Every finding on record at Union County Nursing Home

Based on observations, staff interviews, record review, and review of the facility's policy titled, Comprehensive Care Plan Meetings, the facility failed to implement the comprehensive care plan for one of 34 residents (R) (R82). The deficient practice had the potential to prevent R82 from receiving services according to their care needs.Findings include:Review of the facility's undated policy titled, Care Plan Meetings revealed under Purpose: .Each resident will have an individualized interdisciplinary plan of care in place.The Comprehensive Care plan will be ongoing, focusing on each induvial resident as a unitary being. Resident and their representative will play an active role in the development of goals and implementation of the residents' Comprehensive Care Plan. Under Procedure: number 2.This comprehensive care plan will address resident goals, actual and potential problems, needs, strengths, and individual preferences for the resident.Review of R82's Electronic Medical Record (EMR) revealed diagnoses that included, but were not limited to bilateral hearing loss, receptive expressive language disorder, dementia, cognitive communication deficit. Review of R82's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 04, indicating severe cognitive impairment; Section B (Hearing, Speech, and Vision) a score of 2 for hearing, indicating moderate difficulty-the speaker has to increase volume and speak distinctly-and that a hearing aid or other hearing appliance is used.Review of the care plan dated 5/1/2024 revealed the following problem: She has moderate hearing difficulty with the use of her hearing aids. The speaker must adjust voice tone and speak distinctly. Per resident's daughter, she has 80% hearing loss and is good at reading lips. On 9/25/2024, the family brought in new hearing aids. She has clear speech and is usually understood. She usually understands others. Interventions included: Face resident and speak distinctly when in conversation with her. Provide hearing aid care and storage as ordered. Assist resident as needed.Review of the physician orders revealed an order: Nurse to insert hearing aids daily and ensure hearing aids are on charger every night, two times a day.During an initial screening on 9/30/2025 at 10:04 am, R82 was observed lying in bed and noted to be very hard of hearing, loudly telling the surveyor that she is deaf. Bilateral hearing aids were observed fully charged, with green indicator lights on, sitting on the bedside drawer. R82 asked the surveyor to place them in, stating that it'll help me hear better, and added that staff needed to help her get them in.On 9/30/2025 at 2:40 pm, staff were observed leaving the room. When the surveyor entered, the charged hearing aids were still on the bedside table and not in the resident's ears. R82 did not hear the surveyor, pointed to the hearing aids, again fully charged with green indicator lights on, and stated she can't hear.On 10/1/2025 at 8:26 am, 12:45 pm, and 4:20 pm, R82 was observed lying in bed without hearing aids, which remained on the bedside drawer, fully charged. Communication between the surveyor and R82 was unsuccessful, as R82 asked the surveyor to come closer, stated she was deaf, and again asked the surveyor to place her hearing aids in and check if they were working.Interview on 10/1/2025 at 4:28 pm, with Licensed Practical Nurse (LPN) AA, revealed that when communicating with R82 she comes close, speaks loudly, and that R82 can also read lips. When asked if she places the hearing aids in R82's ears, LPN AA paused for a moment and replied, The hearing aids were in, I saw them in her ears. The surveyor and LPN then entered the resident's room, where LPN AA acknowledged that the hearing aids were not in the resident's ears but were on the bedside drawer.In a phone interview on 10/2/2025 at 9:40 am, with the family member for R82 revealed that staff are supposed to place the residents' hearing aids in the morning and remove them at night, but they often forget to do so. She further stated that this concern had been discussed with staff during interdisciplinary team meetings.Interview on 10/2/2025 at 9:53 am, with the Registered Nurse (RN/MDS coordinator, she stated that care plans are individualized for each resident and developed to address their specific diagnoses and conditions. She explained that care plans guide staff in providing appropriate care and are updated as needed to reflect changes in the residents' condition. She added that her expectation is for staff to refer to the care plan when providing daily care and services.Interview on 10/2/2025 at 10:00 am with the Director of Nursing (DON), revealed that her expectation is for nursing staff to follow the care plans in the course of their work to ensure residents receive care as planned.

Based on observations, staff interviews, record review, and review of the facility's policy titled, Administration of Medications, the facility failed to ensure one of four residents (R) (R82) bilateral hearing aids were applied as ordered by the physician. The deficient practice had the potential to reduce R82 quality of life by increasing the probability of impaired communication.Findings include:Review of the facility's policy titled, Administration of Medications, dated 2/2021, revealed under Procedure: D. The person administering the drugs immediately following the administration must chart medication administration as being given on the eMAR. The eMAR applies the date, time administered, dosage, ect., and e-signs by the person entering the data.Review of R82's Electronic Medical Record (EMR) revealed diagnoses that included, but were not limited to bilateral hearing loss, receptive expressive language disorder, dementia, and cognitive communication deficit.Review of R82's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 04, indicating severe cognitive impairment; Section B (Hearing, Speech, and Vision) a score of 2 for hearing, indicating moderate difficulty-the speaker has to increase volume and speak distinctly-and that a hearing aid or other hearing appliance is used.Review of the care plan dated 5/1/2024 revealed the following problem: She has moderate hearing difficulty with the use of her hearing aids. The speaker must adjust voice tone and speak distinctly. Per resident's daughter, she has 80% hearing loss and is good at reading lips. On 9/25/2024, the family brought in new hearing aids. She has clear speech and is usually understood. She usually understands others. Interventions included: Face resident and speak distinctly when in conversation with her. Provide hearing aid care and storage as ordered. Assist resident as needed.Review of the physician orders revealed an order: Nurse to insert hearing aids daily and ensure hearing aids are on charger every night, two times a day.Review of the Medication Administration Record (MAR) for the last month revealed that the task of inserting hearing aids daily and ensure hearing aids were on the charger every night, twice a day at 9 am and 9 pm, was checked as completed without omissions.During an initial screening on 9/30/2025 at 10:04 am, R82 was observed lying in bed and noted to be very hard of hearing, loudly telling the surveyor that she is deaf. Bilateral hearing aids were observed fully charged, with green indicator lights on, sitting on the bedside table. R82 asked the surveyor to place them in, stating that it'll help me hear better, and added that staff needed to help her get them in.Observation on 9/30/2025 at 2:40 pm, staff were observed leaving the room after providing care. When the surveyor entered, the charged hearing aids were still on the bedside table and not in the resident's ears. R82 did not hear the surveyor, pointed to the hearing aids, again fully charged with green indicator lights on, and stated she can't hear.Observations on 10/1/2025 at 8:26 am, 12:45 pm, and 4:20 pm, R82 was observed lying in bed without hearing aids, which remained on the bedside table, fully charged. Communication between the surveyor and R82 was unsuccessful, as R82 asked the surveyor to come closer, stated she was deaf, and again asked the surveyor to place her hearing aids in and check if they were working.Interview on 10/1/2025 at 4:28 pm, with Licensed Practical Nurse (LPN) AA, who was responsible for the care of R82 was asked how she communicates with the resident, LPN AA stated that she comes close, speaks loudly, and that R82 can also read lips. When asked if she places the hearing aids in R82's ears, LPN AA replied, The hearing aids were in, I saw them in her ears. The surveyor and LPN then entered the resident's room, where LPN AA acknowledged that the hearing aids were not in the resident's ears but were on the bedside table. Continued interview also revealed that staff member was asked about the physician's order documented on the MAR, Nurse to insert hearing aids daily and ensure hearing aids are on charger every night, two times a day, LPN AA could not explain why she had documented the task as completed when it had not been done. She admitted that going forward, she would follow the MAR more closely.Phone interview on 10/2/2025 at 9:40 am with the family member of R82 revealed that staff are supposed to place the residents' hearing aids in the morning and remove them at night, but they often forget to do so. She further stated that this concern had been discussed with staff during interdisciplinary team meetings.Interview on 10/2/2025 at 10:00 am with the Director of Nursing (DON), she stated that her expectation is for nursing staff to follow physician's orders as written, and that if a task is checked off on the MAR, it indicates that the task-whether medication administration or inserting hearing aids-has been completed.

