Every finding on record at University Crossing

Based on observations, record review, and interviews, the facility failed to ensure that one (Resident #154) of one resident observed for respiratory care, from a total survey sample of 29 residents, received respiratory care consistent with professional standards of practice and the resident's care plan. Resident #154 was not receiving oxygen at the flow rate ordered by the physician. The findings include: On 12/16/24 at 10:13 AM, Resident #154 was observed receiving oxygen through a nasal cannula at a flow rate of three liters per minute. (Photographic evidence obtained) On 12/17/24 at 10:35 AM, a second observation was made of Resident #154 receiving oxygen through a nasal cannula at a flow rate of three liters per minute. (Photographic evidence obtained) On 12/17/24 at 11:56 AM, a third observation was made of Resident #154 receiving oxygen through a nasal cannula at a flow rate of three liters per minute. (Photographic evidence obtained) A review of the resident's medical record revealed an admitted [DATE] with diagnoses including acute respiratory failure with hypoxia, pulmonary hypertension, acute on chronic diastolic heart failure, chronic kidney failure - stage 4 (severe), atrial flutter, and dysphasia. A review of Resident #154's 12/6/24 minimum data set (MDS) assessment, revealed that the resident had a brief interview for mental status (BIMS) score of 13 out of a possible 15 points, indicating intact cognition. She displayed no rejection of care and received continuous oxygen therapy via nasal cannula. A review of the care plan initiated on 12/02/24, revealed a focus area for chronic obstructive pulmonary disease (COPD). The care plan goal noted the resident would be free of signs or symptoms of respiratory infections through the review date. Interventions included oxygen (02) settings via nasal cannula per the physician's orders. A review of the active physician's orders for Resident #154 revealed the following: Administer oxygen at 4 liters via nasal cannula with a start date of 11/21/24. An interview was conducted on 12/19/24 at 10:33 AM, with Licensed Practical Nurse (LPN) C, who reported she had worked at the facility for one year. She said she was assigned to Resident #154 and was aware that the resident received oxygen therapy. She was accompanied to the resident's room to check the resident's oxygen flow rate. She reported that the oxygen flow rate was set at 3 liters per minute. She was asked to check the resident's oxygen order. LPN C checked the orders and reported the order for oxygen was for 4 liters per minute via nasal cannula. She explained her process for residents receiving oxygen therapy included checking the resident in the morning at the beginning of her shift. She checked to ensure that the oxygen tubing was in place and the flow rate was accurate. An interview was conducted on 12/19/24 at 10:53 AM, with Certified Nursing Assistant (CNA) D, who reported that she had worked at the facility for two months. She explained that for residents who received oxygen therapy, she would make sure the nasal cannula was inserted correctly and look at the flow rate to ensure the flow rate was accurate. If she saw in inaccurate flow rate, she would inform the nurse. She explained that she was familiar with the Resident #154's care needs and never noticed that the resident's flow rate was inaccurate. A review of the facility's policy and procedure titled Medication Administration (last reviewed on 04/2024, effective 05/2024), revealed that the purpose of the policy was to ensure that all medications were administered safely, accurately, and in a timely manner. Medications are administered safely, accurately, and promptly in accordance with procedures specified. .

Based on observations, interviews, and record review, the facility failed to ensure that one (Resident #151) of two residents reviewed for activities of daily living (ADLs) assistance, out of 29 residents in the total survey sample, received necessary services to maintain good grooming and personal hygiene, specifically fingernail care. The findings include: A review of the medical record revealed that the resident was admitted to the facility on [DATE] with diagnoses including the following: Surgical aftercare following surgery on the circulatory system, acute combined systolic and diastolic heart failure, major depressive disorder, muscle weakness (generalized), hypertension, shortness of breath, diabetes mellitus and legal blindness. On 12/16/24 at 9:35 AM, Resident #151 was observed with the fingernails on both of his hands extending approximately 1/4 of an inch beyond the nail bed. When the resident was asked if he preferred having his fingernails at the current length, he replied that he asked facility staff to trim his nails and was told someone would come trim them. He further explained that he was fearful of scratching himself with such long nails. (Photographic evidence obtained) On 12/17/24 at 10:48 AM, Resident #151 was observed with the fingernails on both of his hands extending approximately 1/4 of an inch beyond the nail bed. (Photographic evidence obtained) On 12/19/24 at 10:45 AM, Resident #151 was observed with the fingernails on both of his hands extending approximately 1/4 of an inch beyond the nail bed. (Photographic evidence obtained) A review of the 2/6/24 minimum data set (MDS) assessment for Resident #151, revealed a brief interview for mental status (BIMS) score of 13 out of a possible 15 points, indicating intact cognition. He had had no indicators of psychosis, physical or verbal behaviors directed toward others, rejection of care, or wandering behaviors documented in the assessment. ADLs were documented as his having no impairment to the upper or lower extremities; eating and oral hygiene required set-up or clean-up assistance; toileting hygiene, lower body dressing and putting on/taking off footwear required partial to moderate assistance. The resident was assessed as independent for self-bathing/showering. Upper body dressing required supervision or touching assistance. For mobility, the resident required supervision or touching assistance. He received scheduled and as needed pain medication. On 12/19/24 at 10:56 AM, an interview was conducted with Certified Nursing Assistant (CNA) A, who reported she had worked at the facility for approximately seven and a half years. She explained that she completed rounds to check on residents every two hours and every hour for residents who were deemed a fall risk. During her rounds, she checked whether residents needed water, needed use the bathroom, or would like to participate in scheduled activities. She also observed her assigned residents' appearance. If a resident's nails appeared soiled, she would use an orange stick to clean underneath the nails. She explained that fingernails extending 1/4 of an inch would be considered too long for a male resident. If a resident's nails were long, she would tell her nurse because CNAs were not permitted to clip residents' fingernails. At 11:02 AM, CNA B observed Resident #151 and verified that his nails were too long and needed to be shortened. On 12/19/24 at 11:11 AM, an interview was conducted with Licensed Practical Nurse (LPN) B, who reported she was agency staff and had worked at the facility for three months. She explained that during administration of medication, she would conduct head-to-toe visual assessments of residents' appearances. She stated nail length beyond the nail bed is too long for a male resident. If the resident was okay with long nails, the resident's preference would be adhered to. She further explained that if she saw a male resident with quarter-of-an-inch long nails, she would ask a CNA what to do about trimming the resident's fingernails, as different facilities she works at through the agency had different practices regarding nail care. She stated she would notify the unit manager and request the resident's fingernails to be clipped. On 12/19/24 at 11:17 AM, LPN B was accompanied to the resident's location. She observed his fingernails and stated they were too long. A review of the facility's policy titled Podiatry and Nail Care (last reviewed 06/2024, effective date 10/2013), revealed that the purpose of the policy was to establish podiatry and nail care for the resident. The policy documented that the community would arrange for or make available foot and nail care. Procedure 1. Caregivers monitor the length and condition of the toe and finger nails of residents receiving bathing, dressing or grooming services. 3. Caregivers (CNAs and nursing) can provide nail care when indicated.

