Every finding on record at Sagecrest Alzheimers Care Center

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs for four residents (Residents #2, #3, #6, #8, and #14) of twelve residents reviewed for care plans.The facility failed to have a comprehensive person-centered care plan for Resident #2, #3, #6, #8, and #14 to address the residents' diagnosis of dementia. The facility failed to have a comprehensive person-centered care plan to address Resident #2's hearing aids.These failures could affect residents and put them at risk for not receiving care and services to meet their needs.Findings include:Resident #2Record review of Resident #2's face sheet dated 12/11/2025, revealed resident was [AGE] year-old female with admission date 07/09/2021.Record review of Resident #2's history and physical dated 09/05/2025 revealed a medical history of Dementia (severe decline in cognitive function), and hearing loss. Record review of Resident #2's quarterly MDS dated [DATE] revealed a BIMS score of 0, indicating severe mental cognitive impairment. Section B titled, Hearing, Speech, and Vision, noted Resident #2 had moderate difficulty with hearing, and the speaker has to increase volume and speak distinctively. Section B also revealed Resident #2 had hearing aids. Section I titled active diagnosis indicated the resident had Alzheimer's Disease (a type of dementia that affects memory, thinking and behavior). Record review of Resident #2's care plan, last revised 09/19/25, revealed the resident's Dementia diagnosis and their hearing aids were not included.Resident #3Record review of Resident #3's face sheet dated 12/11/2025, revealed an [AGE] year-old female admitted to the facility on [DATE].Record review of Resident #3's history and physical dated 09/24/2025 revealed Resident #3 had a diagnosis of Dementia (severe decline in cognitive function).Record review of Resident #3's MDS dated [DATE] revealed Resident #3 had a BIMS of 03 indicating a severe cognitive impairment. Section I titled active diagnosis indicated the resident had Non-Alzheimer's Dementia (severe decline in cognitive function).Record review of Resident 3's Care Plan revised 10/16/2025 revealed the care plan did not indicate anything about a dementia diagnosis.Resident #6Record review of Resident #6's face sheet dated 12/11/2025 revealed an [AGE] year-old female admitted to the facility on [DATE].Record review of Resident #6's history and physical dated 5/15/2025 revealed Resident #6 had a diagnosis of Alzheimer's Dementia (severe decline in cognitive function).Record review of Resident #6's Quarterly MDS dated [DATE] revealed Resident #6 had a BIMS of 03 indicating a severe cognitive impairment. Section I titled active diagnosis indicated the resident had Non-Alzheimer's Dementia (severe decline in cognitive function).Record review of Resident #6's care plan revised 11/13/2025 revealed the care plan did not indicate anything about a dementia diagnosis. Resident #8Record review of Resident #8's face sheet dated 12/11/2025, revealed he was an [AGE] year-old male with admission date 05/21/2020.Record review of Resident #8's history and physical dated 11/17/2025, revealed a medical diagnosis of Dementia (severe decline in cognitive function).Record review of Resident #8's annual MDS dated [DATE], revealed a BIMS score of 3, indicating severe cognitive impairment. Section I titled active diagnosis indicated the resident had Non-Alzheimer's Dementia (severe decline in cognitive function).Record review of Resident #8's care plan, last revised 10/02/25, revealed the resident's Dementia diagnosis was not included.Resident #14Record review of Resident #14's face sheet dated 12/09/2025, revealed an [AGE] year-old male with admission date 05/13/2025.Record review of Resident 14's history and physical dated 11/17/25, revealed a medical diagnosis of Dementia (severe decline in cognitive function).Record review of Resident #14's quarterly MDS dated [DATE] revealed the resident could not complete the BIMS test.Record review of Resident #14's care plan, last revised 09/19/25, revealed the resident's Dementia diagnosis was not included.In an interview on 12/11/2025 at 1:42 PM with RN A, she stated the purpose of the care plan was for staff to provide the residents' needs, the best care the facility could provide. RN A stated that the care plan was reviewed and revised quarterly by the MDS nurse. RN A stated nursing staff also revised the care plan as needed for changes in the residents' conditions, such as transfer assistance from 1-person assist to 2-person assist. RN A stated that the MDS nurse was responsible for monitoring the care plan overall. RN A stated the potential risks of residents' conditions, needs, or adaptive aids, were not included in the care plan, then staff could not provide specific care to meet the residents' needs or that they required adaptive aids. She stated that if the Dementia diagnosis was not included in the care plan, staff could not monitor or provide specific care to residents. She stated the last in-service for care plans was in 10/2025.In an interview on 12/11/25 at 2:08 PM with the MDS nurse, she stated the purpose of the care plan was for staff to know how to care for the resident. She stated the initial care plan was done within 48 hours by the MDS nurse herself. She stated the comprehensive care plan was completed within the resident's first 20 days of admission. She stated residents' care plans were reviewed quarterly by herself, as the MDS nurse. She stated the facility did not include the Dementia diagnosis in the care plans, but the facility added the BIMS score of each resident in the care plan, which was under cognitive loss. She stated that cognitive loss covered the Dementia diagnosis of the residents and their needs. She stated there were no potential risks, because there were other parts of the chart that indicated the residents' dementia diagnosis and their needs. She stated Resident #2's hearing aids should have been added to the care plan, so staff were aware the resident required them and for staff to monitor. She stated the last in-service for care plans was in 10/2025.In an interview on 12/11/2025 at 2:48 PM with the DON, he stated the purpose of the care plan was for staff to provide a continuity of care to residents. He stated that nursing staff monitored the care plan with the MDS nurse who coordinated the care plan, and the nursing staff monitored the care plan as needed. He stated the facility did not include the Dementia diagnosis in the care plan, but the care plan notated the residents' cognitive statuses under BIMS and included interventions for staff. He stated that the care plan and residents' BIMS scores were reviewed quarterly. He stated there were no potential risks for the residents not having the Dementia diagnosis care planned, since the BIMS was included. He stated the potential risk for Resident #2's hearing aids not being care planned could be loss of the hearing aids.Record review of facility policy, Resident Plan of Care, dated 10/09/2025, revealed in part: 1. An initial plan of care will be developed within 48 hours of the resident's admission. This will address immediate care needs, including, but is not limited to, dietary needs, medications, and routine treatments. 2. A comprehensive care plan will be developed within 7 days of completion of the resident's comprehensive assessment (MDS). The Interdisciplinary team develops it . 4. The care plan will identify problem areas and interventions needed to meet the needs of the resident. 5. Assessments of residents are on-going, and care plans are revised as information about the resident and his/her condition changes.

Based on observations, interviews, 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 for 1 (Resident #9) of 6 residents observed for oxygen management. The facility failed to clean the oxygen concentrator air filter for Resident # 9 while the oxygen was in use. This deficient practice could affect residents receiving oxygen therapy and could contribute to an upper respiratory infection and a resident's decline in physical health. The findings included: Resident #9 Record review of Resident #9's face sheet dated 12/11/2025, revealed the [AGE] year old resident was admitted to the facility on [DATE] with diagnosis of chronic obstructive pulmonary disease (a progressive lung disease that blocks airflow, making it hard to breathe). Record review of Resident # 9's MDS dated [DATE] revealed a brief interview for mental status score of 07, indicating severe cognitive impairment. Section O special treatments procedures and programs indicated use of oxygen therapy. Record review of Resident #9's Physician's orders, dated 07/22/2025, revealed an order for oxygen Two Times Daily (Starting 7/22/2025 Days, Nights) via nasal canula at 2-4 Liters per min for SOB / comfort. Record review of Resident # 9's care plan revised 11/06/2025, revealed Resident #9 had a potential for distressed respiratory effort. Had oxygen for SOB and or comfort. Interventions included to administer oxygen as ordered. During an observation of Resident #9 in his room on 12/09/25 at 10:34 AM revealed that the resident's oxygen concentrator was in operation and that the air filter appeared to have dust collected on it. During an interview with the Plant Manager on 12/11/2025 at 11:23 AM revealed that the oxygen concentrators belonging to the facility were cleaned every 30 days. He stated that Resident #9's oxygen concentrator was from a local hospice agency. He stated that maintenance did not check the oxygen concentrators brought in by outside companies. He stared that if there was a problem with it, the facility would notify the hospice agency, and they would come in and check on it. He stated that there was minimal risk to the resident's health because it was a HEPA filter (a denser filter). He said the filters trapped a lot more air particles. He stated that those filters needed to be changed less frequently. During an interview with RN A on 12/11/2025 at 12:40 PM revealed that all the oxygen concentrators in the building were checked on a monthly basis by maintenance. She stated that nurses were responsible for checking the oxygen concentrator, but the nurses mostly check if the concentrator was set to the right amount of liters. She stated that the air filters were not checked by staff, but they were checked once a month by maintenance. She stated that if the nurses see a problem with the concentrator before the monthly check, then they were to let maintenance know and if it was a hospice concentrator they were to call the hospice agency as well and let them know; then the hospice company would then send someone out to the facility to check it. She stated that the hospice company did not regularly go to facility to check the oxygen concentrators, only if called. She stated that a dirty air filter affected the resident by affecting the quality of oxygen that they were receiving. The resident may not be receiving the adequate amount of air due to a clogged filter. She stated that she could not recall the last Inservice over oxygen concentrators. During an interview with the ADON on 12/11/2025 at 1:19 p.m., revealed that oxygen concentrators were checked monthly to include air filter cleaning. She stated that maintenance was responsible for cleaning the air filter. She stated that the nurses were only responsible for ensuring that the tubbing was changed monthly and that it was set at the appropriate amount of liters as per doctors' orders. She stated that maintenance did not regularly check hospice concentrators only facility owned concentrators. She stated that nurses would have to call the hospice company, and they would send someone out to check it. She stated that the risk to the resident was dependent on the filter and she had heard it was a HEPA filter and that those filters needed to be changed out less frequently. She stated that it posed a potential risk for the resident to not receive clean air. She stated that there has not been any formal training on checking oxygen concentrator filters. During an interview with the DON on 12/11/2025 at 1:59 p.m. revealed that maintenance checked the oxygen concentrators monthly to include filters. Maintenance would only check the oxygen concentrators that were owned by the facility. He stated that he was not sure if an outside company came in to check on the concentrators belonging to the hospice. He stated that if there was an issue with the concentrator identified by the nurses, then they would contact the hospice agency. He stated the nurses were only responsible for checking the humidifier, tubing and the setting, but not the filters. He stated that the risk to the resident would be that the resident was not receiving clean air, or the adequate amount of oxygen as indicated. He stated that there has not been a formal training on checking the oxygen concentrator, but there had been a respiratory training in October with annual competencies. Per facility Administrator, on 12/11/2025 at 4:13p.m., she stated that there was not a policy regarding oxygen concentrators.

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 to help prevent the development and transmission of communicable disease and infections for one (Resident #1) of three residents reviewed for infection control practices. CNA A failed to perform proper hand hygiene and glove changes while providing incontinence care to Resident #1. This failure could place residents at risk for the spread of infection. Review of Resident #1's face sheet dated 07/24/25, revealed an 86- year- old male admitted to the facility on [DATE] with diagnoses including covid-19, acute upper respiratory infection, constipation, abnormalities of gait and mobility. Review of Resident #1's MDS assessment dated [DATE] revealed Resident #1 are was dependent on staffs for most activities of daily living (ADLs) and one-person physical assistance with transfer. Resident #1 was frequently incontinent of bowel and bladder. Review of Resident #1's Care Plan dated 07/03/25 revealed Resident #1 was frequently incontinent of bowel most of the time. Its The goal was to manage episodes of bowel incontinence as needed. Observation of incontinence care for Resident #1 on 07/23/2025 at 10:42 a.m. revealed CNA A washed her hands prior to donning gloves. CNA A removed Resident #1's brief that was soiled with urine and fecal matter. CNA A wiped the resident from front to back. She changed her gloves and repositioned Resident #1. CNA A continued to clean the resident. CNA A's gloves were visibly soiled with urine and fecal matter. She did not wash her hands, change gloves or perform hand hygiene before retrieving Resident #1's clean brief and placing it underneath the resident and fastening. She removed her gloves and picked up the trash. CNA A washed her hands before exiting Resident #1's room. In an interview on 07/23/2025 at 10:50 a.m. with CNA A, she revealed she should have washed her hands and changed her gloves before retrieving a clean brief and placing it underneath Resident #1. CNA A stated she has been employed in the facility for 16 years and received infection control training about 1 month ago. She stated cross contamination was mixing clean with dirty which happened while providing care to Resident #1. CNA A noted she was nervous which caused her not to follow standard precautions. She said the resident could acquire an infection when she did not follow good infection control practices including not changing gloves before retrieving Resident #1's clean brief. During an interview with the DON on 07/24/2025 at 11:49 a.m., he revealed he was aware of some of the concerns raised about infection control. He stated he expected the aides to follow the facility's protocols during care, one of which was to ensure hand washing and change of gloves as needed while providing care. He noted CNA A has been in the facility a long time and one of the best staffs. He said she must have been nervous. The DON stated the employees receive infection control training annually and periodically as needed. He explained the facility monitors the employees by observing them give care to the residents. Review of the facility's Hand hygiene policy revised November 26, 2024, reflected, Hand hygiene is the most important procedure for preventing the spread of infections. Hand hygiene should be performed:1) Upon arrival at the workplace and before going home2) After using the toilet, blowing nose, and covering a cough or sneeze3) Before and after eating4) Before and after client contact5) After removing gloves6) Before invasive procedures 7) After touching contaminated items.

