrument completed by the facility staff) Coordinator said he/she completed the TSQ form and placed in a binder, but not in the resident's medical record. The questionnaire should be dated and signed upon completion. The resident's care plan should have interventions in place related to past trauma and PTSD triggers. During an interview on 04/03/25 at 11:01 A.M., the Administrator said she would expect the TSQ to be signed and dated by the person who completed the form. She would expect the care plan to include interventions addressing the resident's triggers related to PTSD.

Based on observation, interview, and record review, the facility failed to ensure staff reconciled narcotics (a process that allows one staff to reconcile the exact narcotic inventory on hand with another staff) at each shift change for two out of two sampled medication carts. The facility also failed to implement procedures to ensure medications were accurately administered, documented, disposed of, and reconciled for one resident (Resident #12) outside of the 12 sampled residents This practice had the potential to affect all residents. The facility census was 46. Review of the facility's policy titled, Controlled Substances, last revised November 2022, showed: - Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up; - The system of reconciling the receipt, dispensing, and disposition of controlled substances includes the following: a. Records of personnel access and usage; b. Medication administration records; c. Declining inventory records; d. Destruction, waste, and return to pharmacy records; - Nursing staff count the controlled medication inventory at the end of each shift, using these records to reconcile the inventory count; - The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the Director of Nursing (DON) Services; - The DON Services documents irreconcilable discrepancies in a report to the Administrator. 1. Review of the 200/300 Hall Medication Cart Narcotic Count Log for Controlled Substances showed: - For day/evening/night shifts for 12/01/24 - 12/31/24, 16 missed out of 84 opportunities to reconcile the narcotic counts; - For day/evening/night shifts for 01/01/25 - 01/31/25, 25 missed out of 84 opportunities to reconcile the narcotic counts; - For day/evening/night shifts for 02/01/25 - 02/28/25, 37 missed out of 84 opportunities to reconcile the narcotic counts; - For day/evening/night shifts for 03/01/25 - 03/31/25, 15 missed out of 84 opportunities to reconcile the narcotic counts. 2. Review of the 100/400 Hall Medication Cart Narcotic Count Log for Controlled Substances showed: - For day/evening/night shifts for 12/24/24 - 12/31/24, 6 missed out of 24 opportunities to reconcile the narcotic counts; - For day/evening/night shifts for 01/01/25 - 01/31/25, 12 missed out of 86 opportunities to reconcile the narcotic counts; - For day/evening/night shifts for 02/01/25 - 02/28/25, 31 missed out of 79 opportunities to reconcile the narcotic counts; - For day/evening/night shifts for 03/01/25 - 03/31/25, 41 missed out of 84 opportunities to reconcile the narcotic counts. 3. Review of Resident #12's medical record showed: - An admitted [DATE]; - An order for morphine sulfate (a narcotic pain medication) 100 milligrams (mg) per five milliliters (ml) 0.25 ml by mouth every 4 hours as needed for pain, dated 01/24/24. Review of the resident's Controlled Drug Receipt/Record/Disposition form for Bottle #2 of morphine sulfate 30 ml showed: - Zero doses signed out as administered by staff. Observation on 04/02/25 at 10:28 A.M., of the 100/400 Medication Cart showed: - Bottle #2 of morphine sulfate 30 ml bottle in a box with tape on the top of the box, and no tape on the bottom of the box; - Bottle #2 of morphine sulfate 30 ml opened, labeled with resident's last name, and with 29.5 ml in the 30 ml bottle. During an interview on 04/02/25 at 10:30 A.M., Certified Medication Technician (CMT) B said he/she thought the box of the resident's Bottle #2 of morphine was unopened so when the counts were done for each shift, the staff only counted opened boxes. The staff didn't look at boxes to see if they had been opened since it had tape on top of the box. to see if those bottles have been opened. If there was ever a discrepancy, it was reported to the DON. During an interview on 04/02/25 at 10:31 A.M., the DON said she boxes of medications that were taped should be unused and therefore a full bottle. She was unsure why Resident #12's morphine bottle had been opened in Box #2. During an interview on 04/03/25 at 9:15 A.M., CMT B said narcotics were counted every shift with the on-coming and off-going staff members. During an interview on 04/03/25 at 9:18 A.M., the DON said she expected two staff, the on-coming and the off-going, to count the narcotics on each cart for each shift. The Administrator was made aware of Resident #12's Box #2 of the opened morphine bottle and the unaccounted missing doses. An audit was done, and other discrepancies were found. During an interview on 04/03/25 at 9:30 A.M., the Administrator said narcotics should be reconciled with two staff members, the on-coming and off-going staff. The DON reported the narcotic discrepancy and an audit was completed.

Based on observation, interview, and record review, the facility failed to maintain a medication error rate of less than five percent (%). There were 28 opportunities with three errors made, resulting in an error rate of 10.71% for one resident (Resident #27) out of four sampled residents. The facility's census was 46. Review of the facility's policy titled, Insulin Administration, last revised September 2014, showed: - Three key characteristics of insulin are: onset of action - how quickly the insulin reaches the bloodstream and begins to lower blood glucose, peak effects - the time when the insulin is at its maximum effectiveness, and duration of effect - the length of time during which the insulin is effective; - Rapid-acting insulin - onset of 10-15 minutes (min), peak of 0.5-3 hours (hrs.), duration of 3-6 hrs.; - Regular/short-acting insulin - onset of 0.5-1 hr., peak of 2.5-5 hrs., duration of 8-12 hrs.; - Steps in the procedure to administer insulin: wash hands, check blood glucose per the physician order or facility protocol, check and re-check the type of insulin on the vial matches the type of insulin ordered, and check the order for the amount of insulin. 1. Review of Resident #27's Physician Order Sheet (POS), dated April 2025, showed: - An order to obtain fasting blood sugars (FSBS-a blood sugar check before eating) before meals, dated 01/27/24; - An order for Humalog (fast-acting insulin) 3 unit subcutaneously (injection under the skin) with meals, dated 03/07/25; - An order for Humalog as per sliding scale if blood sugar 151 - 200 = 3 units; 201 - 250 = 6 units; 251 - 300 = 9 units; 301 - 350 = 12 units; 351 - 400 = 14 units; 401 - 999 = 16 units and call the physician, subcutaneously before meals, dated 01/26/24. Observation of the resident's medication administration on 04/01/25 at 8:26 A.M., showed: - Certified Medication Technician (CMT) B did not check the resident's blood sugar; - CMT B administered the scheduled Humalog 3 units plus Humalog 6 units for a blood sugar of 228 that was obtained at 5:00 A.M.; - CMT B failed to check the resident's blood sugar, failed to administer the correct dose of insulin, and failed to administer the insulin before the resident ate breakfast as ordered. During an interview on 04/01/25 at 8:20 A.M., CMT B said he/she used the resident's blood glucose reading completed at 5 A.M., to determine how much sliding scale Humalog to administer now. During an interview on 04/01/25 at 8:27 A.M., Resident #27 said he/she had already eaten breakfast. His/Her blood sugar was checked at 5:15 A.M. The insulin was administered 1.5 hours after his/her blood sugar was checked. Breakfast was served between 7: 00 A.M. - 7:45 A.M. During an interview on 04/01/25 at 9:10 A.M., CMT B said he/she started administering insulin at 6:15 A.M., using the blood sugar readings obtained from the night shift staff at 5 A.M. During an interview on 04/01/25 10:12 A.M., the Director of Nursing (DON) and the Administrator said staff should check blood sugars for short-acting insulin administration at no more than one hour before it was administered.

