Every finding on record at The Village at Germantown

Based on Centers for Disease Control and Prevention (CDC) guidelines, facility policy review, Glucometer (a device used to check blood sugar levels with the use of a blood sample) User's Guide review, skills check off list review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when a multi-use blood glucose meter was not cleaned or disinfected with an Environmental Protection Agency (EPA) approved disinfecting wipe to prevent the cross-contamination of bloodborne pathogens and failed to ensure staff properly performed hand hygiene for 1 of 2 (Resident #23) sampled residents reviewed for blood glucose monitoring. On 9/9/2025, 2 of 3 (Licensed Practical Nurse (LPN) A and Registered Nurse (RN) B) nurses failed to properly clean and disinfect the multi-use blood glucose meter before and after use on Resident #23 in accordance with current infection control recommendations and facility policy and Registered Nurse (RN) B failed to properly perform hand hygiene when performing a blood glucose test and administering insulin. The facility's failure to ensure staff properly disinfected the blood glucose meter that was used for multiple residents, in accordance with recommendations and the facility's policy, placed the residents at risk for potential contamination with bloodborne pathogens and had the likelihood to cause serious injury, harm, impairment, and/or death, which resulted in Immediate Jeopardy. Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified related to the facility's failure to appropriately clean and disinfect a multi-use blood glucose meter during medication administration for Resident #23. The Administrator and the Administrator for Memory Care Assisted Living were verbally informed of the Immediate Jeopardy on 9/9/2025 at 9:26 PM, in the Administrator's office. The Administrator and Director of Nursing (DON) were given the IJ template on 9/10/2025 at 9:10 AM, in the Private Dining Room. The facility was cited Immediate Jeopardy at F-880 at a scope and severity of J. An extended survey was conducted and completed on 9/11/2025. An acceptable Removal Plan, which removed the immediacy of the jeopardy was received on 9/10/2025 at 9:12 AM, and was validated onsite by the surveyors on 9/11/2025 through review of in-services and posttests, audits, and staff interviews. The Immediate Jeopardy for F-880 began on 9/9/2025 and continued through 9/11/2025. The Immediate Jeopardy was removed on 9/12/2025. The facility's non-compliance at F-880 continues at a scope and severity of D for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction. The findings include: 1. Review of the CDC Considerations for Blood Glucose Monitoring and Insulin Administration, dated 8/7/2024, revealed .Clean and disinfect blood glucose meters after every use, per the manufacturer's instructions .These recommendations apply in .Long-term care settings .Blood glucose meters can easily become contaminated during use. When used in healthcare or other group settings, germs and infections can spread if preventive measures are not in place .If healthcare providers use blood glucose testing or insulin administration devices on more than one patient, equipment and supplies may become contaminated. Unsafe practices during assisted monitoring of blood glucose and insulin administration contribute to the spread of hepatitis B virus [HBV-a serious liver infection most commonly spread by exposure to infected body fluids], hepatitis C virus [HCV-an infection caused by a virus that attacks the liver and is spread by contact with contaminated blood], HIV [Human Immunodeficiency Virus-an immune system disease that interferes with the body's ability to fight infection and disease], and other infections. Unsafe practices include .Using a blood glucose meter for more than one person without cleaning and disinfecting it in between uses .Failing to change gloves and perform hand hygiene between fingerstick procedures . 2. Review of the facility's policy titled, Glucometer Disinfection, dated 12/19/2024, revealed .The glucometers will be disinfected with a wipe pre-saturated with an EPA registered healthcare disinfectant that is effective against HIV, Hepatitis B virus.Glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions regardless of whether they are intended for single resident or multiple resident use. Review of the facility undated policy titled, Hand Hygiene, revealed .All staff will perform 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 hand washing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub.Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to the attached hand hygiene table.After handling contaminated objects. Before applying and removing personal protective equipment (PPE) including gloves.Before preparing resident care products.After handling items potentially contaminated with blood, body fluids, secretions, or excretions . Review of the facility's policy titled, Blood Glucose Monitoring, dated 12/19/2024, revealed .The nurse will abide by the infection control practices of cleaning and disinfection of the glucometer as per the manufacturer's instructions and in accordance with the facility's glucometer disinfection policy. 3. Review of the (Named Glucometer) User Instruction Manual dated 4/2021, revealed .Cleaning and Disinfecting.The meter should be cleaned and disinfected after use of each patient. This Blood Glucose Monitoring System may only be used for testing multiple patients when Standard Precautions and the manufacturer's disinfection procedures are followed.We have validated [Named] Healthcare Bleach Germicidal Wipes.CaviWipes1, and .[Named] Germicidal Disposable Wipe for disinfecting the [Named Glucometer] multi meter. 4. Review of the medical record revealed Resident #23 was admitted to the facility on [DATE], with diagnoses including Dementia, Congestive Heart Disease, Diabetes, and Chronic Pulmonary Edema. Review of the Physician's Order for Resident #23 dated 8/22/2025, revealed .Insulin lispro [medication used to treat diabetes] (u [units]-100) 100 unit/ml [milliliter] subcutaneous solution [generic] - 100 unit/ml Subcutaneous [sq] Four times daily < [less than] 70 Hypoglycemic Protocol 70-149 Hold 150 thru 199 give 2.0 Units 200 thru 249 give 3.0 Units 250 thru 299 give 4.0 Units 300 thru 349 give 5.0 Units > [greater than] 349 6 units. Review of the Care Plan for dated 8/25/2025, revealed .DIABETES-[Named Resident #23] has alteration in Metabolic Function related to Diabetes. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 2, which indicated Resident #23 had severe cognitive impairment. Active diagnoses included Type 2 Diabetes Mellitus. Review of the Medication Administration Record (MAR) dated 9/2025, revealed Resident #23 received insulin before meals and at bedtime and blood glucose levels were scheduled to be checked at 7:30 AM, 12:30 PM, 5:00 PM, and 9:00 PM on the day of the surveyor's onsite survey. Observation at the Care Base 3 Medication Cart on 9/9/2025 beginning at 12:15 PM, revealed LPN A removed the blood glucometer from the black carry case in the top drawer, gathered the glucometer and supplies, and walked down the hall to Resident #23's room. Then LPN A placed the glucometer on a barrier on the nightstand, washed her hands, and donned clean gloves. LPN A retrieved an alcohol prep pad and cleaned the glucometer with the alcohol pad. Then LPN A placed the glucometer on the barrier on the nightstand and left the room to retrieve Resident #23 from the dining room. LPN A returned to the room with Resident #23 and washed her hands, donned a clean pair of gloves, and performed the blood glucose test. LPN A then gathered the trash and threw it in the trash can, removed the gloves, and washed her hands. LPN A donned a clean pair of gloves and used an alcohol prep pad to clean the glucometer. LPN A placed the glucometer on the nightstand to air dry while she retrieved Resident #23 from the dining room. LPN A went to the Care Base 3 Medication Cart and retrieved the insulin pen and supplies for Resident #23 and reentered the Resident's room. LPN A washed her hands, donned a clean pair of gloves and administered the insulin. Then she removed the gloves, washed her hands, and returned Resident #23 to the dining room. LPN A went back to the Resident's room, washed her hands, gathered the glucometer and Insulin pen, and returned to the Care Base 3 Medication Cart. LPN A placed the blood glucometer in a black carry case and placed the case in the drawer of the medication cart without cleaning or disinfecting the glucometer. Observation and interview at the Care Base 3 medication cart beginning on 9/9/2025 at 4:45 PM, revealed RN B opened the medication cart and removed a black carry case that contained a glucometer, testing strips, lancets (medical device used to make a tiny prick or puncture in the skin to collect a small blood sample), and alcohol pads. RN B removed the testing strip container and read the expiration date. RN B failed to perform hand hygiene before gathering the supplies for a blood glucose check. RN B left the medication cart with supplies in her hand. RN B returned to the medication cart at 5:06 PM, placed the black case with the glucometer and testing supplies in it on the medication cart. RN B opened the medication cart and removed a cleaning wipe from the purple top (Named) Wipe container and wiped off a white plastic tray. RN B gathered the black carry case, tray, and a pair of gloves and entered Resident #23's room. RN B placed the items on the tray and placed the tray on Resident #23's nightstand, washed her hands and donned gloves. RN B used an alcohol wipe to clean glucometer. RN B was then asked what the process is for cleaning the glucometer. RN B stated, Clean with an alcohol pad before and purple wipes after and allow time to dry before putting up. RN B was asked how do know the nurse before cleaned the glucometer. RN B stated, When the glucometer is in the pouch [black carry case] and the pouch [black carry case] is zipped up. RN B checked the Resident's blood glucose and with gloved hands exited the Resident's room with the supplies. RN B failed to remove her gloves and failed to preform hand hygiene before exiting Resident #23's room. RN B walked with gloved hands to the Care Base 3 medication cart, placed the testing strip and lancet in the sharps (disposable container for needles, syringes, lancets, razors, and sharp objects) container, and removed her gloves. RN B failed to perform hand hygiene after she removed her gloves at the medication cart. RN B opened the medication cart, got a (Named) Germicidal Wipe, cleaned the glucometer, and placed the glucometer on a barrier. RN B gathered Resident #23's insulin Lispro pen and supplies from the medication cart, reviewed the Resident's order, and turned the dial to 4 units. RN B failed to perform hand hygiene before gathering the Resident's medication. RN B entered Resident #23's room and donned gloves. RN B failed to perform hand hygiene before putting on gloves. RN B removed the cap from the insulin pen and failed to wipe the tip of the insulin pen with an alcohol pad before she attached the needle to the insulin pen. RN B administered Resident #23's insulin and wheeled Resident #23 to the dining room with gloved hands. RN B failed to remove gloves and perform hand hygiene after administering the insulin and before exiting the Resident's room. RN B walked to the medication cart, removed the needle from the insulin pen, placed it in the sharps container, and removed the gloves. RN B failed to perform hand hygiene after she removed the gloves. RN B opened the medication cart, placed the insulin pen in the medication cart, and placed the glucometer back in the black carry case. RN B failed to properly clean and disinfect the glucometer prior to use and failed to properly perform hand hygiene. During an interview on 9/11/2025 at 1:26 PM, the Director of Nursing (DON) stated, No, I was not aware that the nurses were using alcohol pads to clean the glucometers. The DON was asked would she say there was a system failure with cleaning glucometers. The DON stated, Yes, with two nurses, it was. During an interview on 9/11/2025 at 1:56 PM, the Administrator was asked what steps did you follow after we presented the IJ. The Administrator stated, .On Wednesday [9/10/2025] morning the DON and I talked about it, talked with the staff, and reviewed the policies and manufacturer guidelines. We determined nurses did not use [the] appropriate cleaning process for [the] glucometer. The Administrator was asked if this was a system failure. The Administrator stated, Yes, absolutely. Allegation of compliance 9/11/2025 On 9/10/25, when facility was notified of Immediate Jeopardy for F880, the Director of Nursing and [NAME] President of Healthcare reviewed the policy for glucometer disinfection and cross-reference with the manufacture's guidelines for needed revision. Policy revised to follow manufacture's guidelines. The Medical Director was notified on 09/10/2025 by the [NAME] President of Healthcare. On 9/10/25 the Director of Nursing and [NAME] President of Healthcare reeducated LPN A and RN B on the protocol of proper glucometer disinfection. Beginning 9/10/25 and ending 9/11/25 the DON and Nurse Supervisor conducted a Mandatory in-service with all LPN and RN staff at the beginning of the day shift and will continue until all staff have completed in-service. Any staff missing in-services will not work until they have received training. Following the in-service, a post test will be conducted with all employees. Those in services are one on one with Director of Nursing or RN Supervisor and signed by participants. On 9/10/25 an audit was conducted by DON to ensure wipes presaturated with an EPA registered healthcare disinfectant were stocked on each med cart. On 9/10/25 the Blood Glucose Competency form was placed on med cart for reference. Beginning 9/10/25 an audit of each med cart to ensure they are stocked with wipes presaturated with an EPA registered healthcare disinfectant will be conducted daily for four weeks by the RN Supervisor. Beginning 9/10/25 Competencies of glucometer disinfection will be conducted weekly for four weeks by the DON or Supervisor. Competency will be validated by a passing score of 100%. Signed by (Named the [NAME] President of Healthcare for the facility.)

