Every finding on record at Sun Health La Loma Care Center

Based on clinical record review, staff and caregiver interviews, and policy and procedures, the facility failed to ensure advance directives was followed for one resident (#10).Findings include:Resident #10 was admitted on [DATE], with diagnoses of muscle weakness, bacteremia, methicillin resistant staphylococcus aureus (MRSA), acute abscess of female pelvis, acute delirium, atrial-fibrillation, unspecified dementia, psychotic disturbance, mood disturbance, and anxiety.The facesheet of the clinical record revealed no code status documented.The hospital history and physical dated [DATE] revealed that the resident had a code status of Do Not Resuscitate (DNR) and Do Not Intubate (DNI).An undated admission report sheet included that the resident had a code status of DNR.An admission progress note dated [DATE] revealed that resident #10 was alert and oriented with some confusion. The advance medical directive statement signed by the POA (power of attorney) and dated [DATE] included that the resident would receive cardio-pulmonary resuscitation (CPR), hospital transfer, feeding tube, pain medication, and hydration. The NP (nurse practitioner) note dated [DATE] included that the resident had a full code status.The physician's order dated [DATE] revealed that the resident had a full code. A brief interview for mental status (BIMS) assessment was completed on [DATE] included a score of 5 indicating the resident had severe cognitive impairment.Review of the care plan dated [DATE] revealed no code status was identified for resident #10.The provider note dated [DATE] included that the resident had a full code status.The provider note dated [DATE] included that the resident had a full code status.There was also no evidence found in the clinical record that the physician order for the full code status was changed or discontinued.However, review of the shift report sheet for [DATE] documented that the resident's code status was DNR.There was no evidence found in the clinical record that the code status of the resident was clarified with the resident and/or the resident's POA and/or the physician.The progress note dated [DATE] revealed that at 7:15 am, resident was in bed sleeping and had no acute respiratory distress noted. It also included that at 8:05 a.m., the resident was found unresponsive; and that, two nurses assessed the resident and noted that all vital signs ceased. The documentation did not include whether or not CPR was initiated for resident #10.There was no evidence found in the clinical record that CPR was initiated for resident #10.The facility's self report dated [DATE] included that the director of quality management notified the administrator and the DON (director of nursing) that on [DATE] CPR (cardiopulmonary resuscitation) was not performed when resident #10 was found unresponsive with no signs of life; and that, the resident passed away. During an interview conducted with registered nurse (RN/staff#11) on [DATE] at approximately 2:05 p.m., the RN stated that if a resident was found unresponsive she would check the physical chart for the resident's code status and honor the resident's wishes if they were DNR or Full Code. She said that if the resident was a full code then CPR would be started and CPR would continue until paramedics arrived and assumed care.An interview on [DATE] at approximately 2:15 p.m. with a certified nursing assistant (CNA/staff # 5) who stated that if he finds a resident unresponsive, he would call for the nurse and wait for the nurse to instruct him if CPR should be started. In an interview with another CNA (staff #7) conducted on [DATE] at approximately 2:30 p.m., the CNA (staff # 7) stated that if she found a resident unresponsive she would call for the nurse, would get the emergency cart and call 911 if the nurse told her to, and would wait for the nurse to instruct her if CPR should be started. Regarding resident #10, the CNA stated that she was working that day when resident #10 was found unresponsive; and that, she was assigned to provide care to resident #10. She stated that resident #10 did not want to get up after her vital signs were taken and had asked to be covered with her blanket which she did. The CNA stated that she was passing ice water when a student nurse requested her assistance because the resident (#10) was not waking up. The CNA said that she then went and checked the resident who did not seem to be breathing so she called the nurse. She stated that two nurses came: One nurse checked the resident's vitals; and, another nurse who was a licensed practical nurse (LPN) went to check the chart for the resident's code status. The CNA stated that the LPN came back and told her and the other nurse that the resident was a DNR. Further, the CNA stated that at that time, the LPN said the resident was gone.During an interview with another RN (staff #9) conducted on [DATE] at approximately 2:25 p.m., the RN stated that if a resident was found unresponsive she would call for assistance, call code blue and get the code cart. Additionally, she stated that she would check in the paper chart for the resident's code status and follow the direction. The RN stated staff response would depend on what was going on with the resident and the level of the resident's non-responsiveness. She stated she would call 911 if the resident was full code; and, if the resident was a DNR she would not call 911. Regarding the incident on [DATE], the RN stated that she was working in the facility when resident #10 was found unresponsive. The RN said that there were student nurses talking to the LPN (Staff #2) who sent them to do a blood glucose test on resident #10. She said that the student found a CNA (staff#7) and asked for assistance; and, the CNA (staff #7) reported that resident #10 was not responding and was not breathing. The RN said that she and the CNA (staff #7) went to check on the resident while she found the LPN (staff #7) who responded and assessed the resident. The RN also said that the LPN told her that resident #10 was a DNR; and that, CPR was not started for resident #10.On [DATE] at approximately 3:15 p.m., an interview was conducted with the LPN (staff #2) who stated that she was working when resident #10 was found unresponsive. She stated that on [DATE], she was completing her first medication round around 7:15 a.m. and resident # 10 was sleeping and was in no acute distress. The LPN said that the CNA (Staff #7) reported to her the resident's vital sign report; and that the vital signs reading were ok. The LPN stated that she assigned a student nurse to take the resident's blood sugar and, she then continued with med pass. The LPN stated that she could not recall who informed her that the resident was not responsive; but, she went to resident 10's room immediately and the CNA (staff #7) and the RN (staff # 9) were already with the resident. The LPN stated that the resident was non responsive, had no pulse, had no carotid pulse, and had eyes that were fixed and dilated. The LPN (staff #2) recalled that on her report sheet from the night nurse that resident #10 was a DNR and that she followed the facility's DNR protocol. Further, the LPN stated that she had received report that the resident was evaluated for hospice and that hospice was going to admit her when the resident discharged . In an interview with the Director of Nursing (DON) conducted on [DATE] at approximately 3:45 p.m. the DON (staff #14) stated that her expectation was that upon finding a resident unresponsive, the nurse would check vital signs, and would check the code status for the resident in the physical chart. She further stated that her expectation was for the nurse to follow those orders. The DON stated that if the resident was a full code then CPR should be initiated and the crash cart should be present. The DON further stated that it was her expectation that the hard chart be used to verify code status. Regarding the incident with resident #10, the DON said that something broke down with communication and the resident's code status was misread and miscommunicated. The facility policy, titled, Advanced Directives Policy with an implementation date of November of 2024 included that: the facility will adhere to residents' rights to formulate advanced directives. The facility will implement procedures to communicate a resident's code status to those individuals who need to know this information. The policy also included that when an order is written pertaining to a resident's presence or absence of an advanced directive, the directions will be clearly documented in designated sections of the medical record. The nurse who notates the physician order is responsible for documenting the directions in all relevant sections of the medical record. The designated sections of the medical record are at the nurses station/unit.

Based on observations, documentation, staff interviews, and policy and procedures, the facility failed to ensure that one resident (#1) did not elope. The sample was 3. The deficient practice could result in resident harm.Findings include:Resident #1 was admitted to the facility on [DATE] with diagnoses that included wedge compression fracture of third lumbar vertebra, cerebral amyloid angiopathy and dementia.The admission minimum data set (MDS) dated [DATE] revealed a brief interview of mental status (BIMS) score of 03. Which indicates that the resident has severe cognition impairment.The elopement risk assessment was completed on admission with a date of June 3, 2025 and revealed that Resident #1 was a low risk with a score of 0.0.A care plan was initiated on June 17, 2025 with a focus for Resident #1 being at risk for elopement. Interventions included to engage resident in purposeful activity, provide clear, simple instructions, provide reorientation to surroundings/environment, schedule time for regular walks/appropriate activity, staff to do 15 minute checks on resident.An Incident Note documented by Administrator (Staff #3) that was dated June 18, 2025 at 10:02 a.m. (late entry) revealed an Interdisciplinary team (IDT) follow up from elopement on June 16 at approximately 6 p.m was held; and that, Community VPO (Staff #7) notified nurse that Resident #1 was observed outside on a bench behind the independent living facility. It was reported that resident #1 had been sitting there for approximately 1 hour and was holding a TV remote and a napkin. Care plan was updated and new intervention for 1:1 sitter at this time until discharge. Discharge is set for June 18, 2025.Review of an updated elopement risk dated June 18, 2025 revealed that Resident #1 had a history of elopement risk while at home, wonders aimlessly. Elopement score is 6.0, indicating the resident is at risk of elopement.An interview was conducted with the Spouse of Resident #1 on June 25, 2025 at 10:35 a.m. and revealed that she was notified when her husband had eloped. An attempt to interview Licensed Practical Nurse (LPN) Staff #4 was conducted on June 25, 2025 at 11:00 a.m. by telephone. Staff #4 did not pick up the phone call, a message was left with a request to return the call. An attempt to conduct an interview with LPN Staff #5 was done on June 25, 2025 at 11:06 a.m. A message was left to return the call. LPN Staff #5 returned the call on June 25, 2025 at 11:08 a.m. and revealed that she was the nurse that did the skin assessment on Resident #1 after he was examined by the local fire department; and that, the police and fire department assisted the resident by giving him water, down in the lobby of the facility. Staff # 5 stated that the resident was hot and sweaty; and that, he was tired and fell asleep in his chair in his room, after he returned. Staff #5 stated that 15-minute checks were done and was on a continuous watch. Staff #5 stated that if residents elope, they could get hit by a car and are not aware of what is around.An interview was conducted with certified nursing assistant (CNA) Staff #8 who revealed that when residents are wandering or an elopement risk, you keep an eye on them by doing 15-minute checks to make sure they are observed. Redirect and show them the way back.An interview was conducted with provisionary Administrator Staff #6 on June 25, 2025 at 12:35 p.m. who revealed that the independent living building is next door to the care center building and was unable to give the approximate distance to the location as to where Resident #1 was found. Staff #6 then called Staff #7 to find out the distance to the building. Staff #7 stated he would show where the resident was located and arrived to the care center in a golf type cart to transport to the location where Resident #1 was found.Resident #1 was found on a bench on a path that goes through the community and was to the left side of the independent living building. That location was not visible from in front of the care center. Approximately 700 feet from the entrance of the facility to the bench where the resident was found.An interview was conducted on June 25, 2025 at 1:47 p.m. with Staff #6 who revealed that (BIMS) score can have an impact on the elopement assessment, depending on if they are exhibiting behaviors. A nurse to nurse report is done prior to arrival and sometimes there is not a clear indication status when the resident arrives to the building on admission. Anything can happen to a resident once they are out there. Review of the policy Hazardous Wandering and Elopements Policy with revision date of March 2024 revealed that Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so.

Based on observations, staff interviews and policy review, the facility failed to ensure that prepared food were distributed to residents at a safe and appetizing temperature. The deficient practice could result in the potential of bacterial growth in susceptible conditions. Findings include: On March 26, 2025 at 11:03AM, the tray line was observed, and the initial temperatures of the meat was at 180°F, vegetables were tempted at 169°F, starch tempted at 175°F, and a sandwich to which Staff #103 (Interim Dietary Manager) stated is a cheese steak sandwich tempted at 172°F. No cold components were included in the tray line for this observation due to no cold components on the menu for that day. During this tray line, meal service and tray distribution to all units were observed. On March 26, 2025 at 12:23PM a test tray was provided by Staff #103, the final temperatures of the food were obtained by Staff #103, which revealed meat was tempted at 152°F, vegetables were tempted at 140°F, starch tempted at 157°F, and a cheese steak sandwich tempted at 123°F. An interview on March 27, 2025 was conducted at 8:04AM with Staff #102 (Interim Director of Dining Services) and Staff #104 (Part-Time Registered Dietician) revealed that the facility's food temperatures upon arrival to the resident following the food service is to be referred and followed in accordance to FDA recommendations. Staff #102 also stated that cold holding foods should be kept at 41°F or lower, and that hot holding food should be kept at 135°F or higher, when being provided to residents during food services; and that, the risk of not providing residents with food within safe temperatures can create the opportunity for food borne illnesses. When discussing the temperatures of the test tray, Staff #102 stated that hot holding food to atleast 135°F or higher, such as the cheese steak sandwich that tempted at 123°F, is not the facility's meal service expectations. Review of the kitchen policy titled, 'Food Safety Requirements', revealed that food should be prepared as directed by the recommendations of the current FDA temperature guidelines until recommended temperature for the specific foods are reached. Review of a detailed breakdown of FDA temperature guidelines, revealed for kitchens state keeping hot food at 135°F (57°C) or above, and cold food at 41°F (5°C) or below, while also emphasizing the importance of cooling food properly to prevent bacterial growth within the danger zone (41°F to 135°F).

