Every finding on record at The Village at Orchard Ridge

Based on staff interview, facility document review, and clinical record review, the facility staff failed to implement a complete pneumococcal immunization program for five of five resident immunization reviews, Residents #6, #10, #12, #3, and #1. The findings include: 1. For Resident #6 (R6), the facility staff failed to obtain and document the resident's current pneumococcal immunization status. A review of R6's clinical record failed to reveal documentation regarding the resident's pneumococcal immunization status or documentation that R6 was offered the immunization. On 3/5/24 at 2:00 p.m., a request for R6's pneumococcal immunization information was made to the facility administration. On 3/6/24 at 8:04 a.m., ASM (administrative staff member) #2 (the director of nursing) provided an immunization record for R6 that documented the resident received a pneumococcal immunization on 1/1/2000. On 3/6/24 at 8:28 a.m., an interview was conducted with ASM (administrative staff member) #2. ASM #2 stated the former minimum data set coordinator was responsible for immunizations, but that person was no longer employed at the facility, and he had assumed the role. ASM #2 stated that when a resident is admitted , the staff is supposed to obtain information regarding his or her pneumococcal immunization status. ASM #2 stated that on 3/5/24, he reached out to the nurse practitioner, and she pulled the immunization record from the state immunization registry. On 3/6/24 at 11:42 a.m., ASM #1 (the administrator) and ASM #2 were made aware of the above concern. The facility policy titled, Pneumococcal Vaccine documented, 1. Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. 7. Administration of the pneumococcal vaccines or revaccinations will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of vaccination. 2. For Resident #10 (R10), the facility staff failed to obtain and document the resident's current pneumococcal immunization status. A review of R10's clinical record failed to reveal documentation regarding the resident's pneumococcal immunization status or documentation that R6 was offered the immunization. On 3/5/24 at 2:00 p.m., a request for R10's pneumococcal immunization information was made to the facility administration. On 3/6/24 at 8:04 a.m., ASM (administrative staff member) #2 (the director of nursing) provided an immunization record for R10 that documented the resident received a pneumococcal immunization on 2/13/19. On 3/6/24 at 8:28 a.m., an interview was conducted with ASM (administrative staff member) #2. ASM #2 stated the former minimum data set coordinator was responsible for immunizations, but that person was no longer employed at the facility, and he had assumed the role. ASM #2 stated that when a resident is admitted , the staff is supposed to obtain information regarding his or her pneumococcal immunization status. ASM #2 stated that on 3/5/24, he obtained the record from R10's former assisted living records. On 3/6/24 at 11:42 a.m., ASM #1 (the administrator) and ASM #2 were made aware of the above concern. 3. For Resident #12 (R12), the facility staff failed to offer the most updated pneumococcal immunization. A review of R12's clinical record revealed a head-to-toe assessment dated [DATE] that documented the resident had received a pneumococcal immunization but did not know the date received. Further review of R12's clinical record failed to reveal any further documentation regarding the pneumococcal immunization (including the date and type of pneumococcal immunization received). On 3/5/24 at 2:00 p.m., a request for R12's pneumococcal immunization information was made to the facility administration. On 3/6/24 at 8:04 a.m., ASM (administrative staff member) #2 (the director of nursing) presented an informed consent for pneumococcal vaccine (immunization) form for R12, dated 3/5/24 that documented, You are being offered the pneumococcal vaccine because it is recommended by the Advisory Committee on Immunization Practices for your age group to prevent pneumococcal disease. It is recommended that adults >[AGE] years old who have not previously received a pneumococcal conjugate vaccine or whose previous vaccination history is unknown should receive a pneumococcal conjugate vaccine (either PCV20 or PCV15). If PCV15 is used, this should be followed by a dose of PPSV23 at least one year later. On 3/6/24 at 8:28 a.m., an interview was conducted with ASM (administrative staff member) #2. ASM #2 stated the former minimum data set coordinator was responsible for immunizations, but that person was no longer employed at the facility, and he had assumed the role. ASM #2 stated there has been confusion about when a resident is supposed to receive the pneumococcal immunization [in regard to the updated Centers for Disease Control and Prevention guidelines] but he has looked into the current requirements and has now begun to offer the immunization based on the guidelines. On 3/6/24 at 11:42 a.m., ASM #1 (the administrator) and ASM #2 were made aware of the above concern. The CDC website documented, Pneumococcal Vaccination: Summary of Who and When to Vaccinate: Adults [AGE] years or Older Never Received Any Pneumococcal Vaccine For older adults who don't have an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak: Give 1 dose of PCV15 or PCV20. When PCV15 is used, it should be followed by a dose of PPSV23 at least 1 year later. Their vaccines will then be complete. When PCV20 is used, it does not need to be followed by a dose of PPSV23. Their vaccines are then complete. For older adults who have an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak: Give 1 dose of PCV15 or PCV20. When PCV15 is used, it should be followed by a dose of PPSV23 at least 8 weeks later. Their vaccines will then be complete. When PCV20 is used, it does not need to be followed by a dose of PPSV23. Their vaccines are then complete. Also applies to people who received PCV7 at any age and no other pneumococcal vaccines. Only Received PPSV23 Give 1 dose of PCV15 or PCV20 at least 1 year after the most recent PPSV23 vaccination. Regardless of vaccine given, an additional dose of PPSV23 is not recommended since they already received it. Their vaccines are then complete. Only Received PCV13 For older adults who don't have an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak: Give 1 dose of PCV20 or PPSV23 at least 1 year after PCV13. Regardless of vaccine used, their vaccines are then complete. For older adults who have an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak: Give 1 dose of PCV20 or PPSV23. Regardless of vaccine used, their vaccines are then complete. The PCV20 dose should be given at least 1 year after PCV13. The PPSV23 dose should be given at least 8 weeks after PCV13. This information was obtained from the website: https://www.cdc.gov/vaccines/vpd/pneumo/hcp/who-when-to-vaccinate.html. 4. For Resident #3 (R3), the facility staff failed to offer the most updated pneumococcal immunization. A review of R3's clinical record revealed R3 received the Prevnar 13 (PCV13) pneumococcal immunization on 8/3/15. Further review of R3's clinical record failed to reveal any further documentation regarding the pneumococcal immunization. On 3/5/24 at 2:00 p.m., a request for R3's pneumococcal immunization information was made to the facility administration. On 3/6/24 at 8:04 a.m., ASM (administrative staff member) #2 (the director of nursing) presented an informed consent for pneumococcal vaccine (immunization) form for R3, dated 3/5/24 that documented, You are being offered the pneumococcal vaccine because it is recommended by the Advisory Committee on Immunization Practices for your age group to prevent pneumococcal disease. It is recommended that adults >[AGE] years old who have not previously received a pneumococcal conjugate vaccine or whose previous vaccination history is unknown should receive a pneumococcal conjugate vaccine (either PCV20 or PCV15). If PCV15 is used, this should be followed by a dose of PPSV23 at least one year later. On 3/6/24 at 8:28 a.m., an interview was conducted with ASM (administrative staff member) #2. ASM #2 stated the former minimum data set coordinator was responsible for immunizations, but that person was no longer employed at the facility, and he had assumed the role. ASM #2 stated there has been confusion about when a resident is supposed to receive the pneumococcal immunization [in regard to the updated Centers for Disease Control and Prevention guidelines] but he has looked into the current requirements and has now begun to offer the immunization based on the guidelines. On 3/6/24 at 11:42 a.m., ASM #1 (the administrator) and ASM #2 were made aware of the above concern. 5. For Resident #1 (R1), the facility staff failed to offer the most updated pneumococcal immunization. A review of R1's clinical record revealed R1 received the Prevnar 13 (PCV13) pneumococcal immunization on 10/19/16. Further review of R1's clinical record failed to reveal any further documentation regarding the pneumococcal immunization. On 3/5/24 at 2:00 p.m., a request for R1's pneumococcal immunization information was made to the facility administration. On 3/6/24 at 8:04 a.m., ASM (administrative staff member) #2 (the director of nursing) presented an informed consent for pneumococcal vaccine (immunization) form for R1, dated 3/5/24 that documented, You are being offered the pneumococcal vaccine because it is recommended by the Advisory Committee on Immunization Practices for your age group to prevent pneumococcal disease. It is recommended that adults >[AGE] years old who have not previously received a pneumococcal conjugate vaccine or whose previous vaccination history is unknown should receive a pneumococcal conjugate vaccine (either PCV20 or PCV15). If PCV15 is used, this should be followed by a dose of PPSV23 at least one year later. On 3/6/24 at 8:28 a.m., an interview was conducted with ASM (administrative staff member) #2. ASM #2 stated the former minimum data set coordinator was responsible for immunizations, but that person was no longer employed at the facility, and he had assumed the role. ASM #2 stated there has been confusion about when a resident is supposed to receive the pneumococcal immunization [in regard to the updated Centers for Disease Control and Prevention guidelines] but he has looked into the current requirements and has now begun to offer the immunization based on the guidelines. On 3/6/24 at 11:42 a.m., ASM #1 (the administrator) and ASM #2 were made aware of the above concern.

Based on observation, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to review and revise the comprehensive care plan for one of 17 residents in the survey sample; Resident #8. The findings include: For Resident #8, the facility staff failed to review and revise the comprehensive care plan for the use of side rails. On 3/05/24 at 8:23 AM, Resident #8 was observed in bed with bilateral padded grab bars up. A review of the clinical record revealed Side Rail Assessment forms dated 9/19/22, 12/19/22 and 3/19/23. The first two documented that side rails were recommended and the one dated 3/19/23 documented that side rails were not recommended. A review of the comprehensive care plan revealed one dated 9/20/22 for (Resident #8) is high risk for falls r/t (related to) Gait/balance problems, poor safety awareness. This care plan included an intervention dated 9/20/22 for The resident needs a safe environment with 1/4 Side rails as ordered This intervention was resolved on 3/1/23 and was not part of the current care plan. Further review of the clinical record revealed additional Side Rail Assessment forms dated 6/21/23, 9/22/23, and 12/25/23. These assessments documented that the use of a side rail was recommended for Resident #8. Further review of the comprehensive care plan failed to reveal any evidence that it was reviewed and revised to reinstate the use of side rails for Resident #8 after the above assessments documented that they were recommended again. On 3/6/24 at approximately 8:30 AM, an interview was conducted with ASM #2 (Administrative Staff Member) the Director of Nursing, who stated he was responsible for developing, reviewing and revising care plans. He stated that the use of side rails should be on the care plan. He stated that he was not sure why it was not on the care plan. He stated that the purpose of the care plan was to be a blue print of care that is provided to the resident. He stated that anybody who looks at it should have an idea how the resident is cared for. The facility policy, Care Plans - Comprehensive Person-Centered documented, An comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident Assessments of residents are ongoing and care plans are revised as information about the residents and the residents ' conditions change No further information was provided by the end of the survey.

Based on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to follow professional standards of practice for administering medications for one of 17 residents in the survey sample, Resident #19. The findings include: For Resident #19 (R19), the facility staff failed to administer Simvastatin (1) as ordered by the physician. On 3/5/24 at 9:21 a.m., R19 was interviewed. She stated she did not think she had received all her correct medications when she was first admitted to the facility. A review of R19's clinical record revealed the following order, dated 2/22/24 (the date of R19's admission): Simvastatin Oral Tablet 10 MG (milligrams) (Simvastatin) (1) Give 1 tablet by mouth at bedtime for Hyperlipidemia (high fat levels in the blood). A review of R19's 2/22/24 MAR (medication administration record) revealed no evidence that Simvastatin was administered as ordered in the evening on 2/22/24. A review of R19 progress notes revealed the following note dated 2/22/24 at 11:56 p.m.: Simvastatin .not available. A review of the facility's list of medications always available in a back-up supply at the facility included Simvastatin 5 mgs. On 3/6/24 at 9:22 a.m., RN (registered nurse) #1 was interviewed. When asked what steps she would take if a medication for a resident was not available in the resident's supply, she stated she would check the back-up supply. She stated if the medication is stocked in the back-up supply, she would pull it and administer it to the resident. After reviewing R19's February 2024 MAR and progress notes, she stated: It doesn't look like it was given. I assume the back-up supply did not include this medication. On 3/6/24 at 11:42 a.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. A review of the facility policy, Medication Management, failed to reveal information regarding the use of the facility's back-up medication supply in case a medication is not available for administration at the time it is due. No further information was provided prior to exit. References (1) Simvastatin is used together with diet, weight-loss, and exercise to reduce the risk of heart attack and stroke and to decrease the chance that heart surgery will be needed in people who have heart disease or who are at risk of developing heart disease. Simvastatin is also used to decrease the amount of fatty substances such as low-density lipoprotein (LDL) cholesterol (''bad cholesterol'') and triglycerides in the blood and to increase the amount of high-density lipoprotein (HDL) cholesterol (''good cholesterol'') in the blood. This information is taken from the website https://medlineplus.gov/druginfo/meds/a692030.html#:~:text=Simvastatin%20is%20in%20a%20class,other%20parts%20of%20the%20body.

