Every finding on record at Shelby Crossing Health Campus

Based on observation, interview, and record review, the facility failed to ensure opened biologicals were dated or had an identifier on the medication in three of four medication carts reviewed. Findings include: On 03/25/25 at 8:56 AM, the 300 unit medication cart was observed with Licensed Practical Nurse (LPN) A. Four inhalers were not dated when opened or noted with an identifier on the inhaler these included Advair, albuterol and Symbicort. In the 300 medication room a tuberculin multi-use vial was not dated when opened. On 03/25/25 at 9:58 AM, during a medication pass observation the 200 B medication cart was observed with LPN B. An Incruse inhaler and a fluticasone inhaler were observed to be without a date opened on the inhaler and without a resident identifier on the inhaler. Two opened insulin pens were observed without an opened date on the pen. On 03/25/25 at 10:24 AM, the 200 A medication cart was observed with LPN C. A Lantus insulin pen and a Lispro insulin pen for the same resident were without a date opened on the pen. A Humalog insulin pen and a Lantus insulin for a second resident were without a resident identifier and an opened date on the pen. LPN C reported they had come with the resident from the hospital. Two albuterol Inhalers for a third resident were not dated when opened on the inhaler. On 03/26/25 at 10:33 AM, the Director of Health Services reported staff should date items on the actual vial for the tuberculin. It was also reported that at times the pharmacy does not provide a patient label for the medications such as inhalers and the insulin pens. A review of the facility policy titled, .when the original seal of a manufacturer's container or vial is initially broken the container or vial will be dated. A date opened sticker will be placed on the medication. The expiration date of the vial or container will be 30 days unless the manufacturer recommends another date . A review of the prescribing information from the Incruse.com web site revealed, How should I store Incruse Ellipta? Store Incruse Ellipta in the unopened tray and only open when ready for use. Safely throw away Incruse Ellipta in the trash 6 weeks after you open the tray or when the counter reads 0, whichever comes first. Write the date you open the tray on the label on the inhaler .

Based on observation, interview, and record review, the facility failed to perform appropriate hand hygiene and or sanitize a blood pressure cuff during two of six medication pass observations. Findings include: On 03/25/25 at 8:25 AM, Licensed Practical Nurse (LPN) A was observed to bring a machine to measure vital signs into the room of R 30. LPNA place a blood pressure cuff on the right arm of R30. R30 was on enhanced barrier precautions related to a foot wound. Upon completion of the medication pass, LPN A was observed to wheel the machine into the common area. The blood pressure cuff was not observed to be be cleaned. On 03/25/25 at 9:58 AM, LPN B was observed to exit the room of a resident and move the medication cart and a vitals machine to the doorway of another resident. LPN B was observed to bring the vitals machine into the room and check the blood pressure of the resident on their bare left arm. Upon completion of the vitals checks the machine was placed outside the room. The cuff was not observed to be cleaned. LPN B was then observed to prepare 11 medications from the medication cart. The medications were placed on a barrier and transported into the room and placed on the overbed table. LPN B tore open the packages of pill to put them into a medication cup. During this process one of the pills popped out and onto the barrier. LPN B picked up the pill and placed it into the medication cup without first completing hand hygiene or putting on a glove. LPN B picked up a pill splitter and gloves from the medication cart. No hand hygiene was completed before application of the gloves and the return to the medication cart. The pill was cut and the gloves were doffed. No hand hygiene was observed and the pill splitter was not observed to be cleaned. LPN B returned to the medication cart and used a spoon to place some applesauce into the pill cup for the resident. No hand hygiene was observed prior to return to the medication cart. LPN B completed the medication pass after the resident was assisted with two inhalers. LPN B then washed their hands and exited the room. On 03/25/25 at 11:30 AM, the infection control nurse reported gloves should be used to pick up any pill designated for consumption by a resident. On 03/26/25 at 10:33 AM, the Director of Health Services confirmed: the need for gloves to pick up the pills if dropped on the barrier and returned to the cup; the need to complete hand hygiene before and after glove use; and the need to clean the blood pressure cuff after each resident use. A review of the facility policy titled, Medication Administration - General Guidelines revised 11/2018 revealed, .The person administering medication adheres to good hand hygiene: before beginning a medication pass, prior to handling any medications, after coming into direct contact with a resident, .examination gloves are worn when necessary, .hand sanitization is done with an approved sanitizer between handwashings, when returning to the medication cart or preparation area, .at regular intervals during the medication pass .

This citation has two deficient practice statements Deficient Practice Statement # 1 Based on observation, interview, and record review the facility failed to transport clean linen in sanitary manner. Findings Include: On 2/13/2024 at 10:41 AM, a cart with clean linen was observed being transported in the hallway uncovered. Subsequently, clean linen was observed to be getting stocked (in the clean linen storage closet on the 200 hallway) on top of the linen that was observed being transported uncovered in the hallway. On 2/15/2024 at 10:37 AM, an interview was conducted with Laundry Manager C. Laundry Manager C stated that laundry should always be covered when being transported. On 2/15/2024 at 10:49 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that laundry should be covered when they are transporting it in the hallway. A review of a facility policy titled, Guidelines for Handling Linen noted the following, .1.Clean linen should be transported to and from the laundry in a clean, covered cart. 46956 Deficient Practice Statement #2 Based on observation, interview and record review, the facility failed to ensure staff performed hand hygiene while providing meals to multiple residents in a common dining area. Findings include: On 02/14/24 at 12:12 PM, during lunch service in the resident dining room where approximately 25 residents were eating, Food Service Worker (FSW) A was observed having two episodes of coughing into their right hand while moving between resident tables. FSW A then retrieved a cup of water from the counter dispenser and returned to the resident dining table they were servicing without washing or sanitizing their hands. On 02/15/24 at 10:25 AM, the facility Infection Preventionist (IP) reported their expectations for hand hygiene for employees in the dining room is that staff should wash their hands after handling a resident wheelchair and after they have covered a cough. On 02/15/24 at 10:50 AM, the facility Director of Nursing (DON) reported that the expectation regarding staff who have coughed into their hands is to wash their hands prior to further resident interaction. On 02/15/24 at 11:33 AM, the facility Administrator (NHA) reported their expectation is that staff should wash or sanitize their hands after coughing into them. Review of the facility policy Guideline for Handwashing/Hand Hygiene dated 12/21/23 includes the Purpose statement Handwashing is the single most important factor in preventing transmission of infections. Hand hygiene is a general term that applies to either handwashing or the use of an antiseptic hand rub . The policy further states 3. Health Care Workers shall use hand hygiene at times such as: a. Reporting to work; before/after eating; after smoking, toileting, blowing nose, coughing, sneezing, etc. b. Before/after preparing/serving meals, drinks, tube feedings, etc.

Based on observation, interview, and record review, the facility failed to store and serve food under sanitary conditions. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 2/13/24 between 8:45 AM-9:15 AM, during an initial tour of the kitchen with Dietary Staff F, the following items were observed: In the walk-in cooler, there was a container of prepped vegetables with a use by date of 2/10, an opened bag of deli turkey with a use by date of 2/8, and an opened bag of salami with a use by date of 2/10. Dietary Staff F confirmed the items should have been discarded. In the True refrigerator, there was an undated container of chick peas. Dietary Staff F stated she believed they were opened yesterday, but confirmed that they should have been dated. According to the 2017 FDA Food Code section 3-501.17: Ready-to-eat, potentially hazardous food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 41 degrees Fahrenheit or less for a maximum of 7 days. Refrigerated, ready-to- eat, potentially hazardous food prepared and packed by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. The bulk bins of oatmeal and flour were soiled on the outside with dried on food debris. According to the 2017 FDA Food Code section 4-602.13 Nonfood-Contact Surface, Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. In the refrigerator utilized for the storage of resident food items brought in from outside, there was an undated container of fried rice. On 2/13/24 at 11:45 AM, the 3 shelf cart utilized for the storage of beverages and meal trays was observed to be soiled with crumbs and sticky spills. According to the 2017 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, .(C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.