Based on clinical record review, staff interviews and policy review, the facility failed to ensure that a baseline care plan regarding urostomy care/treatment was developed for two of two sampled residents (#145, and #146). The deficient practice could result in goals and interventions not being evaluated, and available to the staff providing the care and treatment. Findings include: -Regarding Resident #145: Resident #145 was admitted on [DATE] with diagnoses that included cerebral infarction, history of malignant neoplasm of bladder, and artificial openings of urinary tract. Physician orders dated March 15, 2025, revealed an order for urostomy care two times a day. A weekly skin assessment dated [DATE], revealed the presence of a urostomy on the resident's left abdomen. A clinical admission progress note dated March 15, 2025, revealed the presence of an intact urostomy, and urostomy stoma. The March 2025 Treatment Administration Record (TAR) revealed evidence that urostomy treatments had been provided as ordered from March 15, 2025 through March 26, 2025. A baseline care plan dated March 17, 2025 revealed no evidence in the plan for nursing care regarding urostomy care/treatment. Review of the electronic health record (EHR) care plan revealed no evidence of a focus or interventions regarding urostomy care/treatment. Further review of the clinical record revealed that a Brief Interview for Mental Status (BIMS) assessment had been conducted on March 19, 2025 with a score of 12, which indicated moderate cognitive impairment. An interview was conducted on March 26, 2025 at 11:43 AM with the Director of Quality Management and Infection Preventionist (DQM-IP/staff #77), who stated that she would expect that a care plan would have been developed for urostomy care/treatment for the resident. She reviewed the clinical record and stated that there was no evidence of a care plan focus for urostomy care/treatment. She also reviewed the resident's baseline care plan and stated that there was no evidence that urostomy care/treatment had been included in the plan. She further stated that urostomy care should have been included in the baseline care plan and in the electronic care plan, but was not. The QM-IP (staff #77) stated the risk of not developing a plan regarding urostomy care/treatment on the baseline care plan could result in the resident/representative not being aware of the care/treatment the facility would provide. A telephonic interview was conducted on March 27, 2025 at 11:48 AM with a Unit Manager (staff #4), who stated that she completes admission care plans in the EHR, that include activity of daily living, skin, and antibiotics, and the MDS Coordinator would add any devices including urostomy care. She further stated that the baseline care plan should include the basic care that the resident should receive, including urostomy care/treatment. She also stated that medical records personnel develop the baseline care plan, and review it with the resident/family. An interview was conducted on March 27, 2025 at 9:09 AM with the Health Information Manager (HIM/staff #44), who stated that baseline care plans are developed on a form that is called the Baseline Care Plan Summary. The HIM stated that she completes the entire form by reviewing the resident's diagnoses, orders, and records that are received during admission. She further stated that she would review the Baseline Care Plan Summary with the resident/representative to include a breakdown of the care that the resident will be receiving while at the facility. She also stated that if a resident had a urostomy diagnosis she would add that in the other section of the baseline care plan form. She reviewed the resident's medical record and confirmed a diagnosis of 'other urinary tract device'. She also reviewed Resident #145's baseline care plan dated March 17, 2025, and stated that there was no evidence of a plan for urostomy care, and that urostomy care should have been included on the baseline care plan. The HIM also stated that she was not aware of any risk to the resident from not including urostomy care on the baseline care plan. An interview was conducted on March 27, 2025 at 9:44 AM with the Director of Nursing (DON/staff # 35), who stated that the unit manager completes the care plan in the EHR, that included orders and diagnoses. The DON also stated that she would expect that urostomy care/treatment would be included in the EHR care plan and the baseline care plan, if there were diagnoses and orders for urostomy care. She reviewed Resident #145's medical records and stated that there was on order for urostomy care dated March 15, 2025; and that, urostomy care should have been included on the baseline care plan within 48 hours of admission. The DON also stated that the risk of not including urostomy care on the baseline care plan could result in staff not knowing how to care for the resident. -Regarding Resident #146: Resident #146 was admitted on [DATE] with diagnoses that included peritoneal abscess, type 2 diabetes mellitus, depression, colostomy and encounter for surgical aftercare following surgery on the digestive system. Physician orders dated March 21, 2025, revealed an order for ostomy care every 7 days and PRN (as needed), and to monitor output every shift. An additional order, dated March 22, 2025, was located for Foley catheter care every shift. During an initial observation of Resident #146 on March 25, 2025, at 9:43 AM, the resident was observed to have an ileostomy and a Foley catheter in place. An Advanced Skilled Evaluation Progress Note dated March 25, 2025, revealed the presence of an ileostomy and a Foley catheter. A Baseline Care Plan Summary (BCP), dated March 24, 2025, revealed no evidence in the plan for nursing care regarding ileostomy or Foley catheter care/treatment. An electronic health record (EHR) Care Plan Report initiated March 22, 2025, revealed no evidence for nursing care regarding ileostomy or Foley catheter care/treatment. An interview was conducted on March 26, 2025 at 1:23 PM with the Director of Nursing (DON/staff # 35), who stated she would expect that ileostomy and Foley catheter care/treatment would be included in the BCP and the EHR care plan report, if there were diagnoses and orders for ileostomy and Foley catheter care. The DON reviewed Resident #146's medical record and stated that there was on order for ostomy and Foley catheter care dated March 21, 2025 and March 22, 2025 respectively, and they should have been included on the baseline care plan within 48 hours of admission. The DON also stated that the risk of not including ostomy and Foley catheter care on the baseline care plan could result in staff not knowing how to care for the resident. A policy titled, Baseline Care Plan Policy, revealed that Sun Health will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care. A written summary of the baseline care plan shall be provided to the resident/representative, and shall include, at a minimum, any services and treatments to be administered by Sun Health and personnel acting on behalf of Sun Health. A policy titled, Ostomy Care - Colostomy, Urostomy, and Ileostomy, revealed that the resident's goals and preferences for care and treatment of the ostomy will be used to formulate a plan of care for the ostomy. The frequency of pouch changes and the products required for changing ostomy devices will be noted on the resident's person-centered care plan.

Based on clinical record review, staff interviews, and facility policy, the facility failed to ensure that anti-hypertensives were administered within parameters for two residents (Residents #14 and #27); and that, pain management medication were administered within parameters for one resident (Resident #27). The deficient practice could result in further instances of inaccurate pain management with opioid medication; and, inaccurate administration of blood pressure medication. Findings include: -Resident #14 was initially admitted on [DATE] and re-admitted on [DATE], with diagnoses that included parkinsonism, unspecified; unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; unspecified atrial fibrillation; and essential (primary) hypertension. A quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident did not have a BIMS (Brief Interview for Mental Status) completed and a staff assessment of the resident's mental status was completed, indicating that the resident rarely/never understood the assessor. A physician's order dated February 27, 2024 revealed an order for Amlodipine 10 milligram, one tab a day for hypertension. The order also revealed that the medication is to be held if the pulse is less than 60 and/or if the systolic blood pressure is less than 110. A physician's order dated February 27, 2024 revealed an order for Metoprolol Succinate Extended Release 25 milligram, one tab a day for hypertension. The order also revealed that the medication is to be held if the pulse is less than 60 and/or if the systolic blood pressure is less than 110. The review of the care plan revealed no evidence of an initiated care intervention regarding the resident's usage of anti-hypertensives. The care plan review did reveal pain management interventions due to the resident having acute and chronic pain. A review of the Medication Administration Record (MAR) for the month of March 2025 revealed that Amplodipine 10 milligram had been administered out of ordered parameters for the dates of March 2; March 8; and, March 12. Metoprolol Succinate Extended Release 25 mlligram had been administered out of ordered parameters for the dates of March 2; March 6; March 12. An interview was conducted on March 27, 2025 at 9:05AM with a Licensed Practical Nurse (LPN/Staff #61) who stated that the facility expectation is that the staff to follow the medication orders as they're ordered by the provider. Staff #61 stated that ordered anti-hypertensive medications will require the completion of vitals, evidenced by the documentation of the blood pressure and pulse records in the MAR, and as well as the confirmation of the administration, evidenced by a signature of the administering nurse. Staff #61 also stated that if the order requires administration within parameters, that the ordered parameters are to be followed; and that, if the order states to hold the medication, that a note can be made by the administering nurse, and to state the reasoning for the medication being held to ensure communication continuity. Staff #61 stated that this is the facility's expectations and that the risk of inaccurate documentation has the potential to for inaccurate administration of medications and inaccurate assessment completion of any changes in condition. When reviewing the medications administered out of parameters of Resident #14, Staff #61 stated that the lack of accurate documentation and administering of medications out of the ordered parameters do not meet the expectations of the facility. An interview was conducted the Director of Nursing/Administrator (Staff #35) who stated the facility expects accurate documentation in the MAR; and that, medications are documented according to what the provider has ordered. Staff #61 stated that if the order states to hold the medication, that a note can be made by the administering nurse, and to state the reasoning for the medication being held to ensure communication continuity. Staff #35 stated that this is the facility's expectations and that the risk of inaccurate documentation has the potential to for inaccurate administration of medications and inaccurate assessment of the resident's condition. When reviewing the medications administered out of parameters of Resident #14, Staff #35 stated that the lack of accurate documentation and administering of medications out of the ordered parameters do not meet the expectations of the facility. - Resident #27 was initially admitted on [DATE] and re-admitted on [DATE] with the diagnosis that include metabolic encephalopathy. A physician's order dated January 20, 2025 revealed an order for Oxycodone HCl 5 mlliram tablet, one tab every four hours as needed for pain levels 4 to 10. The order also revealed that it was discontinued after the first stay. A physician's order dated January 20, 2024 revealed an order for Metoprolol Succinate Extended Release 25 mlligram, one tab two times a day for hypertension. The order also revealed that the medication is to be held if the pulse is less than 60 and/or if the systolic blood pressure is less than 110.The order also revealed that it was discontinued after the first stay. A review of the Medication Administration Record (MAR) for the month of January 2025 revealed that Oxycodone HCl 5 milligram tablet had been administered out of ordered parameters for the dates of January 24; January 25; for one entry on January 26 and for January 27. A review of the Medication Administration Record (MAR) for the month of February 2025 revealed that Metoprolol Succinate Extended Release 25 milligram had been administered out of parameters for the 6:00AM administration for February 3. Oxycodone HCl 5 milligram tablet had been administered out of ordered parameters for the dates of February 13, 2025. An admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a BIMS (Brief Interview for Mental Status) of 15, which indicated that the Resident #27's cognitive function is considered intact. An interview was conducted on March 27, 2025 at 9:05AM with a Licensed Practical Nurse (LPN/Staff #61) who stated that the facility expects the staff to follow the medication orders as they're ordered by the provider. Staff #61 stated that ordered anti-hypertensive medications will require the completion of vitals, evidenced by the documentation of the blood pressure and pulse records in the MAR, and as well as the confirmation of the administration, evidenced by a signature of the administering nurse. Staff #61 also stated that if the order states parameters, that the ordered parameters are to be followed. That if the order states to hold the medication, that a note can be made by the administering nurse, and to state the reasoning for the medication being held to ensure communication continuity. Staff #61 stated that this is the facility's expectations and that the risk of inaccurate documentation has the potential to for inaccurate administration of medications and inaccurate assessment completion of any changes in condition. When reviewing the medications administered out of parameters of Resident #27, Staff #61 stated that administering of medications out of the ordered parameters do not meet the expectations of the facility. An interview was conducted the Director of Nursing/Administrator (Staff #35) who stated the facility expects accurate documentation in the MAR and that medications are documented according to what the provider has ordered. Staff #61 also stated that if the order states to hold the medication, that a note can be made by the administering nurse, and to state the reasoning for the medication being held to ensure communication continuity. Staff #35 stated that this is the facility's expectations and that the risk of inaccurate documentation has the potential to for inaccurate administration of medications and inaccurate assessment of the resident's condition. When reviewing the medications administered out of parameters of Resident #27, Staff #35 stated that administering of medications out of the ordered parameters do not meet the expectations of the facility. A facility policy titled, Physician Orders revealed that once an order has been processed and verified, the execution of the order is required to be documented and to notify the Medical Director with any reactions or concerns. A facility policy titled, Medication Administration Policy revealed that staff is to obtain and record vital signs and hold medications per orders. This policy also revealed that medications that require vitals to be taken prior to the administration include anti-hypertensives. This policy also revealed that the vital signs should be recorded on the MAR if they require it or has ordered for it.