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to follow physicians' orders to promote the highest level of well-being for two of 17 residents in the survey sample, Residents #20 and #10. The findings include: 1. For Resident #20 (R20), the facility staff failed to obtain daily weights as ordered by the physician. A review of R20's clinical record revealed he was admitted with diagnoses including congestive heart failure and edema (swelling). A review of R20's physician's orders revealed an order dated 3/1/24 for daily weights related to his congestive heart failure. Further review of R20's clinical record revealed no evidence of a weight on 3/1/24 or 3/2/24. On 3/6/24 at 9:22 a.m., RN (registered nurse) #1 was interviewed. She stated the CNAs (certified nursing assistants) usually get the daily weights when the nurse asks them to do so, and the nurse is responsible for documenting them. She stated if a resident is on daily weights due to excessive fluid or heart failure, there is a risk of the resident becoming fluid overloaded or the heart working too hard if the resident shows a daily weight gain. On 3/6/24 at 11:42 a.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. A review of the facility policy, Physician Orders, revealed no information related to the necessity of following a physician's order to prevent fluid overload. No further information was provided prior to exit. 31753 2. For Resident #10 (R10), the facility staff failed to position the resident with pillows in a chair, per a physician's order. R10's comprehensive care plan dated 7/9/21 failed to document specific information regarding positioning in a chair. A review of R10's clinical record revealed a physician's order dated 1/26/23 that documented. Please ensure resident is properly positioned in chair with pillow supporting legs and (R) (right) side. Verbal cuing to CNAs (certified nursing assistant) regarding use of pillows to properly position resident every day shift related to ALZHEIMER'S DISEASE. R10's March 2024 treatment administration record documented the same physician's order and was signed by LPN (licensed practical nurse) #1 on 3/5/24. On 3/5/24 at 11:52 a.m., R10 was observed sitting in a chair in the dining room. R10's feet were touching the floor, and no pillows were observed positioning the resident's legs or right side. On 3/5/24 at 3:13 p.m., an interview was conducted with CNA #1 (the CNA caring for Resident #10). CNA #1 stated the need for positioning devices are communicated to the nurses via physician's orders then the nurses review this with the CNAs. CNA #1 stated she was not aware of the physician's order for R10's positioning with pillows in the chair and she did not position the resident with pillows in the chair. On 3/5/24 at 3:23 p.m., an interview was conducted with LPN (licensed practical nurse) #1 (the nurse caring for R10). LPN #1 stated he was an agency nurse and only comes to the facility on ce in a while when needed. LPN #1 stated he was not aware of the physician's order for R10's positioning with pillows in the chair. LPN #1 stated he had just signed the treatment administration record. On 3/6/24 at 11:42 a.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Physician Orders Policy failed to document specific information regarding the implementation of physician's orders.

Based on observation, clinical record review, staff interview and facility document review, it was determined that facility staff failed to implement infection control practices to prevent the spread of infection and communicable disease for one of 13 residents in the survey sample, Resident # 1. The facility staff failed to ensure a visitor from outside the facility was using the appropriate PPE during an end of life visit to Resident # 1 who was under end of life care. The findings include: On 06/18/2020 at 1:45 p.m., an observation of Resident # 1's room revealed a guest sitting in a chair in Resident # 1's room next to their bed. Observation of the guest revealed they were wearing a gown. There was no evidence of the guest wearing gloves or a mask. On 06/18/2020 at 1:45 p.m., an interview was conducted with LPN (licensed practical nurse) # 1, infection control coordinator. When asked to describe the procedure that guest should follow when visiting a resident, LPN # 1 stated that guest cannot visit due to the COVID-19 outbreak. When asked about Resident # 1 having a visitor, LPN # 1 stated that they were under end of life care. OSM # 1 further stated that residents who are at end of life care are allowed visitors as long as they go through the screening process before coming into the facility and that they wear full PPE (personal protective equipment) that includes gown, gloves and mask. At 1:51 p.m., an observation was conducted with LPN # 1 and this surveyor of Resident # 1 room. LPN # 1 stated that the visitor was a family member and further stated that they were not wearing the appropriate PPE. When asked what Resident #1's visitor should be wearing, LPN # 1 stated that they should have had gloves and a mask on. When asked if this observation was an infection control concern, LPN # 1 stated yes. LPN # 1 then approached the visitor and asked them to put on the appropriate PPE. Resident # 1 was admitted to the facility with [DIAGNOSES REDACTED]. Resident # 1's most recent MDS (minimum data set), was not due at the time of the survey. The facility's admission assessment for Resident #1 dated 06/08/2020 documented orientation to person, place and time and requiring assistance with ADLs (activities of daily living). The baseline care plan for Resident # 1 dated 06/08/2020 documented in part, Focus: (Name of Resident #1) has elected Hospice services. Date Initiated; 6/08/2020. The POS 'physician's orders [REDACTED]. Order Date: 06/08/2020. The facility's policy COVID-19 Visitation Policy documented in part, The facility will restrict visitation of all visitors and non-essential health care personnel, except for certain [MEDICATION NAME] care situations, such as an end -of-life situation. In those cases, visitors will be limited to a specific room only. For individuals that enter in [MEDICATION NAME] situations (e.g. end-of-life care), the facility will require visitors to perform hand hygiene and use personal Protective Equipment (PPE), such as facemasks. Those visitors who are permitted, must wear a facemask while in the building and restrict their visit to the resident's room, or other location designated by the facility (such as a designated area by an entrance of the building, if possible for the visit to occur). The CDC (Center for Disease Control and Preparation) guidance dated May 19, 2020 documented in part, Preparing for COVID-19 in Nursing Homes. Implement Visitor Restrictions. Restrict all visitation to their facilities except for certain [MEDICATION NAME] care reasons, such as end-of-life situations. Send letters or emails pdf icon to families advising them that no visitors will be allowed in the facility except for certain [MEDICATION NAME] care situations, such as end of life situations. Use of alternative methods for visitation (e.g., video conferencing) should be facilitated by the facility. Post signs at the entrances to the facility advising that no visitors may enter the facility. Decisions about visitation for [MEDICATION NAME] care situations should be made on a case-by-case basis, which should include careful screening of the visitor for fever or symptoms consistent with COVID-19. Those with symptoms should not be permitted to enter the facility. Any visitors that are permitted must wear a cloth face covering while in the building and restrict their visit to the resident's room or other location designated by the facility. They should also be reminded to frequently perform hand hygiene. On 06/18/2020 at approximately 2:15 p.m., ASM (administrative staff member) #1, the administrator, was made aware of the findings. No further information was provided prior to exit.

Based on observation, staff interview and facility documentation review, it was determined the facility staff failed to store and prepare food and maintain kitchen equipment in a sanitary manner in 3 of 3 kitchens, main kitchen, country kitchen and sunshine kitchen. 1. The facility staff failed to store food in a safe and sanitary manner in the main kitchen. 2. The facility staff failed to store dishware in a safe and sanitary manner in the main kitchen. 3. The facility staff failed to sanitize a food thermometer prior to use. 4. The facility staff failed to monitor the dishwasher temperatures in the sunshine kitchen. 5. The facility staff failed to maintain kitchen equipment in a sanitary manner in the country and sunshine kitchens. The findings include: 1. The facility staff failed to store food in a safe and sanitary manner in the main kitchen. On [DATE] at 8:30 a.m., observation of the main kitchen was conducted. The following was observed: In the refrigerator: - A clear, closed container that contained shredded cheese. The container did not contain manufacturer's information. A facility sticker on the container documented a preparation date of [DATE] and a use by date of [DATE]. On [DATE] at 9:39 a.m., an interview was conducted with OSM (other staff member) #1 (the director of dining services). OSM #1 was asked about the facility process for storing and labeling food. OSM #1 stated that food is labeled for 30 days after being opened. OSM #1 stated that food may be labeled with a date sooner than 30 days if there are plans to use it. OSM #1 was asked about the container of shredded cheese that had a use by date of [DATE]. OSM #1 stated that the container of shredded cheese shouldn't have been in there. OSM #1 stated that a staff member discarded the container of shredded cheese. On [DATE] at 11:19 a.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Food Procurement and Storage Policy documented, Refrigerated food are labeled and dated and monitored for expiration, of which expired foods are discarded. No further information was presented prior to exit. 2. The facility staff failed to store dishware in a safe and sanitary manner in the main kitchen. On [DATE] at 8:30 a.m., observation of the main kitchen was conducted. The following was observed: - A dirty serving pan was on the top shelf rack with clean serving pans. The serving pan had dried food on the edges. On [DATE] at 12:15 p.m., the dirty serving pan was observed on another shelf on the rack and still had dried food on the edges. On [DATE] at 9:39 a.m., an interview was conducted with OSM (other staff member) #1 (the director of dining services). OSM #1 was asked the facility process for ensuring dishware was stored in a sanitary manner. OSM #1 stated that dishware should be ran through the dishwasher and sanitized at the dishwashing station. OSM #1 stated that after dishware is washed and sanitized, it air dries to prevent wet nesting and placed on shelf rack. OSM #1 stated the kitchen supervisor inspects dishware to ensure cleanliness prior to use. OSM #1 was asked what would happen if dirty dishes were found during inspection. OSM #1 stated, If dirty dishware was found during inspection, I would wash all the dishes to prevent cross contamination. OSM #1 stated, If the kitchen supervisor finds anything wrong during a kitchen inspection, education and/or disciplinary action will be provided. OSM #1 was made aware of the dirty serving pan being on the top shelf rack with clean serving pans. The kitchen supervisor was not available for interview during survey. On [DATE] at 11:19 a.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Food Procurement and Storage Policy did not document any information regarding storage of dishware. No further information was presented prior to exit. 3. The facility staff failed to sanitize a food thermometer prior to use. On [DATE] at 12:15 p.m., observation of the main kitchen was conducted. A dietary staff member was observed using an unsanitized digital food thermometer on a pan of beets. The pan of beets was the first food to be checked by the dietary staff member. After the dietary staff member removed the digital thermometer from the pan of beets, OSM (other staff member) #1 (the director of dining services) stepped in, sanitized the thermometer and finished taking temperatures on the remaining food. On [DATE] at 9:39 a.m., an interview was conducted with OSM #1. OSM was asked about the process for taking food temperatures. OSM #1 stated that food temperatures must be recorded after being cooked and prior to being served to residents. OSM #1 stated that food thermometers must be sanitized prior to obtaining food temperatures and between each food. OSM #1 was asked if it was appropriate to not sanitize the food thermometer between each food. OSM #1 stated, No. It must be done right every time. OSM #1 was made aware that the digital thermometer had not been sanitized prior to obtaining temperature on the pan of beets. OSM #1 stated that he was aware and that was the reason he took over obtaining temperatures on the remaining food products. OSM #1 stated that the dietary staff member who made the mistake was educated. The dietary staff member was not available for interview during survey. On [DATE] at 11:19 a.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Food Temperatures Policy documented, 1. The cook or assigned designee will take the temperature of food 15 minutes before meal service begins. 2. Proper food temperature taking requires sanitizing the thermometer between each food product probe. No further information was presented prior to exit. 4. The facility staff failed to monitor the dishwasher temperatures in the sunshine kitchen. On [DATE] at 12:30 p.m., observation of the sunshine kitchen was conducted. The dishwasher was observed without a temperature log. Dishware was observed inside the dishwasher. On [DATE] at 12:40 p.m., an interview was conducted with OSM (other staff member) #1 (the director of dining services). OSM #1 was asked about the temperature log for the dishwasher in the sunshine kitchen. OSM #1 stated, I have no idea what you are talking about. OSM #1 was asked who is responsible for obtaining temperatures on the dishwasher in the sunshine kitchen. OSM #1 walked to look at the dishwasher and stated that dining services is not responsible for obtaining temperature and he did not believe the dishwasher was in use. OSM #1 stated, I have been here less than 100 days and I am still trying to find my way around. OSM #1 was made aware that the temperature needed to be verified on the dishwasher during use. OSM #1 was asked if he had the necessary equipment to check the temperature on the dishwasher in the sunshine kitchen. OSM #1 stated, I know what equipment is needed to check the temperature on the dishwasher however, I don't believe I have it and will need to order it. On [DATE] at 8:00 a.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 was asked if the dishwasher in the sunshine kitchen was used. LPN #1 stated that the dishwasher is used sometimes. On [DATE] at 9:00 a.m., an interview was conducted with ASM (administrative staff member) #2 (the director of nursing). ASM #2 was asked about the dishwasher not having a temperature log. ASM #2 stated that dining services was responsible for ensuring the kitchen dishwashers are monitored for proper temperatures. ASM #2 was asked if there was proper equipment available to check the dishwasher temperatures during use. ASM #2 stated, Yes. We have the proper equipment to check the dishwasher during use. ASM #2 left and returned with a thermometer and was observed obtaining the temperature in the dishwasher. The highest temperature while in use was 180.2 degrees Fahrenheit. On [DATE] at 11:19 a.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Kitchenette Dishwasher Policy documented, Dining will supply temperature strips or specialty thermometers at all times. Any dishwasher user will be required to place strip or thermometer in dishwasher prior to use. After use, user must record on provided log the highest temperature from thermometer or strip. If temperature does not meet 180 degrees or color code on strip, then submit work order to Maintenance; dishes need to be considered dirty and not clean. No further information was presented prior to exit. 5. The facility staff failed to maintain kitchen equipment in a sanitary manner in the sunshine and country kitchens. On [DATE] at 12:30 p.m., an observation of the sunshine kitchen was conducted. The bottom of the refrigerator freezer drawer had dirt and food particles on the inside. On [DATE] at 12:35 p.m., an observation of the country kitchen was conducted. The inside of the microwave contained food particles and the produce drawer in the refrigerator contained dirt and food particles. On [DATE] at 9:39 a.m., an interview was conducted with OSM (other staff member) #1 (the director of dining services). OSM #1 was asked what the process was for ensuring the refrigerators in the sunshine and country kitchen are cleaned out. OSM # stated, It is the nursing department's responsibility to clean the refrigerator out. OSM #1 was made aware that the refrigerators in the sunshine and country kitchen were both unsanitary. OSM #1 was asked who is responsible for ensuring the microwave is sanitized. OSM #1 stated, The microwave is clean as you go. OSM #1 was asked what clean as you go meant. OSM #1 stated, Once you are finished using the microwave, you must clean it. OSM #1 was made aware that the microwave had food particles on the inside. On [DATE] at 11:19 a.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of nursing) were made aware of the above concerns. ASM #1 stated that it is a collaborative effort between nursing and dining services to clean the refrigerators and microwave out. A policy regarding the cleaning of the microwaves and refrigerators was requested. No further information was given prior to exit.