Based on kitchen food service observations, staff interviews, facility document review, and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness, with the potential to affect all residents who consumed foods from the facility, by failing to date mark numerous open food packages in the dry storage room, the refrigerator, and the freezer. Food handling and sanitation is important in health care settings serving nursing home residents. Unsafe food handling practices represent a potential source of pathogen exposure. The findings include: A tour of the kitchen was conducted on 1/17/2023 at 8:20 a.m. During the tour, no date markings were observed on a bin filled with fresh vegetables, an open box filled with pineapples and melons, another open box filled with asparagus, or an open bag of brussels sprouts and carrots on the shelf in the walk-in refrigerator. There was no date marking observed on one open package of blueberries sitting on a shelf in the walk-in freezer. In the dry storage room, there was no date marking observed on one open bag of corn starch. On the opposite side in the dry storage room, on the bottom shelf, there were no date markings identified on four open pasta bags. The bread rack next to tray line had three open bundles of bread with no date markings. These observations were made again on 1/17/2023 at 12:47 p.m., 12:48 p.m., and 12:49 p.m. During the same time, new observations of a bin filled with carrots, one package of cauliflower and five lemons placed on top of a box, and an open box of tomatoes were on the shelf in the walk-in refrigerator with no date marking. (Photographic evidence obtained) A follow-up tour of the kitchen was conducted on 01/19/23 at 10:45 a.m. In the dry storage room, there was no date marking observed on one open bag of corn starch. On the opposite side in the dry storage room, on the bottom shelf, there were no date markings identified on four open pasta bags. The bread rack next to the tray line had two open bundles of bread with no date markings. No date markings were observed on the open bag of celery, vegetable bin filled with vegetables, open box of asparagus, open box of melons, or one package of cauliflower and five lemons placed on the shelf in the walk-in refrigerator. There was no date marking observed on one open package of blueberries or one open bag of biscuits sitting on a shelf in the walk-in freezer. (Photographic evidence obtained) An interview was conducted on 01/20/23 10:17 a.m. with Dietary Aide (DA) A, who confirmed that the facility policy for date marking was to ensure open food was covered, labeled, and dated, and that leftover bread was wrapped, date marked, and discarded after three days. An interview was conducted on 01/20/23 at 10:38 a.m. with Cook B, who stated he and the Director of Dining were responsible for food storage. He confirmed once a food item was opened, it was to be wrapped and dated before going back into the refrigerator, freezer, or dry storage shelf. Opened bread was to be wrapped and dated before placing it back on the rack. An interview was conducted on 01/20/23 at 10:51 a.m. with Director of Dining C, who stated currently it was a collective responsibility of all staff to maintain food storage standards. She confirmed that the facility policy for food storage and date marking was that opened foods should be labeled and dated. Opened bread was wrapped/twisted and dated. A review of the facility's policy and procedure entitled Food and Supply Storage (dated 1/2023), revealed: All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. Procedures: Cover, label and date unused portions and open packages. Complete all sections on a [NAME] orange label or use the Medvantage/Freshdate labeling system. Products are good through the close of business on the date noted on the label . Date and rotate items; first in, first out (FIFO). Discard food past the use-by or expiration date. (Copy obtained) Reference: FDA Food Code 2022 Annex 5. Conducting Risk-Based Inspections Annex 5 - C. Intervention Strategies for Achieving Long-term Compliance. 4. Establish First-In-First-Out (FIFO) Procedures. Page 31. https://www.fda.gov/media/164194/download (Accessed on 1/23/2023): Product rotation is important for both quality and safety reasons. First-In-First Out (FIFO) means that the first batch of product prepared and placed in storage should be the first one sold or used. Date marking foods as required by the Food Code facilitates the use of a FIFO procedure in refrigerated, ready-to-eat, TCS foods. The FIFO concept limits the potential for pathogen growth, encourages product rotation, and documents compliance with time/temperature requirements.

Based on observations, interviews, and record reviews, the facility failed to ensure that drugs and biologicals used in the facility were safely stored for two (Residents #321 and #322) in a total sample of 27 residents. The findings include: 1. On 6/7/2021 at 10:30 AM, Resident #321 was observed lying in bed. There was a container of medication observed on the bedside table. (Photographic evidence obtained) Resident #321 stated in an interview on 6/7/21 at 10:35 AM that she was admitted to the facility on [DATE]. Upon arrival, she was notified that her transplant medication was not available. She stated she had to ask a friend to bring the medication from home, as she could not stay without it. She further stated she had been taking it as prescribed. A medical record review for Resident #321 indicated that she was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. On 6/7/2021 at 11:00 AM, Resident #322 was observed seated in a reclining chair with the bedside table in front of him. There was a bottle of nasal spray on the bedside table, and an anti-fungal powder was observed on the resident's nightstand. (Photographic evidence obtained) In an interview on 6/7/2021 at 11:30 AM, Resident #322 stated he used the nasal spray because at times, he got a dry nose due to the use of oxygen. When asked about the powder on the nightstand, he stated he had a groin infection and the nurses put the powder on daily. On 6/9/2021 at 1:00 PM, the nasal spray and the anti-fungal powder medications were still at the bedside. On 6/9/2021 at 2:08 PM, Employee B, Registered Nurse (RN), confirmed that the resident should not have the antifungal powder or nasal spray at the bedside, as the resident had not been assessed for self-administration of medication. She added that she would discuss it with the nurse responsible for the resident's care. A medical record review for Resident #322 indicated that the resident had skin irritation at the groin, and [CONDITION(S)] ([CONDITION(S)]). Current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no orders for nasal spray. In an interview on 6/9/2021 at 3:33 PM, Employee D, RN/Unit Manager, confirmed that the resident did not have orders for nasal spray, nor should he have medications at the bedside. When asked about Resident #321's and #322's assessments for self-administration, she stated neither resident had an assessment. She added Resident #322 was very forgetful and therefore not a good candidate for self-administration. She also mentioned that all medications were supposed to be in the medication/treatment carts at all times. Another interview was conducted with the Director of Nursing (DON) on 6/10/2021 at 9:00 AM. She stated when a resident arrived at the facility, nurses were to make every effort to ensure that he/she received their medications as ordered. She added there were times when some medications were not available due to insurance coverage, and residents were asked to bring in their home prescription. In this case, the nurse should have documentation indicating that the medication belonged to the resident, and medication should be administered by the nurse and not left at the bedside. The DON also stated medications received from the resident should be added to the inventory sheet. When asked about administration of over-the-counter medications, she stated no medications should be administered without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the facility's policy and procedure titled Nursing Medication Safety (Policy #UC NUR-014, revised on 05/2021) revealed: The purpose of this policy is to communicate safe medication practices to the nursing staff members, patients and their families and facilitate medication safety at all times throughout their stay. All RNs and LPNs will actively participate in safe medication practices in accordance with the procedures specified. 1.Medications are to be administered to the Guest/Residents only when prescribed by a licensed physician. 4. Safe storage and handling of medication: Upon delivery to nursing units, medications are kept in secure areas until administration. These areas include medication rooms, medication carts and refrigerators. 5. Requirements for specific type of orders i. Guest's own supply of medication of medication/self-administration: Policies and processes are not in place as guest are not to self-administer medication and/or maintain medication at the bedside.