Based on policy review, medical record review, and interview, the facility failed to ensure residents were free from unnecessary medications for 3 of 5 (Resident #2, #5, and #9) reviewed for unnecessary medications. The findings include: 1. Review of the facility policy titled, Use of Psychotropic Medications(s), dated 12/19/2023, revealed .Residents who receive an antipsychotic medication will have an Abnormal Involuntary Movement Scale (AIMS) test performed on admission, quarterly, with a significant change in condition, change in antipsychotic medication, PRN [as needed] or as per facility policy.The effects of the psychotropic medications on a residents physical, mental, and psychosocial well-being will be evaluated on an ongoing basis such as.In accordance with nurse assessments and medication monitoring parameters consistent with clinical standards of practice, manufacturer's specifications, and the resident's comprehensive plan of care.The resident's response to the medications(s) including progress towards goals and presence/absence of adverse consequences, shall be documented in the resident's medical record. 2. Review of the medical record review revealed Resident #2 was admitted to the facility on [DATE], with diagnoses including Metabolic Encephalopathy, Dementia, Hypertension, Insomnia, Anxiety, and Depression. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview Mental Status (BIMS) score of 2, which indicated Resident #2 was severely cognitively impaired, with active diagnoses of Anxiety, Depression, Non-Alzheimer's Dementia, and the use of antipsychotic, antidepressant, and antianxiety medications. Review of the Physician's Orders dated 8/30/2025, revealed .Ativan [medication to treat anxiety] 1mg [milligram] .3 times daily for Anxiety . Review of the Physician's Orders dated 8/26/2025, revealed . Olanzapine [an antipsychotic medication] 5mg .at bedtime . Review of the August 2025 Medication Administration Record (MAR) revealed the facility failed to assess and document side effects and behavior monitoring for the use of an antianxiety and an antipsychotic medication. Review of the September 2025 MAR revealed the facility failed to assess and document side effects and behavior monitoring for the use of an antianxiety and an antipsychotic medication. The facility was unable to provide documentation that an AIMS test was completed for Resident #2 upon admission to the facility on 8/26/2025. During an interview on 9/11/2025 at 11:47 AM, the Director of Nursing (DON) was asked when should an AIMS test be completed. The DON stated, On admission, quarterly, and with a significant change . The DON was asked did the facility complete an AIMS when Resident #2 was admitted on [DATE]. The DON stated, No, but we should have . The DON was asked should the facility have completed behavior and side effects monitoring for Resident #2 for the use of an antipsychotic, antianxiety, and an antidepressant medication. The DON stated, Yes. 3. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE], with diagnoses including Insomnia and Bipolar Disorder. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 14, indicated Resident #5 had intact cognition and the resident received antianxiety, antipsychotic, and antidepressant medications. Review of the Physician's Order dated 8/19/2025, revealed .Buspirone [antianxiety medication] 5 mg .at bedtime . Review of the Physician Order dated 8/19/2025, revealed .Latuda [an antipsychotic, used to treat depressive episodes] .40 mg daily . Review of the Physician's Order dated 8/19/2025, revealed .Citalopram [an antidepressant] 20 mg .daily . Review of the August 2025 MAR revealed the facility failed to monitor the side effects of psychotropic medications for Resident #5. Review of the September 2025 MAR revealed the facility failed to monitor the side effects of psychotropic medications for Resident #5. The facility was unable to provide side effect monitoring for Resident #5. 4. Review of the medical record revealed Resident #9 was admitted to the facility on [DATE], with diagnoses including Dementia, Hypertension, and Anxiety. Review of the annual MDS assessment dated [DATE], revealed a BIMS score of 5, which indicated Resident #9 was severely cognitively impaired and received antianxiety and antidepressants medications. Review of the Physician's Order dated 7/15/2025, revealed .Buspirone 5 mg .5:00 PM . Review of the Physician's Order dated 7/15/2025, revealed Zoloft [an antidepressant] 100 mg .bedtime . Review of the August 2025 MAR revealed the facility failed to monitor the side effects of psychotropic medications for Resident #9. Review of the September 2025 MAR revealed the facility failed to monitor the side effects of psychotropic medications for Resident #9. The facility was unable to provide side effect monitoring for Resident #9. During an interview on 9/11/2025 at 10:28 AM, the DON was asked should there be side effect monitoring for the use of Antianxiety, Antidepressants, and Antipsychotic medications on the August 2025 MAR and the September 2025 MAR for Resident #5 and Resident #9. The DON stated, .Yes .should be monitored every shift .someone failed to put the order in .

