Every finding on record at Sunshine Health Care, Inc

Based on observations, interviews, record review, and facility policy review, the facility failed to provide the necessary care and services to maintain personal hygiene and grooming, including physician-ordered nail care and daily clothing changes, for one (1) of eighteen (18) sampled residents (Resident #57).Findings Include: Record review of facility policy titled Activities of Daily Living Policy revealed, It is the policy of this facility to provide the care and services necessary to maintain or improve each resident's ability to perform Activities of Daily Living, unless the resident's clinical condition demonstrates that such improvement is not possible. Activities of Daily Living include bathing, dressing, grooming, toileting, transferring, ambulation, eating, and personal hygiene. Record review of Order Listing Report revealed Trim fingernails monthly and/or PRN (as needed). On 6/22/2026 at 11:10 AM, an observation revealed Resident #57's fingernails were approximately one (1) inch long with a brown substance present underneath the nails. During interview, Resident #57 stated she did not prefer her fingernails to be long and reported she had received a shower that morning, but her nails had not been trimmed. On 6/23/2026 at 11:37 AM, an observation revealed Resident #57's fingernails remained approximately one (1) inch long with a brown substance present underneath the nails. Observation also revealed Resident #57 was wearing the same clothing observed the previous day. Resident #57 stated no one had changed her clothes since the day before. On 6/23/2026 at 11:57 AM, Certified Nursing Assistant (CNA) #1 confirmed Resident #57's fingernails were long with a brown substance present underneath the nails. Upon observing the resident's fingernails, CNA #1 stated, Wow! Those are long! CNA #1 further confirmed the resident's clothing should be changed daily and as needed if soiled. During an interview on 6/24/2026 at 9:10 AM, the Director of Nursing (DON) stated her expectation was that residents' fingernails be kept clean and trimmed. The DON confirmed Resident #57's long fingernails had been observed upon admission but had not been addressed. The DON also confirmed residents should be changed into pajamas each night and into clean clothing each morning. Record review of admission Record revealed Resident #57 was admitted to facility on 6/18/2026 with a diagnosis of Displaced Fracture of Distal Pole of Navicular (Scaphoid) Bone of Right Wrist, Subsequent Encounter for Fracture with Routine Healing. Record review of Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 6/25/2026 revealed under Section C, a Brief Interview for Mental Status (BIMS) summary score of 8 indicating that Resident #57 was moderately cognitively impaired.

Based on observation, staff interview, and record review, the facility failed to maintain a clean and home-like environment by failing to ensure a bedside fan used by a resident was maintained free of dust accumulation for one (1) of 53 residents reviewed. Resident #3Findings Include: Record review of the facility's policy Home-Like Environment Policy with no revision date, stated, The facility will strive to maintain a clean, safe, comfortable, well-lit, temperature-controlled environment with home-like furnishings . During observation of Resident #3's room on 6/22/2026 at 10:30 AM, a bedside fan used by the resident was observed with an accumulation of dust covering the fan blades and the exterior protective cover. The fan was positioned next to the resident's bed and was available for resident use. The accumulation of dust on the fan blades and exterior protective cover indicated the fan had not been maintained in a clean condition necessary to provide a clean resident environment. On 06/24/2026 at 8:30 AM during an interview and observation of Resident #3's room with the Director of Nursing (DON), she confirmed there was dust throughout the fan and stated, This should have been cleaned, and it is the expectation of the facility for fans to be free of dust accumulation. Record review of Resident #3's admission Record revealed the facility admitted the resident on 6/16/2023 with diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction.A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/11/2026 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 5 which indicated Resident #3 had severe cognitive impairment.