Based on interviews and record reviews, the facility failed to ensure the completion of pre-admission screening for individuals with a mental disorder and individuals with an intellectual disability for one (Resident #39) of 27 residents in the sample. The findings include: A medical record review for Resident #39 indicated he was admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . His physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A 5-day admission Minimum Data Set (MDS) assessment revealed the resident had not been evaluated via Level II Pre-admission Screening and Resident Review (PASRR) to determine serious mental illness and/or mental [CONDITION(S)] or related condition. Further review indicated that Resident #39 had a Brief Interview for Mental Status score (BIMS) of 07 out of 15 possible points, indicating severe cognitive impairment. The resident also reported feeling depressed or hopeless, feeling tired and having little energy for 2- 6 days, and received antispychotic and antidepressant medication for 7 days and antianxiety medication for 3 days during the look back period. His care plan indicated that he was on antianxiety, antidepressant and [CONDITION(S)] medications related to anxiety, depression and [CONDITION(S)] disorders respectively. A review of the Level I PASRR dated 4/19/2021, Section 1, revealed the following: [CONDITION(S)] onset prior to [AGE] years of age. Currently receiving services for mental illness (MI), and Intellectual disability (ID). Section II 1. indicated that Resident #39 had or may have had a disorder in functional limitation in major life activities that would otherwise be appropriate for the individual's developmental stage. Previously received services for MI and ID. Section IV was incomplete. (Copy obtained) A review of the Hospital Discharge Summary dated 4/22/2021, revealed: Past medical history indicated mental deficiency, [CONDITION(S)], and intermittent explosive disorder. Resident's father described him as never having issues with depression, always just wild due to his [CONDITION(S)] and requiring [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)], and never on an anti-depressant. During an interview on 06/09/2021 at 12:35 PM, the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were asked about Resident #39's Level II PASRR. They confirmed that the level II PASRR was not completed. They also stated that Resident #39 lived in a group home owned by his parents prior to admission. When asked whether the resident had received a psychiatric evaluation, they stated, No. They added that the facility did not have a psychiatric physician and residents were evaluated on an as-needed basis by the hospital psychiatric physician. The DON stated the facility did not have a policy for PASRR.

Based on observations, interviews, record reviews, a review of the Assure Platinum Blood Glucose Monitoring System QA/QC (quality assurance/quality control) reference guidelines, and a review of the Centers for Disease Control and Prevention guidelines, the facility failed to ensure blood glucose meters were cleaned and disinfected between residents to prevent the spread of bloodborne pathogens. During observations of Blood Glucose Monitoring (BGM) via finger stick testing, one (Employee A) of one licensed practical nurses failed to clean and disinfect the glucometer (a device used to measure blood glucose levels) between each resident's use for two (Resident #27 and #301) of two residents observed, out of a total of 21 residents who required blood glucose monitoring. This failure placed the residents at risk for transmission of potentially infectious bloodborne pathogens. Following re-education on 6/13 and 6/14/2019, with documentation that 55 nurses and then 26 nurses had been retrained, respectively, two (Employees D and L) of four nurses observed, remained unable to appropriately disinfect the glucometer devices. The findings include: On 06/13/19 at 12:24 PM, blood glucose monitoring was observed with Employee A for Resident #27. The nurse removed the glucometer from the medication cart and cleansed it with an alcohol wipe. She placed it down on top of her cart and gathered her other supplies. She picked up a bag containing the resident's insulin pen and placed an extra lancet and alcohol wipe in the bag with the pen. She then entered the residents room, placed all of her items down on the bedside table without a barrier and donned gloves without first performing hand hygiene. She inserted the test strip into the glucometer, opened an alcohol wipe, checked the resident's identity, and cleansed the fourth finger on the resident's right hand. She wiped the first blood drop off with an alcohol wipe, obtained a blood drop on the test strip and stated, Oh, we got an error message. She picked the glucometer up and stated, I need to get another machine. Then she turned the device around and stated, Oh, it's not an error, it says 103 mg/dl (milligrams per deciliter). I thought it said error. She sanitized her hands and returned to the cart. She opened the cart and placed the device on a piece of foil. She obtained a bleach wipe, and wiped the front and back of the glucometer for approximately 4-5 seconds. She failed to wipe the top, bottom or sides of the device. She placed the device on a tissue on her cart. She then removed the items from the bag with the insulin pen, and returned them to the cart's top drawer with all of the other blood glucose testing supplies. On 6/13/19 at 12:31 PM, Employee A moved on from Resident #27 to Resident #301. The nurse removed two lancets, two alcohol wipes and a test strip from the cart. She removed Resident #301's insulin pen and cleaned the top with an alcohol wipe. She dialed the pen to deliver 11 units of insulin. She picked up the same glucometer she used for Resident #27 from the top of the cart, along with the insulin pen and her other blood glucose testing supplies, and went to Resident #301's room. Resident #301 was on transmission-based precautions for [MEDICAL CONDITION]-Resistant Staphylococcus Aureus (MRSA). The nurse donned gloves without first performing hand hygiene, then a gown (personal protective equipment (PPE) before entering the room. She placed all of the items on the bedside table without a barrier, looked in the bathroom and realized the resident was at therapy. She removed the PPE, sanititzed her hands with gel/foam cleanser, picked up all of her supplies and returned to her cart. She laid all the supplies on top of the cart without a barrier. She stated she would have to wait until the resident returned from therapy. On 6/13/19 at 12:42 PM, Resident #301 returned from therapy. Employee A picked up the glucometer from the top of the cart along with the other supplies that were still sitting there. She removed the insulin pen and applied a needle. She removed the needle, discarded it into the sharps container, cleansed the top of the pen and applied a new needle. She confirmed the needle was still dialed up to 11 units of insulin. She donned PPE and entered the resident's room. She placed the items on the bedside table without a barrier. She donned gloves, inserted the test strip, verified resident's identity, cleansed the finger on the resident's left hand and obtained a lancet for the blood sample. The nurse dropped the lancet, and reached into her scrubs pocket to retrieve a second lancet. She pricked the middle finger of the resident's left hand, and obtained a result of 227 mg/dl. She stated she would need to give the resident four more units for coverage, and dialed the pen to 15 units. She verified the dose, then administered the insulin. She placed the lancet in the sharps container, removed the blood test strip, and placed it in the trash can with her gloves. She removed her gown and sanitized her hands. She then realized the call light was not within the resident's reach, so she walked back over to the resident (between the resident and the wall), obtained the call light, and placed it within the resident's reach. The front of her scrub top contacted the resident and the resident's wheelchair when she retrieved the call light. She sanitized her hands again and returned to her cart, placing the items on top of her cart without a barrier. She obtained an alcohol wipe, cleansed the glucometer, and placed it on a tissue to dry. An interview was immediately conducted with Employee A, regarding whether it was acceptable to cleanse glucometers with an alcohol wipe. She stated, Yes, we can use an alcohol wipe or a bleach wipe. I would think so, as long as it is clean, so my answer is Yes. The Director of Nursing approached the medication cart at 1:03 PM and joined the conversation. She was asked if the nurses were permitted to cleanse the glucometers with an alcohol wipe, and she stated, No, it has to be a bleach wipe. Employee A was then asked about priming the insulin pen, and she stated she knew to prime the pen with two units, but she forgot. She was asked about using hand sanitizer versus washing hands when leaving an isolation room, and she stated, We can sanitize if it is not [MEDICAL CONDITIONS]. On 6/13/19 at 1:11 PM, the glucometers on the medication cart on unit Cherry - East were observed with Employee B, Licensed Practical Nurse (LPN). One of two glucometers was