Based on policy review, observation, and interview, the facility failed to ensure food was stored, handle, prepared, and served under sanitary conditions, when food was found opened and undated, and dirty cooking utensils were found on the floor. The census was 52 with 49 residents receiving a meal tray from the kitchen. The findings include: 1. Review of the facility policy titled, Food Storage, dated 1/14/2024, revealed .Date marking to indicate the date or day by which a ready-to-eat, potentially hazardous food should be consumed, sold, or discarded will be visible on all high risk foods.Each item is clearly labeled and dated before being refrigerated. Review of the facility undated policy titled, Cleaning Dishes/Dish Machine, revealed .All flatware, serving dishes, and cookware will be washed, rinsed, and sanitized after each use. Observation and interview during the initial tour in the kitchen on 9/8/2025 at 9:15 AM, revealed the Certified Assistant Dining Director confirmed that open food items should be labeled and dated when the following items were observed in the reach-in freezer: 1 open and undated box of salted butter chips 1 open and undated 12 ounce (oz) bottle of water 1 open and undated box of assorted popsicles Observation during the initial tour in Care Base 1 Rehab dining room on 9/8/2025 at 9:37 AM, revealed the following in the reach-in cooler: 1 open and undated 32-oz carton of ocean spray 100 precent (%) pineapple1 open and undated 46-oz carton of thick and easy clear hydrolyte thickened water with a mint of lemon 1 open and undated 46-oz carton of thickened iced tea 1 open and undated 56-oz bottle of orange juice 1 open and undated 46-oz carton of (Named Brand) 100% grape juice 1 open and undated 46-oz carton of cranberry juice cocktail During the initial tour in Care Base 3 Long Term Care (LTC) dining room on 9/8/2025 at 9:52 AM, revealed the following in the reach-in cooler: 1 open and undated 46-ounce carton of cranberry juice cocktail1 open and undated 56-ounce plastic bottle of orange juice 1 open and undated 32-ounce carton of scrambled egg mix liquid Observation in the ice cream freezer on 9/8/2025 at 5:15 PM, revealed the following: one 3-gallon container of open and undated vanilla bean ice cream Observation in the kitchen on 9/9/2025 at 10:50 AM, revealed the following 2 large cooking pots with red sauce substance inside the covering1 colander on the floor 3 large3 large (Named) containers on the floor 1 open and undated 5-pound bag of breaded okra 1 open and undated 16-ounce container of ground cayenne pepper 1 open and undated 7-ounce container of thyme leaves 1 open and undated 15-ounce container of ground cloves 1 open and undated 4-ounce container of whole tarragon During an interview on 9/10/2025 at 5:06 PM, the Certified Assistant Dining Director was asked should dirty cooking dishes be on the floor. The Certified Dietary Manager stated, .No, they should not have been on the floor.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure the environment was free from accident hazards when unsecure sharps were observed in 4 of 56 (Residents #2, #12, #29, and #42) sampled residents' rooms. The findings include: 1. Review of the facility policy titled, Sharps Disposal, dated 1/2001, revealed .The facility shall discard contaminated sharps into designated containers.Whoever uses contaminated sharps will discard them immediately or as soon as feasible into designated containers.Contaminated sharps will be discarded into container that are .Closable, Puncture resistant, Leakproof on sides and bottom, Labeled or color-coded in accordance with our established labeling system. 2. Review of the Medical Record revealed Resident #2 was admitted to the facility on [DATE], with diagnoses including Dementia, Hypertension, Falls, Anxiety, and Depression. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 2, which indicated Resident #2 was severely cognitively impaired. Resident #2 required assistance with Activities of Daily Living skills (ADLs). Observations in the Resident's room on 9/8/2025 at 9:30 AM, revealed an open package of 5 disposable razors on the Resident #2's bathroom sink. Observation and interview in Resident #2's room on 9/8/2025 at 9:45 AM, revealed Licensed Practical Nurse (LPN) D was asked should razors be left unattended and unsecured in the resident's room. LPN D stated razors should be stored in the storage room and disposed of in the sharps container once they have been used. 3. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, Repeated Falls, Parkinson's Disease, Muscle Weakness, and Assistance with Personal Care. Review of the admission MDS dated [DATE], revealed a BIMS score of 13, indicating Resident #12 was cognitively intact. Resident #12 required set-up assistance of staff with personal hygiene. Observations in the Resident's room on 9/8/2025 at 9:45 AM revealed an open package of 5 disposable razors on Resident #12's bathroom sink. Observation and interview in Resident #12's room on 9/8/2025 at 9:50 AM, revealed LPN D was asked should razors be left unattended and unsecured in the resident's room. LPN D stated razors should be stored in the storage room and disposed of in the sharps container once they have been used. 4. Review of the medical record revealed Resident #29 was admitted to the facility on [DATE], with diagnoses including Pulmonary Edema, Anxiety, Kidney Disease, Pacemaker, and Heart Failure. Review of the admission MDS dated [DATE], revealed a BIMS score of 15, indicating Resident #29 was cognitively intact. Resident #29 required set-up assistance of staff with personal hygiene. Observation in Resident #29's room on 9/8/2025 at 9:25 AM revealed an open package of 8 disposable razors on Resident #29's bathroom sink. Observation and interview in Resident #29's room on 9/8/2025 at 9:30 AM, revealed LPN D was asked should razors be left unattended and unsecured in the resident's room. LPN D stated razors should be stored in the storage room and disposed of in the sharps container once they have been used. 5. Review of the medical record revealed Resident #42 was admitted to the facility on [DATE], with diagnoses including Anxiety, Depression, Dementia, Hypertension, and Kidney Failure. Review of the admission MDS revealed the MDS was incomplete due to resident admitting on 9/3/2025 and it was not yet due to be completed. Observation in Resident #42's bathroom on 9/8/2025 at 9:12 AM, revealed an open package of 4 razors on the counter, 1 razor on the counter, and 1 razor in the wash basin on the bathroom counter. Observation and interview in Resident #42's bathroom on 9/8/2025 at 9:30 AM, revealed LPN D was asked should razors be left unattended and unsecured in the resident's room. LPN D stated razors should be stored in the storage room and disposed of in the sharps container once they have been used. During an interview on 9/10/2025 at 3:02 PM, the Director of Nursing (DON) was asked if razors should be left unattended in the resident's bathrooms. The DON stated that razors should be stored in the storage room and not be left in resident's rooms unattended and if they have been used, they should be disposed of in the biohazard sharps container after use.

Based on policy review, observation, and interview, the facility failed to ensure medications were properly stored and secured for 2 of 5 (Resident #5 and #23) residents observed when 2 of 5 (License Practical Nurse (LPN) A and LPN C) staff members left a medication unattended and out of sight during medication pass and a random observation. The findings include: 1. Review of the facility's policy titled, Medication Storage, dated 12/19/2023, revealed .It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms .sufficient to ensure proper sanitation, temperature .and security .During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart . Review of the facility policy titled, Nebulizer Therapy, dated 12/19/2023, revealed .It is the policy of this facility for nebulizers treatments, once ordered, to be administered by nursing staff as directed using proper technique and standard precautions.observe resident during the procedure for any change in condition . 2. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE], with diagnoses including Atrial Fibrillation, Dyspnea, and History of Pulmonary Embolism. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated Resident #5 had intact cognition. Review of the Physician Order dated 9/2/2025, revealed .Ipratropium-albuterol [breathing treatment in the form of a fine mist, used to improve breathing] 0.5 mg [milligram]-3 mg/(per)3 mL [milliliters] .Nebulizer Solution Inhalation .four times a day . Observation in Resident's #5 room on 9/8/2025 at 4:33 PM, revealed Resident #5 in the room, the nebulizer machine (used to turn liquid medication into a fine mist) turned on and a mask on Resident #5's face. There was no nurse at the bedside while Resident #5 received the breathing treatment. During an interview on 9/8/2025 at 4:35, LPN C confirmed she should not have left the resident alone while the resident received the breathing treatment. During an interview on 9/11/2025 at 11:44 AM, the Director of Nursing (DON) confirmed the nurse should stay in the room the entire time while the resident is receiving the breathing treatment to make sure the resident is tolerating the treatment. 3. Review of the medical record revealed Resident #23 was admitted to the facility on [DATE] with diagnoses including Dementia, Congestive Heart Disease, Diabetes, and Chronic Pulmonary Edema. Review of the Physician Order dated 8/22/2025, revealed .Insulin Lispro [medication used to decrease blood sugar levels] .100 unit/ml . four times per day . The insulin dosage was based on the results of the resident's blood sugar and a sliding scale (range of results). If the blood glucose results were less than 70 refer to the Hypoglycemic Protocol, if 70-149 hold the insulin, if 150 thru 199 give 2 units, if 200 thru 249 give 3 units, if 250 thru 299 give 4 units, if 300 thru 349 give 5 units, and if greater than 349 give 6 units. Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 2, which indicated Resident #48 had severe cognitive impairment. The resident had a diagnosis Type 2 Diabetes Mellitus. Observation and interview at the Care Base 3 medication cart on 9/9/2025 beginning at 12:15 PM, revealed LPN A removed the glucometer from the top drawer, gathered the blood glucose meter and supplies, and walked down the hall to Resident #23's room. LPN A left Resident #23's room to retrieve the Resident from the dining room and assisted him to his room. She went to the Care Base 3 medication cart gathered the insulin pen and supplies. LPN A went back to the Resident's room and administered the insulin. LPN A laid the insulin pen on the barrier next to the glucometer in the Resident's room and left the room to assist Resident #23 back to the dining room. LPN A left the insulin pen out of sight and unattended when she went down the hallway to the dining room. During an interview on 9/10/2025 at 4:55 PM, the DON was asked should the nurses leave medications out of sight and unattended. The DON stated, No, Ma'am.