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, the comprehensive person-centered care plan, the residents' goals and preferences for 1 of 1 resident (Residents #19's) reviewed for respiratory care. 1. The facility failed to ensure Residents #19's nasal cannula was kept in a bag while not in use. These failures could place residents at risk for infections and transmission of communicable diseases. The findings included: 1. Record review of Resident #19's face sheet, dated 09/18/2024, reflected a [AGE] year-old male, who was admitted to the facility on [DATE]. Resident #19 had diagnoses which included Hypertension (high blood pressure), Shortness of breath, Depression, Anxiety, chronic obstructive pulmonary disease (a lung disease that blocks airflow and makes it difficult to breathe). Record review of Resident #19's MDS annual assessment, dated 10/31/2023, reflected a BIMS score of 06, which indicated severe cognitive impairment. Section I: Active diagnosis reflected chronic pulmonary disease, or chronic lung disease. Section O: Respiratory Treatments was marked for Oxygen Therapy. Record review of Resident #19's Physician Orders, dated 09/18/2024, reflected an order for Oxygen at 3 liters per minute via nasal cannula to maintain 02 saturation above 90% Change oxygen and nebulizer tubing weekly. Record review of Resident #19's quarterly Care Plan, 09/18/2024, reflected a care plan for has COPD (obstructive pulmonary disease) - Oxygen at 3 liters per minute continuously to keep oxygen saturation above 90%. The Care Plan did not have an intervention regarding when oxygen tubing needed to be changed. In an observation on 09/17/2024 at 10:30 AM revealed Resident #19 was sitting in the dayroom in his wheelchair. His nasal cannula was uncovered and hanging over the bed rail in his room with the nose prongs on floor. In an observation and interview on 09/18/2024 at 5:45 AM, during morning rounds, revealed Resident #19 was sitting in his wheelchair in his room and his nasal cannula was uncovered and hanging over the concentrator in his room with the nose prongs on floor . In an Interview on 09/18/2024 at 4:45 PM the DON stated oxygen tubing was changed weekly based on the resident's orders, or as needed if the tubing become contaminated or occluded. The DON said oxygen tubing and the humidifier bottle should be changed per doctor's orders and the nasal cannula should have been stored in a plastic bag when not in use to prevent cross contamination and infection. He said the charge nurses were responsible for seeing that it was done. In an Interview on 09/18/2024 at 5:00 PM the Administrator stated the resident care was handled by the nursing department and nasal cannulas should be put in a plastic bag when not in use. The facility was unable to provide a policy for Respiratory Therapy -Prevention of Infection.

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 to help prevent the development and transmission of communicable diseases and infections for one (Resident #11) of two residents reviewed for infection control practices. CNA A failed to perform hand hygiene and change gloves as appropriate while providing incontinence care for Resident #1 This failure could place residents at risk for cross contamination and the spread of infection. Findings included: Review of Resident #11's face sheet, dated 9/19/24, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of urinary tract infection, essential hypertension (high blood pressure), chronic kidney disease (loss of kidney function). Review of Resident #11's Minimum Data Set (MDS) assessment dated on 09/3/24, revealed Resident #11, BIMS score of 15 (cognitively intact), required partial/moderate dependence with most activities of daily living (ADL's) with two-person assistance. She was frequently incontinent of bowel and bladder. Observation on 9/18/24 at 5:56 PM of incontinence care for Resident #11 revealed CNA A assisted the resident to bed. CNA A put on gloves, removed the brief that was soiled with urine and feces from Resident #11. CNA A wiped the resident from front to back with wipes, cleaning both urine and feces. CNA A gloves were soiled with urine and feces, but she continued to use. CNA A did not change gloves or perform hand hygiene but proceeded to retrieve Resident #11's clean brief. CNA A placed the clean brief on the resident, fastened the brief, then pulled up pajama pants into position on the resident . In an interview on 9/18/24 at 6:06 PM CNA A stated that after performing pericare including cleaning urine and fecal material from the resident, her hands/gloves were dirty. CNA A further stated that when going from dirty to clean they should always perform proper hand hygiene and lack of doing so could cause infections . Interview on 9/18/24 at 6:16 PM with the DON revealed his expectation was for clinical staff to follow infection control policy and use proper hand hygiene. The DON further stated that not following proper hand hygiene could lead to cross contamination and infection. The DON also stated that the clinical staff was responsible for following infection control policy and that he was ultimately responsible infection control. Interview on 9/19/24 at 11:55 AM the Administrator revealed her expectation was for staff to follow infection control policy and to use proper hand washing including washing between dirty and clean. The ADM further stated that lack of doing so could cause infection. ADM also stated that everyone in facility is responsible for infection control and proper hand hygiene. Review of Hand Hygiene policy from BRS Operations and Service Standards Manual revised on July 16, 2024 indicated the following [in-part]: Service Standard: Handwashing is the most important procedure to follow to prevent the spread of infection. Associates are expected to follow the CDC guidelines related to hand hygiene. Hand hygiene is the most important procedure for preventing the spread of infections. Hand hygiene should be performed: After touching contaminated items Review of Clinical Safety: Hand Hygiene for Healthcare Workers from the Centers for Disease Control and Prevention (https://www.cdc.gov/handhygiene/providers/index.html ) accessed on 9/19/24 indicated the following: Know when to clean your hands: Immediately before touching a patient. Before performing an aseptic task such as placing an indwelling device or handling invasive medical devices. Before moving from work on a soiled body site to a clean body site on the same patient. After touching a patient or patient's surroundings. After contact with blood, body fluids, or contaminated surfaces. Immediately after glove removal. When to change gloves and clean hands If gloves become damaged. If gloves become soiled with blood or body fluids after a task. If moving from work on a soiled body site to a clean body site on the same patient or if a clinical indication for hand hygiene occurs. If moving from care on one patient to another patient. If they look dirty or have blood or body fluids on them after completing a task. Before exiting a patient room.

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 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure stored foods were properly labeled and dated. 2. The facility failed to ensure that expired foods were discarded. These failures could affect residents who received meals prepared meals from the kitchen at risk for food borne illness and cross-contamination. The findings included: Observation on [DATE] at 9:10 AM of the kitchen dry storage room revealed: -8, 5lb bags of deluxe cornbread mix with no expiration or best by date -1, 7lb6oz container of sliced strawberry topping with no expiration or best by date -4, 6lb bags of chocolate flavored brownie mix with no expiration or best by date -1, 5lb bag of graham cracker crumbs with no expiration or best by date -1, 5lb bag of snowflake sweetened coconut with no expiration or best by date -12, 16oz bags of whipped topping mix with no expiration or best by date -2, 24oz bags of cherry gelatin mix with no expiration or best by date -3, 24oz bags of banana instant pudding/pie filling with no expiration or best by date -1, 24oz container of caramel flavored sauce with no expiration or best by date -1, 1-gallon jar of dill slices with no expiration or best by date -1, 1-gallon jar of dill spears with no expiration or best by date -1, 1-gallon jug of rice wine vinegar with no expiration or best by date -11, 24oz bags of orange gelatin mix with no expiration or best by date -8, 24oz bags of instant lemon pudding/pie filling with no expiration or best by date -8, 24oz bags of chocolate pudding/pie filling with no expiration or best by date -3, 5lb bags of white cake mix with no expiration or best by date -17 boxes of individually wrapped oatmeal cream pies (12 pies per box) with no expiration or best by date -13, 36oz boxes of long grain wild rice with no expiration or best by date -3, 1-gallon containers of mayonnaise with no expiration or best by date -7, 20.35oz bags of sliced scalloped potatoes with no expiration or best by date -28, 4oz containers of mixed fruit in pear juice with no expiration or best by date -10, 12oz bottles of tartar sauce with expiration date of [DATE] -3, 64oz bottles of 100% prune juice with expiration date of [DATE] In an interview on [DATE] at 10:00 AM, the Dietician and Dietary Manager, both were advised of expired food items and lack of expiration/best by dates on food items found during initial inspection of the kitchen. The DM stated that the expired prune juice and the tartar sauce would be disposed of immediately. The Dietician stated that the supplier had been sending the facility items that were very close to the expiration date all the time and they tried to make sure the dates were good before they put anything in the storage areas. The Dietician stated the staff just overlooked the dates on the last delivery. The DM stated that they did not have a system for writing use by dates on food items that were delivered without expiration or use by dates on the label. The DM acknowledged that the staff did have stickers with an area for the date the item was received and a use by date to be written in and then placed on the food item prior to putting it on the shelf. The DM stated the stickers do not always get placed on items. Both stated there should have been a better system in place to prevent expired foods from remaining in the kitchen past their expiration dates. Observation of unit refrigerator #1 on [DATE] at 10:10 AM revealed: -4, 12oz bottles of tartar sauce with expiration date of [DATE] -2, 3.5L containers of apple juice concentrate with no expiration or best by date -2, 3.5L containers of orange juice concentrate with no expiration or best by date -1, 3.5L container of cranberry juice concentrate with no expiration or best by date -1, 12oz bottle of squeeze vegetable oil spread with expiration date of [DATE] -2, 12oz bottles of squeeze vegetable oil spread with expiration date of [DATE] Observation of unit refrigerator #2 on [DATE] at 10:20 AM revealed: -2, 3.5L containers of apple juice concentrate with no expiration or best by date -1, 3.5L container of cranberry juice concentrate with no expiration or best by date -1, 3.5L container of orange juice concentrate with no expiration or best by date -3, 12oz bottles of tartar sauce with expiration date of [DATE] In an interview on [DATE] at 10:35 AM, the Dietician was advised of expired and undated items in unit refrigerators. The Dietician stated that the juice concentrate containers were supposed to be dated when they were removed from the freezer for use. She stated she did not know why the concentrate containers were not dated. She stated that the expired food items would be disposed of immediately. Review of undated facility policy titled Food Storage & Time Guidelines, revealed, in part: To maintain food quality and prevent foodborne illness, food should be stored for a limited amount of time. Always follow these general storage guidelines: - Label food with its expiration date. - If there is a question about a product's storage or expiration, discard it.