Based on observations, staff interviews, record review, and review of the facility's policies, titled Cleaning and Disinfection of Resident-Care Items and Equipment and Enhanced Barrier Precautions, the facility failed to ensure infection control practices were followed for four of 15 residents (R) (R7, R9, R75 and R83). Specifically, the facility failed to maintain Enhanced Barrier Precautions (EBP) when administering medications via gastrostomy tube for R9, and providing urinary catheter care for R7, the facility also failed to ensure shared medical equipment was sanitized between R75 and R83 during medication administration.Findings include:Review of the facility's policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment, revised 2/2021 under Policy Interpretation and Implementation: 1.c.non-critical items are those that come in contact with intact skin but not mucous membranes. 1. Non- critical resident-care items include bedpans, blood pressure cuffs, crutches and computers. d. Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment).Review of the facility's undated policy titled, Enhanced Barrier Precautions, under Policy Explanation and Compliance Guidelines: Number two (2.) Initiation of Enhance Barrier Precautions: b. An order for enhanced barrier precautions will be obtained for residents with any of the following: I. Wounds.and /or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes.PICC lines .even if the resident is not known to be infected or colonized with a MDRO.3. Implementation of Enhanced Barrier Precautions: a. Make gowns and gloves available immediately near or outside of the resident's room.b. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities.4. High-contact resident care activities include a. Dressing b. Bathing c. Transferring d. Providing hygiene e. Changing linens. F. Changing briefs or assisting with toileting. g. Device care or use: central lines, urinary catheters, feeding tubes, .PICC lines.h. Wound care: any skin opening requiring a dressing.Observation on 10/1/2025 at 8:35 am, revealed Licensed Practical Nurse (LPN) AA performed a blood pressure check on R83 prior to administering medications and did not clean the blood pressure cuff or the pulse oximeter either before or after checking the resident's vitals.Observation on 10/1/2025 at 8:45 am, revealed LPN AA proceeded to check R75 blood pressure without sanitizing the blood pressure cuff or the pulse oximeter before or after use. Immediately following the task.Interview on 10/1/2025 with LPN AA confirmed that the blood pressure cuff and pulse oximeter was not sanitized between residents use and should have been. LPN AA stated that the wipes were missing from the basket attached to the machine for use.2. Review of R9 electronic medical records revealed diagnoses that included, but were not limited to dysphagia, and gastrostomy status.Review of the care plan dated 7/22/2025 revealed the following problems and interventions:The resident requires a feeding tube to meet nutrition, and hydration needs related to diagnoses of dysphagia (oral and oropharyngeal phases) and gastroesophageal reflux disease (GERD).Review of the last Quarterly MDS assessment dated [DATE] revealed in Section K (Swallowing/Nutritional Status) that Resident 9 (R9) was receiving tube feedings.Review of the physician's orders revealed the following: The resident is NPO (nothing by mouth) and receives nutrition and medications through a PEG tube only. The resident is to remain on enhanced barrier precautions.Observation on 10/1/2025 at 1:23 pm, LPN AA administered a bolus feeding and medications via PEG tube to R 9. LPN AA wore only gloves as Personal Protective Equipment (PPE) and did not don a gown while providing the feeding and medication administration. Upon exiting the room, the surveyor asked LPN AA what the Enhanced Barrier Precautions (EBP) signage posted above the door indicated. LPN AA read the sign aloud and stated, I should have gowned up before providing care, but was unable to explain the purpose of the precaution or the rationale for donning a gown prior to care.Review of R7's electronic medical records revealed diagnosed included but not limited to UTI, Foley catheter to be placed for dx obstructive uropathy, BPH with lower urinary tract symptoms, acute kidney failure, chronic kidney disease-stage 4, and acquired absence of kidney.Review of the admission Minimum Data Set, dated [DATE] revealed section H Bladder and Bowels: indwelling catheter.Review of R7's care plan revealed that the resident requires an indwelling Foley catheter due to a diagnosis of obstructive uropathy. Interventions include changing the Foley catheter and drainage bag based on clinical indications, such as infection, obstruction, or when the closed system is compromised.Observation on 10/1/2025 at 2:30 pm, revealed catheter care was provided to R7 by two Certified Nursing Assistants (CNAs), CNA BB and CNA CC, neither CNA wore gowns during the procedure. When asked what the signage posted by the door meant, CNA BB stated that it meant to gown up but explained that the infection control nurse had told them they did not need to. CNA CC then corrected CNA BB, stating that gowns were required when providing close-contact care.In a joint interview on 10/1/2025 at 2:40 pm, with the Unit Manager/Infection Preventionist Registered Nurse (RN DD) and the Director of Nursing (DON) they stated that Enhanced Barrier Precautions (EBP) are used to protect residents during high-risk activities such as wound care, urinary catheter care, enteral feeding, and central line care. They explained that the facility does not write specific physician orders or care plan entries for EBP; rather, signage posted on the resident's door indicates that PPE is required. The DON added that her expectation is for staff to don gowns when providing high-contact care to residents with a catheter, PEG tube, PICC line, or wound. Regarding shared medical equipment, the DON further stated that her expectation is for staff to sanitize all shared equipment between each resident use.

Based on observation, staff interviews, and review of the facility-provided document titled Texture Modification Inservice, the facility failed to ensure a puree recipe was followed to conserve the nutrient value of puree country-fried steak for six of six residents receiving a pureed diet. This deficient practice had the potential to cause residents receiving a pureed diet to have a decreased nutritional intake and a potential for weight loss. Findings include: Review of the undated facility-provided document titled Texture Modification Inservice revealed the section titled Guidelines for Texture Modification: Pureed Foods included Never free pour large amounts of liquids or thickeners into purees as it can impact the nutritional value and quality of the food item. Observation on 6/26/2024 at 10:45 am of the Dietary Manager in Training (DMIT) BB preparing pureed foods revealed she did not have or follow a recipe as she prepared the pureed country-fried steaks. DMIT BB prepared the pureed country-fried steak with broth and several cups of water. In an interview during the observation, she stated that she had been working at the facility for three days. DMIT BB stated she did not receive orientation but did receive on-the-job training. DMIT BB stated that the facility policy allows them to modify as needed when preparing pureed food. An interview on 6/26/2024 at 10:50 am with the Registered Dietitian (RD) revealed that he has been working at the facility for three years. The RD stated there was a recipe for pureed food, but it was not provided. An interview on 6/26/2024 at 11:45 am with the Dietary Manager (DM) revealed that water should not be used in preparing pureed food. The DM stated the use of water in preparing pureed food takes away from the nutritional value of the food. An interview on 6/26/2024 at 11:55 am with the District Manager confirmed that pureed food should not be prepared with water. He stated that he would be providing an in-service to staff today. An interview on 6/27/2024 at 3:43 pm with the Administrator revealed that kitchen staff should not use water when preparing pureed food.

Based on observation, staff interviews, and review of the facility's policy titled Receiving, the facility failed to appropriately label and date food items stored in the kitchen's walk-in freezer. The deficient practice(s) had the potential to place 96 residents who received an oral diet from the kitchen at risk of contracting a foodborne illness. The facility census was 101. Findings include: A review of the facility's policy titled Receiving revealed the Policy Statement of Safe food handling procedures for time and temperature control will be practiced in the transportation, delivery, and subsequent storage of all food items. The Procedures section documented 5. All food items will be appropriately labeled and dated either by manufacturer packaging or staff notation. An observation of the walk-in freezer in the kitchen with the Registered Dietitian (RD) and Dietary Manager (DM) on 6/25/2024 at 9:15 am revealed two open boxes of cookie dough with about 60 cookies in one box and 80 cookies in the other box. The RD confirmed the two boxes of cookie dough were opened and not labeled with an opened or discard date. In an interview on 6/26/2024 at 11:55 am, the District Manager confirmed all open foods should be labeled with a date before being placed in the freezer. He stated that he would be providing an in-service to staff today. In an interview on 6/27/2024 at 3:43 pm, the Administrator stated all open food items should be labeled with a date when opened.

Based on observations, staff interviews, and review of the facility policy titled, Storage of Medication, the facility failed to properly maintain, and store three of six medication cart as evidenced by missing end of shift controlled medication count signatures. Findings include: Review of the facility policy titled Storage of Medication revised April 2007 revealed under Policy Statement: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Observation on 6/27/2024 at 9:45 am of three of six medication carts revealed each cart had a controlled substance book which had the current months End of Shift Controlled Drug Count sheet in each book. The Pink A Hall sheet was missing five signatures, the pink B Hall sheet was missing 10 signatures, and the blue C Hall was missing three signatures on their sheets. Interview on 6/27/2024 at 9:52 am with RN NN revealed that the Medication Room Pink B Hall had no issues and the medication cart - Pink B Hall cart had no storage issues. The interview revealed that the nurse who was coming on and the nurse who was going off shift was responsible to count their cart at the end/beginning of each shift. She stated if the nurse worked a partial shift, the medication cart was counted at the beginning and end of the partial shift as well and documented in the eight-hour shift column. She confirmed and verified there were multiple missing signatures from the Narcotic Shift Count Sheet. Observation and interview on 6/27/2024 at 9:58 am of the medication cart - Pink A Hall with Licensed Practical Nurse (LPN) LL revealed the Narcotic Count Sheet had five spaces not signed by the oncoming /off going nurse. She stated the document should be signed by both nurses at the start of each shift (on coming/off going nurse). She stated when nurses do not work a 12- hour shift due to a call out, they come in to fill in for four to eight hours that the nurse who called out would sign in the column indicated for partial shifts. She stated the Unit Manager removed the count sheet at the end of each month, but she was not sure what happened to them after they were removed from the narcotic book. Observation and interview on 6/27/2024 at 10:30 am of the medication cart on the Blue B and C Hall with LPN KK revealed that the count sheet was signed by the nurse as the count was completed at the beginning and end of each nurse's shift. She stated if the nurse was not working a full 12-hour shift, they have a column for partial shift staff to sign and validate the narcotic count was completed. She confirmed and verified that there were some days on the count sheet that did not have a nurse signature for end/beginning of shift counts. She confirmed the sheets were removed by the unit manager at the end of each month. Interview on 6/27/2024 at 10:59 am with the Director of Nurses (DON) revealed that she confirmed and verified the narcotic sheets for three carts were missing nurse's signatures. She verified and confirmed the End of Shift Controlled Drug Count sheet for the Pink B cart was missing 10 signatures, the Pink A cart was missing five signatures, and the Blue cart was missing three signatures. She stated the purpose of the narcotic count and signing the narcotic sheets was to validate the count of the controlled substances on each cart is correct. She stated if the count was not documented this could result in the count not being correct or staff not knowing the count was correct at the end/beginning of their shift. She stated she did not know why this had occurred except that it was an oversight of the nurse who was working on the indicated shifts without signatures. She stated they removed the narcotic sheet at the end of each month and reviewed them. She revealed that if there were any days missing signatures, she would find the nurse responsible for that shift and then she would provide education to the nurse.