Based on observation, interview, and record review, the facility failed to ensure that one resident (Residents #27) out of one sampled resident was free from significant medication errors when staff did not check blood sugars prior to administering insulin (a medication that regulates blood sugar levels). The facility's census was 46. Review of the facility's policy titled, Insulin Administration, last revised September 2014, showed: - Three key characteristics of insulin are: onset of action - how quickly the insulin reaches the bloodstream and begins to lower blood glucose, peak effects - the time when the insulin is at its maximum effectiveness, and duration of effect - the length of time during which the insulin is effective; - Rapid-acting insulin - onset of 10-15 minutes (min), peak of 0.5-3 hours (hrs.), duration of 3-6 hrs.; - Regular/short-acting insulin - onset of 0.5-1 hr., peak of 2.5-5 hrs., duration of 8-12 hrs.; - Steps in the procedure to administer insulin: wash hands, check blood glucose per the physician order or facility protocol, check and re-check the type of insulin on the vial matches the type of insulin ordered, and check the order for the amount of insulin. 1. Review of Resident #27's Physician Order Sheet (POS), dated April 2025, showed: - An admitted [DATE]; - A diagnosis of diabetes mellitus (elevated levels of glucose in the blood); - An order to obtain fasting blood sugars (FSBS-a blood sugar check before eating) before meals, dated 01/27/24; - An order for Humalog (fast-acting insulin) 3 unit subcutaneously (injection under the skin) with meals, dated 03/07/25; - An order for Humalog as per sliding scale if blood sugar 151 - 200 = 3 units; 201 - 250 = 6 units; 251 - 300 = 9 units; 301 - 350 = 12 units; 351 - 400 = 14 units; 401 - 999 = 16 units and call the physician, subcutaneously before meals, dated 01/26/24; - An order for Lantus (long-acting insulin 66 units subcutaneously in the morning, dated 03/08/25. Observation of the resident's medication administration on 04/01/25 at 8:26 A.M., showed: - Certified Medication Technician (CMT) B did not check the resident's blood sugar; - CMT B administered Humalog 9 units; - CMT B failed to check the resident's blood sugar prior to the administration of the insulin. During an interview on 04/01/25 at 8:20 A.M., CMT B said he/she used the resident's blood glucose reading completed at 5 A.M., to determine how much sliding scale Humalog to administer now. During an interview on 04/01/25 at 8:27 A.M., Resident #27 said he/she had already eaten breakfast. His/Her blood sugar was checked at 5:15 A.M. The insulin was administered 1.5 hours after his/her blood sugar was checked. Breakfast was served between 7: 00 A.M. - 7:45 A.M. During an interview on 04/01/25 at 9:10 A.M., CMT B said he/she started administering insulin at 6:15 A.M., using the blood sugar readings obtained from the night shift staff at 5 A.M. During an interview on 04/01/25 10:12 A.M., the Director of Nursing (DON) and the Administrator said staff should check blood sugars for short-acting insulin administration at no more than one hour before it was administered.

Based on observation, interview, and record record review, the facility failed to employ a qualified director of food and nutrition services. The facility did not have a Dietary Manager (DM) with a background or required years of experience in food preparation, food service and/or food storage. This deficient practice had the potential to affect all residents in the facility. The facility census was 46. Review of the facility's policy titled, Dietician, dated November 2022, showed: - If a qualified dietitian is not employed full-time (35 or more hours per week), a director of food and nutrition services will be designated. The individual will: a. Be a certified dietary manager, or; b. Be a certified food service manager, or; c. Be nationally certified for food service management and safety, or; d. Have an associate's (or higher degree) in food service management or hospitality, if the course study includes food service or restaurant management, from an accredited institution, or; e. Has two or more years of experience in the position of director of food and nutrition services in a nursing facility setting and has completed a course of study in food safety and management, by no later than October 1, 2023, that includes topics integral to managing dietary operations including, but not limited to, foodborne illness, sanitation procedures, food purchasing/receiving, and meet any state requirements for food service or dietary managers; f. Receive frequently scheduled consultations from a qualified dietitian or other clinically qualified nutrition professional. Review of the facility's current employee list, dated 03/31/25, showed: - The DM's hire date of 01/16/24; - No full-time dietitian. During an interview on 03/31/25 at 9:13 A.M., the DM said upon hire in January 2024, the prior Administrator enrolled him/her in the required courses to become a certified dietary manager (CDM) within a year of his/her hire date. He/She was enrolled for the required courses, but failed to complete the certification requirement. Administration did not follow up with him/her about the progress or status of the requirement. He/She had no previous long-term care experience as a DM prior to accepting this position. The facility did not have a full-time dietitian. During an interview on 04/03/24 at 10:11 A.M., the Registered Dietician (RD) said he/she gave the facility management guidance and information regarding what course of study the dietary employee should be enrolled in to complete the dietary requirement. During an interview on 04/03/24 at 11:32 A.M., the Administrator said she had been in her position at the facility since January 2025, but would expect the employee enrolled in the required dietary courses to follow up with management on his/her status. She would also expect the person enrolled in the required courses to have the certification completed in a timely manner.

Based on interview and record review, the facility failed to obtain a physician's order for one resident (Resident #11) outside the sample. The facility failed to follow wound care orders for one resident (Resident #17) out of two sampled residents and failed to follow physician orders for Physical Therapy (PT), Occupational Therapy (OT) and Speech Therapy (ST) to evaluate and treat as indicated for two residents (Resident #26 and #30) out of four sampled residents. The facility census was 34. Review of the facility's policy titled, Physician's Services, revised February 2021, showed: - The medical care of of each resident is supervised by a licensed physician; - Once a resident is admitted , orders for the resident's immediate care and needs can be provided by a physician, physician assistant (PA), nurse practitioner (NP), or clinical nurse specialist (CNS); - Supervising the medical care of residents include participating in the resident's assessments, providing consultation or treatment when called by the facility, prescribing medications and therapy, and care planning and overseeing a relevant plan of care for the resident; - The policy did not address colostomy (a surgical procedure in which a piece of the colon is diverted to an artificial opening in the abdominal wall as to bypass a damaged part of the colon) care; - The policy did not address PT, OT, and ST; - The policy did not address wound care. 1. Review of Resident #11's medical record showed: - admitted [DATE]; - Diagnoses of colostomy, ileostomy (an opening into the small intestine from the outside of the body), chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs), anxiety (persistent worry and fear about everyday situations) and schizophrenia (a long term mental disorder that affects a person's ability to think, feel, or behave clearly, sometimes including delusions or hallucinations). Review of the resident's Physician Order Sheet (POS), dated April 2024, showed no order for the colostomy, colostomy care, or resident to self-perform the colostomy care. During an interview on 04/23/24 at 4:15 P.M., the resident said staff brought him/her the supplies to change his/her colostomy. He/She cut out the wafer (skin barrier) and placed it over the stoma (opening). He/She asked staff for assistance with his/her colostomy care at times. His/Her colostomy bag was changed every three to four days. During an interview on 04/26/24 at 12:22 P.M., the Assistant Director of Nursing (ADON) said Resident #11 did not have an order because he/she cleaned it independently. The facility provided the resident with the supplies to change his/her colostomy. During an interview on 04/26/24 at 12:23 P.M., the Director of Nursing (DON) said if a resident had a colostomy, there should be a physician's order and how to care for it. During an interview on 04/26/24 at 12:24 P.M., the Administrator said if a resident had a colostomy, there should be a physician's order for it and how to care for it. 2. Review of Resident #17's medical record showed: - admitted [DATE]; - Diagnoses of cutaneous abscess of limb (wound), atherosclerotic heart disease (fat build up in and on artery walls), diastolic congestive heart failure (main pumping chamber of the heart becomes stiff and unable to pump), acute pulmonary embolism and thrombosis of the lower extremity (blood clots in the lungs and/or deep veins in the legs). Review of the resident's POS, dated 04/22/24, showed an order to change the dressing daily and as needed for soiling, saturation, or unscheduled removal. Review of the resident's April 2024 treatment administration record (TAR) showed: - Licensed Practical Nurse (LPN) D provided wound care on 04/22/24 and 04/24/24; - Wound care was not provided on 04/23/24 and 04/25/24; - ADON provided wound care on 04/26/24; - Two out five opportunities missed. During an interview on 04/26/24 at 9:23 A.M., the ADON said orders for resident's wound care were Monday, Wednesday, and Friday and as needed. During an interview on 04/26/24 at 10:02 A.M., the ADON said the most recent wound company order showed the resident's wound care dressing should be changed daily and as needed. She was not sure how the order got missed. She was the one that scanned the orders into the system and did not check the order before scanning it. 3. Review of Resident #26's medical chart showed: - admitted [DATE]; - Diagnoses of arthritis and pain in the right hand. Review of the resident's POS, dated April 2024, showed: - An order for PT, OT and ST evaluation one time only for 30 days, dated 03/22/24, and the order ended on 04/21/24. No evaluation was completed; - No order for restorative therapy. During an interview on 04/24/24 at 2:48 P.M., the resident said he/she had been teaching him/herself to eat with left hand since he/she hadn't received any therapy. During an interview on 04/26/24 at 8:40 A.M., the Restorative Nurse Aid (RNA) said restorative referrals come from therapy after they had been evaluated. During an interview on 04/26/24 at 8:47 A.M., the ADON said not everyone was evaluated by therapy and Resident #26 was likely not evaluated because of insurance. 4. Review of Resident #30's medical chart showed: - admitted [DATE]; - Diagnoses of stroke and dysphasia (difficulty swallowing). Review of the resident's POS, dated April 2024, showed: - An order for PT, OT, ST to evaluate and treat as indicated, dated 03/19/24; - No order for restorative therapy. During an interview on 04/26/24 at 8:43 A.M., the RNA said Resident #30 was not receiving restorative services and did not know if he/she had been evaluated by therapy or not. During an interview on 04/26/24 at 10:01 A.M., the Administrator said PT/OT/ST evaluate and treat order was a standing order but evaluations were not completed unless the resident needed therapy. Evaluations were not completed if residents did not have a payor source. During an interview on 04/26/24 at 12:04 P.M., the DON said the residents should be screened on admission and she would expect an order to be completed if it was on the POS. During an interview on 04/26/24 at 12:08 P.M., the Corporate Nurse said the electronic medical records program put the orders for PT/OT/ST evaluate and treat in the facility's standing orders. During an interview on 04/26/24 at 12:08 P.M., the Administrator said all residents were screened on admission by therapy assistants but no documentation was completed. During an interview on 05/01/2024 at 3:45 P.M., the Administrator said she would expect orders to be followed and reviewed on a weekly basis. It was the charge nurse who would entered the new orders, but it would be the responsibility of the ADON and/or the Minimum Data Set (MDS - a federally mandated assessment completed by the facility) Coordinator to review the orders for changes. During an interview on 05/02/24 at 9:48 A.M., the DON said she would expect orders to be reviewed and followed. The ADON would be the one that needed to review the orders. 50260