Based on observation, interview, record review, and facility policy review, the facility failed to maintain effective pest control for one (1) of 33 resident occupied rooms. Resident #34Findings Include: Record review of facility policy titled Pest Control Policy revealed, It is the policy of this facility to maintain a year-round pest control program to minimize the infestation of insect pests and rodents in the facility . On 6/22/2026 at 2:30 PM and on 6/24/2026 at 8:55 AM, observation revealed a continuous line of ants extending from the countertop in the resident's room, approximately 3 feet above the floor, down the wall next to the countertop, and continuing along the wall to the closet. Resident #34 stated she had ant bites on her right upper arm. Observation revealed approximately three (3) small red areas, each about the size of the tip of a pen, with scratch marks present on the upper right arm. Resident #34 was observed scratching the affected area. On 6/22/2026 at 2:40 PM, the Director of Nursing (DON) observed and confirmed the presence of ants on the countertop, wall, and floor near the closet in Resident #34's room. The DON also observed and confirmed approximately three (3) small red circular areas with scratch marks on the resident's right upper arm. On 6/22/2026 at 3:05 PM an interview with the Administrator confirmed that it had been an ongoing problem, but they thought they had taken care of it. On 6/24/2026 at 9:00 AM, Certified Nursing Assistant (CNA) #1 observed and confirmed the presence of ants along the wall next to the countertop and on the countertop in Resident #34's room. Record review of admission Record revealed Resident #34 was admitted to facility on 2/3/2025 with a diagnosis of Type 2 Diabetes Mellitus with Hyperglycemia. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/22/2026 revealed under Section C, a Brief Interview for Mental Status (BIMS) summary score of 15 indicating Resident #34 was cognitively intact.

Based on record review, staff interview and facility policy review the facility failed to ensure that the Minimum Data Set (MDS) assessment was coded accurately for a serious mental illness (Resident #10) and for the use of anticoagulant medications (Resident # 1, #3, #7, #21 and #33) for six (6) of 32 sampled residents. Findings include: Record review of the facility policy titled, Resident Assessment Instrument (RAI) Policy with no revision date revealed, It is the policy of this facility that the RAI will be done as follows: According to the guidelines specified by CMS (Centers for Medicare and Medicaid Services). Resident #1 Record review of Order Summary Report during initial pool revealed Resident #1 was not on an anticoagulant medication but was on Plavix, an antiplatelet medication. The resident was coded on the MDS assessment as being on anticoagulant and antiplatelet medication. Record review of Resident #1's Order Summary Report revealed an order dated 4/4/25 for Plavix 75 milligrams (mg) by mouth one time a day for Peripheral Vascular Disease. Review revealed there was no order for an anticoagulant medication. Record review of Resident #1's Minimum Data Set (MDS) Section N dated 7/7/25 revealed the resident was coded for receiving an anticoagulant. Record review of the admission Record revealed Resident #1 was admitted to the facility on [DATE] and diagnoses included Unspecified Atrial Fibrillation and Peripheral Vascular Disease. Resident #3 A record review of Resident #3's “Order Summary Report” with active orders as of 7/23/25 revealed an order dated 6/26/25 for Plavix 75 mg by mouth one time per day. There were no orders identified for an anticoagulant. A record review of Resident #3's MDS with an ARD of 7/03/25 under section N, revealed that Resident #3 was coded as being on an anticoagulant. A record review of the admission Record revealed Resident #3 was admitted by the facility on 6/26/25 with a diagnosis of Metabolic Encephalopathy. Resident #7 Record review of MDS Section N dated 6/9/25 revealed Resident #7 was coded as receiving an anticoagulant medication. Record review of Resident #7's Order Summary Report revealed an order dated 1/2/24 for Clopidogrel (Plavix) 75 mg by mouth daily for Peripheral Vascular Disease. Review revealed there was no order for an anticoagulant medication. Record review of Resident #7's admission Record revealed she was