Based on staff interviews, record review, and review of the facility policies titled, Antipsychotic Drug Use and PRN Medication, the facility failed to make recommendations to include stop dates for psychoactive medications lorazepam, used to treat anxiety, and trazodone, used to treat insomnia, which were prescribed as needed (PRN) for two of five sampled residents (R18 and R64). The deficiency had the potential to adversely affect the severity of the diagnoses for which they were prescribed. Findings include: Review of the undated facility policy titled, Antipsychotic Drug Use revealed under Policy Interpretation and Implementation: The need to continue PRN orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. Review of the facility policy titled PRN Medication, revised 11/7/2022, revealed the Policy was The pharmacist is responsible for assuring appropriate and safe prescribing procedures are followed. The frequency with which PRN or as needed medications may be administered must be monitored to avoid interactions with other medications and to avoid exceeding maximum recommended dosing. The Procedure section stated: I. All physician medication orders which indicate a frequency for administration of PRN or as needed must state how often and for what indications the medication(s) may be administered. Exceptions to this include medications for which only one indication is approved. 1. Review of the Electronic Medical Record (EMR) for R18 revealed she was admitted to the facility with diagnoses to include spondylosis without myelopathy or radiculopathy, delusional disorder, and vascular dementia. Review of the Quarterly Minimum Data Set assessment for R18, dated 4/8/2024 revealed, Section C (Cognitive Patterns) a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment; Section D (Mood) revealed, a Mood score of zero, indicating no depression.; Section E (Behavior) revealed, she displayed verbal behaviors towards others and other behaviors not directed towards others; Section N (Medications) revealed, she received antipsychotic, antidepressant, and diuretic medications during the seven-day assessment period. Review of the care plan for R18 revealed a focus concern for insomnia diagnosis and risk for having trouble sleeping. Interventions included medicate as/if ordered and notify [physician] if medication is ineffective. Review of R18's Medication Administration Record (MAR) for June 2024 included an order for trazodone 100 milligrams (mg) tablet by mouth, dated 12/28/2023, to be given as needed (PRN) at bedtime for insomnia. Continued review of the MAR revealed it was given once in June 2024, not given in May 2024, and given once in April 2024. There was no stop date indicated. Review of the monthly Record of Medication Regimen and Chart Review from June 2023 through June 2024 revealed no recommendations related to the duration of the PRN medication, trazodone. 49673 2. Review of the clinical record revealed R64 was admitted to the facility on [DATE] with diagnoses including, but not limited to, major depressive disorder and mild pain. Review of R64's most recent Minimum Data Set (MDS), dated [DATE], revealed Section N (Medications) documented the resident received an antianxiety for seven of seven days. Review of the Physician Orders dated 12/8/2023 revealed an order for lorazepam (a medication used to treat anxiety) 0.5 milligrams (MG) tablet by mouth as needed every eight hours for agitation. Review of R64's December 2023 through June 2024 Medication Record revealed lorazepam 0.5 milligrams (MG) tablet by mouth as needed every eight hours for agitation with start date of 12/11/2023 and no stop date. In a telephone interview with the Consultant Pharmacist on 6/27/2024 at 6:00 pm, revealed when asked if he knew that Centers for Medicare and Medicaid (CMS) required some psychoactive medication physician orders required a stop date if ordered as needed (PRN), he stated he was aware of the regulation. He confirmed that trazodone, used to treat depression, and lorazepam, used to treat anxiety, were among those medications which required a stop date if ordered PRN. He stated when the pharmacy received a PRN order for trazodone or lorazepam, the pharmacist should contact the physician for an amended order. He confirmed the PRN physician orders for R18, and R64 should have included a stop date which he believed the pharmacy recommended but was unable to locate the documentation. He stated the pharmacy makes an effort to communicate with the provider, but he would still fulfill the order as written. In an interview on 6/27/2024 at 6:08 pm, Pharmacist OO revealed R64's lorazepam was prescribed for agitation. Pharmacist OO confirmed on 5/21/2024, they sent a change of order but were unable to find it. Pharmacist OO confirmed lorazepam required a stop date. Pharmacist OO revealed he didn't have proof of sending the communication to the facility. In an interview on 6/27/2024 at 6:53 pm, the Director of Nursing (DON) revealed the pharmacist reviewed resident's medications monthly and makes recommendations to the provider. She confirmed she was aware there were no stop dates or recommendations for PRN trazodone for R18 or PRN lorazepam for R64. She stated, going forward, she would alert the physician to PRN medications that require stop dates.

Based on observations, family and staff interviews, record review, and review of the facility policy titled, Mouth Care, the facility failed to provide denture care for two of 42 sampled residents (R) (R26 and R78). The deficient practice had the potential to cause mouth pain and discomfort, that could lead to decreased oral intake of nutrition and hydration for R26 and R78. Findings include: Review of the facility policy titled Mouth Care with a revision date of February 2018 revealed that the Purposes of this procedure are to keep the resident's lips and oral tissues moist, to cleanse and freshen the residents' mouth, and to prevent oral infections. 1. Review of the Electronic Medical Record (EMR) for R26 revealed that she was admitted to the facility with diagnoses that included but were not limited to a fracture of shaft of humerus and superior rim of left pubis. Review of the Admission Minimum Data Set (MDS) with a completion date of 5/10/2024 revealed that R26 had a Basic Interview of Mental Status (BIMS) score of five, which indicated she was severely cognitively impaired. Review of Section GG: Functional Abilities revealed that she had impairment on one side for both upper and lower extremities and required substantial/maximal assistance with grooming. Review of the Kardex (plan of care for ADLs (activities of daily living) revealed that the assistance that she needed with oral care was not addressed. Observation and interview on 6/25/2024 at 11:45 am revealed R26 was sitting up in her bed with a hospital gown on, visiting with a family member. The family member stated that she had no complaints with R26's care except for oral/denture care that she was not receiving. She stated that she and another family member come in often, as much as possible. She stated that she feels like R26 was not receiving oral care daily. She stated that staff kept leaving R26's dentures in her mouth and have not been taking them out to clean teeth or provide mouth care. She stated that at one point she came in and R26 was complaining of mouth pain. She stated that she and another family member now clean her teeth because they want to make sure R26's mouth does not hurt and that she will continue to eat some of her meals. Observation on 6/26/2024 at 12:50 pm, revealed R26 was sitting up in her wheelchair, dressed in her clothes. There was a sign noted next to the sink in the bedroom that read, Mom needs help with her dentures daily, to prevent mouth sores. Review of the Functional Abilities 31- day look back for June 2024 revealed that staff had charted for thirteen days that oral care was not attempted. For two of the days, nothing at all was charted, two days it was charted that she needed partial assistance, one day that she needed substantial assistance, seven days that she needed set up assistance only, seven days that she was totally dependent with oral care, and two days that she was independent with oral care. There was only one day out of twenty-five that had oral care completed twice on the same day. 2. Review of the EMR for R78 revealed that she was admitted to the facility with a diagnosis but not limited to Alzheimer's disease. Review of the Quarterly MDS with a completion date of 4/23/2024 revealed that R78's BIMS score was not completed related to the resident is rarely/never understood. Section GG-Functional abilities revealed that she had impairment on one side of upper extremity and that she required total assistance with oral care. Review of the Kardex (plan of care for activities of daily living-ADLs) revealed that R78 was to brush teeth and wash face daily. Observation on 6/26/2024 at 4:01 pm revealed R78 laying in her bed with eyes closed. Observation on 6/27/2024 at 8:00 am revealed R78 sitting up in her bed with her meal sitting in front of her. Interview on 6/26/2024 at 3:32 pm with R78's family member revealed that he came to the facility every day to visit R26. He stated that her face does not get washed daily, and that oral care occurs maybe once a week. Review of the Functional Abilities 31-day lookback for R78 revealed that staff charted nothing for five days, was not attempted for five days, partial assistance on one day, and total assistance on 15 days. Interviews on 6/27/2024 at 3:29 pm with Certified Nursing Assistant (CNA) HH and CNA II revealed that when they were shown the Functional Abilities charted for R26 and R78, they stated that if they were to look at the charting and the days had a 9 charted, then they would think that it meant that it was not attempted. They then stated that if they did not see anything charted, just blanks, that it would mean that it was not done or not charted. They both said that denture care should be completed in the morning and at night. Interview on 6/27/2024 at 3:45 pm with Licensed Practical Nurse/Unit Manager (LPN/UM) JJ, she stated that if she looked at the functional abilities charting for oral care and there were blank boxes and a 9 charted, then she would have to assume that it was not completed. Interview on 6/27/2024 at 3:50 pm with CNA EE, she stated that oral care should be completed first thing in the morning. She stated that there are many times that she had come in to work her shift and dentures would still be in the resident's mouth from the night before. She then stated that if she were to look at the charting on the functional abilities for a resident and saw 9's and blanks, she would think that it was not done or not charted. Interview on 6/27/2024 at 3:55 pm with CNA FF, she stated that oral care should be completed when the resident wakes up and just before they go to bed. She then stated that if she looked at the chart for oral care and it says nothing but blanks and 9's, then she would think that it was not done. Interview on 6/27/2024 at 4:04 pm with the Director of Nursing (DON), she stated that oral care should be completed daily and as needed. She then stated that if oral care was not charted or there were 9's charted, that it must just be an oversite. She stated that oral care should always be offered or attempted.