Based on interview and record review, the facility failed to develop a baseline care plan for an armpit/chest wall wound for one resident (R354) of three residents reviewed for timely initiation of a base line care plan. Findings include: R354 On 2/13/2024 at 12:32 PM, an interview with R354 revealed that they currently had an armpit/chest wall wound that was healing and being treated daily. A medical record review revealed that R354 was admitted on [DATE] with the following pertinent diagnoses: Cellulitis of chest wall, Diabetes, type 2 with chronic kidney disease stage 3. Further review of the record noted a physician order for the left chest wound as follows: Cleanse left lower axilla (armpit/chest wall) wound with normal saline, pack with small piece of Aquacel AG and cover with dry dressing. A second order documented clean left upper extremity near armpit skin tear with normal saline and cover with island dressing daily. Further review revealed that there was not a base line care plan for a chest/armpit wound requiring specialized care within 48 hours. On 2/13/2024 at 12:24 PM, an interview was conducted with the Director of Nursing (DON) regarding the expectations for baseline care plans. The DON stated that the expectation was that residents should have a base line care plan for specialized issues within 48 hours.

Based on observation, interview, and record review, the facility failed to apply offloading heel boots per physician orders for one resident (R5) out of one reviewed for wounds. Findings include: On 2/13/2024 at 9:30 AM, R5 was observed laying in bed. R5 was noted to have wound care products in the room with a positioning wedge on their right side. R5's ankles were noted to be on a pillow with their heels resting on the mattress. On 2/14/2024 at 6:36 AM, R5 was observed in bed with a wedge on their left side. R5's heels were observed to be resting on the mattress. On 2/14/2024 at 8:48 AM, R5 heels were observed resting on the mattress. On 2/14/2024 at 11:35 AM, R5 heels were observed resting on the mattress. On 2/15/2024 at 9:46 AM, R5 was noted to have on their offloading boots. A review of the medical record revealed that R5 admitted into the facility on [DATE] with the following diagnoses, Pressure ulcer of left heel, unstageable (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) and Pressure Ulcer of Right Buttocks, unstageable. A review of the progress notes revealed that R5 required staff assistance with bed mobility and transfers. Further review of the physician orders revealed the following, Received Date: 1/26/2024. Start Date 1/26/2024. Order Description: Offloading Boots used while in bed. A review of the skin care plan dated 2/14/2024 revealed the following approach, .Offloading boots WIB (While in Bed) . Further review of a wound note dated 2/9/2024 revealed the following, .Interventions in place will continue such as APM (Alternate Pressure Mattress), roho, float heels using offloading boots while in bed, turning and repositioning, and supplements. On 2/15/2024 at 10:51 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the order should include as tolerated for the offloading boots. The DON stated that if R5 refused the offloading boots, then a progress note should be entered. On 02/15/24 11:28 AM, an interview was conducted with the Nursing Home Administrator (NHA) during a Quality Assurance and Performance Improvement (QAPI) meeting. The NHA reported their expectation for following wound interventions is to ensure order is accurate, treat as ordered, monitor wound progress, and report any concern or lack of progress. A review of a facility policy titled, Guidelines for General Wound and Skin Care noted the following, Purpose: To provide measures that will promote and maintain good skin integrity.

Based on observation, interview, and record review, the facility failed to ensure a call light was within reach for one resident (R48) out of two reviewed for call lights. Findings include: On 2/13/2024 at 9:20 AM, R48 was observed sitting in their wheelchair with their head resting on their bedside table. R48's call light was noted to be behind them resting on the headboard of the bed, it appeared to be out of reach. On 2/13/2024 at 9:27 AM, R48 could be heard yelling out, Nurse, Nurse, I don't have my call light! On 2/13/2024 at 9:28 AM, a dining worker pushing another resident to their room stopped and handed R48 their call light. On 2/13/2024 at 9:29 AM, an interview was conducted with R48. R48 stated that them not having their call light happens often. R48 stated that it mostly happens at night, and they have to scream out for the nurse to hand them their call light. On 2/13/2024 at 9:30 AM, R48 activated their call light to ask for some coffee. The call light was showing that it was activated from the hallway by a light at the top of the door and answered by a Nurse. A review of the medical record revealed that R48 admitted into the facility on [DATE] with the following diagnoses, Repeated Falls and Muscle Weakness. A review of the progress notes revealed that R48 had an intact cognition. On 2/15/2024 at 10:49 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that they expect for a call light to always be within reach. A review of a facility Policy titled, Guidelines for Answering Call Lights noted the following, .2. Ensure the call light is plugged in securely to the outlet and in reach of the resident.

Based on interview, and record review the facility failed to ensure 1) a comprehensive assessment was completed, 2) effective non-pharmacological interventions were implemented and 3) an appropriate diagnosis for the use of a psychotropic medication for one resident (R82) of five reviewed for psychotropic medications, resulting in potential for unnecessary medication and side effects. Findings include: On 01/05/23 at 10:45 AM, a review of the medical record for R82 revealed, R 82 was admitted into the facility on [DATE]. Diagnoses included: Unspecified Dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety; Metabolic Encephalopathy (mental status change related to chemical imbalance in the blood) and Delirium (mental status change) related to known physiological condition and Idiopathic (disease of one's own) Normal Pressure Hydrocephalus (fluid on the brain). A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed R82 did not trigger for Delirium on the Care Area Assessment for section V and care planning. R82 did trigger for psychotropic drug use. The psychotropic drug Seroquel was discontinued by the primary care physician (Dr. G) on 10/26/22. R82 was not on additional psychotropic medications until prescribed Risperidone 0.25 mg (milligrams) by mouth two times a day was for 7 days on 11/02/22 by the Psychiatrist (Dr. H) for seven days for Delirium. The November 2022 Medication Administration Record (MAR) documented R82 received the Risperidone for seven days. A review of the Drug to Condition Interaction Alert dated 11/03/22 revealed, Resperidone oral tablet .25 mg should be used with extreme caution when senile dementia a condition which exists with diagnoses code for Delirium due to known physiological condition exists . A review the progress note by Dr. H dated 10/31/22 (corrected to be 11/01/22) and printed/signed 11/02/22. The note revealed: Initial psychiatric assessment to assist in treatment planning .Patient is new to writer . The note referenced a urinary tract infection diagnosed in the hospital and two nurse notes. One which indicated a fall on 10/26/22 which stated the resident tried to get up because they wanted to go home and a second note dated 10/27/22 which indicated, Resident alert with confusion, up in wheelchair in common area, observed to be very fidgety, messing with wheelchair locks, wheels, anything in reach .Plan: Patient not seen however chart was reviewed and discussed with staff. (R82) is reported to be exhibiting symptoms that are indicative of Delirium. Will therefore start Risperdal .25 mg BID (two times a day) for seven days . A note by Dr. H dated 11/15/22 indicated an onsite visit and R82 .presented a calm and pleasantly confused .appeared to be in no distress . A review of the hospital consult note dated 10/20/22 at 3:59 PM for Altered Mental Status revealed, .discussed delirium treatment and prevention .(family member stated (R82) is always busy moving things or adjusting things .redirect patient as first line of care for any behavior issue, use medications as second line of treatment only when patient's behavior is negatively impacting care . A progress note by Social Worker (SW) F dated 10/27/22 at 2:38 PM, documented, No mood/behavior concerns. A progress note dated 10/28/22 at 10:06 AM, by Dr. G documented, .cooperative in care . A nursing progress note dated 11/02/22 at 11:25 PM, documented R82 slid out of the seat of their wheelchair an some non slip material was placed in the seat of the wheelchair. A progress note dated 11/04/22 at 10:08 AM, by Dr. G did not include acknowledgement of the Risperdal use under the medications listed and documented, .sitting in chair. No acute distress .cooperative in care . A progress note dated 11/08/22 at 2:59 PM, by the Nurse Practitioner did not include acknowledgement of the Risperdal use under the medications listed and documented, .very forgetful .possible underlying dementia .cooperative in care . A progress note dated 11/11/22 at 3:27 PM, documented and unwitnessed fall and Resident was given some towels. Very busy folding towels. Resident was very pleasant and seemed to enjoy folding the towels. A review of the care plan with created date of 10/26/22 revealed the folding of the towels and coloring were documented as added to the falls prevention plan approach on 11/14/22. The care plan approach dated 11/04/22 documented, Redirect resident when agitated behaviors are present or potential for injury is evident. The care plan approach dated 10/27/22 indicated, Encourage resident outing common area while awake . On 01/05/23 at 12:52 PM, the identified concerns were reviewed with Social Worker (SW) F. SW F reported that is was not the practice of the facility to prescribe medications such as Risperdal without a physical visit by the doctor. On 01/06/23 at 9:25 AM, SW F was asked about the concerns identified and indicated they had not heard back from Dr. H. SW E indicated they noted R82 was not actually seen by Dr. H but the doctor did physically visit the facility regularly. An email provided by SW E documented SW F had emailed the office of Dr. H on 11/14/22 for an appropriate diagnosis for the Risperdal. On 01/06/23 at 9:53 AM, Registered Nurse (RN) I reported they recalled R82 as prone to falls, confused, easy to give medications two and sat out in the common area. On 01/06/23 at 11:28 AM, Dr. G reported the facility was very aggressive about anti-psychotics and noted the Seroquel discontinued. The Administrator reported that the quality measures indicated no anti-psychotic use at the facility for the reported period of 05/02/22 to 10/31/22. SW E presented the email by SW F and indicated a review of the practices of the behavioral care group was conducted. A review of the Psychotropic Medication Usage and Gradual Dose Reductions policy dated 11/07/22 revealed, Purpose: To ensure every effort is made for residents receiving psychoactive medications to obtain the maximum benefit with minimal unwanted side effects through appropriate use, evaluation, and monitoring by the interdisciplinary team. 1. Residents shall receive psychotropic medications only if designate medically necessary by the prescriber, with appropriate diagnosis, or documentation to support its usage .'.

