Every finding on record at S.P.J.S.T. Rest Home No 2

Based on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 4 residents (Resident #31) reviewed for incontinent care.The facility failed to ensure CNA E properly cleaned Resident #31 during incontinent care when CNA E did not separate Resident #31's labia on 12/03/2025.This failure could have placed residents at risk for pain, infection, injury, and hospitalization. Findings included:Record review of Resident #31's face sheet dated 12/04/25 revealed an [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included: hypertension (when the blood pushing against the artery walls is constantly too high), dementia (decline in mental ability severe enough to interfere with daily life), and senile degeneration of the brain (breakdown of brain cells causing a serious decline in memory, thinking, and ability to do daily tasks).Record review of Resident #31's annual assessment MDS dated [DATE] revealed a BIMS of 03 out of 15, which indicated severely impaired cognition. It also showed Resident #31 was dependent on staff for bed mobility. Further review revealed the resident was incontinent of bowel and bladder.Record review of Resident #31's care plan dated and edited 08/01/25 read in part, . resident experiences bladder and bowel incontinence. Approach: Provide incontinence care after each incontinent episode. Apply skin barrier cream to peri area to prevent feces or urine from causing skin breakdown.During an observation on 12/03/25 between 10:16 a.m. and 10:35 a.m., incontinent care provided for Resident #31 by CNA E revealed CNA E wiped Resident #31's left peri area once, and there was bowel movement. CNA E did not separate her labia, and she turned the resident to the right and wiped the buttocks and rectum. She pulled out the soiled incontinent brief and applied a clean incontinent brief and was about to fasten the brief when the surveyor intervened. Then CNA E separated Resident #31's labia and cleaned the labia four times, and there were bowel movements; on the fifth wipe, the wipe was clean.During an interview on 12/03/25 at 10:40 a.m., CNA E said she should have separated Resident #31's labia and cleaned until there was no bowel movement. She said if she did not clean Resident #31's labia properly, the resident could have gotten an infection, rashes, or skin breakdown. CNA E said she should have cleaned the peri area first before she turned the resident to her side and cleaned the buttocks area.During an interview on 12/03/25 at 10:42 a.m., LVN B said CNA E should have separated Resident #31's labia and cleaned until there was no bowel movement to prevent Resident #31 from getting an infection (UTI) or skin breakdown.During an interview on 12/05/25 at 4:09 p.m., the MDS said CNA E should have separated Resident #31's labia area and cleaned one side with one wipe, the other side with another wipe, and the middle, and also assessed the skin area. She said if CNA E did not clean the labia area properly, the resident could have gotten an infection.During an interview on 12/05/25 at 4:26 p.m., the DON said CNA E should have separated Resident #31's labia and cleaned with one wipe once and thrown it away, then another wipe for the other side and used another wipe for in the middle area. The DON said Resident #31's labia should have been separated and the area cleaned appropriately, and if it was not, the resident could have gotten an infection.During an interview on 12/05/25 at 4:33 p.m., the Administrator said CNA E should have separated Resident #31's labia during incontinent care to make sure the area was clean to prevent infection.Record review of the facility policy on perineal care dated 2001 MED-PASS, Inc. read in part, .Purpose: the purposes of this procedure were to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. For a female resident. #8b1. Separate labia and wash area downward from front to back. Rinse perineum thoroughly.

Based on observation, interview, and record review, the facility failed to ensure residents had a right to personal privacy for 1 of 4 residents (Resident #6) reviewed for privacy. The facility failed to ensure LVN F closed Resident #6's privacy curtain and room door while providing G-tube medication and feeding for the resident. This failure could have placed residents at risk for loss of self-esteem, self-worth, and dignity. Findings included: Record review of Resident #6's face sheet dated 12/04/25 revealed a [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted on [DATE]. He had a diagnosis included moderate protein-calorie malnutrition (person not getting enough essential nutrients for the body to work well), malignant neoplasm of the hypopharynx (cancer that grows in the lower part of the throat), and gastrostomy tube (a tube inserted through the abdominal wall used for delivering liquid food and medication). Record review of Resident #6's annual assessment MDS dated [DATE] revealed a BIMS of 03 out of 15, which indicated severely impaired cognition. It also showed Resident #6 was dependent on staff for feeding. Further review revealed the resident had a G-tube for feeding. Record review of Resident #6's care plan dated 10/29/23 showed the resident was receiving G-tube feeding. Intervention: Check placement and patency of feeding tube before each feeding or medication administration. Check gastric residuals as ordered by MD.Assess for /anxiety/depression, aspirations, self - extubation, fever, pneumonia, SOB, displacement into lungs, abdominal distension/pain. During an observation on 12/03/25 at 9:12 a.m., it was observed that LVN F did not close the privacy curtain or Resident #6's room door while she administered medication and feeding through the resident's G-tube, and his abdominal area was exposed. Staff and other people walked past Resident #6's door and were able to see his exposed abdominal area. CNA E passed by the resident's door and called out to the surveyor, saying she was waiting for the surveyor. During an interview on 12/03/25 at 10:00 a.m., Resident #6 said he would have preferred the privacy curtain to be pulled during medication and feeding to prevent people walking past his room from seeing him, because he could see the people passing and they could see him too. During an interview on 12/03/25 at 10:06 a.m., CNA E said she saw Resident #6's exposed abdomen when she walked past his room twice, and that was when she told the surveyor she was waiting for her. She said LVN F was supposed to close the door and the privacy curtain to prevent anybody from seeing Resident #6's exposed abdomen because it was a dignity issue and Resident #6 could have felt bad During an interview on 12/03/25 at 1:15 p.m., LVN F said she did not close Resident #6's room door or pull the privacy curtain. She said Resident #6's abdomen was exposed and anybody who walked past the resident's room door could have seen the resident. LVN F said it was a dignity issue, and the resident would not have felt good when other residents saw his exposed body. She said she should have closed the door or at least pulled the privacy curtain. During an interview on 12/05/25 at 3:55 p.m., the MDS said LVN F should have closed the door and pulled the privacy curtain to prevent Resident #6 from being exposed. She said it was a dignity issue because the staff, other residents, and visitors could have seen Resident #6 exposed, and Resident #6 would have been upset. During an interview on 12/05/25 at 4:10 p.m., the DON said LVN F should have pulled the privacy curtain and closed the door before she exposed Resident #6's G-tube site for medication administration and feeding. She said by pulling the privacy curtain and closing the door, LVN F would have provided privacy for the resident. She said it was a dignity issue because the door and the privacy curtain were left open and anybody who walked past the resident's room door would have seen the exposed abdomen, and Resident #6 would not have felt good about being exposed. During an interview on 12/05/25 at 4:35 p.m., the Administrator said LVN F was supposed to close the privacy curtain and Resident #6's room door to provide privacy for the resident during medication and feeding through a G-tube. She said the resident would have been upset because he was exposed, and it was a dignity issue. Record review of the facility policy on resident right dated 2001 MED - PASS, Inc read in part . employees shall treat all residents with kindness, respect and dignity. policy interpretation.guarantee certain basic rights to all residents of this facility. #1t. privacy and confidentiality.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the kitchen in that: 1. The facility failed to ensure unlabeled foods were not stored in the refrigerator. 2. The facility failed to ensure unsealed foods were not stored in the dry good storage. This failure had the potential to place residents at risk of serious complications from foodborne illness as a result of their compromised health status. Findings include: Interviews and observation s on [DATE] at 8:15 AM with the [NAME] revealed while in the dry food storage there was a bag cereal that was opened which the [NAME] identified as corn flakes. There was also a bag of potato chips unsealed. Observation in the refrigerator was made of a bag of frozen meat that the cook identified as breaded pork chops were unlabeled/dated. She said the date was supposed to be on there. Also observed were bags of frozen steak fries that were not labeled/dated. There was another unlabeled bag of frozen meat that the Dietary Manager identified as catfish nuggets. Interview on [DATE] at 9:27 AM with the [NAME] revealed she had worked at the facility for 2.5 months as a Cook. She said the policy or procedure for storing food was it needed to be labeled and dated. She said the reason for labeling the food was to make sure it was still good /not expired. She said the older food was used first. She said she did not know why the food was left opened and undated. She said the last time she was in-serviced for food storage was when working at the hospital where she came from. She said the supervisor/Dietary Manager was responsible for ensuring foods were labeled and closed and was responsible for oversight to ensure staff followed protocol. She said the risk to the residents when policy/protocol was not followed was the residents may get sick. Interview on [DATE] at 9:35 AM with the Dietary Manager revealed she had worked at the facility for 4 years that upcoming March. She said the policy or procedure for storing food was to label and date them and make sure it was closed. If the food was in its own box, the box was labeled. If the food was outside its box, then the food was individually labeled. She said the date on the food was the date it was received and use-by date. She did not know what happened and why the food was no labeled or closed properly. She said the foods were not labeled because the staff might have been distracted and didn't know why it was not done. She said the last time she was trained on food storage was around July of that year. She said she was responsible for ensuring policy/protocol was followed. She said the worst thing that can happen to the residents if staff did not follow policy/protocol was residents could get sick. Record review of Labeling and Dating Foods (Date Marking) policy dated 2020 read in part . 2. Date marking for refrigerated storage food items- Unopened cases of refrigerated food items will be dated with the date the item was received into the facility and will be stored using the first in -first out method of rotation. Once a case is opened, the individual, refrigerated food items are dated with the date the item was received into the facility and placed in/on the proper storage location utilizing the first in -first out method of rotation . Record review of the Food Receiving and Storage policy dated [DATE] read in part . 7. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). Other opened containers must be dated and sealed or covered during storage . Record review of U.S. Food and Drug Administration Food Code dated 2022 reflected in part . ,d+[DATE].11 (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination . A record review of the [DATE] version of the TFER reflected the following: (b) The department adopts by reference the U.S. Food and Drug Administration (FDA) Food Code 2017 (Food Code) and the Supplement to the 2017 Food Code. A record review of the FDA food code and the code that is relevant to the failure. https://www.fda.gov/media/110822/download