Based on interview and record review, the facility failed to ensure residents with limited range of motion (ROM) received appropriate treatment and services to increase their ROM and/or prevent a further decrease in their ROM for one resident (Resident #8) out of two sampled residents. The facility census was 34. Review of the facility's policy titled, Restorative Nursing Services, revised July 2017 showed: - Residents will receive restorative nursing care as needed to help promote optimal safety and independence; - Restorative nursing consist of nursing interventions that may or may not be accompanied by formalized rehabilitative services; - Residents may be started on a restorative nursing program upon admission and during the course of the stay; - Restorative goals and objectives are individualized and resident-centered, and are outlined in the resident's plan of care. 1. Review of Resident #8's medial record showed: - admitted [DATE]; - Diagnoses of muscle weakness (decreased strength in the muscles), abnormal posture (rigid body movements and chronic abnormal positions of the body), need for assistance with personal care (loss of, or loss of use of, all or part of the neurological, muscular or skeletal functions of the body to the extent that the person requires assistance of another person), and spinal stenosis of the cervical region (changes in the vertebrae of the neck and joints). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 04/24/24 showed: - Cognition intact; - Dependent of staff with activity of daily living (ADL's) and self care. Review of the resident's care plan, dated 04/24/24, showed: - Required assistance with ADL's due to weakness, generalized muscle weakness, left sided weakness, and need for assistance with personal care; - Wore a brace to the left upper extremity when tolerated; - Restorative care three times weekly for 90 days, dated 02/28/24, to increase left hand splint tolerance, decrease flaccidity, increase strength in the left upper extremity, demonstrate and maintain sitting up position. Review of the resident's Physician Order Sheet (POS), dated April 2024, showed an order for Restorative Nursing Services to be provided three times weekly, dated 02/28/24. Review of the resident's restorative nursing documentation, dated March 2024 through April 26, 2024, showed: - Increase left hand splint tolerance, decrease flaccidity, increase strength in the left upper extremity, and demonstrate and maintain sitting up position; - March 2024 calendar showed six missed opportunities out of 12 opportunities for restorative therapy; - April 2024 calendar showed nine missed opportunities out of 12 opportunities for restorative therapy. During an interview on 04/26/24 at 8:40 A.M., the Restorative Nurse Aide (RNA), said he/she did not get RNA tasks completed as ordered due to him/her doing the transportation for the facility. The RNA said he/she tried to do as much as he/she could. During an interview on 04/26/24 at 8:50 A.M., the Administrator said the RNA needed to let staff know when he/she was going to be out of the facility, which would allow someone else to complete the restorative tasks. 49999

Based on observation, interview and record review, the facility failed to ensure placement of the Foley catheter (a tube inserted into the bladder to drain urine) tubing and drainage bags for one resident (Resident #27) out of four sampled residents. The facility census was 34. Review of the facility's policy titled, Urinary Catheter Care, revised August 2022, showed the position of the drainage bag should be lower than the bladder at all times to prevent urine from flowing back into the urinary bladder. 1. Review of Resident #27's medial record showed: - An admitted [DATE]; - Diagnosis of urinary retention (an inability to empty the bladder of urine); - Physician Order Sheet (POS), dated April 2024, with an order to change the Foley catheter monthly, dated 02/22/24. Observations of the resident showed: - On 04/23/24 at 12:10 P.M., the resident sat in a wheelchair in the dining room and the uncovered catheter drainage bag hung on the right armrest of the wheelchair; - On 04/24/24 at 11:45 A.M., the resident sat in a wheelchair in the hallway and the uncovered catheter drainage bag hung on the right armrest of the wheelchair; - Observation on 04/25/24 at 10:28 A.M., the resident sat in a wheelchair near the nurses' station and the uncovered catheter drainage bag hung on the right armrest of the wheelchair. During an interview on 04/26/24 at 9:00 A.M., Certified Nurse Aide (CNA) B said staff usually hung the resident's catheter bag on the arm of the wheelchair. There were bars under the wheelchair and staff could hang it there. The catheter bag should be placed in a privacy bag and did not know if the facility had any at this time. During an interview on 04/26/24 at 10:21 A.M., Licensed Practical Nurse (LPN) C said the catheter should be in a privacy bag if the resident was outside of his/her room. The facility had privacy bags and staff should be using them. The catheter bag should be placed under the wheelchair and always below the resident's bladder. During an interview on 04/26/24 at 10:27 A.M. the Assistant Director of Nursing (ADON) said the catheter bag should be placed underneath the wheelchair on the crossbars on the non-movable part of the wheelchair. The catheter bag should always be placed in a privacy bag. During an interview on 04/26/24 at 12:10 P.M., the Director of Nursing (DON) said the catheter drainage bag should be positioned lower than the bladder, should be placed under the wheelchair and always in a privacy bag.

Based on observation, interview and record review, the facility failed to maintain a medication error rate of less than five percent (%). There were 35 opportunities with three errors made, resulting in an error rate of 8.57% for three residents (Residents #1, #5 and #22) out of three sampled residents. The facility's census was 34. Review of the facility's policy titled, Administering Medications, dated April 2019, showed: - Medications are administered in accordance with prescriber orders, including any required time frame; - The policy did not address insulin pen administration technique. Review of the Humalog/lispro (a rapid insulin injected just below the skin that helps lower mealtime blood sugar spikes) Kwik Pen (Insulin in a pen-type device) instructions, revised, July 2023, showed: - Pull the Kwik Pen cap straight off; - Wipe the rubber seal with an alcohol swab; - Check the liquid in the Pen which should be clear and colorless; - Place the new capped needle straight onto the Pen and twist the needle on until it is tight; - Pull off the outer needle shield. Do not throw away; - Pull off the inner needle shield and throw it away; - Prime the pen by turning the dose knob to two units; - Hold the pen with the needle pointing up; - Tap the cartridge holder gently to collect air bubbles at the top; - Push the dose knob in until it stops, and 0 is seen in the dose window, count to five slowly, insulin will be visible at the tip of the needle; - Select the dose; - Give the injection after selecting the area and cleaning the site with an alcohol swab. 1. Review of Resident #1's Physician Order Sheet (POS), dated April 2024, showed an order for Mucinex (medication to treat cough and colds) oral tablet extended release (ER) 600 milligram (mg) by mouth every morning and at bedtime for chronic obstructive pulmonary disease (COPD - a group of diseases that cause blockage of airflow and breathing-related problems), dated 4/04/24. Observation of Resident #1's medication administration on 04/25/24 at 7:30 A.M., showed Certified Medication Technician (CMT) A did not administer the resident's Mucinex ER 600 mg dose in the morning as ordered. 2. Review of Resident #5's POS, dated April 2024, showed an order for Keppra (a medication to treat seizures) 500 mg, give two tablets by mouth two times a day at 8:00 A.M., and 8:00 P.M., for seizures, dated 2/04/24. Observation of the resident's medication administration on 04/25/24 at 7:35 A.M., showed: - CMT A administered one Keppra 500 mg tablet to the resident; - CMT A failed to administer two Keppra 500 mg tablets to the resident as ordered. 3. Review of Resident #22's POS, dated April 2024, showed: - An order for lispro insulin pen 100 units per milliliter (ml) subcutaneous (an injection just below the skin) with meals per a sliding scale of blood sugar of if 151 - 200 = 3 Units, 201 - 250 = 6 Units, 251 - 300 = 9 Units, 301 - 350 = 12 Units, 351 - 400 = 14 Units, 401 - 999 = 16 Units and call the medical doctor (MD), dated 1/26/24. Observation of Resident #22 medication administration on 04/25/24 at 11:38 A.M., showed: - CMT A administered 14 units of lispro subcutaneously per order of the sliding scale for a blood sugar of 381 with the resident's lispro Kwik Pen; - CMT A failed to prime the lispro Kwik Pen per the manufacturer's instructions prior to the administration to the resident. During an interview on 04/25/24 at 7:38 A.M., CMT A said he/she thought Resident #5 should only get one tablet of Keppra 500 mg. During an interview on 4/25/24 at 11:36 A.M., CMT A said he/she was trained to prime the insulin pen needles prior to an insulin injection. During an interview on 05/03/24 at 8:23 A.M., the Assistant Director of Nursing (ADON) said she would expect staff to prime the insulin pen needle with 2 units of insulin before selecting the dosage amount and administering the insulin injection. She would expect staff to follow the physician's orders when administering medications.