admitted to the facility on [DATE]. Diagnoses included Stage 3 Chronic Kidney Disease and Peripheral Vascular Disease. Resident #21 A record review of the “Order Summary Report” dated 07/23/25, revealed an order for Plavix 75 mg by mouth one time per day. There were no orders identified for an anticoagulant. A record review of MDS with an ARD of 04/23/25 under section N, revealed that Resident #21 was on an anticoagulant. A record review of the admission Record revealed Resident #21 was admitted by the facility on 10/08/24 with a diagnosis of Diabetes Mellitus. Resident #33 A record review of the MDS with an ARD of 04/24/25 under section N, revealed that Resident #33 was on an anticoagulant. A record review of “Order Summary Report” dated 07/23/25, revealed an order for Plavix 75 mg by mouth one time per day. There were no orders identified for an anticoagulant. A record review of the admission Record revealed Resident #33 was admitted by the facility on 01/20/25 with a diagnosis of Metabolic Encephalopathy. During an interview with the Registered Nurse (RN) MDS Coordinator on 7/22/25 at 1:30 PM, she revealed that Resident #1, #3, #7, #21 and #33 were on Plavix (Clopidogrel) and aspirin, and she coded Plavix as an anticoagulant and aspirin as an antiplatelet. She stated she was unaware that Plavix was an antiplatelet and not an anticoagulant medication and confirmed she should have coded this as an antiplatelet. She confirmed the MDS represents the care and condition of the resident and should be coded accurately, and she failed to do this when an antiplatelet was coded inaccurately as an anticoagulant. During an interview on 7/22/25 at 2:20 PM, the Director of Nursing (DON) confirmed that Plavix was an antiplatelet, not an anticoagulant medication. She stated her expectation was for the MDS, which represents the condition of the residents, to be accurately completed. She confirmed the facility failed to accurately complete the MDS assessment for these residents. Resident #10 Record review of Resident # 10's Significant Change MDS with an ARD of 1/9/25, revealed Section A 1500 coded as No, Is the resident currently considered by the state level II PASRR (Preadmission Screening and Resident Review) process to have serious mental illness and/or intellectual disability or a related condition? Record review of Resident # 10's Summary of Findings Report, from the PASRR Office, dated 8/18/23, under Mental Health revealed the individual meets criteria for having a diagnosis of mental illness as defined by PASRR. During an interview with the MDS Coordinator on 7/22/25 at 2:45 PM, she verified that the Significant Change MDS with an ARD of 1/9/25, for Resident # 10 was coded incorrectly. She agreed that the MDS should be coded correctly to ensure that the resident is receiving the correct level of care. In an interview with the Director of Nursing (DON), on 7/22/25 at 3:00 PM she agreed that it was her expectation that the MDS would be coded correctly. A record review of the admission Record revealed Resident #10 was admitted by the facility on 5/19/22 with diagnoses of Schizoaffective Disorder and Major Depressive Disorder.

Based on record review and staff interview the facility failed to accurately code the Minimum Data Set (MDS) assessment for discharge for one (1) of 17 resident assessments reviewed. Resident #56. Findings include: Record review of Resident #56's Discharge assessment-return not anticipated MDS with an Assessment Reference Date (ARD) of 12/16/23, revealed Resident # 56 was discharged to an acute care hospital. During an interview with the Director of Nursing (DON) on 3/6/24 at 10:00 AM, she stated Resident #56 was not hospitalized . In an interview with MDS Licensed Practical Nurse (LPN) and the MDS Coordinator on 3/6/24 at 10:10 AM, she verified that Resident #56 discharged home not to the hospital. MDS LPN revealed that she was the one who coded the MDS and that it was coded incorrectly and stated it was a data entry error. MDS Coordinator verified that the MDS was coded incorrectly and revealed that it was her expectation that the MDS would be coded correctly. They both agreed the importance of correctly coding the MDS accurately is to identify where the resident is located. Record review of Resident # 56's Face Sheet revealed that the facility admitted her on 9/8/23 with a diagnosis of Femur fracture.