45411 48043 Based on observation, interview, and record review the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 4 of 16 residents (Residents #2, #24, #30 and #45) reviewed for care plans in that: Resident #2 had no care plan in place to address his oxygen use. Resident #24 had no care plan in place to address her oxygen use. Resident #30 had no care plan in place to address the need for palliative care. Resident #45 had no care plan in place to address his Out-Of-Hospital-Do-Not-Resuscitate status. This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs. The findings included: Review of Resident #2's Face Sheet, dated [DATE], revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included quadriplegia (unable to use arms or legs), malaise (general feel bad for unknown reason), and respiratory disorders. Review of Resident #2's Annual MDS Assessment, dated [DATE], revealed: He scored a 15 of 15 on his mental status exam with no signs or symptoms of delirium (indicating he was cognitively intact). He received special treatments while a resident that included oxygen. Review of Resident #2's Order Summary, dated [DATE], revealed orders dated [DATE] for oxygen at 2 - 4 L/min per nasal cannula as needed. Observation on [DATE] at 9:30 a.m. showed Resident #2 in bed with the head of bed raised. Resident #2 had oxygen on. Review of Resident #2's Care Plan, revision undated, revealed no care plan for the oxygen use. Resident #24 Review of Resident #24's Face Sheet dated [DATE] revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included respiratory failure with hypoxia (low levels of oxygen in the blood) and congestive heart failure. Review of Resident #24's Admission MDS assessment, dated [DATE], revealed: She had active diagnoses of heart failure and respiratory failure. She received special treatments prior to admission and as a resident that included oxygen therapy. Review of Resident #24's Physician Order Sheet, dated [DATE], revealed the following: Albuterol sulfate HFA 90 mcg/actuation aerosol inhaler (2 puffs) as needed every 4 hours (order date [DATE]) Oxygen at 2 L/min per nasal canula continuous (order date [DATE]) Observation on [DATE] at 2:49 PM revealed Resident #24 sitting in her wheelchair in her room after returning from an appointment. Resident #24 was waiting to be assisted to her bed and was wearing a nasal canula attached to a portable oxygen tank set to 2 L/min. Observation on [DATE] at 3:03 PM revealed Resident #24 resting in bed with oxygen via nasal canula attached to her in room oxygen machine at 2 L/min. Review of Resident #24's Care Plan, revision undated, revealed no care plan for oxygen use. Resident #30 Review of Resident #30's Face Sheet dated [DATE] revealed he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included diabetes, dementia, altered mental status, pain, and muscle weakness. Review of Resident #30's quarterly MDS Assessment, dated [DATE], revealed. He scored a 3 of 15 on his BIMS and showed no signs of delirium (indicating severe cognitive impairment). He needed extensive assistance of one or two staff for all ADLs except eating. Review of Resident #30's Nurse's Notes, revealed notes dated [DATE]: Resident #30's son has now signed Out of Hospital Do Not Resuscitate for elder. Resident #30's son also sent an email expressing the following In light of my conversation with Nurse Practitioner in [DATE], Resident #30's nurse yesterday, Resident #30's latest BIMS score of 3, and after consultation with Resident #30's daughter who is in agreement with this action, [the son] has signed his OOH-DNR order. I've included the Palliative Care form I signed in January as well. Resident #30's son had previously signed Palliative Care back in January however, soon after signing, he expressed he wanted to retract it. Resident #30's son is now in agreement with palliative care services for elder. Review of Resident #30's Care Plan, revision date unknown, revealed: Problem: Advanced Directives: Resident #30 has the following advanced directives; (DNR/OOHDNR, POA Medical or POA Financial, Living Will or Directive to Physicians) Palliative Care signed Goal: Resident #30 /or Family will have wishes respected regarding Directives over next 90 days. Interventions: Hospice referral for Resident #30 as needed. Resident #30 will have DNR/OOHDNR available in the chart. Resident #30's chart will be designated with the appropriate DNR/Full Code status. Support Resident #30 and family with their decisions and respect choices made. Interview on [DATE] at 3:30 PM the ADON stated she was part of the care plan process. She stated when a resident was admitted to the facility there was a care plan that was completed within 48 hours of the initial admission, and it was just part of the admission a RN had to complete. She said by day 20 the resident would have a comprehensive care which was completed by the nursing department, social work, activities, and the dietician. The ADON stated she expected to see ADL status, pain, skin issues, nutrition, hydration, mood, behaviors, cognition, fall risk and just about anything else you would think was pertinent to the resident's care. The ADON stated if the Resident had the oxygen all the time, she would expect a care plan. The ADON reviewed Resident #2's chart and said she did not see a care plan for his oxygen use. Interview on [DATE] at 11:23 AM, the ADON stated an interdisciplinary team did the care plans. The ADON stated Social Work, Activities, and the Dietician were also involved with care plans. The ADON said the expectation for what should be on the care plan included ADL status, pain, falls, skin conditions, psychosocial wellbeing, nutrition, advanced directives, mood, and behaviors. The ADON said specific diagnoses would be care planned if the resident took a medication for it, she added she did not care plan every medication the resident was on. The ADON elaborated that she would care plan a medication if it was about pain, or stuff at affected the resident's continence status. She said respiratory stuff could be care planed . should be care planned if the resident had cardiac diagnoses that affected the oxygen saturations. The ADON stated Resident #24 did have continuous oxygen and an as needed inhaler. The ADON said Resident #24 had not received the as needed inhaler since her admission. The ADON stated she could see why respiratory issues were separate from cardiovascular disfunction. The ADON said palliative care was care planned under advanced directives and did not require its own category. Then the ADON stated she did not know if it would require its own category, she said Palliative Care had its own EMR section and a place information would be scanned in. The ADON stated a resident would have a separate care plan for hospice. Interview on [DATE] at 11:44 AM the DON stated the OOHDNR was the residents CPR status while palliative care was about the resident or family's end of life wishes. The DON said a resident could have an OOHDNR and not be on palliative care so they would require separate care plans. The DON stated the facility would put the approaches together because it was about what the resident's wishes were. The DON read Resident #30's care plan on advanced directives and agreed the care plan did not cover services provided about the palliative care. The DON stated the facility did have a corporate nurse who would come to the facility and audit the care plans at least annually. Resident #45 Review of Resident #45's Admission Record, dated [DATE], revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: Disorder of the autonomic nervous system, Encounter for surgical aftercare following surgery on the digestive system, Other Secondary Parkinsonism, Torticollis, Ataxia, Drug induced subacute dyskinesia, Major Depressive Disorder, Anxiety Disorder, Polyosteoarthritis, Hyperlipidemia, Retention of urine, Essential Hypertension, Gastroesophageal Reflux Disease without Esophagitis, Chronic Diastolic Heart Failure, Pain, Constipation, Benign Prostatic hyperplasia with lower urinary tract symptoms, Malnutrition, and Polyneuropathy. Review of Resident #45's Admission MDS, dated [DATE], revealed: -He had clear speech and had no difficulty in normal conversation, social interaction, listening to TV. He did wear hearing aids. -He scored a 10 of 15 on his mental status exam showing moderate signs of impairment. Review of Resident #45's Physician Order Summary Report, dated [DATE], revealed orders: -Out-of-Hospital-Do-Not-Resuscitate (OOH-DNR) (order dated [DATE]) Review of Resident #45's Care Plan dated [DATE] revealed no care plan in place for the Out-of-Hospital-Do-Not-Resuscitate Order. In an interview on [DATE] at 9:00 AM, the DON and ADON stated the facility will always address Out of Hospital Do Not Resuscitate Orders in Care Plans. The ADON stated that she completes the Care Plans, and this was always addressed. Review of facility policy Resident Plan of Care, revised [DATE], revealed, in part: Utilizing the resident assessment (MDS) an interdisciplinary team will develop a plan of care for each resident with input from the resident and/or family. 1. An initial care plan will be developed within 48 hours of the resident's admission. This will address immediate care needs, including, but is not limited to, dietary needs, medications, and routine treatments. 2. A comprehensive care plan will be developed within 7 days of completion of the resident's comprehensive assessment (MDS). The Interdisciplinary Team develops it. 3. The plan of care will include input, if given, from the resident and/or the resident's a. family, or the resident's legal representative. All are encouraged to participate in the development of the care plan and subsequent changes to the care plan. 4. The care plan will identify problem areas and interventions needed to meet the needs of the resident. 5. Assessments of residents are on-going and care plans are revised as information about the resident and his/her condition changes. 6. The Interdisciplinary Team is responsible for updating the care plan: a. When there has been a significant change in the resident's condition; b. When the desired outcome is not met; c. When the resident has been readmitted to the nursing community from a hospital stay; and d. At least quarterly. The Discharge Plan of Care will be developed in coordination with the resident/resident representative to provide for an effective transition to the post-discharge location.

Based on observation, interview, and record review the facility failed to store all drugs and biologicals in locked compartments for 2 of 4 medication carts reviewed for medication storage in that: MA B failed to ensure the medication cart was secured when it was left unattended. LVN A failed to ensure the treatment cart was secured when it was left unattended. These failures could place residents at risk for drug diversion or accidental ingestion. Findings included: During an observation on 07/18/23 at 09:10 AM the medication cart for hall 200 was seen unlocked and unattended. Inside the cart were several medication packets and pill bottles. During an interview on 07/18/23 at 09:14 AM MA B said if she did not push all the cart drawers then they would not all lock. MA B said she thought she had locked the medication cart before she had stepped away. MA B said she knew that she had to make sure the cart was locked because there were some residents that might try to open the drawers on the medication cart and could get access to the medications. During an observation and an interview on 07/19/23 at 10:15 AM the treatment cart for hall 200 was seen unlocked and unattended for approximately 10 minutes. Inside the cart were several medications, ointments and scissors. LVN A said whenever they stepped away from the carts, they were supposed to make sure they were locked. LVN A said he must have forgotten to lock the cart when he stepped away. LVN A said it could be possible for some residents to get into the items in the cart and injure themselves and that he would be more careful to make sure and lock the cart when leaving it unattended. During an interview on 07/20/23 at 11:14 AM the DON said if the medication or treatment carts were out of the staff's eyesight that they had to be locked. The DON said if the carts were left unlocked and unattended a resident could get access of the medications, items that were in the carts and could ingest them. The DON also said staff that were not authorized to the carts could have access to them. The DON said the failure probably occurred because staff got in a hurry and forgot to lock the cart. During an interview on 07/20/23 at 11:36 AM the Administrator said if the staff stepped away from their medication cart or treatment cart, they were supposed to make sure the carts were locked, and nothing left out on the top of the carts. The Administrator said residents could get into the medication cart and possibly ingest medications or ointments due to staff leaving the carts unlocked and unsupervised. Record review of the facility policy titled storage of medications dated 4/8/18 indicated in part: The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner. Any compartments containing drugs and biologicals shall be locked when not in use and are not to be left unattended if open. Only persons authorized to prepare and administer medications should have access to the medication room and medication cart including any keys.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services, including procedures that ensure the accurate administering of all drugs to meet the needs of the residents for 1 of 1 wound care/treatment carts inspected for medication storage in that: There were several expired items found in the facility's wound care/ treatment cart. This failure could place residents at risk of receiving medications that were expired and not produce the desired effect. Findings included: During an observation and record review on 07/19/23 at 3:28 PM the wound care/treatment cart was observed with LVN C present. Observation revealed the following expired supplies and medications: 2 catheter stabilization device kits expired 02/28/2021; 1 Antimicrobial 10 X 12.5 cm dressing expired 3/28/2022; 9 Absorbant wound dressings expired 03/2021; 1 Antimicrobial skin and wound gel (3 oz. tube) expired 05/28/2022; 1 Wound solution (16 fluid oz. bottle) expired 04/2021; 1 PICC line dressing change kit expired 11/30/2019; 2 Duoderm wound dressings expired 06/2022; 1 Non-adhering dressing (3 in. X 3 in.) expired 12/2022. During an interview on 07/19/23 at 3:45 PM, LVN C said that she usually checks the carts when she was working. LVN C stated that she was unaware that the expired supplies were in the cart. LVN C stated that she will throw them out immediately. During an interview on 07/20/23 at 08:45 AM, the DON stated that the nurse assigned to the unit should be checking their medication carts, treatment carts and medication room daily for expired medications and supplies. The DON stated that he rounds and checks the med carts but forgets about the treatment carts and supplies in certain areas. The DON stated he needs to ensure that expired medications were removed from the medication room and medication carts for residents safety. During an interview on 07/20/23 at 9:00 AM, the Administrator stated that DON and ADON should be rounding each unit and checking for expired meds and supplies. The Administrator stated that staff were expected to work as a team to ensure resident safety. Record review of the facility's policy titled Storage of Medications revised 04/02/2018 indicated in part: The facility may not use medication that has been discontinued, outdated, or has deteriorated. In these cases, medication is returned to the dispensing pharmacy or destroyed by the pharmacist and licensed nursing staff.