Based on observation, resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide respiratory care and services for two of 20 residents in the survey sample, Residents #12 and #68. 1. a. The facility staff failed to obtain a physician's orders [REDACTED]. b. The facility staff failed to store Resident #12's incentive spirometer mouthpiece in a clean and sanitary manner. 2. a. The facility staff failed to obtain a physician's orders [REDACTED]. b. The facility staff failed to store Resident #68's incentive spirometer mouthpiece in a clean and sanitary manner. (1) An incentive spirometer is a device used to help you keep your lungs healthy after surgery or when you have a lung illness, such as pneumonia. Using the incentive spirometer teaches you how to take slow deep breaths. Deep breathing keeps your lungs well-inflated and healthy while you heal and helps prevent lung problems, like pneumonia. How to use an Incentive Spirometer Many people feel weak and sore after surgery and taking big breaths can be uncomfortable. A device called an incentive spirometer can help you take deep breaths correctly. By using the incentive spirometer every 1 to 2 hours, or as instructed by your nurse or doctor, you can take an active role in your recovery and keep your lungs healthy. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/ 1.htm The findings include: 1. a. The facility staff failed to obtain a physician's orders [REDACTED]. Resident #12 was admitted to the facility on [DATE]. Resident #12's [DIAGNOSES REDACTED]. Resident #12's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 3/20/19, coded the resident as being cognitively intact. Section G coded Resident #12 as requiring limited assistance of one staff with bed mobility and walking. Review of the active physician's orders [REDACTED]. [REDACTED]. Review of Resident #12's care plan, last reviewed on 3/25/19 failed to reveal documentation regarding an incentive spirometer. On 4/2/19 at 10:09 a.m., observation revealed Resident #12 was out of the room. An incentive spirometer sitting on the table in the resident's room. On 4/2/19 at 1:03 p.m., observation revealed, Resident #12 was sitting up in bed. An incentive spirometer was sitting on the table in the resident's room. An interview was conducted with Resident #12 regarding the incentive spirometer. Resident #12 stated she uses the incentive spirometer a few times a day. On 4/3/19 at 10:34 a.m., observation revealed, Resident #12 was ambulating in the room. An incentive spirometer was sitting on the table in the room. On 4/3/19 at 10:54 a.m., an interview was conducted with LPN (licensed practical nurse) #1 regarding the purpose of an incentive spirometer. LPN #1 stated an incentive spirometer provides good airflow and movement in the lungs and prevents pneumonia. When asked if a physician's orders [REDACTED].#1 stated an order should be obtained because an order is needed for everything. On 4/3/19 at 11:23 a.m., LPN #1 stated she identified residents who were using incentive spirometers and obtained physician's orders [REDACTED]. On 4/3/19 at 11:17 a.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Incentive Spirometer documented, Physician Order: A physician order [REDACTED]. No further information was presented prior to exit. b. The facility staff failed to store Resident #12's incentive spirometer mouthpiece in a clean and sanitary manner. Review of the active physician's orders [REDACTED]. [REDACTED]. Review of Resident #12's care plan, last reviewed on 3/25/19, failed to reveal documentation or interventions addressing the use of an incentive spirometer. On 4/2/19 at 10:09 a.m., Resident #12 was out of the room. Observation revealed an uncovered incentive spirometer on a table in the resident's room. The mouthpiece was exposed to potential contaminates in the air. On 4/2/19 at 1:03 p.m., observation revealed, Resident #12 sitting up in bed. An uncovered incentive spirometer was sitting on the table in the resident's room. An interview was conducted with Resident #12 regarding the incentive spirometer. Resident #12 stated she uses the incentive spirometer a few times a day. When asked if the facility staff had ever provided a bag to cover the incentive spirometer, Resident #12 confirmed they had not. On 4/3/19 at 10:34 a.m., Resident #12 was ambulating in the room. Observation revealed, an uncovered incentive spirometer sitting on the table in the room. On 4/3/19 at 10:54 a.m., an interview was conducted with LPN (licensed practical nurse) #1, regarding how an incentive spirometer should be stored. LPN #1 stated, In a bag. When asked why, LPN #1 stated, Infection control. LPN #1 confirmed an uncovered incentive spirometer may be exposed to potential contaminates in the air. On 4/3/19 at 11:23 a.m., LPN #1 stated she identified all residents who have incentive spirometers and bagged all the incentive spirometers. On 4/3/19 at 11:17 a.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Incentive Spirometer documented, Store incentive spirometer in a bag . No further information was presented prior to exit. 2. a. The facility staff failed to obtain a physician's orders [REDACTED]. Resident #68 was admitted to the facility on [DATE]. Resident #68's [DIAGNOSES REDACTED]. Resident #68's admission MDS (minimum data set) assessment was not complete. Resident #68's admission nursing assessment dated [DATE] documented the resident was alert and oriented to person, place and time. Review of active physician's orders [REDACTED]. Resident #68's care plan with a print date of 4/2/19 failed to reveal documentation regarding an incentive spirometer. On 4/2/19 at 10:14 a.m., observation revealed, Resident #68 was out of the room. An incentive spirometer was sitting on the table in the resident's room. On 4/2/19 at approximately 1:30 p.m., observation revealed, Resident #68 sitting in a chair in the room. An incentive spirometer was sitting on the table in the room. An interview was conducted with Resident #68 regarding the incentive spirometer. Resident #68 stated she brought the incentive spirometer from the hospital and uses it once or twice a day. On 4/3/19 at 10:35 a.m., observation revealed, Resident #68 was out of the room. An incentive spirometer was sitting on the table in the room. On 4/3/19 at 10:54 a.m., an interview was conducted with LPN (licensed practical nurse) #1, regarding the purpose of an incentive spirometer. LPN #1 stated an incentive spirometer provides good airflow and movement in the lungs and prevents pneumonia. When asked if a physician's orders [REDACTED].#1 stated an order should be obtained because an order is needed for everything. On 4/3/19 at 11:23 a.m., LPN #1 stated she identified residents who were using incentive spirometers and obtained physician's orders [REDACTED]. On 4/3/19 at 11:17 a.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of nursing) were made aware of the above concern. No further information was presented prior to exit. b. The facility staff failed to store Resident #68's incentive spirometer mouthpiece in a clean and sanitary manner. Review of active physician's orders [REDACTED]. Resident #68's care plan with a print date of 4/2/19 failed to reveal documentation regarding an incentive spirometer. On 4/2/19 at 10:14 a.m., observation revealed, Resident #68 was out of the room. An uncovered incentive spirometer was sitting on the table in the resident's room. The mouthpiece was exposed to potential contaminates in the air. On 4/2/19 at approximately 1:30 p.m., observation revealed, Resident #68 sitting in a chair in the room. An uncovered incentive spirometer was sitting on the table in the room. An interview was conducted with Resident #68 regarding the incentive spirometer. Resident #68 stated she brought the incentive spirometer from the hospital and uses it once or twice a day. When asked if the facility staff had ever provided a bag to cover the incentive spirometer, Resident #12 confirmed they had not. On 4/3/19 at 10:35 a.m., observation revealed, Resident #68 was out of the room. An incentive spirometer was sitting on the table in the room. On 4/3/19 at 10:54 a.m., an interview was conducted with LPN (licensed practical nurse) #1 regarding how an incentive spirometer should be stored. LPN #1 stated, In a bag. When asked why, LPN #1 stated, Infection control. LPN #1 confirmed an uncovered incentive spirometer may be exposed to potential contaminates in the air. On 4/3/19 at 11:23 a.m., LPN #1 stated she identified all residents who have incentive spirometers and bagged all the incentive spirometers. On 4/3/19 at 11:17 a.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of nursing) were made aware of the above concern. No further information was presented prior to exit.

Based on observation, resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to implement infection control practices for two of 20 residents in the survey sample, Residents #12 and #68. 1. The facility staff failed to store Resident #12's incentive spirometer mouthpiece in a clean and sanitary manner. 2. The facility staff failed to store Resident #68's incentive spirometer mouthpiece in a clean and sanitary manner. (1) An incentive spirometer is a device used to help you keep your lungs healthy after surgery or when you have a lung illness, such as pneumonia. Using the incentive spirometer teaches you how to take slow deep breaths. Deep breathing keeps your lungs well-inflated and healthy while you heal and helps prevent lung problems, like pneumonia. How to use an Incentive Spirometer Many people feel weak and sore after surgery and taking big breaths can be uncomfortable. A device called an incentive spirometer can help you take deep breaths correctly. By using the incentive spirometer every 1 to 2 hours, or as instructed by your nurse or doctor, you can take an active role in your recovery and keep your lungs healthy. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/ 1.htm The findings include: 1. The facility staff failed to store Resident #12's incentive spirometer mouthpiece in a clean and sanitary manner. Resident #12 was admitted to the facility on [DATE]. Resident #12's [DIAGNOSES REDACTED]. Resident #12's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 3/20/19, coded the resident as being cognitively intact. Section G coded Resident #12 as requiring limited assistance of one staff with bed mobility and walking. Review of the active physician's orders [REDACTED]. [REDACTED]. Review of Resident #12's care plan, last reviewed on 3/25/19 failed to reveal documentation regarding an incentive spirometer. On 4/2/19 at 10:09 a.m., observation revealed Resident #12 was out of the room. An incentive spirometer sitting on the table in the resident's room. On 4/2/19 at 1:03 p.m., observation revealed, Resident #12 was sitting up in bed. An incentive spirometer was sitting on the table in the resident's room. An interview was conducted with Resident #12 regarding the incentive spirometer. Resident #12 stated she uses the incentive spirometer a few times a day. On 4/3/19 at 10:34 a.m., observation revealed, Resident #12 was ambulating in the room. An incentive spirometer was sitting on the table in the room. On 4/3/19 at 10:54 a.m., an interview was conducted with LPN (licensed practical nurse) #1 regarding the purpose of an incentive spirometer. LPN #1 stated an incentive spirometer provides good airflow and movement in the lungs and prevents pneumonia. When asked if a physician's orders [REDACTED].#1 stated an order should be obtained because an order is needed for everything. On 4/3/19 at 11:23 a.m., LPN #1 stated she identified residents who were using incentive spirometers and obtained physician's orders [REDACTED]. On 4/3/19 at 11:17 a.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Incentive Spirometer documented, Physician Order: A physician order [REDACTED]. No further information was presented prior to exit. 2. The facility staff failed to store Resident #68's incentive spirometer mouthpiece in a clean and sanitary manner. Resident #68 was admitted to the facility on [DATE]. Resident #68's [DIAGNOSES REDACTED]. Resident #68's admission MDS (minimum data set) assessment was not complete. Resident #68's admission nursing assessment dated [DATE] documented the resident was alert and oriented to person, place and time. Review of active physician's orders [REDACTED]. Resident #68's care plan with a print date of 4/2/19 failed to reveal documentation regarding an incentive spirometer. On 4/2/19 at 10:14 a.m., observation revealed, Resident #68 was out of the room. An incentive spirometer was sitting on the table in the resident's room. On 4/2/19 at approximately 1:30 p.m., observation revealed, Resident #68 sitting in a chair in the room. An incentive spirometer was sitting on the table in the room. An interview was conducted with Resident #68 regarding the incentive spirometer. Resident #68 stated she brought the incentive spirometer from the hospital and uses it once or twice a day. On 4/3/19 at 10:35 a.m., observation revealed, Resident #68 was out of the room. An incentive spirometer was sitting on the table in the room. On 4/3/19 at 10:54 a.m., an interview was conducted with LPN (licensed practical nurse) #1, regarding the purpose of an incentive spirometer. LPN #1 stated an incentive spirometer provides good airflow and movement in the lungs and prevents pneumonia. When asked if a physician's orders [REDACTED].#1 stated an order should be obtained because an order is needed for everything. On 4/3/19 at 11:23 a.m., LPN #1 stated she identified residents who were using incentive spirometers and obtained physician's orders [REDACTED]. On 4/3/19 at 11:17 a.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of nursing) were made aware of the above concern. No further information was presented prior to exit.