Based on observation, staff interviews, and facility policy review, the facility failed to post Oxygen In Use signage for residents that utilized oxygen therapy for two (2) of four (4) residents observed. Resident #15 and Resident #25. Resident #15 and Resident #25 Respiratory Care Review of the facility policy titled, Oxygen Policy, with no date, revealed there was no documentation regarding Oxygen (O2) In Use signage to be posted for residents using oxygen. The facility administrator provided documentation, on the facility's letterhead, dated 11/3/22, that revealed, to whom it may concern, as (Facility proper name) including its building and grounds is a smoke free facility which prohibits the use of any and all smoking items. For this reason, the posting of such signs in and or near oxygen use is a [NAME] point. New residents and their family members are advised of this rule upon admission. Staff are advised as new hires and this rule is closely monitored by administrative staff. An observation on 11/1/22 at 12:52 PM, of the room entrance of the assigned room shared by Resident #15 and Resident #25, revealed there was no O2 In Use sign posted on the room entrance to indicate Resident #15, and Resident #25 used O2. An oxygen concentrator, with an oxygen tubing set-up for use, was observed for Resident #15 and Resident #25. An interview on 11/1/22 at 12:52 PM with Resident #15 revealed he used his O2 during the night. An observation and interview on 11/1/22 at 12:52 PM with Resident #25 revealed he was actively using his O2, and he revealed he used his O2 majority of the day, everyday of the week. An observation on 11/1/22 at 3:00 PM of the room entrance of the assigned room shared by Resident #15 and Resident #25 revealed, there was no O2 In Use sign posted on the room entrance to indicate O2 was in use in their room. The observation also revealed Resident #25 was actively using his O2. An observation and interview on 11/2/22 at 2:50 PM with Licensed Practical Nurse (LPN)#1 confirmed, there was not a O2 In Use sign posted on the room entrance for Resident #15 and Resident #25. She revealed an O2 In Use sign should have been posted on the entrance to alert visitors and staff of there being O2 in use in the room. An observation and interview on 11/2/22 at 2:52 PM with LPN #2 confirmed Resident #15 and Resident #25 did not have an O2 In Use sign posted on their room entrance. She revealed she would have to go back to check the policy to see if she should have posted the sign, but an O2 In Use sign would be a safety alert for residents using O2 and would let visitors and staff know to take necessary precautions before entering a room where O2 was in use. An observation and interview on 11/2/22 at 2:56 PM with the Director of Nursing (DON)#1, confirmed there was not an O2 In Use sign posted on the room entrance for Resident #15 and Resident #25. She revealed she would have to go and check the policy to see if it indicated an O2 In Use sign had to be posted for residents using O2 but confirmed the signage would have been a safety alert for residents using O2 and would have alerted visitors and staff to take the necessary precautions to avoid the likelihood of any incident or a negative outcome for a resident using O2. Record review for Resident #15 revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review for Resident #25 revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Physician's Orders for Resident #15 revealed the order, O2 continuous at (@) two (2) liters per minute (lpm) / by nasal cannulas (bnc) (may leave off at intervals as tolerated) to wean off) O2, dated 3/15/22. Record review of the Physician's Orders for Resident #25 revealed the order, O2 continuous @ 2 lpm/bnc (may leave off at intervals as tolerated), dated 6/9/22. Record review of Section O of the Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 8/10/22, for Resident #15, revealed Resident #15 was captured for the use of O2 while a resident. Record review of Section O of the Quarterly MDS Assessment, with an ARD of 9/9/22, for Resident #25, revealed Resident #25 was captured for the use of O2 while a resident. Record review of Section C of the Quarterly MDS Assessment, with an ARD of 8/10/22, for Resident #15, revealed Resident #15 has a Brief Interview for Mental Status (BIMS) score of 11, indicating Resident #15 is moderately cognitively impaired. Record review of Section C of the Quarterly MDS Assessment, with an ARD of 9/9/22, for Resident #25, revealed Resident #25 has a BIMS score of 06, indicating Resident #25 is severely cognitively impaired.