Based on observation, interview, and record review, the facility failed to label and store medications in a safe and effective manner. This had the potential to affect all residents. The facility census was 34. Review of the facility's policy titled, Medication Labeling and Storage, dated February 2023, showed: - If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items; - Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. Review of the facility's policy titled, Administering Medications, dated April 2019, showed: - The expiration/beyond use date on the medication label is checked prior to administering; - When opening a multi-dose container, the date opened is recorded on the container. Review of the facility's policy titled, Insulin Administration, dated September 2014, showed: - Via syringe, check expiration date, if drawing from an opened multi-dose vial. If opening new vial, record expiration date and time on vial; - No policy was given for insulin pens. Review of the manufacturer's instructions for use for Humalog (an insulin used to lower blood sugar) In-use Pen showed throw away the Humalog Pen you are using after 28 days, even if it still has insulin left in it. Review of the manufacturer's instructions for use for lispro (an insulin used to lower blood sugar) showed do not use insulin lispro past the expiration date printed on the label or 28 days after you first use it. Review of the manufacturer's instructions for use for Victoza (medication used to improve blood sugar) showed: - Use a Victoza pen for only 30 days; - Throw away a used Victoza pen 30 days after you start using it, even if some medicine is left in the pen. Review of the manufacturer's instructions for use for Ozempic (medication used to help lower blood sugar) showed the Ozempic pen you are using should be disposed of (thrown away) after 56 days, even if it still has Ozempic left in it. Review of the manufacturer's instructions for use for Lantus (an insulin used to lower blood sugar) showed after 28 days, throw your opened Lantus pen away-even if it still has insulin in it. Observations on 04/24/2024 at 1:18 P.M., of the medication cart showed: - Three Humalog pens labeled with the resident's names but with no opened or expiration dates; - Four lispro injection pens labeled with the resident's names but with no opened or expiration dates; - One Victoza injection pen labeled with the resident's name but with no opened or expiration date; - One Ozempic injection pen labeled with the resident's name but with no opened or expiration date; - One Lantus injection pen labeled with the resident's name but with no opened or expiration date. During an interview on 04/25/2024 at 1:20 P.M., Certified Medication Technician (CMT) A said that he/she did not always date the insulin pens when opening for use. The insulin pens were good for 30 days. During an interview on 04/25/2024 at 1:22 P.M., the Assistant Director of Nursing (ADON) said that pens should be dated with either an opened date, or an expiration date when they were first opened. Some insulin pens were good for 28 days and some were for 30 days. It was the CMT's responsibility to make sure this was done. During an interview on 04/25/2024 at 2:15 P.M., the Director of Nursing (DON) and the Administrator said that medications should be dated when opened. Medications not properly labeled when opened should be disposed of. 50260