Based on observation, interview and record review the facility failed to ensure hand hygiene was done appropriately and/or gloves were used consistently during the care of three patients (R62, R204, R205) of six reviewed during care resulting in standard precautions not being used and the potential for the spread of hand borne microbes and infection. Findings include: On 01/04/23 at 4:26 PM, Nurse C was observed to prepare medications for R205 and R206. Nurse C prepared a syringe of insulin for R205 and one pain pill for R206. Nurse C entered the room of R205 and R206. Nurse C handed the pill to R206 with the right hand while holding the syringe of insulin for R205 in the left hand. Nurse C then placed on gloves without hand hygiene and proceeded to inject the insulin from the syringe into the abdomen of R205. Nurse C then removed their gloves and exited the room. Hand hygiene was not completed prior to exit. Nurse C then walked to the medication cart at the nurse station, lifted the lid of the computer, signed off the medication they had given. Nurse C was then asked about hand hygiene and reported they had forgotten and then proceeded to use the hand sanitizer on top of the medication cart. On 01/05/23 at 1:30 PM, the Infection Preventionist was asked about hand hygiene during medication pass and reported the expectation was for hand hygiene to be completed and that education and spot checks are done to ensure that staff is following hand hygiene practices. On 01/06/23 at 7:36 AM, Nurse D was observed to provide R62 there oral medications. Nurse D helped R62 with there pills and bed positioning. Nurse D then went to the hand sink and washed their hands. The first two happy birthdays of the happy birthday song were counted as Nurse D washed their hands. Nurse D finished washing their hands before the second two lines were counted. Nurse D was asked about their hand washing and acknowledged it was short of the 15-20 seconds recommended. On 01/06/23 at 7:48 AM, Nurse C was observed to fill a syringe with heparin for R206. Nurse C cleansed the site on the abdomen with alcohol and administered the heparin. Nurse C did not wear gloves for the administration of the heparin which carries the potential for exposure to blood and or body fluids. On 01/06/23 at 10:00 AM, the Administrator was asked about the hand hygiene concerns. The Administrator reported hand hygiene should be performed between patients; hand hygiene should be performed If contact was made with the resident, hand hygiene should be completed after removal of gloves, hands should be washed for twenty seconds and gloves should be worn for the heparin administration. A review of the facility policy titled, Infection Prevention and Control Guidelines with revised dated of 11/15/21 revealed, Purpose: to provide guidelines to prevent the spread of infection from one person to another. 3. Handwashing is the most important method of infection prevention and control. 5. Hands should be washed between direct contact with any resident, after doing cleaning tasks. after using the restroom or any other task that provides and opportunity for infection. 6. Gloves should be worn when coming in contact with blood or body secretions . A review of the Guideline for Handwashing/Hand Hygiene revised 02/09/17, revealed .1. All healthcare workers should utilize hand hygiene frequently and appropriately. 3. Healthcare workers shall use hand hygiene at times such as: C. Before or after having direct physical contact with residents. D. After removing gloves, worn per standard precautions for direct contact with secretions or excretions .

Based on observation, interview, and record review, the facility failed to ensure food items were labeled, dated, and discarded after the use by date, resulting in the increased potential for foodborne illnesses. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 10/25/21 between 8:30 AM and 9:00 AM, during an initial tour of the kitchen with Director of Food Services V, the following items were observed: In the walk-in cooler, there was a 5 pound container of cottage cheese with a written use by date of 10/19, and a manufacture's use by date of 10/18/21. When queried about the cottage cheese, Director of Food Services V confirmed that the facility use by date should not go past the manufacturer's use by date. In addition, there was a container of cut melon and a container of chopped lettuce that were unlabeled/undated. Director of Food Services V confirmed the melon and salad should have both been dated. In the dry storage room, there were 2 opened containers of cooking wine with a use by date of 5/12/20. Director of Food Services V stated she would discard the cooking wine. In the True reach-in refrigerator, there was an undated container of minced garlic, and numerous individual cups of salad dressing and mayonnaise, with use by dates of 10/18/21 and 10/22/21. Director of Food Services V stated the undated/outdated food items would be discarded. According to the 2013 FDA Food Code section 3-501.17: Ready-to-eat, potentially hazardous food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 41 degrees Fahrenheit or less for a maximum of 7 days. Refrigerated, ready-to- eat, potentially hazardous food prepared and packed by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. According to the 2013 FDA Food Code section 3-501.18 Ready-to-Eat, Potentially Hazardous Food (Time/Temperature Control for Safety Food), Disposition, (A) A food specified in 3-501.17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3-501.17(A), except time that the product is frozen; (2) Is in a container or package that does not bear a date or day; or (3) Is appropriately marked with a date or day that exceeds a temperature and time combination as specified in 3-501.17(A).