observed with a red-tinged substance on it. When asked about the substance on the device, Employee B stated the nurses were supposed to clean them and not leave blood on them. On 6/13/19 at 1:32 PM, the glucometers on the medication cart on unit Cherry - West were observed with Employee C, Registered Nurse (RN). The glucometer labeled West #2 was soiled with a red-tinged substance. Employee C proceeded to unit Cherry - South and the glucometers were observed. Glucometer #2 was soiled with a red-tinged substance. On 6/13/19 at 1:43 PM, the director of nursing (DON) observed two glucometers (Cherry East and Cherry West) in the conference room, and confirmed that both glucometers were soiled with a red-tinged substance. She stated the facility would be replacing all of their glucometers. She was asked for the policy and procedure related to blood glucose monitoring and she stated, We do not have a copy here, but I called our sister facility and they are sending me one. A review of nursing competencies for all facility nurses revealed that 43 of a total of 64 nurses had documentation of completion of successful use of blood glucose monitors. Employee A was included in these competencies. The facility used two separate forms for each nurse to record competency. The first form was titled Blood Glucose Testing New Competency. Upon completion of the form, the observing RN signed off, indicating the tasks were properly conducted by the nurse being observed. The criteria for demonstration included: a. Disinfected glucometer prior to use . h. Glucometer cleaned and disinfected after use. The second form was three pages long and titled Assure Platinum Blood Glucose Monitoring System Competency Checklist. It instructed the certified trainer to observe the operator performing the following tasks: .2. Use lancet/lancing device correctly . 9. Clean/disinfect meter correctly . Page 2 and 3 was a question and answer section, required to be completed by the nurse being evaluated . Question 8 asked: 8. The Assure Platinum a. Does not need to be cleaned. (Incorrect answer) b. Should be immersed or held under running water to clean. (Incorrect answer) c. Cleaned with a lint-free cloth, dampened with soapy water, [MEDICATION NAME] alcohol, or diluted household bleach. (Correct answer for cleaning, but not disinfecting) d. Should be cleaned and disinfected between patient tests to avoid cross contamination. (Correct answer for disinfection) The question and answer section did not clarify whether nurses knew to clean and disinfect the blood glucometer upon removal from the medication storage cart prior to the first use, or if they knew to clean and disinfect the meter after use on the last patient prior to storing it in the medication cart. On 6/13/19 at 1:03 PM, the director of nursing (DON) was asked for the facility's policy and procedure for blood glucose monitoring. It was again requested on 6/13/19 at 1:43 PM as noted above. She stated she was unable to locate a copy in the facility, but had requested one from a sister facility. At 2:08 PM she produced the policy and stated again that the facility was obtaining new glucometers. A review of the policy and procedure for Bedside Blood Glucose Monitoring Policy #1.0 (effective 9/1/16), last reviewed (MONTH) 2019, revealed the following: Blood glucose levels may be monitored at the bedside with Accu-Chek Inform glucose meter by licensed nursing personnel. Equipment: 1. Assure bedside blood glucose monitor 2. Test strips 3. Lancet 4. Gloves 5. Alcohol swabs 6. Cotton ball, gauze Under Procedures, it instructed: 1. Verify physician's orders [REDACTED]. 2. Gather equipment. Check expiration date . 3. Wash hands . don gloves. 4., Verify correct patient . 5. Explain procedure . 6. Remove test strip . 7. Gently insert test strip .(before applying blood). 8.clean the site with an alcohol swab and thoroughly dry the site using a dry gauze pad. 9. When flashing blood droplet appears . obtain blood sample . . 12. Remove test strip and discard. 12. Clean the meter with a dispatch wipe per protocol . Maintenance: 1. Clorox Germicidal Wipes 2. Super Sani-Cloth Germicidal Disposable Wipes 3. Clorox Dispatch Hospital Cleaner wipes will be used at (facility) as they are chemically similar to the Germicidal wipes . 4. The meter should be cleaned and disinfected between each patient use per protocol . The policy did not instruct nursing staff to clean and disinfect the meter after removal from the medication storage cart and prior to use on the first resident as per the competency forms the facility was currently using to train the nursing staff. There were two separate blood glucose meters observed in use during the survey, and both user guides were reviewed: The User's Guide for the Evencare ProView blood glucose monitoring system revealed the following Important Safety Instructions: - The meter should be disinfected after use on each patient. Cleaning Instructions: Step 1. Wash hands . put on single use medical protective gloves. Step 2. Prepare the (disinfecting wipe). Take out a wipe from the container and follow instructions on the package. If needed squeeze the wipe slightly to remove the excess liquid. Step 3. Wipe the glucose meter thoroughly . Do not wrap the meter in a wipe . Disinfection Instructions: Step 1. Before disinfecting, clean the meter as described . Step 2. Wash hands . put on gloves. Step 3. Prepare the (disinfecting wipe) . squeeze the wipe slightly to remove excess liquid. Step 4. Wipe the glucose meter thoroughly . Step 5.allow the surface of the meter to remain wet for the contact time listed on the disinfecting wipe's instructions . A review of the Assure Platinum User Instruction Manual was conducted and revealed the following: Assure Platinum User Instruction Manual Page 47 Cleaning & Disinfecting Guidelines Healthcare professionals should wear gloves when cleaning the Assure Platinum meter. Wash hands after taking off gloves. Contact with blood presents a potential infection risk. We suggest cleaning and disinfecting the meter between patient use. Option 1: Cleaning and disinfecting can be completed by using a commercially available EPA-registered disinfectant detergent or germicide wipe. To use a wipe, remove from container and follow product label instructions to disinfect the meter. Take extreme care not to get liquid in the test strip and key code ports of the meter. many wipes act as both a cleaner and disinfectant, though if blood is visibly present on the meter, two wipes must be used; use one wipe to clean and a second wipe to disinfect. Option 2: To clean the outside of the blood glucose meter, use a lint-free cloth dampened with soapy water or [MEDICATION NAME] alcohol (70-80%). To disinfect the meter, dilute 1 mL of household bleach (5-6% sodium hypochlorite solution) in 9 mL of water to achieve 1:10 dilution (final concentration of 0.5-0.6% sodium hypochlorite). The solution can then be used to dampen a paper towel (do not saturate the towel). Then use the dampened paper towel to thoroughly wipe down the meter. Please note that there are commercially available 1:10 bleach wipes from a variety of manufactures. Take extreme care not to get liquid in the test strip and key code ports of the meter. With all the recommended meter cleaning and disinfecting methods, it is critical that the meter be completely dry before testing a resident's glucose level. Please follow the disinfectant product label instructions to ensure proper drying time. On 6/13/19 the facility began retraining and measuring licensed nurse competencies for the proper use of the blood glucometers. Based on a review of the records provided, 55 licensed nurses were assessed for competency from a total pool of 64 nurses employed by the facility. A revised one-page New Competency form was now being utilized which included the following criteria to be observed: a. Disinfected the glucometer prior to use . h. Lancet/finger stick devices and test strip disposed of in sharps container. j. Brought glucometer to cart with barrier and disinfected with bleach wipes . Employee D, Registered Nurse (RN) Employee L, RN, and Employee G, Licensed Practical Nurse (LPN), were included in the training and were deemed competent. On 6/13/19 at 4:32 PM, an observation of blood glucose monitoring was made with Employee D, RN, for the resident in room [ROOM NUMBER]. After obtaining the blood glucose reading, the nurse returned to the cart and cleansed/disinfected the glucometer with a germacidal bleach wipe. After cleansing the glucometer, it was visibly wet, and she stated if it was not dry in one minute, that she could then wipe it dry. The unit manager confirmed that she could wipe it dry after one minute. On 6/14/19, the facility began retraining and assessing competencies again for proper handling of the glucometers. Based on a review of the records provided, 26 of 64 licensed nurses had been reassessed for competency on this day. Employees D, L, G and N (RN) were included. On 6/14/19 at 2:23 PM, an interview was conducted with Employee D, RN, regarding the education that she received yesterday related to cleaning/disinfecting glucometers. She stated she had been re-educated yesterday and corrected regarding the fact that she could not dry it; it had to air dry. She was then asked to