Based on observation, staff interview, and facility policy review, the facility failed to provide incontinent care in a manner to prevent the possible spread of infection for one (1) of two (2) incontinent care observations for Resident #15. Findings include: A review of the facility's Infection Control Policy, not dated, revealed it is the policy of this facility to maintain an infection control program to help prevent the development and transmission of disease and infection. On 10/30/18 at 9:55 AM, observation revealed Certified Nursing Assistant (CNA) #2 and CNA to #1 provided incontinent care for Resident #15. Both CNAs washed their hands and applied clean gloves. CNA #1 walked past Resident #15's bed and picked up the plastic bag for the soiled trash that had fallen on the floor and returned it to Resident #15's bed. After CNA #2 had wiped Resident #15's buttocks, CNA #1 folded the soiled brief underneath Resident #15 and removed the stool-soiled brief. Using the same soiled gloves, CNA #1 placed a clean brief underneath Resident #15, but then removed the clean brief stating, We've got to wipe her (referring to Resident # 15) some more. Using the same soiled gloves, CNA #1 retrieved clean wipes from the package of wipes, passed them to CNA #2, and CNA #2 continued to wipe Resident #15. CNA #1 replaced the previous clean brief back underneath Resident #15 and assisted CNA #2 to put pants on Resident #15. CNA #1 never changed her gloves during the entire incontinent care process. Both CNAs transferred Resident #15 back to her wheelchair. On 11/1/18 at 8:40 AM, interview with the Director of Nurses (DON) revealed the problem with CNA #1 not changing her soiled gloves was an infection control issue. The DON stated CNA #1 has had trainings on incontinent care. The DON also stated competencies on hand washing and perineal care are completed with the CNAs as well. On 11/1/18 at 9:37 AM, interview with CNA #2 revealed she could have communicated better to CNA #1 while providing incontinent care to Resident #15. CNA #2 also stated not changing her gloves when they are soiled would be an infection control issue. On 11/1/18 at 9:40 AM, interview with CNA #1 revealed she realized what mistakes she had made. CNA #1 stated, she was nervous and should have washed her hands and changed her gloves after her gloves had become soiled. CNA #1 also stated she knows she should have not picked up the plastic bag off the floor and placed it back on Resident #15's bed to use, because of infection control issues. On 11/1/18 at 10:24 AM, interview with RN #1 revealed once CNA #1 realized she had become contaminated, she should have removed the soiled gloves, washed her hands, and applied clean gloves, because of infection control issues.

Based on observation, staff interview and facility policy review, the facility failed to store and serve food properly as evidenced by failure to properly calibrate thermometers prior to testing food temperatures on the tray line, failure to date food items, and failure to state the required food line temperatures for two (2) of three (3) dietary tours. Findings Include: The facility policy, Calibrating Manual Thermometer Policy and Procedure, un-dated, revealed, It is the policy of this facility to ensure calibration of manual thermometer for dietary use as follows: Calibrated weekly and as needed. Dietary staff will be in-serviced monthly and checked off for accuracy in performance. The facility policy, Dietary Temperature Policy, un-dated revealed, It is the policy of this facility that food be cooked to proper temperature and held and served hot food at 135 degrees or above and cold foods at 41 degrees or below. Observation of the walk in cooler in the dietary department upon initial tour on 07/29/2015 revealed one glass of white thick substance without a date. Interview with Dietary Staff #4 on 07/29/2015 revealed the thick substance in an undated glass was a milk shake. Dietary Staff #4 stated, I made it today but I forgot to date it. Observation on 07/30/2015 at 11:20 AM during preparation for tray line temperatures revealed Dietary Staff #2 and Dietary Staff #3 were unable to calibrate the digital or the manual thermometers to 32 degrees Fahrenheit. The digital thermometer read 36 degrees Fahrenheit and the manual thermometer read 32.6 degrees Fahrenheit. Dietary Staff #2 stated, See this sheet over the steam table tells us for meats and vegetables it (the temperature) has to be different temperatures. The referenced chart showed cooking temperatures for various foods. Observation on 07/30/2015 at 11:10 AM revealed the Dietary Manager (DM) made several attempts to calibrate the manual thermometer to thirty-two degrees without success. Interview with Dietary Staff #3 on 07/30/2015 at 11:20 AM revealed food temperatures should be, 145 to 150 degrees (Fahrenheit) for food temps on tray line. Observation and Interview on 07/30/2015 at 11:40 AM with the DM revealed, I've gone to class at (name of university) showing me how to use a manual thermometer. I can only calibrate it (manual thermometer) to zero degrees. Interview with DM on 07/30/2015 at 2:10 PM confirmed staff were not aware of correct holding temperatures and needed further in-services. Interview with the Registered Dietician (RD), Dietary Staff #5, on 07/31/2015 at 9:10 AM revealed, I don't recommend the use of the digital thermometer. The digital thermometer will be thrown out. The DM did call me about correctly calibrating the manual thermometer. The food temperatures should be checked every day with every meal. The RD said, I don't know why the DM was not able to calibrate the thermometer.