This citation pertains in part to MI 832. Based on observation, interview and record review the facility failed to ensure shower or baths were provided and or documented and or preferences were honored for four sampled Residents (R32, R13, R16, R4) and one non sampled resident (R28), of 8 reviewed for Activities of Daily Living (ADLs), resulting in verbalized dissatisfaction with care provided and the potential showers were completed at staff convenience and or not provided. Findings include: Resident #32 (R32) On 10/25/21 at 10:43 AM, R32 was observed to be dressed and seated in a wheelchair in their room. R32 was queried about the care at the facility. R32 reported they required assistance with toileting and recently they had to wait 40 minutes to be helped off the toilet. R32 reported their legs can get painful from the swelling and is only able to stand for a few minutes. R32 also reported not always being provided two showers a week. R32 indicated that recently hospice did not show up and the facility staff had to provide their shower. R32 indicated they did not get that dirty and may not always need two showers. R32 further noted the shower chair in the bathroom is no good as it does not have anything to hold on to. The one they prefer to use is bigger and has sides but often the aide has to go search for it. On 10/26/21 at 1:12 PM, during the group meeting R32 voiced concerns over a 30-40 minutes wait to be assisted off the toilet and that the shower bench in their bathroom had no handles on it. R32 and two additional group meeting residents reported they receive one shower a week but agreed that they would like at least two showers week. A review of the medical record for R32 revealed R32 was admitted into the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] indicated intact cognition with a 15/15 Brief Interview for Mental Status (BIMS) score and the need for extensive assistance by two persons for transfer and extensive assistance of one person for personal hygiene and bathing. The nursing care plan reflected, (R32) has a significant decline in (their) over all condition related to CHF (Congestive Heart Failure) and was admitted under hospice care. (R32) requires extensive to total assist in most of (their) ADL needs. (R32) is alert and responsive. (R32) uses the wheelchair as (their) primary mode of locomotion. (R32) is expected to continue to decline due to the disease progression. (R32) is incontinent of both bowel and bladder. (R32) requires assistance in (their) toileting needs. (R32) wears pads daily to protect (their) skin and avoid soiling (their) clothes. The Hospice care plan indicated ADL care was to be provided every visit. This included bathing. The initial Hospice Care plan did not include the use of a nurse aide. This was noted as NA or not applicable. An update dated 10/08/21 indicated (Home Health Aide) HHA effective 10/10/21 (one time a week times 7 weeks) 1WK7. A visit by the hospice HHA was not found in the provided hospice documentation. The October 2021 Point of Care ADL Report for bathing, documented one shower was provided on Friday 10/01/21, from 10/0/21 through 10/27/21. The September 2021 Point of Care ADL Report for bathing, documented five showers were provided (Wednesday 09/08/21, Friday 09/10/21, Tuesday 09/14/21, Thursday 09/16/21 (partial) and Friday 09/17/21), from 09/01/21 through 09/30/21. The August 2021 Point of Care ADL Report for bathing, documented six bathing episodes (Friday 08/06/21, Tuesday 08/10/21, Tuesday 08/17/21, Thursday 08/19/21 (partial), Friday 08/20/21, Friday 8/27/21 and Tuesday 8/31/21. Nine of the twelve weeks reviewed had one shower documented as provided. No refusals were documented. Resident #28 (R28) On 10/27/21 at 8:31 AM, R28 was observed to be dressed and seated in a wheelchair in their room. R 28 was able to move themselves around in the wheelchair. R28 reported they had to fight for a shower as they liked their shower in the morning, and reported they were in a much better mood as the aide had showered them that morning. R28 reported that their shower was not always done in the morning and at times they had been short of bath towels or wash cloths. R28 indicated staff are good when they do provide care. It was more about getting showers done when they like them to be done. Shower days were reported to be Wednesdays and Saturdays. The resident reported they felt they had received their two showers a week. A review of the medical record for R28 revealed an admission into the facility on [DATE] and readmission on 01/06/21. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] indicated intact cognition with a 15/15 BIMS score and the need for the supervision of one person for bathing and extensive assistance of one person for transfer. The nursing care plan revealed, .continues to require assistance from staff in most of (their) ADL needs secondary to generalized weakness .Approach Start Date: 02/26/2018 Requires 1 person assist for Bed mobility. The October 2021 Point of Care ADL Report for bathing, documented showers provided (on Saturday 10/02/21, Wednesday 10/06/21, Sunday 10/10/21, Wednesday 10/13/21, Wednesday 10/20/21, Saturday 10/23/21), from 10/1/21 through 10/27/21. No refusals were documented. Resident #13 (R13) A review of the medical record for R13 revealed an admission into the facility on [DATE] and a readmission on 04/22/21. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The October 2021 Point of Care ADL Report for bathing, documented bathing was provided on Saturday 10/02/21, Monday 10/11/21 (partial), Wednesday 10/13/21, Wednesday 10/20/21, Monday 10/25/21 (partial) and Wednesday 10/27/21. The September 2021 Point of Care ADL Report for bathing, documented bathing was provided Wednesday 09/08/21, Saturday 09/11/21, Wednesday 09/15/21, Saturday 09/18/21 and Friday 09/24/21 (partial), 9/25/21 and Monday 09/27/21 (partial). The August 2021 Point of Care ADL Report for bathing, documented bathing was provided Wednesday 08/04/21, Wednesday 08/11/21, Wednesday 08/18/21, Saturday 08/21/21 (partial), Wednesday 08/25/21, Saturday 8/28/21 and Monday 8/30/21 (partial). No refusals were documented. Resident #16 (R16) A review of the medical record for R16 revealed R16 was admitted into the facility on [DATE], diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The October 2021 Point of Care ADL Report for bathing, documented bathing was provided on Friday 10/08/21 (partial), Saturday 10/09/21 (other), Monday 10/11/21, Thursday 10/14/21, Friday 10/22/21 (partial), and Monday 10/25/21. The September 2021 Point of Care ADL Report for bathing, documented bathing was provided Thursday 09/02/21, Monday 09/06/21, Monday 09/13/21, Tuesday 09/16/21, Saturday 09/18/21 (partial) and Monday 09/20/21. No refusals were documented. Resident #4 (R4) On 10/25/21 at 10:04 AM, R4 was observed to be in bed. R4 was dressed on top and covered with blankets to the abdomen. R4 reported at times the staff seem to take all day to come in. The October 2021 Point of Care ADL Report for bathing, documented bathing was provided on Friday 10/22/21 partial) and Tuesday 10/26/21. The September 2021 Point of Care ADL Report for bathing, documented bathing was provided Thursday 09/02/21 (partial), Thursday 09/13/21 (partial), Thursday 09/16/21 (partial), Friday 09/17/21 (partial), Saturday 09/18/21 (partial), Monday 09/20/21 (partial), and Saturday 9/25/21 (partial). The August 2021 Point of Care ADL Report for bathing, documented bathing was provided Friday 08/06/21, Friday 08/13/21 (partial), Saturday 08/21/21 (partial), Wednesday 08/25/21 (partial), Thursday 08/26/21 (partial) and Friday 08/27/21. No refusals were documented. On 10/26/21 at 4:25 PM, Certified Nursing Assistant (CNA) L was asked about showers. CNA L reported they would note they would document activity did not occur if refused and would then let the nurse know. CNA L also reported they were able to chart if care was rejected in the behavior portion of the electronic charting. On 10/26/21 at 4:36 PM, Nurse M reported the CNA would let them know if a resident refused and would attempt to make other arrangements for the residents bathing to ensure the resident preferences were met. Nurse M also indicated Therapy may give showers but not document them. On 10/27/21 at 9:56 AM, bathing concerns were reviewed with the Director of Nursing (DON). The DON reported the staff should document if refused or not given verses not applicable. The DON reported the facility was working on hospice documentation for R32's showers. The hospice documentation provided did not indicate that a nurse aide nor bathing was provided for R32. Additional documentation for refusal or showers provided was requested, however no further documentation was received prior to survey exit. A review of the Electronic ADL Documentation Guidelines (review dated 05/22/21) revealed, .1. The residents' self performance for each activities of daily living as well as the amount of staff support should be documented each shift using the available software system .5. Self-Performance Bathing codes to be coded per (Resident Assessment Instrument) RAI guidelines . The policy did nor specifically address documentation of refusals.

This citation pertains in part to MI 832. Based on interview and record review the facility failed to ensure hospice services were provided for one sampled resident (Resident #32) of two residents reviewed for hospice services, resulting in hospice Home Health Aides services and coordination of care communication not provided. Findings Include: The Hospice care plan indicated Activities of Daily Living (ADL) care was to be provided every visit. This included bathing. The initial Hospice Care plan did not include the use of a nurse aide. This was noted as NA or not applicable. An update dated 10/08/21 indicated (Home Health Aide) HHA effective 10/10/21 (one time a week times 7 weeks) 1WK7. A visit by the hospice HHA was not found in the provided hospice documentation. In addition, there was no documentation available in the medical record or provided by the facility, that justified a rationale for missed HHA hospice visits. On 10/27/21 at 9:56 AM, bathing concerns were reviewed with the Director of Nursing (DON). During the interview, the DON reported the staff should document if refused or not given verses not applicable. The DON reported the facility was working on hospice documentation for R32's showers. The hospice documentation provided did not indicate that a nurse aide nor bathing was provided for R32. Additional documentation for refusal or showers provided was requested, however no further documentation was received prior to survey exit.