demonstrate cleaning/disinfection of the glucometer, and she failed to complete the task appropriately. After cleaning the device, she placed it back down on a soiled barrier. On 6/14/19 at 2:27 PM, an interview was conducted with the DON. She confirmed that nursing management was only using the new checklist to provide re-education to the nurses about glucometer disinfection. When asked whether the facility had incorporated information from the manufacturer's instructions or the disinfecting wipes package regarding disinfection of the devices, she confirmed that they were not. On 6/14/19 at 4:39 PM, blood glucose monitoring was conducted with Employee L, RN, for Resident #86. The nurse cleaned/disinfected the glucometer prior to use. She entered the resident's room, sanitized her hands, donned gloves, cleansed his finger on the left hand with an alcohol wipe, pricked his finger, inserted the test strip into the glucometer, and the glucometer was not working. She explained that she had to get another glucometer. She placed the lancet in the sharps container, removed her gloves, did not perform hand hygiene, and exited the room. She returned to the cart, donned clean gloves without performing hand hygiene, and cleansed the glucometer that was not working. She placed it down on a soiled tissue. She then removed her gloves, failed to perform hand hygiene, reached into the cart and obtained a second glucometer. She entered the resident's room, used hand sanitizer, donned clean gloves and obtained his blood glucose reading using the second glucometer. She did not clean/disinfect the device first. Prior to cleaning/disinfecting the first glucometer, the nurse stated, I am new on this cart, so I do not know if these are clean or not, so I have to clean them before I use them. On 6/14/19 at 4:53 PM, Employee L, RN, confirmed she had failed to clean/disinfect the second glucometer prior to use. On 6/14/19 at 5:03 PM, blood glucose monitoring was observed with Employee M, LPN, for Resident #191. No concerns were identified with infection control; however, when asked whether she had received any training on the new glucometer that she was currently using, she confirmed she had not. On 6/14/19 at 5:38 PM, blood glucose monitoring was observed with Employee N, RN, for Resident #23. The nurse obtained the blood glucose reading, then disposed of the second lancet in the regular trash can in the room. During an interview with Employee N at 5:57 PM, she confirmed that she should have disposed of the soiled lancet in the sharps container. An interview was conducted with the Medical Director Designee (MDD) at 2:05 PM on 6/14/19. The MDD confirmed alcohol wipes should not have been used, saying I don't know why they used alcohol. We must try to avoid this from ever happening again. The MDD stated he did not know why there was blood on the glucometers. He said he expected the glucometers to be cleaned before and after each use, referring to it as common sense. The MDD reviewed the photographs of the soiled glucometers and stated, We definitely need retraining. That should not ever happen again. An interview was conducted on 6/15/19 at 3:55 PM with the Director of Nursing (DON). She reviewed the three different competency forms used by the facility for assessing nurses, the facility's policy and procedure, and the user guides for the two blood glucose meters being used by the facility. She confirmed the discrepancies regarding the cleaning and disinfecting of the devices, and the lack of consistency regarding the cleaning/disinfection of the meters before the initial use and after the final use. She confirmed knowledge that the policy and procedure in use failed to address cleaning the device after removal from the medication cart and prior to use on the first resident. The DON agreed the competencies did not make it clear that the nurses were aware the glucometer should be cleaned and disinfected after use on the last resident and prior to storage. She acknowledged that the lack of consistent information and instruction may have contributed to the discrepancies observed during the course of the survey. A review of the Centers for Disease Control and Prevention (CDC) guidelines for Infection Prevention during Blood Glucose Monitoring and Insulin Administration (6/8/2017) revealed the following, The Centers for Disease Control and Prevention (CDC) has become increasingly concerned about the risks for transmitting [MEDICAL CONDITION] virus (HBV) and other infectious diseases during assisted blood glucose (blood sugar) monitoring and insulin administration. Whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions. If the manufacturer does not specify how the device should be cleaned and disinfected, then it should not be shared. Outbreaks of [MEDICAL CONDITION] virus (HBV) infection associated with blood glucose monitoring have been identified with increasing regularity, particularly in long-term care settings, such as nursing homes and assisted living facilities, where residents often require assistance with monitoring of blood glucose levels and/or insulin administration. A review of the facility's policy and procedure for infection control revealed the following: Infection Control and Prevention Last Review/Update: (MONTH) 2019 Effective: (MONTH) (YEAR) Page 2 Care of Contaminated Articles and Equipment 1. Follow Standard Precautions when handling contaminated articles/equipment. 2. Discard disposables in the appropriate receptacle. 3. Disinfect non-disposables with an Environmental Protective Agency (EPA) approved disinfectant or a freshly prepared bleach solution of one part bleach to ten parts water. 4. Cover medical equipment prior to resident/patient use and/or cleanse with a disinfectant solution when visibly contaminated. Page 8 and 9 Resident/Patient Care Equipment 1. Bag or cover used resident/patient care equipment soiled with blood, body fluids, secretions, and excretions to prevent skin and mucous membrane exposures, contamination of clothing, or transfer of microorganisms to other residents/patients and environments. 2. Ensure that reusable equipment is not used for the care of another resident until it has been cleaned and disinfected appropriately. Single use items are to be properly discarded. Contact Precautions Gown 3. Remove the gown before leaving the resident/patient environment and discard in appropriate container. Ensure clothing does not contact potentially contaminated environmental surfaces after gown removal.

Based on observations, record reviews and interviews, the facility failed to provide nursing staff with the appropriate competencies and skills sets necessary to care for residents' needs, by failing to appropriately disinfect blood glucose meters between two residents. During observations of blood glucose monitoring (BGM), one(Employee A) of one licensed practical nurses (LPNs) failed to clean and disinfect the glucometer (a device used to measure blood glucose levels) between each resident's use for two (Resident #27 and #301) of two residents observed, from a total of 21 residents who required blood glucose monitoring. This failure placed the residents at risk for transmission of potentially infectious bloodborne pathogens. Following re-education on 6/13 and 6/14/2019, with documentation that 55 nurses and then 26 nurses had been retrained, respectively, two (Employees D and L) of four nurses observed, remained unable to appropriately disinfect the glucometer devices. The findings include: On 06/13/19 at 12:24 PM, blood glucose monitoring was observed with Employee A for Resident #27. The nurse removed the glucometer from the medication cart and cleansed it with an alcohol wipe. She placed it down on top of her cart and gathered her other supplies. She picked up a bag containing the resident's insulin pen and placed an extra lancet and alcohol wipe in the bag with the pen. She then entered the resident's room, placed all of her items down on the bedside table without a barrier and donned gloves without first performing hand hygiene. She inserted the test strip into the glucometer, opened an alcohol wipe, checked the resident's identity, and cleansed the fourth finger on the resident's right hand. She wiped the first blood drop off with an alcohol wipe, obtained a blood drop on the test strip and stated, Oh, we got an error message. She picked the glucometer up and stated, I need to get another machine. Then she turned the device around and stated, Oh, it's not an error, it says 103 mg/dl (milligrams per deciliter). I thought it said error. She sanitized her hands and returned to the cart. She opened the cart and placed the device on a piece of foil. She obtained a bleach wipe and wiped the front and back of the glucometer for approximately 4-5 seconds. She failed to wipe the top, bottom or sides of the device. She placed the device on a tissue on her cart. She then removed the items from the bag with the insulin pen and returned them to the cart's top drawer with all of the other blood glucose testing supplies. On 6/13/19 at 12:31 PM, Employee A moved on from Resident #27 to Resident #301. The nurse removed two lancets, two alcohol wipes and a test strip from the cart. She removed Resident #301's insulin pen and cleaned the top with an alcohol wipe. She dialed the pen