Based on clinical record review, staff interviews and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure that Minimum Data Set (MDS) assessments for 1 of 12 sampled residents (#37) accurately reflected their status regarding falls. The deficient practice could result in suboptimal care planning and effect the quality of care provided. Findings include: Resident #37 was admitted on [DATE] with diagnoses that included Parkinson's disease, dementia, repeated falls, muscle weakness, abnormalities of gait/mobility, malignant neoplasm of prostate and skin. An admission summary progress note dated March 6, 2025, revealed that the resident's spouse stated that he was admitted due to frequent falls. A fall risk evaluation progress note dated March 6, 2025, revealed a history of three or more falls within the past three months, and a fall risk of 26, which indicated a moderate fall risk. A clinical admission progress note dated March 6, 2025, revealed safety concerns related to falls. A Care Plan initiated on March 6, 2025, revealed the following areas of focus: -Safety, with interventions to encourage the use of prescribed assistive devices. -Risk for falls -Safety Concerns: Safety measures A physician progress note dated March 7, 2025, revealed that the resident had presented to the emergency room after multiple falls attributed to increasing unsteadiness, dizziness, and altered mental status. The progress note also revealed that the resident had poor safety awareness and was a high fall risk. A Baseline Care Plan Summary dated March 7, 2025, revealed the reason for admission included frequent falls and Parkinson's. An admission Medicare 5 Day Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 10, which indicated moderate cognitive impairment. Further review of the assessment revealed that the resident had sustained no falls prior to admission, despite a diagnosis of repeated falls. The assessment also included the digital signature of the MDS Coordinator (staff # 31) as the person completing the fall section of the MDS (Section J) on March 18, 2025, and certifying that the information accurately reflected resident assessment information for the resident. An interview was conducted on March 26, 2025 at 12:02 PM with the MDS Coordinator (staff #31), who stated that the MDS assessment policy indicated that MDS assessments should accurately reflect the resident's status. She reviewed the clinical record and stated that Resident #37 had a diagnosis of previous falls. She reviewed the resident's admission 5 Day Medicare MDS Assessment, dated March 12, 2025, and stated that the fall portion of the assessment, indicated that the resident had no falls at any time in the last 2-6 month's prior to admission, and the code entered was 0, which indicated no. She stated that Section J of the MDS regarding previous falls, should have been coded as 1, indicating yes. She further stated that the fall section of the MDS was inaccurate and that she would need to send a modification MDS to correct the error. The MDS Coordinator stated that a Registered Nurse (RN) would sign off that the MDS was complete, and the MDS Coordinator signs all the MDS assessments that she completed. She reviewed Section Z of the 5-Day Medicare MDS assessment dated [DATE], and stated that there is a statement at the top of the form relaying that the accompanying information accurately represents the resident assessment. She stated that the MDS was not accurate, regarding Section J previous falls, of the admission 5-day MDS Assessment, and that she would not have noticed, if it had not been brought to her attention. She stated that she will send a correction for Section Jof the MDS regarding previous falls. An interview was conducted on March 27, 2025 at 9:44 AM with the Director of Nursing (DON/staff #35), who stated that she expected MDS assessments to be as accurate as possible, including the section regarding previous falls. She also stated that prior to signing the MDS sections, the nurse should review the assessments for accuracy. The DON also stated that she was made aware of the inaccurate 5-Day Medicare Assessment for Resident #37 yesterday after the surveyor brought it to the attention of the MDS Coordinator. The DON stated that the risk of an inaccurate MDS assessment could result in inaccurate data submitted to the Centers for Medicare and Medicaid Services (CMS). A facility titled, MDS 3.0 Completion, revealed that residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan. Persons completing part of the assessment must attest to the accuracy of the section they completed by signature and indication of the relevant sections. According to federal regulations, Sun Health conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity, using the RAI specified by the State. The RAI manual for the MDS stated that the importance of accurately completing and submitting the MDS assessment cannot be over emphasized. The manual also included that the MDS assessment is the basis for the development of an individualized care plan.

Based on observations, clinical record review, resident and staff interviews and policy review, the facility failed to provide indwelling (Foley) catheter care in accordance with professional standards of practice for one of one sampled resident (#146). This deficient practice could lead to indwelling foley catheter complications. Findings include: Resident #146 was admitted to the facility on [DATE] with diagnoses that included peritoneal abscess, type 2 diabetes mellitus, depression, colostomy and encounter for surgical aftercare following surgery on the digestive system. An initial observation was conducted on March 25, 2025 at 9:43 AM of Resident #146, who was lying in her bed with a catheter bag hanging on the bed frame. The resident stated she had a Foley catheter. A Nursing Skilled Evaluation Progress Note, dated March 25, 2025 indicated that the resident had a Foley catheter due to urinary retention. A provider order was written on March 21, 2025, for Foley catheter care to be conducted on every shift, by wiping from the proximal end (closest to the body) to the distal end (farthest away from the body) of the Foley catheter. The Treatment Administration Record (TAR), dated March 2025, revealed no evidence that Foley catheter care had been performed on March 24, 2025 during the day shift. A provider order was written on March 25, 2025 to remove the catheter at bedtime, and to perform PVR checks (bladder scans) every 8 hours for 24 hours. The order further revealed to notify the provider if Resident #146 was retaining urine (not able to urinate). The March 2025 TAR indicated that the Foley catheter had been removed on March 25, 2025, per order. Further review of the March 2025 TAR revealed no evidence that the scheduled 6:00 AM bladder scan had been performed per provider order. A provider order was written on March 26, 2025 to re-insert the Foley catheter that night. An additional review of the March 2025 TAR revealed that the Foley catheter was not documented as being re-inserted until March 27, 2025 at 5:37 AM, despite the order to re-insert the Foley catheter the night of March 26, 2025. An interview was conducted on March 26, 2025 at 10:37 AM with Resident #146, who stated that the Foley catheter had been removed at bedtime, on March 25, 2025. The resident stated she had not urinated since the Foley catheter was removed, and that nobody had performed a bladder scan or asked her if she had urinated. An interview was conducted on March 26, 2025 at 10:56 AM, with a Registered Nurse (RN/staff #41), who stated that she knew Resident 146's Foley catheter had been removed, but she did not know if the resident had urinated since the removal of the catheter. The RN confirmed a bladder scan should have been performed on March 26, 2025 at 6:00 AM. The RN reviewed the March 2025 TAR and stated there was no evidence that scan had been performed. An interview was conducted on March 26, 2025 at 12:07 PM, with a Certified Nurse Assistant (CNA/staff #42), who confirmed that Resident #146 had still not urinated; and that, a Licensed Practical Nurse (LPN/staff #39) had recently performed a bladder scan on the resident. An interview was conducted on March 26, 2025, at 12:12 PM with the LPN (staff #39) who stated she scanned the resident's bladder and found 69 milliliters of urine (small amount) in the bladder. The LPN confirmed that the resident was unable to urinate and had not urinated since the Foley had been removed the previous night. An interview was conducted on March 27, 2025 at 9:43 AM, with a Licensed Practical Nurse (LPN/staff #100), who stated Resident #146 had a Foley catheter re-inserted due to urine retention. She stated that the order was received from the provider on March 26, 2025 at approximately 5:00 PM, but the catheter was not re-inserted until the morning of March 27, 2025. An interview was conducted on March 27, 2025 at 10:49 AM, with the Director of Nursing (DON/staff #35), who reviewed the provider's orders and stated that the provider ordered the Foley catheter to be re-inserted the night of March 26, 2025. The DON then reviewed the March 2025 TAR and stated there was no evidence that the scheduled bladder scan had been performed at 6:00 AM on March 26, 2025. She also stated there was no evidence that the catheter had been re-inserted on March 26, 2025, per provider order. However, the DON stated the catheter may have been re-inserted on March 26, 2025, but it was not documented as being inserted until the morning of March 27, 2025. The DON stated that the risk of not performing the bladder scans, and not re-inserting the catheter per provider orders, could lead to urine retention and the need to send the resident to the emergency room. Review of a policy titled, Indwelling Catheter Use and Removal, indicated that the facility would: conduct ongoing assessments for residents with indwelling catheters, provide timely and appropriate assessments, adhere to professional standards of practice, recognize and assess for complications and their causes, maintaining a record of any catheter-related problems and monitor for excessive post void residual after removing a catheter. Review of a policy titled, Catheter Care Policy, indicated the facility was to ensure that residents with indwelling catheters received appropriate catheter care. The policy further specifies that catheter care will be performed on every shift and as needed. Review of a policy titled, Incontinence, indicated that residents who are incontinent of bladder will receive appropriate treatment to prevent infections and to restore continence to the extent possible. Review of a policy titled, Documentation in Medical Record Policy, indicated that all assessments, observations and services provided by licensed staff will be meticulously documented in the resident's medical record.

Based on observations, clinical record review, resident and staff interviews and policy review, the facility failed to provide ileostomy care in accordance with professional standards of practice for one of two sampled residents (#146). This deficient practice could lead to ileostomy skin complications. Findings include: Resident #146 was admitted to the facility on [DATE] with diagnoses that included peritoneal abscess, Type 2 diabetes mellitus, depression, colostomy and encounter for surgical aftercare following surgery on the digestive system. A skilled nursing note dated March 21, 2025, revealed the resident had an ileostomy, rather than a colostomy. A provider order was written on March 21, 2025, for ileostomy care to be conducted every seven days and PRN (as needed): cleanse gently the skin and stoma with a wet washcloth or wipe, pat dry, apply wafer and pouch. The Treatment Administration Record (TAR) revealed no evidence that ileostomy care had been performed on March 24, 2025, on the day shift. A progress note dated March 26, 2025 at 5:45 PM written by RN (staff #41) revealed Resident #146's ileostomy was always leaking with liquid stool and the bag had to be changed eight times on her shift. On March 27, 2025 at 9:48 AM, an observation was conducted of the resident's ileostomy site with the Licensed Practical Nurse (LPN/staff #100) present. A light green fluid was observed leaking from the bottom of the ileostomy wafer onto the resident's skin. The skin was observed to be pink in color with no open areas. The LPN (staff #100) reviewed the resident's clinical record who stated there was no evidence that the provider had been notified regarding the ileostomy leaking or received further orders regarding the ongoing care of the ileostomy. An interview was conducted on March 26, 2025 at 10:10 AM, with a Registered Nurse (RN/staff #41), who stated that she had changed Resident 146's ileostomy bag at approximately 10:00 AM due to leakage. She further stated, it had to be changed; it had been waiting too long. An interview was conducted with Resident #146 and her daughter on March 26, 2025 at 10:30 AM. Resident #146 stated her ileostomy bag was leaking this morning when the aide helped me get dressed, around 5:30 AM. The resident's daughter stated she arrived at the facility at approximately 10:00 AM and observed the nurse leaving the resident's room with an armful of very dirty towels, and stated the ileostomay bag should have been changed sooner. An interview was conducted on March 26, 2025 at 12:05 PM, with a Certified Nurse Assistant (CNA/staff #42), who stated she observed the ileostomy bag leaking between 6:30 AM and 7:00 AM and that she notified the nurse at that time. An additional interview was conducted with the RN (staff #41) on March 26, 2025 at 12:50 PM, who confirmed that the CNA informed her about the ileostomy leakin, but that she waited to change the ileostomy until approximately 10:00 AM. An interview was conducted on March 27, 2025 at 9:43 AM with an LPN (staff #100), who stated she was not informed about Resident #146's ileostomy bag leaking during the morning shift report. An interview was conducted on March 27, 2025 at 10:49 AM, with the Director of Nursing (DON/staff #35) who reviewed the clinical record and stated there was no evidence of the provider being notified of the leaking ileostomy. She further stated that she expected the ileostomy would be changed as soon as leakage was observed, and that the provider be notified of the ileostomy requiring multiple changes due to leakage. The DON reviewed the March 2025 TAR and stated there was no evidence that ileostomy care had been provided as ordered on the day shift of March 24, 2025. She stated that treatments should be charted when completed; and that, if they were not charted, it was not done. She stated the risk of not providing ileostomy care promptly and as scheduled could lead to, several issues. Review of a policy titled, Ostomy Care-Colostomy, Urostomy and Ileostomy, revealed that direct care staff will observe and respond to any signs of resident's discomfort about the ostomy or its care. Review of a policy titled, Documentation in Medical Record Policy, indicated that all assessments, observations and services provided by licensed staff will be meticulously documented in the resident's medical record.