Based on observation, interview and record review, the facility failed to maintain proper infection control practices during the medication administration for one resident (Resident #5) out of four sampled residents. The facility failed to maintain proper infection control practices during incontinent care for one resident (Resident #8) out of four sampled residents. The facility failed to maintain proper infection control practices during a wound care treatment for one resident (Resident #17) out of two sampled residents. The facility also failed to maintain proper infection control practices during blood glucose monitoring when the staff did not properly disinfect the glucose monitor three residents (Resident #1, #22, and #30) out of three sampled residents. The facility census was 34. Review of the facility's policy titled, Handwashing/Hand Hygiene, revised October 2023, showed: - The facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections; - All personnel are trained a regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections; - Hand hygiene is indicated immediately before touching a resident, after touching a resident, and after touching the resident's environment; - Perform hand hygiene before applying non-sterile gloves and after removing gloves. 1. Observation on 04/25/24 at 7:38 A.M., of the medication administration for Resident #5 showed: - Certified Medication Technician (CMT) A performed hand hygiene; - CMT A placed one levetiracetam (medication to prevent seizures) 500 milligram (mg) tablet, one benztropine (medication to improve muscle control) 1 mg tablet, one clopidogrel (heart medication) 75 mg tablet, one furosemide (a fluid medication) 20 mg tablet, one gabapentin (nerve pain medication) 800 mg tablet, one lamotrigine (an anticonvulsant medication) 25 mg tablet, one carvedilol (high blood pressure medication) 6.25 mg tablet, one isosorbide dinitrate (high blood pressure medication) 30 mg tablet, one solifenacin (a bladder relaxant medication) 10 mg tablet, one raloxifene (diabetic medication) 60 mg tablet, one potassium chloride (used to treat low potassium levels) extended release (ER) 20 milliequivalent (mEq) tablet, one pantoprazolene (heartburn medication) 40 mg tablet, one nitrofurantoin (an antibiotic) 100 mg tablet, and one metformin (diabetic medication) 500 mg tablet with his/her bare hand and then placed them into the medication cup; - CMT A, without putting on gloves and performing hand hygiene, poured two tablets of magnesium oxide (used for magnesium deficiency) 400 mg into the lid of the bottle. CMT A poured one tablet from the lid into the medication cup and held the other tablet with his/her bare fingers. CMT A placed the tablet held with his/her bare fingers back into the bottle which was used for multiple residents. 2. Observation on 04/25/24 at 2:02 P.M., of incontinent care for Resident #8 showed: - Certified Nursing Aide (CNA) B and CNA E put on gloves and did not perform hand hygiene; - CNA B and CNA E removed the resident's pants and unfastened the brief; - CNA B cleaned the front peri area; - Without changing gloves, CNA B and CNA E rolled the resident to his/her left side and CNA E cleaned the resident's rectal area; - CNA B and CNA E placed a clean brief under the resident by rolling him/her from side to side wearing the same gloves; - Continuing with the soiled gloves, CNA B and CNA E fastened the clean brief, pulled the resident's pants up, repositioned the bed linens, and clipped the resident's call light to the bed linens; - CNA B and CNA E removed the gloves, did not perform hand hygiene, and exited the resident's room with the trash. During an interview on 04/26/24 at 10:25 A.M., CNA B said he/she should have removed the gloves after performing peri care and before the clean brief was placed on the resident. He/she said staff should always wash their hands before putting gloves on and before exiting the resident's room. During an interview on 04/26/24 at 10:28 A.M., the Assistant Director of Nursing (ADON) said staff should remove their gloves between dirty and clean care, use hand sanitizer or use soap/water between glove changing. The staff should wash their hands prior to entering the resident's room and before exiting the rooms. Review of the facility's policy titled, Cleaning and Disinfecting Resident Care Items, dated September 2022, showed: - Reusable items are cleaned and disinfected or sterilized between residents; - Did not address scissors used for wound care. 3. Observations on 04/26/24 at 9:23 A.M., of Resident #17's wound care treatment showed: - ADON performed hand hygiene and put on gloves; - ADON lay the wound care supplies, including a pair of scissors, on the resident's incontinent pad next to where the resident lay without a clean barrier under the supplies; - ADON changed gloves but did not perform hand hygiene; - ADON picked up the scissors off of the resident's incontinent pad and without disinfecting the scissors, cut the Hydrofera Blue Strip (a treatment used to absorb wound drainage and for wound healing); - ADON packed the resident's wound with the Hydrofera Blue Strips with a cotton swab; - ADON changed gloves but did not perform hand hygiene; - ADON picked up the scissors from the resident's resident's incontinent pad without disinfecting them, and cut another Hydrofera Blue Strip; - ADON placed the Hydrofera Blue Strip to the wound area and finished the wound care treatment. During an interview on 04/26/24 at 11:05 A.M., the ADON said the scissors do not get cleaned before or after using them for wound dressing changes because the scissors remain in Resident #17's room. The scissors did not need to be cleaned since they remained in Resident #17's room. He/She lay the dressing supplies on the resident's incontinent pad as a barrier to the bed linens. He/She would normally sanitize or wash his/her hands between glove changes. During an interview on 05/02/2024 at 11:52 P.M., the DON said she would expect hand hygiene and equipment, such as scissors, to be disinfected anytime gloves were changed, and the scissors go from clean to dirty care. She would still expect scissors to be cleaned this way even if they were only being used for the same resident each time. Review of the facility's policy titled, Obtaining a Fingerstick Glucose Level, dated October 2011, showed: - Wear clean gloves; - Clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current infection control standards of practice. Review of Cleaning and Disinfecting Procedures for Assure Prism Blood Glucose Monitoring System (a device used to read blood sugar levels by using a drop of blood collected from a finger stick), dated August 2015, showed: Cleaning: - Wear appropriate protective gear such as disposable gloves; - Open the towelette container and pull out one towelette and close the lid; - Wipe the entire surface of the meter three times horizontally and three times vertically using one towelette to clean blood and other body fluids; - Dispose of the used towelette in a trash bin; Disinfecting: - The meter should be cleaned prior to disinfection; - Pull out one new towelette and wipe the entire surface of the meter three times horizontally and three times vertically to remove blood-borne pathogens; - Dispose of the used towelette in a trash bin; - Allow exteriors to remain wet for the appropriate contact time (Super Sani-Cloth Germicidal Disposable Wipe is two minutes) and then wipe the meter using a dry cloth; - After disinfection, the user's gloves should be removed and thrown away. Wash hands before proceeding to the next patient. 4. Observation on 04/25/24 at 11:32 A.M., of the blood glucose monitoring for Resident #1 showed: - CMT A performed hand hygiene and put on gloves; - CMT A pulled glucometer supplies from the medication cart and placed on top of the cart; - CMT A picked up the glucometer strip and placed it into the glucometer, picked up a lancet, pushed the lock on the medication cart, knocked on the resident's door, and entered the resident's room; - CMT A performed the blood glucose monitoring for the resident; - CMT A, without changing gloves or performing hand hygiene, exited the resident's room and walked back to the medication cart; - CMT A opened the bottom drawer on the medication cart and removed two wipes from the Sani-Cloth Germicidal Wipes container; - CMT A wiped the glucometer in two circular motions on the front and one circular motion on the back; - CMT A placed the glucometer on the medication cart, removed the gloves and performed hand hygiene; - CMT A failed remove gloves and perform hand hygiene prior to exiting the resident's room; - CMT failed to clean the glucometer as directed in the facility's policy and he/she failed to allow the glucometer to remain wet in the sanitizing solution for two minutes. 5. Observation on 04/25/24 at 11:35 A.M., of the blood glucose monitoring for Resident #22 showed: - CMT A performed hand hygiene and put on gloves; - CMT A pulled a second glucometer from the top drawer of the medication cart and placed it on top of the cart; - CMT A picked up the glucometer strip and placed it into the glucometer, picked up a lancet, pushed the lock on the medication cart, knocked on the resident's door, and entered the resident's room; - CMT A performed the blood glucose monitoring for the resident; - CMT A, without changing gloves or performing hand hygiene, exited the resident's room and walked back to the medication cart; - CMT A opened the bottom drawer on the medication cart and removed two wipes from the Sani-Cloth Germicidal Wipes container; - CMT A wiped the glucometer in two circular motions on the front and one circular motion on the back; - CMT A placed the glucometer on the medication cart, removed the gloves and performed hand hygiene; - CMT A failed remove gloves and perform hand hygiene prior to exiting the resident's room; - CMT A failed did to clean the glucometer as directed in the facility's policy and he/she failed to allow the glucometer to remain wet in the sanitizing solution for two minutes. 6. Observation on 04/25/24 at 10:37 A.M., of the blood sugar monitoring for Resident #30 showed: - CMT A pulled glucometer supplies from the medication cart and placed on top of the cart; - CMT A performed hand hygiene and put on gloves; - CMT A pulled the medication cart from the medication room, closed the medication room door, and pushed the cart down the hall to Resident #30's room; - CMT A picked up glucometer strip and placed it into the glucometer, picked up a lancet, pushed the lock on the medication cart, knocked on the resident's door, entered the resident's room, and did not change gloves or perform hand hygiene; - CMT A performed the blood glucose monitoring for the resident; - CMT A, without changing gloves or performing hand hygiene, exited the resident's room, walked back to the medication cart, cleaned the glucometer, and removed the gloves without performing hand hygiene; - CMT A put on gloves without performing hand hygiene, opened the bottom drawer on the medication cart and removed two wipes from the Sani-Cloth Germicidal Wipes container; - CMT A wiped the glucometer in two circular motions on the front and one circular motion on the back; - CMT A placed the glucometer on the medication cart, removed the gloves and did not perform hand hygiene; - CMT A failed remove gloves and perform hand hygiene prior to exiting the resident's room; - CMT A failed did to clean the glucometer as directed in the facility's policy and he/she failed to allow the glucometer to remain wet in the sanitizing solution for two minutes. During an interview on 04/25/24 at 11:36 A.M., CMT A said he/she wiped the glucometer and it should stay wet for two minutes. 50260

Based on interview and record review, the facility failed to ensure the accuracy of the advance directive (a written statement of a person's wishes regarding medical treatment) regarding the resuscitation status (lifesaving technique that's useful in many emergencies, such as a [CONDITION(S)], in which someone's breathing or heartbeat has stopped) for five residents (#1, #5, #7, #12, and #15) out of eight sampled residents. The facility's census was 15. 1. Review of the facility's undated policy titled, Advance Directive, showed: - Purpose: The facility will respect advance directives in acceptance with state law; - Upon admission of a resident to the facility, the social service designee will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate an advance directive; - Upon admission of a resident to the facility, the social service designee will inquire of the resident, and/or his/her family members, about the existence of any written advance directive; - Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record under the advance directive tab; - In accordance with current Omnibus Budget Reconciliation Act (OBRA) definitions and guidelines governing advance directives, the facility has defined advanced directives as preferences regarding options and include, but not limited to: - Living Will- A document that specifies a resident's preferences about measures that are used to prolong life when there is a terminal prognosis; - DO Not Resuscitate (DNR, indicates that, in case of respiratory or cardiac failure, the resident, legal guardian and/or representative has directed no cardiopulmonary resuscitation or life-saving methods are to be used. 2. Record review of Resident #1's medical record, showed: - An admission face sheet with an admitted [DATE] and latest return of 1/16/21; - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] - Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] - Has a living will dated 10/12/17, stating the resident's desire of his/her dying not be prolonged by the administration of artificial life-sustaining or death-prolonging procedures as set forth in the living will; - No documentation the living will had been rescinded. 3. Record review of Resident #5's medical record, showed: - An admission face sheet with an admitted [DATE]; - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] - Code status form, signed/dated 8/20/19, for DNR; - POS, dated October 2021, showed an order dated 4/30/18, for full code (life saving measures to be performed); -Social service note, dated 10/20/21, showed documentation regarding the resident's code status as a DNR. 4. Review of #7's medical record, showed: - An admission face sheet with an admitted [DATE]; - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] - Code status form, signed/dated 6/14/21, for DNR; - POS, dated October 2021, no code status order. 5. Record review of Resident #12's medical record, showed: - An admission face sheet with an admitted [DATE]; - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] - POS shows order for full code dated 12/04/18. Further review of the resident's medical record, showed no documentation regarding the resident's updated/signed elective code status since 12/04/18. 6. Review of Resident #15's medical record, showed: -An admission face sheet with an admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Code status form, signed/dated 5/21/19, for DNR; -POS, dated October 2021, no code status order. Further review of the resident's medical record, showed no documentation regarding an updated/signed code status form since 5/21/19. During an interview on 10/22/21 at 12:18 P.M., the Administrator said he expected the QA nurse to complete a chart audit to ensure each resident's code status is reviewed and updated at least annually. The resident's signed code status form should match the code status order on the POS.