Based on observations, staff interviews, record review, and review of facility policies titled Hand Hygiene, Perineal Care, and Administering IV Medications, the facility failed to use proper hand hygiene during perineal and catheter care for one resident (R) (R75), failed to properly close the door to a transmission-based precautions (TBP) room for one resident (R257), and to properly disinfect a needleless connector on a percutaneous intravenous central catheter (PICC) line after flushing and before connecting the intravenous antibiotic for one resident (R258). The deficient practices had the potential to place the residents at risk for serious infections. The sample size was 42 residents. Findings include: Review of the undated facility policy titled Hand Hygiene under Policy revealed, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Under Policy Explanation and Compliance Guidelines revealed, Additional considerations: (a) The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Review of the facility policy titled Perineal Care revised February 2018 under Purpose revealed, The purpose of the procedure is to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. Under Steps in the Procedure revealed, 10. Remove gloves and discard them into designated containers. 11. Wash and dry your hands thoroughly. Review of the facility policy titled Administering IV Medications revised December 2012 under Purpose revealed, The purpose of this procedure is to provide guidelines for the aseptic administration of a medication bolus directly into the venous system through a vascular access device. Under Steps in the Procedure revealed, To Administer medication directly through an IV catheter: 1. Disinfect catheter port with alcohol pad or antiseptic caps; 2. Attach saline-filled syringe and flush the catheter; 3. Disinfect catheter connection device again; 4. Attach medication - filled syringe and administer medications according to prescribed rate. 1. Review of the Electronic Medical Record (EMR) for R75, revealed that he was admitted to the facility with diagnoses that included but were not limited to bladder-neck obstruction. Review of the physician orders for R75 revealed an order for staff to provide catheter care every shift that instructed staff to hold catheter near meatus and wipe tube downward, away from meatus opening and to rinse using the same technique. Review of the care plan for R75 revealed that resident required an indwelling catheter related to bladder-neck obstruction. Due to that requirement, he has an increased risk for urinary tract infection (UTI) related to having an indwelling catheter. Review of the quarterly Minimum Data Set (MDS) assessment for R75, dated 4/8/2024, revealed Section C (Cognitive Patterns), a Brief Interview of Mental Status (BIMS) score of three, indicating severe cognitive impairment. Section D (Behaviors), documented hallucinations and delusions. Section H (Bladder and Bowel) urinary catheter present and frequently incontinent of bowel. Observation on 6/25/2024 at 9:45 am. revealed, R75 asleep in his room on Enhanced Barrier Precautions related to having a urinary catheter. An observation of catheter care and perineal care was conducted on 6/27/2024 at 10:31 am for R75 with Certified Nursing Assistant (CNA) VV and the Registered Nurse (RN) Educator who both entered the room and provided privacy after donning personal protective equipment (PPE). They uncovered the resident and then recovered him with a sheet to expose just the perineal area and the catheter. The CNA provided perineal care, using a fresh wipe for each stroke of the penis. She then held the base of the catheter and then provided catheter care and used a fresh wipe for each swipe of the catheter and went from tip downwards towards the bag. The resident was then repositioned on to his side with the assistance of the RN Educator and then perineal care was provided, due to the resident having had a bowel movement (BM). R75 was cleaned from front to back until all feces were removed. The dirty brief and dirty wipes were removed, and the RN Educator went outside the room. The RN Educator returned with clean gloves however she did not perform hand hygiene before leaving the room. The RN Educator and CNA VV donned fresh gloves and resumed and completed the catheter care. CNA VV then applied barrier cream and a new brief to the resident. CNA VV removed her gloves, and then went to the door, to get more gloves however, she did not perform hand hygiene before leaving the room. CNA VV returned with a fresh pair of gloves, emptied the catheter bag and cleaned the drainage system with an alcohol wipe, after closing it. The trash and dirty linen were collected, and PPE was doffed. The Nurse Educator and CNA VV then performed hand hygiene upon leaving the resident's room. An interview on 6/27/2024 at 10:50 am with CNA VV confirmed hand hygiene was to be performed before entering a room, after finishing with resident when exiting, and when hands are soiled. In an interview on 6/27/2024 at 11:20 am with RN Nurse Educator confirmed hand hygiene should be performed before a procedure, when you change your gloves and after the procedure. She confirmed she did perform hand hygiene at the PPE cart outside of the room before returning to the room with gloves. She confirmed CNA VV did not perform HH after changing gloves in the room. In an interview with the RN Nurse Educator on 6/27/24 at 2:45 pm, she stated she started at the facility about four months ago. She then stated that she conducts annual competencies for peri care with return demonstration as well as upon hire and as needed (PRN). She then stated that nurses are to monitor the CNAs for compliance. She ended her interview by stating that she is currently reviewing old policies and competencies and conducts CNA training classes. 2. Review of the EMR for R257 revealed that he was admitted to the facility with diagnoses that included but were not limited to pneumonitis due to the inhalation of food and vomit, and dysphagia. Review of the physician orders for R257 revealed that he was to receive vancomycin liquid (an antibiotic) from 6/19/2024 until 6/24/2024. An observation of the resident was completed on 6/25/2024 at 10:35am. The resident was in his room, and there was an Enteric Contact isolation signage on his door. The door was completely open. An observation of a medication administration was conducted on 6/26/2024 at 8:25am. Licensed Practical Nurse (LPN) KK was observed preparing medication for R257. She prepared the medications and then placed medication on top of the electronic blood pressure cuff. She entered the room with the electronic blood pressure cuff and medications without donning personal protective equipment and then left the room to don PPE. Before entering the room, she donned (put on) personal protective equipment (PPE), to prepare for going into the transmission-based precaution room. The door to the room was completely open. After entering the room, she remembered that she did not have her stethoscope in the room to check for placement of the percutaneous endoscopic gastrostomy (PEG) tube. She then doffed (removed) her PPE and used hand sanitizer before leaving the room. After administering the medications and tube feeding, she doffed the PPE and then washed her hands at the sink. After leaving the room, she went back to the medication cart. At the cart she stated that she cleans the blood pressure cuff after using it with the purple topped wipes. She stated that R257 had a history of Clostridium difficile (c-diff). She stated that the door to his room needed to be closed. In an interview on 6/27/2024 at 3:35 pm with LPN/Unit Manager (UM) JJ, she confirmed R257 was on isolation precaution for a history of C-diff. 3. Review of the EMR for R258 revealed that she was admitted to the facility with diagnoses that included but were not limited to acute respiratory failure with sepsis. Review of physician orders revealed that R258 was to receive two grams of ceftriaxone intravenously (IV) once a day for a urinary tract infection until the date of the last dose to be administered on 6/27/2024. Observation on 6/27/2024 at 11:07 am of RN GG preparing to administer medications for R258 revealed, she verified the orders for the IV antibiotic and gathered her supplies. She donned PPE and then entered the room. She verified the resident, who was observed dressed and seated in her wheelchair. The peripherally inserted central catheter (PICC) line was observed with a change date of 6/25/2024, and dressing was clean, dry and intact. She removed the cap that was on the end of the connector and flushed the line with 10 milliliters (ml) normal saline (NS). She stated that she did not need to clean it because it had a cap on it. She left the syringe in place and clamped the port. She then mixed the antibiotic, primed the tubing, then programmed the pump to administer the antibiotic. She then removed the syringe and attached the primed tubing. She verified that the antibiotic was running and dripping before leaving the room. She removed the PPE and then washed hands and returned to the cart. In an interview on 6/27/2024 at 3:35 pm with LPN/UM JJ, she stated that even if a PICC line connector has a cap on it, the nurse should still disinfect the connector after removing the cap and before attaching the saline flush to flush the line, before attaching the antibiotic to administer it. In an interview on 6/27/2024 at 4:04 pm with the Director of Nurses (DON), she confirmed hand hygiene (HH) should be completed before entering the room, before donning gloves, after doffing gloves, and before leaving the resident's room. She confirmed that a PICC line connector should be disinfected with an alcohol wipe prior to attaching the flush or medication.

Based on observations, interviews, and review of policies titled Receiving, Food Storage: Dry Goods, and Food Storage: Cold Foods, the facility failed to ensure opened food items in the dry storage area were labeled and dated; failed to discard expired food items in the walk-in freezer, two reach in freezers and two of two resident pantries. This deficiency had the potential to affect 90 of 91 residents receiving an oral diet. Findings include: 1. Review of the policy titled Receiving revised ,d+[DATE], revealed the policy is that safe food handling procedures for time and temperature control will be practiced in the transportation, delivery, and subsequent storage of all food items. Procedure: 5. All food items will be appropriately labeled and dated either through manufacturer packaging or staff notation. 6. All food items will be stored in a manner that ensures appropriate and timely utilization based on the principals of first in-first out inventory management. Review of the policy titled Food Storage: Dry Goods revised ,d+[DATE], revealed the policy is all dry goods will be appropriately stored in accordance with the Food and Drug Administration (FDA) Food Code. Procedure: 6. Storage areas will be neat, arranged for easy identification, and date marked as appropriate. Observation on [DATE] from 8:45 a.m. to 9:20 a.m. during the initial kitchen tour with the Certified Dietary Manager (CDM) and the Registered Dietician (RD) revealed the following in the dry storage pantry: Four 6.38-pound cans of green beans without a storage date Three 99-ounce cans of pickle spears without a storage date 2. Review of the policy titled Food Storage: Cold Foods revised ,d+[DATE], revealed the policy is all Time/Temperature Control for Safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA Food Code. Procedure: 5. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. Observation on [DATE] from 8:45 a.m. to 9:20 a.m. during the initial kitchen tour with the Certified Dietary Manager (CDM) and the Registered Dietician (RD) revealed the following: a.) Walk-in freezer revealed the following items without an expiration date or storage date: Six five-pound bags of breaded chicken patties Two five-pound bags of raw chicken breast One two-pound bag of frozen ravioli Two five-pound bags of breaded chicken tenders Three five-pound bags of tater tots Four wrapped pound cakes b.) Reach-in freezer #1 located next to the walk-in refrigerator revealed the following: One three-pound bag of shredded mozzarella cheese with an expiration date of [DATE]. Four 16-ounce containers of whipped topping without an expiration date or storage date. Six one-gallon size freezer bags containing sliced pepperoni without an expiration date or storage date. Two wrapped pound cakes without an expiration date or storage date. One three-pound bag of breaded fish patties without an expiration date or storage date. One five-pound bag of meatballs without an expiration date or storage date. Two two-pound bags of spinach without an expiration date or storage date. One one-pound bag of breaded sliced fried squash without an expiration date or storage date. One one-gallon bag of shredded parmesan cheese without an expiration date or storage date. One two-pound bag of cheese ravioli without an expiration date or storage date. c). The reach-in freezer #2 located next to reach-in freezer #1 revealed the following: Two five-pound bags of shredded mozzarella cheese without an expiration date or storage date. One five-pound bag of breaded chicken strips without an expiration date or storage date. Interview on [DATE] at 9:25 a.m. with the CDM and the RD confirmed the above items during the initial tour, and stated all food items should be dated with a storage date when removed from the original package and all expired food items should be discard when expired. 3. Observation on [DATE] at 2:30 p.m. the resident pantry located on the Pink Hall revealed the following items without expiration dates or storage dates: 20 individual oatmeal snack cakes 49 individual packaged cookies five packs of 4-pack peanut butter cheese crackers 37 packs of two per pack honey graham crackers Observation on [DATE] at 2:40 p.m. the resident pantry located on the Blue Hall revealed the following items without expiration dates or storage dates: 10 individual packaged cookies 16 packs of 4-pack peanut butter cheese crackers The following items in the Blue Hall resident pantry were observed to be past expiration date: three one-ounce bags of Fritos corn chips with expiration date [DATE] one one-ounce bag of Fritos corn chips with expiration date [DATE] two containers of Ensure Vanilla pudding four-ounce cups with expiration date of [DATE] Observation on [DATE] at 3:00 p.m. the CDM and the RD verified the unlabeled and expired food products in the Pink Hall and the Blue Hall resident pantries. Interview on [DATE] at 3:05 p.m. with the CDM and the RD revealed all food items in the resident pantries should be dated with a storage date and should be discarded when the expiration date is reached. The CDM revealed she will make sure all food items are labeled and expired food items are discarded. Interview on [DATE] at 12:00 p.m. Administrator revealed her expectations were for all food items to have appropriate labeling and for expired food items to be discarded when expired.