Based on observation, interview and record review, the facility failed to ensure infection control procedures were followed during intravenous (IV) medication preparation and a Peripherally Inserted Central Catheter (PICC) dressing was changed timely for one non sampled resident (R306) of one observed for IV administration resulting in the potential for the spread/development of infection, contamination of medication and delayed response to a potential infection at the PICC insertion site. Findings include: On 10/27/21 at 9:48 AM and 10:15 AM, Nurse O was observed during the preparation and administration of IV antibiotics for R306. The antibiotic was in a powder form inside a capped clear vial. The nurse had gathered the vial of antibiotic, a 250 milliliter (ml) IV bag of saline fluid, saline flush syringes, IV administration tubing, a transfer device/mixing device, alcohol wipes, a face towel and a foam tray. These items were observed on top of the medication cart outside the resident's room. The items were stacked on the foam tray and brought into the room of R306. Nurse O removed resident items from half of the tray table, placed the face towel on the tray table and then placed the foam tray on the towel. Nurse O picked up a syringe opened it and placed it back on the foam tray. Nurse O then removed the 250 ml bag of saline from its sealed (sterile) plastic wrap, held onto the bag and removed the blue cap from the access port for the IV administration tubing and placed the open bag onto the foam tray. The bag had two ports, one covered with the blue cap for connection to the IV tubing and one with a white rubber membrane for transfer of the antibiotic from the vial. Nurse O then picked up the vial removed the pop off cap and placed the vial on the table. The transfer device was removed from its sterile packaging and connected to the vial. The membrane on the vial was not cleaned with an alcohol wipe prior to the connection. The vial and transfer device were then connected to the white membrane covered port on the saline bag. This port was not cleaned with alcohol prior to the connection. The medication was then mixed with the solution from the bag by nurse O squeezing fluid into the powder. The powder dissolved in the saline and the solution was returned to the IV bag for administration. At this time Nurse O used an alcohol wipe to clean the IV tubing access port, connected the tubing, primed the tubing, connected the tubing through an IV pump and hooked the IV to R306's PICC line. The hub of the PICC line was cleaned with an alcohol wipe and the IV tubing was connected. It was noted that the PICC line was dated 10/22/21. The PICC line dressing was observed to have gauze in place under the transparent dressing. Gauze had been placed under the wings of the PICC line and around the insertion site of the PICC line. The gauze had a V shaped split in it to go around the catheter. The skin around the area at which the PICC entered the skin of the arm could not be seen. The insertion site was not visible in the V shaped opening. Nurse O was asked about the gauze under the dress and indicated that the IV had been inserted by an outside IV nurse. On 10/27/21 at 12:48 PM and 3:08 PM, the observations during the IV administration for R306 were reviewed with the Director of Nursing (DON). The DON reported that they follow the facility protocol for PICC lines. The DON reported they did not consider there to be a break in the sterility of the ports on the bag when placed on the non sterile surface of the foam tray and that the vial was considered sterile as long as this was the initial opening of the vial. The DON further noted that their policy indicated it was OK to have a gauze dressing in place greater than 24 hours if the insertion site was visible. A blown up picture of the IV site had been presented and the insertion site was not visible at the base of the V shaped notch. It was further noted that the dressing was viewed by the doctor and verbalized no concerns. A note to document this was not provided. A review of the facility policy Central Venous Catheter Dressing Changes (revised 12/15), revealed General Guidelines: 4. After original insertion of (Central Venous Access Device) CVAD, the dressing will consist of gauze and (transparent dressing) TSM. This will be changed within 24 hours. Replace with sterile transparent dressing .6. Change gauze dressings and TSM over gauze dressings every 48 hours .8. If gauze is used to support the wings of the access needle under a TSM dressing, and does not obscure the insertion site, it can be changed every 5 to 7 days with the TSM dressing. A review of the facility provided Administering Medications through a Secondary Tubing Line (revised 12/15), Administration Set/Tubing Changes (revised 12/15) and Changing the Needleless Connection Device and Extension Tubing (revised 12/15) did not address the cleaning of the vial top or procedure for reconstituting medications nor the PICC dressing. A review of the Institute for Safe Medication Practices (ISMP) Safe Practice Guidelines for Adult IV Push Medications (dated 2015) revealed: .2. Aseptic Technique 2.1 Use aseptic technique when preparing and administering IV push medications, flush/locking solutions, and other [MEDICATION(S)] solutions administered by direct IV injection. Aseptic technique includes: 2.1a Hand hygiene prior to and after preparation and administration of the medication or solution 2.1b Disinfection of the medication access diaphragm on a vial or the neck of an [MEDICATION(S)] prior to accessing the medication or solution. 2.1c Disinfection of the IV access port, needleless connector, or other vascular access device (VAD) prior to administration of the medication or solution .Discussion: According to CDC guidelines (IV.H.1), the use of aseptic technique when preparing and administering IV push medications, flush/locking solutions, or other [MEDICATION(S)] solutions administered by direct IV injection is necessary to avoid contamination of sterile injection equipment .Practitioners may not be aware that the 'pop-off' vial caps from manufacturers are considered 'dust covers' and are not intended to maintain sterility of the vial diaphragm or access point. Thus, the diaphragm must always be disinfected after removing the cap of a new vial. According to the Association for Professionals in Infection Control and Epidemiology (APIC) Safe Injection, Infusion, and Medication Vial Practices in Health Care, practitioners should disinfect vials by cleansing the access diaphragm 'using friction and a sterile 70% [MEDICATION(S)] alcohol, ethyl alcohol, [MEDICATION(S)], or other approved antiseptic swab.' Organizational standards for infection control in each facility should identify which disinfectant to use. It is also important to wait at least 10 seconds to allow the diaphragm to dry before inserting any device into the vial or accessing the medication .3.3 If dilution or reconstitution of an IV push medication becomes necessary outside of the pharmacy sterile compounding area, perform these tasks immediately prior to administration in a clean, uncluttered, and functionally separate location using organization-approved, readily-available drug information resources and sterile equipment and supplies .https://www.cdc.gov/injectionsafety/ip07_standardprecaution.html. The APIC Position Paper: Safe Injection, Infusion, and Medication Vial Practices in Health Care (2016) was reviewed and revealed, .Aseptic technique refers to the use of various barriers and precautions to prevent the transfer of microorganisms from HCP and the environment to the patient during a procedure. Sterile is the absence of all microbes .Use aseptic technique in all aspects of [MEDICATION(S)] medication preparation, administration, medication vial use, injection, and point-of-care testing .Avoid having nonsterile contact with sterile areas of devices, containers and drugs .Disinfect the rubber stopper of medication vials and the neck of glass [MEDICATION(S)] with sterile 70% alcohol before inserting a needle or breaking the [MEDICATION(S)] .MEDICATION VIALS . Always follow the manufacturer ' s instructions for storage and use .Disinfect the rubber septum on all vials prior to each entry, even after initially removing the cap of a new, unused vial .

Based on observation, interview, and record review the facility failed to store nasal cannulas in a sanitary manner affecting two residents (R194 and R195) of two residents reviewed for respiratory care equipment resulting in the potential for the preventable spread of infections. Findings include: R194 Review of R194's Electronic Health Record (EHR) revealed R194 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A Brief Interview for Mental Status (BIMS) assessment dated [DATE] revealed R194 had an intact cognition. On 02/11/20 at 1:33 PM, R194 was interviewed regarding the care received at the facility. During the interview it was observed that using an oxygen (O2) concentrator for supplemental O2 via a nasal cannula. R194's wheel chair was observed to have an O2 tank and the nasal cannula was wrapped around the O2 tank and the tip was dangling on the side of the O2 tank. R194 was asked about the nasal cannula and stated, I don't know who did that. On 02/11/20 at 1:09 PM, Registered Nurse A was asked about the facility's policy and procedure regarding the storage of nasal cannulas and other respiratory care equipment and stated, Whoever brought (R194) back (from the dining room) did that. They should be stored in a clean bag. R194 stated, A big girl from the kitchen brought me back. R195 Review of R195's EHR revealed R195 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A BIMS assessment dated [DATE] revealed R195 had a moderately impaired cognition. On 02/12/20 at 8:39 AM, a medication administration observation was conducted with Nurse B. During the administration it was observed that R195's wheel chair had a portable O2 tank on the back and the nasal cannula was wrapped around the back of the wheel chair and the tip was dangling against the O2 tank. Nurse B was asked about the facility's policy and procedure regarding the storage of nasal cannulas and other respiratory equipment and stated, That is not stored properly. It should be stored in a plastic bag. On 02/13/20 at 9:12 AM, R195 was asked about the use of the nasal cannulas and stated, Well, I can put it on and take it off now, but I did not wrap it around the wheel chair yesterday. On 02/13/20 at 11:30 PM, the Director of Nursing (DON) was asked about the facility's policy and procedure regarding storing nasal cannulas and stated, I have started in-servicing people. Review of the facility's policy and procedure titled, RESPIRATORY EQUIPMENT dated as, Effective Date: (YEAR)0511 (May 5, (YEAR)) revealed that, 2. j. Keep oxygen cannula and tubing used PRN (as needed) in a plastic bag when not in use.