Based on observation, interview, and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice, physicians orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 42 (Resident #34) residents reviewed for quality of care The facility failed to ensure Resident #34's oxygen tubing was labeled and dated. This failure places the resident at an increased risk of infection leading to a decline in health. The findings included: Record review of Resident #34's face sheet dated 07/02/2024 reflected a [AGE] year-old female with admitted [DATE] and re-admitted [DATE]. Pertinent diagnoses included Pneumonia, unspecified organism, Allergic rhinitis (also called hay fever, is an allergic reaction that causes sneezing, congestion, itchy nose and watery eyes), unspecified, Cough, unspecified, and acute respiratory disease. Record review of Resident #34's MDS assessment , dated 08/13/2024 reflected Resident #34 had a BIMS score of 8 (severe cognitive impairment) and indicated she used Oxygen. Record review of Resident #34's Care Plan last updated 07/02/2024 read in part . Administer oxygen therapy as ordered . Record review of Resident #34's Treatment Administrative Record dated 09/06- 09/19/2024 read in part . Order: Change tubing on O2 concentrator Weekly. Frequency: Once A Day on Tue. Record review of the facility Oxygen Administration policy dated October 2010 did not mention labeling and or dating the oxygen tubing or hydration bottle. Interview and observation on 09/17/2024 at 9:08 AM with Resident #34 revealed she had an O2 concentrator, and there was no date on the tubing. Interview and observation on 09/18/2024 at 9:55 AM with Resident #34 revealed the oxygen tubing was still unlabeled. Resident #34 said staff had not changed the tubing since this surveyor was there yesterday. Interview on 09/18/2024 at 9:51 AM with CNA A revealed she recently started back the previous week. She stated before, she worked 2 years at the facility. She said she was familiar with Resident #34 and knew the resident was on O2. She said routinely, she helped toilet and bathe the resident, and looked over the O2 machine to make sure things were connected and labeled for the resident. She observed the oxygen tubing was not labeled. She said normally the nurse changed the O2 tubing and said it was supposed to be labeled. She said she did not know why the O2 tube was unlabeled. She said she should have had training on O2 tubing to be aware of how things looked but did not recall the last time she had training on O2 tubing. She said the charge nurse for the wing was responsible for oversight to ensure staff followed protocol regarding the Oxygen care. She said the risk to the resident if policy/ procedure was not followed was bacteria could or germs could transfer to the resident if the tubing touched the floor or was not changed and the worst thing that can happen to the resident when proper protocols are not practiced was it could cause the resident to become ill. Interview on 09/18/2024 at 9:58 AM with LVN A revealed she had worked at the facility for [AGE] years as an LVN. She said she was acting medication aide. She said she gave medications, performed wound care, documented her work and, tried to make the residents happy. She said she normally worked from 6am- 2pm, Monday through Friday. She said she was familiar with and routinely would do things like positioning the resident. She said regarding the resident's oxygen, the O2 was set on 2ml and generally the tubing and water was replaced on the night shift. She said the policy or procedure was the O2 tubing was changed weekly on night shift unless the water in the hydration bottle ran out sooner than weekly. She observed there was no date on the O2 tubing on the resident. LVN A replaced the tubing and added a hydration bottle. She said there was a failure to date the tubing . She said there was a new night nurse who have had 2 days training. She said in-services on Oxygen care and tubing was reinforced all the time. She said they were all aware that dating the tubing was supposed to be done. She said she was responsible for ensuring the tubing was dated. She said the risk to the resident if policy/procedure was not followed was bacteria could get in side the tubing and in the resident, and the resident and or their roommate could get sick. Interview on 09/18/2024 at 12:11 PM with DON revealed O2 tubing was changed weekly and as needed. She said nursing was responsible for changing the O2 tubing. She said the night nurse was scheduled to change the O2 tubing. She said nurses were responsible for checking that the O2 tubing were dated and CNAs, if aware, could bring it to the nurse's attention. She said the policy or procedure was that the O2 tubing was changed out every 7 days and was dated for when it was changed. When not in use, it was bagged up. She said she was not aware of the O2 tubing not being dated. She said the last trained staff on O2 tubing on 2/08/2024. She said she and the Administrator were responsible for ensuring protocol was followed. She said the risk to the resident if policy/protocol was not followed could be infection. Interview on 09/18/2024 at 12:52PM with the Administrator revealed the policy or procedure for Oxygen tubing was it was supposed to be changed out every 7 days, and when not in use it was bagged up. She said it was labeled with the date of when the tubing was changed. She said she was familiar with Resident #34. She said she did not know why the O2 tubing was not labeled, and it was supposed to happen every 7 days and it looked like the night nurse should have looked at the oxygen tubing. She said every nurse was responsible, but especially the night nurse was responsible for the oxygen tubing because the night nurse was supposed to change and label for O2 tubing. She said she last was in-serviced on residents with oxygen recently, within last 2 months. She said she was responsible for ensuring policy was followed. She said the risk to the resident if policy or proper protocols was not followed, was there was the potential for respiratory infection , and it could lead to hospitalization .

Based on observation, interview, and record review, the facility failed to coordinate assessments with the Preadmission Screening and Resident Review (PASARR) program to the maximum extent practicable for 1 of 5 residents (Resident #36) reviewed for PASARR. -The facility failed to update the PASARR Level 1 forms for Resident #36 to indicate mental health illness. This failure could place residents requiring PASARR services at risk of not having their special needs assessed and met by the facility. Findings included: Record review of Resident # 36's face sheet provided by the facility on 09/18/2024 revealed that Resident # 36 was a 67 -year-old female who admitted to the facility on [DATE] and had an active diagnosis of Bipolar Disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) with an onset documented as of 12/04/2023. Record review of the comprehensive MDS assessment revealed Resident # 36 Brief Interview for Mental Status (BIMS) score of 15, indicating the resident's cognition was intact. The MDS assessment for Resident #36 revealed had an active Psychotic Disorder of Bipolar Disorder and had received an antipsychotic 7 days in the 7-day -look -back -period. Record review of Resident #36's care plan dated 08/19/2024 read in part Resident #36 uses psychotropic medications antipsychotic medication, Zyprexa. Record review of Resident #36 physician's order summary report revealed the following order: Zyprexa Oral Tablet 15 mg give one tablet by mouth at bedtime for Bipolar disorder, with a start date of 12/04/2024. Record review of the PASARR Level 1 Screening for Resident #36 dated for 12/04/2023 indicated no mental health illness. It was determined that resident was not eligible for PASARR specialized services because serious mental (Bipolar Disorder) illness was not indicated on initial PASARR Level 1 Screening. Interview and record review on 09/18/2024 at 11:00 AM with the MDS Coordinator revealed that she completed an updated PASARR Level 1 screening on 09/18/2024 after surveyors asked for the PASARR for Resident #36. She said she would wait to see what the recommendations were after the referral was processed. She stated that she did not know why the PASARR referral had not been completed on 12/04/2023. She stated that it would be important for a resident to receive PASARR services if they qualified. The MDS Coordinator stated that by not coordinating PASARR services it placed residents at risk for not receiving the necessary mental health services that the residents may have qualified for. Interview on 09/18/2024 at 3:30 PM, Resident #36 stated that she received antipsychotic medication but did not know what medications dosage and side effects associated with medications. Resident #36 denied receiving and services and support related to coping with bipolar disorder. Resident denied being sad at the time of the interview but stated that she feelings sad frequently and she could benefit from supportive. Record review of the facility's Resident Assessment-Coordination with PASARR Program policy dated implemented 06/2023 and Date Revised: 06/2023 revealed 9. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review .b. A resident whose intellectual disability or related was not previously identified and evaluated through PASARR.

Based on interview, and record review, the facility failed to inform residents in advance of the risks and benefits of proposed care and treatment for 1 of 5 residents (Resident #36) reviewed for resident rights, in that: The facility failed to obtain a signed consent for antipsychotic medication, Zyprexa Oral Tablet 15 mg, administered to Resident #36. The failure affected residents who received psychoactive medications and placed them at risk of receiving treatments without informed consent. Findings include: Record review of Resident #36's face sheet provided by the facility on 09/18/2024 revealed that Resident # 36 was a 67 -year-old female who admitted to the facility on [DATE] and had an active diagnosis of Bipolar Disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) with an onset documented as of 12/04/2023. Record review of the comprehensive MDS assessment revealed Resident # 36 Brief Interview for Mental Status (BIMS) score of 15, indicating the resident's cognition was intact. The MDS assessment for Resident #36 revealed had an active Psychotic Disorder of Bipolar Disorder and had received an antipsychotic 7 days in the 7-day -look -back -period. Record review of Resident #36 care plan dated 08/19/2024 read in part Resident #36 uses psychotropic medications antipsychotic medication, Zyprexa. Record review of Resident #36 physician's order summary report revealed the following order: Zyprexa Oral Tablet 15 mg give one tablet by mouth at bedtime for Bipolar disorder, with a start date of 12/04/2024. Record review of Resident #36 MAR revealed that Zyprexa Oral Tablet 15 mg was administered by the facility's nursing staff on 12/04/2023 thru 01/30/2024 to Resident #36. Interview on 09/18/2024 at 1:45 PM, the Administrator stated that the nurses were required to ensure that there is signed consent for Antipsychotic Medication prior to administering. Interview on 09/18/2024 at 2:00 PM, the DON stated that the nurses were required to obtain consent and confirm that there is a signed Form 3713 consent for Zyprexa Oral Tablet 15 mg and verbal consent for other medications. The DON stated that the facility obtained a consent on 12/04/2024, but the consent referenced was not the correct consent for Zyprexa Oral Tablet 15 mg. Medication Administration and Antipsychotic Medication Use/Consent Policy was requested. Interview on 09/18/2024 at 3:30 PM, Resident #36 stated that she received antipsychotic medication but did not know what medications dosage and side effects associated with medications. Resident #36 denied receiving and services and support related to coping with bipolar disorder. Resident denied being sad at the time of the interview but stated that she feelings sad frequently and she could benefit from supportive. In an interview on 09/19/2024 at 11:00AM, the Administrator stated that the facility did not have Antipsychotic Medication Use/Consent Policy. Record review of the facility's Admission Packet, Psychoactive Medication Informed Consent Page 12 of the Admission Packet If a psychoactive medication is prescribed for a resident either before admission or after, you will be contacted regarding completing the consent form.