Based on observation, staff interview, facility document review, and clinical record review, it was determined that facility staff failed to have a complete Legionella program, and failed to follow infection control practices for four of 14 residents in the survey sample, Resident #3, #8, #4 and #6. 1. The facility staff failed to have a complete Legionella program. 2. The facility staff failed to maintain infection control practices during wound care for Resident #3. 3. The facility staff failed to store respiratory equipment in a manner to prevent infections for Resident #8. 4. For Resident #4 and #6, facility staff failed to maintain infection control practices during medication administration observation. The findings include: 1. On 4/5/18 at 2:17 p.m., review of the Legionella Program was conducted with OSM (other staff member) #3, the Director of Environmental Services. OSM #3 handed this writer a Legionella policy that the facility was going to use a guide to develop their program. A blank form titled, Water Management Program- Site Monitoring log was also handed to this writer. When OSM #3 was asked if the Legion program was completed, OSM #3 stated, We are planning on doing testing but we haven't done it yet. When asked if the program was incomplete, OSM #3 stated, Well, we developed our policy. OSM #3 was not aware the Legionella program had to be completed at this time. On 4/5/18 at 5:10 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the DON (Director of Nursing) and ASM #3, the administrative support clerk were made aware of the above concerns. No further information was provided prior to exit. The facility policy Water Management Program to Prevent Legionnaire's Disease documented in part the following: The facility is committed to establishing and maintaining an effective water management program system to minimize the occurrence of Legionnaire's Disease. The bacterium Legionella can cause serious type of pneumonia called LD in persons at risk .outbreaks have been linked to poorly maintained water systems in building with large or complex water systems including hospitals and long-term care facilities. People contact Legionella by inhaling aerosolized water droplets containing the bacteria, or less commonly, aspiration of contaminated drinking water. 2. The facility staff failed to maintain infection control practices during wound care for Resident #3. Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #3's most recent MDS (minimum data set) was a significant change assessment with an ARD (assessment reference date) of 1/19/18. Resident #3 was coded as being moderately impaired in cognitive function, scoring 10 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #3 was coded as requiring extensive assistance with one to two staff members with most ADLS (activities of daily living). Review of Resident #3's clinical record revealed she had a stage three pressure sore (2) on her left buttock. Review of Resident #3's most recent POS (physician order [REDACTED]. Apply Santyl (3) cover with Meplix border dressing daily. This order was initiated on 3/23/18. On 4/5/18 at 3:39 p.m., wound care observation was conducted with LPN (licensed practical nurse) #1. LPN #1 had set up her supplies before calling this writer in for observation. LPN #1 with her gloves on removed Resident #3's old dressing. Resident #3 had a stage three pressure wound with minimal drainage. LPN #1 then removed her gloves and placed on new gloves. LPN #1 did not wash her hands before applying new gloves. LPN #1 washed the wound with soap and water. LPN #1 then cleaned the wound with normal saline and applied Santyl to a Q-tip. LPN #1 applied the Santyl into the wound bed and then covered the wound with a meplix border. LPN #1 removed her gloves, placed on new gloves, and put a new brief on the resident. LPN #1 then removed her gloves and washed her hands. On 4/5/18 at 4:45 p.m., an interview was conducted with LPN #1. When asked how to maintain infection control during wound care, LPN #1 stated that she should have washed her hands before putting on her new gloves. LPN #1 stated, I know that is what I missed. On 4/5/18 at 5:10 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the DON (Director of Nursing) and ASM #3, the administrative support clerk were made aware of the above concerns. Facility policy titled, treatment of [REDACTED]. Wash your hands thoroughly with soap and water at the following intervals: .d. when changing/removing gloves or any personal protective equipment. No further information was presented prior to exit. *A pressure ulcer is an inflammation or sore on the skin over a bony prominence (e.g., shoulder blade, elbow, hip, buttocks, or heel), resulting from prolonged pressure on the area, usually from being confined to bed. Most frequently seen in elderly and immobilized persons, decubitus ulcers may be prevented by frequently change of position, early ambulation, cleanliness, and use of skin lubricants and a water or air mattress. Also called bedsores. Pressure sores. Barron ' s Dictionary of Medical Terms for the Non Medical Reader 2006; Mikel A. Rothenberg, M.D. and [NAME] F. Chapman. Page 155. (1) Stage II pressure sore Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. (MONTH) also present as an intact or open/ruptured serum-filled blister. Further description: Presents as a shiny or dry shallow ulcer without slough or bruising.* This stage should not be used to describe skin tears, tape burns, perineal [MEDICAL CONDITION], maceration or excoriation. *Bruising indicates suspected deep tissue injury. This information was obtained from National Pressure Ulcer Advisory Panel website at http://www.npuap.org/pr2.htm. (2) Stage III pressure sore Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining and tunneling. Further description: The depth of a stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep stage III pressure ulcers. Bone/tendon is not visible or directly palpable. This information was obtained from National Pressure Ulcer Advisory Panel website at http://www.npuap.org/pr2.htm. (3) SANTYL® Ointment is an FDA-approved active enzymatic therapy that continuously removes necrotic tissue from wounds at the microscopic level. This works to free the wound bed of microscopic cellular debris, allowing granulation to proceed and [MEDICATION NAME] to occur. (<http://www.santyl.com/about>) 3. The facility staff failed to store respiratory equipment in a manner to prevent infections for Resident #8. Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #8's most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 3/17/18. Resident #8 was coded as being cognitively intact in the ability to make daily decisions scoring 15 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #8 was coded as requiring extensive assistance with one to two staff members with most ADLS (activities of daily living). Review of Resident #8's most recent POS (physician order [REDACTED]. (MONTH) titrate to maintain 02 greater or equal to 92 percent every shift. On 4/5/18 at 10:30 a.m. and 12:56 p.m., an observation was made of Resident #8. He had his oxygen in place via nasal cannula. Resident #8's oxygen tubing was hooked up to his oxygen concentrator while sitting up in his wheelchair. Resident #8 also had an oxygen tank that was secured on the back of his wheelchair. The oxygen tubing for the oxygen tank was rolled up behind his wheelchair, not stored in a bag. On 4/5/18 at 1:25 p.m., an interview was conducted with LPN (licensed practical nurse) #1. When asked how oxygen tubing should be maintained when not in use, LPN #1 stated that oxygen tubing should be stored in a plastic bag. When asked why oxygen tubing should be stored in a plastic bag when not in use, LPN #1 stated, To keep dust particles or anything else out of it. Infection control. LPN #1 followed this writer to Resident #8's room. LPN #1 confirmed that the Resident #8's oxygen tubing attached to his oxygen tank was not stored in a bag. On 4/5/18 at 5:10 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the DON (Director of Nursing) and ASM #3, the administrative support clerk were made aware of the above concerns. Facility policy titled, Oxygen Therapy did not address the above concerns. No further information was provided prior to exit. 4. For Resident #4 and Resident #6, facility staff failed to maintain infection control practices during medication administration observation. Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #4's most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 2/4/18. Resident #4 was coded as being severely impaired in cognitive function scoring 2 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #4 was coded as requiring extensive assistance from one to two staff members with most ADLs (activities of daily living). Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #6's most recent MDS (minimum data set) assessment was a significant change assessment with an ARD (assessment reference date) of 3/12/18. Resident #6 was coded as being severely impaired in cognitive function scoring 99 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #6 was coded as being totally dependent of staff with most ADLs (activities of daily living). On 4/4/18 at 8:31 a.m., medication administration was observed of LPN (licensed practical nurse) #1. At 8:40 a.m., LPN #1 was preparing medications for Resident #4. The following medications were prepared: 1) Aspirin 81 mg (milligrams)- 1 tablet 2) Vitamin D 3 1000 IU (international unit)- 1 tablet 3) [MEDICATION NAME] 2 mg - 1 tablet 4) Edler tonic multivitamin- 10 ml 5) [MEDICATION NAME] capsule 30 mg - 1 capsule At approximately 8:42 a.m., LPN #1 used a blood pressure cuff and her stethoscope to take Resident #4's blood pressure. Resident #4's blood pressure was 148/72. LPN #1 placed the cuff and stethoscope on the medication cart. This writer did not see LPN #1 sanitize the blood pressure cuff or stethoscope after use. LPN #1 then prepared the following medication: 6) [MEDICATION NAME] 25 mg- 1 tablet At 8:56 a.m., LPN #1 administered the Edler tonic to Resident #4. LPN #1 placed her bare fingers on the rim of the medication cup and administered the medication to Resident #4. Resident #4 had her lips directly on the rim of the medication cup, where LPN #1 had touched with her bare fingers. At 8:56 a.m., LPN #1 stated that she had to open up the [MEDICATION NAME]. LPN #1 grabbed the [MEDICATION NAME] with her bare hands from the medication cup that contained all the other medications, and placed it into an empty medication cup. LPN #1 stated that she shouldn't have touched the medication with her bare hands but she didn't have gloves on her cart. At 8:56 a.m., LPN #1 left the medication cart with all of Resident #4's medications on top of the cart. The cart was also left unlocked. Resident #4 remained in front of the medication cart. LPN #1 went to the back of Resident #4's room to grab gloves. On 4/4/18 at 8:58 a.m. LPN #1 came back with a handful of gloves. She then placed gloves on and opened up the [MEDICATION NAME] capsule. LPN #1 then crushed all other medications and mixed the contents of the [MEDICATION NAME] into the medication cup with the crushed medications. LPN #1 then removed her gloves. LPN #1 added chocolate pudding to medications and administered the crushed medications to Resident #4. LPN #1 then poured a glass of water and grabbed the rim of the cup with her bare hands and gave the cup of water to Resident #4. Resident #4 had her lips directly on the rim of the water cup, where LPN #1 had touched with her bare fingers. LPN #1 then sanitized her hands. This writer did not observe LPN #1 sanitize the blood pressure cuff or her stethoscope. On 4/4/18 at 9:15 a.m., LPN #1 was observed walking up the hallway with the same blood pressure cuff and stethoscope that was used on Resident #4. LPN #1 took Resident #6's blood pressure using the same equipment. On 4/4/18 at 9:18 a.m., an interview was conducted with LPN #1. When asked what she uses to sanitize a blood pressure cuff, LPN #1 stated that she uses sani wipes but that she did not have them on her cart at the moment. When asked if she had sanitized the blood pressure cuff in between using it on Resident #4 and Resident #6, LPN #1 stated that she did. LPN #1 stated, I am not even going to lie, I forgot to wipe my stethoscope in between the two residents. On 4/5/18 at 1:25 p.m., further interview was conducted with LPN #1. When asked how to maintain infection control practices during medication pass, LPN #1 stated that she should wash or sanitize hands before and after each resident, wipe off equipment before using on another person, and she shouldn't touch the pills with her bare hands/fingers. When asked if bare fingers should be touching the rim of the medication or water cup, LPN #1 stated that it shouldn't. LPN #1 stated that her hands could spread germs. On 4/5/18 at 5:10 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the DON (Director of Nursing) and ASM #3, the administrative support clerk were made aware of the above concerns. The facility policy titled, Medication Administration documents in part, the following: Staff shall follow established facility infection control procedures (e.g. handwashing, antispetic technique, gloves, isolation precautions. etc.) for the administration of medications as applicable. (1) Aspirin is used to decrease mild to moderate pain associated with [MEDICAL CONDITION] disorders. This information was obtained from Davis's Drug Guide, 11th edition, p. 1087. (2) Vitamin D Tablet- Vitamin D is a fat-soluble vitamin that is naturally present in very few foods, added to others, and available as a dietary supplement. This information was obtained from The National Institutes of Health. https://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional/. 3) [MEDICATION NAME] is a diuretic used to treat fluid retention. This information was obtained from The National Institutes of Health. https://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT 43/?report=details 4) Edler tonic is a multivitamin used to treat vitamin deficiency. This information was obtained from https://www.webmd.com/drugs/2/drug- /[MEDICATION NAME]-oral/details. 5) [MEDICATION NAME] is used to treat depression and anxiety. This information was obtained from The National Institutes of Health. https://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT 59/?report=details. 6) [MEDICATION NAME] is used to treat high blood pressure, [MEDICAL CONDITION], and heart failure. This information was obtained from The National Institutes of Health. https://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT 86/?report=details.

Based on observation, staff interview, and facility document review it was determined that the facility staff failed to store medications in a safe manner for one of two medication carts (medication cart on the long term care unit); and one of two medication rooms (the skilled rehabilitation (rehab.) medication room). 1. The medication cart on the long term care unit was left unsecured during medication administration observation. 2. One expired vial of [MEDICATION NAME] PPD (purified protein derivative) solution, three expired bottles of [MEDICATION NAME] sterile powder and five expired [MEDICATION NAME] lock flush syringes was observed in the skilled rehab medication room. The findings include: 1. On [DATE] at 8:31 a.m., medication administration was observed on the long term care unit with LPN (licensed practical nurse) #1. At 8:40 a.m., LPN #1 was preparing medications for Resident #4. The following medications were prepared: 1) Aspirin 81 mg (milligrams) - 1 tablet 2) Vitamin D3 1000 IU (international unit) - 1 tablet 3) [MEDICATION NAME] 2 mg - 1 tablet 4) Edler tonic multivitamin- 10 ml 5) [MEDICATION NAME] capsule 30 mg - 1 capsule 6) [MEDICATION NAME] 25 mg- 1 tablet At 8:56 a.m., LPN #1 stated that she had to open up the [MEDICATION NAME]. LPN #1 grabbed the [MEDICATION NAME] with her bare hands from the medication cup that contained all the other medications, and placed it into an empty medication cup. LPN #1 stated that she shouldn't have touched the medication with her bare hands but she didn't have gloves on her cart. At 8:56 a.m., LPN #1 left the medication cart with all of Resident #4's medications on top of the cart. The cart was also left unlocked. Resident #4 remained in front of the medication cart. LPN #1 went to the back of Resident #4's room to grab gloves. LPN #1 was not in view of the medication cart. On [DATE] at 8:58 a.m., LPN #1 came back with a handful of gloves. She then placed gloves on and opened up the [MEDICATION NAME] capsule. Resident #4's most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of [DATE]. Resident #4 was coded as being severely impaired in cognitive function scoring 2 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. On [DATE] at 1:25 p.m., an interview was conducted with LPN #1. When asked how the medication cart should be kept when she is not near the cart, LPN #1 stated the cart should be locked. LPN #1 stated she always locks the cart when she is not near the cart. When asked if she had left the cart during medication administration, LPN #1 stated she did, to get gloves. When asked if Resident #4 was in front of the cart when she left the cart, LPN #1 stated that she was. LPN #1 stated if Resident #4 got a hold of the medications on top of the cart, nothing would happen because they were her medications. LPN #1 stated narcotics were in a locked box in the medication cart. LPN #1 stated, The only thing that might have happened was Resident #4 could have choked on the medications if she were to reach for it on the cart. When asked if it was possible for other residents to walk by and access the unlocked cart, LPN #1 stated that she didn't think about that. On [DATE] at 5:10 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the DON (Director of Nursing) and ASM #3, the administrative support clerk were made aware of the above concerns. The facility policy titled, Medication Administration documents in part, the following: During administration of medications, the medication cart will be kept closed and locked when out of sight of the medication nurse. It may be kept in the doorway of the resident's room with open drawers facing inward and all other sides closed. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications and all outward sides must be inaccessible to residents or others passing by. (1) Aspirin is used to decrease mild to moderate pain associated with [MEDICAL CONDITION] disorders. This information was obtained from Davis's Drug Guide, 11th edition, p. 1087. (2) Vitamin D Tablet- Vitamin D is a fat-soluble vitamin that is naturally present in very few foods, added to others, and available as a dietary supplement. This information was obtained from The National Institutes of Health. https://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional/. 3) [MEDICATION NAME] is a diuretic used to treat fluid retention. This information was obtained from The National Institutes of Health. https://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT 43/?report=details 4) Edler tonic is a multivitamin used to treat vitamin deficiency. This information was obtained from https://www.webmd.com/drugs/2/drug- /[MEDICATION NAME]-oral/details. 5) [MEDICATION NAME] is used to treat depression and anxiety. This information was obtained from The National Institutes of Health. https://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT 59/?report=details. 6) [MEDICATION NAME] is used to treat high blood pressure, [MEDICAL CONDITION], and heart failure. This information was obtained from The National Institutes of Health. https://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT 86/?report=details. 2. One expired vial of [MEDICATION NAME] PPD (purified protein derivative) solution (1), three expired bottles of [MEDICATION NAME] sterile powder (2) and five expired [MEDICATION NAME] lock flush syringes (3) was observed in the skilled rehab medication room. On [DATE] at 7:35 a.m., observation of the skilled rehabilitation medication room was conducted with LPN (licensed practical nurse) #1. The following was observed: - One open vial of [MEDICATION NAME] PPD solution with a written open date of ,[DATE] was observed in the medication refrigerator. - An IV (intravenous) starter emergency box with a label that documented, THIS BOX EXPIRES ON [DATE] (YEAR). Observation of the contents in the box revealed three bottles of [MEDICATION NAME] sterile powder with a manufacturer's expiration date of [DATE] and five [MEDICATION NAME] lock flush syringes with a manufacturer's expiration date of [DATE]. Immediately after the above observations, an interview was conducted with LPN #1. LPN #1 was asked how long the PPD solution was good for after being opened. LPN #1 stated, I want to say 30 days. LPN #1 also confirmed the manufacturer's expiration dates on the [MEDICATION NAME] and [MEDICATION NAME]. When asked who was responsible for checking the medication refrigerator and the IV starter emergency box, LPN #1 stated she did not know. On [DATE] at 7:43 a.m., ASM (administrative staff member) #2 (the director of nursing) confirmed the written open date on the vial of PPD solution was ,[DATE]. ASM #2 was asked when the PPD solution expired after being opened. ASM #2 stated she would check. ASM #2 was made aware of the expired [MEDICATION NAME] and [MEDICATION NAME] in the rehabilitation medication refrigerator. On [DATE] at 7:55 a.m., ASM #2 stated the PPD solution was good for 30 days after being opened. ASM #2 stated she was going to dispose of the PPD solution and had already disposed of the [MEDICATION NAME] and [MEDICATION NAME]. On [DATE] at 3:16 p.m., another interview was conducted with ASM #2. ASM #2 was asked who is responsible for checking the IV starter emergency box. ASM #2 stated the consulting pharmacist is supposed to check the box each month when she completes her medication regimen reviews and the pharmacy is supposed to replace the box each month. ASM #2 was asked who is responsible for checking the medication refrigerators. ASM #2 stated the night nurse is supposed to check the refrigerators once a week. On [DATE] at 5:11 p.m., ASM #1 (the administrator), ASM #2, ASM #3 (the administrative support clerk) and OSM (other staff member) #3 (the director of environmental services) were made aware of the above concern. The facility policy titled, Medication Storage documented, The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. No further information was presented prior to exit. (1) [MEDICATION NAME] PPD solution is used in the [DIAGNOSES REDACTED]. This information was obtained from the website: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=1e91a67c-[DATE]-58f7a 34 The solution manufacturer's instructions documented, Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency . (2) [MEDICATION NAME] sterile powder is used to prevent or treat infections. This information was obtained from the website: https://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=0713a847-a,[DATE]b73-af,[DATE]aa b9&type=display (3) [MEDICATION NAME] lock flush syringes are used to maintain patency of an indwelling venipuncture device. This information was obtained from the website: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=cbc26e3c-aee,[DATE]c0d-bdb1-bf 8fbce