to deliver 11 units of insulin. She picked up the same glucometer she used for Resident #27 from the top of the cart, along with the insulin pen and her other blood glucose testing supplies and went to Resident #301's room. Resident #301 was on transmission-based precautions for [MEDICAL CONDITION]-Resistant Staphylococcus Aureus (MRSA). The nurse donned gloves without first performing hand hygiene, then a gown (personal protective equipment (PPE) before entering the room. She placed all of the items on the bedside table without a barrier, looked in the bathroom and realized the resident was at therapy. She removed the PPE, sanititzed her hands with gel/foam cleanser, picked up all of her supplies and returned to her cart. She laid all the supplies on top of the cart without a barrier. She stated she would have to wait until the resident returned from therapy. On 6/13/19 at 12:42 PM, Resident #301 returned from therapy. Employee A picked up the glucometer from the top of the cart along with the other supplies that were still sitting there. She removed the insulin pen and applied a needle. She removed the needle, discarded it into the sharps container, cleansed the top of the pen and applied a new needle. She confirmed the needle was still dialed up to 11 units of insulin. She donned PPE and entered the resident's room. She placed the items on the bedside table without a barrier. She donned gloves, inserted the test strip, verified resident's identity, cleansed the finger on the resident's left hand and obtained a lancet for the blood sample. The nurse dropped the lancet and reached into her scrubs pocket to retrieve a second lancet. She pricked the middle finger of the resident's left hand and obtained a result of 227 mg/dl. She stated she would need to give the resident four more units for coverage and dialed the pen to 15 units. She verified the dose, then administered the insulin. She placed the lancet in the sharps container, removed the blood test strip, and placed it in the trash can with her gloves. She removed her gown and sanitized her hands. She then realized the call light was not within the resident's reach, so she walked back over to the resident (between the resident and the wall), obtained the call light, and placed it within the resident's reach. The front of her scrub top contacted the resident and the resident's wheelchair when she retrieved the call light. She sanitized her hands again and returned to her cart, placing the items on top of her cart without a barrier. She obtained an alcohol wipe, cleansed the glucometer, and placed it on a tissue to dry. An interview was immediately conducted with Employee A, regarding whether it was acceptable to cleanse glucometers with an alcohol wipe. She stated, Yes, we can use an alcohol wipe or a bleach wipe. I would think so, as long as it is clean, so my answer is Yes. The Director of Nursing approached the medication cart at 1:03 PM and joined the conversation. She was asked if the nurses were permitted to cleanse the glucometers with an alcohol wipe, and she stated, No, it has to be a bleach wipe. Employee A was then asked about priming the insulin pen, and she stated she knew to prime the pen with two units, but she forgot. She was asked about using hand sanitizer versus washing hands when leaving an isolation room, and she stated, We can sanitize if it is not [MEDICAL CONDITIONS]. On 6/13/19 at 1:11 PM, the glucometers on the medication cart on unit Cherry - East were observed with Employee B, Licensed Practical Nurse (LPN). One of two glucometers was observed with a red-tinged substance on it. When asked about the substance on the device, Employee B stated the nurses were supposed to clean them and not leave blood on them. On 6/13/19 at 1:32 PM, the glucometers on the medication cart on unit Cherry - West were observed with Employee C, Registered Nurse (RN). The glucometer labeled West #2 was soiled with a red-tinged substance. Employee C proceeded to unit Cherry - South and the glucometers were observed. Glucometer #2 was soiled with a red-tinged substance. On 6/13/19 at 1:43 PM, the director of nursing (DON) observed two glucometers (Cherry East and Cherry West) in the conference room and confirmed that both glucometers were soiled with a red-tinged substance. She stated the facility would be replacing all of their glucometers. She was asked for the policy and procedure related to blood glucose monitoring and she stated, We do not have a copy here, but I called our sister facility and they are sending me one. A review of nursing competencies for all facility nurses revealed that 43 of a total of 64 nurses had documentation of completion of successful use of blood glucose monitors. Employee A was included in these competencies. The facility used two separate forms for each nurse to record competency. The first form was titled Blood Glucose Testing New Competency. Upon completion of the form, the observing RN signed off, indicating the tasks were properly conducted by the nurse being observed. The criteria for demonstration included: a. Disinfected glucometer prior to use . h. Glucometer cleaned and disinfected after use. The second form was three pages long and titled Assure Platinum Blood Glucose Monitoring System Competency Checklist. It instructed the certified trainer to observe the operator performing the following tasks: .2. Use lancet/lancing device correctly . 9. Clean/disinfect meter correctly . Page 2 and 3 was a question and answer section, required to be completed by the nurse being evaluated . Question 8 asked: 8. The Assure Platinum a. Does not need to be cleaned. (Incorrect answer) b. Should be immersed or held under running water to clean. (Incorrect answer) c. Cleaned with a lint-free cloth, dampened with soapy water, [MEDICATION NAME] alcohol, or diluted household bleach. (Correct answer for cleaning, but not disinfecting) d. Should be cleaned and disinfected between patient tests to avoid cross contamination. (Correct answer for disinfection) The question and answer section did not clarify whether nurses knew to clean and disinfect the blood glucometer upon removal from the medication storage cart prior to the first use, or if they knew to clean and disinfect the meter after use on the last patient prior to storing it in the medication cart. On 6/13/19 at 1:03 PM, the director of nursing (DON) was asked for the facility's policy and procedure for blood glucose monitoring. It was again requested on 6/13/19 at 1:43 PM as noted above. She stated she was unable to locate a copy in the facility, but had requested one from a sister facility. At 2:08 PM she produced the policy and stated again that the facility was obtaining new glucometers. A review of the policy and procedure for Bedside Blood Glucose Monitoring Policy #1.0 (effective 9/1/16), last reviewed (MONTH) 2019, revealed the following: Blood glucose levels may be monitored at the bedside with Accu-Chek Inform glucose meter by licensed nursing personnel. Equipment: 1. Assure bedside blood glucose monitor 2. Test strips 3. Lancet 4. Gloves 5. Alcohol swabs 6. Cotton ball, gauze Under Procedures, it instructed: 1. Verify physician's orders [REDACTED]. 2. Gather equipment. Check expiration date . 3. Wash hands . don gloves. 4., Verify correct patient . 5. Explain procedure . 6. Remove test strip . 7. Gently insert test strip .(before applying blood). 8.clean the site with an alcohol swab and thoroughly dry the site using a dry gauze pad. 9. When flashing blood droplet appears . obtain blood sample . . 12. Remove test strip and discard. 12. Clean the meter with a dispatch wipe per protocol . Maintenance: 1. Clorox Germicidal Wipes 2. Super Sani-Cloth Germicidal Disposable Wipes 3. Clorox Dispatch Hospital Cleaner wipes will be used at (facility) as they are chemically similar to the Germicidal wipes . 4. The meter should be cleaned and disinfected between each patient use per protocol . The policy did not instruct nursing staff to clean and disinfect the meter after removal from the medication storage cart and prior to use on the first resident as per the competency forms the facility was currently using to train the nursing staff. There were two separate blood glucose meters observed in use during the survey, and both user guides were reviewed: The User's Guide for the Evencare ProView blood glucose monitoring system revealed the following Important Safety Instructions: - The meter should be disinfected after use on each patient. Cleaning Instructions: Step 1. Wash hands . put on single use medical protective gloves. Step 2. Prepare the (disinfecting wipe). Take out a wipe from the container and follow instructions on the package. If needed squeeze the wipe slightly to remove the excess liquid. Step 3. Wipe the glucose meter thoroughly . Do not wrap the meter in a wipe . Disinfection Instructions: Step 1. Before disinfecting, clean the meter as described . Step 2. Wash hands . put on gloves. Step 3. Prepare the (disinfecting wipe) . squeeze the wipe slightly to remove excess liquid. Step 4. Wipe the glucose meter thoroughly . Step 5.allow the surface of the meter to remain wet for the contact time listed on the disinfecting wipe's instructions . The User Instruction Manual for the Assure Platinum device instructed: Cleaning and Disinfecting Guidelines: Option 1 -Cleaning and disinfecting can be completed using a commercially available EPA-registered disinfectant detergent or germicide wipe. -Many wipes act as a cleaner and a disinfectant, though if blood is present on the meter, two wipes must be used. use one wipe to clean and a second wipe to disinfect. Option 2 -To clean the outside of the blood glucose meter, use a lint free cloth dampened with soapy water or [MEDICATION NAME] alcohol . -To disinfect the meter, dilute 1 ml of household bleach with 9 milliliters (ml) of water then thoroughly wipe down the meter. Please note there are commercially available 1:10 bleach wipes . On 6/13/19 the facility began retraining and measuring licensed nurse competencies for the proper use of the blood glucometers. Based on a review of the records provided, 55 licensed nurses were assessed for competency from a total pool of 64 nurses employed by the facility. A revised one-page New Competency form was now being utilized which included the following criteria to be observed: a. Disinfected the glucometer prior to use . h. Lancet/finger stick devices and test strip disposed of in sharps container. j. Brought glucometer to cart with barrier and disinfected with bleach wipes . Employee D, Registered Nurse (RN) Employee L, RN, and Employee G, Licensed Practical Nurse (LPN), were included in the training and were deemed competent. On 6/13/19 at 4:32 PM, an observation of blood glucose monitoring was made with Employee D, RN, for the resident in room [ROOM NUMBER]. After obtaining the blood glucose reading, the nurse returned to the cart and cleansed/disinfected the glucometer with a germacidal bleach wipe. After cleansing the glucometer, it was visibly wet, and she stated if it was not dry in one minute, that she could then wipe it dry. The unit manager confirmed that she could wipe it dry after one minute. On 6/14/19, the facility began retraining and assessing competencies again for proper handling of the glucometers. Based on a review of the records provided, 26 of 64 licensed nurses had been reassessed for competency on this day. Employees D, L, G and N (RN) were included. On 6/14/19 at 2:23 PM, an interview was conducted with Employee D, RN, regarding the education that she received yesterday related to cleaning/disinfecting glucometers. She stated she had been re-educated yesterday and corrected regarding the fact that she could not dry it; it had to air dry. She was then asked to demonstrate cleaning/disinfection of the glucometer, and she failed to complete the task appropriately. After cleaning the device, she placed it back down on a soiled barrier. On 6/14/19 at 4:39 PM, blood glucose monitoring was conducted with Employee L, RN, for Resident #86. The nurse cleaned/disinfected the glucometer prior to use. She entered the resident's room, sanitized her hands, donned gloves, cleansed his finger on the left hand with an alcohol wipe, pricked his finger, inserted the test strip into the glucometer, and the glucometer was not working. She explained that she had to get another glucometer. She placed the lancet in the sharps container, removed her gloves, did not perform hand hygiene, and exited the room. She returned to the cart, donned clean gloves without performing hand hygiene, and cleansed the glucometer that was not working. She placed it down on a soiled tissue. She then removed her gloves, failed to perform hand hygiene, reached into the cart and obtained a second glucometer. She entered the resident's room, used hand sanitizer, donned clean gloves and obtained his blood glucose reading using the second glucometer. She did not clean/disinfect the device first. Prior to cleaning/disinfecting the first glucometer, the nurse stated, I am new on this cart, so I do not know if these are clean or not, so I have to clean them before I use them. On 6/14/19 at 4:53 PM, Employee L, RN, confirmed she had failed to clean/disinfect the second glucometer prior to use. On 6/14/19 at 5:03 PM, blood glucose monitoring was observed with Employee M, LPN, for Resident #191. No concerns were identified with infection control; however, when asked whether she had received any training on the new glucometer that she was currently using, she confirmed she had not. On 6/14/19 at 5:38 PM, blood glucose monitoring was observed with Employee N, RN, for Resident #23. The nurse obtained the blood glucose reading, then disposed of the second lancet in the regular trash can in the room. During an interview with Employee N at 5:57 PM, she confirmed that she should have disposed of the soiled lancet in the sharps container. An interview was conducted with the Medical Director Designee (MDD) at 2:05 PM on 6/14/19. The MDD confirmed alcohol wipes should not have been used, saying I don't know why they used alcohol. We must try to avoid this from ever happening again. The MDD stated he did not know why there was blood on the glucometers. He said he expected the glucometers to be cleaned before and after each use, referring to it as common sense. The MDD reviewed the photographs of the soiled glucometers and stated, We definitely need retraining. That should not ever happen again. An interview was conducted on 6/15/19 at 3:55 PM with the Director of Nursing (DON). She reviewed the three different competency forms used by the facility for assessing nurses, the facility's policy and procedure, and the user guides for the two blood glucose meters being used by the facility. She confirmed the discrepancies regarding the cleaning and disinfecting of the devices, and the lack of consistency regarding the cleaning/disinfection of the meters before the initial use and after the final use. She confirmed knowledge that the policy and procedure in use failed to address cleaning the device after removal from the medication cart and prior to use on the first resident. The DON agreed the competencies did not make it clear that the nurses were aware the glucometer should be cleaned and disinfected after use on the last resident and prior to storage. She acknowledged that the lack of consistent information and instruction may have contributed to the discrepancies observed during the course of the survey.

Based on observations, record reviews and interviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical well-being of each resident, by failing to ensure consistent nursing practice and education/training as it related to blood glucose monitoring. During observations of blood glucose monitoring (BGM), one (Employee A) of one licensed practical nurses (LPNs) failed to clean and disinfect the glucometer (a device used to measure blood glucose levels) between each resident's use for two (Resident #27 and #301) of two residents observed, from a total of 21 residents who required blood glucose monitoring. The facility failed to develop and follow a policy and procedure for cleaning/disinfecting blood glucose meters until the time of the survey. The facility's new policy did not coincide with the three separate competency forms being used to train the nursing staff, and the three competency forms did not coincide with each other. The facility clinical management was not monitoring the disinfection process of their glucometers, and following re-education on 6/13 and 6/14/2019, with documentation that 55 nurses and then 26 nurses had been retrained, respectively, two (Employees D and L) of four nurses observed, remained unable to appropriately disinfect the glucometer devices. The findings include: On 06/13/19 at 12:24 PM, blood glucose monitoring was observed with Employee A for Resident #27. The nurse removed the glucometer from the medication cart and cleansed it with an alcohol wipe. She placed it down on top of her cart and gathered her other supplies. She picked up a bag containing the resident's insulin pen and placed an extra lancet and alcohol wipe in the bag with the pen. She then entered the residents room, placed all of her items down on the bedside table without a barrier and donned gloves without first performing hand hygiene. She inserted the test strip into the glucometer, opened an alcohol wipe, checked the resident's identity, and cleansed the fourth finger on the resident's right hand. She wiped the first blood drop off with an alcohol wipe, obtained a blood drop on the test strip and stated, Oh, we got an error message. She picked the glucometer up and stated, I need to get another machine. Then she turned the device around and stated, Oh, it's not an error, it says 103 mg/dl (milligrams per deciliter). I thought it said error. She sanitized her hands and returned to the cart. She opened the cart and placed the device on a piece of foil. She obtained a bleach wipe, and wiped the front and back of the glucometer for approximately 4-5 seconds. She failed to wipe the top, bottom or sides of the device. She placed the device on a tissue on her cart. She then removed the items from the bag with the insulin pen, and returned them to the cart's top drawer with all of the other blood glucose testing supplies. On 6/13/19 at 12:31 PM, Employee A moved on from Resident #27 to Resident #301. The nurse removed two lancets, two alcohol wipes and a test strip from the cart. She removed Resident #301's insulin pen and cleaned the top with an alcohol wipe. She dialed the pen to deliver 