Based on observation, interview, and record review, the facility failed to ensure 1 resident (CR #84) of 5 residents reviewed for medication administration was free of a significant medication error. -Resident #84 was administered 60 units of long-lasting insulin. -Resident #84 exhibited a blood sugar of 22 mg/dl. -Resident #84 required hospitalization . The failure placed residents at risk for complications and possible death from receiving the wrong or excessive dosage of medication. An Immediate Jeopardy (IJ) was identified on [DATE] at 10:38 a.m. The noncompliance was identified as Past Noncompliance. The IJ began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the survey began. Findings Include: Record review of the CR #84's Face Sheet revealed a 68-years-old female who admitted to the facility on [DATE]. Diagnoses were Type 2 diabetes mellitus (chronic health condition that affects how the body turns food into energy) without complications, other specified diseases of the pancreas (an organ in the digestive system), and cognitive communication deficit (difficulty understanding and being understood). CR #84 expired at the facility on [DATE] due to causes unrelated to this event. Record review of CR #84's hospital Physician Consultation dated [DATE] revealed she presented with hypoglycemia (low blood sugar) and was administered IV dextrose. Her blood sugar levels remained low (not specified in this Consultation). Record review of CR #84's hospital Physician Consultation dated [DATE] revealed she was discharged back to the facility on [DATE]. Record review of the hospital Discharge Summary dated [DATE] revealed Resident #84 was brought to the Emergency Department for hypoglycemia. She was admitted and was administered dextrose. Her blood sugars were monitored closely, and the hypoglycemia was resolved. Record review of CR #84's admission 5-day MDS assessment dated [DATE] revealed Resident #84 exhibited modified independence for cognitive skills for daily decision making . CR #84 required physical assist from one person for bed mobility, transfers, locomotion, dressing, toilet use, and personal hygiene. Record review of CR #84's Care Plan dated [DATE] read in part there was potential for complications related to diabetes mellitus. The 'goal' was for the resident to have blood glucose levels within acceptable limits and absence of signs of hypoglycemia or hyperglycemia (high blood sugar). One approach was to administer medications as ordered by MD and evaluate/record/report effectiveness and any adverse side effects. Record review of CR #84's admission Prescription Order dated [DATE] at 6:10 p.m. read in part the resident was to receive 6 units of Lantus Solostar (long-acting) insulin every night at bedtime (8:00 p.m.). It was ordered by Physician A and transcribed by LVN B. Record review of CR #84's Patient Medication Profile dated [DATE] read in part the resident was to be administered Humulog U-100 (fast-acting) insulin on a sliding scale (the amount of insulin to be administered based on the fsbs reading). If the fsbs was greater than 401 mg/dl, administer 12 units of Humulog U-100 and re-check the fsbs in 15 minutes. If the fsbs was still greater than 401 mg/dl at that time, notify Physician. Record review of CR #84's NN dated [DATE] at 8:37 p.m. (late entry) read in part Resident #84's had a fsbs of 412 mg/dl. Sliding scale insulin was administered. The fsbs after 15 minutes was 409 mg/dl. The Physician was notified. A new order for 60 units of insulin was noted. The type of insulin was not specified. The NN was signed by LVN C. Record review of CR #84's Prescription Order dated [DATE] at 8:19 p.m. read 60 units of Lantus Solostar insulin administer at bedtime (8:00 p.m.). The Order reflected a start date of [DATE]. Record review of the NN dated [DATE] at 12:28 p.m. revealed LVN C conducted a fsbs for Resident #84 at 7:15 a.m. The resident had a blood glucose level of 26 mg/dl. LVN C rechecked, and got a reading of 21 mg/dl. The NN reflected another nurse (LVN D) brought a different glucometer and obtained a fsbs. The reading reflected 26 mg/dl. LVN C called NP E and NP E ordered Glucagon (a hormone that acts to increase blood sugar) 1 mg and to recheck the fsbs at 7:35 a.m. The Glucagon was administered into the left deltoid (muscle around the shoulder). The fsbs recheck after 15 minutes yielded 44 mg/dl. A fsbs at 8:35 a.m. was 85 mg/dl, followed by a 49 mg/dl reading at 10:30 a.m. Physician A was notified, and he ordered Glucagon 1 mg to be administered, and the resident was to be sent to the ER for further evaluation. The Glucagon was administered, and the resident was transported to the hospital via 911. Record review of the Provider Investigation Report dated [DATE] revealed Resident #84 required hospitalization for four days. Interview on [DATE] at 11:37 a.m. with LVN C revealed she said she worked the 6:00 a.m. to 6:00 p.m. shift on [DATE]. She said she was checking blood sugars in the morning, and Resident #84's was 26 mg/dl. She had not received any report regarding insulin for Resident #84. She said she went and got the other nurse (LVN D). LVN D's glucometer reflected a reading of 21 mg/dl. The NP was called, and an order for Glucagon was received. The Glucagon was administered. She said she believed the blood glucose level went up to 89 mg/dl. When the next fsbs reflected 49 mg/dl, Physician A was called. The resident was administered another dose of Glucagon and was sent to the hospital. LVN C said Resident #84 was at the hospital for '3 or 4 days.' Interview on [DATE] at 11:45 a.m. with LVN D revealed she said LVN C approached her and said Resident #84 had a low blood sugar that was in the 20's (mg/dl). She said they called and received the order for the Glucagon. The Glucagon was administered, and the blood glucose level began to rise. She said at that time she went back to her nursing station in another part of the facility. She said the resident was then sent to the hospital. Interview via telephone on [DATE] at 11:00 a.m. with LVN B revealed she said Resident #84 was admitted to the facility on [DATE]. She said she verified the admission orders with Physician A. She said the order for insulin (Lantus) was 6 units. She said she checked Resident #84's blood sugar, and it was between ,d+[DATE] mg/dl. She said she had already given the 6 units per the admission order. She said she called the doctor and he said to give 60 units of Lantus. She said she repeated '60?' and it was confirmed. She said LVN F was present when she spoke with Physician A. She said she was not sure if Physician A was on the speaker on the phone, but she repeated it to LVN F, and LVN F entered the order into the computer. She said she gave the 60 units of Lantus. She said the resident was 'fine, alert' when she left the facility in the morning. Interview on [DATE] at 11:20 a.m. with LVN F revealed she said Resident #84's blood sugar level 'was in the 400s.' She said the physician gave a verbal order to administer additional insulin, but she could not recall the amount. She said she let LVN B use her cell phone, but she did not stand next to her. She said LVN B told her (LVN F) to change the insulin order in the computer to reflect the new order. LVN F said she entered the new order into the computer, even though she had not spoken with Physician A directly. When asked if that was the normal procedure for entering orders, LVN F said typically the nurses enter their own orders, but LVN B was not feeling well so she helped her. Interview on [DATE] at 11:45 a.m. with the DON revealed she said when a nurse calls the doctor for an order, that nurse is the person who would enter the order into the computer. She said if both nurses heard the doctor, either could enter the order. She said it was inappropriate for LVN F to enter the order if LVN B spoke to the doctor and relayed the order. Interview on [DATE] at 1:26 p.m. with Physician A revealed he said he received the call that Resident #84 had a high blood sugar. He said he thought he ordered the insulin to be increased to 14 units. He said he did not know where the '60' came from. He said that was too much of an increase. The above failures were determined to be a past non-compliance Immediate Jeopardy (IJ) on [DATE] at 10:38 a.m. The Administrator and the Director of Nursing were notified at that time. The Administrator was provided with the IJ template on [DATE] at 10:38 a.m. The facility had addressed the non-compliance prior to entry by the HHS surveyors. The facility actions to correct the non-compliance was accepted in lieu of a Plan of Removal. SPJST Rest Home No. 2 Facility actions to correct the non-compliance included: -The nurse (LVN B) who administered the 60 units of insulin was suspended then resigned on [DATE]. -LVN F received written counseling on improper transcription of physician orders and was required to receive CEU education on proper transcription of physician orders . -Eight nurses were in-serviced on insulin administration with return-demonstration on [DATE]. The signatures of nurses observed during the survey and investigation were on the in-service attendance sheet. The nurses were LVN C, LVN D, LVN E, LVN F, LVN G, LVN H, LVN I, and LVN J. -Eight nurses were in-serviced on receiving physician orders and proper transcription on [DATE]. The signatures of nurses observed during the survey and investigation were on the in-service attendance sheet. The nurses were LVN C, LVN D, LVN E, LVN F, LVN G, LVN H, LVN I, and LVN J. In an interview on [DATE] at 11:00 a.m., LVN C said she had been in-serviced regarding insulin and physician orders. In an interview on [DATE] at 11:10 a.m., LVN D said she had received in-services regarding insulin and physician orders . Observation on [DATE] at 11:15 a.m. revealed LVN D performed a fsbs for Resident #90. The resident required sliding scale insulin. LVN D reviewed the order, and then administered the correct insulin and the correct dosage. In an interview on [DATE] at 1:50 p.m., the Administrator said the insulin incident was discussed extensively in the QAPI. She said the Physician was not able to attend, but he did review the notes . In an interview on [DATE] at 4:00 p.m., the DON said there were a total of 16 nurses employed at the facility, including her and the Administrator (RN). She said all nurses who have worked since the incident had had been in -serviced. She said the remainder of the nurses would receive the in-services prior to starting their first shift. Record review of the facility's policy titled Insulin Administration (revised [DATE]) read in part .3. The type of insulin, dosage requirements, strength, and method of administration must be verified before administration, to assure it corresponds with the order on the medications sheet and the physician's order. The policy revealed long-acting insulins reached their peak effect (maximum effectiveness) at 'up to 8 hours' and for a duration of up to 24 hours . Add in the MerckManual reference that was included in the original visit and include access date. Record review of MerckManuals.com Professional Version revealed hypoglycemia (low blood sugar) is defined as a glucose level of equal or less than 70 mg/dl. Hypoglycemia could result stroke-like symptoms of aphasia (inability to speak) or hemiparesis (limited ability to move one side of the body, and is likely to precipitate stroke, myocardial infarction (heart problems), and sudden death.