Based on observation, interview and record review, the facility failed to ensure accurate advanced directive information was in place for one (#138) of three residents reviewed for advanced directives, resulting in an inaccurate medical record and the potential for a resident's preferences for medical care to not be followed by the facility staff. Findings include: On 2/11/20 at 8:30 AM, during the initial tour Resident #138 was observed in bed eating breakfast. On 2/11/20 at 12:23 PM, during a record review in the Electronic Medical Record (EMR), Resident #138's code status bar was noted to be highlighted green with the words Full Code. Further review noted a physician's orders [REDACTED]. A review of the section in the EMR titled resident documents revealed a completed do-not-resuscitate (DNR) form signed and dated by Resident #138, 2/1/20. On 2/13/20 at 8:42 AM, Resident #138 was asked their code status and stated, I'm a total DNR. On 2/13/20 at 9:48 AM, Social Worker (SW) was asked about the facility's process for advanced directives. The SW explained that they run a daily report to make sure the code status is correct. SW was asked about Resident #138's code status and the completed DNR advance directive. SW stated, the code status bar and face sheet reflect the active physician order. SW continued and stated, Resident #138 recently changed their status and it may have not been changed in the computer. On 2/13/20 at 9:54 AM, Nurse C was asked in an emergency where do they look for the code status at. Nurse C stated, I look on the face sheet and will look in the hard chart to make sure. On 2/13/20 at 11:30 AM, the Administrator was asked the facility's procedure regarding advanced directives. The Administrator stated, Advanced Directives are reviewed upon admission, we scout every single resident's chart every day in morning meeting, by Minimum Data Set, Director Of Nursing ,Physical Therapy, SW, Dietitian, and sometimes a different nurse, because the Assistant Director is on a leave. I don't know how we missed that one. A review of the facility's policy titled, Guidelines for DNR Orders undated, notes, PURPOSE: To ensure residents wishes to not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect is followed. Procedures: 2. A Do Not Resuscitate Form shall be completed and signed by the attending physician/Extender and resident and placed in the resident's electronic medical record

Based on observation, interview, and record review, the facility failed to maintain wheelchairs in good and safe operating condition for 6 (# 9, 26, 31, 56, 209, 259) residents using wheelchairs, resulting in the potential for skin tears. The findings include: On 04/23/19 at 8:30 AM, R#9 was observed lying in their bed watching TV. The resident's right and left armrest on the wheelchair had multiple cracks with deep edges in the leather that exposed the internal padding in several sections. On 04/23/19 at 12:40 AM, R#26 was observed sitting in their wheelchair eating lunch in the dining room. The resident's right armrest on the wheelchair had multiple cracks in the leather that exposed the internal padding in several sections. On 04/23/19 at 12:44 PM, R#56 was observed sitting in their wheelchair eating lunch in the dining room. The resident's left armrest on the wheelchair had multiple cracks in the leather that exposed the internal padding in several sections. On 04/23/19 at 12:45 PM, R#31 was observed sitting in their wheelchair eating lunch in the dining room. The resident's left and right armrest on the wheelchair had multiple cracks in the leather that exposed the internal padding in several sections. On 04/24/19 at 7:59 AM, R#209 was observed sitting in their wheelchair watching TV in their room. The resident's right armrest on the wheelchair had a long crack in the leather that exposed the internal padding in several sections. On 04/24/19 at 8:09 AM, R#259 was observed sitting in their wheelchair eating breakfast in the dining room. The resident's right armrest on the wheelchair had multiple cracks in the leather that exposed the internal padding in several sections. On 4/24/19 at 8:22 AM, an interview was conducted with Unit Manager (UM) D regarding wheelchair repairs. UM D confirmed the observed wheelchairs needing to be repaired. UM D stated, I will notify the maintenance department to look at all the wheelchairs. On 04/24/19 at 10:37 AM, an interview was conducted with the Administrator regarding wheelchair repairs. The Administrator stated, The care staff wash the wheelchairs at night. There is a schedule. If we (facility) notice a wheelchair that needs repair, we put a work order in, and maintenance staff E will look into it. A review of the facility's policy titled, TELS, Revised 2-9-2018, did not address wheelchair repairs.

Based on observation, interview, and record review the facility failed to ensure staff covered facial hair when entering the kitchen, affecting all residents that eat in the dining room with the likelihood of contamination of the food with facial hair. Findings include: On 4/23/19 at 7:40 AM, a dining observation was conducted in the main dining room. During the meal service two staff with facial hair Staff B and Staff C entered the dining room from the back door and walked through then entered the kitchen and walked passed a sign that said Dietary staff only passed the yellow line. walked passed the tray line, then went into the dining room on the other side of the kitchen. Upon re-entering the kitchen Staff B was asked about the facility's policy and procedure on facial hair in the kitchen and asked, Does it need to be covered? Staff C was asked the same question and stated, It's normally not this long, I should cover it. On 4/24/19 at 9:04 AM, the Director of Dining Services was asked about the facility's policy and procedure on facial hair in the kitchen and stated, Those two are not dietary staff. The (corporate) policy is 1/8th an inch. We've reviewed the policy and updated it. Review of the facility's policy and procedure titled,(NAME)Restraint Policy dated as Revised (MONTH) 2, (YEAR) revealed under Procedures Some common approaches include: -cover all facial hair below the corner of the mouth. -More than a day or two growth. -More than 1/8 inch. -Like hair covers, beard nets must be worn .

Based on observation, interview, and record review the facility failed to perform hand hygiene to Center for Disease Control (CDC) standards and to the facility's policy and procedure during a wound care observation affecting 1 (R#15) of 2 residents reviewed for pressure ulcers, with the likelihood of the preventable spread of infection. Findings include: On 4/23/19 at 9:30 AM, a wound care observation was conducted with Nurse A on R#15. Nurse A knocked on the door, explained the procedure to R#15, assembled the supplies and washed hands for a brief amount of time and applied gloves. Nurse A removed the old dressing, removed gloves, washed hands for six seconds, and applied new gloves. NurseA then cleansed the wound, applied skin-prep, then the prescribed dressing, removed the gloves and washed hands for 11 seconds and turned the water off with a bare hand before reaching for a paper towel. Later in the hall Nurse A was asked how long one should wash their hands and stated, Oh, a couple of minutes. Nurse A was then asked how one should turn the water off and stated, With a paper towel. On 4/24/19 at 11:00 AM, the Infection Control Preventionist (ICP) was asked about he facility's policy and procedure on hand hygiene and stated, That Nurse was spoken to. Review of the facility's policy and procedure on hand hygiene titled Guidelines for Handwashing/Hand Hygiene dated as Revised 2/9/17 revealed under Procedure, 1. c) Wash well for 15-20 seconds. Apply liquid soap and work into a lather. 1. f) Turn faucet off with paper towel to avoid recontamination hands from the faucet. Review of a CDC document dated as Reviewed (MONTH) 7, (YEAR) revealed, Scrub your hands for at least 20 seconds. Need a timer? Hum the Happy Birthday song from beginning to end twice.