Based on review of the National Pressure Injury Advisory Panel (NPIAP) Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] #16) reviewed with in-house acquired pressure ulcers. The facility's failure to provide preventative treatment, identification, assessment, reporting, and appropriate treatment resulted in actual Harm for Resident #16. The findings include: Review of the National Pressure Injury Advisory Panel (NPIAP) Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .Conduct a comprehensive skin and tissue assessment for all individuals at risk of pressure injuries: As soon as possible after admission/transfer to the healthcare service .As a part of every risk assessment .Periodically as indicated by the individual's degree of pressure injury risk Unstageable: Depth unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth and therefore Category/Stage, cannot be determined. Stable (dry, adherent, intact without [CONDITION(S)] or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed .Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even without optimal treatment . Review of the facility's undated policy titled, .Skin Assessment, dated 2/24/2021, revealed .It is our policy to perform a full body skin assessment as part of our systematic approach to pressure injury prevention and management .A full body .skin assessment will be conducted .The assessment may also be performed after a change of condition or after any newly identified pressure injury .Thoroughly inspect each surface of a skin fold . Review of the facility's undated policy titled, .Wound Treatment Management, revealed .To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .the facility will follow specific physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .treatments will be monitored through ongoing assessment of the wound . Review of the medical record, revealed Resident #16 was admitted to the facility on [DATE] with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #16 had severely impaired cognition, was totally dependent on staff for Activities of Daily Living (ADLs), was always incontinent of bladder and bowel, was at risk for pressure ulcers, had 3 unstageable pressure ulcers, and 1 deep tissue injury pressure ulcer. Review of a quarterly Braden Scale dated 4/12/2022, revealed Resident #16 was at risk for developing pressure ulcers. Review of the undated Care Plan revealed .I have a pressure ulcer .Addition pressure ulcers form brace that was ordered .Right medial knee. 5/19/22-foul odor noted from R medial knee wound .Right lateral knee .Right posterior leg with 3 wounds .DTI-right heel . Review of a Physicians' Order dated 4/6/2022, revealed .Okay to remove brace from Right Knee for bathing. Apply brace on the outside clothing to the right upper leg . Review of the Physicians' Order dated 4/22/2022, revealed .DC [discontinue] brace Resident to stay in bed at all times . Review of the Physicians' Orders dated 5/13/2022, revealed .Wound Care Mon [Monday] & [and] Fri [Friday] R [right] post [posterior] thigh .R Heel .R medial Knee .R lateral Knee . Review of the Physicians' Orders dated 5/19/2022, revealed [MEDICATION(S)] 875 mg[milligrams]/125 PO [by mouth] BID [twice day] x [times] 10 d [day] .wound infec [infection] .[MEDICATION(S)] 50 mg PO TID [three times day] x 10 d . Review of the Interdisciplinary Notes dated 4/4/2022, .Returned to facility .from [Named Hospital] .Brace to Rt [right] leg in place . Review of the Interdisciplinary Notes dated 4/6/2022, .Possible DTI [deep tissue injury] noted to right heel . Review of the Interdisciplinary Notes dated 4/22/2022, .resident has 5 new wounds noted under leg brace. Addressed by wound care MD [medical doctor] .MD wish for brace to remain off at this time . Review of the Wound Flow Sheet. Dated 4/22/2022, revealed .DTI [deep tissue injury] .R [right] heel 3.4 x [times] 2.5 x 0.1 .DTI .R distal Lg [leg] 1.4 x1 x0 x 0 .R distal Lg 6 x 4 x 0 .R distal Lg 1.8 x 0.5 x 0 .R Knee Lateral 2.8x2 x 9 x 0 .R medial Knee 4.5x2.8x0.1 . Review of the Interdisciplinary Notes dated 4/29/2022, revealed .Resident seen by [Named Wound Care MD] .Wound to right lateral knee was a fluid filled blister measuring 3x2.5x2.1 .Wound cleansed .calcium alginate applied and covered .Wound to right knee medial measured 4x2x0.1 .Calcium alginate .applied and covered with bordered gauze .Wound to right posterior foot measured as cluster of 3 as 5x3x0.1 .Wound to right heel measured 4x3x0 .wound bed is becoming eschar .apply iodosorb paste [topical treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Interdisciplinary Notes dated 5/27/2022, revealed .Resident seen by [Named Wound Care Doctor] During his assessment he noted that wound to R [right] pos [posterior] leg had tendon exposed .right heel has stable eschar .right thigh excoriations .Lateral Right knee remains dry with eschar .Right medial knee was denrided [debrided] and packed .right medial knee is looking better. Odor is gone. Resident remains on oral abx [antibiotic] for infection to right medial knee wound . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the [Named Wound Care MD] History and Physical Note dated 4/8/2022, revealed .right leg immobilizers in place .Right ft [foot] is floating .small medial heel deep tissue injury [DTI] .Applied [MEDICATION(S)] bandage with application of wound boots . Review of the [Named Wound Care MD] Progress Note, dated 4/15/2022, revealed .right heel wound .Deep tissue injury over heel continues to evolve, with formation of surface eschar .measure approximately 1.5 x 1.5x 0 cm [centimeters] .[MEDICATION(S)] dressing for protection, with recommendation to change twice a week . Review of the [Named Wound Care MD] Progress Note, dated 4/22/2022, revealed .On exam today, her right heel DTI has transition to eschar, measuring 3.4 x 2.5 x 0.1 .has 5 new sites of pressure injury, 3 on the posterior leg measuring .1.4 x 1 x 0 cm; 6 x 4 x 0 cm; 1.8 x 0.5 x 0 cm. All have formation of eschar .has 2 proximal [CONDITION(S)] that have blistered near her knee measuring .Right knee lateral, 2.8 x 2.9 x 0 cm .right knee medial 4.5 x 2.8 x 0.1 cm .with recommendations to maintain [MEDICATION(S)] protection .remove her knee immobilizer give contribution of this to her pathology .remain bedbound . Review of the Product Insert for DeRoayal Knee Immobilizer [Knee Immobilizer (deroyal.com)] revealed .The knee immobilizer should fit, generally. 2 [symbol for inches] above ankle bones and 2 below groin. Any longer could result in abnormal wear and skin pressure . The facility was unable to provide orders for treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility provided shower/skin observation sheet for 4/6/2022, 4/8/2022, 4/13/2022, 4/14/2022 and 4/25/2022. Review of the shower/skin observation sheets revealed no documentation of the knee immobilizer or the identified wounds or dressings. Observation in the resident's room on 9/21/2022 at 9:29 AM, with the Wound Care Physician revealed the right heel with thick dark eschar cap measuring 4.5 x 5.0 x 0.6 cm, the right outer ankle a newly identified unstageable DTI measuring 1.1 x 0.8 x 0 cm, and the back of the lower leg measuring 3.0 x 1.0 x 0.3 cm. Observation and interview in the resident's room on 9/22/2022 at 10:16 AM, revealed the Director of Therapy removed the knee immobilizer from Resident #16's closet and demonstrated the placement of the knee immobilizer. The Director of Therapy confirmed the knee immobilizer should be placed from the upper thigh to the mid-calf of the resident's leg for proper placement. During a telephone interview on 9/21/2022 at 2:31 PM, Licensed Practical Nurse (LPN) #1 confirmed she never removed the resident knee immobilizer she was not on her shift for the weekly skin assessment. LPN #1 confirmed the only time the immobilizer was taken off was with wound care. During an interview on 9/21/2022 at 4:36 PM, the Wound Care Nurse confirmed the nursing staff should have removed the knee immobilizer and assessed the resident's skin daily. Observation and interview on 9/22/2022 at 7:44 AM, the Administrator confirmed the staff members should monitor, treat, and assess a resident skin with a knee immobilizer. The Administrator confirmed the facility completed a PIP (Performance Improvement Program) on the pressure ulcers but was unable to provide documentation of the weekly audits, education with all staff members, and follow-ups. The Administrator confirmed the PIP was not effective and was not completed. Observation of the Quality Assurance and Performance Improvement (QAPI) minutes from April 2022, June 2022 and July 2022 there was no documentation of the PIP on wound management. The Administrator confirmed she is ultimately responsible for the staff to assure they are doing their jobs. Observation and interview on 9/22/2022 at 6:57 PM, the Director of Nursing (DON) confirmed there should be doctor orders to address each wound identified and should be reflected on the Medication Administration Records (MAR) for treatments. Observation of the April 2022 show sheets showed no documentation the knee immobilize. The DON confirmed she would expect the staff to remove the knee immobilizer to assess the skin for skin breakdown once a shift, that is the standard of practice for monitoring a resident with a knee immobilizer. During an interview on 9/22/2022 at 7:33 PM, the Quality Assurance Nurse confirmed there were no treatments on the MAR for the pressure ulcers identified on 4/22/202. The facility's failure to identify, assess, report, and provide treatment before newly identified skin changes and pressure ulcers deteriorated and progressed to Unstageable pressure ulcers resulted in actual Harm for Resident #16.