Based on observations, interviews, and policy review, the facility failed to ensure that essential equipment in the kitchen was in working order as evidenced by ice buildup inside the walk-in freezer on an air flow vent above the doorway, ice formation down the interior door frame, and across the floor. This deficiency had the potential to affect 90 of 91 residents receiving an oral diet. Findings include: Review of the policy titled Equipment revised 9/2017, revealed the policy statement is all foodservice equipment will be clean, sanitary, and in proper working order. Procedure: number 1. All equipment will be routinely cleaned and maintained in accordance with manufacturer's directions and training materials. Number 4. All non-food contact equipment will be clean and free of debris. During the initial tour of the kitchen on 1/10/2023 at 9:25 a.m. with the Certified Dietary Manager (CDM) and the Registered Dietician (RD), the walk-in freezer was observed to have ice formation measuring approximately four inches by four inches on the air flow vent located above the doorway, ice formation down the interior door frame underneath the air flow vent, and ice formation on the floor across the entrance. The CDM and RD verified the presence of the ice formations at this time. The CDM revealed maintenance was responsible for maintaining the kitchen equipment and was made aware of the ice formation. She further revealed maintenance had worked on the walk-in freezer sometime in the last few weeks. Observation on 1/11/2023 at 10:10 a.m. of the walk-in freezer with the CDM and RD revealed ice formation measuring approximately four inches by four inches on the air flow vent located above the doorway, ice formation down the interior door frame underneath the air flow vent, and ice formation on the floor across the entrance. Both the CDM and RD verified the presence of the ice formations remained present in the walk-in freezer. Interview on 1/11/2023 at 11:25 a.m. with the Director of Engineering stated that a refrigeration unit on the roof malfunctioned on 12/25/2022, causing the ice formation in the walk-in freezer. He revealed he contacted the [name] support system as soon as he was notified the walk-in refrigerator was not cooling adequately. During further interview, he stated the unit was repaired on 12/27/2022. When asked what the solution would be to fix the cause of the ice buildup, he revealed he would need to manually remove the ice and that should fix the problem. Interview on 1/11/2023 at 12:00 p.m. with the administrator revealed she was aware there was a malfunction of the refrigeration unit on 12/25/2022. She stated as far as she knew, repairs were made. During further interview, she stated she was unaware of the ice buildup in the walk-in freezer and would discuss this with the maintenance supervisor. She stated her expectations were for kitchen equipment to be maintained in working order. Interview on 1/12/2022 at 10:00 a.m. Director of Engineering revealed the ice in the freezer was removed on 1/11/2023. He further revealed he had consulted with the heating, ventilation, and air conditioning (HVAC) personnel with [name], and revealed the air flow vent had malfunctioned and needed to be replaced. He stated the part will be ordered and replaced when it is available. Interview on 1/12/22 at 11:40 a.m. with the Administrator revealed she had initiated daily checks of the freezer by the CDM and the maintenance department until the part is ordered and installed. She stated if the replacement of the air flow vent does not resolve the problem, she will get further evaluations from the HVAC company.

Based on observations, staff interviews, and review of the facility policy titled Bathrooms, the facility failed to maintain a safe, clean, comfortable, and homelike environment related to dust build up on bathroom air vents on one of six resident halls, rooms 201 through 217. Findings include: Review of the facility policy titled Bathrooms revised 4/2006, revealed the policy statement is bathrooms shall be maintained in a clean and sanitary manner and shall be cleaned on a daily basis. Observation on 1/10/2023 at 11:57 a.m. and 1/11/2023 at 11:25 a.m. revealed the bathroom air vents in resident rooms 201 through 217 were noted to have dust buildup on and in them. Observation and interviews on 1/12/2023 at 11:26 a.m. with the Administrator, Engineering Supervisor, and the Housekeeping Supervisor, verified the dust buildup on the vents in the bathrooms of rooms 201 through 217. The Engineering Supervisor indicated they take the vents down yearly and clean them. The Administrator indicated that housekeeping should be cleaning them as needed when dust is visible. The Administrator indicated she would expect the vents to be clean. Interview on 1/12/2023 at 2:43 p.m. with Housekeeper (HK) GG revealed he cleans the bathrooms of the resident's rooms daily. He stated if he sees dust in the bathroom vents, he will clean the dust off as needed.

Based on observations, record review, interviews, and policy review, the facility failed to ensure the environment was free from potential accident hazards by not ensuring that medications, biologicals, or other potentially harmful material was not left within the reach of one resident (R) (R#94). The sample size was 32. Findings include: Review of the policy titled Copy of 5.d Storage and Expiration of Medications, Biologicals, Syringes, and Needles dated 1/2023 revealed procedure: C. General storage procedures: 3. Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. M: Bedside medication storage: 1. Facility should not administer/provide bedside medications or biologicals without a physician/prescriber order and approval by the interdisciplinary care team and facility administration. 2. Facility should store bedside medication or biologicals in a locked compartment within the resident's room. 3. Facility should ensure that only facility representatives and the appropriate resident maintains the keys, access cards, electronic codes, or combination which open the locked compartment. Review of the policy titled Safety and Supervision of Residents revised 7/2017, revealed the policy statement is our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Policy Interpretation and Implementation: 'Facility Oriented Approach to Safety' number 3 indicated: Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards and try to prevent avoidable accidents. Review of the clinical record revealed R#94 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, weakness, and cognitive communication deficit. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) coded as 11, indicating moderately impaired cognition. She required assistance of one person for dressing, personal hygiene, and eating. Review of the physician's orders revealed an order dated 10/27/2022 for Nystatin 100,000 units (U) per one gram (GM) powder apply topically once a day for fungal infections. There is no order for resident to self-administer this medication. Review of the clinical record revealed no assessment for self-administration of medications. Review of R#94's current care plan revealed no evidence that resident was assessed to self-administer any medications. Review of the Nurses' Notes dated 11/9/2022 revealed nurse observed a red rash area to bottom and lower back. Treatment nurse notified of findings. Review of the Medication Administration Record (MAR) dated 11/1/2022 to 1/11/2023 revealed documentation that resident received Nystatin 100,000 U/1 GM powder one application topically once a day every day. Observations on 1/10/2023 at 10:22 a.m. and 1/11/2023 at 8:00 a.m. in R#94 room, revealed a 30 milliliter (ml) plastic cup containing approximately 15 ml of a white powdery substance sitting on R#94's bedside table. The cup was uncovered and within R#94's reach. R#94 was observed sitting in a wheelchair and propelling herself in her room unassisted. Interviews on 1/10/2023 at 10:22 a.m. and 1/11/2023 at 8:00 a.m. with R#94 revealed she did not know what the substance in the cup was, did not know who left it there and did not know what it was for. She further revealed staff sometimes applied it to her perineal areas for irritation but revealed she did not use or apply it herself. Interview on 1/11/2023 at 7:55 a.m. with Certified Nursing Assistant (CNA) AA revealed R#94 required two persons assist to be out of bed and that resident is out of bed daily. She further revealed while resident required assist with ADLS, she does propel herself in her wheelchair unassisted. Interview on 1/11/2023 at 8:30 a.m. with Licensed Practical Nurse (LPN) CC revealed R#94 is out of bed every day and propels herself in her wheelchair. LPN CC confirmed the 30 ml plastic medication cup containing a white powdery substance on R#94's bedside table, uncovered and within her reach. LPN CC stated she was unsure what the white powdery substance was and stated it might have been left by the treatment nurse. LPN CC did not offer to remove the cup of white powdery substance from the resident's room. Interview on 1/11/2023 at 8:35 a.m. with LPN DD, revealed she is one of the treatment nurses. Observation of the 30 ml plastic medication cup containing a white powdery substance sitting on R#94's bedside table with LPN DD revealed she is unsure what the substance is or who put it in the room. She removed the cup from the resident's room and confirmed it should not have been in the resident's room. Interview on 1/11/23 at 11:45 a.m. with the Director of Nursing (DON) revealed her expectation is that staff are not to leave anything in a resident's room in a medication type container. She revealed nursing staff had an in-service on 10/31/2022 to include survey preparedness and infection control. During further interview, she revealed she plans to meet with nursing staff to educate them of the importance of medication, biologicals, and other substance storage and accident prevention.