Based on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure dietary staff performed hand washing/sanitation, and appropriate glove and hairnet use to reduce the risks of cross-contamination. These failures could place residents at risk of food-borne illness. Findings include: Observations in Kitchen 05/18/22 10:30 AM - 12:00 PM: An unknown female staff came in the back door of kitchen, which was left ajar, with a rolling ice chest. She was not wearing a hairnet. She donned gloves without first washing her hands. She scooped ice from the ice machine into the rolling ice chest. She removed her gloves and exited the back door. DA C made salad in a large metal bowl while wearing gloves, touching multiple surfaces, and handling salad ingredients (lettuce, tomatoes) She tossed the salad by pushing her contaminated gloved hands and bare lower arms into the salad to mix the ingredients. Still wearing the same gloves, she wrapped some remaining lettuce in clear wrap, labeled it, and placed it in refrigerator. DM and Cook D lined chafing pans with plastic liners by pushing the plastic down into the pans with bare, unwashed hands, then putting hush puppies into the lined pans. DA C transferred salad from the large bowl into 4 foil pans using her hands, still wearing the same contaminated gloves. DA C changed gloves without washing/sanitizing her hands. DM changed gloves without washing her hands, . She opened drawers, got a spoon, and scooped corn from a large pan on the stove into a chafing pan and put into the food processer. Cook D got chaffing pans and lined with plastic. She changed gloves without washing her hands. She poured pureed corn into the lined pans. DA C doffed her gloves. She loaded dirty cookware that DM had previously rinsed into the dishwasher. DA C donned gloves without washing her hands. She pushed the cart to a storage rack and put away the clean colanders and cutting board. She changed gloves without washing her hands. She used gloved hands to transfer salad from the large bowl into 2 orange bowls and a Styrofoam plate. She placed the bowls and plate into refrigerator. She went to dry storage, gathered items, and went to baking station. Still wearing same gloves, she removed wrapping from a block of cream cheese and placed it on the food scale. She picked up the recipe book with both gloved hands and looked at recipe. She took the block of cream cheese from food scale and placed it in a large bowl. She picked up the recipe book again. She said she was making (chilled) blueberry cheesecake pies. The 11 baked pie crusts were observed uncovered on a 3-tier cart during this 1 1/2-hour observation period. The pie crusts were on the bottom 2 shelves. The top shelf of the cart was used to transport various things around the kitchen. Cook D got a wet cleaning rag from sanitizer bucket, wiped a work surface, picked up a food thermometer and wiped the stem with same rag and put it away. She donned gloves without washing her hands and transferred fried shrimp from fryer basket and placed in a lined pan. She doffed the gloves. DA C went to the dishwasher room and got clean measuring cups, then went into dry storage and got a bag of powdered sugar and placed them at the baking station. She removed her gloves and used scissors to cut the top of the plastic bag containing whipped cream. She squeezed whipped cream into a measuring cup and transferred it into the large bowl. A white glob was noticed in the whipped cream. She fished it out with a fork and said it was the lid off the whipped cream container. DM reminded DA C she did not put on gloves. DA C donned gloves without washing her hands. She wiped spilled powdered sugar from the baking station and the top of a 3-tiered cart with a rag. She washed her hands and donned gloves. While transferring the pie filling into baked pie shells, she touched the pie crust edges and the pie filling with her gloved fingers. Cook D left kitchen with the loaded food cart for the 2 cottages, separate from the main building. When she returned to the kitchen, she donned an apron and put away clean pots/pans/utensils without washing her hands/donning gloves. When she picked up/held the items her bare fingers touched the food contact surfaces. DM got celery and onion from refrigerator. She donned gloves without washing her hands. She pulled apart the stalks and rinsed the celery. She placed a cutting board on the work surface and got a knife out of a drawer. She changed gloves without washing her hands and diced the celery then scraped the celery into a bowl. During an interview with the RD and DM on 05/18/22 at 1:00 PM they both agreed there was a definite lack of hand washing and appropriate glove use during the preparation of lunch today. They said the back kitchen door was not supposed to be left ajar as this would allow pests to enter the kitchen. They said the person who had entered with the rolling ice chest was from one of the ALF buildings. One of their ice makers was broken and the other one did not make enough ice for both houses. They said the back door had been left ajar so ALF staff could come get ice. If closed all the way the door locks automatically. They said the kitchen staff are unlikely to hear someone knocking due to the noise in the kitchen. There was a small window in the door, but the ALF staff would have to wait until someone in the kitchen noticed them through the window. The said anyone entering the kitchen is required to wear a hairnet or other appropriate hair cover/restraint. They said there should be no hand or soiled glove contact with food or food-contact surfaces. They said the cooked pie crusts should have been covered. They said anytime staff leave kitchen they must wash hands upon return. They agreed that the above failures could cause cross-contamination and place residents at risk of food-borne illness. Review of Dietary/Food Service Personnel Policy and Procedures, revised 07/10/19, included the following, in part: WORK CONDUCT: 6. Only dietary employees are allowed in the kitchen or food/supply storage areas. Residents, visitors, salesmen and other facility employees are not permitted in the department unless requested or approved by the Dietary Manager/designee. PERSONNEL APPEARANCE: 6. Employees must wash their hands whenever they may be dirty such as: a. Immediately before beginning food preparation including working with exposed food, clean equipment and utensils, and unwrapped single serve and single use items. b. After touching human body parts (including touching of hair or face) other than clean hands, and clean, exposed portion of the forearms, g. before handling food, i. whenever hands become soiled, j. after handling soiled dishes or utensils, l. when returning to kitchen after making a delivery to another area, m. during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks, o. before putting on gloves when starting a new task; when changing gloves; removed soiled gloves, wash hands using proper procedure then put on new gloves p. at all other times when working with or activity that could contaminate the hands. 7. ABSOLUTELY NO BARE HAND CONTACT WITH FOOD. 8. When to change gloves: as soon as they become dirty or torn, before beginning a new task, after any interruption (taking a phone call, leaving the serving area, etc.); 12. Employees will not handle food with their hands, (sic) disposable gloves or utensils will be used at all times.

Based on observation, interview, and record review the facility failed to maintain an infection control program designed to prevent the development and transmission of infections for 1 of 3 (Residents #51) reviewed for infection control. The facility failed to ensure: Resident #51's SVN mask and oxygen nasal cannula tubing was bagged when not in use. This failure placed residents at risk for infection. Findings included: Record review of Resident #51's face sheet dated 05/21/2022 indicated she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was [AGE] years of age. Record review of Resident #51's care plan dated 05/12/2022 indicated in part: Focus: the resident needs to wear oxygen during the day, the resident likes to come out for meals and then go back to her room to rest. Goal: The resident will wear her oxygen during the day, resident will come out for meals and then rest after she eats during the day, the resident will be invited and reminded when the daily activities are going on. Interventions: Staff will remind the resident to wear her oxygen daily x 7. Record review of Resident #51's medication profile dated 05/19/2022 indicated in part: May use oxygen 1-2L via NC at bedtime related to shortness of breath. [MEDICATION(S)] 0.5 mg-[MEDICATION(S)] 3 mg (2.5 mg base)/3 mL nebulization PRN Every 4 Hours related to shortness of breath. During an observation on 05/17/22 at 10:20 AM Resident #51's oxygen tube cannula was on the floor and the SVN mask was lying on the top of the bedside dresser next to some hair from an elastic hair tie and hair brush. During an interview on 05/17/22 at 10:25 AM RN A said Resident #51's oxygen tubing cannula and SVN mask were supposed to be stored in a plastic bag when not in use. The RN said it was the CNA's responsibility to place the supplies in the bag when it was removed from the resident. The RN said the resident was not able to remove the cannula herself, so it was the CNA's responsibility to store the cannula in the bag. RN A said it was the nurse's responsibility to place the SVN mask in the bag after the resident received her breathing treatment. The RN said Resident #51 was currently using the oxygen only while in bed and PRN breathing treatments. The RN said they would replace the tubing and SVN mask and place them in the bags. During an observation on 05/18/22 at 09:32 AM observed Resident #51's oxygen tubing cannula wrapped around the bedside dresser drawer. During an interview on 05/18/22 at 09:35 AM RN A said Resident #51's oxygen tubing cannula was supposed to be stored in a plastic bag when not in use. The RN said they had just placed it in a bag yesterday 05/17/22 but the staff had not stored it in the bag as they were supposed to. RN A said they would replace the tubing and get a bag to store it in again. The RN said the charge nurses would usually do rounds throughout the day and monitor to see the oxygen items were stored in the bags. RN A said the failure occurred because the staff did not store the oxygen cannula and the nurse did not store the SVN mask in the bag. The RN said if the items were not stored correctly it could lead to respiratory infections and possibility of bacteria being inhaled by the resident. During an interview on 05/18/22 at 11:04 AM CNA B said Resident #51 only used the oxygen cannula when she was in bed. The CNA said whenever they got the resident out of the bed, they stored the cannula tubing in a plastic bag. CNA B said she was not sure who got the resident out of bed that morning. During an interview on 05/19/22 at 3:20 PM the DON said the SVN masks and nasal cannulas were supposed to be cleaned and stored when not in use. The DON said the nurses would monitor that the oxygen items were stored properly. The DON viewed a photo of the SVN mask taken by the surveyor where it showed the mask lying next to the hair and hairbrush and he said that was not the ideal way to store the mask. The DON said if the oxygen cannula was left on the floor and then used again it could lead to respiratory infections. The DON said the failure occurred due to lack of staff education or them just forgetting to store the supplies in the bag. During an interview on 05/19/22 at 3:25 PM the Administrator said they did not have a policy for storing oxygen nasal cannulas or SVN masks. The Administrator said the expectation was for staff to store the cannulas and SVN masks in an area that was considered clean. The Administrator said it was everyone's responsibility to make sure the items were stored safely. The Administrator said the oxygen items left on the floor could lead to respiratory infections. The Administrator said the failure occurred due to lack of staff education or them just forgetting to store the supplies in the bag. Record review of the facility's undated policy titled Surveillance for infections indicated in part: Process surveillance reviews practices related directly to resident care, such as monitoring of compliance with transmission-based precautions, hand hygiene, use of disposable gloves, ensuring sterile procedures are appropriately followed, ensure that reusable equipment is appropriately cleaned, disinfected, or reprocessed.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and time frames to meet residents' mental and psychosocial needs for two of five residents (Resident #24 and Resident #34 ) reviewed for comprehensive care plans, in that: Resident #24's daily treatments for mycosis (a skin fungus) were not care planed. Resident # 34's care plan did not reflect her use of a Broda Chair (a specialized wheelchair that reclines as needed) or the use of a Hoyer lift. This failure places residents at risk of unmet or unmonitored care needs related to the care plan not being followed. Findings include: Resident #24 Review of Resident #24's Face Sheet dated 2/25/21 documented she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #24's 12/22/2020 quarterly MDS Assessment documented she had applications of ointments/medications other than to feet. Review of Resident #24's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] 1% topical cream as needed dated 10/15/20 for unspecified mycosis. [MEDICATION(S)] 1% topical cream to affected areas on the bottom of bilateral feet daily dated 11/23/20 for unspecified mycosis. Review of Resident #24's care plans, reviewed 2/23/21, that addressed Resident #24's skin status regarding pressure ulcers but did not address the mycosis. Review of Resident #24's weekly skin assessment dated [DATE] (most recent in electronic record) documented Blisters, small sores on bottom of feet treat with econozole daily. Interview on 02/25/21 at 5:00 PM the ADON and DON stated things that needed to be care planned included communication, activity of daily living ability, incontinence status, hygiene, skin, falls, psychiatric medications - things that were identified in the MDS; the ADON confirmed she was responsible for care plans. The ADON stated skin care plans included anything skin related including the risk for skin breakdown. She stated Resident #24 had blisters to her feet and she received treatments for them once a day. She stated yeah, you could do a care plan for them. You could plan that. She stated the order was from 11/23/20 (indicating it was not a new treatment). The ADON stated the facility documented Resident #24 received treatments on it daily for her feet and the facility did weekly skin assessments, but they did weekly skin assessments on everyone. The DON stated the goal was for Resident #24's feet to get healed completed. The ADON stated she did not know if Resident #24's feet were healing or not. Resident #34 Review of Resident #34's Face sheet dated 2/25/21 documented she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #34's Initial MDS assessment dated [DATE] documented: She scored a 3 of 15 on her mental status exam (indicating severe cognitive impairment); She showed signs of [CONDITION(S)] that included inattention and disorganized thinking; She needed extensive assistance of two-people for all transfers; She used mobility devices that included a walker and a wheelchair; She had no history of falls. Review of Resident #34's Care Plan, reviewed 2/23/21, documented: Problem: Transfers - Resident #34 requires extensive assistance. Uses sit to stand PRN. Goal: Resident #34 will complete transfers with the assistance of 1-2 people/lift devices as required over the next 90 days. (there was no mention of the Broda Chair or other specialized wheelchair and no mention of the use of the Hoyer, a full mechanical lift). Intervention: Update transfer assessment quarterly and PRN. Problem: Cognition/Decision Making: Elder scored 03/15 on BIMS indicating severe impairment. Elder was only able to perform immediate recall. Elder has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Elder is alert and oriented to herself only. She does not use her call light. Goal: Resident #34 will participate in ADLs and facility routines/activities over the next 90 days. Review of Resident #34's Transfer Assessment, undated, documented: #1: Does the resident require any physical assistance or guidance for transferring or bed mobility? Yes (Proceed to question #2) #2: If yes to question #1, does the resident contribute a moderate effect (50%) or more to the transfer? Yes (No lift needed. Use gait belt if not contraindicated. Proceed to ASSESSMENT SUMMARY Lift Transfer Gait Belt If applicable, Sit to Stand Lift Sling size If applicable, Total Lift Sling size Comments Sit to Stand or Gait Belt x 2 (staff) - depending on patient Observation on 2/22/21 at 3:13 PM showed Resident #34 in a Broda Chair and CNA A and CNA B did a Hoyer lift with Resident #34. Observation on 2/25/21 at 4:08 p.m. through 4:41 p.m. showed Resident #34 in a wheelchair at a table. She used the table to stand up and was able to bear weight while standing for 10 seconds (indicating the Hoyer lift may or may not have been appropriate). Interview on 2/25/21 at 1:10 PM the DON stated Resident #34 was assessed as a one or two person or sit to stand lift. He explained if Resident #34 was in the Broda chair the sit to stand lift was not safe to use. Interview on 2/25/21 at 1:38 PM the Administrator was informed of the Hoyer lift observation for Resident #34. The Administrator stated Resident #34 was a 2-person transfer with a gait belt or a sit-to-stand lift. The Administrator stated if Resident #34 was in Broda Chair the sit-to-stand lift would not be safe to use. Interview on 2/25/21 at 4:12 PM CNA D stated Resident #34 was an extensive assist with transfers, but she was able to use the sit-to-stand lift or a gait belt transfer. CNA D stated Resident #34 had been working with therapy and was able to pull herself up using a bar and stand. Interview on 2/25/21 at 4:17 PM LVN K stated Resident #34 wanted to get up, up, up all the time. She stated staff assisted with transfers but Resident #34 was able to bear weight. LVN K stated Resident #34 was supposed to use a sit-to-stand lift or a gait belt transfer. LVN K stated if Resident #34 was in the Broda Chair it was because they were struggling to keep her from climbing out of the wheelchair. LVN K stated she did not know how often Resident #34 used the Broda Chair. LVN K stated if Resident #34 was in the Broda Chair the staff used the sit-to-stand lift or a gait belt transfer because the Broda Chair could be positioned to fully upright. Interview on 2/25/21 at 4:41 PM CNA E stated Resident #34 was a two person assist with a gait belt transfer. CNA E stated when Resident #34 first got to the facility she was a total assist with transfers but staff had been using the gait belt since after the first week. She stated the last time she was aware of Resident #34 being in the Broda Chair was over a week ago. She stated Resident #34 could not get out of the Broda Chair so the staff would put her in it for safety. CNA E stated when Resident #34 was in the Broda Chair she had to use the total lift (Hoyer lift). CNA E stated therapy moved Resident #34 to a regular wheelchair and she did much better. Interview on 2/25/21 at 4:46 PM the DON stated Resident #34 was care planned to use the sit to stand lift and gait belt. He stated if Resident #34 was fatiguesd or the staff felt it was unsafe they could go down (in level of assistance). He stated if Resident #34 was fatigued the staff could use the Broda Chair. The DON shrugged when asked why Resident #34's care plan did not reflect that. Review of the facility's policy on Resident Plan of Care, revised 8/2/20 documented: Utilizing the resident assessment (MDS) an interdisciplinary team will develop a plan of care for each resident with input from the resident and/or family. The care plan will identify problem areas and intervention needed to meet the needs of the resident. Assessments of residents are on-going and care plans are revised as information about the resident and his/her condition changes.