Based on policy review, observation, and interview, the facility failed to ensure food was served under sanitary. The facility had a census of 36 with 21 of those residents receiving a food tray from the Care Base 3 Kitchen. The findings include: Review of the facility's undated policy titled, Food Temperatures, revealed .To take temperatures, a clean, rinsed, sanitized .thermometer .is needed .read and record the temperature .and immediately clean and sanitize. Repeat these guidelines until all hot food temperatures have been taken . Review of the facility's undated policy titled, Food Storage Guidelines, revealed .3 days .open lunch/deli meats . Review of the facility's undated policy titled, Food Storage, revealed .All containers must be legible and accurately labeled and dated .date marking to indicate .discarded will be visible on all high risk foods . Observation in the Care Base 3 Kitchen on [DATE] at 12:06 PM, revealed Dietary Staff #1 removed a thermometer and cleaned it with a stained soiled dish towel that was lying on top of the steam table, inserted the thermometer into the green beans and then inserted the thermometer into the mushrooms. Dietary Staff #1 failed to clean the thermometer after acquiring the temperature for the green beans and before obtaining the temperature of the mushrooms. Dietary Staff #1 then inserted the same thermometer into the prime rib and obtained the temperature, walked over to the oven and took the temperature of the cheese grits. Dietary Staff #1 failed to clean the thermometer after using it for the prime rib and before using it in the cheese grits. Dietary Staff #1 then inserted the same thermometer into the bread pudding, wiped the thermometer off with a soiled dish towel, inserted the thermometer into the broccoli cheese soup and then cleaned the thermometer off with the same soiled dish towel. Observation in the Care Base 3 Kitchen reach in refrigerator by the steam table on [DATE] at 12:15 PM and 4:55 PM, revealed a gallon of fat free milk opened and dated [DATE] with a use by date of [DATE]. Observation in the Care Base 3 Kitchen reach in refrigerator by the dishwasher on [DATE] at 12:19 PM, revealed a plastic container of pineapple and cantaloupe with the plastic wrap pulled all the way back exposing the fruit. Observation in the Care Base 3 Kitchen reach in refrigerator by the dishwasher on [DATE] at 12:19 PM and 4:58 PM, revealed the following: a. A plastic container with 5 slices of turkey with an opened date of [DATE] b. One 12 oz (ounce) plastic bottle of Squeeze Butter opened and undated with a use by date of [DATE]. During an interview on [DATE] at 5:00 PM, the Certified Dietary Manager (CDM) confirmed all expired foods and milk should be thrown away. The CDM confirmed all foods should be labeled, dated, and covered properly in the refrigerators. The CDM confirmed when using a thermometer to check tray line temperatures, the thermometers should be cleaned and sanitized between each item.

Based on medical record review and interview the facility failed to ensure Care Plan conference meetings were held at least quarterly for 2 of 16 sampled residents (Resident #7 and #10) reviewed for care plan meetings. The findings include: Review of the medical record, revealed Resident #7 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #7 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's Interdisciplinary Care Plan Conference sheets revealed a care plan conference was held on 5/7/2021, 1/13/2022, and 6/16/2022. The facility failed to ensure a care plan conference was held quarterly in 8/2021, 11/2021, and 4/2022. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment dated [DATE], revealed Resident #10 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's Interdisciplinary Care Plan Conference sheets revealed a care conference was held on 9/24/2021, 1/19/2022, and 5/6/2022. The facility failed to ensure a Care Plan conference was held quarterly on 12/2021, 4/2022, and 8/2022. During an interview on 9/21/22 at 8:00 AM, the Social Services Director confirmed that care plan conferences with family and/or residents should be held at least quarterly. During an interview on 9/21/22 at 9:05 AM, the Director of Nursing (DON) confirmed that she expects all care planning conferences to be held at least quarterly and when the need arises for all residents.

Based on policy review, medical record review, and interview the facility failed to ensure pressure risk assessments were completed at least quarterly for 1 of 4 sampled residents (Resident #7) reviewed for pressure ulcers. The findings include: The facility's undated policy titled, Pressure Injury Risk Assessment, revealed .Pressure injury risk assessments will be conducted by a licensed or registered nurse on admission/readmission, weekly times four weeks, then quarterly . Review of the medical record, revealed Resident #7 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #7 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's Skin Evaluation Form dated 8/26/2022, confirmed Resident #7 developed a Stage 2 Pressure wound to her sacrum. Review of the facility's Braden Scale for Predicting Pressure Sore Risk assessments revealed Resident #7 was assessed for pressure ulcers on 10/13/2021 with no further risk assessment completed until 3/8/2022. Review of the facility's Braden Scale for Predicting Pressure Sore Risk assessments revealed the facility failed to complete a quarterly assessment in January 2022. Review of the facility's Braden Scale for Predicting Pressure Sore Risk assessments revealed the facility completed an assessment on 4/12/2022 with no further assessments completed. Review of the facility's Braden Scale for Predicting Pressure Sore Risk assessments revealed the facility failed to complete a quarterly assessment in July 2022. During an interview on 9/21/22 at 2:32 PM, the Director of Nursing (DON) confirmed that the pressure ulcer risk assessments should be completed on admission, readmission and quarterly. The DON confirmed that the assessments for Resident #7 should have been completed at least quarterly and when something arises.

Based on policy review, medical record review, and interview the facility failed to ensure vitals signs were taken for the use of an antihypertensive medication for 1 of 5 sampled residents (Resident #7) reviewed for unnecessary medication. The findings include: Review of the facility's undated policy titled, Medication Administration, revealed .Obtain and record vital signs, when applicable or per [by way of] physician orders .Medications requiring vital signs prior to administration .Antihypertensives . Review of the medical record, revealed Resident #7 was admitted to the facility on [DATE] with diagnoses of [CONDITION(S)], Long Term Use of Antithrombolytic, Anxiety and Depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was assessed with a Brief Interview for Mental Status of 7, indicating Resident #7 was severely cognitively impaired and was assessed with an active diagnoses of Hypertension. Review of the Physician Orders dated 6/08/2022 and signed on 8/20/2022 revealed, .[MEDICATION(S)]/HCTZ [[MEDICATION(S)]] 20-25 MG [milligrams] TAKE 1 TABLET BY MOUTH ONCE DAILY .HOLD FOR BP [blood pressure] < [less than] 100/60 OR HR [heart rate] <60 .THROUGH 09/30/22 .[MEDICATION(S)]-HCTZ [[MEDICATION(S)]] (medication for hypertension) 20-25 MG [milligrams] .ONCE DAILY .HOLD FOR BP [Blood Pressure] < [sign for less than] 100/60 or HR [heart rate] < 60 . Review of the July 2022 Medication Administration Record (MAR) revealed the antihypertensive medication was administered for 31 days and staff obtained the blood pressure on 1 of those 31 days. Review of the August 2022 MAR revealed the antihypertensive medication was administered for 29 days with no blood pressure and heart rates obtained. Review of the September 2022 MAR revealed the antihypertensive medication was administered for 19 days with no blood pressure or heart rates obtained. The facility failed to ensure staff obtained blood pressures and heart rates prior to administering a antihyerpertensive medication. During an interview on 9/22/22 at 8:52 AM, the Director of Nursing (DON) confirmed that the staff should have obtained the residents blood pressure and heart rate prior to administering the medication.