Based on observations, staff interviews and policy review, the facility failed to that ensure that policies regarding storing opened food and leftovers were followed. The deficient practice could result in the potential of bacterial growth in susceptible conditions. Findings include: On March 25, 2025 at 8:20AM, an observation was conducted of the facility's kitchen with the Interim Director of Dining Services (Staff #102) providing guidance during this initial observation. At the end of the initial observation of the kitchen and dining services, an observation of the nourishment refrigerator revealed food items including canned beverages and a wrapped item within the freezer, with no labeled dates. An interview was conducted with Staff #102 during the observation above, where Staff #102 reported that they were unsure on whether or not closed items, such as canned beverages and yogurts, require a written date on the item itself due to the best by date on each individual item, however, stated that any leftovers or any items that are opened and then put back into the refrigerators, are to be dated and labeled according to the facility's policy. On March 26, 2025 at 9:02AM, a second observation of the nourishment refrigerators in both the second floor and the first floor were completed. A container with a thick and pink substance was observed with no evidence of a label or a date on the container in the 1st floor nourishment refrigerator. Following this observation, an interview was conducted with Staff #103 (Interim Dietary Manager) and Staff #104 (Part-Time Registered Dietician) at 9:11AM, where Staff #103 and #104 who stated that any leftovers or any items that are opened and then put back into the refrigerators, are to be dated and labeled according to the facility's policy. Further stating that the undated and unlabeled item in the nourishment refrigerator does not meet the facility's expectation. Staff #104 further stated that the expectation of staff is to go through the nourishment fridges at the end of each shift and to dispose of any items that are not properly labeled, and proceeded to dispose the unlabeled items in the nourishment refrigerator. An interview on March 27, 2025 was conducted at 8:04AM with Staff #102 who stated that any leftovers or any items that are opened and then put back into the refrigerators, are to be dated and labeled according to the facility's policy. Staff #102 stated that the undated and unlabeled items in the nourishment refrigerator do not meet the facility's expectation, due to the risk of food borne illness, and for the potential of servicing expired food. A policy titled, 'Monitoring of Cooler/Freezer Temperature', revealed that any refrigerated food should be labeled, dated and monitored so that it is used by the use by date. A policy titled, 'Food Safety Requirements', revealed that to the facility is expected to be labeled and be dated to ensure proper food storage. A policy titled, 'Resident Refrigerators', revealed that to the facility is expected provide weekly deep cleans of the resident's personal refrigerators to ensure items that are expired and past the used by date are disposed of properly. A policy titled, 'Kitchen Sanitization', revealed the facility's daily expectation for food service staff to inspect refrigerators, coolers, freezers and storage areas on a daily basis.

Based on observations, interviews and policy, the facility failed to ensure proper infection control practices were implemented to prevent development and transmission of communicable disease/infection for two of two sampled residents related to urostomy care for one resident (#145), and foley catheter care for one resident (#146). The deficient practice could result in transmission of infection. Findings Include: -Regarding Resident #145, PPE Donning/Doffing and hand hygiene: Resident #145 was admitted on [DATE] with diagnoses that included cerebral infarction, history of malignant neoplasm of bladder, and artificial openings of the urinary tract. Physician orders dated March 15, 2025, revealed an order for urostomy care two times a day. Further review of the clinical record revealed that a Brief Interview for Mental Status (BIMS) assessment had been conducted on March 19, 2025 with a score of 12, which indicated moderate cognitive impairment. An observation of Resident #145's urostomy care was conducted on March 26, 2025 at 10:11 AM with a Registered Nurse (RN/staff #41). The RN was observed to exit another resident's room, walk down the hall to gather supplies required for Resident #145's urostomy care. There was an enhanced barrier precautions (EBP) sign posted outside of the resident's room. Prior to entering the resident's room, the RN donned a gown, without tying the neck or waist, and then donned gloves without sanitizing her hands prior to entering the resident's room. As the RN placed a clean towel under the urostomy bag, her gown was observed to fall off of one shoulder, and the RN pulled the gown up onto her shoulder with her gloved hand. The RN opened an alcohol wipe and wiped down the tubing from the stoma. As the RN proceeded to open a second alcohol wipe, her gown was observed to fall off her shoulder, and the RN pulled the gown back up onto her shoulder with her gloved hands. As the observation continued, the RN turned around from the resident's urostomy toward the closet door, and opened the resident's closet door, without removing the gloves that she had used for the ostomy treatment. The RN was observed to check the ostomy stock in the resident's closet, touching a 4x4 gauze package, stoma wafers, and stoma adhesive packages without changing or removing her gloves. The RN was observed to close the closet door, and as she turned, the RN's gown was observed to have fallen off both of her shoulders, down to chest level and was not tied at the neck. The RN removed the towel from under the urostomy pouch and placed a clean wash cloth under the urostomy pouch. The RN was observed to remove the gloves, and as she was removing the gloves the gown fell from her shoulders across her chest. The RN then removed the gown and placed it in a laundry bin. The RN was observed to entere the resident's bathroom and wash her hands with soap and water in the sink. Immediately after the observation an interview was conducted with the RN (staff # 41) on March, 26, 2025 at 10:34 AM, regarding PPE donning and doffing. The RN stated that the facility policy regarding EBP included that staff donn PPE prior to entering a resident's room to perform urostomy care. The RN stated that she had received training on infection prevention related to donning and doffing PPE, and part of that training included securing the gown at the neck and waist, to prevent the gown from falling, and to protect the resident and staff from infection. The RN stated that she did not secure the gown at the neck or waist when she donned if for the resident's urostomy care. She also stated that the gown did fall off her shoulders and across her chest during the urostomy treatment. The RN stated that this did not meet the facility infection control policy regarding PPE donning/doffing, and she admitted that she was in a hurry when she donned the gown. The RN stated that the risk of not securing the gown could result in the gown falling from her shoulders and exposing the resident and staff to infection. The interview with the RN (staff #41) continued regarding hand hygiene. The RN stated that when donning gloves, she usually does not sanitize her hands prior to treatments, stating that she just puts the gloves on and does the treatment. She stated that she sanitized her hands as she exited a resident's room, before entering Resident #145's room. However, the RN stated that she did not immediately enter Resident #145's room, that she went down the hall to get supplies, and was in other areas prior to entering the resident's room. The RN stated that she did not sanitize her hands prior to entering the resident's room and placing on gloves, and she should have. The RN also stated that she should have removed the gloves she was wearing during the urostomy treatment, prior to checking the supplies in the resident's closet, due to the risk of infection, or contamination of the supplies. She stated that during the treatment some infection control concerns had occurred that did not meet the infection control policy. An interview was conducted on March 26, 2023 at 10:53 AM with the Infection Preventionist/ Director of Quality Management (IP/DQM, staff #77), who stated that she expected staff to use a hand sanitizer or wash hands upon entrance/exit to every resident's room. She also stated that she would not expect staff to sanitize their hands again before entering another resident's room, if the staff member was immediately entering another room, unless they touch something in between rooms. The IP/DQM also stated that staff should sanitize hands prior to donning gloves before entering a room that is placed on EBP. She further stated when staff donn gowns for treatments, that she did not expect the gowns to be tied at both the neck and waist, but did expect the gown to be tied at one or the other, but she would definitely want staff protected. She stated that it did not meet her expectations for a gown to fall off a staff member's shoulders to the chest level, due to the risk of possible contamination and infection. She further stated that opening a closet door without first removing soiled gloves used for urostomy treatment, and touching the clean supplies stored in the closet with the gloves, could result in contamination of the supplies. An interview was conducted on March 27, 2025 with the Director of Nursing (DON/staff #35), who stated that when staff donn a gown she would expect the gown to be tied at the neck or waist, so that the gown does not fall off during treatment/care. She also stated the risk of a gown falling off staff's shoulders during care/treatment could result in exposure to infection, and that there is a reason for those precautions. The DON further stated that she expected staff to sanitize their hands prior to donning gloves and entering a resident's room. She also stated that opening a closet door and touching clean supplies without changing gloves that had been worn during urostomy care/treatment did not meet her expectations, and could result in the risk of contamination of the supplies. A facility policy titled, Personal Protective Equipment, revealed that Sun Health promotes appropriate use of personal protective equipment to prevent the transmission of pathogens to residents, visitors, and other staff. Perform hand hygiene before donning gloves and after removal. Change gloves and perform hand hygiene between clean and dirty tasks. Gowns should fully cover torso from neck to knees, arms to end of wrist, and wrap around the back, fasten in back at neck and waist. A facility policy titled, Hand Hygiene, revealed that all staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, known as alcohol-based hand rub (ABHR). The use of gloves does not replace hand hygiene. If a task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. -Regarding Resident #146, Foley catheter: During an initial observation of Resident #146's room, conducted on March 25, 2025 at 9:30 AM, a foley catheter bag was observed without a privacy bag, and the catheter bag outlet spout was observed unclipped/open, laying on the floor. There was no urine observed to be on the floor by the outlet spout, and a small amount of urine was observed in the catheter bag. Resident #146 was admitted to facility on March 21, 2025 with diagnoses that included peritoneal abscess, type 2 diabetes mellitus, depression, colostomy and encounter for surgical aftercare following surgery on the digestive system. Review of physician orders dated March 15, 2025 through March 25, 2025, revealed no evidence of a PRN (as needed) order to change the foley catheter bag. Further review of Physician orders were written for the following: -Indwelling foley catheter 16 fr (French scale/gauge), 10 ml (millimeter) for urinary retention, dated March 22, 2025. -Catheter care every shift, wipe from proximal to distal end of foley. Maintain dignity cover for drain bag, dated March 22, 2025. -Change foley drain bag every 30 days every night shift for foley care, dated 3/22/2025. -Enhanced Barrier Precautions due to IV access, foley care, wound care: wear increased PPE when working with these items every shift, dated March 23, 2025. Review of the March 2025 Treatment Administration Record (TAR), revealed no evidence that the resident's catheter bag had been changed, despite nursing being informed by a surveyor that the catheter bag outlet spout had been observed open and laying on the floor of the resident's room, on March 25, 2025. Further observations were conducted on March 25, 2025: -11:56 AM, the catheter bag outlet spout was observed to be clipped to the catheter bag, and was not touching the floor. -3:00 PM, the catheter bag was observed to have been be placed in a privacy bag. An interview was conducted on March 25, 2025 at 12:02 PM with a Registered Nurse (RN/staff #65), who stated that she would change the catheter drainage bag, if the catheter bag outlet was found to be unclipped, open and touching the floor. The RN stated that she had not been notified by a Certified Nursing Assistant (CNA) that the resident's catheter bag outlet spout had been left unclipped, open and was lying on the floor. An interview was conducted on March 25, 2025 at 12:05 PM with a CNA (staff #42), who stated that the facility policy regarding catheter care included keeping the catheter bag from touching the floor. She further stated that the catheter bag outlet spout is used to empty urine in the catheter bag, and should be folded up and clipped to the catheter bag when the outlet spout is not in use. She also stated that if the outlet spout would touch the floor it should be cleansed with an alcohol wipe. The CNA stated that the nurse would not need to be notified if the catheter bag outlet spout was left unclipped, open and touching the floor. The CNA stated that she had emptied the resident's catheter bag about a half hour ago, and had observed that the outlet spout was touching/laying on the floor. The CNA further stated that she cleaned the outlet spout with peri-care wipes, because she did not have a chance to use an alcohol wipe. The CNA stated that the peri-wipes are not antibacterial. She stated that when urine is emptied from the catheter bag, a paper towel is placed on the floor under the catheter bag for infection purposes. The CNA stated that she was not sure if there was a risk of infection related to the catheter bag outlet spout lying on the floor. Further interview was conducted on March 25, 2025 at 12:15 PM with RN (staff #65), who stated that the outlet spout on catheter bags should not touch the floor and be clipped closed, due to contamination and risk of infection, as she did not know what could be on the floor. She further stated that the catheter bag would need to be changed if that occurred. The RN stated that she had not changed the catheter bag because she had not been notified by the CNA (staff #41) that the outlet spout had been found lying on the floor. She stated that the spout should have been cleaned with an alcohol wipe or sani-wipe (something with antibacterial properties) by the CNA, and that the CNA should have notified her. The RN stated that the risk of the catheter bag outlet spout laying on the floor could result in contamination. An interview was conducted on March 26, 2023 at 10:53 AM with the IP/DQM (staff #77), who stated that she expected that the catheter bag outlet spout would be kept secured/clipped to the catheter bag, and not be left open and laying on the floor. She also stated that the risk of the outlet spout laying on the floor could result in the spread of infection. She further stated that when a catheter outlet spout is left open and touches the floor, the CNA should clean the outlet spout with an alcohol wipe before re-clipping the spout onto the catheter bag, and then inform the nurse, then nursing should change the catheter bag and document in nursing notes or on the TAR. She further stated that cleaning the outlet with a personal care wipe would be acceptable if the CNA told the nurse, however best practice would be to cleanse the outlet spout with an alcohol swab. The IP/DQM stated that it did not meet her expectations for the catheter bag outlet spout to be left open and laying on the floor. She also stated that the risk of the catheter bag outlet spout unclipped, open and touching the floor could result in contamination. An interview was conducted on March 27, 2025 at 1:01 PM with the DON, who stated that foley catheter bags should be kept off the floor, with the outlet spout clipped in the closed position, and that the catheter bag should be covered with a privacy bag. The DON further stated that once a catheter bag outlet spout had been found open and laying on the floor, she would expect staff to follow the policy and clean the spout with a antiseptic wipe, and inform the nurse so that the catheter bag would be changed as soon as possible. The DON stated that it would not meet her expectation for the outlet spout to touch the floor, or for the catheter bag to not be covered with a privacy bag. She also stated that cleaning the outlet spout with an alcohol wipe would be acceptable, but it did not meet her expectation for the outlet spout to be cleansed with a personal wipe, and it did not meet her expectations that the incident was not reported to a nurse. The DON reviewed the March 25, 2025 progress notes and TAR, and stated that there was no evidence that the catheter bag had been changed by nursing. The DON further stated that this did not meet her expectations. A facility policy titled, Catheter Care, revealed that if a foley catheter drainage bag or tubing touches the floor, it is considered contaminated and should be replaced as soon as possible. If immediate replacement is not feasible, the contaminated external surface should be disinfected with a facility-approved disinfectant wipe and allowed to air dry. Staff must change the system as soon as possible.