Based on observation, interview and record review, the facility failed to ensure As Needed (PRN) [MEDICAL CONDITION] medications had a 14 day stop date for 1 (R#15) of 6 residents reviewed for unnecessary [MEDICAL CONDITION] medications, resulting in the likelihood for adverse reactions and the use of duplicate drug therapies. Findings include: On 4/22/19 at 9:12 AM and 3:15 PM, R#15 was observed in a chair in the room sleeping. On 4/23/19 at 8:51 AM, R#15 was observed sleeping in their chair in their room. At 9:30 AM, the resident was awakened for wound care, and remained calm and cooperative during the procedure. On 4/23/19 at 1:14 PM, R#15 was observed sleeping in a chair in the room. Certified Nurses Aide (CNAG) was asked if R#15 had any inappropriate behaviors and stated, Not that I know of. On 4/23/19 at 2:16 PM, record review was conducted of R#15's Electronic Health Record (EHR) revealed that R#15 was admitted into the facility 12/31/18 and readmitted on [DATE] with [DIAGNOSES REDACTED]. R#15's most recent Minimum Data Set Assessment ((MDS) dated [DATE] revealed the resident needed extensive assistance with activities of daily living and had a Brief Interview for Mental Status (BIMS) score of 14 indicating an intact cognition. Further review revealed no inappropriate behaviors were documented in the last 120 days. On 4/23/19 2:25 PM R#15's medication orders included, [MEDICATION NAME] (quetiapine) amt: 25 milligrams (mg); oral; At Bedtime - PRN. Special instructions: In addition to scheduled dose as needed for increased Hallucinations. Order Dates: 4/4/19 - Open. Review of R#15's Medication Administration Record [REDACTED]. On 4/24/19 at 10:27 AM, the Administrator was asked about the facility's policy and procedure on PRN [MEDICAL CONDITION] medications and stated, We must have missed it, we look at it, then put a stop date and then the doctor follows up on it. On 4/24/19 at 12:04 PM, Social Worker H was asked about the facility's policy and procedure on PRN [MEDICAL CONDITION] medications and stated, It was ordered by Hospice, Psych (psychological staff) recommends discontinuing it. I will talk to them again.

Based on observation, interview, and record review, the facility failed to ensure medications and Biologicals were labeled and stored according to professional standards of practice for 4 (#'s 158, 260, 309, and 311) in two (Unit 100 and Unit 200) out of three units reviewed for appropriate medication and biological storage and labeling and failed to ensure one of one medication cart in the 100 hall of the facility was locked and secured when unsupervised by authorized personnel, resulting in the potential for administration of expired medication, reduced effectiveness of medications, and unauthorized access to medications. Findings include: On [DATE] at 9:47 AM, an unlabeled saline flush was observed on the night stand in Resident #260's room. On [DATE] at 11:12 AM, the contents of Unit 200 medication cart B were inspected along with Staff Nurse B. An open multi-dose vial of [MEDICATION NAME] (long-acting insulin) for Resident #260 was observed without an open date. A multi-dose [MEDICATION NAME] (fast-acting insulin) [MEDICATION NAME] for Resident #158 was observed with the seal broken and without an open date. Staff Nurse B was asked if the [MEDICATION NAME] and [MEDICATION NAME] should indicate when they were opened. Staff Nurse B agreed that they should be labeled with open dates and proceeded to use a marker to write a date on the vial and the [MEDICATION NAME]. On [DATE] at 11:36 AM, the contents of the medication cart for Unit 100 were inspected along with Staff Nurse K. An open bottle of multi-dose eye drops for Resident #311 were observed without an open date. An open bottle of multi-dose [MEDICATION NAME] (allergy steroidal nasal spray) for Resident #309 was observed without an open date. On [DATE] at 12:30 PM, the 100 hall medication cart was observed unlocked and unsupervised by facility staff. On [DATE] at 12:35 PM, Nurse K was observed exiting a Resident room and walking to the 100 hall medication cart. Nurse K began using the computer located on the top of the cart without locking the medication cart. An interview was conducted with Nurse K at this time. When queried regarding the medication cart being unlocked while unattended, Nurse K replied, Oh no and locked the medication cart. When queried if the cart is supposed to be locked when unattended by facility staff, Nurse K indicated the cart should have been locked. No further explanation was provided. An interview was conducted with the Assistant Director of Health Services (ADHS) on [DATE] at 2:40 PM. When queried regarding the unlocked and unsupervised medication cart in the 100 hall of the facility, the ADHS indicated the medication cart should have been locked. No further explanation was provided. On [DATE] at 2:58 PM, the facility provided a policy/procedure (p/p) titled, Medication Storage In The Facility with a revision date of ,[DATE], which was reviewed and revealed the following: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed facility personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedures: B. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications .are permitted to access medications. Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. Certain medications or package types, such as .multiple dose injectable vials, ophthalmic's (for the eyes) .once opened, require an expiration date shorter than the manufacturer's expiration date to insure medication purity and potency . c. Drugs dispensed in the manufacturer's original container will carry the manufacturer's expiration date. Once opened, these will be good to use until the manufacturer's expiration date is reached unless the medication is: 1. In a multi-dose injectable vial. 2. An ophthalmic medication. 3. An item for which the manufacturer has specified a usable life after opening. D. When the original seal of a manufacturer's container or vial is initially broken and the manufacturer recommends that the medication's expiration date be adjusted based on the date opened, the container or vial will be dated. 1) A 'date opened' sticker shall be placed on the medication .The expiration date of the vial or container will be (30) days unless the manufacturer recommends another date or regulations/guidelines require different dating.