Based on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide dignity for six of 14 residents in the survey sample, Residents #1, #3, #4, #6, #9 and #61. The facility staff failed to provide breakfast to all residents seated at the dining room table at the same time on 4/4/18. Residents #1, #3, #4, #6, #9 and #61 were placed at the dining room table with no food while another resident was observed eating. The findings include: Resident #1 was admitted to the facility on [DATE]. Resident #1's [DIAGNOSES REDACTED]. Resident #1's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 3/28/18, coded the resident's cognition as severely impaired. Section G coded Resident #1 as requiring supervision with setup help only with eating. Resident #2 was admitted to the facility on [DATE]. Resident #2's [DIAGNOSES REDACTED]. Resident #2's most recent MDS, an annual assessment with an ARD of 12/29/17, coded the resident as cognitively intact. Section G coded Resident #2 as requiring supervision with setup help only with eating. Resident #3 was admitted to the facility on [DATE]. Resident #3's [DIAGNOSES REDACTED]. Resident #3's most recent MDS, a significant change in status assessment with an ARD of 1/19/18, coded the resident's cognition as moderately impaired. Section G coded Resident #3 as requiring limited assistance of one staff with eating. Resident #4 was admitted to the facility on [DATE]. Resident #4's [DIAGNOSES REDACTED]. Resident #4's most recent MDS, a quarterly assessment with an ARD of 2/4/18, coded the resident's cognition as severely impaired. Section G coded Resident #4 as requiring extensive assistance of one staff with eating. Resident #6 was admitted to the facility on [DATE]. Resident #6's [DIAGNOSES REDACTED]. Resident #6's most recent MDS, a significant change in status assessment with an ARD of 3/12/18, coded the resident's cognitive skills for daily decision-making as severely impaired. Section G coded Resident #6 as being totally dependent on one staff with eating. Resident #9 was admitted to the facility on [DATE]. Resident #9's [DIAGNOSES REDACTED]. Resident #9's most recent MDS, a quarterly assessment with an ARD of 3/21/18, coded the resident's cognition as severely impaired. Section G coded Resident #9 as being totally dependent of one staff with eating. Resident #61 was admitted to the facility on [DATE]. Resident #61's most recent MDS, an admission assessment with an ARD of 4/2/18 (completed but not yet submitted to the Centers for Medicare and Medicaid Services), coded the resident's cognitive skills for daily decision making as severely impaired. Section G coded Resident #61 as requiring extensive assistance of one staff with eating. On 4/4/18 at 8:25 a.m., a dining observation was conducted in the long-term care dining room. Four square tables were pushed together to create one long table. Resident #2 was observed feeding himself at the dining room table. Resident #3 was observed sitting at the table drinking a beverage. Resident #61 was observed sitting at the table with her husband. Resident #61's husband was assisting her with a beverage. Neither Resident #3 nor Resident #61 had food at the table. On 4/4/18 at 8:37 a.m., Resident #6 was wheeled to the table. On 4/4/18 at 8:39 a.m., Resident #1 was wheeled to the table. On 4/4/18 at 9:00 a.m., Resident #9 was wheeled to the table. At this time, the only resident observed with food was Resident #2. Also at this time, an interview was conducted with OSM (other staff member) #6 (the Chaplain who was observed talking with residents sitting at the dining room table). OSM #6 was asked who was responsible for serving food to residents at the dining room table. OSM #6 stated the cook usually makes food and brings it out to the unit. When asked why residents were not yet being served, OSM #6 stated some residents need assistance from care staff so she thought they were waiting to serve residents at the table when care staff was available to assist them. OSM #6 stated the care staff is typically getting residents ready to come out to the dining room. On 4/4/18 at 9:03 a.m., Resident #4 was wheeled to the dining room table. On 4/4/18 at 9:05 a.m., Resident #61 and her husband were served breakfast. On 4/4/18 at 9:16 a.m., Residents #3 and #1 were served breakfast then Residents #4, #6 and #9 were served and assisted with breakfast. During the above observations, staff was not observed offering food to the above residents until the times documented above. On 4/5/18 at 2:16 p.m., an interview was conducted with CNA (certified nursing assistant) #2 (a CNA working on the long-term care unit on 4/4/18). CNA #2 was asked about the process for serving meals to residents. CNA #2 stated many of the residents needed assistance with feeding so the CNAs try to get all the residents up and bring them out to the dining room at once so they can help each one of them with breakfast in the mornings. CNA #2 was asked if residents are brought to the dining room table while other residents are eating. CNA #2 stated Residents #2, #3 and #1 like to eat earlier so they get their breakfast first and the CNAs do sometimes push other residents up to the table. CNA #2 stated the residents are placed in the living room at other times. When asked why residents are sometimes placed in the living room versus the dining room table, CNA #2 stated, I thought it wasn't good to put them at the table while others are eating so they aren't watching others eating. When asked how she would feel if she was at a table where someone else was eating and had to wait fifteen or more minutes to eat, CNA #2 stated, That would probably make you inpatient. CNA #2 stated a majority of residents require two-person assistance with ADLs (activities of daily living). CNA #2 stated there was one CNA on the rehab (rehabilitation) unit and two CNAs on the long-term care unit so it takes longer to get residents up in the morning. On 4/5/18 at 5:11 p.m., ASM #1 (the administrator), ASM #2 (the director of nursing), ASM #3 (the administrative support clerk) and OSM (other staff member) #3 (the director of environmental services) were made aware of the above concern. The facility policy titled, Quality of Life- Dignity documented, Each resident and guest shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. The policy did not specifically document information regarding meal service. No further information was presented prior to exit.

Based on observation, staff interview and facility document review, it was determined that the facility staff failed to prepare and store food in a sanitary manner. 1. The facility staff failed to change gloves and wash her hands in between answering the telephone and frying scrambled eggs. 2. One cup of ice cream was observed open to air and not labeled in the skilled rehab unit freezer. The findings include: 1. The facility staff failed to change gloves and wash her hands in between answering the telephone and frying scrambled eggs. On 4/4/18 at 7:31 a.m., observation of the kitchen was conducted. OSM (other staff member) #4 was observed wearing gloves and frying scrambled eggs with a spatula on the stove. The telephone rang and OSM #4 answered the telephone with the gloves remaining on her hands. After hanging up the phone, OSM #4 continued frying the eggs with a spatula on the stove. OSM #4 did not change gloves or wash her hands. On 4/5/18 at 2:20 p.m., an interview was conducted with OSM #4. OSM #4 was asked what should be done if she is cooking food with gloves on and answers the phone with the same gloves on her hands. OSM #4 stated, Take the gloves off and wash your hands. When asked if she removed her gloves and washed her hands after answering the phone on the previous day, OSM #4 stated, Probably not because I was rushing. On 4/5/18 at 5:11 p.m., ASM #1 (the administrator), ASM #2 (the director of nursing), ASM #3 (the administrative support clerk) and OSM (other staff member) #3 (the director of environmental services) were made aware of the above concern. The facility policy titled, Food Preparation and Handling failed to document information regarding the above findings. No further information was presented prior to exit. 2. One cup of ice cream was observed open to air and not labeled in the skilled rehab unit freezer. On 4/4/18 at approximately 8:00 a.m., observation of the skilled rehab unit freezer was conducted. One Styrofoam cup containing a brown substance resembling ice cream was observed in the freezer. A clear dome lid with a hole in the top was on the cup and a spoon was stuck in the hole down into the substance resembling ice cream. The substance was exposed to air and the cup was not labeled. On 4/4/18 at 9:08 a.m., OSM (other staff member) #5 (the social worker) was observed looking at and removing items from the long-term care refrigerator. After OSM #5 left the refrigerator, this surveyor asked OSM #5 what she was doing in the refrigerator. OSM #5 stated, Periodically we just do checks so I was checking expiration dates. OSM #5 was asked if items in the refrigerator and freezer should be labeled. OSM #5 stated if the item is for a particular resident then the item should be labeled with an open date. OSM #5 was made aware of this surveyor's observation of the skilled rehab unit freezer. OSM #5 stated the item should be labeled with the resident's name and date, and covered. OSM #5 was asked to make an observation of the freezer. On 4/4/18 at 9:14 a.m., OSM #5 returned to this surveyor. OSM #5 stated the item in the freezer was ice cream a family member stuck in the freezer. OSM #5 stated the family member was supposed to remove the item during the previous night but left it. When asked if family members had access to unit refrigerators and freezers, OSM #5 stated, Yes. When asked how staff ensures food is properly stored in the unit refrigerators and freezers, OSM #5 stated, We need to have a sign that instructs them what to do on that fridge. OSM #5 stated a sign was already posted on the long-term care unit refrigerator. On 4/5/18 at 5:11 p.m., ASM #1 (the administrator), ASM #2 (the director of nursing), ASM #3 (the administrative support clerk) and OSM (other staff member) #3 (the director of environmental services) were made aware of the above concern. The facility policy titled, Use and Storage of Resident Obtained Foods documented, Purpose: To assure that foods obtained by residents through personal purchase, family member or visitor, is used in a safe and sanitary manner related to storage, handling and consumption .7. Should a resident choose to consume food at the Community that was not obtained by the Community, safe and sanitary use, storage and handling shall be maintained as follows: a. All foods shall be labeled with the resident's name, and dated. b. All foods shall be placed in a closed container and may be stored in the country kitchen in the appropriate location . No further information was presented prior to exit.

Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to follow professional standards of practice for one of 14 residents in the survey sample, Resident #3. The facility staff failed to clarify Resident #3's pain medication orders with the physician. The findings include: Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #3's most recent MDS (minimum data set) was a significant change assessment with an ARD (assessment reference date) of 1/19/18. Resident #3 was coded as being moderately impaired in cognitive function, scoring 10 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #3 was coded as requiring extensive assistance of one to two staff members with most ADLS (activities of daily living). Review of Resident #3's most recent POS (physician order [REDACTED]. 1) [MEDICATION NAME] (Tylenol) (1) Tablet 325 mg (milligrams) Give 2 tablets by mouth every 6 hours as needed for pain. This order was initiated on 1/8/18. 2) Tylenol Extra Strength 500 MG Give 1 tablet by mouth every 6 hours as needed for pain. This order was initiated on 3/5/18. 3) [MEDICATION NAME] (2) HCL ([MEDICATION NAME]) Tablet 50 MG Give 1 tablet by mouth every 6 hours as needed for pain. This order was initiated on 1/16/18. Review of Resident #3's (MONTH) (YEAR) MARS (Medication Administration Record) revealed Resident #3 received [MEDICATION NAME] 50 MG on 3/12/18 and Tylenol Extra Strength 500 mg on 3/16/18, 3/20/18, 3/22/18. There were no parameters or instructions on the above orders on when to give each pain medication. On 4/5/18 at 1:25 p.m., an interview was conducted with LPN (licensed practical nurse) #1. When asked how she would know which medication to give if a resident had three different orders for pain medication, LPN #1 stated she would call the medical director and clarify the orders. LPN #1 stated the pain medication orders should have pain scales attached to them to determine when to give each one. When asked if nurses were able to determine which medication to give at their own discretion, LPN #1 stated, No. Nurses are not allowed to determine which medication to give when. LPN #1 stated she doesn't normally work on the skilled nursing unit and that she was not a nurse who administered the above pain medication. On 4/5/18 at 5:10 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the DON (Director of Nursing) and ASM #3, the administrative support clerk were made aware of the above concerns. No further information was provided prior to exit. The facility policy titled, Orders and Order Clarification did not address the above concerns. According to Potter and Perry's, Fundamentals of Nursing, 7th edition, page 268 documents the following statements: Clarifying an order is competent nursing practice, and it protects the client and members of the health care team. When you carry out an incorrect or inappropriate intervention, it is as much your error as the person who wrote or transcribed the original order. (1) Tylenol is used to treat minor aches and pains and reduces fever. This information was obtained from The National Institutes of Health. https://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT 85/?report=details. (2) [MEDICATION NAME] is an [MEDICATION NAME] used to treat moderate to severe pain. This information was obtained from Davis's Drug Guide for Nurses, 11th edition p. 1197.