Based on observations, record review, interviews, and review of facility policies, the facility failed to clean and ensure proper storage continuous positive airway pressure (CPAP) mask in a manner to prevent cross contamination for one of three residents (R) R#85, receiving CPAP administration. The census was 91. Findings include: 1. Review of the policy titled Cleaning and Disinfection of Resident-Care Items and Equipment revised 10/2018, revealed the Policy Interpretation and Implementation number 1. The following categories are used to distinguish the levels of sterilization/disinfection necessary for items in resident care: b.) Semi-critical items consists of items that may come in contact with mucus membranes or non-intact skin (e.g., respiratory therapy equipment). 2. Critical and semi-critical items will be sterilized/disinfected in a central processing location and stored appropriately until use. 2. Review of the policy titled CPAP/BiPAP Support revised 3/2015 revealed: General Guidelines section number 7. Masks, nasal pillows, and tubing: clean daily by placing in warm, soapy water and soaking/agitating for five minutes. Mild dish detergent is recommended. Rinse with warm water and allow to air dry between uses. Review of the clinical record revealed R#85 was admitted to the facility on [DATE] with diagnoses including obstructive sleep apnea (OSA), unspecified dementia, hemiplegia and hemiparesis following cerebral infarction, weakness, other specified arthritis. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Section G revealed resident was totally dependent of two persons for activities of daily living (ADLS) and required set-up assistance with meals. Section O revealed she received oxygen therapy. Review of the Active Orders Report revealed an order dated 11/14/2022 that resident wears CPAP, apply at night and remove in the morning. Review of the care plan initiated 4/21//2022 revealed resident used a CPAP related to the diagnoses of sleep apnea. The goal included the resident will not have complications related to the use of the machine. Interventions included to clean the mask daily. Review of the Nurses' Notes revealed no evidence or documentation that R#85's CPAP mask had been cleaned or the proper storage of the mask, when not in use. Review of Medication Administration Record (MARS) dated 6/1/2022 to 1/10/2023 revealed no evidence or documentation of cleaning or storage of the CPAP face mask. Observations on 1/10/2023 at 11:31 a.m. and 1/11/2023 at 8:40 a.m. in room [ROOM NUMBER], revealed R#85's CPAP mask lying on top of the CPAP machine, unbagged, and uncovered, exposed to the environment. Interviews on 1/10/2023 at 11:31 a.m. and 1/11/2023 at 8:40 a.m. with R#85, stated she uses the CPAP machine every night and was unsure if the mask was ever cleaned or placed into a protective bag when not in use. She revealed she is unable to use the CPAP machine independently and staff help her with placing the mask on her face and turning the machine on at bedtime and removes the mask and turns the machine off in the morning. Interview on 1/11/2023 at 7:55 a.m. with Certified Nursing Assistant (CNA) AA revealed resident requires two-person assist with most ADLS. She further revealed the nurses provide all oxygen related care and monitoring. Interview on 1/11/2023 at 8:40 a.m. with Licensed Practical Nurse (LPN) BB revealed residents that use CPAP machines have the CPAP applied at bedtime by the night shift nurse and it is removed before the dayshift nurse arrives. She revealed she does not assist with resident CPAPs and does not know how often CPAP masks are cleaned. During further interview, she stated the CPAP mask should be placed in a protective bag when not in use. LPN BB confirmed at this time that R#85's CPAP machine, tubing, and mask to be lying on top of the machine, uncovered and not in a protective bag. Interview on 1/11/2023 at 11:40 a.m. with the Director of Nursing (DON) revealed the night shift nurses are responsible for placing and removing the resident's CPAP masks. She revealed her expectation is for CPAP mask to be cleaned and placed in a protective bag when not in use. During further interview, she revealed she had met with nurses last week to educate them on survey preparedness and infection control practices.

Based on observation, interview and policy review, the facility failed to ensure one of six housekeeping staff (Staff DD) followed manufacturer recommendations by not allowing the disinfectant to remain on the surface for 10 minutes before wiping in the non- COVID-19 unit. Finding include: During observation and interview on 01/18/21 at 11:45 a.m., Housekeeper (Staff DD) was observed cleaning room [ROOM NUMBER] which was empty at the time. Staff DD sprayed the sink in the room with a bottle and then immediately began to wipe. When asked what Staff DD was using to clean and disinfect, Staff DD responded it was called Virex. Staff DD was asked about the contact time. Staff DD stated I just spray and wipe it. That is good enough. During an interview on 01/18/21 at 2:00 p.m., the Environmental Services Supervisor (Staff CC) was asked about the contact time of the Virex. Staff CC stated the Virex has a 10 minute contact time. Staff have been told that during an in-service. When asked when the in-service was, Staff CC stated there was no sign in sheet. During an interview on 01/18/21 at 7:00 p.m., the Administrator and Director of Nursing (DON) stated it was expected for staff to follow the manufacturer's recommendation of 10 minutes. Review of the bottle's label revealed under, Direction for Use.10 minute contact time this product kills. Review of the undated facility policy titled, Cleaning And Disinfection of Environmental Surfaces, Policy Statement: Environmental surfaces will be cleaned and disinfected according to current CDC (Centers for Disease Control and Prevention) recommendations for disinfection of healthcare facilities and the OSHA (Occupational Safety and Health Administration) Bloodborne Pathogens Standard. Policy and Implementation.2. Non-critical surfaces will be disinfected with an EPA (Environmental Protection Administration) -registered intermediate or low-level hospital disinfectant according to the label's safety precautions and use directions. A. Most EPA-registered hospital disinfectants have contact time of 10 minutes.5. Manufacturers' instructions will be followed for proper use of disinfecting products.

Based on observation, record review, review of the policy titled Policy for Resident's Rights, resident and staff interviews, the facility failed to ensure privacy in one of two shower rooms (Blue Side Shower Room) for four residents (R) (D, C, A and B) and failed to ensure privacy for one resident while receiving an insulin injection (R#61) from a sample of 30 residents. Findings include: Review of the facility policy titled Policy for Resident's Rights dated 7/21/17 documented under Privacy & Confidentiality- You have the right to respect and privacy in your medical, personal, and bodily care program. Your case discussion, consultation, examination, treatment, and care shall be confident and shall be conducted in privacy. Those persons not directly involved in your care must have permission to be present. 1. Record review for R D revealed a Quarterly Minimum Data Set (MDS) assessment dated [DATE] which documented a Brief Interview for Mental Status (BIMS) summary score of 15, indicating no cognitive impairment. During an interview on 6/18/18 at 3:57 p.m. with R D, she stated that there are four to five residents in the shower room at one time. The resident stated she would prefer to have her privacy. R D stated the staff pulls the curtain when she is in the shower stall but stated she has to undress in front of the other residents before she goes into the shower stall. The resident stated the staff puts two towels on her when she comes out of the shower room and is taken over by the bathtub. R D stated the staff help her dress and the other residents in the waiting area can see her. R D further revealed that she doesn't say anything to the staff stating that's just how they do it and I don't want to get them mad at me or blacklist me. Interview on 6/19/18 at 9:57 a.m. with R D revealed she had her shower this morning. The resident stated there were more curtains than usual in the shower room this morning. R D stated she did not have to undress in front of anyone this morning and the staff pulled the curtain. She stated I know it is just because the State is here. An observation was conducted on 6/19/18 at 6:10 a.m. of the Blue Side Shower Room. The Bath Aide/CNA BB cracked opened the door and stated there were three residents currently in the shower room and stated no residents were exposed. She stated that one resident was in the shower stall, one resident was around the corner by the tub and one clothed female resident was observed through the door, toward the back wall. The shower room was not entered due to residents in the shower room and only one shower curtain could be observed on the left side of the shower room near the toilet room. This shower curtain was not pulled closed at the time of the observation. 2. Record review for R C revealed an Admission MDS assessment dated [DATE] revealed a BIMS score of 15, indicating no cognitive impairment. Interview on 6/19/18 at 12:43 p.m. with R C revealed there is usually three to four residents in the shower room. She stated when she leaves the shower stall, the staff put two towels over her and she has to get dressed in front of everyone in the shower room. R C stated the other residents have to do the same thing. R C revealed she has never complained about the privacy stating I don't know why I haven't said anything, it's just the way things are. R C stated it does not embarrass her and stated It might embarrass someone else though. 3. Record review for R A revealed an Annual MDS assessment which documented a BIMS score of 15, indicating no cognitive impairment. Interview on 6/20/18 at 12:35 p.m. with R A revealed there is often four to five residents in the shower room at one time. The resident stated there is one shower stall and one bathtub. She stated that she undresses herself near the bathtub, while other residents are in the room. R A stated the curtains are never pulled closed for privacy and this is the first week they have had closed curtains. She stated the residents do dress and undress in front of each other but for her personally, it does not bother her but it may bother the others. Interview on 6/20/18 at 12:45 p.m. in the Blue Side Shower Room with two Bath Aides/CNA (CNA BB and CNA CC) revealed that typically there is only have two residents in the shower room at one time. CNA BB stated that they try to provide privacy and pull curtains but confirmed there are times when there are four residents in the shower room at one time and the resident's privacy had been breached. CNA BB stated she undressed the resident's in the shower room but there is a moment when a resident comes out of the shower stall when they are covered with a towel and taken over bathtub areas and hand rail in which they may be exposed to others. CNA CC stated that most of the resident's don't care and she has not had any complaints or concerns related to privacy or dignity reported to them by the residents. 4. Record review for R B revealed a Quarterly MDS assessment dated [DATE] which documented a BIMS score of 15, indicating no cognitive impairment. Interview on 6/20/18 at 1:10 p.m. with R B revealed there is often at least four residents in the shower room at the same time. She stated that sometimes the staff will pull privacy curtains but most of the time the residents have to dress and undress in front of each other. R B stated that the staff will cover her with towels when she gets out of the shower and put her near the bathtub or on the bench near the door to dry off and get dressed. R B stated I don't like to dress in front of other people, but I thought that was my only choice if I want to get my shower. The resident stated she can see the other residents too when they are drying off and getting dressed. She stated that she dries off as fast as possibly because everyone can see her and she is a private person. The resident stated she can see the other residents too when they are drying off and getting dressed. R B stated It's my thoughts that they should only have two people in the shower room at one time, one in the shower and one dressing with the privacy curtains pulled. R B further stated It takes our dignity away. She stated that her husband is blind and has a [MEDICAL CONDITION] and he has asked staff to shower him last so he can be in the shower room alone. She stated My husband is blind but he still deserves his privacy. He can't see the other residents but they can see him. Observation on 6/20/18 at 12:45 p.m. of the Blue Side Shower Room with two Bath Aides/CNA (CNA BB and CNA CC) revealed one curtain to the left of the room near the toilet room. There was one shower stall with its own privacy curtain. There was another privacy curtain that ran the length of the area with the whirlpool bathtub. There was a bench on the back wall by the bathtub and one bench along the left wall near the entrance door. Interview with the Bath Aides at the time of the observation revealed they typically only have two residents in the shower room at one time. CNA CC stated they start their shift at 5:30 a.m. and there are usually several residents waiting to get in the shower room. She stated that some residents walk to the shower room and some propel themselves in their wheelchairs. CNA CC stated the nightshift CNAs will also bring residents to the shower room for their scheduled showers. CNA BB stated that they try to provide privacy and pull curtains. CNA BB and CNA CC both confirmed there are times when there are four residents in the shower room at one time. CNA BB confirmed there have been occasions when residents' privacy had been breached. CNA BB stated some of the independent residents will come in and just start undressing by themselves and there are other residents in the waiting area without the curtain pulled. She stated if they tell the residents that they can't come in, they get mad. CNA BB stated she undresses the resident's in the shower room but there is a moment when a resident comes out of the shower stall, covered with a towel and taken over to the bathtub area and hand rail. She stated she typically pulls the shower curtain when the dry off and get dressed. CNA CC stated that most of the resident's don't care and she has not had any complaints or concerns related to privacy or dignity reported to them by the residents. CNA BB stated for the most part, they usually only have two residents in the shower room at one time. CNA BB and CNA CC both stated that they have been in the shower room for only a couple of weeks and there has been a turnover with the Bath Aides over the last couple of months. Interview on 6/20/18 at 3:50 p.m. with the Administrator revealed he had not received any complaints or grievances related to privacy in the shower rooms. He stated these concerns had not been brought to the facility's attention in Resident Council or through grievances. The Administrator stated that that there should only be two residents in the shower room at one time. On 06/20/18 at 10:30. a.m. observed Licensed Practical Nurse (LPN) DD administered [MEDICATION NAME] 12 units Subcutaneous to R #61. R#61 is alert and confused sitting on Geri-chair, nurse entered the room and stated to R #61 that she is administering insulin [MEDICATION NAME] 12 units in her abdomen. Licensed Practical Nurse (LPN) DD pulled R#61 blouse in front of her roommate without pulling a privacy curtain and door was open during administration of insulin, this was done in the presence of surveyor and R#61's roommate. No privacy curtain used. On 6/20/18 at 10:32. a.m. An interview with Licensed Practical Nurse (LPN) DD stated, I'm sorry I did not pay attention to close the door or pull the privacy curtain, I was carried away talking to her roommate. On 6/20/18 at 11:00. a.m. An interview with Unit Manager (UM) EE stated facility policy is to close the door and pull the curtain before administration of injection. On 6/21/18 at 9:00. a.m. An interview with Director of Nursing (DON), Assistant Director of Nursing (ADON) and Staff development revealed Licensed Practical Nurse (LPN) DD is a difficult nurse to deal with they have been training her for one year. DON states they will follow up with her immediately and in-service all Licensed Nurses.