Based on observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were secured in locked compartments, labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 of 3 medication carts ( Hall C medication cart and Hall C PRN medication cart) reviewed for drug labeling and storage. - LVN A failed to ensure all medications were secured in locked carts when not in use and unattended. - The facility failed to ensure the Hall C PRN Medication cart did not contain multidose containers with no open dates. These failures could place residents at risk of adverse medication reactions and drug diversions. Findings Included: An observation and interview on [DATE] at 07:48 AM, LVN A revealed, a medication cup with white crushed powder suspended in water and a unit dose vial of [MEDICATION(S)]/[MEDICATION(S)], a breathing solution, was left unattended on top of the Hall C Medication Cart. LVN A said the medication in the cup was crushed medication prepped earlier at approximately 7:00 AM for administration via G-tube to Resident #30. She said the medication was located in a separate cart, the Hall C PRN Medication Cart, so she pulled it out in anticipation of the resident's medication administration. LVN A said the vial of breathing solution came in a pack of two that she retrieved from the Hall C PRN cart and after administering 1 to her resident she forgot to return the unused vial to the cart. She said all medications should be stored in their original pharmacy container with medication and patient identifiers and locked in the cart at all times. LVN A said medications left unattended left residents at risk of medication errors and adverse drug reactions. In an observation and interview on [DATE] at 09:34 AM, inventory of the Hall C PRN Medication Cart revealed: - An open and in use bottle of Pro-Stat, a protein supplement, with manufacturer instructions of Discard 3 months after opening and Record date opened on bottom after opening, the bottle had no open date. LVN A said t nursing staff are supposed to check their medication carts for expired and inappropriately labeled medications on each shift. She said since the bottle of Pro-Stat did not have an open date it could not be used, and it must be discarded in the drug disposal bin located in the medication room. LVN A said administration of expired Pro-Stat could place residents at risk of GI upset and adverse reactions. In an interview on [DATE] at 11:26 AM the DON said, all medications should be stored in their original medication containers which include the pharmacy labeling and stored in secured carts. She said medications should be prepared immediately before administration, the medication should not be prepped in advance and should not be left unattended. The DON said unattended medications create risks of drug diversion and place residents at risk of missing medications and adverse reactions if taken by the wrong resident. She said nursing staff are expected to check their carts on each shift for inappropriately labeled medications and multidose containers should be labeled with the open date in order to track its expiration date. The DON said if there was no open date an expiration date cannot be determined so the medication must be discarded in the drug disposal bin located in the medication room. She said t if the expired pro-stat supplement was administered it could place residents at risk of contamination, lack of efficacy, and GI upset . Record review of the facility's policy, Labeling of Medication Containers revised [DATE] revealed 3- Labels for individual drug containers shall include all necessary information, such as: The resident's name, the prescribing physician's name, the name, strength, and quantity of the drug. 5- Labels for each single unit dose package shall include all necessary information Record review of the facility's policy, Storage of Medications revised [DATE]- Drugs and biologicals shall be stored in the packaging, containers, or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. 3- Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. 8- Drugs shall be stored in an orderly manner in cabinets, drawers, carts or automatic dispensing systems. Each resident's medication shall be assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents.

Based on observations, interviews and record reviews, the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice and the comprehensive person-centered care plan for 1 (Residents #30) of 2 residents observed for oxygen management in that: Resident #30's oxygen concentrator was set on 5.5 L/min continuously and did not have a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] This deficient practice could affect residents on oxygen therapy and could result in too much or too little oxygen administered and result in respiratory distress. The findings were: Record review of the admission face sheet for Resident #30 revealed she was an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .) with behavioral disturbance. Record review of quarterly MDS dated [DATE] revealed that Resident # has a BIMS score of 00 indication she was severely impaired with cognition for decision making. She required extensive assistance with two plus per person physically assisted for bed mobility, transfer, dressing, toileting and personal hygiene. She was incontinent of bowel and bladder. Review of Resident #30's Order Summary Report dated 7/15/2021 : Check oxygen sat every shift, apply oxygen for oxygen sat < 93% . The order did not reflect specific rate for oxygen. Review of Resident #30's comprehensive person-centered care plan initiated 7/22/21 revealed The resident has altered respiratory status/difficulty breathing AEB worsening dyspnea on exertion, check oxygen sat every shift, apply oxygen for 02 sats < 93% every shift-PRN, day, evening and night mild productive cough/rales and respiratory wheezing. NON-COMPLIANT WITH OXYGEN. No rate was specified. Observations on 6/7/22 ,Resident #30 was on continuous oxygen concentrator set at 5.5 liter/ nasal cannula during the following times: -at 9:20AM, -at11:00 AM, -at1:00 PM, -at3:00 PM and -at4:30 PM. Observations on 6/8/22 Resident #30's oxygen rate on her concentrator was set at 5.5 L/min via nasal cannula during the following times. -at 10:00 AM, -at 12:30 PM, -at 1:00 PM, and -at 2:00 PM Review of Resident #30's vitals Report revealed Resident #30 was on oxygen at 5.5L/NC with oxygen saturation documented on the following dates: ( the normal level of oxygen is usually 95% or higher) and the nurses were documenting oxygen concentrator set at 2L/mins via nasal cannula. 5/9/22: 98 % - oxygen use-liter flow ( 2L/min) 5/10/22: 98 % - oxygen use-liter flow 2 5/11/22: 98 % - oxygen use-liter flow 2 5/13/22: 98 % - oxygen use-liter flow 2 5/14/22: 99 % - oxygen use-liter flow 2 5/16/22: 98 % - oxygen use-liter flow 2 5/18/22: 98 % - oxygen use-liter flow 2 5/19/22: 97 % - oxygen use-liter flow 2 5/20/22: 97 % - oxygen use-liter flow 2 5/21/22: 96 % - oxygen use-liter flow 2 5/24/22: 96 % - oxygen use-liter flow 2 5/25/22: 96 % - oxygen use-liter flow 2 5/26/22: 98 % - oxygen use-liter flow 2 5/27/22: 98 % - oxygen use-liter flow 2 5/28/22: 98 % - oxygen use-liter flow 2 5/29/22: 95 % - oxygen use-liter flow 2 6/03/22: 97 % - oxygen use-liter flow 2 6/4/22: 98 % - oxygen use-liter flow 2 6/8/22: 95 % - oxygen use-liter flow 2 Interview on 6/8/22 at 10:30 AM with LVN A revealed Resident #30's oxygen rate is 2 L/min and the nurses checked oxygen saturation. Interview on 6/8/22 at 12:40 PM with LVN A she stated she did not check the orders for Resident #30 and knew she should have. She stated it was important to make sure the resident was on the correct oxygen rate because of their ability to breath and have enough saturation of oxygen in the blood, LVN A stated she was not aware that Resident #30 did not have an oxygen order and she stated that oxygen was considered a medication and needed to have an order. She did not know how long resident had been receiving oxygen. Interview on 6/9/22 at 1:00 PM, the DON revealed the nurses needed to follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated she called the physician on 6/9/22 at 2:00 p.m. and got a telephone order for oxygen at 2L/min continuous via nasal cannula She said Resident #30 oxygen sat rate, needed to be checked each shift and oxygen given when saturation was < 93%. When asked if the facility had a policy or procedure for oxygen management, she stated it did not. Interview with the Administrator on 6/9/22 at 2:00 PM she said the former the DON was responsible for checking physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She knew too much oxygen can cause toxicity to the lungs and they will be doing a lot of in-services.

Based on observation, interview, and record review the facility failed to ensure residents who are fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 of 1 residents (Resident #30) reviewed for gastrostomy tube management, in that: - LVN A failed to check the placement and residual of Resident #30's gastrostomy tube (G-tube), a tube inserted through the belly that brings nutrition directly to the stomach, prior to administering medications. - LVN A flushed Resident #30's G-tube which the force from a syringe instead of with gravity. These failures could place residents who receive medication at risk for adverse reactions, inadequate therapy, and a decreased quality of life. Findings include: Record review of Resident #30's face sheet revealed, a [AGE] year-old female admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Resident #30's Quarterly MDS dated [DATE] revealed, severely impaired cognition and total dependence on all ADLs . Record review of Resident #30's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #30's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Every Shift; Day, Evening, Night. An observation and interview on 06/08/22 at 08:00 AM revealed, LVN A preparing medication for administration via G-tube for Resident #30. She retrieved each medication and crushed them individually and placed them in individual medication cups. LVN A entered into the resident room, she placed the cups in the medications and suspended each medication in 10 to 15 mL of water. She then withdrew 30 mL from a bottle into a syringe, attached the syringe to Resident #30's G-tube and pushed 30 mL through the feeding tube without first checking for residual or placement. Once she completed the push/flush she removed the plunger and administered Resident #30's medications with a 15 mL flush in between each medication. After medication administration LVN A flushed the resident with 30 mL of water. LVN A said she forgot to check to check for placement and residual and she used a syringe to push the initial flush because Resident #30 was previously receiving continuous feeding, so her G-tube was clogged . She said she was not supposed to push the flush through the syringe but let the flush run through gravity. LVN A said the purpose of checking for placement was to make sure the tube was still in the resident's stomach and failure to check for placement placed residents at risk for leakage of administered medications or food into the cavities outside of the stomach if the tube was pulled out of the stomach . In an interview on 06/08/22 at 11:26 AM, the DON said prior to medication administration via G-tube nursing staff should check for placement and residual. She said the purpose of checking for residual and placement was to check for tolerance of feeding and to make sure it the G-tube in place before medication/food administration. The DON said if placement was not checked you cannot know if the G-tube was still in the stomach and if it wasn't, medication administered could leak into areas outside of the stomach leading to adverse reactions. The DON said all flushes and medication should be administered via gravity and not by pushing through a syringe. She said pushing fluid into a G-tube with a syringe can lead to perforation or damaged tubing . Record review of the facility's policy, Administering Medications through an Enteral Tube revised March 2015 revealed, Steps in the Procedure 18- Confirm placement of feeding tube .20- Check gastric residual volume (GRV) to assesses for tolerance of enteral feeding .21- When correct tube placement and acceptable GRV have been verified, flush with 15-30 mL warm sterile water (or prescribed amount).