Based on clinical record review, staff interviews, and facility policy review, the facility failed to ensure a copy of the notice of two out of two discharges for one resident (# 47) to a representative of the Office of the State Long-Term Care Ombudsman. The failure may result in residents not having the advocacy and support from the State Long-Term Ombudsman during the discharge process. Findings include: Resident # 47 was admitted on [DATE]. Resident # 47 was readmitted on [DATE], with a diagnosis of unspecified fracture of right femur, subsequent encounter for closed fracture with routine healing, unspecified atrial fibrillation, cerebral infarction, and Alzheimer's disease, and then discharged home with hospice December 29, 2023. The Minimum Data Set assessment (MDS) on December 19, 2023, revealed a Brief Interview of Mental Status (BIMS) score of 1. Indicating that the resident had severe cognitive impairment. A review of clinical records revealed no evidence of sent notice of discharge to a representative of the Office of the State Long-Term Care Ombudsman for discharges on December 16, 2023, and December 29, 2023, An interview was conducted with Staff # 31 on February 23, 2024, at 1:41 PM, who stated that she does not notify the ombudsman about discharges or transfers, admissions coordinator would notify the ombudsman. The Admissions Coordinator Staff # 87 was interviewed on February 23, 2024, at 1:45 PM, Staff # 87 stated that the social worker talks to the ombudsman about discharges. On February 23, 2024, at 2:29 PM, the Administrator came into the surveyor conference room with a printed email from the Social worker to the representative of the Office of the State Long-Term Care Ombudsman of discharges. The Administrator stated that these were just sent out today. In an interview with the Administrator on February 23, 2024, at 2:32 PM, the administrator stated no to social services notifying the Ombudsman of discharges and that she is new in her role. Review of the facility policy Transfer and Discharge reviewed in October of 2023 revealed that section #4 stated that the facility's transfer/discharge notice will be provided to the resident and the resident's in a language and manner in which they can understand. the notice will include all of the following at the time it is provided: h. The name, address (mailing and email), and phone number of the representative of the Office of the State Long-Term Care Ombudsman. Also 7. the facility will maintain evidence that the notice was sent to the Ombudsman.

Based on an observation, clinical record review, interviews, and facility policies, the facility failed to ensure that necessary treatment and services were provided to one resident (#13) to assist in the healing of a pressure ulcer. The sample size was one resident. The deficient practice could result in delayed wound healing. Findings include: Resident #13 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an annual Minimum Data Set (MDS) dated [DATE] revealed that the resident scored a 15 on the Brief Interview for Mental Status (BIMS) indicating he was cognitively intact. The assessment included that the resident had one suspected Deep Tissue Injury (DTI) that was present on admission. The resident's clinical record indicated that the DTI was on his right buttock. Review of the resident's nutrition care plan, created 4/16/2021, revealed that the resident had a DTI to his right buttocks and was being followed by a wound clinic and the wound nurse. Review of the resident's skin breakdown care plan, created 4/19/2021, revealed that the resident was at risk for skin breakdown related to decreased mobility and incontinence of bowel and bladder, MS, [CONDITION(S)], and other diagnoses. Interventions included to monitor the resident's skin and to assist and/or remind the resident to turn and reposition every two hours and as needed. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This order was rewritten on 9/6/2021 with no changes to the wound treatment. The order was discontinued on 9/11/2021. Review of the Treatment Administration Record (TAR) for June 28 through September 11, 2021 revealed that wound treatment was completed as ordered except it was documented that on 9/3/2021 the resident said he was going to the wound clinic on that day and he did not want the nurse to do the treatment. Also, it was documented that on 9/10/2021, the resident went to the wound clinic and the dressing was completed then. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the wound assessments conducted at the wound clinic revealed the following: -There were more than five wound assessments starting on 9/3/2021 and ending on 10/15/2021 that did not include staging of the resident's right buttock pressure ulcer. -The wound was documented as improving on 10/15/2021 and was measured to be 0.7 centimeters (cm) long by 0.3 cm wide by 0.1 cm deep. After 10/15/2021, there was no documentation from the wound clinic that the resident's right buttock wound had been assessed or treated. Review of the wound assessments completed by the facility revealed no evidence that the resident's right buttock wound had been assessed after 9/18/2021. None of the wound assessments completed by the facility included the stage of the right buttock wound. Review of the TAR from 10/15/2021 through 11/16/2021 revealed no evidence that right buttock wound treatments had been done by the facility. An interview was conducted with the director of quality management/Registered Nurse (RN/staff #14) on 11/16/2021 at 12:42 p.m. She stated that the DTI was from January 21, 2020 and developed at the hospital prior to readmission. She said the wound is still being classified as unstageable and the wound clinic has been seeing him weekly. She said that he went to the wound clinic on 11/12/2021 and the notes did not address the right buttocks or include any orders for treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] An observation of the resident's right buttock wound was conducted on 11/16/2021 at 1:06 p.m. with the director of quality management/RN (staff #14). After removal of the wound dressing, what appeared to be a round, dry dark red/purple scab to the upper right buttock area was present. The nurse measured the area to be 0.5 cm long by 0.3 cm wide. The nurse said she would continue to call the area a DTI as she did not know what was under the scab. She said that now that a scabbed area was seen, she would call the physician and probably use a barrier cream for protection. At 1:32 p.m. on 11/16/2021, the director of quality management/RN (staff #14) stated that after the wound observation, the scab had come off and underneath there was pink and intact skin which was blanchable. She said that she would continue to follow for a week to ensure that the area remained healed. An interview was conducted with a Licensed Practical Nurse (LPN/staff #92) on 11/17/2021 at 11:23 a.m. The LPN stated that for residents with pressure ulcers, the nurses care for the wounds and call the physician and notify the director of quality management/RN (staff #14) if they notice any changes in the wound. The LPN said that this resident receives care for some of the wounds by going to a wound clinic and the staff in the facility are not to touch the wounds that are being treated by the wound clinic unless they are told otherwise. She said that this means that the assessments and the treatments of the wounds are to be handled by the wound clinic. The LPN said that often the wound clinic will fax their notes to the facility and the floor nurse will give the information to the physician to review for any changes in the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted with the director of quality management/RN (staff #14) on 11/17/2021 at 12:46 p.m. She stated that the care of the resident's wounds is coordinated by the facility and the wound clinic. She stated that the wound clinic focused mainly on the resident's coccyx wound and the wound on his right buttocks. She reviewed the clinical record and said that on 1/21/2020, the resident had the DTI to the right buttock and it measured 1.5 cm long by 1.0 cm wide. She stated that when the resident goes to the wound clinic, the wound clinic faxes the information to the facility. She said that the floor nurse will get this information and then implement the treatment indicated by the wound clinic. She said the physician will also get this information and will review and sign any new orders. She said that if anything is missing or incorrect in the wound clinic notes, the facility staff would call and notify the wound clinic about this issue. An interview was conducted on 11/18/21 at 2:34 p.m. with the Director of Nursing (DON/staff #34). She stated that all residents with wounds receive weekly wound assessments. She said that the components of the wound assessment include assessing the wound for odor, redness, color of the wound bed, presence of slough and/or eschar, pain, size of the wound, and the stage of the wound. She said that the physician prefers that the person doing the wound assessment and staging remain consistent to ensure consistent assessments. She said that if there were any inaccuracies noted in the record, herself or the director of quality management/RN (staff #14) can perform a second assessment and add a note to clarify any incorrect information. She said that if the assessment comes from an exterior source and is found to be inaccurate, the staff in the facility will call to clarify the information and document. She said that all the wound clinic notes that were available had been provided. A policy titled, Skin Assessment, revealed that a full body skin assessment must be completed upon admission/readmission and weekly thereafter. In this assessment, skin conditions such as ulcers are noted and any findings, observations, and description are to be noted. A policy titled, Pressure Ulcer Care, revealed that looking for presence of a pressure injury is considered part of a full body assessment. Complete pressure injury assessment includes the stage of the pressure injury, anatomical location, and type of tissue in the wound bed.