Based on resident interview, staff interview, facility document review, and clinical record review, it was determined that facility staff failed to orient, prepare, and document the same, a resident for transfer to the hospital for two of 14 residents in the survey sample, Resident #3 and #8. 1. The facility staff failed to document that Resident #3 was properly oriented and prepared for a hospital transfer that occurred on 1/5/18. 2. The facility staff failed to document that Resident #8 was properly oriented and prepared for a hospital transfer that occurred on 2/4/18. The findings include: 1. Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #3's most recent MDS (minimum data set) was a significant change assessment with an ARD (assessment reference date) of 1/19/18. Resident #3 was coded as being moderately impaired in cognitive function, scoring 10 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #3 was coded as requiring extensive assistance of one to two staff members with most ADLS (activities of daily living). Review of Resident #3's clinical record revealed that she went out to the hospital on [DATE]. The following nursing note was documented, Guest fell this AM (morning) 0745 (7:45 a.m.) in bathroom witnessed by CNA (certified nursing assistant). Hit head on toilet and implemented neuro (neurological) checks. 0940 (9:40 a.m.) resident sitting in DR (dining room) per her request for breakfast and stated her vision was blurry. BP (blood pressure) 72/42, HR (heart rate) 67, T (temperature) 97.4. Resident diaphoretic (sweaty) and clammy. Assisted back to bed x 2 assist and BP rechecked 88/52. MD (medical doctor) made aware and given orders to send resident to ER (emergency room ) for eval (evaluation), S/P (status/post) fall with head injury. Left facility at 1030 (10:30 a.m.) am with x 3 EMS (emergency services) personnel. Alert to voice and speech clear at the time. Able to answer all questions appropriately. Further review of Resident #3's clinical record revealed she was admitted to the hospital with [REDACTED]. Resident #3 arrived back to the facility on [DATE]. There was no documentation in the clinical record evidencing the resident was oriented and prepared for 1/5/18 facility-initiated transfer to the hospital. On 4/5/18 at approximately 12:15 p.m., an interview was conducted with Resident #3. She could not recall the day she was transferred to the hospital on [DATE]. On 4/5/18 at 1:25 p.m., an interview was conducted with LPN (Licensed practical nurse) #1, regarding the nurses' role when a resident is transferred out to the hospital. LPN #1 stated she would first assess the resident, and then obtain vital signs to determine the need for the resident to be sent out. LPN #1 stated she would then call the physician to obtain an order to send the resident out to the hospital. LPN #1 stated she would also call the administrator, family or POA and then the ambulance. When asked about the documentation for a hospital transfer, LPN #1 stated that should document everything in a nurse's note such as the resident's vital signs, the change in condition, who she had contacted etc. When asked if nurses should be documenting if the resident was oriented and prepared for the transfer, LPN #1 stated, I believe so. When asked why this should be documented, LPN #1 stated, the resident should be oriented to the transfer so they know what is going on and it gives the resident a chance to refuse the transfer. On 4/5/18 at 5:10 p.m., ASM #1, the administrator, ASM #2, the DON (Director of Nursing) and ASM #3, the administrative support clerk were made aware of the above concerns. The facility policy titled, Transfer or Discharge notice, did not address the above concerns. 2. The facility staff failed to document that Resident #8 was properly oriented and prepared for a hospital transfer that occurred on 2/4/18. Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #8's most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 3/17/18. Resident #8 was coded as being cognitively intact in the ability to make daily decisions scoring 15 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #8 was coded as requiring extensive assistance with one to two staff members with most ADLS (activities of daily living). Review of Resident #8's clinical record revealed he had been transferred to the hospital on [DATE]. The following was documented in a nursing note: Around 0400 (4:00 a.m.), CNAs (certified nursing assistants) alerted this writer that guest was cold to the touch. This writer assessed the guest and the tympanic temp (temperature) read 91.0. Multiple blankets were added over top of him. Blood sugar was taken and resulted at 47. Guest was slow to respond and had a blank stare on the wall. Guest was able to drink a cup of orange juice. BS was checked 15 minutes later to result at 41. He then has another cup of orange juice and BS was checked another 15 minutes later to result 33. This writer then called (Name of physician) around 4:30 a.m., who gave orders to send him out to the hospital. The DON (Director of Nursing) was also called. Vitals upon EMS arrival were: blood sugar 51, BP 70/38, respirations 14, HR (heart rate) 58 and irregular and temp 95.0. The next note dated 2/4/18 documented the following: POA (power of attorney), (Name of POA) updated on resident condition and being sent out to the hospital. In agreement with plan. Further review of the clinical record revealed that Resident #8 was admitted to the hospital with [REDACTED]. Resident #8 arrived back to the facility on [DATE]. There was no documentation in the clinical record evidencing the resident was oriented and prepared for 2/4/18 facility-initiated transfer to the hospital. On 4/5/18 at 12:56 p.m., an interview was conducted with Resident #8. Resident #8 stated he thought the staff did tell him why he was going to the hospital prior to his transfer on 2/4/18. On 4/5/18 at 1:25 p.m., an interview was conducted with LPN (Licensed practical nurse) #1, regarding the nurses' role when a resident is transferred out to the hospital. LPN #1 stated she would first assess the resident, and then obtain vital signs to determine the need for the resident to be sent out. LPN #1 stated she would then call the physician to obtain an order to send the resident out to the hospital. LPN #1 stated she would also call the administrator, family or POA and then the ambulance. When asked about the documentation for a hospital transfer, LPN #1 stated that should document everything in a nurse's note such as the resident's vital signs, the change in condition, who she had contacted etc. When asked if nurses should be documenting if the resident was oriented and prepared for the transfer, LPN #1 stated, I believe so. When asked why this should be documented, LPN #1 stated, the resident should be oriented to the transfer so they know what is going on and it gives the resident a chance to refuse the transfer. On 4/5/18 at 5:10 p.m., ASM #1, the administrator, ASM #2, the DON (Director of Nursing) and ASM #3, the administrative support clerk were made aware of the above concerns. The facility policy titled, Transfer or Discharge notice, did not address the above concerns. (1) Lactic acidosis is a buildup of lactic acid in the blood. This information was obtained from The National Institutes of Health. https://search.nih.gov/search?utf8=%E2%9C%93&affiliate=nih&query=lactic+acidosis. (2)[MEDICAL CONDITION] is a serious illness. It happens when your body has an overwhelming immune response to a bacterial infection. The chemicals released into the blood to fight the infection trigger widespread inflammation. This information was obtained from The National Institutes of Health. https://medlineplus.gov/sepsis.html

Based on observation, staff interview, facility document review and clinical record review, it was determined that facility staff failed to provide treatment and services to promote the healing and prevent infection of a pressure sore for one of 14 residents in the survey sample, Resident #3. The facility staff failed to wash hands after removing Resident #3's pressure wound dressing and prior to donning new gloves, worn to perform wound care. The findings include: Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #3's most recent MDS (minimum data set) was a significant change assessment with an ARD (assessment reference date) of 1/19/18. Resident #3 was coded as being moderately impaired in cognitive function, scoring 10 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #3 was coded as requiring extensive assistance of one to two staff members with most ADLS (activities of daily living). Review of Resident #3's clinical record revealed she had a stage three-pressure sore (1) pressure sore* on her left buttock. Review of Resident #3's most recent POS (physician order [REDACTED]. Apply Santyl (2) cover with Meplix border dressing daily. This order was initiated on 3/23/18. On 4/5/18 at 3:39 p.m., wound care observation was conducted with LPN (licensed practical nurse) #1. LPN #1 had set up her supplies before calling this writer in for the observation. LPN #1 with her gloves on removed Resident #3's old dressing. Resident #3 had a stage three pressure wound with minimal drainage. LPN #1 then removed her gloves and placed on new gloves. LPN #1 did not wash her hands before applying new gloves. LPN #1 washed the wound with soap and water. LPN #1 then cleaned the wound with normal saline and applied Santyl to a Q-tip. LPN #1 applied the Santyl into the wound bed using the Q-tip, and then covered the wound with a meplix border. LPN #1 removed her gloves, placed on new gloves, and put a new brief on the resident. LPN #1 then removed her gloves and washed her hands. On 4/5/18 at 4:45 p.m., an interview was conducted with LPN #1. When asked how to maintain infection control during wound care, LPN #1 stated that she should have washed her hands before putting on her new gloves. LPN #1 stated, I know that is what I missed. On 4/5/18 at 5:10 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the DON (director of nursing) and ASM #3, the administrative support clerk were made aware of the above concerns. The facility policy titled, treatment of [REDACTED]. Wash your hands thoroughly with soap and water at the following intervals: .d. when changing/removing gloves or any personal protective equipment. No further information was presented prior to exit. *A pressure ulcer is an inflammation or sore on the skin over a bony prominence (e.g., shoulder blade, elbow, hip, buttocks, or heel), resulting from prolonged pressure on the area, usually from being confined to bed. Most frequently seen in elderly and immobilized persons, decubitus ulcers may be prevented by frequently change of position, early ambulation, cleanliness, and use of skin lubricants and a water or air mattress. Also called bedsores. Pressure sores. Barron's Dictionary of Medical Terms for the Non Medical Reader 2006; Mikel A. Rothenberg, M.D. and [NAME] F. Chapman. Page 155. (1) Stage III pressure sore Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining and tunneling. Further description: The depth of a stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep stage III pressure ulcers. Bone/tendon is not visible or directly palpable. This information was obtained from National Pressure Ulcer Advisory Panel website at http://www.npuap.org/pr2.htm. (2) SANTYL® Ointment is an FDA-approved active enzymatic therapy that continuously removes necrotic tissue from wounds at the microscopic level. This works to free the wound bed of microscopic cellular debris, allowing granulation to proceed and [MEDICATION NAME] to occur. (<http://www.santyl.com/about>)

Based on staff interview, clinical record review, and facility document review, it was determined that facility staff failed to ensure residents were free from accidents or hazards for one of 14 residents in the survey sample, Resident #3. The facility staff failed to develop and implement fall preventive interventions after Resident #3 sustained fall on 1/5/18. The findings include: Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #3's most recent MDS (minimum data set) was a significant change assessment with an ARD (assessment reference date) of 1/19/18. Resident #3 was coded as being moderately impaired in cognitive function, scoring 10 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #3 was coded as requiring extensive assistance of one to two staff members with most ADLS (activities of daily living). Review of Resident #3's clinical record revealed that she went out to the hospital on [DATE]. The following nursing note was documented, Guest fell this AM (morning) 0745 (7:45 a.m.) in bathroom witnessed by CNA (certified nursing assistant). Hit head on toilet and implemented neuro (neurological) checks. 0940 (9:40 a.m.) resident sitting in DR (dining room) per her request for breakfast and stated her vision was blurry. BP (blood pressure) 72/42, HR (heart rate) 67, T (temperature) 97.4. Resident diaphoretic (sweaty) and clammy. Assisted back to bed x 2 assist and BP rechecked 88/52. MD (medical doctor) made aware and given orders to send resident to ER (emergency room ) for eval (evaluation), S/P (status/post) fall with head injury. Left facility at 1030 (10:30 a.m.) am with x 3 EMS (emergency services) personnel. Alert to voice and speech clear at the time. Able to answer all questions appropriately. Further review of Resident #3's clinical record revealed she was admitted to the hospital with [REDACTED]. Resident #3 arrived back to the facility on [DATE]. Review of Resident #3's fall care plan dated 6/20/17 and revised 10/24/17 failed to evidence the care plan was reviewed or updated following her 1/5/18 fall. Review of Resident #3's fall report dated 1/5/18 failed to evidence that an intervention was put into place to prevent future falls. Further review of Resident #3's clinical record revealed that she had not had any further falls since 1/5/18. On 4/5/18 at 9:52 a.m., an interview was conducted with ASM (administrative staff member) #2, the DON (director of nursing), regarding the process staff follows when a resident has a fall. ASM #2 stated, when a resident falls, a nurse would add an intervention at the time of the fall to prevent future falls. ASM #2 stated therapy will also evaluate a resident. When asked if the intervention that is put into place should be on the care plan, ASM #2 stated that it should. When asked about the importance of a fall intervention being added to the care plan, ASM #2 stated that it was important for the care plan to reflect the fall so everyone was in the loop and aware of the fall or any change in condition. When asked who had access to the care plan, ASM #2 stated that all team members have access to the care plan. ASM #2 stated the floor nurses and the MDS nurse could update the care plan. ASM #2 confirmed she did not see where the care plan was reviewed or updated after Resident #3's 1/5/18 fall. ASM #2 also viewed the incident report and confirmed that she did not see an intervention put into place after the 1/5/18 fall. On 4/5/18 at 5:10 p.m., ASM (administrative staff member) #1, the administrator, ASM #2 and ASM #3, the administrative support clerk were made aware of the above concerns. A policy could not be provided regarding the above concerns.