Based on observations, record reviews and interviews the facility failed to ensure the resident environment remained as free of accident hazards as possible for 1 of 1 resident (Resident #34) reviewed for accidents/hazard/supervision, in that: CNA A and CNA B failed to lock Resident #34's Broda Chair (a specialized wheelchair that reclines as necessary) when completing a Hoyer lift transfer ( a type of lift that assists in transferring a resident from surface to surface supporting the resident's entire weight and utilizes a sling). The facility failed to follow its own assessments and care plan and ensure Resident #34 used the care planned wheelchair and type of transfer. This deficient practice could affect residents and place them at risk of accidents and hazards resulting in injury. Findings included: Resident #34 Review of Resident #34's Face sheet dated 2/25/21 documented she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease, pain, other abnormalities of gait and mobility, and muscle weakness. Review of Resident #34's Initial MDS assessment dated [DATE] documented: She scored a 3 of 15 on her mental status exam (indicating severe cognitive impairment); She showed signs of [CONDITION(S)] that included inattention and disorganized thinking; She needed extensive assistance of two-people for all transfers; She used mobility devices that included a walker and a wheelchair; She had no history of falls. Review of Resident #34's Care Plan, reviewed 2/23/21, documented: Problem: Transfers - Resident #34 requires extensive assistance. Uses sit to stand PRN. Goal: Resident #34 will complete transfers with the assistance of 1-2 people/lift devices as required over the next 90 days. Intervention: Update transfer assessment quarterly and PRN. Problem: Cognition/Decision Making: Elder scored 03/15 on BIMS indicating severe impairment. Elder was only able to perform immediate recall. Elder has a diagnosis of dementia and exhibits short-term memory or long-term memory impairment as well as inattention and disorganized thinking. Elder is alert and oriented to herself only. She does not use her call light. Goal: Resident #34 will participate in ADLs and facility routines/activities over the next 90 days. Review of Resident #34's Transfer Assessment, undated, documented: #1: Does the resident require any physical assistance or guidance for transferring or bed mobility? Yes (Proceed to question #2) #2: If yes to question #1, does the resident contribute a moderate effect (50%) or more to the transfer? Yes (No lift needed. Use gait belt if not contraindicated. Proceed to ASSESSMENT SUMMARY Lift Transfer Gait Belt If applicable, Sit to Stand Lift Sling size If applicable, Total Lift Sling size Comments Sit to Stand or Gait Belt x 2 (staff) - depending on patient Review of Resident #34's Fall Risk Assessment, undated, documented: - Resident #24 is at Risk for Falls related to weakness. Will try to self transfer. Has a low bed with mat. Has bolster mattress for bed boundaries'/2 side rails for repositioning as needed. Fall risk eval- 16. Goal: Jean will complete transfers with the assistance of 1-2 people/lift devices as required over the next 90 days. Intervention: Update transfer assessment quarterly and PRN. Disciplines: CNA, Nursing Observation on 2/22/21 at 3:13 PM showed CNA A and CNA B using a Hoyer lift with Resident #34. CNA B did not lock Resident #34's Broda Chair (a specialized wheelchair providing more support to the resident's trunk and legs than a regular wheelchair). While rearranging the sling to the Hoyer lift, Resident #34 stated please try to keep me on it. CNA A and CNA B placed all six straps to the sling onto the lift and moved Resident #34 as high as the lift permitted and approximately 6 feet across the room to her bed and the head of the bed was flat. Resident #34's bottom was sliding out of the sling. Observation on 2/25/21 at 4:08 p.m. through 4:41 p.m. showed Resident #34 in a wheelchair at a table. She used the table to stand up and was able to bear weight while standing for 10 seconds. Interview on 2/24/21 at 11:36 a.m. CNA A stated she did not usually work in the nursing home but did every two or three weeks. She stated she remembered the transfer. CNA A stated she felt the transfer went more quickly than it should have. She stated she felt the Broda Chair was too far away from the bed and should have been closer. She stated when she was in control of the lift/transfer she would make sure that sling was crisscrossed between the resident's legs and would move the resident more slowly. She stated the other person would hold the bar and double check the loops for placement. She stated the chair had to be locked so when the Hoyer lift went up, the chair would not move. CNA A stated she never worked with CNA B before and was not familiar with how she worked. CNA A stated CNA B went too fast and she did not have a chance to see if the Broda Chair was locked or if the sling was in the right position. CNA A stated she did not know if the Broda Chair was locked, she hoped CNA B locked it. CNA A stated she did not have a chance to position Resident #34 the way she wanted. CNA A stated it just went too fast for her to check everything she felt needed to be checked. CNA repeated the chair was too far away from the bed; Resident #34 swung too much; and there were too many turns in the transfer. She stated she believed the placement of the sling was ok. She stated the sling was supposed to cover the top half of the resident's bottom and she felt the sling was too high when Resident #34 was lifted but CNA A did not have a chance to say anything. CNA A stated she did not say anything to CNA B because she was trained not to speak over the staff member talking to the resident because it confused the resident; she stated she did not have the chance to speak up. Interview on 2/24/21 at 12:00 PM CNA B stated the only thing she felt she could have done better was move Resident #34 closer to the bed and turned the chair around. She stated she did not think to move the chair at the time. CNA B stated she though CNA A locked the chair. CNA B stated Resident #34 was not positioned right in the sling because the sling was too big for her . She stated the sling slid up as they lifted Resident #34 in the lift. Interview on 2/24/21 at 2:57 PM the DOR stated the therapy department did the training and competency check on how to use the mechanical lifts. She stated they taught the staff how to check the weight limit of the resident; how to know which type of lift to use for the resident; and what size of sling to use. The DOR stated they trained the staff to always use two people, make sure the size of the sling was correct, to widen the legs of the lift for stability, and make sure the sling is positioned correctly on the body. Interview on 2/24/21 at 4:10 PM the DOR stated the facility used divided leg slings. She stated the slings would go down to the resident's coccyx (tail bone). The DOR stated there was no competency checklist for how to use the mechanical lift but the staff knew there was an open-door policy if they had questions on how to operate the lift. Interview on 2/25/21 at 1:10 PM the DON stated his expectation for Hoyer transfers were for the staff to talk to the resident and explain what they were doing; get the resident set up; get sling set up and on the resident. He stated if the resident was a total lift there needed to be two people. He stated the lift needed to be locked prior to moving the resident up or down and the legs of the lift needed to be apart. The DON stated Resident #34 was assessed as a one or two person or sit to stand lift. He explained if Resident #34 was in the Broda chair the sit to stand lift was not safe to use. He stated in a Hoyer transfer the sling was supposed to be under the resident and crossed through the legs so it went around the resident. He stated he did not know if there was a specific place for the edge of the sling to be when the resident started to be lifted. He stated he did not know if locking the resident's wheelchair was addressed in the aide's training of use of the sling. He stated he would have to do some research on if locking the Broda Chair was safe practice or not. Interview on 2/25/21 at 1:38 PM the Administrator was informed of the observation. She stated it was impossible for anyone to fall out of the sling as long as the legs were crossed. The Administrator stated Resident #34 was a 2-person transfer with a gait belt or a sit-to-stand lift. The Administrator stated if Resident #34 was in Broda Chair the sit-to-stand lift (a type of lift used for residents who are able to bear weight for a short amount of time by helping them stand with a padded belt around their waist) would not be safe to use. She did not comment on the unlocked Broda Chair . Interview on 2/25/21 at 4:08 PM MA C stated she had only seen Resident #34 use a regular wheelchair. Interview on 2/25/21 at 4:12 PM CNA D stated Resident #34 was an extensive assist with transfers but she able to use the sit-to-stand lift or a gait belt transfer. CNA D stated Resident #34 had been working with therapy and was able to pull herself up using a bar and stand. Interview on 2/25/21 at 4:17 PM LVN K stated Resident #34 wanted to get up, up, up all the time. She stated staff assisted with transfers but Resident #34 was able to bear weight. LVN K stated Resident #34 was supposed to use a sit-to-stand lift or a gait belt transfer . LVN K stated if Resident #34 was in the Broda Chair it was because they were struggling to keep her from climbing out of the wheelchair . LVN K stated she did not know how often Resident #34 used the Broda Chair. LVN K stated if Resident #34 was in the Broda Chair the staff used the sit-to-stand lift or a gait belt transfer because the Broda Chair could be positioned to fully upright. Interview on 2/25/21 at 4:41 PM CNA E stated Resident #34 was a two person assist with a gait belt transfer. CNA E stated when Resident #34 first got to the facility she was a total assist with transfers but staff had been using the gait belt since after the first week. She stated the last time she was aware of Resident #34 being in the Broda Chair was over a week ago. She stated Resident #34 could not get out of the Broda Chair so the staff would put her in it for safety. CNA E stated when Resident #34 was in the Broda Chair she had to use the total lift. CNA E stated therapy moved Resident #34 to a regular wheelchair and she did much better. Review of the instructions for the Manual/Electric portable lift, undated, documented: (Only lift the resident as high as needed to complete the transfer): The lower center of gravity provides stability making the patient feel more secure and the lift easier to move. Transfer to a wheelchair.: 1. ensure the legs of the lift (with patient are in open position) 2. move the wheelchair into position. 3. engage the rear wheel locks of the wheelchair to prevent movement of the chair. Warning: the wheelchair locks MUST be in a locked position before lowering the patient into the wheelchair. Review of the facility's policy and procedure on The Mechanical Lift Program reviewed 1/2010, documented: Purpose to provide individuals with safe assistance of mechanical lifts indicated by the resident's condition; to eliminate unnecessary manual positioning and lifting by employees. The policy: The TOTAL lift will be used for individual who cannot bear weight and who offer minimal assistance with lift/transfers and requires two people. The SIT-TO-STAND lift will be used for individuals who can bear weight and offer assistance with transfers/lifts. A lift will not be used for individuals that can assist greater than 50% with their transfers/lifts in order to continue to promote their highest level of functioning. Individual residents are to be lifted/transferred by the designated lift and appropriate sling.