Based on clinical record review, staff interviews, facility policy, the National Institute of Mental Health and the DSM-5 (Diagnostic and Statistical Manual of Mental Disorder - 5th edition), the facility failed to ensure that one resident (#7) had adequate indications for the use of an antipsychotic medication. The sample size was five residents. The deficient practice could result in resident receiving an unnecessary [CONDITION(S)] medication. Findings include: Resident #7 was admitted on [DATE] with hospice services and diagnoses that include [CONDITION(S)], recurrent depressive disorders, anxiety, and dementia without behavioral disturbance. The preadmission hospice certification and plan of care with a start of care date of February 9, 2021 included diagnoses of [CONDITION(S)] and dementia with behavioral disturbance. It included an order to assess for signs/symptoms of anxiety/terminal agitation and to provide instruction regarding origin and management. The goal included that anxiety/agitation is minimized or controlled. Mental status assessment revealed the resident was oriented, but at times forgetful and disoriented. Medications included [MEDICATION(S)] (an antipsychotic) 100 mg (milligram) tablet at bedtime and 50 mg tablet every morning for a diagnosis of dementia. The preadmission hospice physician narrative dated February 13, 2021 included the resident was admitted to hospice service with late effects of cerebral vascular disease with comorbidities of dementia. The hospice Client Medication Report signed by the provider on February 24, 2021 included the following orders: -[MEDICATION(S)] 100 mg one tablet by mouth at bedtime; and, -[MEDICATION(S)] 50 mg one tablet by mouth every morning. The reason for the use of [MEDICATION(S)] was documented as dementia. The consent for use of [CONDITION(S)] medication dated February 24, 2021 included the use of [MEDICATION(S)]. Reason for use was documented as antipsychotic. The physician order dated February 24, 2021 included [MEDICATION(S)] 100 mg one tablet by mouth at bedtime and 50 mg one tablet by mouth every morning for diagnosis of dementia. This order was transcribed onto the Medication Administration Record (MAR) and was administered as ordered on February 24, 2021. It also included that this order was discontinued on February 25, 2021. The admission nursing note dated February 25, 2021 revealed the resident was pleasantly alert and verbally responsive with forgetfulness and was admitted under hospice care. The consultant pharmacist's medication regimen review dated February 25, 2021 revealed an instruction for the provider to choose an approved antipsychotic diagnosis and behavior to monitor for [MEDICATION(S)] use or to taper and discontinue [MEDICATION(S)]. The box for delusion was marked as the behavior to monitor. There was also a handwritten note on side of the instruction that read mood disorder and [CONDITION(S)] NOS (not otherwise specified). A physician order dated February 25, 2021 included the following orders: -[MEDICATION(S)] 100 mg one tablet at bedtime for mood disorder; -[MEDICATION(S)] 50 mg one tablet every morning for mood disorder; and, -Behavioral flow record for [MEDICATION(S)] to monitor twice daily for resisting care, auditory/visual hallucination and harm to self. Diagnosis was mood disorder. These orders were transcribed onto the MAR for February 2021 and were administered as ordered. The care plan with effective date of February 25, 2021 revealed the resident was at risk for adverse effects from the use of [CONDITION(S)] medication, [MEDICATION(S)]. Interventions included medications administered as ordered, pharmacist to review drug regimen monthly and to monitor for dosage reduction at least quarterly. The behavior flow record from February 25 through February 28, 2021 revealed that the resident did not manifest any behaviors. Review of the clinical record from February 25 through 28, 2021 revealed documentation that the resident was alert and oriented x 2-3, pleasant, answered questions appropriately, was able to make himself understood, and was coherent with forgetfulness at times. The physician admission history and physical note dated February 28, 2021 included the resident was moved to the facility for higher level of care. Physical examination included the resident was alert and oriented, calm and cooperative. Assessments included anxiety, depression and mild dementia. However, it did not include diagnoses of mood disorder and/or [CONDITION(S)]. Plan was to continue psych medications and to monitor for side effects. The physician order for [MEDICATION(S)] was revised on March 1, 2021 to include [CONDITION(S)] as the diagnosis for the use of [MEDICATION(S)]. The admission MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 9 indicating the resident had moderate cognitive impairment, did not have behaviors such as disorganized thinking, physical/verbal behavioral symptoms and rejection of care. Active diagnoses included non-Alzheimer's dementia, anxiety disorder, recurrent depression and [CONDITION(S)]. Further, the MDS revealed the resident did not have potential indicators of [CONDITION(S)] such as hallucinations and delusions; and that, antipsychotics were received on a routine basis during the last 7 days of the assessment. A physician progress note dated April 19, 2021 included the resident was alert and oriented, calm and cooperative. Assessments included mild dementia, anxiety and depression. The documentation did not include any psychotic behavior the resident had. Plan was to continue psych medications and to monitor for side effects. The behavior record flow from March 1 through May 31, 2021 documented that behavior was present on multiple dates on each month. However, documentation did not include the details of the behavior or what specific behavior the resident had. Review of the clinical record from March 1 through May 31, 2021 revealed no documentation the resident had any psychotic behavior such as delusions or hallucinations. It also revealed documentation that the resident was alert and oriented x 2-3 with confusion and forgetfulness. Behaviors documented during this period included the following: -Agitation; -Confused with behaviors; -Anxious and wanting to go home; -Verbally abusive and/or aggressive; -Expressed condescending words such as calling staff monkeys -Asking people to let him out; -Restlessness; -Refusing cares and medications; -Swearing and yelling at staff during cares; and, -Yelling and getting angry with staff. The quarterly MDS assessment dated [DATE] revealed a BIMS score of 9 indicating the resident had moderate cognitive impairment, did not have behaviors such as disorganized thinking, physical/verbal behavioral symptoms and rejection of care. Active diagnoses included non-Alzheimer's dementia, anxiety disorder, recurrent depression and [CONDITION(S)]. Further, the assessment coded no hallucinations and delusions; and, antipsychotics were received on a routine basis during the last 7 days of the assessment. A physician progress note dated June 16, 2021 included the resident was alert and oriented, calm and cooperative and had an overall gradual decline. Assessments continued to include mild dementia, anxiety and depression. Plan was to continue psych medications and to monitor for side effects. The documentation did not that the resident had a diagnosis of [CONDITION(S)] or had psychotic behaviors. A physician progress note dated July 6, 2021 included the resident was seen and examined due to increased behaviors with care. The note included the resident was alert and oriented, calm and cooperative. Assessments included mild dementia with worsening behavioral issues, anxiety, and depressions. The documentation did not include the resident had psychotic behaviors. Review of a physician progress note dated August 19, 2021 revealed the resident refused medications, showers, and care at times and then later takes the medication after convincing him. Physical examination included the resident was alert and oriented, calm and cooperative. Assessments included refusal of care, mild dementia, anxiety, and depression. Per the documentation, the resident was advised regarding refusal of care. Plan included to continue psych medications and to monitor for side effects. The quarterly MDS assessment dated [DATE] included the resident had moderate cognitive impairment and did not have disorganized thinking, physical/verbal behavioral symptoms, rejection of care, hallucinations, or delusions. Active diagnoses included non-Alzheimer's dementia, anxiety disorder, recurrent depression and [CONDITION(S)]. The assessment also included that antipsychotics were received on a routine basis during the last 7 days of the assessment. The Behavior Record Flow from June 1 through November 15, 2021 documented the resident had behaviors on multiple dates on each month. However, the details of the behavior or what specific behavior the resident had were not consistently included in the documentation. On those days when behaviors were described, the documentation included that the resident manifested agitation and refusal of medications. Review of the clinical record from June 1 through November 15, 2021 revealed no documentation the resident had any psychotic behavior or symptom such as delusions or hallucinations. It also revealed documentation that the resident was alert and oriented x 1-2 with confusion, was forgetful and was able to make simple needs known. During this period, the clinical record revealed documentation of the following behaviors: -Agitation; -Verbally abusive/aggressive to staff; -Aggressive to staff; -Refused to eat, get out of bed, take medications and cares; -Name calling to staff; -Impaired memory; -Combative with caregiver; -Yelled at staff during cares; -Attempted to kick and punch staff; and, -Mood swings There was no evidence found in the clinical record the resident had psychotic behavior/symptoms such as hallucinations and/or delusions from March 1 through November 15, 2021. Continued review of the clinical record revealed no evidence of an adequate indication for the use of the [MEDICATION(S)]. An interview was conducted on November 18, 2021 at 12:28 p.m. with a Licensed Practical Nurse (LPN/staff #29) who stated the orders for [CONDITION(S)] medications include the diagnosis, the specific behavior the resident has related to the diagnosis and what the medication is given for. She stated when a resident is on a [CONDITION(S)] medication, staff are looking for side effects, and behaviors before and after medication is administered. She said behavior monitoring is done every shift. She also said that if a [CONDITION(S)] medication is continued then a psych evaluation is important so that the resident does not receive unnecessary medication. The LPN said that when a resident is agitated, she will not give the [CONDITION(S)] medication right away. She will try to see what is causing the resident's agitation such as wanting to go to the bathroom or wanting to stretch and she will provide appropriate intervention to help the resident. The LPN also stated that agitation is not a behavior and cannot be a symptom for [CONDITION(S)]. She further stated that agitation is a symptom of what is going on and it is not a behavior. In an interview conducted on November 18, 2021 at 1:23 p.m. with a Certified Nursing Assistant (CNA/staff #6), she stated she had been at the facility for [AGE] years and had always been assigned in the unit where the resident resides. She stated that the resident is mostly confused but does not have any other behaviors such as hallucinations or delusions. An interview with a LPN (staff #67) was conducted on November 18, 2021 at 1:38 p.m. The LPN said when she receives an order for a [CONDITION(S)] medication, she ensures a consent is signed and the order includes the diagnosis and the specific behavior the [CONDITION(S)] medication is prescribed for. She stated the order will be entered in the electronic record and medication will be administered as ordered. She said that behaviors are monitored every shift and documented in the MAR. However, the LPN said the MAR does not have a space to write the specific behavior the resident had manifested so she will document the details in a progress note. She said when documenting behavior, she will include the type of behavior, the number of episodes of the behavior, and whether the physician or family was notified, if necessary. The LPN stated the resident is alert and oriented to self and does not have any psychotic behavior such as hallucinations, delusions, or paranoia. She said the only behaviors the resident has is getting mad if staff approach him the wrong way and he curses. The LPN also stated that the behavior of getting mad is usually triggered when the resident does not have enough sleep. She said that night shift staff reported that sometimes the resident does not get changed earlier in the night. She said this results in the resident being woken up and he does not sleep after he is woken up which eventually makes him mad. During an interview with the Director of Nursing (DON/staff #34) on November 18, 2021 at 2:24 p.m., she stated that when an order for [CONDITION(S)] medication is received, staff are to ensure the consent is signed. She stated that the physician's order usually includes the diagnosis for the use of the drug and the specific behavior it is prescribed for. She said the nurse will enter the order in the electronic record, administer the medication as ordered, and monitor behaviors every shift. Regarding the lack of documentation and/or evidence that the resident had [CONDITION(S)], she stated that she will try to look at hospice documentation to see whether there is something to support the diagnosis of [CONDITION(S)] and to justify the use of [MEDICATION(S)]. However, the hospice documentation provided to the survey team revealed no evidence that the resident had [CONDITION(S)] and/or had psychotic behaviors/symptoms. The facility's policy on [CONDITION(S)] Medication revealed that residents are not given [CONDITION(S)] drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication. The policy also included that the indication for use of any [CONDITION(S)] drug will be documented in the medical record. The facility's policy on Dementia Care included that it is their policy to provide the appropriate treatment and services to every resident who displays signs of, or is diagnosed with, dementia to meet his or her highest practicable physical, mental and psychosocial well-being. The National Institute of Mental Health defined [CONDITION(S)] as conditions that affect the mind, where there has been some loss of contact with reality. During a period of [CONDITION(S)], a person's thoughts and perceptions are disturbed and the individual may have difficulty understanding what is real and what is not. Symptoms of [CONDITION(S)] include delusions (false beliefs) and hallucinations (seeing or hearing things that others do not see or hear). Other symptoms include incoherent or nonsense speech, and behavior that is inappropriate for the situation. The DSM-5 included that psychotic disorder not otherwise specified (PNOS) has been recategorized as unspecified/other [CONDITION(S)] spectrum and unspecified/other psychotic disorder. These categories refer to symptoms that are typical of a [CONDITION(S)] spectrum or other psychotic disorder diagnosis. Symptoms that may be present include delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior and flat affect.

Based on an observation, an interview, and review of facility policy, the facility failed to ensure expired foods were not available for resident use. The facility census was 31 residents. The deficient practice could result in an increased risk for foodborne illness. Findings include: A kitchen observation was conducted on [DATE] at 10:15 a.m. with the sous chef (staff #70). The following was observed in the dry food storage room: -Thickened applesauce: 1 with a use by date of [DATE], 4 with a use by date of [DATE], and 2 with a use by date of [DATE] -Thickened dairy: more than 20 individual 8 fluid ounce cartons with a use by date of [DATE] -Cake mix with an open date of [DATE] and a good through date of [DATE] -Muffin mix with a good through date of [DATE] -Cake mix with a good through date of [DATE] -Scalloped potato box with open date of [DATE] and good through date of [DATE] -Waffle mix box with open date of [DATE] and a good through [DATE] An interview was conducted with the sous chef (staff #70) at the time of the kitchen observation. She said that they follow the use by date and that food items should not be used beyond that date. She said the good through dates refer to the date that the food item is still okay to use. She said that the items that were beyond the use by dates and good through dates will be discarded and not used for the residents. She said that the kitchen staff are responsible for checking the food storage room for expired items every week. She said that the room was checked a week ago, but she does not have a copy of the audit that was conducted. Review of the facility's food and supply storage policy revealed that all food shall be stored in such a manner to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. The procedure included that the words sell by, best by, enjoy by or use by should precede the date. Food past the use by, sell by, best by, or enjoy by date should be discarded after that date. The policy included that food items should be rotated and first in first out (FIFO) should be followed. The policy included to discard food past the use-by or expiration date.

Based on an observation, clinical record review, staff interviews, and facility policies, the facility failed to administer a medication as ordered for one resident (#280). The sample size was 12 residents. The deficient practice could result in residents not receiving medications as ordered by the physician. Findings include: Resident #280 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's nutrition care plan, dated November 9, 2021, revealed that the resident was nutritionally at risk, had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The interventions included administering medications as ordered. A medication administration observation was conducted on November 17, 2021 at 8:11 a.m. with a Licensed Practical Nurse (LPN/staff #67). The nurse dispensed one tablet labeled [MEDICATION(S)] [MEDICATION(S)] 500 mg from the multi-dose medication blister pack/card taken from the medication cart. The nurse administered the medication to the resident. Review of the Medication Administration Record (MAR) for November 2021 revealed documentation that the nurse administered the [MEDICATION(S)] 500mg extended release tablet at 8:00 a.m. on November 17, 2021. However, the observed [MEDICATION(S)] administered to the resident was not labeled as extended release. An interview was conducted with the LPN (staff #67) on November 17, 2021 at 10:00 a.m. The nurse reviewed the card used for the [MEDICATION(S)] administered in the medication observation and stated that the [MEDICATION(S)] that she administered to the resident was not labeled as an extended release tablet. She stated that she was supposed to give the extended release tablet as ordered by physician and that she would need to notify the physician of the medication error. She stated that the risk to the resident was that the resident would experience adverse side effects and that she would need to observe the resident and monitor the resident's blood sugar. An interview was conducted with the Director of Nursing (DON/staff #34) on November 17, 2021 at 12:32 p.m. She stated that it was her expectation that staff would follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated that the medication administration did not meet her expectations since the resident received the non-extended release form of the medication when the order specified to give the extended release form. She stated that the risk of giving the wrong medication form was that the resident would not have the coverage needed to manage diabetes correctly. She stated that this was considered a medication error. Review of a facility policy for diabetes care, dated April 7, 2015, revealed that diabetic medications will be administered in accordance with physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a facility policy for medication administration, dated August 18, 2016, revealed a purpose to aid residents in overcoming illness, relieve and prevent symptoms, and help with their diagnoses. The policy included that all medications are to be administered safely and appropriately. The nursing professional's responsibilities are to be aware of the classification, action, correct dosage, and side effects of a medication before administration. Medications must be administered in accordance with the attending physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The policy included that the procedure is to check the electronic MAR and to read each order entirely. The procedure included to remove the medication from the drawer and read the label three times. The policy included that if there is any discrepancy between the electronic MAR and the label on the medication, clarify the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a facility policy for physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The policy included that all physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure one resident (#179) was provided pain management consistent with professional standards of practice, by failing to administer pain medications within the ordered parameters. The sample size was one resident. The deficient practice could result in residents receiving more pain medications than they require. Findings include: Resident #179 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the baseline care plan, initiated November 2, 2021, revealed the resident had the potential for alteration in comfort and pain related to right tibia/fibula fracture status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included to monitor pain every shift and as needed (PRN), have the resident identify pain on scale of 1 to 10 and monitor effectiveness and side effects of interventions. Review of a physician order, dated November 5, 2021, revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) assessment, dated November 15, 2021, revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. The assessment included the resident had occasional pain. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Further review of the clinical record revealed no documentation why the pain medication was administered outside of the ordered parameters or that the physician was notified when this occurred. An interview was conducted on November 17, 2021 at 1:01 p.m. with a Licensed Practical Nurse (LPN/staff #92), who stated that pain is assessed on a 1 to 10 scale and PRN pain medication is administered depending on the pain scale. She stated if the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated if the resident requests the specific medication and if no other pain medication is available, the physician will be notified. She stated this resident constantly complains of pain and he receives PRN pain medication every 4 hours as well as a scheduled pain medication. She stated the resident always rates his pain at a high level and stated maybe this was a documentation mistake. An interview was conducted on November 17, 2021 at 1:22 p.m. with a Registered Nurse (RN/staff #27), who stated the resident always complains of pain and rates the pain at a 7 or an 8. She stated the resident has orders for scheduled pain medications every 8 hours but also requests the PRN oxycodone for pain. She stated that prior to giving the PRN pain medication, she reviews the order to ensure the resident can receive this medication. She said that the medication should not be given if the resident's pain level is outside of the ordered parameter. She stated the resident should be given a weaker pain medication when the pain level is lower than the ordered parameter, such as Tylenol. She stated if there is no alternate pain medication ordered then the physician is called and the physician's direction is followed. She stated the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted on November 18, 2021 at 11:53 a.m. with the Director of Nursing (DON/staff #34), who stated the expectation is that the nurses assess the resident's pain level, use non-pharmacological interventions and if not effective, administer PRN pain medication according to the parameter set on the physician order. She stated her expectation is for the nurses to follow the guidance on the order and assess the effectiveness of the medication. She said that if the resident stated pain level is lower than the set parameter, then the nurses would notify the physician and document the notification in the nurse's progress notes. She stated the pain medication should be given within the parameter ordered as the medication is ordered that way for a reason. She stated the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's implementation of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The policy further stated alternate orders should be requested, recorded the same as a telephone or verbal order, and charted in the resident's record.