Based on medical record review and interview the facility failed to revise the comprehensive care plan to reflect the use of anticoagulant medication (blood thinning medication) for 1 of 5 sampled residents (Resident #15) reviewed for unnecessary medications. The findings include: Review of the medical record revealed Resident #15 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan dated 1/17/2022, and revised 6/20/2022, revealed there was no documentation Resident #15 received or was being monitored for side effects of anticoagulant medication use. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)] [a blood thinner] 5 MG [milligrams] .Twice Daily . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 9/21/2022 at 4:05 PM, the Minimum Data Set Coordinator confirmed the Care Plan should include the use of anticoagulant medications and the risks associated with its use.

Based on policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions when staff failed to perform proper hand hygiene and handle food properly in the Long Term Care Kitchen and failed to maintain food at the proper holding temperature in the Rehabilitation Kitchen. The facility had a census of 44 residents, with 19 of those residents receiving a meal from the Long Term Care Kitchen and 23 of those receiving a meal from the Rehabilitation Kitchen. The findings include: 1. Review of the facility's Hand Hygiene Table dated 2019 documented, .Either Soap and Water or Alcohol Based Hand Rub .Before applying and after removing personal protective equipment .including gloves . 2. Observations in the Long Term Care Kitchen on 8/12/19 at 11:55 AM revealed the following: a. Hospitality Staff #1 wearing gloves washed a knife at the sink, removed the gloves, donned clean gloves, and did not perform hand hygiene. b. Hospitality Staff #1 prepared a chef salad using her gloved hands to scoop out lettuce from a container which she placed on a plate. She then used the same gloved hand to scoop out ham from its container and placed it on the plate. She continued to use the same gloved hands to scoop the cheese out of its container and place it on the plate. Hospitality Staff #1 cut an egg up holding it with the same gloved hand and placed it on the plate. Hospitality Staff #1 did not change gloves, perform hand hygiene, or use utensils while preparing the chef salad and contaminated the lettuce, meat, cheese and egg when she used the same gloved hand to scoop out the food items from their individual containers. c. The Kitchen Supervisor picked up trash off of the floor and placed it in the garbage can with her right gloved hand. The Kitchen Supervisor removed the glove from the right hand, did not perform hand hygiene, and donned a clean glove. The Kitchen Supervisor then prepared a chef salad using the same gloved right hand to scoop lettuce from a container which she placed on a plate. She then used the same gloved hand to scoop ham from its container and placed it on the plate. She continued to use the same gloved hand to scoop the cheese from a container and placed it on the plate. The Kitchen Supervisor cut an egg into pieces holding it with the same gloved hand and placed it on the plate. The Kitchen Supervisor did not change gloves, perform hand hygiene, or use utensils while preparing the chef salad and contaminated the lettuce, meat, cheese and egg when she used the same gloved hand to scoop the food items from their individual containers. The Kitchen Supervisor removed her gloves and performed hand hygiene. She then picked up a condiment cup from a stack on the counter. The Kitchen Supervisor used that condiment cup to scoop salad dressing from a container. The Kitchen Supervisor's hand came in contact with the salad dressing as she dipped the condiment cup into the salad dressing. Observations in the Long Term Care Kitchen on 8/13/19 at 7:55 AM revealed the following: a. Hospitality Staff #2 handled a waffle with gloved hands and cut it up. Hospitality Staff #2 then removed her gloves, donned clean gloves, and did not perform hand hygiene prior to donning clean gloves. Hospitality Staff #2 took a piece of bread out of the bread bag and placed it in the toaster. b. Hospitality Staff #2 prepared a plate of food, removed the gloves and donned clean gloves without performing hand hygiene. c. Hospitality Staff #2 took a covered plate out of the warmer cabinet, removed the gloves and donned clean gloves without performing hand hygiene. Hospitality Staff #2 then began to handle a waffle with the same gloved hands. d. The Certified Dietary Manager (CDM) performed hand hygiene at the sink, used a clean paper towel to dry her hands, turned off the water with the same paper towel, and then continued to dry her hands with the contaminated paper towel. 3. Interview with the CDM on 8/14/19 at 1:07 PM in the Conference Room, the CDM was asked if staff should turn the water off with a paper towel and continue to dry their hands with the same paper towel. The CDM stated, No. The CDM was asked what staff should do when they removed dirty gloves and donned clean gloves. The CDM stated, Wash their hands. The CDM was asked if it was acceptable for staff to use gloved hands to touch each separately stored food item to prepare a chef salad wearing the same gloves. The CDM stated, No, I'd rather them use utensils . The CDM confirmed that staff should have used a ladle to obtain salad dressing and that staff's hands should not come in contact with the salad dressing. 4. Review of the facility's Food Temperatures policy documented, .hot foods stay above 135 degrees F (Fahrenheit) .during the portioning, transporting, and serving process . 5. Observations in the Rehabilitation Kitchen on 8/13/19 at 12:05 PM revealed prime rib with a holding temperature of 120. 6. Interview with CDM on 8/14/19 at 8:05 AM outside the Main Kitchen, the CDM was asked what the holding temperature for hot foods should be. The CDM stated, all warm food should be at 135 degrees.

Based on Caviwipes Directions for Use review, policy review, observation, and interview, 3 of 3 (Licensed Practical Nurse (LPN) #1, 2, and 3) nurses failed to ensure practices to prevent the potential spread of infection were maintained when glucometers (glucose testing machine) were not disinfected properly after use and hand hygiene was not performed properly during medication administration. The findings include: 1. Review of the CAVIWIPES .DIRECTIONS FOR USE . documented, .CaviWipes will clean and disinfect, when used as directed .Cleaning Instructions .Use one CaviWipes towelette to completely preclean surface .Use a second CaviWipes towelette to thoroughly wet the surface . 2. Reveiw of the facility's undated .Hand Hygiene policy documented, .All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors .Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice .Hand hygiene technique when using soap and water .Dry thoroughly with a single-use towel .Use towel to turn off the faucet . 3. Observations at the Care Base 1 Medication Cart on 8/13/19 at 11:37 AM revealed LPN #1 cleaned a glucometer with one CaviWipes towelette, allowed it to air dry, placed it in a cover, and placed the glucometer in the medication cart drawer. LPN #1 did not use a second CaviWipes towelette to clean the glucometer. Observations at the Care Base 1 Medication Cart on 8/13/19 at 4:57 PM revealed LPN #2 cleaned a glucometer with an alcohol pad and placed the glucometer in the medication cart drawer. LPN #2 did not use 2 CaviWipes towelettes to clean the glucometer. Observations in Resident #16's room during medication administration on 8/14/19 at 10:19 AM revealed LPN #3 performed hand hygiene at the sink four times during the medication administration. Each time LPN #3 performed hand hygiene she dried her hands with a paper towel, obtained a second paper towel to turn off the faucet, and then continued to dry her hands with the contaminated paper towels. Interview with the Assistant Director of Nursing (ADON) on 8/14/19 at 3:18 PM in the Conference Room, the ADON was asked the procedure for cleaning the glucometer. The ADON stated, They are supposed to clean with the wipes .after they use the glucometer, follow the directions . The ADON confirmed it was a two step process. The ADON confirmed it was not acceptable to use an alcohol pad to clean a glucometer. Interview with the Director of Nursing (DON) on 8/14/19 at 3:23 PM in the Conference Room, the DON was asked if staff should continue to dry their hands with the same paper towels that was used to turn the faucet off. The DON stated, That's not proper protocol.

Based on review of the GERIATRIC MEDICATION HANDBOOK, 13TH EDITION provided by the American Society of Consultant Pharmacists, medical record review, observation, and interview, the facility failed to ensure 1 of 3 (Licensed Practical Nurse (LPN) #1) nurses failed to administer medications free of significant medication errors. The findings include: 1. Review of the GERIATRIC MEDICATION HANDBOOK, 13TH edition provided by the American Society of Consultant Pharmacists documented, .DIABETES: INJECTABLE MEDICATIONS .[MEDICATION NAME] R .Regular insulin .ADMINISTRATION/COMMENTS .30 minutes prior to meals . 2. Medical record review revealed Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].[MEDICATION NAME] .Regular .Insulin 100 unit/mL (milliliter) .200-249 (blood glucose level) .5u (units) .Subcutaneous . Observations in Resident #24's room on 8/13/19 at 11:52 AM revealed LPN #1 administered [MEDICATION NAME] Regular Insulin 5 units subcutaneously to Resident #24 for a blood glucose level of 219. There was no meal or substantial snack offered until LPN #1 served a bowl of French Onion Soup to Resident #24 at 12:35 PM, 43 minutes after Resident #24 received the [MEDICATION NAME] Regular Insulin injection. The failure of the nurse to provide a meal or substantial snack within 30 minutes of administration of the [MEDICATION NAME] Regular Insulin resulted in a significant medication error. 3. Interview with the Director of Nursing (DON) on 8/14/19 at 4:07 PM in the Conference Room, the DON was asked when a meal or substantial snack should be given to a resident after the resident received [MEDICATION NAME] Regular Insulin. The DON stated, .within 15 to 20 minutes . The DON was asked if it was acceptable that Resident #24 was not served a meal or substantial snack within 30 minutes after he received the [MEDICATION NAME] Regular Insulin. The DON stated, No.