Based on interview and record review in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are accurately documented for one (Resident #35) of one resident reviewed for pressure ulcers. The facility failed to document appropriate pressure ulcer wound staging. This could place residents at risk for inappropriate care driven by misinformation. Findings include: Record review of Resident #35's Minimum Data Set, MDS, dated [DATE], revealed skin assessment documentation under Section 'M' with no pressure ulcers noted. MDS dated [DATE], revealed skin assessment documentation under Section 'M' with 1 unstageable pressure ulcer noted. Record review of Resident #35's most recent care plan printed on 3/6/19 does address Resident's risk for skin breakdown, Braden Scale score of 13 indicates Resident is at moderate risk for getting a pressure sore. Review of wound care note documentation by the wound care team (Nurse Practitioner 1; Dietician 1; Physical Therapist 1 and the nurse on duty on the unit) concerning the pressure ulcer on Resident #35's right great toe revealed on 9/11/18 unstageable, 12/4/18 stage 3, 12/18/18 unstageable, 2/26/19 unstageable and Stage 2 and on 3/5/19 unstageable. In an interview on 3/7/19 at 10:30 a.m. NP reviewed the documentation in the wounds care notes. She reported once the wound was able to be staged (stage 3 on 12/4/18), all the documentation should reflect the wound being a Stage 3. Review of National Pressure Ulcer Advisory Panel website (www.npuap.org) concerning the documentation of wound staging: 'Pressure ulcers heal to progressively more shallow depth, they do not replace lost muscle, subcutaneous fat, or dermis before they re-[MEDICATION NAME]. Instead, the ulcer is filled with granulation (scar) tissue composed primarily of endothelial cells, fibroblasts, collagen and extracellular matrix. A Stage IV pressure ulcer cannot become a Stage III, Stage II, and/or subsequently Stage I.Therefore, reverse staging does not accurately characterize what is physiologically occurring in the ulcer. The progress of a healing pressure ulcer can only be documented using ulcer characteristics or by improvement in wound characteristics .'

Based on observation, interview, and record review the facility failed to ensure staffing information was posted in a prominent place readily accessible to residents and visitors. The facility failed to post staffing information in prominent place that is easily accessible to residents, resident responsible parties, and visitors. This failure denied residents, resident responsible parties, and visitors easy access to information that is needed to make informed decisions regarding their care and/or the care of loved ones. Finding included: Observation on 03/06/19 at 10:00 AM revealed no postings for nursing staffing anywhere in the facility. In an interview on 03/06/19 at 10:20 AM with CMA A she stated daily staffing sheets are kept in a notebook at the nursing station, and not posted. During interview she produced a white notebook with sheets of staffing information. In an interview on 03/06/19 at 10:30 AM the DON confirmed they do not post staffing and it is kept in a notebook at the nursing station. The DON could not produce a facility policy concerning posting of staffing information by exit.

Based on observations, interviews, and record reviews, the facility failed to provide treatment and care in accordance with professional standards of practice for 1 of 1 (Residents #34) reviewed for indwelling catheters. The facility failed to ensure Resident #34 indwelling catheter was secured to prevent pulling or tugging. The failure placed one resident and could place one other resident with a urinary catheter at risk for discomfort, urethral trauma, and urinary tract infections. Findings included: Resident #34's MDS (Minimum Data Sheet) admission assessment, dated 12/22/17, indicated the resident was an [AGE] year-old male admitted to the facility on [DATE]. The resident required extensive assistance of one to two person physical assistance, was always incontinent of bowel, and had a Foley catheter for urinary incontinence. Resident #34's BIMS (Brief Interview for Mental Status) was recorded at moderate cognitive impairment. Record review of Resident #34's Face Sheet dated 2/14/18 indicated the following Diagnosis: [REDACTED]. Review of Resident #34's Care Plan updated 12/18/17 indicated: Problems: Bladder- Has Foley relate to retention and [MEDICAL CONDITIONS]. Resident #34 is at risk for infection related to indwelling catheter. Goals: Resident #34 will remain free of urinary tract infection during period of catheterization over next 90 days. Interventions: No interventions were related to securing the catheter tubing. During an observation of Resident #34's catheter care by CNA A on 2/14/18 at 1:20 p.m. revealed the resident had an indwelling catheter draining red tinged yellow urine to a catheter bag on the left side of his bed. The catheter tubing was not secured to the resident's leg with an anchor. When he was turned to his side, the tubing moved frequently during the incontinence care During an interview and observation with LVN A, who was also in the room during the catheter care on 2/14/18 at 1:37 p.m., she said Resident #34 should have an anchor on. She went and retrieved an anchor and attached it to the resident's right leg after the CNA had completed catheter care. The LVN also said that Resident #34 usually had an anchor on and did not know why he did not have one on currently. LVN A said that Resident #34 admitted with red tinged urine and has many medical issues related to his bladder. During an interview with the DON on 2/14/18 at 3:42 pm he said that residents with catheters should have anchors unless they refuse or take off the anchor in which case it should be care planned or had nursing notes on the refusal documented by the staff. The DON after looking at nursing notes, care plans, and care plan meeting notes since admission for Resident #34, was unable to provide such documentation. Record review of nursing notes for Resident #34 indicated the following: -Admission nursing note dated 12/15/17 indicated the resident admitted to the facility with a Foley catheter and had blood tinged urine. -Nurse's note dated 12/17/17 indicated catheter care provided with Foley output dark amber and blood tinged. -Nurse's noted dated 12/18/17 Resident #34 pulling at catheter, elder disconnected catheter 3 times during shift. -Nurse's note dated 1/8/18 indicated observation of catheter disconnected from catheter bag and sitting on floor. -Nurse's note 1/9/18 indicated Foley catheter emptying blood tinged urine. -Nurse's note dated 1/11/18 indicated Foley catheter draining blood tinged urine. -Nurse's note dated 1/12/18 indicated during incontinence care in shower room, when pants were removed Foley catheter came out. Nurse observed balloon deflated. 200cc of blood tinged urine in Foley catheter bag. No signs or symptoms of pain observed. -Nurse's note dated 1/17/18 indicated catheter emptying red tinged urine. -Nurse's note dated 1/18/18 indicated catheter emptying dark blood tinged urine. -Nurse's note dated 1/25/18 indicated the catheter was flushed and returned 100cc of bloody return. The nurse's notes for this period of time indicated communication with the doctor with findings and follow up orders. The nurse's notes also indicated unsuccessful attempts at discontinuing the Foley catheter due to urine retention and periods of no voiding from the resident. Resident #34 was also monitored for pain. Review of the Catheter Care Policy revised 1/2014 indicated the following: Refer to current edition of Lippincott Manual of Nursing Practice located on each nursing unit for further information. Lippincott Manual of Nursing Practice 9th Edition, page 783 indicated the following in regards to securing a urinary catheter: General Considerations: .Secure the indwelling catheter to patient's thigh using tape, strap, adhesive anchor, or other securement device. The Resident Census and Condition Form CMS-672, dated 2/12/18, indicated 2 residents had urinary catheters.

Based on observations, interviews, and record reviews, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 1 (Residents #34) reviewed for indwelling catheters. The facility failed to ensure Resident #34 indwelling catheter was secured to prevent pulling or tugging. The failure placed one resident and could place one other resident with a urinary catheter at risk for discomfort, urethral trauma, and urinary tract infections. Findings included: Resident #34's MDS (Minimum Data Sheet) admission assessment, dated 12/22/17, indicated the resident was an [AGE] year-old male admitted to the facility on [DATE]. The resident required extensive assistance of one to two person physical assistance, was always incontinent of bowel, and had a Foley catheter for urinary incontinence. Resident #34's BIMS (Brief Interview for Mental Status) was recorded at moderate cognitive impairment. Record review of Resident #34's Face Sheet dated 2/14/18 indicated the following Diagnosis: [REDACTED]. Review of Resident #34's Care Plan updated 12/18/17 indicated: Problems: Bladder- Has Foley relate to retention and [MEDICAL CONDITIONS]. Resident #34 is at risk for infection related to indwelling catheter. Goals: Resident #34 will remain free of urinary tract infection during period of catheterization over next 90 days. Interventions: No interventions were related to securing the catheter tubing. During an observation of Resident #34's catheter care by CNA A on 2/14/18 at 1:20 p.m. revealed the resident had an indwelling catheter draining red tinged yellow urine to a catheter bag on the left side of his bed. The catheter tubing was not secured to the resident's leg with an anchor. When he was turned to his side, the tubing moved frequently during the incontinence care During an interview and observation with LVN A, who was also in the room during the catheter care on 2/14/18 at 1:37 p.m., she said Resident #34 should have an anchor on. She went and retrieved an anchor and attached it to the resident's right leg after the CNA had completed catheter care. The LVN also said that Resident #34 usually had an anchor on and did not know why he did not have one on currently. LVN A said that Resident #34 admitted with red tinged urine and has many medical issues related to his bladder. During an interview with the DON on 2/14/18 at 3:42 pm he said that residents with catheters should have anchors unless they refuse or take off the anchor in which case it should be care planned or had nursing notes on the refusal documented by the staff. The DON after looking at nursing notes, care plans, and care plan meeting notes since admission for Resident #34, was unable to provide such documentation. Record review of nursing notes for Resident #34 indicated the following: -Admission nursing note dated 12/15/17 indicated the resident admitted to the facility with a Foley catheter and had blood tinged urine. -Nurse's note dated 12/17/17 indicated catheter care provided with Foley output dark amber and blood tinged. -Nurse's noted dated 12/18/17 Resident #34 pulling at catheter, elder disconnected catheter 3 times during shift. -Nurse's note dated 1/8/18 indicated observation of catheter disconnected from catheter bag and sitting on floor. -Nurse's note 1/9/18 indicated Foley catheter emptying blood tinged urine. -Nurse's note dated 1/11/18 indicated Foley catheter draining blood tinged urine. -Nurse's note dated 1/12/18 indicated during incontinence care in shower room, when pants were removed Foley catheter came out. Nurse observed balloon deflated. 200cc of blood tinged urine in Foley catheter bag. No signs or symptoms of pain observed. -Nurse's note dated 1/17/18 indicated catheter emptying red tinged urine. -Nurse's note dated 1/18/18 indicated catheter emptying dark blood tinged urine. -Nurse's note dated 1/25/18 indicated the catheter was flushed and returned 100cc of bloody return. The nurse's notes for this period of time indicated communication with the doctor with findings and follow up orders. The nurse's notes also indicated unsuccessful attempts at discontinuing the Foley catheter due to urine retention and periods of no voiding from the resident. Resident #34 was also monitored for pain. Review of the Catheter Care Policy revised 1/2014 indicated the following: Refer to current edition of Lippincott Manual of Nursing Practice located on each nursing unit for further information. Lippincott Manual of Nursing Practice 9th Edition, page 783 indicated the following in regards to securing a urinary catheter: General Considerations: .Secure the indwelling catheter to patient's thigh using tape, strap, adhesive anchor, or other securement device. The Resident Census and Condition Form CMS-672, dated 2/12/18, indicated 2 residents had urinary catheters.