Based on observation, interview and record review, the facility failed to provide and implement interventions for residents with poor appetite and prevent weight loss for 2 (#s 703 and 705) of six residents sampled for weight loss from a total of 14 sampled residents, resulting in continued weight loss and a potential for malnutrition, decline in health or death. Findings include: Resident #703 On 7/31/17 at 10:25 a.m., an observation was made of Resident #703 in his room with a meal tray at his bed side. Resident #703 was sitting up at his bedside. Resident #703 was confused and not answering questions. There was approximately 85 percent (% ) of his food still on his meal tray. Resident #703 did not appear to be eating. On 7/31/17 at 3:00 p.m., a record review of the face sheet and Minimum Data Set (MDS) assessment revealed that Resident #703 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. According to the MDS dated [DATE], Resident #703 had severe cognitive impairment, had an unplanned weight loss, and was receiving limited assistance with meals. On 8/1/17 at 8:45 and 9:40 a.m., Resident #703 was observed in his room, lying in bed, holding a white foam cup and playing with the lid. There was a meal tray at his bedside. The food was covered with a lid. There was no staff in the room encouraging him or assisting with feeding. On 8/1/17 at 9:55 a.m. a record review of Resident #703's weights revealed the following: 3/3/17 239.2 pounds ( lbs) (initial weight) 4/2/17 230 lbs 5/1/17 229.5 lbs 6/3/17 209.8 lbs 7/17/17 201 lbs On 8/1/17 at 10:00 a.m., a record review of the Nutrition care plan which was not created until 7/11/17, revealed the following: Problem: Resident (#703) has experienced a significant weight change Goal: No further unwarranted significant weight change will occur Interventions (all dated 7/11/17): Offer encouragement and assistance with eating PRN (as needed) Provide diet, supplements, and/or snacks as ordered Weigh as ordered No other interventions were modified or added after the creation of the care plan. On 8/1/17 at 10:15 a.m., an interview was completed with the Registered Dietician (RD) F. During the interview, RD F was queried about what new interventions were placed to prevent further weight loss for Resident #703. RD F stated, He (Resident #703) has poor po (oral) intake. His weight loss happened quickly and he gets supplements. RD F also stated, Sometimes he (Resident #703) will sit at a table and eat, other times we have to give him finger foods. He needs cueing and encouragement to come out of his room and eat. RD F was queried about the frequency of weights being completed on Resident #703 and if the weights should be done more frequently than monthly, RD F stated, No, we don't really want him to gain anymore weight. RD F also confirmed that she creates the care plan for nutrition during the interview and she is works in the facility 2-3 times per week. On 8/1/17 at 11:00 a.m., a record review of the progress notes was completed. The following was revealed: 3/22/17 (RD F)-Initial nutrition assessment stated, Needs set up assist but able to feed self independently (Resident #703). Good appetite, meeting nutrition needs. 6/15/17 (RD F)-Significant weight loss 12% (29 pounds) .decreased appetite. Not been interested in sitting down and eating a meal. Prefers to walk around and eat finger foods. Continue to provide encouragement at meals. Trial finger foods with each meal and (liquid nutritional supplement) plus BID (twice per day) between meals. Weekly weights. 7/7/17 (RD F)-Staff continues to encourage PO intake at meals, honor food preferences and offer alternatives PRN. Will monitor acceptance of supplement and per poc (plan of care). Good PO intake of fluids. Prefers juice-will try (nutritional liquid supplement) clear TID (three times per day). 7/11/17 (physician note)- .(Resident #703) seen for significant weight loss, per nursing staff patient had lost almost 30 pounds for last 4 months .patient's oral intake is also poor. Patient's (Resident #703) weight loss multifactorial, possible secondary to loss of pedal [MEDICAL CONDITION] and patient's poor oral intake . 7/11/17 (RD F)-Family request for (nutritional liquid supplement) plus, not clear. 7/17/17 (RD F)-Weight down .increase (nutritional liquid supplement) plus to 5/d (five times per day) to equal 1800 cal (calories) per day. On 8/1/17 at noon, a record review of the physician's order for Resident #703 revealed: (Nutritional liquid supplement) Plus TID (was not increased to five times per day). On 8/1/17 at 12:05 p.m., a record review of the acceptance of the nutritional liquid supplement revealed Resident #703 had varying intake of the supplement. On 8/1/17 at 12:40 p.m., Resident #703 was observed lying in bed resting with his eyes closed. His meal tray was at his bedside uncovered (stuffed cabbage, potato and dessert). Resident #703's spouse at his bed side (Family Member G). Resident #703 had not eaten any of his meal. Family Member G was queried in regards to Resident #703's weight loss. Family Member G stated, I am not crazy about it. I try to bring him in snacks to eat, sometimes he will eat them, sometimes he won't. The meal ticket for Resident #703 stated, No chicken;soup with meal. Offer finger food if intake less than 50%. There was no staff in the room. On 8/1/17 at 2:05 p.m., Resident #703 was observed sitting up in a chair in his room with Family Member G attempting to feed him the same meal tray that was at his bedside earlier. On 8/2/17 at 10:35 a.m., the Director of Nursing (DON) was queried regarding Resident #703's weight loss. The DON stated, He (Resident #703) has dementia and has behaviors, a lot of times he doesn't let anyone feed him, we give him supplements if he doesn't eat. During that time the July FAR (food acceptance report) for Resident #703 was requested for the second time but not received by the end of the survey. On 8/2/17 at 11:30 a.m., during a quality assurance meeting with the Administrator and DON, the Administrator had asked about the concern with Resident #703's weight loss. When the Administrator was asked about interventions put into place for Resident #703 to prevent further weight loss, the Administrator responded, He (Resident #703) has behaviors and we don't like to agitate him. We are looking for more appropriate placement for him. The DON and Administrator were further queried in regards to the notes that RD F had documented but not care planned or implemented (weekly weights, finger foods) the Administrator stated, The doctor did not want weekly weights. The Administrator was also queried in regards to if other alternatives were discussed with the family for Resident #703 (tube feeding, appetite stimulants), the Administrator stated, We have casual conversations with (Family Member G), she doesn't want that (tube feeding) she is happy with his weight. The progress note stating the discussions with the family and the physician not wanting weekly weights was requested but not given by the end of survey. On 8/2/17 at 1:30 p.m., a record review of the facility policy titled, Guidelines for Weight Tracking reviewed 5/15/2016 stated in the purpose statement, To ensure weight is monitored for weight gain or loss to prevent complications arising from compromised nutrition/hydration. On 8/2/17 at 1:40 p.m., a record review of the facility policy titled, Nutritional Supplement (no revision or creation date) stated, b. if current intake is not meeting needs, the clinical nutrition practitioner will investigate the reasons for inadequate intake and will recommend one or more of the following: iii. fortified foods iv. Snacks v. Double portions, if the individual eats well vi. Frequent, small meals vii. Feeding Assistance viii. Speech Therapy or Occupation Therapy Evaluation Resident #705 Record review on 7/31/17 at 12:00 PM revealed Resident #705 was most recently admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. hearing. Review of the Minimum Data Set ((MDS) dated [DATE] revealed the Resident was severely cognitively impaired and required extensive assistance to perform Activities of Daily Living (ADL's). Additional review revealed the Resident developed two facility acquired pressure ulcers since admission to the facility on [DATE]. On 7/31/17 at 2:55 PM, record review of Resident #705's care plans were completed. Review revealed a care plan entitled, Nutrition: Resident has potential for alteration in nutritional status related to diagnoses, medications, fluid balance, diet, intake, physical activity and metabolic demands (Start Date: 04/27/2017, Revised Date: 06/12/2017). The following interventions were included in the care plan: -Assist with meals as needed (Start Date: 4/27/17) -Obtain weight as ordered/needed (Start Date: 4/27/17) -Offer alternate food and beverage items as needed (Start Date: 4/27/17) -Provide diet/supplements/medications as ordered (Start Date: 4/27/17) Additional review at this time revealed the following documentation of the Resident's weights within the medical record: -7/8/17 125 lbs (pounds) -6/9/17- 135 lbs (Documented as admission weight) Documentation within the medical record revealed the following documentation authored by Registered Dietician F: -Nutrition Assessment - Readmitted d 6/12/17 at 4:39 PM: .Nutrition Dx (Diagnosis)/Assessment: Resident is at risk for insidious weight loss and decreased skin integrity r/t (related to) hx (history) weight loss, decreased appetite, refusing ONS (Ensure Plus, Medpass 2.0), cognitive impairment, debility and resisting assistance w/meals. Per SLP eval/tx, moving forward (the Resident) will be encouraged to eat in the private DR (dining room), with supervision. Family is aware of decreased PO (oral) intake. Recommend trying Ensure Clear ONS with resident, in cup, over ice. Will monitor nutritional status prn (as needed)/per poc (Plan of Care). -Nutrition Note on 6/15/17 at 4:19 PM: Resident continues to have poor PO intake at meals and w/ fluids - at increased risk for weight loss and dehydration. Staff continues to encourage resident at meals providing 1:1 assistance in the private dining room; staff offering sips of fluids/ONS throughout day. Will continue to monitor nutritional status prn (as needed). On 8/1/17 at 10:20 AM, an interview was completed with Registered Dietician F. When queried, Dietician F stated, I'm here two to three times week. When asked about Resident #705's weight, Dietician F stated, (Resident #705) has been a tough one. (The Resident) had a significant weight loss in the last 30 days but not in 90 or 180 days. With further inquiry, Dietician F explained that the Resident had been a Resident of the facility previously. When queried regarding facility policy for weighing Residents, Dietician F stated, We usually weigh Residents monthly. When there are (weight) changes or they are clinically at risk, we weight them more often- four times a month. When queried if Resident #705 was clinically at risk, Dietician F replied, Yes. When asked why Resident #705 was not weighted more frequently due to them being at risk, Dietician F replied, (Resident #705 probably should have been weighted more, yes. When queried how often a Resident that is a risk for altered nutrition is seen by the Dietician, Dietician F replied, Typically monthly. When queried regarding why Resident #705 was not seen in over a month and had experienced a significant weight loss, Dietician F stated, I can't comment. I don't have an answer. Dietician F then stated, I put in a note this morning. When queried regarding nutritional interventions for Resident #705, Dietician F stated, (The Resident) is getting Ensure three times a day. When asked if interventions had been updated related to known risk for nutritional deficits, recent development of two facility acquired pressure ulcers, and significant weight loss over one month, Dietician F stated, No. With further inquiry, Dietician F stated, Weights are important, I agree. Record review on 8/1/17 at 11:00 AM revealed the following documentation by Dietician F: -Nutrition Note on 8/1/17 at 9:44 AM: Current weight: 125#(7/8) Ht 69 BMI <19 Wt hx: 135#(6/9) 125#(5/3) 123.4#(4/2) 132#(2/1) .NUTRITION DX/ASSESSMENT: Altered nutritional status r/t medical condition/comorbid conditions. Resident has experienced a significant weight loss 7%/30 Day based on June/July weights R/T poor PO intake and sarcopenia, not unexpected with current dx/medical condition. Weight hx reflects no significant change x 90 Day/180 Day, with an average weight of 127#/6 months (BMI 19) .Will continue to monitor nutrition related parameters. See NUTRITION POC for goals/interventions. An interview with completed with the facility Administrator, the Director of Nursing (DON), and the ADON on 8/2/17 at 3:00 PM. When queried regarding weight monitoring and frequency of assessment by a Registered Dietician for Residents identified as at risk for alterations in nutritional status, the Administrator stated, I understand what you are saying. On 8/2/17 at 3:45 PM, record review of facility policy entitled, Guidelines for Weight Tracking (Reviewed 5/15/2016) stated, Purpose: To ensure weight is monitored for weight gain or loss to prevent complications arising from compromised nutrition/hydration.