Based on staff interview, record review, and facility policy review, the facility failed to maintain communication records between the hospice provider and the facility in order to provide coordinated care and ensure Resident #1 and Resident #4's highest well being; for two (2) of four (4) residents receiving hospice. Findings Include: Review of the facility's policy entitled, Hospice, undated, revealed, The hospice and facility will communicate with each other when any changes are indicated or made to the plan of care. Review of the facility's contract with the Hospice, provider dated 12/15/10, revealed under Coordination of Care, Facility will assist with periodic review and modification of the Hospice Plan of Care. Records: Compilation, Retention and Inspection of Records: Facility and Hospice shall each prepare and maintain complete and detailed clinical records concerning each Hospice Patient receiving services under this agreement. Resident #1 Record review of Resident #1's hospice visits revealed there were no nurse's notes on Resident #1's hospice chart. Interview with the Director of Nursing (DON) on 07/30/15 at 11:15 AM revealed the Resident was admitted to Hospice on 06/27/15 and the Hospice Nurse has not left any notes regarding visits with the facility staff. The DON stated the Hospice Nurse should be leaving notes weekly. The DON stated the Hospice Nurse communicated findings to her, but confirmed there was no documentation to provide continuation of care for nurses on other shifts. Review of the facility's face sheet revealed the facility admitted Resident #1 on 03/30/2005. Resident #1's [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with an assessment reference date of 07/02/15 revealed Resident #1's cognitive status was severely impaired. Resident #4 Record review and interview on 07/30/15 at 10:20 AM with the Director of Nursing (DON) confirmed Resident #4 was admitted to hospice services on 07/16/15. The DON confirmed the record of services from the hospice provider for communication between the hospice provider and the facility had no evidence of nursing visits notes, care provided, or a care plan. The DON stated, Yeah I've called hospice now to come and update their chart. Resident #4 was admitted to the facility on [DATE] with diagnosis, which included [MEDICAL CONDITIONS] and Weakness. Most recent Brief Interview for Mental Status (BIMS) was conducted on 07/21/15 with a BIMS score of 99 which indicated resident had severe cognitive impairment. Interview with the Hospice Nurse on 07/30/15 at 3:00 PM confirmed there were no hospice nurses notes on Resident #1's record or Resident #4's record. The Hospice Nurse stated she was responsible for bringing notes to the facility on a weekly basis and ensuring the facility had the required documentation. She stated, I didn't realize I didn't have any notes on the chart.