Based on observation, interview, and record review the facility failed to ensure Residents who are incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 2 residents ( Resident#30) reviewed for incontinent care, in that: During perineal care for Resident #30, CNA A failed to change gloves and perform hand hygiene when going from dirty to clean sites. CNA B did not separate Resident #30's labia to clean during incontinent and did not perform appropriate hand hygiene with glove changes throughout the care. This deficient practice could affect residents who received perineal care and place them at-risk of increased urinary tract infections due to improper care. Findings include: Resident #30 Record review of the admission face sheet for Resident #30 revealed she was an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of quarterly MDS dated [DATE] revealed that Resident #30 has a BIMS score of 00 indication she was severely impaired with decision making. She was coded for ADLs as extensive assistance with two plus per person physically assisted for bed mobility, transfer, dressing, toileting and personal hygiene. She was coded as incontinent of bowel and bladder. Record review of Resident # 30's care plan dated dated 4/9/2021 and updated 1/2/22 revealed Resident's ability to (ADL: e.g., transfer, walk in room, walk in corridor, dress, eat, toilet, maintain personal hygiene) has deteriorated dementia. Intervention: provide total assistance for all ADL. Total assist x 2 for toileting. Incontinent of bowel and bladder. Record review of the facility antibiotic stewardship revealed Resident #30 was on antibiotic on 3/22/22 treated urinary tract infection ([CONDITION(S)]) ( UA C&S done Lab pseudomonas aeruginosa 50,000-99,000) [MEDICATION(S)] x 7days ( antibiotics). On 5/9/2022 [MEDICATION(S)] x7 days for [CONDITION(S)]. On 5/29/22-6/5/22 [MEDICATION(S)] and [MEDICATION(S)] for [CONDITION(S)] Observation on 6/8/2022 at 3:20 p.m., CNA A provided incontinent care to Resident #30. The CNA A removed Resident #30's brief and CNA B was assisted with turning the resident on her side. The resident had a moderate loose yellowish stool. CNA A did not change gloves, wash or sanitize her hands after removing the soiled brief. CNA A used wet wipes clean her buttocks, then repositioned Resident #30 on her back. CNA B cleaned peri area with wipes. CNA B did not open resident labia to clean, she did not remove her dirty gloves and placed clean brief and clean incontinent pad under the resident, then adjusted Resident #30's clothing and adjusted her bed linens. CNA A and CNA B used the same gloves throughout incontinent care without sanitizing their hands and changing their soiled gloves. CNA B left the room without washing/sanitizing her hands. Interview on 6/8/22 at 3:40 PM, C.NA B regarding incontinent care she said I thought we did a good job. In an interview on 6/9/22 at 1:21 PM, CNA B said she had been working at this facility for past two years as a full-time employee, she said was nervous. She said she had received training from other CNAs on the floor upon hire. She said she should have changed her gloves and performed hand hygiene when moving from a dirty area to a clean area when performing incontinent care as it was risk for infections and cross contamination. She said she was in serviced on hand washing/ infection control sometime last month and did not remember the date. Interview on 6/8/22 at 3:40 PM, CNA A said she had the training from high school, and she has not had any training on incontinent care in the facility. CNA A said she started working with the facility about 2 months ago as hospitality aide and went to CNA school and had her license as CNA. In an interview on 6/9/2022 at 1:45 PM, the Administrator said she expected staff to remove their gloves and either wash or sanitize their hands after touching a dirty area prior to moving to a clean area when performing incontinent care. She said staff was in-serviced on infection control / hand hygiene upon hire and annually. She said she will go talk to the CNA and correct it right now, so she does not continue to do the same thing. Further interview with the Administrator on 6/9/22 at 2:00 PM regarding C.NA A and C.NA B skilled check for incontinent care, she said the DON quit a week ago, she dumped all her files in her office and she has not had time to look through pile. In an interview on 6/9/2022 at 2:45 PM, the DON she just took over the DON position on 6/7/22 and she would be performing in- services. DON said she expected staff to use hand sanitizers or wash their hands with glove change during care. DON said she expected staff to separate the residents labia and clean them appropriately, The DON said she expected the nursing staff to change their gloves when touching clean from dirty. Record review of facility's perineal care policy (revised October 2010) read in part: .the purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. Preparation: 1. Review the resident's care plan to assess any special needs of the resident. 2. Assemble the reequipment and supplies as needed. Steps in the procedure: e. wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks. Do not reuse the same washcloth or water to clean the labia. 11. Discard disposable items into designated containers. 12. Remove gloves and discard into designated containers. Wash and dry your hands thoroughly . No in-service documentation on incontinent care was provided prior to exit on 6/9/22 at 5:30 PM.

Based on observation, interview, and record review, the facility failed to provide services as outlined by the comprehensive care plan that meet professional standards of quality for 1 of 2 residents reviewed for wound care. (Resident #30) The facility did not provide Podus boot's (heel protector) to Resident #30's heel as ordered by the physician. This failure could place residents with pressure sores at risk of not receiving the care and services to meet their needs. Findings include: Record review of the admission face sheet for Resident #30 revealed she was an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of quarterly MDS dated [DATE] revealed that Resident #30 has a BIMS score of 00 indication she was severely impaired with decision making. She was coded for ADLs as extensive assistance with two plus per person physically assisted for bed mobility, transfer, dressing, toileting and personal hygiene. She was coded as incontinent of bowel and bladder. Resident #30's skin condition was coded as high risk for pressure sores. Record review of the care plan for Resident #30's wound care dated 4/9/2021 and updated 1/2/22 for treatment indicated to apply skin prep and offload heel, frequently turn and reposition. Record review of Resident #30's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Every Shift: 06:00 AM - 02:00 PM, 02:00 PM - 10:00 PM, 10:00 PM - 06:00 AM 04/05/2021 Open Ended Treatments. Record review of the Treatment Administration History dated 06/01/2022 to 06/08/2022 had initials of nurses indicating Resident #30 was wearing Podus boot's t to bilateral feet at all times of the day. Every Shift: 06:00 AM - 02:00 PM, 02:00 PM - 10:00 PM, 10:00 PM - 06:00 AM . During the following observations on 6/7/22, Resident #30 was in bed with no Podus boots (heel protectors) in place: - at 9:20 AM, - at 1:00 PM, - at 3:00 PM, and - at 4:30 PM. During the following observations on 6/8/22 Resident #30 was in bed with no Podus boots (heel protectors) in place: -at 10:00 AM, -at12:30 PM, -at1:00 PM, and -at2:00 PM. During an observation of incontinent care on 6/8/22 at 3:20 PM with CNA B and C.NA A Resident # 30 was lying in bed with no heel protector on, Resident #30 had redness to both heel and 0.5 cm ( approximately by surveyor) open area to lateral aspect to right heel. Interview with CNA B on 6/8/22 at 4:30 PM, said she has not seen Resident #30 with heel protectors she works 2:00 PM to 10:00 PM shift and the nurse put it on the residents Interview with CNA A on 6/8/22 at 3:30 PM, said she has not seen Resident #30 with heel protectors and she has worked with Resident #30 over 3 months. Interview with LVN A on 6/8/22 at 4:36 PM, said she would check the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . . In an interview on 6/9/202 at 11:20 AM, LVN A stated after reviewing the orders she said she did not follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated Resident #30 could have more skin breakdown and they should follow doctor's order. In an interview on 6/9/2022 at 11:45 AM, the DON said the staff should always follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON said Resident #30 had on her Podus boots last night and the outcome of not wearing Podous boots could lead to further skin break down. In an interview with the Administrator on 6/9/22 at 11:45 AM, she said all nurses should always follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of the policy and procedure for physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, interview and record review, the facility must dispose of garbage and refuse properly for 1 of 1 dumpster reviewed for garbage disposal. -The facility failed to ensure the dumpster lids and doors were secured. This failure could place residents at risk of infection from improperly disposed garbage. Findings include: Observation of the dumpster area on 06-09-22 at 7:30 am revealed a commercial -size dumpster ¾ full of garbage and the door was open. Interview on 06-09-22 at 7:45 am, with the Food Service Director stated the dumpster lids must always be closed by the facility staff dumping garbage after each use to keep vermin, pests and insects out of the dumpster and from entering the facility. Record review of facility policy and procedure on Food-Related Garbage and Rubbish Disposal dated April 2006 revealed: Policy: Food -related garbage and rubbish shall be disposed of in accordance with current state laws regulating such matters. Policy Interpretation and Implementation read in part' .1. All garbage and rubbish containing food wastes shall be kept in containers. 5. Garbage and rubbish containing food wastes will be stored in a manner that is inaccessible to vermin. 7. Outside dumpster provided by garbage pickup services will be kept closed and free of surrounding litter.