Based on interview and record review, the facility failed to complete and notify in the proper time frame of at least two calendar days before services were to end for the Notice of Medicare Non-Coverage (NOMNC) form for one resident (Resident #116) out of two sampled residents. The facility census was 15. Record review of the instruction for the Notice of Medicare Non-Coverage form, showed: - The NOMNC must be delivered at least two calendar days before Medicare covered services end or the second to last day of service if care is not being provided daily. Record review of Resident #116's medical record showed: - Skilled Medicare services started on 2/5/21; - Skilled Medicare services ended on 2/23/21; - The resident signed the NOMNC form on 2/23/21; - The resident was not given two day notice as required by Medicare. During an interview on 10/22/21 at 9:37 A.M., the Social Services/Activity Director (SS/AD) said, residents should be notified at least two days before coverage is to end. The SS/AD said he/she always tries to be sure and have them notified and to sign the NOMNC form at least two days before end of coverage. He/she is not sure why it was not done for Resident #116. During an interview on 10/22/21 at 12:20 P.M., the Administrator said he would expect residents to receive notification of end of coverage at least two days before their Medicare coverage would end.

Based on interview and record review, the facility failed to ensure residents had complete, accurate, and individualized care plans to address the resident's elected code status with interventions and goals. This affected four residents (Resident #2, #12, #13, and #15) out of eight sampled residents. The facility census was 15. 1. Record review of the facility's undated policy titled, Care Plan Comprehensive, showed: - An individualized comprehensive care plan that includes measurable goals and time frames will be developed to meet the resident's highest practicable physical, mental, and psychosocial well-being; - A well-developed care plan will be oriented to: - Preventing avoidable declines in functioning or functional events or otherwise clarifying why another goal takes precedence; - Managing risk factors to the extent possible or indicating the limits of such interventions; - Addressing ways to try to preserve and build upon resident strengths; - Applying current standards of practice in the care planning process; - Evaluating treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] - Respecting the resident's right to decline treatment; - Offering alternative treatments, as applicable; - Using an appropriate interdisciplinary approach to care plan development to improve the resident's functional abilities; - Involving resident, resident's family and other resident representatives as appropriate; - Assessing and planning for care to meet the resident's medical, nursing, mental and psychosocial needs; - Involving the direct care staff with the care planning process relating to the resident's expected outcomes; - Addressing additional care planning areas that are relevant to meeting the resident's needs in a long-term care setting; -The interdisciplinary care plan team is responsible for the periodic review and updating of care plan: - When a significant change in the resident's condition has occurred; - At least quarterly; - When changes occur that impact the resident's care (i.e., change in diet, discontinuation of therapy and changes in care areas that do not require a significant change assessment. 2. Record review of Resident #2's medical record, showed: - An admission face sheet with an admitted [DATE]; - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] - A Code status form which showed the resident to be a Do Not Resuscitate (DNR) ( an order that instructs health care providers not to do cardiopulmonary resuscitation (CPR) lifesaving technique used if a patient's breathing stops or if the patient's heart stops beating), updated on [DATE]. Record review of Resident #2 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] - an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the resident's care plan, last updated on [DATE], showed no updated elected code status with interventions and goals addressed on the care plan. 3. Record review of Resident #12's medical record, showed: - An admission face sheet with an admitted [DATE]; - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] - an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's care plan, last revised [DATE], and in use during the survey, showed no updated elected code status with interventions and goals addressed on the care plan. 4. Review of Resident #13's medical record, showed: - An admission face sheet with an admitted [DATE]; - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] - an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's care plan, last revised [DATE], and in use during the survey, showed no updated elected code status with interventions and goals addressed on the care plan. 5. Review of Resident #15's medical record, showed: - An admission face sheet with an admitted [DATE]; - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] - Code status form, signed/dated [DATE], for DNR; - POS, dated [DATE], without no code status. Further review of the resident's medical record, showed no documentation regarding an updated/signed code status form since [DATE]. Review of the resident's care plan, dated [DATE] and [DATE], showed no updated elected code status with interventions and goals addressed on the care plan. During an interview on [DATE] at 12:18 P.M., the Administrator said the MDS coordinator is responsible to ensure the resident's comprehensive care plans are completed and updated to reflect the care needs of each resident. The resident's code status should be addressed on the care plan with interventions/goals to reflect the resident's current code status.

Based on interview and record review, the facility failed to ensure the resident and/or the resident's family or representative were involved in the revision or updating of the resident's care plan. This affected four residents, (Resident #1, #2, #12, and #13) out of a sample of eight. The facility census was 15. Record review of the facility's undated policy titled, Care Plan Comprehensive, showed: - An individualized comprehensive care plan that includes measurable goals and time frames will be developed to meet the resident's highest practicable physical, mental, and psychosocial well-being; - A well-developed care plan will be oriented to: - Preventing avoidable declines in functioning or functional events or otherwise clarifying why another goal takes precedence; - Managing risk factors to the extent possible or indicating the limits of such interventions; - Addressing ways to try to preserve and build upon resident strengths; - Applying current standards of practice in the care planning process; - Evaluating treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] - Respecting the resident's right to decline treatment; - Offering alternative treatments, as applicable; - Using an appropriate interdisciplinary approach to care plan development to improve the resident's functional abilities; - Involving resident, resident's family and other resident representatives as appropriate; - Assessing and planning for care to meet the resident's medical, nursing, mental and psychosocial needs; - Involving the direct care staff with the care planning process relating to the resident's expected outcomes; - Addressing additional care planning areas that are relevant to meeting the resident's needs in a long-term care setting; - The interdisciplinary care plan team is responsible for the periodic review and updating of care plan: - When a significant change in the resident's condition has occurred; - At least quarterly; - When changes occur that impact the resident's care (i.e., change in diet, discontinuation of therapy and changes in care areas that do not require a significant change assessment. 1. During an interview on 10/19/21 at 2:30 P.M., Resident #1 said he/she did not know if he/she had ever been to a meeting where they discussed his/her care. Record review of the resident's care plan showed: - Last reviewed on 7/21/21; - Signatures for the MDS coordinator and the Social Services/Activity Director (SS/AD); - No signatures or notation of the resident or the resident's representative present. 2. Record review of Resident #2's care plan, showed: - Last reviewed on 10/6/21; - Signature for the MDS coordinator; - No signatures or notation of the resident involved or present. 3. Record review of Resident #12's care plan, showed: - Last reviewed on 8/1/21; - Signature for the MDS coordinator; - No signatures or notation of the resident or the resident's family involved or present. 4. Record review of Resident #13's care plan, showed: - Last reviewed on 10/5/21; - Signatures for the MDS coordinator and the SS/AD; - No signatures or notation of the resident or the resident's family involved or present. During an interview on 10/22/21 at 12:20 P.M., the MDS coordinator/Administrator said he knew the residents and/or their families should be involved in the care planning process, but he had not gotten their involvement started back up again since COVID. The administrator said he expected the resident and/or family member to be involved with the care plan process and care plan meeting. The care plan meeting with staff, resident and family signatures should be documented on each resident's care plan.