Based on observation, interview and record review, the facility failed to implement and monitor care plan interventions related to smoking for one Resident (R) (A) of 30 sampled residents. Findings include: Review of the record for R A reflected he was admitted [DATE] .Interview for Mental Status (BIMS) with a score of 15, indicating normal cognition and a functional assessment indicating a need for limited, one person assistance with activities of daily living. Review of the resident's current care plan reflects that the resident has problems and/or risks related to a history of falling, he needs assistance with activities of daily living related to weakness, balance problems, limited mobility, neuropathies, muscle spasms, contractures and pain. He is care planed for a history of exhibiting threatening verbal behaviors to others at times; and care planned for activities-that the resident enjoys going outside in his motorized wheelchair. Review of the R A's care plan for smoking, dated [DATE] and [DATE], indicates the resident is a smoker and wishes to continue doing so; was assessed by Social Services for smoking safety and deemed safe to smoke without supervision; with a smoking goal that he will smoke safely and will continue to abide by the facility smoking policy without supervision. Smoking interventions document: 1. cigarettes and lighter will be maintained at the nurse's station dated [DATE] 2. any violations of the smoking policy will be reported to the Social Services Department or Care Plan Team immediately, dated [DATE] 3. staff will provide smoking apron if applicable, dated, [DATE] 4. staff will monitor [MEDICAL CONDITION] changes in level of needed supervision, dated [DATE] 5. staff will continue routine assessments for safe smoking, dated [DATE] Policy Interpretation and Implementation No. #4 documents that specific residents of Union County Nursing Home have been grandfathered-in and therefore continue to be permitted to smoke and are limited to do so only in designated smoking area located outside and under the Pink (A) Hall covered porch. Policy Interpretation and Implementation No. #8 documents a resident that smokes may be deemed safe, only after an assessment is completed. Social Services will complete a smoking assessment at least every quarter to determine if resident continues to be safe to smoke without supervision. Policy Interpretation and Implementation No. #9 documents nursing home Administration reserves the right to do periodic room checks/personal property checks to search for smoking materials especially if there is reasonable suspicion that a resident may have smoking materials in their room or on their person. Policy Interpretation and Implementation No. #13 documents that any resident found to have any smoking materials in their room or on their person and/or is found to be in non-compliance with this policy, and shall be subject to smoking privilege being revoked. If any resident continues to not abide by smoking policy, the resident can be subjected to receiving a thirty (30) discharge notice to home or another facility. On [DATE] at 10:55 a. m. R A was observed by surveyor # smoking in the parking lot near the trees across from the main entrance and the roundabout driveway to the facility, not in the designated smoking area for residents. The resident was sitting in his powered wheelchair, then observed maneuvering toward the front door to re-enter the facility. On [DATE] at 3:10 p.m. a subsequent interview was conducted with R A, while he was sitting in a motorized wheelchair smoking. He stated he is the only one in the facility that smokes now, that the other 6 smokers have died . He confirmed he had been assessed to smoke unsupervised, he confirmed the smoking policy was reviewed with him some time ago. The resident was observed with a pack of Marlboro cigarettes (brown and white in color) and a lighter on his person, the pack of cigarettes was observed tucked up in the pants leg of his shorts, he was holding the lighter. On [DATE] at 11:30 a. m. an observation was conducted of R A smoking in the designated smoking area in the shade with proper disposal of his cigarette butts in the ash tray. Resident was observed sitting in his powered wheelchair, dressed appropriately with shoes and socks on. He was observed returning directly to his room. On [DATE] at 11:35 a. m. an interview was conducted with Social Worker FF where she confirmed that R A could smoke without supervision. She stated he was grandfathered in when the facility went to a no smoking facility a few years ago, and confirmed that he knows the smoking rules. She stated that he is the only resident in the facility that smokes now and that employees are not allowed to smoke on the facility campus, that there is not another smoking area on the facility grounds. She stated that the resident is assessed for safe smoking quarterly by their department. She referred the surveyor to the Assistant Administrator. On [DATE] at 11:40 a. m. during an interview with Registered Nurse (RN) EE at the Pink Hall nurse's station, she explained that the resident smoking process is for the resident to come to the desk and ask a nurse for his cigarettes and lighter, then he can go outside to the smoking area and smoke independently. She stated that the cigarettes and lighter are kept in a box in the medication room. On [DATE] at 11:45 a. m. during a brief interview with the Assistant Administrator, she confirmed that R A was assessed quarterly by Social Services for smoking independently. She stated that the resident's son and his son's girlfriend visit and take the resident out of the facility frequently. That the resident keeps to himself otherwise, preferring not to socialize much with the other residents. She stated that the resident's cigarettes and lighter are expected to be kept by the floor nurses. On [DATE] 11:50 a. m. an observation of the cigarette box in the locked medication room on the Pink Hall was conducted with Licensed Practical Nurse (LPN) HH where the cigarette box was found to be empty of the resident's cigarettes and lighter. A cigarette sign out notebook was located on top of the cigarette box; no (YEAR) sign out dates were found for the resident. At that time, the LPN went to the resident's room with the surveyor, the LPN asked R A where he kept his cigarettes, he then pointed they were on the TV table and showed us his lighter hidden between his thighs. Additionally, on [DATE] at 11:55 a. m. during the interview of R A in the resident's room with the LPN HH present, the resident confirmed that he keeps his cigarettes and lighter in his room. When asked, who buys his cigarettes for him he stated his son gets them for him. When asked about the lighter, he stated that he bought it when he was taken out to Walmart. At that time, the resident did not offer any more information to questions. On [DATE] at 1:00 p. m. during an interview with the Assistant Administrator she confirmed that R A is only allowed to smoke in the covered designated smoking area outside the Pink (A) Hall exit door. She confirmed she did not know the process the nurses were using for signing out his cigarettes and lighter. She confirmed that he can use his powered wheelchair to ride around the facility grounds, but stated he was not allowed to smoke outside the designated smoking area, and not on the pavement by the trees. She confirmed that cigarettes and lighters are not allowed in his, or any resident's room, that he was not following facility policy and she would speak to him about it. She stated he had been talked to previously about smoking an illegal substance outside the facility building, but confirmed that incident was not witnessed, but smelled on his person. Cross Refer F689