Based on interview and record review the facility failed use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for one of one facility reviewed for 8-hour RN coverage. The facility failed to have RN coverage when they had the Administrator acting as the DON, RN 8-hour coverage, and the Administrator (LNFA). This failure could place residents at risk of not receiving services and lack of quality of care. Findings include: Review of Facility's Shift Coverage on the wall dated 12/16/21 reflected there was one RN in the building and no other RN coming in on another shift. Review of the facility schedule book dated 12/16/21 revealed there was one RN the Administrator acting as RN 8-hour coverage. The weekend RN covered the weekends. Observation of the facility on 12/16/21 from 10:30 AM - 5:30 PM revealed there was one Administrator acting as a DON and 8-hour RN coverage. In an interview on 12/16/21 at 1:00 PM and 4:30 PM the Administrator stated she was the Administrator because she has her LNFA, she was also the DON until they have a new one start, and she was the 8-hour RN coverage Monday through Friday. She stated she could be all the positions because the census was less than 60. She said she worked 40 hours a week covering the two roles. She confirmed the facility census was 34 and she ( Administrator) was responsible for hiring a RN and DON. Review of the Administrators LNFA license on 12/16/21 reflected she was license and it was up to date. Review of the facility's policy dated reflected:

Based on observation, interview and record review, the facility failed to provide a safe and sanitary environment for residents, staff and the public, as evidenced by; The facility failed to ensure: -Multiple leaks in the activity room were contained, -Keep floors dry in the activity room water puddles were on the floor, -The sink and garbage disposal were working properly in the kitchen, and -Dead bugs and grease, and broken crates were not on the floor in the kitchen. These failures placed residents at risk of harm and unsafe and sanitary conditions. Findings included: Observation on 06/09/21 at 9:50 AM revealed 4 water spots in the activity room coming from the ceiling leaks. Vents in activity room have black and brown substances on them. Tile on ceiling discolored. Observation on 06/09/21 at 10:55 AM in the kitchen revealed: Stove/Oven/Fryer - thick amount of grease on the floor. Sink near window - dead bugs underneath the sink. Sink near dishwasher - water not draining sink stopped up. Crate broken into multiple pieces on the floor between sink and dishwasher. Sink near garbage disposal - water in sink not draining, sink stopped up, garbage disposal not working. In an interview on 06/09/21 at 11:10 AM, the Dietary Manager said staff did manual cleaning of the kitchen on Wednesday afternoon. In an interview on 06/09/21 at 11:20 AM the Head Cook stated the staff tried to clean daily but only had 3 staff. They did not have the supplies to do a deep cleaning. The sinks have been clogged up for about two months, the garbage disposal does not work but nobody will fix it at the facility. The broken crate had been there for a long time. The facility management is cheap and does not want to fix anything. In an interview on 06/09/21 at 11:45 AM, the Maintenance Director stated the disposal just broke this morning, its an electrical issue, he was waiting on corporate to give the okay to fix. Since the facility did not have an administrator, he had to call the corporate office to get okay for the work. There are some things blocking the pipes with the sink, staff reported it three weeks ago to corporate office. Once the facility got the okay then he will call the plumber to get the issues fixed. Last year the facility put in a new disposal, two months later it shorted and broke. He was not sure what's going on with the disposal. The drain had been damaged or about a month. The facility had brand new Air conditioner units there was no insulation so when it gets cold, they leak. It's an old facility and that is why there was no insulation. The building was old need a lot of repairs. The ceiling was one piece, and all connected, he cannot just take one apart and change or paint it. In an interview on 06/09/21 at 12:20 PM, the DON stated the facility did not have a policy on facility environment maintenance or on safe environment. In an interview on 06/09/21 at 1:07 PM, the Dietary Manger stated she did not keep a log of the cleaning schedule or task for the staff because it was too much paperwork. She said the facility did not have a policy for safe /sanitary maintenance. Record review of the facility Policy Cleaning Schedules dated 06/14 revealed .The Dietary staff shall maintain the sanitation of the Dietary Department through compliance with written, comprehensive cleaning schedules developed for the facility by the Dietary Manager .The Dietary Manager/ Dietary Technician shall record all cleaning and sanitation tasks for the Dietary Department .A cleaning schedule shall be posted with tasks designated to specific positions in the department All tasks shall be addressed as to frequency of cleaning .General Daily and Weekly Cleaning schedules may be used or Cleaning Schedules by position may be used .

Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the facility's only kitchen. The facility failed to ensure: -Food was not stored on the floor and dated in the dry storage area. -Fruit in open containers had mold and mildew on outside and not dated. -Food in containers not labeled with use by date. -Outdated food was discarded. These failures placed residents at risk of food borne illness and cross contamination. Findings included: Observations on 06/09/21 at 10:55 AM in the kitchen revealed: Dry storage area - Large bag of cornmeal on the floor. Large open bag of all-purpose flour on the floor not dated. Dead insect on floor near door. Walk in refrigerator - open package of ham in a plastic container dated 4/26. Two cantaloupes in container not dated, cantaloupe with black and white substance on outside. In an interview on 06/09/21 at 11:10 AM, the Dietary Manager stated the cornmeal was supposed to have been poured into the bin but the staff got busy and did not do what she was supposed to do after opening it. Staff are supposed to date and label the items and put them on the shelf. She said she will discard the ham, they had sandwiches last night. She will look at the melons, if not any good she will discard the items. In an interview on 06/09/21 at 11:20 AM, the Head Cook stated the groceries came in the morning and staff forgot to put up the flour and cornmeal. She said the kitchen was shorthanded and only had 3 staff today. She said it could have been one of the new staff that did not store food properly. Record review of the facility policy Food Receiving and Storage dated 07/2014 revealed Food shall be received and stored in a manner that complies with safe food handling practices . 6. Food in designated dry storage areas shall be kept off the floor (at least 18 inches) and clear of sprinkler heads, sewage/waste disposal pipes and vents 8. All foods stored in bins will be removed from original packaging, labeled, and dated (use by date) .