Based on observation, interview and record review, the facility failed to safely transfer residents in order to prevent accidents for two (Residents #1 and #2) of four sampled residents which resulted in a serious injury for Resident #1. The facility census was 34. 1. Record review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/13/15, showed: - Resident required extensive assistance of 2 or more staff for transfers; - Ambulated with either a walker or wheelchair; - [DIAGNOSES REDACTED]. Record review of the care plan dated 7/6/15, identified resident at risk for falls and instructed staff to use two staff assist with toileting as needed. Review of the Certified Nurse Aide (CNA) care card updated 7/14/15, instructed staff to transfer Resident #1 with one to two staff due to fall risk and to use gait belts on all residents. Review of the resident's Lift Mobility Status Form, dated 7/6/15, showed the resident could not bear weight on at least one leg. The Life Mobility Status Form had not been completed and did not designate the type of lift or sling needed for Resident #1. Review of nurses' notes, dated through the month of July, 2015, showed the resident required assistance of two staff with gait belt for transfer. Review of nurses' notes, dated 7/18/15 at 2:11 P.M., showed Licensed Practical Nurse (LPN) A documented the resident complained of left shoulder and left leg above the knee pain. At 2:21 P.M., LPN A documented Certified Nurse Aide (CNA) B had transferred the resident to the bedside commode and the resident lost the ability to stand. The CNA guided the resident over onto the bed. The resident could not raise his/her left arm or leg and was shaking more than normal. The physician was contacted and gave orders to send the resident to the emergency room for evaluation. Review of Resident #1's hospital history and physical examination [REDACTED]. The resident was admitted with a left hip fracture and awaiting left hip reduction and surgical procedure. During an interview on 7/29/15 at 1:58 P.M., LPN A said on 7/18/2015 at 2:11 P.M. the resident's spouse reported that Resident #1 fell and was complaining of a lot of pain. The resident complained of pain in the left shoulder and in the left leg above the knee after CNA B tried to toilet the resident. LPN A said she questioned CNA B about the incident. CNA B said he/she was helping the resident to the commode, the resident's knee gave out and they both fell on the bed. LPN A said the resident had a dislocated shoulder and hip fracture. During an interview on 7/29/15 at 9:10 A.M., Registered Nurse (RN) D said Resident #1 could stand with assist and a gait belt, but two staff was preferred. During an interview on 7/29/15 at 8:35 A.M. and 11:15 A.M., the Administrator said CNA B transferred Resident #1 to the commode and the resident's knees buckled. The CNA tried to swing the resident over to the bed and lost their balance. The resident didn't complain of pain to the CNA and the CNA didn't report the fall to the nurse. Thirty minutes later, the resident's spouse reported to the nurse the resident was in pain. The CNA was borrowed from a sister facility and has since been terminated from both facilities. The CNA did not use a gait belt to transfer the resident. During an interview on 7/29/15 at 11:35 A.M., the Director of Nurses (DON) said CNA B did not use a gait belt to transfer Resident #1. The DON said she is new to this position and started after the incident occurred. On 7/23/15 she started inservices with staff regarding transfers, care cards and gait belts but had not completed the inservices with all staff. The DON said they are still in the process of assessing and auditing all of the resident's charts for transfer needs. During an interview on 8/6/15 at 9:14 A.M., CNA B said he/she had worked at this facility six or seven times. On 7/18/15 the CNA answered Resident #1's call light and the resident needed to use the commode. The CNA had the resident put his/her arms around the CNA's neck and attempted the transfer. She did not use a gait belt. The resident's legs buckled and they fell on to the bed. CNA B put the resident into the bed and changed his/her brief. A few minutes later, the resident's spouse said the resident's leg was hurting. CNA B reported to the nurse what the spouse had said. CNA B said he/she found out the next day the resident's shoulder was dislocated. On 7/19/15 the former DON explained that any fall must be reported immediately. CNA B worked both 7/19/15 and 7/20/15 at the facility and did not receive a care card. He/she did ask a staff member to tell her who required what to transfer. 2. Record review of Resident #2's admission MDS dated [DATE], showed: - Resident required extensive assistance of 2 or more staff for transfers; - Wheelchair for locomotion; - No ambulating; - [DIAGNOSES REDACTED]. Record review of the facility's Lift Mobility Status Form dated 6/12/15, showed: - Resident as non-ambulatory; - Therapy recommended resident be transferred by two staff members with gait belt until further notice. Record review of the resident's care card updated on 7/23/15, showed: - Two person transfer. Record review of the resident's care plan dated 6/15/15, showed: - Transfer assistance of two staff and use of gaitbelt. Observation on 7/29/15 at 10:00 A.M., showed: - The resident sat in the wheelchair with the wheelchair facing towards the shower chair in the shower room; - CNA E applied the gaitbelt around the residents waist; - CNA E place one hand on each side of the resident and lifted the resident using the gait belt; - CNA E instructed NA F to pull the residents pants down before placing the resident on the shower chair; - CNA E transferred the resident over to the shower chair. Observation on 7/29/15 at 10:25 A.M., showed: - CNA E placed the gait belt on the resident's waist; - CNA E lifted the resident using the gait belt with one hand on each side of the resident; - The resident held onto the shower chair arms as NA F attempted to remove the residents hands. CNA E continued to move the resident around to place him/her in the wheelchair that sat opposite of the shower chair. CNA E placed his/her left foot behind the wheelchair and the resident sat sideways in the wheelchair on the right hip. During an interview on 7/29/15 at 10:30 A.M., CNA E said the resident is a two person transfer with the use of a gait belt. He/she said a two person gait belt transfer is meant to be with two staff with their hands fully engaged on the belt. CNA E said that he/she can easily transfer this resident most of the time without any assistance and that he/she was not sure if the NA was able to assist so he/she allowed NA F to only guide the resident during the transfer. During an interview on 7/29/15 at 1:00 P.M., the DON said NA F had received the required 16 hours of training and is able to assist with transfers. She said she would expect if the plan of care for a resident is to be a two person transfer that two staff complete the transfer with each staff fully assisting with the use of the gaitbelt. During an interview on 7/29/15 at 3:35 P.M., LPN A said a two person transfer with a gait belt should be done with two staff members, one on each side of the resident holding on to the gait belt during a transfer. Review of the facility transfer policy, dated 2006, showed a transfer belt listed as equipment needed. Under the procedure to follow during a transfer, staff were instructed to apply the transfer belt while the resident is in a sitting position. Staff are further instructed to not allow a resident to put arms around the neck and to obtain assistance of another individual if necessary for a safe transfer. Complaint #MO 7