Based on staff interview, record review and facility policy review, the facility failed to develop and implement care plans related to hospice care for Resident #1 and Resident #4 and failed to develop a care plan specifying the type of lift for transfers for Resident #7 for three (3) of 11 care plans reviewed. Findings Include: Review of the facility's policy entitled, Total Care Plan Policy, with no date, stated, It is the policy of this facility that the Interdisciplinary care plan will be done as follows: Identify problems that affect the resident and his/her care needs, address areas identified on the MDS, identify the interventions related to the specific problems, all goals should be measurable and attainable. Resident #1 Record review on 07/30/15 at 11:00 AM revealed Resident #1 lacked a comprehensive care plan addressing Hospice needs at the time of admission to Hospice on 06/27/15. Interview on 07/30/15 at 11:15 AM with the Director of Nursing (DON) confirmed there was not a care plan on Resident #1's chart addressing Hospice needs. DON confirmed a care plan would be needed to address Hospice specifically with goals and interventions. The DON stated the MDS Nurse was not aware she needed an individualized care plan addressing Hospice. Review of the facility's face sheet revealed the facility admitted Resident #1 on 03/30/2005. Resident #1's [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with an assessment reference date of 07/02/15 revealed Resident #1's cognitive status was severely impaired. Resident #4 Record review for Resident #4 on 07/30/15 at 9:30 AM revealed the resident was admitted to hospice services on 07/16/15 and did not have a care plan with measurable goals and approaches to address hospice. Interview with Licensed Practical Nurse (LPN) #1 on 07/30/15 at 9:45 AM confirmed she developed the care plans for the residents and confirmed Resident #4 had a significant change assessment completed on 07/21/15 due to her admission to hospice services. LPN #1 also confirmed she failed to develop an individualized care plan to address hospice care and services when she did the significant change assessment for Resident #4. LPN #1 stated, I guess I didn't know I was suppose to do that. Record review of the Minimum Data Set (MDS) revealed the facility completed a significant change assessment on 07/21/15 due to Resident #4's admission to hospice services. The Brief Interview for Mental Status (BIMS) conducted on 07/21/15 indicated a BIMS score of 99 which indicated resident was unable to conduct the interview and had severe impairment for daily decision making. The facility admitted Resident #4 on 12/07/13 with diagnosis, which included [MEDICAL CONDITIONS], and Weakness. Resident #7 Record review of Resident #7's care plan revealed no care plan addressing the type of lift that staff should use with Resident #7. Review of the, Resident Assessment for Lift/Transfer/Assistance revealed s/s (sit to stand) lift for bath only. Interview on 07/30/2015 at 10:05 AM with the DON (Director of Nursing) regarding use of a lift during shower/bath time revealed, I don't see a care plan on the e-charting for care plans. Let me look in the chart. I don't see one (care plan). Typically the QA (Quality Assurance Nurse) would have carried it through to add the intervention, Use of lift with transfers with bathing/shower/whirlpool, since she was involved with writing the incident (related to a fall on 06/03/2015). Interview on 07/30/2015 at 10:25 AM with RN # 1 revealed the Instant Care Plan which showed the resident was at risk for falls, and the CNA (certified nursing assistant) was counseled. The CNA reported she had used the lift more with the resident. RN #1 admitted the lift (stand-by) should have been added to the care plan for all staff involved with bathing, or showering the resident due to the potential for resident falling and resident's history of falling. Review of the facility face sheet revealed the facility admitted Resident #7 on 10/22/13. The resident had [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 which indicated moderate cognitive impairment.

Based on observation, staff interview and policy review, the facility failed to implement a proper infection control program to prevent the possible spread of infection during incontinent care for one (1) of four (4) care observations (Resident #4). Findings include: Resident #4 Record review revealed that Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set, dated dated [DATE], revealed a Brief Interview for Mental Status score of 3, which indicated that Resident #4 ' s cognitive status was severely impaired. Observation on 9/5/12 at 2:30 p.m. revealed Certified Nurse Aides (CNAs) #1 and CNA #2 prepared to provide Resident #4's incontinent care. Observation revealed that CNA #1 and CNA #2 double gloved. CNA #1 cleaned resident's perineal area properly, with CNA #2 assisting, then removed the top pair of gloves and proceeded to complete care. CNA #1 and CNA #2 repositioned Resident #4 then removed the second pair of gloves. Then, CNA #1 and CNA #2 washed their hands. Interview with Certified Nurse Aide (CNA) #1 on 9/5/12 at 2:35 p.m. revealed that the facility trained the CNAs to double-glove when providing incontinent care. CNA #1 also stated that the facility approved of keeping gloves in their pockets. CNA #2 confirmed this statement. Interview on 9/5/12 at 2:40 p.m. with Assistant Director of Nurses (ADON) on 9/5/12 at 2:40 p.m. revealed that the facility did in fact train the CNAs (Certified Nurse Aides) to double-glove. The ADON also confirmed that the facility did train the CNAs it was appropriate to keep gloves in their pockets. Review of the facility's "Perineal Care" policy, not dated, did not address double-gloving. Review of the facility's "Peri Care Policy", not dated, revealed there as no mention of double-gloving for incontinent care.