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment including the use of PPE and following CDC guidelines for COVID-19 for 1 of 6 residents (Resident #1) reviewed for infection control. -The facility failed to ensure staff providing care to both quarantined and non-quarantined residents used appropriate PPE as recommended by the CDC. This failure placed all residents at risk of contracting an infectious disease which could result in hospitalization or death. Findings Include: Record review of CDC.gov website read in part, .The PPE recommended when caring for a patient with known or suspected COVID-19 includes: ·Respirator or Facemask (Cloth face coverings are NOT PPE and should not be worn for the care of patients with known or suspected COVID-19 or other situations where a respirator or facemask is warranted) Put on an N95 respirator (or higher level respirator) or facemask (if a respirator is not available) before entry into the patient room or care area, if not already wearing one as part of extended use or reuse strategies to optimize PPE supply. Higher level respirators include other disposable filtering facepiece respirators, PAPRs, or [MEDICATION NAME] respirators. N95 respirators or respirators that offer a higher level of protection should be used instead of a facemask when performing or present for an aerosol generating procedure (See Section 4). See appendix for respirator definition. Disposable respirators and facemasks should be removed and discarded after exiting the patient ' s room or care area and closing the door unless implementing extended use or reuse. Perform hand hygiene after removing the respirator or facemask. If reusable respirators (e.g., powered air-purifying respirators (PAPRs)) are used, they must be cleaned and disinfected according to manufacturer ' s reprocessing instructions prior to re-use. *When the supply chain is restored, facilities with a respiratory protection program should return to use of respirators for patients with known or suspected COVID-19. Those that do not currently have a respiratory protection program, but care for patients with pathogens for which a respirator is recommended, should implement a respiratory protection program. · Eye Protection *Put on eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face) upon entry to the patient room or care area, if not already wearing as part of extended use or reuse strategies to optimize PPE supply. Personal eyeglasses and contact lenses are NOT considered adequate eye protection. Remove eye protection before leaving the patient room or care area. Reusable eye protection (e.g., goggles) must be cleaned and disinfected according to manufacturer ' s reprocessing instructions prior to re-use. Disposable eye protection should be discarded after use unless following protocols for extended use or reuse. Gloves -Put on clean, non-sterile gloves upon entry into the patient room or care area. Change gloves if they become torn or heavily contaminated. Remove and discard gloves when leaving the patient room or care area, and immediately perform hand hygiene. · Gowns -Put on a clean isolation gown upon entry into the patient room or area. Change the gown if it becomes soiled. Remove and discard the gown in a dedicated container for waste or linen before leaving the patient room or care area. Disposable gowns should be discarded after use. Cloth gowns should be laundered after each use. If there are shortages of gowns, they should be prioritized for: *aerosol generating procedures *care activities where splashes and sprays are anticipated *high-contact patient care activities that provide opportunities for transfer of pathogens to the *hands and clothing of HCP. Examples include: *dressing *bathing/showering *transferring *providing hygiene *changing linens *changing briefs or assisting with toileting *device care or use *wound care Additional strategies for optimizing supply of gowns are available. · Facilities should work with their health department and healthcare coalition to address shortages of PPE. 3. Patient Placement · For patients with COVID-19 or other respiratory infections, evaluate need for hospitalization . If hospitalization is not medically necessary, home care is preferable if the individual ' s situation allows. · If admitted , place a patient with known or suspected COVID-19 in a single-person room with the door closed. The patient should have a dedicated bathroom. Airborne Infection Isolation Rooms (AIIRs) (See definition of AIIR in appendix) should be reserved for patients who will be undergoing aerosol generating procedures (See Aerosol Generating Procedures Section) · As a measure to limit HCP exposure and conserve PPE, facilities could consider designating entire units within the facility, with dedicated HCP, to care for patients with known or suspected COVID-19. Dedicated means that HCP are assigned to care only for these patients during their shift. Record review of CDC.gov website read in part: .HCP use of homemade masks: In settings where facemasks are not available, HCP might use homemade masks (e.g., bandana, scarf) for care of patients with COVID-19 as a last resort. However, homemade masks are not considered PPE, since their capability to protect HCP is unknown. Caution should be exercised when considering this option. Homemade masks should ideally be used in combination with a face shield that covers the entire front (that extends to the chin or below) and sides of the face. Record review of the facility's PPE inventory count provided to surveyor by the DON on 06/10/20 revealed as of 6/9/20 the facility had 1,010 N95's, 750 gowns, 1850 face masks, 170 face shields, 1,200 shoe covers, 17,000 XL gloves, 10,000 large gloves, 9,000 medium gloves, and 6,000 small gloves. Resident #1 Record review of Resident #1's face sheet revealed a [AGE] year old male admitted on [DATE] and readmitted on [DATE] with the following [DIAGNOSES REDACTED]. Record review of Resident #1's Post-Acute Care Facility Transfer COVID-19 assessment dated [DATE], 4 days prior to readmission, revealed a check mark next to the question, yes, test performed for COVID-19 on date 5/29/2020 there was check mark next to negative test. Record review of Resident # 1's significant change in status MDS assessment dated [DATE] revealed Resident #1 had a BIMS score of 12 out of 15 indicating moderately impaired cognition. Further review revealed Resident #1 required limited assistance with bed mobility, transfer, and personal hygiene. Resident #1 required extensive assistance with dressing and toilet use. Resident #1 was occasionally incontinent of bowel and bladder. Record review of Resident #1's care plans dated 06/02/20 read in part: .Problem: potential for complications related to respiratory infection COVID -19. Contact precautions, Quarantine monitoring for s/s COVID-19. Returned from hospital Quarantine x 14 days as a precaution. Approach: .contact precautions Quarantine monitoring for s/s COVID-19 as indicated .private room . Observation on 6/10/20 at 8:45 am revealed Resident #1's room door was open. The door had a sign outside that read, Report to nurse before entering, sequence for putting on PPE, and an O2 sign. There was PPE set up outside the room, biohazard baskets were observed inside the room. The PPE set up outside the door included: gloves, procedure droplet precaution masks, gowns, and hand sanitizer. A tray was observed sitting inside his room on the side table. Interview and observation with LVN A on 6/10/20 at 8:47 am, in the hallway, revealed she was wearing a cloth mask, which is not PPE. She said she was the nurse for Resident #1. She said Resident #1 was on isolation because he was a readmit from the hospital. When asked what all she puts on when going to Resident #1's room, who is on quarantine, she said she takes off her cloth mask and puts on the surgical mask that was set up outside, gown and gloves. She did not list a faceshield or N95 as part of the needed PPE. When asked why Resident #1's door was open to the hallway, she said Resident #1 was pretty independent and that he opens the door even though they close it. Resident #1's quarantine room was at the end of the hallway. Interview and observation with Medication Aide A on 6/10/20 at 9:00 am, revealed she was wearing a cloth mask, which is not PPE. She was on the hall which had quarantined and non-quarantined residents. She said she was assigned to pass medication to Resident #1. When asked what PPE she wore when she goes into Resident #1's room to give him his medication, she said she puts on a surgical mask, gown, and gloves. She did not list a faceshield or N95 as part of the needed PPE to care for a quarantined resident. At this time Resident #1 was observed standing at his door way, the Medication Aide A yelled out I am coming. When asked why the resident's room door was open, she said they close it but the resident always opens it because he likes to see what's going on. Interview and observation with CNA A on 6/10/20 at 9:07 am, she was observed wearing a cloth mask, which is not PPE, while on the hall where there were quarantined and non-quarantined residents. She said she was working with Resident #1. When asked why Resident #1 was on quarantine, she said it was because he just came back from the hospital and when they come from hospital they need to be quarantined for 14 days. When asked what PPE she put on when she went into Resident #1's room, she said she put on the surgical mask set up outside resident's room, a gown, and gloves. CNA A did not list a faceshield or N95 as PPE needed. When asked about Resident #1's tray that was sitting in his room, she said his tray was the last one she picks up and she brings it to the kitchen and lets them know it was Resident #1's. She said Resident #1 was pretty independent and he just needed help with dressing and putting on shoes. As CNA A was talking to the surveyor, her mask was going down below her nose, surveyor pointed this out to her and she said, Oh and raised up her mask. Interview and observation with CNA B on 6/10/20 at 9:10 am, revealed she was wearing a cloth mask, which is not PPE, while in a patient care area. She said the facility provided surgical masks, but she was wearing her own. She said she was not working with any quarantine residents today. When asked if she received any in-service on working with quarantine resident's she said she had. When asked what PPE would she wear for the residents on quarantine, she said she would wear, a gown, gloves, and a surgical mask. She did not list a faceshield as part of the needed PPE. Observation on 6/10/20 at 9:15 am outside of Resident #1's room, revealed CNA A was seen removing her worn cloth mask and hanging it on the hand rail. She then put on a surgical mask, gown, and gloves and entered Resident #1's room. She was not wearing a faceshield or goggles. The room door was open and she was observed to be talking to Resident #1. Resident #1 was not wearing a mask. They were not 6 feet apart. She was having a conversation with the resident. Further observation on 6/10/20 at approximately 9:20 am revealed CNA A coming out of Resident #1's room with no PPE on, including no mask. She stepped outside the room, used hand sanitizer, and then put on her cloth mask that was hanging on the hand rail. She then stepped back into Resident #1's room, approximately one step into the room, to grab his tray, came out, and went down the hallway. She left the hallway and carried the tray to the dining room and placed it on a table by the kitchen entrance. Interview with the DON on 6/10/20 at 9:35 am, she said if a resident was on quarantine then staff were required to wear surgical mask, gown, and gloves when going into that resident's room. She did not list any eye protection as being needed or an N95. She said if staff were wearing a cloth mask, they would have to remove the cloth mask, and don on surgical mask. She said she even put signs on the door to indicate how to put on and remove PPE. She said she had done so many in-services on COVID and also on putting on PPE. She said she was following CDC guidelines and watched webinars every Friday and all the webinar said that there was no need to follow any specific guidelines for residents on quarantine isolation. She said the webinar's and CDC had not said that N95's were required for residents on quarantine. She said they had no [MEDICAL TREATMENT] patients at this time and Resident #1 was the only one on isolation. She said Resident #1 could not come outside of his room and they knew the door needed to be closed but the resident always opened it. She said he had not been displaying any signs of COVID-19 and that he was tested at the hospital prior to coming to the facility and he was negative. She said they were checking the residents temperature every shift. She said if any residents were displaying signs of COVID-19 then they would isolate the resident, put on PPE, like an N95, goggles, gown, etc. She said Resident #1 had been at the facility for 8 days. She said Resident #1 did not have to wear a mask in his room, even if a staff member was inside, and that was ok for him to do. She said they were not wearing N95s and eye protection to go into his room because they were preserving PPE for when they really needed it. She said her only concern was with the CNA coming out of the room and then reaching back in the room to get the tray. She said the CNA should have stayed in the room and maybe handed the tray to someone that was in the hall before coming out. In another interview with the DON on 6/10/20 at 11:40 am, she said they were following the CDC guidelines and the state response plan. She said Resident #1's status was not unknown because he was tested while at the hospital and he was negative. She said Resident #1 was also not displaying any signs or symptoms. She said he was placed on quarantine just to be monitored. In an interview and observation on 6/10/20 at 12:16 pm with CNA C, she had a cloth mask on, which is not PPE, while in resident care area. She said CNAs were going room to room passing/setting up lunch trays right now. She said she had on a facility provided cloth mask. She said a mask and gloves were required to care for all the residents. In an interview and observation on 6/10/20 at 12:19 pm with CNA D, she had a cloth mask on in the resident care area. She said she was passing lunch trays. She said she had on a facility provided cloth mask. In an interview and observation on 6/10/20 at 12:26 pm with CNA E, she had a cloth mask on. She said CNAs were done passing lunch trays to the residents in their rooms. She said she had on a facility provided cloth mask. She said she was getting ready to feed the residents in their room that required assistance with feeding. Record review of the facility's policy for Emergent Infectious Disease policy (undated) read in part, .The center's emergency operation program will include a response plan for a community-wide infectious disease outbreak .COVID-19 .as part of the emergency operations plan, the center will maintain a supply of personal protective equipment including moisture-barrier gowns, face shields, foot and head coverings, surgical masks, assorted sizes of disposable N95 respirators and gloves .staff will be educated on the exposure risks, symptoms and prevention .and the use of the full complement of appropriate PPE including N95 masks, eye protection, gowns, gloves .PPE will be immediately available outside the door of the resident room .the center will identify dedicated staff to care for .residents and appropriate infection control training will be provided .signs will be posted on the door or wall outside of the residents room that clearly describes the type of precautions needed and required PPE .for Quarantine Residents, full complement of PPE, including N95 facemasks, eye protection, gowns and gowns will be immediately available outside of the resident room .