Based on policy review, Certified Nursing Assistant (CNA) training record review, and interview, the facility failed to ensure 2 of 8 (CNA #1 and 2) CNAs employed for a full year received at least 12 hours of in-service training. The findings include: 1. Review of the facility's In-Service Training Program, Nurse Aide policy revised (MONTH) (YEAR) documented, .Annual in-services must: a. Ensure the continuing competence of nurse aides; b. Be no less than 12 hours per employment year . 2. Review of the CNA In-service Hour Form revealed CNA #1 had a hire date of 11/2/17 and completed 7.25 in-service hours for the year, 4.75 hours less than the required 12 hours for the year. CNA #2 had a hire date of 9/20/17 and completed 8.75 in-service hours for the year, 3.25 hours less than the required 12 hours. 3. Interview with the Administrator on 8/12/19 at 3:42 PM in the Conference Room, the Administrator stated, .They (CNA #1 and #2) just didn't get them in. I have no explanation .

Based on policy review, new employee file review, and interview, the facility failed to ensure 2 of 8 (Certified Nursing Assistant (CNA) #3 and 4) employee files reviewed had a current certification/license. The findings include: 1. The facility's Licensed Nurse Credentialing and License Verification policy reviewed/revised [DATE] documented, .If the licensed nurse has not provided renewal information prior to his/her license's expiration date, the nurse may not work past midnight of the expiration date of his/her current license . 2. Review of the certification for CNA #3 revealed CNA #3's certification expired on [DATE]. Review of the Payroll Schedule documented CNA #3 had a hire date of [DATE] and worked in the facility 6 days between [DATE] and [DATE]. 3. Review of the certification for CNA #4 revealed CNA #4's certification expired on [DATE]. Review of the Payroll Schedule documented CNA #4 had a hire date of [DATE] and worked in the facility 42 days between [DATE] and [DATE]. 4. Interview with the Administrator on [DATE] at 7:38 AM in the Conference Room, the Administrator stated, There are 2 new hires who have certifications that have expired .We are transitioning HR (Human Resources) . Interview with the Director of Nursing (DON) on [DATE] at 9:55 AM in the Conference Room, the DON stated, .the Licensed Nurse Credentialing and License Verification policy is used for any staff that requires renewal of a license or certification so the CNA's certification would fall under here .

Based on policy review, observation and interview, the facility failed to ensure practices were maintained to prevent the potential spread of infection when 5 of 9 (Hospitality Associates #4, 5, 6 and 9 and Certified Nursing Assistant (CNA) # 7) staff members failed to perform proper hand hygiene during dining observations. The findings included: 1. The facility's Handwashing/Hand Hygiene policy, revised on (MONTH) (YEAR), documented, .Before and after direct contact with residents .After removing gloves .Before and after assisting a resident with meals .Dry hands thoroughly with paper towel and then turn off faucets with a clean, dry paper towel . Observations in the care base 3 dining room on 10/1/18 beginning at 12:13 PM, revealed Hospitality Associate #4 failed to perform hand hygiene after removing gloves, repeatedly. Observations in Resident #88's room on 10/1/18 at 12:20 PM, revealed CNA #7 served Resident #88 his lunch tray, washed her hands, dried her hands with a paper towel, and turned off the faucet with her bare hands. Observations in the care base 3 dining room on 10/1/18 at 12:37 PM, revealed Hospitality Associate #4 touched the trash can, removed her gloves and failed to perform hand hygiene. Observations in the care base 3 dining room on 10/1/18 at 12:40 PM, revealed Hospitality Associate #9 removed his gloves, performed hand hygiene at the sink, turned off the faucet with his bare hands, and wiped his hands on his pants. Observations in the care base 3 dining room on 10/2/18 at 5:10 PM, 5:16 PM, 5:18 PM, 5:21 PM, and 5:24 PM, revealed Hospitality Associate #5 performed hand hygiene at the sink and turned off the faucet with his bare hands. Observations in the care base 3 dining room on 10/2/18 at 5:12 PM, 5:14 PM, revealed Hospitality Associate #6 performed hand hygiene at the sink and turned off the faucet with his bare hands. Interview with the Certified Dietary Manager (CDM) on 10/03/18 at 8:46 AM, in the care base 1 dining room, the CDM was asked if it was acceptable for staff to turn off the faucet with their bare hands. The CDM stated, No .they should use a dry towel. The CDM was asked if staff members should wash their hands after removing their gloves. The CDM stated, Yes. The CDM was asked if the staff members should wash their hands between serving residents and after touching dirty objects. The CDM stated, Yes they should.

Based on policy review, medical record review and interview, the facility failed to send the ombudsman a notice of transfer or discharge for 3 of 3 (Resident #11, 38, and 90) sampled residents reviewed for transfer/discharge requirements and failed to complete a transfer form for 1 of 3 (Resident #38) sampled residents reviewed for transfer and discharge requirements. The findings included: 1. The facility's Transfer or Discharge, Emergency policy, revised on (MONTH) (YEAR), documented, .Prepare a transfer form to send with the resident . 2. Medical record review revealed Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].Transfer to ER (emergency room ) . Review of a facility Transfer Form dated 7/8/18 revealed Resident #11 was transferred to the hospital. The facility was unable to provide documentation the Ombudsman was notified Resident #11 was transferred to the hospital. 3. Medical record review revealed Resident #38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].Resident to D/C (discharge) (named psychiatric facility) on 8/13/18 . The facility was unable to provide documentation the Ombudsman was notified that Resident #38 was transferred to the hospital or a transfer form was completed. 4. Medical record review revealed Resident #90 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].Transport to (Named Hospital) for Eval (Evaluation) . The facility was unable to provide documentation the Ombudsman was notified Resident #90 was transferred to the hospital. Interview with the Administrator on 10/2/18 at 3:25 PM, in the conference room, the Administrator was asked for the transfer list for the Ombudsman. The Administrator stated, We have not been doing that. Interview with the Clinical Quality Coordinator on 10/03/18 at 2:47 PM, in the conference room, the Clinical Quality Coordinator was asked if it was acceptable not to complete a transfer form on discharge. The Clinical Quality Coordinator stated, No it's not acceptable.

Based on policy review, medical record review, observation and interview, the facility failed to have a complete and accurate medical record for pressure ulcers for 1 of 2 (Resident #90) sampled residents reviewed for pressure ulcers and failed to ensure medical information was kept private and confidential for 8 of 39 (Resident #20, 22, 91, 140, 141, 142, 188, and 238) sampled residents . The findings included: 1. Medical record review revealed Resident #90 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Interdisciplinary Notes dated 9/21/18 documented, .a red area to the crease of buttock area . The Skin Evaluation Form dated 9/21/18 documented, .Area noted to sacral/coccyx area with yellow adherent tissue . There were no wound measurements documented. The WEEKLY PRESSURE ULCER TRACKING LOG documented, Date of Onset 9/21/18 .Location on Body Sacral/Coccyx .Unstageable . There were 3 different wound assessments that contained descriptions of the same wound that were not similar. Interview with the Interim Director of Nursing (DON) on 10/3/18 at 2:20 PM, in the conference room, the Interim DON was asked if the wound documentation was accurate. The Interim DON stated, No. 2. The facility's Confidentiality of Personal and Medical Records policy, dated 9/20/18, documented, .This facility honors the resident's right to secure and confidential personal and medical records. This includes the right to confidentiality of all information contained in a resident's records, regardless of the form of storage or location of the record .8. Paper notes or reminders with resident's personal or medical information shall not be left unattended or viewable by unauthorized person's . Random observations outside the entrance of the facility on 10/3/18 at 1:15 PM, revealed 3 pages of the daily therapy schedule for Resident #20, 22, 91, 140, 141, 142, 188, and 238 personal information that included [DIAGNOSES REDACTED]. Interview with the Administrator on 10/3/18 at 1:17 PM, outside the entrance of the facility, the Administrator was asked if it was appropriate for resident's private and confidential information to be left out for the public to view. The Administrator stated, No it's not .