Based on observation, staff interview, and facility policy and procedure review the facility failed to ensure infection control measures were maintained during observations and treatments for two (2) of three (3) days of survey. Nursing Staff took the container of glucose test strips in resident's rooms and the facility failed to clean and disinfect resident care equipment before and after using it. This is for Unsampled Resident A, B, C, D and Resident#6. Findings: Observations on 11/21/11 beginning at 11:05 a.m. revealed that LPN #1 performed a finger stick glucose check for Unsampled Resident A. LPN #1 obtained the disinfectant wipe, glucometer, container of test strips, cotton balls and gloves and entered Unsampled Resident A's room. LPN #1 placed the glucometer on a barrier on the over-bed table along with the lancets, alcohol wipe and cotton ball. The vial of test strips were placed on the counter without a barrier. LPN #1 opened the container of test strips and obtained a test strip. After the completion of the procedure, the container of test strips were taken back and placed on the medication cart. Observations on 11/21/11 beginning at 11:14 a.m. revealed that LPN #2 performed a finger stick glucose check for Unsampled Resident (B) . LPN #2 obtained a disinfectant wipe, vial of test strips, lancet, and alcohol wipe. The disinfectant wipe was placed on the dresser in the resident's room without a barrier. After the completion of the glucose testing, the bottle of test strips were taken out of the Resident's room and placed on the medication cart. Observations on 11/21/11 beginning at 11:20 a.m. revealed LPN #2 performed a finger stick glucose check for Unsampled Resident C. LPN #2 disinfected the glucometer, obtained a lancet, the bottle of test strips from the medication cart, a disinfectant wipe, alcohol wipe, and lancet. LPN #2 entered the Unsampled Resident C's room and placed the bottle of test strips on the table with no barrier. After the completion of the blood glucose testing, LPN #2 took the bottle of test strips and placed them on top of the medication cart. Observations on 11/20/11 beginning at 6:10 p.m. revealed that LPN #4 administered medications during medication pass observation to Unsampled Resident D through the feeding tube. LPN #4 checked the feeding tube placement by auscultation using the stethoscope. LPN #4 was not observed cleaning or disinfecting the stethoscope before or after use. After checking placement of the feeding tube, LPN #4 placed the streetscape around her neck. An interview on 11/22/11 at 11:55 a.m. with the Director of Nurses (DON) confirmed that the stethoscope should have been disinfected before use. Review of the facility "Equipment Cleaning Policy" with a hand written date of July 2005, revealed, "It is the policy of this facility that wheelchairs, gerichairs, walkers, canes, urinals, bedpans, shower chairs, feeding pumps, IV poles, commode chairs, etc. will be cleaned as follows: -Will be cleaned by nursing and housekeeping personnel. Will be cleaned as scheduled and as needed using germicidal solution. Record review revealed that Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/19/11 revealed that Resident #6 had a Brief Interview for Mental Status (BIMS) score of 00 indicating Resident #6's cognitive status was severely impaired - rarely/never made decisions. Observation on 11/22/11 at 11:30 a.m. during a feeding tube flush revealed Licensed Practical Nurse (LPN) #2 ascultated for tube placement by placing a stethoscope onto Resident #2's abdominal area and listened for gastric sounds. LPN #2 did not clean her stethoscope before or after using the stethoscope. In an interview on 11/22/11 at 11:40 a.m., LPN #2 confirmed that she did not clean her stethoscope before or after using it to check for placement on Resident #2. Review of the facility policy "Infection Control Policy" with no date revealed; "It is the policy of this facility to maintain an infection control program as follows: To help prevent the development and transmission of disease and infection."