Based on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections involving 1 of 1 staff (CNA A) and 1 of 4 residents (Resident #1) reviewed for infection control in that: -CNA A failed to perform hand hygiene when changing gloves and wash or sanitize her hands when moving from a dirty area to a clean area when providing incontinent care to Resident #1. -CNA A contaminated clean resident use items by touching them while wearing contaminated gloves. These failures affected one resident and placed her at risk for cross contamination and/or spread of infection. Findings include: Record review of the admission sheet for Resident # 1 revealed she was an [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE]. Her [DIAGNOSES REDACTED]. Record Review of Resident #1's quarterly MDS assessment dated [DATE] revealed her staff assessment for mental status was conducted due to the resident was unable to complete the brief interview for mental status questions. She was assessed as having short term memory problems, long term memory problems, and cognitive skills for daily decision making was severely impaired never/rarely made decision. She was totally dependent on two persons physical assist for dressing, toilet use, and personal hygiene. She was always incontinent of bowel and bladder. Record review of Resident # 1's care plan initiated 6/17/16 revealed Resident experiences bladder and bowel incontinence R/T impaired mobility and dementia. Goal: Resident will remain free of skin breakdown. Resident will not show signs or symptoms of UTI over the next 90 days. Approach: Ensure adequate bowel elimination. Provide assistance for toileting in a timely manner. Asses her recognition of the need to void. Provide incontinence care after each incontinent episode. Apply skin barrier cream to peri area to prevent feces or urine from causing skin breakdown. Observation on 10/16/19 at 2:50 pm revealed, CNA A provided Resident #1 with incontinence care. CNA A removed Resident #1's brief and tucked it under the resident's buttocks. CNA A did not spread Resident #1's labia to thoroughly clean the area and the resident's urinary meatus. CNA A assisted Resident #1 to turn onto her left side in order to clean her buttocks. Resident #1 had a large bowel movement. CNA A placed the dirty bed pad on the floor near the trash can. CNA A during perineal care removed her gloves, did not wash or sanitize her hands. CNA A then put on new gloves, and continued with perineal care. CNA A completed perineal care and with the same soiled gloves on, touched the Resident's clean gown and brief. CNA A then removed her gloves, placed the dirty pad off the floor in a bag and left the room without washing or sanitizing her hands. In an interview on 10/16/19 at 3:05 pm CNA A said she had been working at the facility for the past two months as a full-time employee. She said she had received training from other CNAs on the floor upon hire. CNA A confirmed she did not spread Resident #1's labia and clean the resident's meatus during incontinent care. She said she should have washed her hands or used hand sanitize after changing gloves since the resident had a bowel movement. She said the failure placed the resident at risk for infections. She said she had been in-serviced on hand washing/ infection control sometime this month. She said she did not recall having to do the CNA competency check for incontinent care with the DON. In an interview on 10/16/19 at 3:10 pm with the DON and the Administrator, the DON said she expected staff to provide appropriate care to residents based on their needs. She said CNA A should have either washed or sanitized her hands after touching a dirty area prior to moving to a clean area when performing incontinent care. She said staff were in-serviced on infection control / hand hygiene upon hire and annually. She further said she provided monthly in-services on infection control to staff with return demonstration on how to provide appropriate incontinent care. Record review of the facility's Handwashing/Hand hygiene policy and procedure revised (MONTH) (YEAR) read in part: .this facility considers hand hygiene the primary means to prevent the spread of infections. Policy interpretation and implementation: .1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 3. Hand hygiene products and supplies (sink, soap, towels, alcohol-based hand rub, etc). shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies.6. Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: a. when hands are visibly soiled. 7. Use an alcohol-based hand rub containing at lease 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .b. before and after direct contact with residents; .h. before moving from a contaminated body site to a clean body site during resident care; i. after contact with a resident's intact skin; .m. after removing gloves.9. the use of gloves does not replace hand washing/hand hygiene. Integration of gloves use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections . Record review of the facility's Infection Control Guidelines for All Nursing Procedures policy revised (MONTH) 2012 read in part: .to provide guidelines for general infection control while caring for residents.3. Employees mush wash their hands for ten (10) to fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: a. before and after direct contact with residents; d. after removing gloves .

Based on observation, interview, and record review, the facility failed to ensure residents who were incontinent received appropriate treatment and services to prevent urinary tract infections for 1 of 2 residents (Resident #1) reviewed for incontinent care in that: - CNA A did not completely clean Resident #1 during incontinent care. These failures affected one resident and placed her at risk for urinary tract infections [MEDICAL CONDITION], urethral erosions, discomfort, skin breakdown, and a decreased quality of life. Findings include: Record review of the admission sheet for Resident # 1 revealed she was an [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE]. Her [DIAGNOSES REDACTED]. Record Review of Resident #1's quarterly MDS assessment dated [DATE] revealed her staff assessment for mental status was conducted due to the resident was unable to complete the brief interview for mental status questions. She was assessed as having short term memory problems, long term memory problems, and cognitive skills for daily decision making was severely impaired never/rarely made decision. She was totally dependent on two persons physical assist for dressing, toilet use, and personal hygiene. She was always incontinent of bowel and bladder. Record review of Resident # 1's care plan initiated 6/17/16 revealed Resident experiences bladder and bowel incontinence R/T impaired mobility and dementia. Goal: Resident will remain free of skin breakdown. Resident will not show signs or symptoms of UTI over the next 90 days. Approach: Ensure adequate bowel elimination. Provide assistance for toileting in a timely manner. Asses her recognition of the need to void. Provide incontinence care after each incontinent episode. Apply skin barrier cream to peri area to prevent feces or urine from causing skin breakdown. Observation on 10/16/19 at 2:50 pm revealed, CNA A provided Resident #1 with incontinence care. CNA A removed Resident #1's brief and tucked it under the resident's buttocks. CNA A did not spread Resident #1's labia to thoroughly clean the area and the resident's urinary meatus. CNA A assisted Resident #1 to turn onto her left side in order to clean her buttocks. Resident #1 had a large bowel movement. CNA A placed the dirty bed pad on the floor near the trash can. CNA A during perineal care removed her gloves, did not wash or sanitize her hands. CNA A then put on new gloves, and continued with perineal care. CNA A completed perineal care and with the same soiled gloves on, touched the Resident's clean gown and brief. CNA A then removed her gloves, placed the dirty pad off the floor in a bag and left the room without washing or sanitizing her hands. In an interview on 10/16/19 at 3:05 pm CNA A said she had been working at the facility for the past two months as a full-time employee. She said she had received training from other CNAs on the floor upon hire. CNA A confirmed she did not spread Resident #1's labia and clean the resident's meatus during incontinent care. She said she should have washed her hands or used hand sanitize after changing gloves since the resident had a bowel movement. She said the failure placed the resident at risk for infections. She said she had been in-serviced on hand washing/ infection control sometime this month. She said she did not recall having to do the CNA competency check for incontinent care with the DON. In an interview on 10/16/19 at 3:10 pm with the DON and the Administrator, the DON said she expected staff to provide appropriate care to residents based on their needs. She said CNA A should have either washed or sanitized her hands after touching a dirty area prior to moving to a clean area when performing incontinent care. She said staff were in-serviced on infection control / hand hygiene upon hire and annually. She further said she provided monthly in-services on infection control to staff with return demonstration on how to provide appropriate incontinent care. Record review of the facility's policy and procedure for Perineal Care policy revised (MONTH) (YEAR) read in part: .the purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition.Preparation: 1. Review the resident's care plan to assess any special needs of the resident. Steps in the procedure: b. wash perineal area, wiping from front to back. (1). Separate labia and wash area downward from front to back.e. wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks. Do not reuse the same washcloth or water to clean the labia.11. Discard disposable items into designated containers. 12. Remove gloves and discard into designated containers. Wash and dry your hands thoroughly .

Based on observation record review and interview the facility failed to prepare, serve and distribute food in accordance with professional standards for food safety in that: Food on the steam table was not at the correct holding temperature Plates and serving utensils with food stains and food particles Foods were not labeled and dated Expired foods in the dry storage room. These failures have the potential to affect all residents who ate foods prepared by the kitchen by placing them at risk of food borne illness and disease Findings include: Observation of the kitchen on [DATE] at 9:50 AM revealed the following: 1. Serving utensils with dried food particles 2. Plates with yellow food stains In an interview with the Dietary Manager on [DATE] at 10:20 AM she instructed the dietary aide to rewash the utensils and plates. She further said she had some plates on order to replace the plates and bowls that they were currently using. Observation of the side by side freezer [DATE] at 10:00 AM revealed the following: 1. A plain white container identified by Dietary Aide A as ice cream not labeled and dated. 2. A plain plastic bag identified by Dietary Aide A as chicken patties not labeled and dated. 3. A plain plastic bag with meat identified by the Dietary Aide A as salami not labeled and dated. 4. A plain plastic bag with waffles not labeled and dated. In an interview and observation on [DATE] at 10:05 with Dietary A she said would label and date that unlabeled and undated food items. Observation of the dry storage room on [DATE] at 10:10 AM revealed the following: 1. Nonfat dry milk with an expiration date of [DATE]. 2. Chicken bouillon cubes best used date of ,[DATE]. 3. Strawberry syrup with best used date of [DATE]. 4. Gluten free chocolate cookie mix with best used date of [DATE]. 5. Gluten free cake mix with best used date of [DATE] Observation of the steam table for lunch on [DATE] at 11:30 AM revealed mechanical chopped meat at a temperature of 120 degrees. At that point Cook A removed the menu item to be reheated to 165 degrees F. In an interview with the Dietary Manager on [DATE] at 2:00 p.m. she said she discarded the expired foods. She said the gluten free food products were purchase for a resident who was on a gluten free diet and did not like the gluten free product. She said she did not even know that the gluten free products had expired. She said the strawberry syrup was ordered over the weekend, so they must have missed checking the date on that one because the other syrup dates were current. Record review of the Operational Policy and Procedures Manual for Long Term Care revised (MONTH) 2019 entitled Food preparation and Service read in part . Food Preparation, Cooking and Holding Time/Temperatures 1. The danger zone for food temperatures is between 41 degrees F and 135 degrees F. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness. 2. Potentially hazardous foods (PHF) include meats, poultry, seafood, cut melon, eggs, milk, yogurt and cottage cheese. 3. The longer foods remain in the danger zone the greater the risk for growth of harmful pathogens. There, PHF must be maintained below 41 degrees F or above 135 degrees F. 11. Mechanically altered hot foods prepared for a modified consistency diet remain above 135 F during preparation or they are reheated to 165 degrees F for 15 seconds.