Based on review of personnel files, staff interviews, facility documentation, review of the facility assessment and policies and procedures, the facility failed to provide dementia management training to 11 of 14 sampled employees (staff #'s 78, 61, 46, 43, 10, 68, 28, 104, 108, 42 and 35), and failed to provide abuse training to 4 of 14 sampled employees (staff #'s 78, 61, 68 and 102). The deficient practice could result in staff not being knowledgeable of how to care for residents with dementia, and a lack of training regarding prevention and identification of abuse and implementing appropriate actions. Findings include: Regarding dementia training: Review of the personnel files revealed the following staff did not have evidence of any dementia training: -Registered Nurse (RN/staff #78) with a hire date of (MONTH) 27, (YEAR) -RN (staff #61) with a hire date of (MONTH) 12, (YEAR) -Licensed Practical Nurse (LPN/staff #46) with a hire date of (MONTH) 19, (YEAR) -LPN (staff #43) with a hire date of (MONTH) 12, (YEAR) -Certified Nursing Assistant (CNA/staff #10) with a hire date of (MONTH) 2, 2019 -CNA (staff #68) with a hire date of (MONTH) 25, (YEAR) -Physical Therapist (PT/staff #28) with a hire date of (MONTH) 1, 2019 -Speech Language Pathologist (SLP/staff #104) with a hire date of (MONTH) 4, 2013 -Life Enrichment Assistant (staff #108) with a hire date of (MONTH) 19, (YEAR) -Kitchen Steward (staff #42) with a hire date of (MONTH) 1, 2019 -Director of Social Services (staff #35) with a hire date of (MONTH) 2, 2005 Review of the facility's assessment dated (MONTH) 29, (YEAR) revealed the facility will conduct and document a facility-wide assessment to determine what resources are necessary to care for its resident competently during both day-to-day operation and emergencies. The facility resources included all personnel, including managers, staff (both employees and those who provide services under contract) and volunteers, as well as their education and/or training and any competencies related to resident care. The assessment also included the required in-service training for nurse aides must include dementia management training. Review of the New Hire Compliance Training list revealed that dementia management training was not included in the list. An interview with the Administrator (staff #121) was conducted on (MONTH) 15, 2019 at 1:46 p.m. Staff #121 stated that all staff had dementia training 4 months ago. He stated the facility has mandatory training, which staff must complete annually, within the month after his/her hire date. The Executive Director (staff #122) who was also present during this interview stated the dementia training conducted 4 months ago was comprehensive, meaning it involved the training of all staff on the campus, because the facility was opening a memory unit. In an interview with the Director of Nursing (DON/staff #83) conducted on (MONTH) 15, 2019 at 2:38 p.m., she stated that about 4 months ago the facility had some training on dementia presented by the medical director. She stated all staff must complete this training. Staff #121 provided a list of topics which comprised the facility's Annual Compliance Training, however, dementia management training was not included as an in-service topic. The facility was unable to provide any evidence that the above staff had received dementia management training. Regarding Abuse Training: Review of the personnel file for staff #78 (RN) revealed a hire date of (MONTH) 27, (YEAR). There was no evidence that staff #78 had abuse training in (YEAR), (YEAR) and 2019. Review of the personnel file for staff #61 (RN) revealed a hire date of (MONTH) 2, (YEAR). There was no evidence that staff #61 had completed abuse training in (YEAR), (YEAR) and (YEAR). The file did contain training on Abuse and Neglect that was completed on (MONTH) 13, 2019, which was during the survey. Review of the personnel file for staff #68 (CNA) revealed a hire date of (MONTH) 27, (YEAR). There was no documentation that staff #68 had abuse training in (YEAR). The file did contain training on Abuse and Neglect that was completed on (MONTH) 13, 2019, which was during the survey. The personnel file for staff #28 (physical therapist) included a hire date of (MONTH) 1, 2019. There was no evidence that staff #28 had completed any abuse training since being hired. The personnel file for staff #102 (Certified Occupational Therapy Assistant) included a hire date of (MONTH) 16, (YEAR). There was no documentation that staff #102 had received any abuse training in (YEAR) and (YEAR). Further review of the facility assessment included the facility continues to train and in-service staff throughout the year regarding Abuse, Neglect and Exploitation. Review of the list of topics that comprise the facility's Annual Compliance Training revealed that Abuse and Neglect were included. An interview with the Administrator (staff #121) was conducted on (MONTH) 15, 2019 at 1:46 p.m. Staff #121 stated the facility's Human Resources department ensures that all orientation topics include the core topics such as; abuse and resident rights. He stated the facility has mandatory training which staff must complete annually within the month after his/her hire date. He stated that when an in-service is scheduled, staff must complete the in-service within one week unless staff is on leave. He said in this case, there will be a grace period of 30 days to complete the required in-service when staff returns for work. Review of the policy titled, Continuing Education included that compliance with the facility's policies and procedures is a condition of employment. This includes compliance with the policies and procedures of the facility's training program. All levels of employees are expected to complete on-going training, within the designated time frames. A policy on the Training Requirements included the facility develops, implements and maintains an effective training program for all new and existing staff, individuals providing services under a contractual arrangement and volunteers, consistent with their expected rules. The policy included the training content includes at a minimum dementia management and care of the cognitively impaired, and abuse, neglect and exploitation.

Based on closed clinical record review, staff interviews and policy review, the facility failed to ensure there was adequate indication for the use of an as needed (PRN) antipsychotic medication for one resident (#97) and that there was a 14 day stop date or documentation by the prescribing practitioner that the resident was evaluated for the appropriateness of the medication. The deficient practice could result in residents receiving antipsychotic medications without medical necessity. Findings include: Resident #97 was admitted to the facility on (MONTH) 1, (YEAR) with [DIAGNOSES REDACTED]. Review of the clinical record revealed the resident was receiving hospice services. An annual History and Physical dated (MONTH) 18, (YEAR) revealed the resident had acute [MEDICAL CONDITION] and agitation, although no specific behaviors were addressed. A significant change MDS (Minimum Data Set) assessment dated (MONTH) 10, (YEAR) included a BIMS (Brief interview for Mental Status) score of 3, indicating the resident had severe cognitive impairment. The PHQ-9 (9-Item Patient Health Questionnaire) revealed a total severity score of 0, indicating no depression. The assessment also included the resident did have any hallucinations, delusions or behaviors. The physician progress notes [REDACTED]. It also included the resident had no current anxiety or depression. The note included [DIAGNOSES REDACTED]. The plan included for monitoring mood and behaviors. The Recertification Nurse Visit note dated (MONTH) 2, (YEAR) included the resident had no anxiety or agitation beyond comfort level. The resident was disoriented to place and time and was forgetful. The resident had no behavior problem per se but would roll his wheelchair away from the nurse whenever she tried to interact with him. The note also included that the assessment was limited. Review of a music therapy routine visit note dated (MONTH) 6, (YEAR) revealed the resident had no anxiety or agitation beyond comfort level. Per the note, the resident was more lethargic, did not respond appropriately to questions and was more forgetful and confused. It also included the resident reported feeling well. Further review of the clinical record revealed no specific behaviors that the resident had exhibited from (MONTH) (YEAR) through (MONTH) 6, (YEAR). A hospice IDT (interdisciplinary team) care plan for the certification period of (MONTH) 10, (YEAR) to (MONTH) 7, (YEAR) included a [DIAGNOSES REDACTED]. The social worker visit note dated (MONTH) 7, (YEAR) included the resident was sleeping soundly and had no anxiety or restlessness/agitation beyond comfort level. Despite the lack of documentation regarding specific behaviors, a hospice physician's orders [REDACTED]. The order did not include a 14 day stop date. A care plan dated (MONTH) 7, (YEAR) included the resident was receiving the antipsychotic [MEDICATION NAME] (brand name for [MEDICATION NAME]) on an as needed basis. Interventions included to give medication as ordered, record behaviors on the Behavior Tracking Form and monitor patterns of behavior such as time of day, precipitating factors and specific staff or situations. A Behavior/Intervention Flow Record was initiated on (MONTH) 7, (YEAR). From (MONTH) 7 through 11, (YEAR), the resident was being monitored for behaviors related to agitation, as evidenced by yelling. The documented number of episodes that the resident displayed was marked 0, indicating no behaviors were present. Further review of the flow record revealed that on (MONTH) 12, (YEAR) during the night shift, there were 3 greater episodes of behavior. It also included that interventions such as 1:1, change in position, fluids, redirection and medications were provided to the resident and the outcome improved. According to a Consent for the Use of [MEDICAL CONDITION] Medication dated (MONTH) 12, (YEAR), the resident was being administered [MEDICATION NAME] for agitation. Review of the MAR (medication administration record) for (MONTH) (YEAR) revealed that [MEDICATION NAME] was administered on (MONTH) 12, (YEAR) at 6:20 p.m., during a wound dressing change. The behavior exhibited prior to administering the [MEDICATION NAME] was documented as behavior present, combative, yelling out. The behavior/intervention flow record for (MONTH) 13, (YEAR) revealed that during the day shift, the resident had 3 greater episodes of behavior. The following interventions were implemented which resulted in improved outcome: 1:1, change in position, activity, giving of fluids, toileting and medications. The record also showed that during the night shift, the resident had 2 episodes of behavior. The only intervention which was implemented was the administration of the antipsychotic medication. The documentation also included that the resident manifested a side effect of lip smacking-chewing. Continued review of the clinical record revealed there was no evidence the physician/provider or that hospice were notified the resident had manifested a side effect of lip smacking. Despite documentation that the resident experienced a side effect of lip smacking, the MAR indicated [REDACTED] Further review of the clinical record revealed there was no evidence of adequate indications for the use of an antipsychotic medication for this resident. Per the clinical record, the resident continued on hospice services and expired on (MONTH) 20, (YEAR). During an interview with a licensed practical nurse (LPN/staff #93) conducted on (MONTH) 14, 2019 at 11:13 a.m., she stated the physician orders [REDACTED]. She said the number of episodes of behaviors will be monitored and documented to include interventions provided every shift. An interview with another LPN (staff #24) was conducted on (MONTH) 14, 2019 at 1:51 p.m. Staff #24 stated that the order for an antipsychotic will include the [DIAGNOSES REDACTED]. She said the specific symptom for the target behavior may be different for each resident, so staff is supposed to assess and monitor the specific symptom the resident has. She stated the number of episodes of behavior is monitored every shift and is documented in the behavior sheet. She said it is pretty common for an antipsychotic such as [MEDICATION NAME] to be prescribed and given to residents with agitation, especially when they are under hospice service. In an interview with the Director of Nursing (DON/staff #83) conducted on (MONTH) 15, 2019 at 2:38 p.m., she stated the resident was not alert and oriented and had no psychotic behaviors like delusions and paranoia. She stated that after a family member passed, resident #97 started to decline. She stated there was one time when the resident had hallucinations and this was the reason why [MEDICATION NAME] was prescribed. She stated the resident had periods of agitations and eventually was admitted to hospice, who prescribed the [MEDICATION NAME]. She stated that an antipsychotic such as [MEDICATION NAME] is usually prescribed by hospice for agitation and is okayed by the facility's provider when a resident is under hospice services. A policy on [MEDICAL CONDITION] Medication included the physicians or prescribing practitioners will use [MEDICAL CONDITION] medications appropriately in collaboration with the interdisciplinary team to ensure appropriate use, evaluation and monitoring. The policy included that based on a comprehensive assessment of a resident, the facility will ensure residents who have not used [MEDICAL CONDITION] drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. The facility will identify and document in the clinical record the specific medical [DIAGNOSES REDACTED]. The policy also included that PRN orders for antipsychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.