Based on observation, interview and record review the facility failed to investigate, control and prevent the spread of scabies for seven residents (Resident #1, #2, #3, #4, #5, #6 and #7) that were identified with on-going rashes. The facility census was 44. 1. Observation on 9/5/13 at 9:00 A.M., showed Resident #1 had a red rash covering his/her abdomen, legs and back. Staff posted a sign indicating isolation precautions had been implemented for the resident. Record review showed Resident #1, who entered the facility on 7/2/12, developed a rash on his/her body on 6/1/13. Record review of a treatment administration record (TAR), dated July 2013, showed on 7/13/13 the physician ordered staff to administer [MEDICATION NAME] lotion (treatment for [REDACTED]. Review of a physician's progress note, dated 8/6/13, showed the resident had a rash on the abdominal wall, arms and lower extremities. A second opinion showed possible scabies with improvement noted following the administration of [MEDICATION NAME]. Review of the medication administration record (MAR), dated August 2013, showed on 8/27/13 the physician ordered staff to administer Ivermectin (oral medication for treatment of [REDACTED]. Review of the MAR, dated September 2013, showed on 9/4/13 the physician ordered staff to administer Ivermectin 3 mg for three days. During an interview on 9/5/13 at 9:00 A.M., Certified Nurse Aide (CNA ) B said the resident had the rash for about two months. 2. Observation on 9/5/13 at 9:25 A.M. showed Resident #2 had a red rash and scratch marks covering his/her abdomen, legs and back. Record review of skin assessments, dated 7/3/13, 7/10/13 and 9/4/13 showed staff identified the resident had a rash. Review of the MAR, dated September 2013, showed on 9/1/13 the physician ordered staff to administer [MEDICATION NAME]. During an interview on 9/5/13 at 9:30 A.M., CNA B said the resident had the rash for at least one month. During an interview on 9/5/13 at 9:30 A.M., Resident #2 said the rash itched. 3. Observation on 9/5/13 at 9:35 A.M., showed Resident #3 had a red rash and scratch marks covering his/her abdomen, back and buttocks. Resident #3 scratched his/her buttocks. Record review of the care plan, dated 5/14/13, showed the resident had a rash and had been placed on isolation precautions. Review of a skin assessment, dated 5/26/13, showed the resident had a rash. Review of the MAR, dated August 2013, showed on 8/30/13 the physician ordered staff to administer Ivermectin 3 mg for three days. During an interview on 9/5/13 at 9:40 A.M., CNA B said the resident had the rash for about one month. 4. Observation on 9/5/13 at 10:00 A.M., showed Resident #4 had a red rash covering his/her legs, arms, back, buttocks and chest. Record review the TAR, dated April 2013, showed on 4/1/13 the physician ordered the administration of [MEDICATION NAME]. Review of a dermatologist report, dated 4/17/13, showed the resident had a punch biopsy (a procedure used to diagnose skin disorders) on 4/15/13 due to a rash. The physician diagnosed the resident with dermatitis (inflammation of the skin) possibly due to a response to medication, arthropod bite (invertebrate insect) or other [MEDICATION NAME] (allergic) stimuli. Review of a MAR, dated June 2013, showed the physician ordered the administration of Ivermectin 3 mg, 7 tablets for one day. Review of the MAR, dated August 2013, showed the physician ordered the administration of Ivermectin 3 mg, 5 tablets for three days During an interview on 9/5/13 at 10:00 A.M., Resident #4 said the rash itched a lot. During an interview on 9/10/13 at 11:00 A.M., the facility's Registered Nurse (RN) Consultant said the resident received [MEDICATION NAME] for scabies while in the hospital on [DATE] then received Ivermectin upon readmission to the facility. 5. Observation on 9/5/13 at 1:20 P.M., showed a red rash covered his/her back and abdomen. The resident scratched his/her chest. Record review of a physician's progress note, dated 5/13/13, showed the resident had a rash and itching of the lower extremities. Review of dermatology Nurse Practitioner's (NP) note, dated 6/3/13, showed the resident had a rash. The NP ordered the administration of [MEDICATION NAME]. Review of a NP's note, dated 6/14/13, showed the resident continued to have a rash. Review of a dermatologist report, dated 6/19/13, showed the resident had a punch biopsy on 6/17/13 with no scabies noted. Review of the TAR, dated September 2013, showed the physician ordered the administration of [MEDICATION NAME] on 9/1/13. During an interview on 9/5/13 at 1:20 P.M., Licensed Practical Nurse (LPN) A said the resident had a rash for approximately two months. The physician ordered the administration of [MEDICATION NAME] but the treatment was not effective. 6. Observation on 9/5/13 at 1:35 P.M. showed a red rash covered Resident #6's back, abdomen and webs of finger. The resident scratched him/herself under the covers. Review of the MAR, dated May 2013, showed the physician ordered the administration of Ivermectin 3 mg, 5 tablets for one day on 5/1/13. On 5/16/13, the physician ordered the administration of [MEDICATION NAME]. Review of a nurse's note, dated 7/26/13, showed the resident had a blistery red rash on the front of the neck. Staff noted the resident scratched the rash. Review of the MAR, dated September 2013, showed the physician ordered the administration of Ivermectin for 3 days on 9/1/13. During an interview on 9/5/13 at 1:40 P.M., LPN A said the resident was worse than he/she was the previous month and the rash had spread over the resident's entire body. 7. Record review of th facility's contact precaution isolation policy showed it directed staff to wear gloves and a disposable gown upon entering the rooms of residents identified or suspected to be infected with microorganisms, such as scabies, that could be transmitted with direct contact with the resident or indirect contact with environmental surfaces. The policy also directed staff to wash hands before leaving the room. Observation on 9/5/13 at 12:00 P.M. showed Resident #7 in a room with a isolation sign posted outside the door indicating isolation precaution had been implemented for the resident. Staff placed disposable gowns and gloves on the clean linen cart to be worn before entering the room. Staff placed red bags (used for contaminated clothing and trash) in the floor along side the wall and by the unoccupied bed in the resident's room. Registered Nurse Assessment Coordinator (RNAC) sat on the bed without wearing gloves or a gown. The RNAC exited the resident's room without washing her hands and proceeded to common areas in the facility. Observation on 9/5/13 at 1:20 P.M., showed Resident #7 had a red rash covering the back, abdomen, chest and under the arms. Record review of nurse's notes showed: - On 7/22/13, the resident had pink areas under the breasts and abdominal fold. - On 8/4/13, the resident's family member requested the physician be contacted for [MEDICATION NAME] due to itching. - On 8/9/13, the resident's family was upset about a faint rash on the resident's breast. Review of a readmission assessment, dated 8/29/13, showed staff identified the resident had tiny pink spots on the abdominal area and left shoulder/upper back. Review of a nurses' note, dated 9/4/13 showed the resident had a red, blotchy rash on the left side of the back and under the left arm. The physician ordered a skin scraping (for scabies), contact isolation and [MEDICATION NAME] if a positive scraping was obtained. During interviews on 9/5/13 at 12:00 A.M. and 1:20 P.M., Resident #7's family member said Resident #7 had a rash which covered his/her body for over a month. The rash started on the resident's back and spread around to the front causing the resident to scratch self until bleeding. The family member reported the rash to nursing staff but the resident had yet to receive treatment. Staff placed the resident on isolation on 9/4/13 and placed the red bags in the room. Staff had not deep cleaned the resident's room, bagged clothing or initiated treatment. During an interview on 9/5/13 at 12:15 P.M., LPN A said the resident had a slight rash on the back and arms prior to admission to the hospital (on 8/22/13). Two to three days earlier, the resident's family member again brought the rash to staff's attention During an interview on 9/5/13 at 12:45 P.M., the RNAC said she did not know what sanitation measures should have been put into place to control the spread of scabies. The RNAC said staff should wear gloves and gowns in rooms and she should not have sat on the bed in Resident #7's room as she could have contributed to the spread of scabies. Review of the TAR, dated September 2013, showed staff administered [MEDICATION NAME] on 9/6/13. During an interview on 9/11/13 at 9:30 A.M., the Physician said no one contacted him to report the resident's rash did not improve. 8. During an interview on 9/5/13 at 9:52 A.M., Housekeeping/Laundry Staff C said he/she was unaware of the specific policy related to cleaning of rooms for residents with scabies but that they cleaned rooms as usual. Staff placed laundry in red bags and washed separately. During an interview on 9/5/13 at 9:53 A.M., Housekeeping Staff D said staff cleaned rooms as usual for residents with scabies but wore a gown and gloves. During interviews on 9/5/13 at 9:54 A.M. and 1:55 P.M., the Housekeeping/Laundry Supervisor said: - She was aware of only one resident (Resident #1) who had been diagnosed with [REDACTED]. - When notified that resident's had scabies, staff continued to clean rooms on the normal weekly schedule with monthly deep cleaning but wore gowns and gloves. Rooms were not deep cleaned, privacy curtains were not washed and common areas were not cleaned. Staff did not bag additional clothing. - She was not aware of the facility's policy related to scabies until several days previously. - She knew staff should not throw red bags on the floor or hang them on door knobs but no one would listen. -Staff did not communicated well. During an interview on 9/5/13 at 12:15 P.M., LPN A said if a resident had a rash, the physician ordered a skin scraping. If positive in 48 to 72 hours, staff initiated treatment. LPN A said staff placed soiled laundry and trash in red bags. He/she was unaware of any special cleaning for isolation rooms or bagging of extra clothing. During an interview on 9/5/13 at 12:45 P.M. and 3:10 P.M., the Director of Nursing Services (DNS) said she did not know what sanitation measures should have been put into place to control the spread of scabies but that the Administrator and Medical Director had discussed the issue. The DNS said she did not implement a monitoring system for the outbreak of rashes. During interviews on 9/5/13 at 3:15 P.M. and 9/6/13 at 8:39 A.M. and 1:18 P.M. the Administrator said: -The DNS made rounds with the physician and should have informed him of skin issues. -The DNS and RNAC did not track or monitor rashes and did not present trends during the infection control meetings. -She had spoken to the physician on 9/3/13 and had plans to treat everyone and clean the building. -The physician had treated residents for scabies but they continued to have outbreaks. -Staff did not report the treatment/[DIAGNOSES REDACTED]. During an interview on 9/10/13 at 9:00 A.M., the RN Consultant and the Administrator said: -The DNS did not trend, track or monitor the outbreak/spread of rashes as per policy. -Staff did not deep clean or wash down the facility following the first identified/treated case of scabies nor did they handle clothing as directed by the facility's policy. -Staff did not notify families or the health department of the scabies infestation. -The facility's system was broken and communication problems were identified. -Since 9/5/13, the facility identified 11 residents and six staff with scabies. -Without cleaning and isolating residents, the facility would not be able to get rid of scabies. During an interview on 9/11/13 at 9:30 A.M., the Physician said when scabies was suspected he ordered treatment. He expected staff to follow the policy regarding treatment for [REDACTED]. Record review of the facility's policy to treat residents with scabies and prevent the spread of scabies showed: - Negative skin scrapings do not exclude a [DIAGNOSES REDACTED]. - Infected residents should remain on contact isolation precautions for 24 hours after treatment. - Staff should notify family and friends who have been in close contact with the infected resident. - Roommates of infected residents should be examined and treaded accordingly - Those coming into contact with infected residents or potentially contaminated bedding or clothing should wear a gown and gloves. - While treating the resident, remove four sets of clothing from the room, bag and send to laundry to be cleaned. Place all remaining clothing in a bag and seal for 14 days. - During a scabies outbreak, the infection preventionist or committee will coordinate interdepartmental planning to facilitate rapid and effective treatment. - Staff should clean lobbies, lounges, shower rooms and common areas before bathing and treatment times. - Staff should vacuum cloth furniture and wrap in plastic for 14 days. - Staff should initiate cleaning protocol on days 1, 7 and 8 which included cleaning privacy curtains, linens, mattresses, pillows, furniture, and rooms. - Staff should initiate cleaning on days 2 through 6 which include cleaning linens and floors. Complaint #MO