Based on observations, interview, record review and review of facility policy, the facility failed to provide precautions and monitoring that would ensure safe smoking for one Resident (R)(A) of 30 sampled residents. Findings include: On [DATE] at 10:55 a. m. R A was observed by surveyor # smoking in the parking lot near the trees across from the main entrance and the roundabout driveway to the facility, not in the designated smoking area for residents. The resident was sitting in his powered wheelchair, then observed maneuvering toward the front door to re-enter the facility. Review of the Minimum Data Set (MDS) Quarterly Assessment, dated [DATE], revealed that R A had a Brief Interview for Mental Status (BIMS) with a score of 15, indicating normal cognition and a functional assessment indicating a need for limited, one person assistance with activities of daily living. On [DATE] at 3:10 p.m. an observation was conducted of R A smoking outside in the designated smoking area directly outside the Pink (A) Hall. Resident A was observed smoking safely, using one of 4 ash trays provided in the smoking area. On [DATE] at 3:10 p.m. a subsequent interview was conducted with R A, while he was sitting in a motorized wheelchair smoking. He stated he is the only one in the facility that smokes now, that the other 6 smokers have died . He confirmed he had been assessed to smoke unsupervised, he confirmed the smoking policy was reviewed with him some time ago. The resident was observed with a pack of Marlboro cigarettes (brown and white in color) and a lighter on his person, the pack of cigarettes was observed tucked up in the pants leg of his shorts, he was holding the lighter. On [DATE] at 8:15 a. m. an observation was conducted of R A smoking in the designated smoking area with proper disposal of his cigarette butts in the ash tray. On [DATE] at 9:05 to 10:05 a. m. an observation was conducted of the facility's front entrance area around the walkway outside the main entrance door and the roundabout area. Three brown and white cigarette butts were found on the pavement, two in the garden bark. Observation of the sidewalk area and parking lot outside of the Pink (A) Hall entrance, beyond and outside the designated smoking area, revealed 4 cigarette butts on the pavement along with an older appearing cigarette lighter. On [DATE] at 11:30 a. m. an observation was conducted of R A smoking in the designated smoking area in the shade with proper disposal of his cigarette butts in the ash tray. Resident was observed sitting in his powered wheelchair, dressed appropriately with shoes and socks on. He was observed returning directly to his room. On [DATE] at 11:35 a. m. an interview was conducted with Social Worker FF where she confirmed that R A could smoke without supervision. She stated he was grandfathered in when the facility went to a no smoking facility a few years ago, and confirmed that he knows the smoking rules. She stated that he is the only resident in the facility that smokes now and that employees are not allowed to smoke on the facility campus, that there is not another smoking area on the facility grounds. She stated that the resident is assessed for safe smoking quarterly by their department. She referred the surveyor to the Assistant Administrator. On [DATE] at 11:40 a. m. during an interview with Registered Nurse (RN) EE at the Pink Hall nurse's station, she explained that the resident smoking process is for the resident to come to the desk and ask a nurse for his cigarettes and lighter, then he can go outside to the smoking area and smoke independently. She stated that the cigarettes and lighter are kept in a box in the medication room. On [DATE] at 11:45 a. m. during a brief interview with the Assistant Administrator, she confirmed that R A was assessed quarterly by Social Services for smoking independently. She stated that the resident's son and his son's girlfriend visit and take the resident out of the facility frequently. That the resident keeps to himself otherwise, preferring not to socialize much with the other residents. She stated that the resident's cigarettes and lighter are expected to be kept by the floor nurses. On [DATE] 11:50 a. m. an observation of the cigarette box in the locked medication room on the Pink Hall was conducted with Licensed Practical Nurse (LPN) HH where the cigarette box was found to be empty of the resident's cigarettes and lighter. A cigarette sign out notebook was located on top of the cigarette box; no (YEAR) sign out dates were found for the resident. At that time, the LPN went to the resident's room with the surveyor, the LPN asked R A where he kept his cigarettes, he then pointed they were on the TV table and showed us his lighter hidden between his thighs. Additionally, on [DATE] at 11:55 a. m. during the interview of R A in the resident's room with the LPN HH present, the resident confirmed that he keeps his cigarettes and lighter in his room. When asked, who buys his cigarettes for him he stated his son gets them for him. When asked about the lighter, he stated that he bought it when he was taken out to Walmart. At that time, the resident did not offer any more information to questions. On [DATE] at 1:00 p. m. during an interview with the Assistant Administrator she confirmed that R A is only allowed to smoke in the covered designated smoking area outside the Pink (A) Hall exit door. She confirmed she did not know the process the nurses were using for signing out his cigarettes and lighter. She confirmed that he can use his powered wheelchair to ride around the facility grounds, but stated he was not allowed to smoke outside the designated smoking area, and not on the pavement by the trees. She confirmed that cigarettes and lighters are not allowed in his, or any resident's room, that he was not following facility policy and she would speak to him about it. She stated he had been talked to previously about smoking an illegal substance outside the facility building, but confirmed that incident was not witnessed, but smelled on his person. Review of the resident's current care plan reflects that the resident has problems and/or risks related to a history of falling, he needs assistance with activities of daily living related to weakness, balance problems, limited mobility, neuropathies, muscle spasms, contractures and pain. He is care planed for a history of exhibiting threatening verbal behaviors to others at times; and care planned for activities-that the resident enjoys going outside in his motorized wheelchair. Review of the R A's care plan for smoking, dated [DATE] and [DATE], indicates the resident is a smoker and wishes to continue doing so; was assessed by Social Services for smoking safety and deemed safe to smoke without supervision; with a smoking goal that he will smoke safely and will continue to abide by the facility spoking policy without supervision. Smoking interventions document: 1. cigarettes and lighter will be maintained at the nurse's station dated [DATE] 2. any violations of the smoking policy will be reported to the Social Services Department or Care Plan Team immediately, dated [DATE] 3. staff will provide smoking apron if applicable, dated, [DATE] 4. staff will monitor [MEDICAL CONDITION] changes in level of needed supervision, dated [DATE] 5. staff will continue routine assessments for safe smoking, dated [DATE] A review of the facility's smoking policy and procedure entitled, Smoke-Free Facility Policy dated [DATE], reflect their policy is to provide a smoke free environment for all employees and visitors. This policy covers the smoking of any tobacco product, as well as the use of e-cigarettes, and it applies to employees, non-employee visitors and residents of Union County Nursing Home. Policy Interpretation and Implementation No. #4 documents that specific residents of Union County Nursing Home have been grandfathered-in and therefore continue to be permitted to smoke and are limited to do so only in designated smoking area located outside and under the Pink (A) Hall covered porch. Policy Interpretation and Implementation No. #8 documents a resident that smokes may be deemed safe, only after an assessment is completed. Social Services will complete a smoking assessment at least every quarter to determine if resident continues to be safe to smoke without supervision. Policy Interpretation and Implementation No. #9 documents nursing home Administration reserves the right to do periodic room checks/personal property checks to search for smoking materials especially if there is reasonable suspicion that a resident may have smoking materials in their room or on their person. Policy Interpretation and Implementation No. #13 documents that any resident found to have any smoking materials in their room or on their person and/or is found to be in non-compliance with this policy, and shall be subject to smoking privilege being revoked. If any resident continues to not abide by smoking policy, the resident can be subjected to receiving a thirty (30) discharge notice to home or another facility. A review of the facility form entitled, Review of Safe Smoking Assessment reflects that an assessment is to be done annually, quarterly or with a significant change. It reflects that the resident was assessed for safe smoking and that his care plan was reviewed 11 times from [DATE] to [DATE] to date. This form reflected that dated smoking assessments were signed by the Social Services Director and document approved by Administration. Cross reference F656

Based on observations, interviews, and record review facility failed to clean blood glucose monitor equipment before and after used for R#1; the equipment was left in resident's room after used. Upon reviewed facility policies dated 3/18/2014 revealed equipment such as blood glucometer should be cleaned and disinfected according to manufacturer's instructions, using an Environmental Protection Agency-registered disinfectant prior to use on other residents. Sample size 30. Findings include: On 6/20/18 at 10:13. a.m. Observed Licensed Practical Nurse (LPN) DD performed blood sugar for R#1, without cleaning the glucometer before and after used then left the glucometer in the resident's room. On 6/20/18 at 10:15. a.m. during a interview with Licensed Practical Nurse (LPN) DD regarding the observation she stated, I am sorry I have to give another resident a medication. On 6/20/18 at 11:00. a.m. during an interview with Unit Manager (UM) EE regarding the policy for cleaning the glucometer the UM stated facility policy is to clean the glucometer before and after use. On 6/21/18 at 9:00. a.m. An interview with Director of Nursing (DON), Assistant Director of Nursing (ADON) and Staff development revealed Licensed Practical Nurse (LPN) DD, it was stated that they have been training her for one year. DON states they will follow up with her immediately, and in-service all Licensed Nurses.

Based on observation, record review, review of the policy titled Posting Direct Care Daily Staffing Numbers and staff interview, the facility failed to ensure that complete and current Nurse Staffing Information was posted daily prior to each shift. The facility census was 147 residents. Findings include: Review of the policy titled Posting Direct Care Daily Staffing Numbers dated 2/15/18 documented: Our facility will post, on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents. Policy Interpretation and Implementation documented in #3- Shift staffing information shall be recorded on the Nursing Staff Directly Responsible for Resident Care form for each shift. The information recorded on the form shall include: The name of the facility, the date for which the information is posted, the resident census at the beginning of the shift for which the information is posted, twenty four hour shift schedule operated by the facility, the shift for which information is posted, type (RN, LPN, or CNA) and category (licensed or non-licensed) of nursing staff working during that shift, the actual times worked during that shift for each category and type of nursing staff work during that shift, total number of licensed and certified nursing staff working the posted shift. #5- Within two hours of the beginning of each shift, the ward clerk shall compute the number of direct care staff and complete the Nursing Staff Directly Responsible for Resident Care form. The shift supervisor shall date the form, record the census and post the staffing information in the location(s) designated by the Administrator. Review of the form titled Union County Nursing Home Staffing form posted in the front lobby of the facility revealed a calendar type grid that included the facility name, the month and year, table with each day of the month, Day Shift Registered Nurse (RN), Wound Care (WC), Licensed Practical Nurse (LPN), Certified Nurse Aide (CNA), Evening Shift RN, WC, LPN, CNA, Night Shift RN, WC, LPN, CNA. The form specified the number of each licensed staff working each day but did not specify the actual scheduled work hours. The form did not specify units (Blue Side and Pink Side) and did not include the resident census. Further review on 6/21/18 revealed the last day completed on the form was 6/19/18. Interview on 6/21/18 at 9:40 a.m. with the Payroll Based Journal (PBJ) Coordinator revealed she is responsible for posting the nurse staffing information. The PBJ stated she does not post the staffing until the following day because that's how she knows who actually worked the day before. She stated she only list the number of RNs, LPNs and CNAs because she does not know the actual hours worked until they have actually worked. She stated the form does not reflect staff absences due to call outs or illness and she did not know they had to include that. The PBJ confirmed that the facility's staffing form does not indicate the staffing hours, the facility census for that day, specified units in the facility, call outs or changes related to call outs or changes to the staffing. The PBJ further stated that there is no assigned to post nurse staffing on the weekends and she fills out the form for the previous Friday, Saturday and Sunday when she returns to work on Monday. The PBJ stated this is the form they have been using for the last three years and she was not familiar with the regulatory requirements of nurse staffing posting. The PJB stated they would get it corrected.