Based on interview and record review, the facility failed to provide pharmaceutical services including the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals to meet the needs of each resident for four (Resident #34, #50, #3, and #8) of six residents reviewed for pharmacy services. Also, the facility failed to ensure the Narcotic Count Sheets were signed by the on-coming and off-going nurses to document the narcotic count was correct at the change of each shift, on 2 of 4 units. a) Staff failed to accurately document: 1) [MEDICATION NAME] (pain medication) for Resident #50 and #3; 2.) [MEDICATION NAME] (pain medication) for Resident #8; and 3) [MEDICATION NAME]-[MEDICATION NAME] (pain medication) for Resident #34 administrations on the residents' EMARs and controlled substance count sheets. b) Staff failed to sign the Narcotic Check Sheet at each shift change at(NAME)House and Talley House. These failures could affect the 26 residents who have been receiving controlled medications and could result in administration errors and drug diversion. Findings included: 1. Review of Physicians Order Sheet of Resident # 50 and #3, dated 2/14/18, provided by the DON indicated a physician order [REDACTED]. Review of Resident #50's [MEDICATION NAME] administration record from 12/2017 to 2/2018 revealed one administration was missing on 1/8/18 on Resident #50's EMAR after reconciling with the count sheet. The medications was signed out on the count sheet but not documented on the EMAR. Review of Resident #3's [MEDICATION NAME] administration record from 11/2017 to 2/2018 revealed one administration was missing on 11/29/17 on Resident #3's EMAR after reconciling with the count sheet. The medications was signed out on the count sheet but not documented on the EMAR. 2. Review of Physicians Order Sheet of Resident # 8, dated 2/12/18, provided by the DON indicated a physician order [REDACTED]. Review of Resident #8's [MEDICATION NAME] administration record from 2/7/2018 to 2/14/2018 revealed a total of one administration was missing on Resident #8's EMAR after reconciling with the count sheet. The medications was signed out on the count sheet but not documented on the EMAR. 3. Review of Physicians Order Sheet of Resident # 34, dated 2/14/18, provided by the DON indicated a physician order [REDACTED]. Review of Resident #34's [MEDICATION NAME] of 300mg-[MEDICATION NAME] 30mg administration record from 12/2017 to 1/2018 revealed a total of 14 administrations were missing on Resident #34's EMAR after reconciling with the count sheet. The medications were signed out on the count sheet but not documented on the EMAR. The dates and dosages were as follows: -12/10/17 2 doses -12/11/17 2 doses -12/12/17 2 doses -12/13/17 2 doses -12/14/17 1 dose -12/18/17 1 dose -12/19/17 2 doses - 01/15/18 2 doses Review of the facility's undated form, Narcotic Check Sheet, included the following statement beneath the title: I, the undersigned, acknowledge that I have counted all of the Controlled Substances on the above listed unit. This count was taken within plus-or-minus 30 minutes of the time corresponding to the shift change as listed on this document. Review of the Narcotic Check Sheets at(NAME)House from (MONTH) (YEAR) through (MONTH) 11, (YEAR) revealed 20 incidents of nursing staff failing to sign the Narcotic Check Sheet at each shift change: 11/17/17 off-going 7:00 PM 11/22/17 on-coming 7:00 PM 11/23/17 on-coming 7:00 AM 11/25/17 on-coming 7:00 AM 11/25/17 off-going 7:00 PM 11/26/17 on-coming 7:00 AM 11/26/17 off-going 7:00 PM 12/21/17 on-coming 7:00 AM 12/21/17 off-going 7:00 PM 12/26/17 off-going 7:00 PM 01/03/18 off-going 7:00 PM 01/04/18 on-coming 7:00 PM 01/05/18 off-going 7:00 AM 01/07/18 off-going 7:00 PM 01/11/18 on-coming 7:00 PM 01/12/18 off-going 7:00 AM 01/16/18 on-coming 7:00 AM 01/16/18 off-going 7:00 PM 01/27/18 on-coming 7:00 AM 01/27/18 off-going 7:00 PM Review of the Narcotic Check Sheets at Talley House from (MONTH) (YEAR) through (MONTH) 11, (YEAR) revealed 10 incidents of nursing staff failing to sign the Narcotic Check Sheet at each shift change: 12/02/17 off-going 7:00 AM 12/09/17 off-going 7:00 AM 12/24/17 on-coming 7:00 PM 12/25/17 off-going 7:00 AM 01/02/18 on-coming 7:00 PM 01/03/18 off-going 7:00 AM 01/13/18 off-going 7:00 PM 01/23/18 off-going 7:00 PM 02/09/18 on-coming 7:00 AM 02/09/18 off-going 7:00 PM During an interview with the DON on 2/14/18 at 3:31 pm he said his expectations are that nurses document narcotics in the MAR indicated [REDACTED]. Review of facility policy on Control of Narcotics and Other Controlled Substances updated 11/2017 indicated the following: 1/The nursing community must comply with all Federal and State laws and regulations relating to the procurement, storage, dispensing, administration, and disposal of: a. Narcotics . Review of the list of residents with controlled substances dated 2/14/18 indicated 26 residents who received controlled medications in the facility.

Based on observation, record review and interview the facility failed to ensure 2 of 4 residents (#34 and #15) reviewed for incontinent and catheter care received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible 1. CNA A did not sanitize or wash her hands between change of gloves while providing catheter care and perineal care to resident #34. 2. CNA B did not sanitize or wash her hands between changes of gloves while providing incontinent care to resident #15. This deficient practice could affect 2 residents who were receiving catheter care, and 25 residents who were receiving frequent or occasional incontinent care on Tucker Unit and place them at risk for infection and improper care. The findings include: 1. During record review Resident #34's MDS (Minimum Data Sheet) admission assessment, dated 12/22/17, indicated the resident was an [AGE] year-old male admitted to the facility on [DATE]. The resident required extensive assistance of one to two person physical assistance, was always incontinent of bowel, and had a Foley catheter for urinary incontinence. Resident #34's BIMS (Brief Interview for Mental Status) was recorded at moderate cognitive impairment. During record review of Resident #34's Face Sheet dated 2/14/18 indicated the following Diagnosis: [REDACTED]. Observation on 2/14/18 at 1:20 p.m. during perineal care and indwelling urinary catheter care for resident #34. CNA A did not change gloves or wash hands after wiping tubing with a small moist towel. CNA then grabbed a new towel, CNA A was observed touching the area of the towel she used to wipe the catheter tubing. The CNA wiped 3 inches in front of the opening of the penis. The CNA did not change gloves or wash hands after wiping the head of the penis and surrounding area and grabbing a new towel. CNA A then cleaned Resident #34's peri-area, removed gloves, but did not wash or sanitize her hands before donning new gloves. CNA A then cleaned Resident #34's Peri-anal area. Resident #34 did not have any bowel movement during the catheter care. CNA A washed her hands before and after the procedure only. During an interview on 2/14/18 at 1:40 p.m. CNA A confirmed she did not sanitize or wash her hands between glove changes. CNA A said that touching the clean towels after touching the head of the penis and then touching the clean towels without washing her hands was cross contamination. She said she should have cleaned her hands in between going from a dirty area to a clean area or item. During an interview with the DON on 2/14/18 at 3:42 pm, he said the staff should be following CDC guidelines for hand washing. 2 . Record review of Resident #15's MDS (Minimum Data Sheet) annual assessment, dated 11/29/17, indicated the resident was an [AGE] year-old female admitted to the facility on [DATE]. The resident required extensive assistance of one to two person physical assistance, was always incontinent of bowel and bladder. Resident #15's BIMS (Brief Interview for Mental Status) was recorded at severe cognitive impairment. Record review of Resident #15's Face Sheet dated 2/14/18 indicated the following Diagnosis: [REDACTED]. During observation on 2/14/18 at 10:40 a.m. during incontinence care for resident #15, CNA B cleaned resident #15's peri-area then removed her gloves and donned clean gloves but did not sanitize or wash her hands between change of gloves. CNA B then cleaned Resident #15's peri-anal area, she removed the soiled brief that had Resident 15's bowel movement, her gloves were visibly soiled with BM during the removal of the resident's brief, and she then removed her soiled gloves and donned clean gloves but did not sanitize or wash her hands before touching the clean brief. CNA B washed her hands before and after the procedure only. During an interview on 2/14/18 at 10:51 a.m. with CNA B, she said she should have washed her hands in between glove changes. CNA B said that she was nervous and said that there could be rips in the gloves that she could not see and should have washed her hands in between changing gloves. During an interview with the DON on 2/14/18 at 3:42 pm, he said the staff should be following CDC guide lines for hand washing. Review of the facilities Hand Hygiene policy updated 11/207 indicated the following: Hand hygiene is the most important procedure to follow in the prevention of the spread of infections. Staff are expected to follow the CDC guidelines related to hand hygiene. Record review of the facilities policy for incontinent care revised 1/2014 indicated the following: Consult CDC or refer to current edition of Lippincott Manual of Nursing Practice located on each nursing unit for further information. Review of the Center for Disease Control and Prevention website, (https://www.cdc.gov/handhygiene/providers/index.html), hand hygiene for healthcare providers in healthcare settings includes the performance of hand hygiene when: -Before and after having direct contact with a patient's intact skin (taking a pulse or blood pressure, performing physical examinations, lifting the patient in bed) -After contact with blood, body fluids or excretions, mucous membranes, non-intact skin, or wound dressings -If hands will be moving from a contaminated-body site to a clean-body site during patient care, and -After glove removal The Lippincott Manual of Nursing Practice, 7th edition, 2001, page 958, Fundamentals of Standard Precautions reflected: 1. Hand washing is the single most important measure to reduce the risks of transmitting microorganisms. 2. Washing hands as promptly and thoroughly as possible between patient contacts; after contact with blood, body fluids, secretions, excretions, and contaminated equipment or articles; and after gloves are removed is vital for infection control. 3. It may be necessary to wash hands between tasks on the same patient to prevent cross-contamination of different body sites . 4. Wearing gloves does not replace the need for hand washing because gloves may have small, in apparent defects or may be torn during use, and hands can become contaminated during removal of gloves. Review of the residents on Tucker unit indicated 2 residents with catheters and 25 residents occasionally or frequently incontinent of bowel or/and bladder.