Based on policy review, medical record review, observation and interview, the facility failed to ensure 1 of 1 (Resident #11) residents received podiatry services. The findings included: The facility's Podiatry Services policy, revised 9/15/18, documented, .It is the policy of this facility, in accordance with residents' needs, to assist residents in obtaining routine podiatry care .The podiatric needs of each resident are identified through the physical assessment . Medical record review revealed Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 had severely impaired cognition, and required extensive to total assistance from staff for all activities of daily living. A physician's orders [REDACTED].May see podiatry as needed for routine foot and nail care . Observations in Resident #11's room on 10/3/18 at 10:23 AM, revealed Licensed Practical Nurse (LPN) #1 removed Resident #11's socks and inspected his toenails. Interview with LPN #1 on 10/3/18 at 10:27 AM, in Resident #11's room, LPN #1 was asked if Resident #11's toenails needed to be trimmed. LPN #1 stated, Yes. LPN #1 was asked about the process for getting a resident's nails trimmed. LPN #1 stated, When the nurse assesses the nails have gotten long they call the family and let them know .podiatry was here last week . LPN #1 confirmed Resident #11 should have been seen by podiatry last week. Interview with the Assistant Director of Nursing (ADON) on 10/3/18 at 10:44 AM, in the conference room, the ADON was asked if the family had been notified Resident #11 needed podiatry services. The ADON stated, .there's no documentation that the family was notified . The ADON confirmed Resident #11 should have had his nails trimmed.

Based on policy review, closed medical record review and interview, it was determined the facility failed to identify a pressure ulcer/sore before it became unstageable and failed to provide pressure ulcer treatments as ordered by the physician for 1 of 2 (Resident #63) sampled residents reviewed of the 2 residents included in stage 2 with pressure ulcers. The failure to identify a pressure ulcer/sore before it became unstageable and failure to provide treatments as ordered resulted in actual harm to Resident #63. The findings included: Review of the facility's pressure ulcer prevention and management policy documented, "...All risk factors are care planned with at least one intervention per risk factor... Positioning/pressure reduction devices are in place for residents with "actual" or "High Risk" skin breakdown... There is a care plan in place for all wounds for management and to prevent further development of wounds in "high risk" residents... All new facility acquired pressure areas will be investigated and include both the clinical/medical component and facility process... There is a care plan in place for all wound management and to prevent further development of wounds in "high risk" residents..." Closed medical record review for Resident #63 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with an assessment reference date (ARD) of 12/24/13 section M-Skin Condition documented, presence of stage I or higher Pressure Ulcer (PU), at risk for PU and presence of a stage 3 pressure ulcer with measurements of 3.5 by (x) 2.0 x 0.2. Review of the MDS with an ARD of 1/14/14 documented presence of a PU with measurements of 4.2 x 1.5 x 0.1 and as a pressure ulcer with deep suspected tissue injury. Review of a nursing admission assessment dated [DATE] documented, "...open area noted to sacrum and with suspected deep tissue injury..." Review of a "Skin Assessment Form" dated 12/17/13 documented, "...Category... Partial Thickness Wound... Type... Pressure Ulcer... Cleanse sacral wound with wound wash. Apply [MEDICATION NAME] oint (ointment). TID (three times daily) until healed. Apply border gauze 4X4 QD (daily) and prn (as needed) dislodgement..." Review of a Interdisciplinary Team (IDT) note dated 12/17/13 documented, "...Open area to sacral area with dark surrounding possible deep tissue injury..." Review of the Braden scale for predicting pressure sore risk dated 12/19/13 documented, "...If the resident total is 18 or less, consider him/her at risk for pressure ulcer development..." Resident #63's total Braden score was 17, indicating the resident is at risk for pressure sore development. Review of a physician's orders [REDACTED]. Review of a physician's orders [REDACTED]. Apply [MEDICATION NAME] ointment Tid (three times daily) until healed. Apply border gauze 4x4 QD (daily) & (and) PRN dislodgement..." Review of a physician's orders [REDACTED]. Pat dry apply [MEDICATION NAME] drsg (dressing) q (every) 2 days and prn..." Review of a physician's orders [REDACTED]. Change daily and PRN..." Review of Resident #63's sacral ulcer treatment records revealed the following: a. December 2013 - there was no documentation the treatment was done on 12/19, 12/20, 12/23, 12/25 and 12/26. b. January 2014 - there was no documentation the treatment was done on 1/4 and 1/5. c. February 2014 - there was no documentation the treatment was done on 2/18, 2/20 and 2/22. Review of a skin assessment dated [DATE] documented presence of a pressure ulcer to right upper buttocks - Stage 2 1.4 x 0.7 x 0.1. Review of a "Skin Assessment Form" dated 12/30/13 documented, "...Site... Buttock Right Upper... Category: Partial Thickness Wound... Type: Pressure Ulcer... Treatment: cleanse with wound wash and cover with [MEDICATION NAME] dressing qod (every other day) and prn..." Review of a skin assessment dated [DATE] documented, Buttocks midline pink/white/red in color: x 3 areas (1 large area to L (left) and 2 small areas to R (right) foul odor and brown drainage noted..." Review of a physician's orders [REDACTED]. Review of Resident #63's January 2014 treatment record for the right buttock pressure ulcer revealed there was no documentation the treatments were done on 1/6, 1/12, 1/13, 1/14, 1/18, 1/19 and 1/20. Review of a "Skin Assessment Form" dated 1/15/14 documented, "...Site... Buttock Left Upper... Category... Full thickness Wound... Type... Pressure... Treatment... cleanse, dry apply santyl ointment, cover with [MEDICATION NAME] gauze, 4x4 gauze, and cover with semiocclusive dressing and change qod..." Review of a physician's orders [REDACTED]. Review of the treatment records for the left buttock pressure sore revealed the following: a. January 2014 - there was no documentation the treatment was done on 1/18, 1/19 or 1/20. b. February 2014 - there was no documentation the treatment was done on 2/18, 2/20 and 2/22. Review of a" Follow up wound evaluation" dated 1/29/14 documented, "...R (right) lateral heel unstageable pressure ulcer; care ordered with enzymatic, to be reapplied daily..." Review of a physician's orders [REDACTED]. Review of the January 2014 treatment records for the right lateral heel pressure ulcer revealed there was no documentation the treatment was done on 1/30 or 1/31. Review of a weekly pressure ulcer tracking log dated 2/6/14 documented, "...(R) lat (lateral heel... stg (stage) 3...cont (continue) POC (plan of care)..." Review of a "Skin Assessment Form" dated 2/8/14 documented, "...Category... Partial Thickness Wound... Treatment... using wound cleanser, skin prep, santyl, gauze, 2x2 cover dressing... Cause... Pressure..." Review of a physician's orders [REDACTED]. Review of a physician's orders [REDACTED]. Apply Iodosorb gel to provide antimicrobial -sloughing action and support healing. Dressing is to be changed every day and as needed..." Review of the February 2014 treatment records for the right lateral heel pressure ulcer revealed there was no documentation the treatment was done on 2/19, 2/20 and 2/22. Review of "Skin Assessment Form" dated 12/17/13, 12/30/13, 1/3/14, 1/7/14, 1/15/14, 1/28/14, 2/8/14, 2/13/14 and 2/25/13 revealed there was no documentation related to the resident's right lateral ankle or the presence of a pressure ulcer. These included general skin checks that were done on 1/15/14, 2/8/14, 2/13/14 and 2/25/14. Review of a weekly pressure ulcer tracking log dated 3/28/14 had no documentation of a pressure ulcer to the resident's right heel. During an interview in the Director of Nursing's (DON) office on 4/15/14 at 8:20 AM, the DON was asked about the blanks on the resident's treatment record, resident's condition and development of in-house pressure ulcers. The DON stated, "There's a paper MAR/TAR (Medication Administration Record [REDACTED]. Some nurses think the paper MAR indicated [REDACTED]." The DON was then asked how do you determine where the documentation is actually done or if it's done. The DON stated, "No accurate answer for that. If it's not documented in either place and I was doing an audit I would say it's not done... When he was admitted on [DATE]th there was an area on his coccyx and on the 30th (December) there was an area on his right buttocks... I would expect the nurses to document treatments..." The DON was asked about the development of a Stage III on his right lateral heel. The DON stated, "Weekly skin assessments are done and it should have been documented as redness or something before it became a Stage 3..." The DON was shown the December 2013, January 2014 and February 2014 blank spaces on treatment records indicating treatments were not done. The DON verified the blank spaces on the treatment record. The failure to identify a pressure ulcer before it became unstageable and the failure to provide treatments as ordered resulted in actual harm to Resident #63.