Based on clinical record review, facility documentation, staff interview and policy review, the facility failed to implement their abuse policy for one resident (#92), by failing to report an allegation of abuse to the State agency, within two hours after the allegation was made. Findings include: Resident #92 was admitted to the facility on (MONTH) 11, (YEAR), with [DIAGNOSES REDACTED]. Review of the facility's investigative report revealed that on (MONTH) 14, (YEAR) at 6:40 p.m., resident #92 reported to a registered nurse (staff #105) that she was in the dining room for dinner and sat by a male resident. The report included that resident #92 stated that she was conversing with the male resident, when he started to rub her arm and then touched her breast. Further review of the investigative report revealed documentation that the facility did not notify the State agency until (MONTH) 15, (YEAR) at 4:36 p.m. An interview was conducted with the administrator (staff #61) on (MONTH) 19, (YEAR) at 10:30 a.m. He stated that the State agency had not been notified within two hours after the allegation was made. Review of the facility policy titled Abuse, Neglect and Exploitation revealed the facility must ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source are reported immediately to the State agency, but no later than two hours after the allegation is made.

Based on clinical record review, facility documentation, staff interview and policy review, the facility failed to ensure that an allegation of abuse involving one resident (#92) was reported to the State agency, within two hours after the allegation was made. Findings include: Resident #92 was admitted to the facility on (MONTH) 11, (YEAR), with [DIAGNOSES REDACTED]. Review of the facility's investigative report revealed that on (MONTH) 14, (YEAR) at 6:40 p.m., resident #92 reported to a registered nurse (staff #105) that she was in the dining room for dinner and sat by a male resident. The report included that resident #92 stated that she was conversing with the male resident, when he started to rub her arm and then touched her breast. Further review of the investigative report revealed documentation that the facility did not notify the State agency until (MONTH) 15, (YEAR) at 4:36 p.m. An interview was conducted with the administrator (staff #61) on (MONTH) 19, (YEAR) at 10:30 a.m. He stated that the State agency had not been contacted within two hours after the allegation was made. Review of the facility policy titled Abuse, Neglect and Exploitation revealed the facility must ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source are reported immediately to the State agency, but no later than two hours after the allegation is made.

Based on observations, clinical record review, resident and staff interviews, documentation from the Centers for Disease Control (CDC) and policy review, the facility failed to maintain an effective infection control program, by failing to ensure that contact precautions were followed for one resident (#252), with an active [MEDICATION NAME] Resistant [MEDICATION NAME] (VRE) wound infection. As a result, the Condition of Immediate Jeopardy (IJ) was identified. The facility also failed to follow infection control practices regarding one resident (#266) with Clostridium Difficile (C-diff). Findings include: On April 4, 2016 at 1:15 p.m., the Condition of Immediate Jeopardy (IJ) was identified. The Administrator was informed of the facility's failure to implement infection control procedures for resident #252, who was on contact precautions for VRE wound infection. Observations were conducted of one housekeeping staff member who was inside of the resident's room with a gown on, but no gloves. The housekeeper exited the residents room holding a vacuum with bare hands and with the gown still on. She then retrieved the mop from the housekeeping cart and re-entered the residents room, without applying gloves. The housekeeper was then observed to exit the room, with the gown still on and discarded the gown in the trash bin on the cart. The housekeeper did not wash her hands and then entered another residents room. In addition, a physician was observed going in and out of this resident's room, without donning a gown and gloves, and then entered other resident's rooms, without washing his hands. The Administrator presented a plan of correction on April 4, 2016 at 2:45 p.m. The Administrator was informed that the plan of correction needed to include how the posted signs outside of the isolation rooms can be understood by all staff and visitors regardless of the language it was written; how to monitor that infection control procedures are being followed and policy and procedures for discontinuing isolation precautions. A revised plan of correction was presented at 4:32 p.m. The Administrator was informed that the plan of correction needed to clarify what staff were to be in-serviced regarding infection control procedures. Another plan of correction was presented at 5:39 p.m. and was accepted at 5:56 p.m. The plan included the process for discontinuing contact precautions for resident #252; all standard precautions signs will contain a pictogram and will be written in English and Spanish; revision of the facility's policy on cleaning resident's room after contact precautions are discontinued, daily cleaning on all residents rooms according to the facility's revised Cleaning Policy; conducting in-service trainings on their infection control policy; and performing direct observations of infection control practices related to residents on contact precautions. Multiple observations were conducted of the facility implementing their plan of corrections, which included thorough cleaning of resident's #252 room; staff in- services regarding infection control, use of personal protective equipment (PPE) and hand washing; and observations of staff implementing infection control procedures for other residents who were on contact precautions. The Condition of Immediate Jeopardy was abated on April 5, 2016 at 2:48 p.m. -Resident #252 was admitted on [DATE], with [DIAGNOSES REDACTED]. A temporary care plan dated March 28, 2015 identified that the resident had VRE on the right thigh surgical incision. Interventions included for contact precautions, administration of antibiotics and wound care to the right hip as ordered. A physician order [REDACTED]. Review of the admission nursing notes from March 28, 2016 revealed that the resident was admitted for right lower extremities cellulitis post op infection and was placed on contact precautions. A review of the nursing notes from March 29 through April 4, 2016 revealed that the resident continued on contact precautions and IV antibiotics for VRE to the wound on the right thigh. Review of the Minimum Data Set admission assessment dated [DATE], revealed the resident was cognitively intact and had a surgical wound. The MDS also included that the resident was receiving IV antibiotics. The [DIAGNOSES REDACTED]. On April 4, 2016 at 10:56 a.m., a sign was observed outside of the resident's room, which stated to report to the nurse before entering the room. There was also an isolation cart containing gowns, gloves, masks and booties outside of the resident's room. In addition, a housekeeping cart containing cleaning tools and solutions was observed to be outside of the resident's room. At this time, a facility housekeeping staff (staff #7) was observed inside the resident's room with a gown on, but no gloves. She was then observed to exit the resident's room with the gown still on and holding a vacuum, with her bare hands. She then proceeded to the housekeeping cart, took the mop from the cart, and went back into the resident's room, without putting on gloves. Another observation was conducted at this time of a physician entering resident #252's room, without applying a gown and gloves. Approximately two minutes later, the physician exited the resident's room and did not wash his hands. He was then observed to speak to a nurse and then entered another resident's room. At 10:59 a.m., housekeeping staff (staff #7) was observed exiting the resident's room still with the gown on and proceeded to the housekeeping cart, where she removed the gown and placed the gown in the yellow trash bin in her cart. She was not observed to wash her hands and entered the room adjacent to resident #252's room. In an interview with a registered nurse (RN/staff #45) conducted on April 4, 2016 at 11:01 a.m., she stated that resident #252 was on isolation precautions for a VRE infection of the wound to the right thigh. She said that the physician asked her whether the isolation precautions could be discontinued, but she recommended that the precautions remain in place, because the resident's wound was still draining heavily. She said that the resident was still on isolation precautions and all staff including housekeeping and the physician are expected to wear a gown and gloves before entering the resident's room and to remove the gown and gloves and dispose of them in the trash receptacle inside the resident's room, and then wash their hands, prior to exiting room. An interview with housekeeping staff (staff #7) was conducted on April 4, 2016 at 11:21 a.m. She stated that when she sees the sign outside a resident's door, she will go see the nurse before entering the room. She said that she will follow the instructions given by the nurse regarding wearing a gown, gloves, mask or bootie. Further, she said that when she entered resident #252's room, she was wearing a gown, however, she could not remember if she was wearing any gloves. Another interview with the RN (staff #45) was conducted on April 4, 2015 at 11:40 a.m. She stated that resident #252 has a surgical wound to the right thigh, which is currently infected with VRE and resident was being treated with IV antibiotics. She said that she changed the dressing to the resident's wound at 9:00 a.m., and there was a reddened area in the wound that has quite a bit of bloody drainage. Further, she stated the dressing change was ordered for twice daily and as needed, however, the drainage from the wound prompted for more frequent dressing changes. She also stated that the resident's wound dressing needed to be changed twice during the night shift prior to her shift, because of drainage. She further stated that the resident prefers to wear shorts, because the resident did not want the soaked bandages to soak her clothes. An interview was conducted on April 4, 2016 at 12:07 p.m., with the housekeeping manager (staff #129), who stated that when there is a sign posted outside of the resident's room to see the nurse, she expects her staff to check with the nurse and follow the instructions from the nurse before entering the room. She said that that she expects her staff to wear a gown and gloves for contact precautions and expects them to take the gown and gloves off and wash their hands before exiting the room. An interview was conducted on April 5, 2016 at 10:41 a.m., with resident #252 who stated that the isolation precautions were discontinued and her room was deep cleaned on the afternoon of April 4, 2016. However, she stated that she did not know why the precautions were discontinued, because the resident's wound was still draining bad. On April 7, 2016 at 12:53 p.m., an interview was conducted with the Infection Control Nurse (staff #125). She said that when isolation precautions are in place, all staff and physicians are expected to follow the isolation precautions. A review of the facility's policy regarding Categories of Infection Precautions revealed, In addition to Standard Precautions implement Contact Precautions for individuals known or suspected to be infected or colonized with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or patient-care items in the resident's environment. Examples of infections requiring Contact precautions include .wound infection or colonization with multidrug-resistant bacteria (e.g., VRE). The facility's policy on Gloves and Hand washing during Contact Precautions included wearing gloves when entering the room, removing and discarding gloves within the room and washing hands immediately with antimicrobial agent. The facility's policy on Gowns during Contact precautions included wearing a gown when entering the room and removing the gown before leaving the resident's environment. Review of the facility's Housekeeping policy on Wearing Gloves, with a revision date of January 6, 2016 revealed to require all Environmental Services and laundry personnel to wear gloves when handling potentially hazardous materials. Further, it included to always wear gloves during any cleaning procedure or when skin may contact potential hazardous material. The 2007 CDC Guidelines on the Management of Multidrug-Resistant Organisms in Healthcare Settings included those healthcare providers caring for patients on contact precautions for Multidrug-Resistant Organisms (MDRO) like VRE infections should wear a gown and gloves for all interactions that may involve contact with patient or potentially contaminated areas in the patient's environment. It further stated that Donning gown and gloves upon room entry and discarding before exiting the patient room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination (e.g., VRE .). -Resident #266 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the clinical record revealed that a verbal physician's orders [REDACTED]. An interim care plan dated April 4, 2016 identified that the resident had[DIAGNOSES REDACTED]. An intervention included for contact precautions. An observation was conducted on April 4, 2016 at 5:30 p.m., outside of the resident's room. A sign was attached to the door frame which stated stop check with nurse. An isolation cabinet was also observed just outside the resident's room. At this time, a registered nurse (RN/staff #37) donned a gown and gloves and entered the resident's room carrying a meal tray. She was observed placing the tray on the over the bed side table. The nurse then removed first her gloves and then pulled the front part of the gown off, using her bare hands. She disposed of the gown and gloves in the trash receptacle. She was then observed opening the door to the resident's bathroom with her bare hands and then washed her hands in the resident's bathroom. As the nurse was leaving the bathroom, she touched the door handle and closed the door, with her now clean hands and exited the room. An interview was conducted with the RN immediately following the observation. She stated she did not realize that she removed the gloves before taking the gown off and touched the bathroom door with her bare hands before exiting the room, but acknowledged that it was wrong. An interview was conducted on April 6, 2016 at 1:30 p.m. with the Director of Nursing (DON) and she explained that she expects when staff leave an isolation room, they take the gown off, then take off the gloves and wash their hands in the resident's bathroom and then exit the room, without touching anything inside the resident's room. On April 7, 2016, at 12:53 p.m., an interview was conducted with the Infection Control Nurse (staff #125). She said that all staff undergo an annual training, which includes the use of personal protection equipment (PPE) and isolation precautions. She also said when isolation precautions are in place, she would expect that all staff would obey the isolation precautions including physicians. Review of the 2007 CDC guidelines regarding[DIAGNOSES REDACTED] revealed that[DIAGNOSES REDACTED] spores are transferred to patients mainly via the hands, who have touched a contaminated surface or item. For prevention of transmission of[DIAGNOSES REDACTED] in healthcare settings, use contact precautions for patients with known or suspected[DIAGNOSES REDACTED]. The guidelines included to use gloves and gowns when entering patients rooms and during care and for all interactions that may involve contact with patient or potentially contaminated areas in the patients environment. Review of the recommendations from the CDC regarding the removal of PPE revealed the following: the front of the gown and sleeves are contaminated; pull the gown away from the neck and shoulders, touching the inside of the gown only. Review of the[DIAGNOSES REDACTED] policy revealed the purpose was to provide guidelines for the care of persons with known or suspected[DIAGNOSES REDACTED] and to prevent transmission to others. The policy included to wash hands after handling items which may be contaminated.