Based on interview and record review; it was determined the facility failed to provide an ongoing program to support residents in their choice of activities designed to meet the interests of and support the physical, mental, and psychosocial well-being for 3 of 13 residents reviewed for activities (Resident #1, Resident #2, and Resident #4 and residents who attended the confidential Group interview). The facility failed to provide routine one-on-one and group weekend activities for residents living on(NAME)and Mayfield units. The facility's failure to provide an ongoing program on the weekends could place all 46 residents living on the(NAME)and Mayfield units at risk boredom, poor quality of life, depression, behaviors and decreased cognitive function. Findings included: Resident #1 A record review of Resident #1 ' s face sheet dated 11///10/2016 indicated she was a [AGE] year old female who was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. A review of the quarterly MDS dated [DATE] for Resident #1 indicated she had adequate hearing, impaired vision and clear speech. She was able to understand and be understood by others. She had a BIMS score of 13 out of 15 which is indicative of having no cognitive impairment. She required supervision by one staff with bed mobility, supervision and set up with toileting, and dressing and set up only with ambulation and eating. She required limited assistance by one staff with hygiene and extensive assistance by two staff with bathing. She was frequently incontinent of the bladder and continent of the bowel. She had a history of [REDACTED]. During an interview on 12/19/2016 at 4:25 pm Resident #1 said she enjoyed living in the facility and received good care from all of the staff. She said she attended activities regularly during the weekday and liked bingo, exercising and musical activities the most. She said she gets bored on the weekends and evenings because there was not as much to do as during the weekday. She said she simply wanted more activities offered during those times. Resident #2 A record review of Resident #2s face sheet dated 12/22/2016 revealed she was an [AGE] year old female who was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. A record review of the quarterly MDS dated [DATE] for Resident #2 revealed she had a staff assessment of mental status that indicated she had a BIMS score of 9 out of 15 which was indicative of a moderate cognitive impairment. She did not exhibit any behaviors and had no falls. She required supervision with transfers, ambulation, dressing, eating and hygiene and extensive assistance by one staff with bathing. She was continent of the bowel and bladder and occasionally had pain. She used a wheelchair and walker for mobility. During an interview on 12/20/2016 at 10:45 am Resident #2 said she enjoyed attending exercise and musical activities. She said there were not as many activities offered on the weekends as during the weekday. She said the weekends are boring and she would like more to do. She said she would enjoy having good speakers or good music on the weekends. Resident #4 A record review of Resident #4 ' s face sheet dated 11/10/16 revealed he was an [AGE] year old make who was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. A record review of the annual MDS dated [DATE] for Resident #4 revealed he had moderate difficulty hearing, adequate vision with corrective lenses, clear speech and was understood and able to understand others without difficulty. He had a BIMS score of 4 which is indicative of having a severe cognitive impairment. His previous quarterly MDS dated [DATE] indicated he had a BIMS score of 15 of 15 which is indicative of having no cognitive impairment. He required limited assistance by one staff with bed mobility, transfers, dressing, and toileting. He required supervision and set up for eating and extensive assist by one staff for bathing. He was continent of the bowel and occasionally incontinent of the bladder. He used a wheelchair for mobility and had 1 fall with no injury. During an interview on 12/20/2016 at 4:35 pm Resident #4 said he enjoyed living in the facility for the most part. He said he regularly attended activities during the weekday and had no complaints about the activity staff. He said the activities offered on the weekends were weak and he would like more games offered to play on Saturday and Sunday. He said when he was younger he looked forward to each weekend after a long week and now he dreads the weekends because he does not have enough to keep him busy. He said he visits his son every other weekend and enjoys getting away from the facility for a short time to see his son. He said he enjoyed playing dominoes and wished he had someone available on the weekends that he could play dominoes with. During a confidential Group Interview on 12/20/2016 at 10:05 am 8 residents (including Resident #1, and #4) attended the group meeting/interview. The residents stated they felt that the facility did not offer enough to do on the weekends. The residents stated they got bored and would like more activities offered on the weekends. Two residents said they would like to have shuffle board or ping pong, or some similar activity to keep them busy and active. During an interview on 12/21/16 at 10:31 am CNA A said the CNA's were responsible for coordinating activities on weekends. CNA A said the activities schedule depended on if it (the unit) was busy or if residents were having behaviors. She said when the CNA ' s were busy or if residents were exhibiting behaviors the staff didn't have time to do the activity. During an interview on 12/21/16 at 10:05 am CNA B said that the majority of time the staff would be able to have time to do activities on the weekends, however that ability was based on times when everyone is good and not a lot of chaos was going on. During an interview on 12/22/2016 at 11:50 am the DON said the activity director did not document a daily log that indicated what activities the residents participated in daily. He said the activity director did complete annual and quarterly assessments to determine each resident ' s interests. A review of the Activity calendar for November 2016 listed Saturday activities to include morning visits, manicures, dominoes, bingo, hot chocolate or cookies and a drink, ice cream social, dinner time and TV time. The calendar listed activities on Sundays included: morning visits, news and juice, manicures, church on TV, dominoes, and bingo. A review of the Activity calendar for December 2016 listed Saturday activities included: morning visits, coffee and news, manicures, dominoes, bingo, movie and popcorn, cookies and drink, dinner time and TV time. The Sunday activities listed included: morning visits, coffee, juice and news, manicures, church on TV, bingo, cookies, popcorn and drink and dinner time. A review of the facility ' s policy and procedure for Activities, no date, indicated the facility would provide an ongoing program of activities designed to meet the interest and the physical, mental, and psychosocial well-being of the residents. The expectations are for resident -directed relationships based on meaningful lives. A review of the resident roster by payer source dated 12/19/2016 revealed 46 residents resided in the(NAME)and Mayfield units of the facility.

Based on observation, interview and record review the facility failed to establish infection control measures to prevent the transmission of infection and disease by bloodborne pathogens for one of five (Resident #11) residents reviewed who received blood glucose testing. The facility failed to ensure that lancing pen devices were not used on multiple residents to obtain blood for blood glucose tests. One of one LVN, LVN A performed a blood glucose test and stated that the same lancing pen device was used for all three residents that require blood glucose tests on that one unit. RN A said that the same lancing device was used for the two residents on a second unit and the same lancing device was used for the five residents on a third unit. These failures resulted in the identification of an IJ (Immediate Jeopardy) on 01/03/12. While the IJ was removed prior to exit on 01/04/12, the facility remained out of compliance at a severity level of "No actual harm with a potential for more than minimal harm that is not Immediate Jeopardy" and a scope of "Pattern". These failures could affect 10 residents who required the use of a lancing pen device to obtain blood by fingerstick for blood glucose testing. These 10 residents were placed at risk of bloodborne infections. Fingerstick devices (lancing pen devices) come in close proximity to blood with every use. Even if the lancet itself is changed between each use there is potential for blood to contaminate the pen device. Bloodborne pathogens such as Hepatitis B, Hepatitis C and HIV could potentially be transmitted from one person to another. The findings included: Record review of Resident #11's "Admission Record" revealed an [AGE] year old female who was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #11's "History and Physical" dated 10/22/11 revealed [DIAGNOSES REDACTED]. Record review of Resident #11's physician orders [REDACTED]." Observation on 01/03/11 at 4:00 p.m. revealed LVN A performed a fingerstick for blood glucose testing for Resident #11. LVN A took a handled plastic container from the medication room. The container had several plastic cups inside, one of the plastic cups had one [MEDICATION NAME] lancing pen device (pen-shaped automatic lancing device designed for simple glucose testing) and several individual lancets and in another plastic cup was a Contour glucometer. There was also a sharps container and individually wrapped Gluco-Chloro wipes in the handled container. LVN A took the handled container to Resident #11's room and placed it on the bedside chest. He did not clean the glucometer or the lancing device prior to use. He removed the lancing device from the cup inside the handled container. The lancing device already had a lancet attached. He cleaned Resident #11's right little finger with an alcohol wipe, performed the stick, placed the test strip into the glucometer and ran the glucose test. He removed the lancet from the lancing device, discarded the lancet in the sharps container, and placed the lancing device back into the cup with the unused lancets. He did not clean the lancing device. He did clean the glucometer with a Gluco-Chloro wipe. LVN A then picked up the handled container and carried it back to the medication room and placed it on top of the small refrigerator in the medication room. Observation of the lancing device that had been placed back in the cup with the unused lancets was noted to have dried red blood on the device. In an interview on 01/03/11 at 4:15 p.m. LVN A said that it was facility procedure to clean the glucometer between resident use but not the lancing device. LVN A observed the red blood on the lancing device and did clean it with a Gluco-Chloro wipe. LVN A said that there were three residents on the Tucker unit that received glucose testing, one resident was tested on ly once a week on Fridays and another resident received glucose testing two hours after the biggest meal of the day. Observation on 01/03/11 at 4:30 p.m. and 4:35 p.m. revealed that each of the Green Houses (Alison and Talley) had a handled container that had a [MEDICATION NAME] lancing device with several lancets in it that were used to perform glucose testing. In an interview on 01/03/11 at 4:30 p.m. RN A, who worked in the Green Houses (Alison and Talley), said that she performed glucose tests using the [MEDICATION NAME] lancing device and changed the lancets between resident use. RN A said that she had been performing glucose tests using this system for about three years. RN A said that she cleaned the glucometer and lancing device between resident use but was not aware that the lancing device should not be used on multiple residents. RN A said that she had two residents at the Talley House and five residents at the Alison House who received glucose testing. In an interview on 01/03/11 at 4:50 p.m. the DON said that the facility blood glucose testing procedure was to use the lancing pen devices and change the individual lancets between residents. Record review of the facility provided "Nursing Policy and Procedure Manual Use of Glucometer" dated 03/08/10 revealed, "Follow manufacturer guidelines to placement of lancet and use of glucometer .... Environmental surfaces, such as glucometers should be decontaminated regularly and anytime contamination with blood or body fluid occurs or is suspected." Record review of the facility provided "Contour Blood Glucose Monitoring System User Guide", page 41, revealed "Potential Biohazard. Healthcare professionals or persons using this system on multiple patients should follow the infection control procedure approved by their facility. All products or objects which come in contact with human blood, even after cleaning, should be handled as if capable of transmitting viral diseases. Information posted by the Center of Disease Control, updated 08/26/10, at website http://www.cdc.gov/injectionsafety/Fingerstick-DevicesBGM.html contained the following: "The shared use of fingerstick devices is one of the common root causes of exposure and infection in settings such as long-term care (LTC) facilities, where multiple persons require assistance with blood glucose monitoring. Risk for transmission of bloodborne pathogens is not limited to LTC settings but can exist anywhere multiple persons are undergoing fingerstick procedures for blood sampling. For example, at a health fair in New Mexico earlier this year, dozens of attendees were potentially exposed to bloodborne pathogens when fingerstick devices were reused to conduct diabetes screening. Recommendations Anyone performing fingerstick procedures should review the following recommendations to ensure that they are not placing persons in their care at risk for infection. ? Fingerstick devices should never be used for more than one person. ? Auto-disabling single-use fingerstick devices should be used for assisted monitoring of blood glucose. These recommendations apply not only to licensed healthcare facilities but also to any setting where fingerstick procedures are performed, including assisted living or residential care facilities, skilled nursing facilities, clinics, health fairs, shelters, detention facilities, senior centers, schools, and camps. Protection from infections, including bloodborne pathogens, is a basic requirement and expectation anywhere healthcare is provided. " An Immediate Jeopardy (IJ) was identified and the Administrator was informed on 01/03/12 at 5:30 p.m. The facility submitted an action plan to remove the immediacy dated 01/04/12 to the regional office consisting of the following actions: 1) Existing devices disposed of on 01/03/12 at 5:45 p.m. 2) Replacement single use auto disabling devices in facility at 6:05 p.m. 3) Policy reviewed In-service developed at 6:05 p.m.; See attached 4) Trainings with staff inititated at 6:15 p.m. and will be ongoing until all Nurses educated. Will be completed on January 4, 2012 except for one nurse who is ill. She will be in-serviced prior to being released to work. 5) Policy reviewed and updated January 4, 2012; See attached 6) Training to continue until all Nuses educated on new device, policy, and procedure. 7) Random weekly monitoring to be in place for ninety days. Monitoring will be performed by DON, ADON, or Infection Control Coordinator. Weekly reports will be addressed during QAAC on monthly basis. This action plan was verified to have been completed on 01/04/12 at 2:55 p.m. as follows: 1) The facility purchased single use lancets and placed them in the glucose testing handled containers for the Tucker/Mayfield units and both the Alison and Talley Green Houses. 2) On 01/03/12 at 5:50 p.m. the DON was observed discarding four lancet pen devices. He said he had collected them from each of the four units of the facility and there were no more of the devices in the facility. No lancet pen devices were found in the medication cart or the medication room. 3) Inservices were conducted with the facility nurses at 01/03/12 and 01/04/12 regarding not using lancing pen devices for fingersticks due the possibility of residents being exposed to blood borne pathogens. 4) Interviews were completed on 01/04/12 at 4:45 p.m. with facility nurses to confirm that inservices were conducted and nurses understood what type of lancing device to use and the rational for not using a lancing pen device on multiple residents. While the IJ was reduced on 01/04/12 at 2:55 pm., the facility remained out of compliance at a severity level of "No actual harm with a potential for more than minimal harm that is not Immediate Jeopardy" and a scope of "Pattern" as the facility must monitor their action plan over time to ensure that the corrections for this issue are effective. There were 10 residents requiring the use of a lancing device to obtain blood by fingerstick for blood glucose testing according to the list provided by LVN A and RN A on 01/03/12 at 4:15 p.m. and 4:30 p.m. respectively.