Based on staff interview, facility document review, and clinical record review, it was determined that facility staff failed to have the required documentation of a facility-initiated transfer for two of 14 residents, Resident #3 and #8. 1. For Resident #3, facility staff failed to evidence that all required information was provided to the receiving provider for a facility-initiated transfer on 1/5/18. 2. For Resident #8, facility staff failed to evidence that all required information was provided to the receiving provider for a facility-initiated transfer. The findings include: 1. Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #3's most recent MDS (minimum data set) was a significant change assessment with an ARD (assessment reference date) of 1/19/18. Resident #3 was coded as being moderately impaired in cognitive function, scoring 10 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #3 was coded as requiring extensive assistance with one to two staff members with most ADLS (activities of daily living). Review of Resident #3's clinical record revealed that she went out to the hospital on [DATE]. The following nursing note was documented, Guest fell this AM (morning) 0745 (7:45 a.m.) in bathroom witnessed by CNA (certified nursing assistant). Hit head on toilet and implemented neuro (neurological) checks. 0940 (9:40 a.m.) resident sitting in DR (dining room) per her request for breakfast and stated her vision was blurry. BP (blood pressure) 72/42, HR (heart rate) 67, T (temperature) 97.4. Resident diaphoretic (sweaty) and clammy. Assisted back to bed x 2 assist and BP rechecked 88/52. MD (medical doctor) made aware and given orders to send resident to ER (emergency room ) for eval (evaluation), S/P (status/post) fall with head injury. Left facility at 1030 (10:30 a.m.) am with x 3 EMS (emergency services) personnel. Alert to voice and speech clear at the time. Able to answer all questions appropriately. Further review of Resident #3's clinical record revealed that she was admitted to the hospital with [REDACTED]. Resident #3 arrived back to the facility on [DATE]. There was no evidence that all the required information; Resident #3's advanced directives, responsible party contact information, and Resident #3's care plan was provided to the hospital for the facility-initiated transfer. On 4/5/18 at 4:42 p.m., an interview was conducted with LPN (Licensed practical nurse) #1, the only nurse on the unit. When asked what documentation was sent with residents who were being transferred to the hospital, LPN #1 stated that she would send their advanced directives, a medication list, and any other pertinent information for the hospital staff. When asked if she would send the resident's care plan, LPN #1 stated she had never heard of nurses sending the care plan with the resident to the hospital. LPN #1 stated she was new to the unit and had not yet sent anyone out to the hospital. When asked if it should be documented that certain documentation was sent with the resident to the hospital, LPN #1 stated that she would write a general statement that all paperwork was sent out with the resident. LPN #1 stated she probably wouldn't specify which paperwork was sent with the resident. LPN #1 stated there was no way of knowing what paperwork was sent out with Resident #3 for her transfer on 1/5/18. On 4/6/18 at approximately 8:30 a.m., an interview was conducted with ASM (administrative staff member) #2, the Director of Nursing. ASM #2 handed this writer a checklist of items that are usually sent with every resident during a hospital transfer. The following was documented: Acute Care Transfer List, copies and documents sent with the patient (check all that apply): Patient transfer form, personal belongings identified on Patient Transfer Form are enclosed, Face sheet, Current Medication List or Current MAR (medication administration record), SBAR (situation, background, assessment, recommendation) and or other change in condition progress note, advance directives, advance care orders. Send these documents if available: Most recent history and physical, recent hospital discharge summary, recent MD/NP (nurse practitioner)/PA (physician's assistant) and Specialist orders, flow sheets, relevant lab (laboratory) results, Relevant X-Rays and other Diagnostic Test Results, Nursing Home Capabilities. Emergency Department: Please ensure that these documents are forwarded to the hospital unit if the patient is admitted . Thank you. ASM #2 could not evidence what was sent to the hospital with Resident #3. ASM #2 stated the care plan was also something that wasn't typically sent with the resident to the hospital. ASM #2 stated she was going to update her transfer checklist to include the care plan. On 4/5/18 at 5:10 p.m., ASM #1, the administrator, ASM #2 and ASM #3, the administrative support clerk were made aware of the above concerns. The facility policy titled, Transfer or Discharge notice, did not address the above concerns. No further information was presented prior to exit. 2. For Resident #8, facility staff failed to evidence that all required information was provided to the receiving provider for a facility-initiated transfer. Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #8's most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 3/17/18. Resident #8 was coded as being cognitively intact in the ability to make daily decisions scoring 15 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #8 was coded as requiring extensive assistance with one to two staff members with most ADLS (activities of daily living). Review of Resident #8's clinical record revealed he had been transferred to the hospital on [DATE]. The following was documented in a nursing note: Around 0400 (4:00 a.m.), CNAs (certified nursing assistants) alerted this writer that guest was cold to the touch. This writer assessed the guest and the tympanic temp (temperature) read 91.0. Multiple blankets were added over top of him. Blood sugar was taken and resulted at 47. Guest was slow to respond and had a blank stare on the wall. Guest was able to drink a cup of orange juice. BS was checked 15 minutes later to result at 41. He then has another cup of orange juice and BS was checked another 15 minutes later to result 33. This writer then called (Name of physician) around 4:30 a.m., who gave orders to send him out to the hospital. The DON (Director of Nursing) was also called. Vitals upon EMS arrival were: blood sugar 51, BP 70/38, respirations 14, HR (heart rate) 58 and irregular and temp 95.0. The next note dated 2/4/18 documented the following: POA (power of attorney), (Name of POA) updated on resident condition and being sent out to the hospital. In agreement with plan. Further review of the clinical record revealed that Resident #8 was admitted to the hospital with [REDACTED]. There was no evidence that all the required information; Resident #8's advanced directives, responsible party contact information, and Resident #8's care plan was provided to the hospital for the facility-initiated transfer. Resident #8 arrived back to the facility on [DATE]. On 4/5/18 at 4:42 p.m., an interview was conducted with LPN (Licensed practical nurse) #1, the only nurse on the unit. When asked what documentation was sent with residents who were being transferred to the hospital, LPN #1 stated that she would send their advanced directives, a medication list, and any other pertinent information for the hospital staff. When asked if she would send the resident's care plan, LPN #1 stated she had never heard of nurses sending the care plan with the resident to the hospital. LPN #1 stated she was new to the unit and had not yet sent anyone out to the hospital. When asked if it should be documented that certain documentation was sent with the resident to the hospital, LPN #1 stated that she would write a general statement that all paperwork was sent out with the resident. LPN #1 stated she probably wouldn't specify which paperwork was sent with the resident. LPN #1 stated there was no way knowing what paperwork was sent out with Resident #8 for his transfer on 2/4/18. On 4/6/18 at approximately 8:30 a.m., an interview was conducted with ASM (administrative staff member) #2, the Director of Nursing. ASM #2 handed this writer a checklist of items that are usually sent with every resident during a hospital transfer. The following was documented: Acute Care Transfer List, copies and documents sent with the patient (check all that apply): Patient transfer form, personal belongings identified on Patient Transfer Form are enclosed, Face sheet, Current Medication List or Current MAR (medication administration record), SBAR (situation, background, assessment, recommendation) and or other change in condition progress note, advance directives, advance care orders. Send these documents if available: Most recent history and physical, recent hospital discharge summary, recent MD/NP (nurse practitioner)/PA (physician's assistant) and Specialist orders, flow sheets, relevant lab (laboratory) results, Relevant X-Rays and other Diagnostic Test Results, Nursing Home Capabilities. Emergency Department: Please ensure that these documents are forwarded to the hospital unit if the patient is admitted . Thank you. ASM #2 could not evidence what was sent to the hospital with Resident #8. ASM #2 stated the care plan was also something that wasn't typically sent with the resident to the hospital. ASM #2 stated she was going to update her transfer checklist to include the care plan. On 4/5/18 at 5:10 p.m., ASM #1, the administrator, ASM #2 and ASM #3, the administrative support clerk were made aware of the above concerns. Facility policy titled, Transfer or Discharge notice, did not address the above concerns. No further information was presented prior to exit. (1) Lactic acidosis is a buildup of lactic acid in the blood. This information was obtained from The National Institutes of Health. https://search.nih.gov/search?utf8=%E2%9C%93&affiliate=nih&query=lactic+acidosis. (2)[MEDICAL CONDITION] is a serious illness. It happens when your body has an overwhelming immune response to a bacterial infection. The chemicals released into the blood to fight the infection trigger widespread inflammation. This information was obtained from The National Institutes of Health. https://medlineplus.gov/sepsis.html

Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide written notification to the resident representative and the long term care ombudsman for a facility-initiated transfer for two of 14 residents in the survey sample, Resident #3 and #8. 1. The facility staff failed to provide written notification to the resident representative and ombudsman when Resident #3 was transferred to the hospital on [DATE]. 2. The facility staff failed to provide written notification to the resident representative and ombudsman when Resident #8 was transferred to the hospital on [DATE]. The findings include: 1. Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #3's most recent MDS (minimum data set) was a significant change assessment with an ARD (assessment reference date) of 1/19/18. Resident #3 was coded as being moderately impaired in cognitive function, scoring 10 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #3 was coded as requiring extensive assistance of one to two staff members with most ADLS (activities of daily living). Review of Resident #3's clinical record revealed that she went out to the hospital on [DATE]. The following nursing note was documented, Guest fell this AM (morning) 0745 (7:45 a.m.) in bathroom witnessed by CNA (certified nursing assistant). Hit head on toilet and implemented neuro (neurological) checks. 0940 (9:40 a.m.) resident sitting in DR (dining room) per her request for breakfast and stated her vision was blurry. BP (blood pressure) 72/42, HR (heart rate) 67, T (temperature) 97.4. Resident diaphoretic (sweaty) and clammy. Assisted back to bed x 2 assist and BP rechecked 88/52. MD (medical doctor) made aware and given orders to send resident to ER (emergency room ) for eval (evaluation), S/P (status/post) fall with head injury. Left facility at 1030 (10:30 a.m.) am with x 3 EMS (emergency services) personnel. Alert to voice and speech clear at the time. Able to answer all questions appropriately. Further review of Resident #3's clinical record revealed she was admitted to the hospital with [REDACTED]. Resident #3 arrived back to the facility on [DATE]. Further review of Resident #3's clinical record revealed that she was admitted to the hospital with [REDACTED]. Resident #3 arrived back to the facility on [DATE]. On 4/5/18 at 1:25 p.m., an interview was conducted with LPN (Licensed practical nurse) #1, regarding the nurses' role when a resident is transferred out to the hospital. LPN #1 stated she would first assess the resident, and obtain vital signs to determine the need for the resident to be sent out. LPN #1 stated she would then call the physician to obtain an order to send the resident out to the hospital. LPN #1 stated she would also call the administrator, family or POA (power of attorney) and then the ambulance. When asked how she would notify the family, LPN #1 stated it is usually verbally over the phone. When asked if she would provide written notification to the family explaining the reason for resident transfer, LPN #1 stated, I haven't sent anyone to the hospital over here. LPN #1 stated she usually works in assisted living. When asked if nurses should be sending written notification to the long term care ombudsman regarding a resident's transfer to the hospital, LPN #1 stated, I will have to get verification on that one. On 4/5/18 at 3 p.m., an interview was conducted with OSM (other staff member) #7, the social worker. OSM #7 stated that she did not notify the long term care ombudsmen with every facility initiated transfer to the hospital. On 4/5/18 at 5:10 p.m., ASM (administrative staff member) #1, the administrator and ASM #2, the DON (Director of Nursing) were made aware of the above concerns. ASM #1 and ASM #2 stated they were not aware the resident's representative was to be notified in writing of the reason for transfer. ASM #1 and ASM #2 were also not aware the long term care ombudsman had to be provided written notification for every facility-initiated transfer to the hospital. The facility policy titled, Transfer or Discharge notice, did not address the above concerns. No further information was presented prior to exit. 2. The facility staff failed to provide written notification to the resident representative and ombudsman when Resident #8 was transferred to the hospital on [DATE]. Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #8's most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 3/17/18. Resident #8 was coded as being cognitively intact in the ability to make daily decisions scoring 15 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #8 was coded as requiring extensive assistance with one to two staff members with most ADLS (activities of daily living). Review of Resident #8's clinical record revealed he had been transferred to the hospital on [DATE]. The following was documented in a nursing note: Around 0400 (4:00 a.m.), CNAs (certified nursing assistants) alerted this writer that guest was cold to the touch. This writer assessed the guest and the tympanic temp (temperature) read 91.0. Multiple blankets were added over top of him. Blood sugar was taken and resulted at 47. Guest was slow to respond and had a blank stare on the wall. Guest was able to drink a cup of orange juice. BS was checked 15 minutes later to result at 41. He then has another cup of orange juice and BS was checked another 15 minutes later to result 33. This writer then called (Name of physician) around 4:30 a.m., who gave orders to send him out to the hospital. The DON (Director of Nursing) was also called. Vitals upon EMS arrival were: blood sugar 51, BP 70/38, respirations 14, HR (heart rate) 58 and irregular and temp 95.0. The next note dated 2/4/18 documented the following: POA (power of attorney), (Name of POA) updated on resident condition and being sent out to the hospital. In agreement with plan. Further review of the clinical record revealed Resident #8 was admitted to the hospital with [REDACTED]. Resident #8 arrived back to the facility on [DATE]. Further review of Resident #8's clinical record failed to evidence the RP (responsible party) was notified in writing of the reason for Resident #8's transfer to the hospital, and that the ombudsman received a copy of this written notification. On 4/5/18 at 1:25 p.m., an interview was conducted with LPN (Licensed practical nurse) #1, regarding the nurses' role when a resident is transferred out to the hospital. LPN #1 stated she would first assess the resident, and obtain vital signs to determine the need for the resident to be sent out. LPN #1 stated she would then call the physician to obtain an order to send the resident out to the hospital. LPN #1 stated she would also call the administrator, family or POA (power of attorney) and then the ambulance. When asked how she would notify the family, LPN #1 stated it is usually verbally over the phone. When asked if she would provide written notification to the family explaining the reason for resident transfer, LPN #1 stated, I haven't sent anyone to the hospital over here. LPN #1 stated she usually works in assisted living. When asked if nurses should be sending written notification to the long term care ombudsman regarding a resident's transfer to the hospital, LPN #1 stated, I will have to get verification on that one. On 4/5/18 at 3 p.m., an interview was conducted with OSM (other staff member) #7, the social worker. OSM #7 stated she did not notify the long term care ombudsmen with every facility initiated transfer to the hospital. On 4/5/18 at 5:10 p.m., ASM (administrative staff member) #1, the administrator and ASM #2, the DON (Director of Nursing) were made aware of the above concerns. ASM #1 and ASM #2 stated they were not aware the resident's representative was to be notified in writing of the reason for transfer. ASM #1 and ASM #2 were also not aware the long term care ombudsman had to be provided written notification for every facility-initiated transfer to the hospital. The facility policy titled, Transfer or Discharge notice, did not address the above concerns. No further information was presented prior to exit. (1) Lactic acidosis is a buildup of lactic acid in the blood. This information was obtained from The National Institutes of Health. https://search.nih.gov/search?utf8=%E2%9C%93&affiliate=nih&query=lactic+acidosis. (2)[MEDICAL CONDITION] is a serious illness. It happens when your body has an overwhelming immune response to a bacterial infection. The chemicals released into the blood to fight the infection trigger widespread inflammation. This information was obtained from The National Institutes of Health. https://medlineplus.gov/sepsis.html

Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to review and revise the comprehensive care plan for one of 14 residents in the survey sample, Resident #3. 1a. The facility staff failed to review or revise Resident #3's comprehensive care plan following a fall on 1/5/18. 1b. The facility staff failed to revise Resident #3's comprehensive care plan when an L2 (lumbar spine) compression fracture was found on 1/15/18. The findings include: 1a. Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #3's most recent MDS (minimum data set) was a significant change assessment with an ARD (assessment reference date) of 1/19/18. Resident #3 was coded as being moderately impaired in cognitive function, scoring 10 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #3 was coded as requiring extensive assistance of one to two staff members with most ADLS (activities of daily living). Review of Resident #3's clinical record revealed that she went out to the hospital on [DATE]. The following nursing note was documented, Guest fell this AM (morning) 0745 (7:45 a.m.) in bathroom witnessed by CNA (certified nursing assistant). Hit head on toilet and implemented neuro (neurological) checks. 0940 (9:40 a.m.) resident sitting in DR (dining room) per her request for breakfast and stated her vision was blurry. BP (blood pressure) 72/42, HR (heart rate) 67, T (temperature) 97.4. Resident diaphoretic (sweaty) and clammy. Assisted back to bed x 2 assist and BP rechecked 88/52. MD (medical doctor) made aware and given orders to send resident to ER (emergency room ) for eval (evaluation), S/P (status/post) fall with head injury. Left facility at 1030 (10:30 a.m.) am with x 3 EMS (emergency services) personnel. Alert to voice and speech clear at the time. Able to answer all questions appropriately. Further review of Resident #3's clinical record revealed she was admitted to the hospital with [REDACTED]. Resident #3 arrived back to the facility on [DATE]. Review of Resident #3's fall care plan dated 6/20/17 and revised 10/24/17 failed to evidence the care plan was reviewed or updated following her 1/5/18 fall. Review of Resident #3's fall report dated 1/5/18 failed to evidence that an intervention was put into place to prevent future falls. On 4/5/18 at 9:52 a.m., an interview was conducted with ASM (administrative staff member) #2, the DON (director of nursing), regarding the process staff follows when a resident has a fall. ASM #2 stated, when a resident falls, a nurse would add an intervention at the time of the fall to prevent future falls. ASM #2 stated therapy will also evaluate a resident. When asked if the intervention that is put into place should be on the care plan, ASM #2 stated that it should. When asked about the importance of a fall intervention being added to the care plan, ASM #2 stated that it was important for the care plan to reflect the fall so everyone was in the loop and aware of the fall or any change in condition. When asked who had access to the care plan, ASM #2 stated that all team members have access to the care plan. ASM #2 stated the floor nurses and the MDS nurse could update the care plan. ASM #2 confirmed she did not see where the care plan was reviewed or updated after Resident #3's 1/5/18 fall. ASM #2 also viewed the incident report and confirmed that she did not see an intervention put into place after the 1/5/18 fall. On 4/5/18 at 5:10 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the DON and ASM #3, the administrative support clerk were made aware of the above concerns. The facility policy titled, Care Plans documents in part the following: An comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .The Care Planning/Interdisciplinary team is responsible for the review and updating care plans: a. when there has been a significant change in the resident's condition. b. When the desired outcome is met. c. When the resident has been readmitted to the facility from a hospital stay; and d. At least quarterly, in conjunction with the required quarterly MDS assessment. According to Fundamentals of Nursing Lippincott Williams and Wilkins 2007 pages 65-77 documented, A written care plan serves as a communication tool among health care team members that helps ensure continuity of care .The nursing care plan is a vital source of information about the patient's problems, needs, and goals. It contains detailed instructions for achieving the goals established for the patient and is used to direct care .expect to review, revise and update the care plan regularly, when there are changes in condition, treatments, and with new orders . No further information was provided prior to exit. 1b. The facility staff failed to revise Resident #3's comprehensive care plan when an L2 (lumbar spine) compression fracture was found on 1/15/18. Review of Resident #3's clinical record revealed that she went out to the hospital on [DATE]. The following nursing note was documented, Guest fell this AM (morning) 0745 (7:45 a.m.) in bathroom witnessed by CNA (certified nursing assistant). Hit head on toilet and implemented neuro (neurological) checks. 0940 (9:40 a.m.) resident sitting in DR (dining room) per her request for breakfast and stated her vision was blurry. BP (blood pressure) 72/42, HR (heart rate) 67, T (temperature) 97.4. Resident diaphoretic (sweaty) and clammy. Assisted back to bed x 2 assist and BP rechecked 88/52. MD (medical doctor) made aware and given orders to send resident to ER (emergency room ) for eval (evaluation), S/P (status/post) fall with head injury. Left facility at 1030 (10:30 a.m.) am with x 3 EMS (emergency services) personnel. Alert to voice and speech clear at the time. Able to answer all questions appropriately. Further review of Resident #3's clinical record revealed she was admitted to the hospital with [REDACTED]. Resident #3 arrived back to the facility on [DATE]. Further review of Resident #3's clinical record revealed that Resident #3 started to complain of increased back pain following her fall. An x-ray was ordered on [DATE]. The x-ray dated 1/15/18, documented the following: Age-indeterminate mild to moderate L2 compression fracture. CT (computed tomography) is recommended. A nursing note dated 1/17/18 documented that Resident #3's responsible party had declined the CT scan. Review of Resident #3's care plan dated 6/20/17 and revised 4/5/18 did not evidence her L2 compression fracture. On 4/5/18 at 9:52 a.m., an interview was conducted with ASM (administrative staff member) #2, the DON (director of nursing). When asked if Resident #3's L2 fracture should be reflected on her care plan. ASM #2 stated that it should be. ASM #2 stated she would expect the fracture to be on the care plan so that facility staff know how to transfer the resident and know how to monitor and manage the resident's pain. When asked who had access to the care plan, ASM #2 stated that all team members have access to the care plan. ASM #2 stated the floor nurses and the MDS nurse could update the care plan. ASM #2 confirmed she did not see where the care plan was updated after the discovery of Resident #3's L2 compression fracture. On 4/5/18 at 5:10 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the DON and ASM #3, the administrative support clerk were made aware of the above concerns. No further information was provided prior to exit.

Based on resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide a written bed hold notice for a facility initiated transfer for two of 14 residents in the survey sample, Residents #3 and #8. 1. The facility staff failed to provide Resident #3 or the resident's representative written notification of the bed hold policy when the resident was discharged to the hospital on [DATE]. 2. The facility staff failed to provide Resident #8 or the resident's representative written notification of the bed hold policy when the resident was discharged to the hospital on [DATE]. The finding include: 1. Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #3's most recent MDS (minimum data set) was a significant change assessment with an ARD (assessment reference date) of 1/19/18. Resident #3 was coded as being moderately impaired in cognitive function, scoring 10 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #3 was coded as requiring extensive assistance of one to two staff members with most ADLS (activities of daily living). Review of Resident #3's clinical record revealed that she went out to the hospital on [DATE]. The following nursing note was documented, Guest fell this AM (morning) 0745 (7:45 a.m.) in bathroom witnessed by CNA (certified nursing assistant). Hit head on toilet and implemented neuro (neurological) checks. 0940 (9:40 a.m.) resident sitting in DR (dining room) per her request for breakfast and stated her vision was blurry. BP (blood pressure) 72/42, HR (heart rate) 67, T (temperature) 97.4. Resident diaphoretic (sweaty) and clammy. Assisted back to bed x 2 assist and BP rechecked 88/52. MD (medical doctor) made aware and given orders to send resident to ER (emergency room ) for eval (evaluation), S/P (status/post) fall with head injury. Left facility at 1030 (10:30 a.m.) am with x 3 EMS (emergency services) personnel. Alert to voice and speech clear at the time. Able to answer all questions appropriately. Further review of Resident #3's clinical record revealed she was admitted to the hospital with [REDACTED]. Resident #3 arrived back to the facility on [DATE]. A bed hold policy signed by the representative on 6/22/17 was found in Resident #3's chart. Further review of the clinical record failed to evidence a copy of the written bed hold notice for the facility-initiated transfer to the hospital on [DATE]. Review of the (MONTH) (YEAR) social worker notes failed to evidence that the bed hold policy was discussed with the resident or representative for the 1/5/18 facility-initiated transfer to the hospital. On 4/5/18 at approximately 12:15 p.m., an interview was conducted with Resident #3. She could not recall the day she was transferred to the hospital on [DATE]. On 4/5/18 at 1:25 p.m., an interview was conducted with LPN (Licensed practical nurse) #1, regarding the nurses' role when a resident is transferred out to the hospital. When asked who was responsible for offering the bed hold policy at the time of a transfer, LPN # 1 stated that she was not sure about bed holds. LPN #1 stated she has never sent anyone out to the hospital on the nursing unit. LPN #1 stated that she normally works for assisted living. On 4/5/18 at 3 p.m., an interview was conducted with OSM (other staff member) #7, the social worker. OSM #7 stated that when a resident is sent to the hospital, the nurse is supposed to ask them about the bed hold. OSM #7 stated the nurses should go over the bed hold policy that was signed by the resident and/or resident representative upon admission to the facility, at the time of transfer. OSM #7 stated if the resident is admitted to the hospital, she will follow up with the family member about whether they want to hold the bed. OSM #7 stated she would notify them over the telephone and get a verbal confirmation. When asked if she writes a note that she went over the bed hold policy with the family, OSM #7 stated, Typically yes. When asked if the resident is provided written notification of the bed hold policy during the time of transfer, OSM #7 stated, They get the bed hold policy on admission. The resident or resident representative signs the policy and it is placed in their chart. Admissions goes over the bed hold policy during the resident's admission. At the time of transfer, the nurses go over that form with the resident. OSM #7 confirmed residents do not receive written bed hold notification at the time of transfer to the hospital. On 4/5/18 at 5:10 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the DON (Director of Nursing) and ASM #3, the administrative support clerk were made aware of the above concerns. No further information was provided prior to exit. Review of the facility's Bed Hold Policy documents in part the following: You are being sent to the hospital today. If your stay is covered by Medicare, Medicaid or a private insurance carrier, your insurance will not pay to hold your room while you are in the hospital. Additionally, private pay residents must continue to pay for the room while at the hospital to reserve the room. If you do not wish to pay for your room while you are in the hospital, there is a possibility that someone else may be admitted to that room . 2. The facility staff failed to provide Resident #8 or the resident's representative written notification of the bed hold policy when the resident was discharged to the hospital on [DATE]. Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #8's most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 3/17/18. Resident #8 was coded as being cognitively intact in the ability to make daily decisions scoring 15 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #8 was coded as requiring extensive assistance with one to two staff members with most ADLS (activities of daily living). Review of Resident #8's clinical record revealed he had been transferred to the hospital on [DATE]. The following was documented in a nursing note: Around 0400 (4:00 a.m.), CNAs (certified nursing assistants) alerted this writer that guest was cold to the touch. This writer assessed the guest and the tympanic temp (temperature) read 91.0. Multiple blankets were added over top of him. Blood sugar was taken and resulted at 47. Guest was slow to respond and had a blank stare on the wall. Guest was able to drink a cup of orange juice. BS was checked 15 minutes later to result at 41. He then has another cup of orange juice and BS was checked another 15 minutes later to result 33. This writer then called (Name of physician) around 4:30 a.m., who gave orders to send him out to the hospital. The DON (Director of Nursing) was also called. Vitals upon EMS arrival were: blood sugar 51, BP 70/38, respirations 14, HR (heart rate) 58 and irregular and temp 95.0. The next note dated 2/4/18 documented the following: POA (power of attorney), (Name of POA) updated on resident condition and being sent out to the hospital. In agreement with plan. Further review of the clinical record revealed that Resident #8 was admitted to the hospital with [REDACTED]. Resident #8 arrived back to the facility on [DATE]. A bed hold policy signed by the representative on 12/13/17 was found in Resident #8's chart. Further review of the clinical record failed to evidence a copy of the written bed hold notice for the facility initiated transfer to the hospital on [DATE]. Review of the (MONTH) (YEAR) social worker notes failed to evidence that the bed hold policy was discussed with the resident or representative. On 4/5/18 at 12:56 p.m., an interview was conducted with Resident #8. Resident #8 could not recall being offered a bed hold policy prior to transfer. On 4/5/18 at 1:25 p.m., an interview was conducted with LPN (Licensed practical nurse) #1, regarding the nurses' role when a resident is transferred out to the hospital. When asked who was responsible for offering the bed hold policy at the time of a transfer, LPN # 1 stated that she was not sure about bed holds. LPN #1 stated she has never sent anyone out to the hospital on the nursing unit. LPN #1 stated that she normally works for assisted living. On 4/5/18 at 3 p.m., an interview was conducted with OSM (other staff member) #7, the social worker. OSM #7 stated that when a resident is sent to the hospital, the nurse is supposed to ask them about the bed hold. OSM #7 stated the nurses should go over the bed hold policy that was signed by the resident and/or resident representative upon admission to the facility, at the time of transfer. OSM #7 stated if the resident is admitted to the hospital, she will follow up with the family member about whether they want to hold the bed. OSM #7 stated she would notify them over the telephone and get a verbal confirmation. When asked if she writes a note that she went over the bed hold policy with the family, OSM #7 stated, Typically yes. When asked if the resident is provided written notification of the bed hold policy during the time of transfer, OSM #7 stated, They get the bed hold policy on admission. The resident or resident representative signs the policy and it is placed in their chart. Admissions goes over the bed hold policy during the resident's admission. At the time of transfer, the nurses go over that form with the resident. OSM #7 confirmed residents do not receive written bed hold notification at the time of transfer to the hospital. On 4/5/18 at 5:10 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the DON (Director of Nursing) and ASM #3, the administrative support clerk were made aware of the above concerns. No further information was provided prior to exit. (1) Lactic acidosis is a buildup of lactic acid in the blood. This information was obtained from The National Institutes of Health. https://search.nih.gov/search?utf8=%E2%9C%93&affiliate=nih&query=lactic+acidosis. (2)[MEDICAL CONDITION] is a serious illness. It happens when your body has an overwhelming immune response to a bacterial infection. The chemicals released into the blood to fight the infection trigger widespread inflammation. This information was obtained from The National Institutes of Health. https://medlineplus.gov/sepsis.html