11 units of insulin. She picked up the same glucometer she used for Resident #27 from the top of the cart, along with the insulin pen and her other blood glucose testing supplies, and went to Resident #301's room. Resident #301 was on transmission-based precautions for [MEDICAL CONDITION]-Resistant Staphylococcus Aureus (MRSA). The nurse donned gloves without first performing hand hygiene, then a gown (personal protective equipment (PPE) before entering the room. She placed all of the items on the bedside table without a barrier, looked in the bathroom and realized the resident was at therapy. She removed the PPE, sanititzed her hands with gel/foam cleanser, picked up all of her supplies and returned to her cart. She laid all the supplies on top of the cart without a barrier. She stated she would have to wait until the resident returned from therapy. On 6/13/19 at 12:42 PM, Resident #301 returned from therapy. Employee A picked up the glucometer from the top of the cart along with the other supplies that were still sitting there. She removed the insulin pen and applied a needle. She removed the needle, discarded it into the sharps container, cleansed the top of the pen and applied a new needle. She confirmed the needle was still dialed up to 11 units of insulin. She donned PPE and entered the resident's room. She placed the items on the bedside table without a barrier. She donned gloves, inserted the test strip, verified resident's identity, cleansed the finger on the resident's left hand and obtained a lancet for the blood sample. The nurse dropped the lancet, and reached into her scrubs pocket to retrieve a second lancet. She pricked the middle finger of the resident's left hand, and obtained a result of 227 mg/dl. She stated she would need to give the resident four more units for coverage, and dialed the pen to 15 units. She verified the dose, then administered the insulin. She placed the lancet in the sharps container, removed the blood test strip, and placed it in the trash can with her gloves. She removed her gown and sanitized her hands. She then realized the call light was not within the resident's reach, so she walked back over to the resident (between the resident and the wall), obtained the call light, and placed it within the resident's reach. The front of her scrub top contacted the resident and the resident's wheelchair when she retrieved the call light. She sanitized her hands again and returned to her cart, placing the items on top of her cart without a barrier. She obtained an alcohol wipe, cleansed the glucometer, and placed it on a tissue to dry. An interview was immediately conducted with Employee A, regarding whether it was acceptable to cleanse glucometers with an alcohol wipe. She stated, Yes, we can use an alcohol wipe or a bleach wipe. I would think so, as long as it is clean, so my answer is Yes. The Director of Nursing approached the medication cart at 1:03 PM and joined the conversation. She was asked if the nurses were permitted to cleanse the glucometers with an alcohol wipe, and she stated, No, it has to be a bleach wipe. Employee A was then asked about priming the insulin pen, and she stated she knew to prime the pen with two units, but she forgot. She was asked about using hand sanitizer versus washing hands when leaving an isolation room, and she stated, We can sanitize if it is not [MEDICAL CONDITIONS]. On 6/13/19 at 1:11 PM, the glucometers on the medication cart on unit Cherry - East were observed with Employee B, Licensed Practical Nurse (LPN). One of two glucometers was observed with a red-tinged substance on it. When asked about the substance on the device, Employee B stated the nurses were supposed to clean them and not leave blood on them. On 6/13/19 at 1:32 PM, the glucometers on the medication cart on unit Cherry - West were observed with Employee C, Registered Nurse (RN). The glucometer labeled West #2 was soiled with a red-tinged substance. Employee C proceeded to unit Cherry - South and the glucometers were observed. Glucometer #2 was soiled with a red-tinged substance. On 6/13/19 at 1:43 PM, the director of nursing (DON) observed two glucometers (Cherry East and Cherry West) in the conference room, and confirmed that both glucometers were soiled with a red-tinged substance. She stated the facility would be replacing all of their glucometers. She was asked for the policy and procedure related to blood glucose monitoring and she stated, We do not have a copy here, but I called our sister facility and they are sending me one. On 6/14/19 at 11:43 AM, an interview was conducted with the DON, and she confirmed that nursing management had not been monitoring/auditing the facility's glucometer use/handling/storage/disinfection since she had been here for the last two months. When asked for documentation of monitoring/audits, she was unable to produce any for review. A review of nursing competencies for all facility nurses revealed that 43 of a total of 64 nurses had documentation of completion of successful use of blood glucose monitors. Employee A was included in these competencies. The facility used two separate forms for each nurse to record competency. The first form was titled Blood Glucose Testing New Competency. Upon completion of the form, the observing RN signed off, indicating the tasks were properly conducted by the nurse being observed. The criteria for demonstration included: a. Disinfected glucometer prior to use . h. Glucometer cleaned and disinfected after use. The second form was three pages long and titled Assure Platinum Blood Glucose Monitoring System Competency Checklist. It instructed the certified trainer to observe the operator performing the following tasks: .2. Use lancet/lancing device correctly . 9. Clean/disinfect meter correctly . Page 2 and 3 was a question and answer section, required to be completed by the nurse being evaluated . Question 8 asked: 8. The Assure Platinum a. Does not need to be cleaned. (Incorrect answer) b. Should be immersed or held under running water to clean. (Incorrect answer) c. Cleaned with a lint-free cloth, dampened with soapy water, [MEDICATION NAME] alcohol, or diluted household bleach. (Correct answer for cleaning, but not disinfecting) d. Should be cleaned and disinfected between patient tests to avoid cross contamination. (Correct answer for disinfection) The question and answer section did not clarify whether nurses knew to clean and disinfect the blood glucometer upon removal from the medication storage cart prior to the first use, or if they knew to clean and disinfect the meter after use on the last patient prior to storing it in the medication cart. On 6/13/19 at 1:03 PM, the director of nursing (DON) was asked for the facility's policy and procedure for blood glucose monitoring. It was again requested on 6/13/19 at 1:43 PM as noted above. She stated she was unable to locate a copy in the facility, but had requested one from a sister facility. At 2:08 PM she produced the policy and stated again that the facility was obtaining new glucometers. A review of the policy and procedure for Bedside Blood Glucose Monitoring Policy #1.0 (effective 9/1/16), last reviewed (MONTH) 2019, revealed the following: Blood glucose levels may be monitored at the bedside with Accu-Chek Inform glucose meter by licensed nursing personnel. Equipment: 1. Assure bedside blood glucose monitor 2. Test strips 3. Lancet 4. Gloves 5. Alcohol swabs 6. Cotton ball, gauze Under Procedures, it instructed: 1. Verify physician's orders [REDACTED]. 2. Gather equipment. Check expiration date . 3. Wash hands . don gloves. 4., Verify correct patient . 5. Explain procedure . 6. Remove test strip . 7. Gently insert test strip .(before applying blood). 8.clean the site with an alcohol swab and thoroughly dry the site using a dry gauze pad. 9. When flashing blood droplet appears . obtain blood sample . . 12. Remove test strip and discard. 12. Clean the meter with a dispatch wipe per protocol . Maintenance: 1. Clorox Germicidal Wipes 2. Super Sani-Cloth Germicidal Disposable Wipes 3. Clorox Dispatch Hospital Cleaner wipes will be used at (facility) as they are chemically similar to the Germicidal wipes . 4. The meter should be cleaned and disinfected between each patient use per protocol . The policy did not instruct nursing staff to clean and disinfect the meter after removal from the medication storage cart and prior to use on the first resident as per the competency forms the facility was currently using to train the nursing staff. There were two separate blood glucose meters observed in use during the survey, and both user guides were reviewed: The User's Guide for the Evencare ProView blood glucose monitoring system revealed the following Important Safety Instructions: - The meter should be disinfected after use on each patient. Cleaning Instructions: Step 1. Wash hands . put on single use medical protective gloves. Step 2. Prepare the (disinfecting wipe). Take out a wipe from the container and follow instructions on the package. If needed squeeze the wipe slightly to remove the excess liquid. Step 3. Wipe the glucose meter thoroughly . Do not wrap the meter in a wipe . Disinfection Instructions: Step 1. Before disinfecting, clean the meter as described . Step 2. Wash hands . put on gloves. Step 3. Prepare the (disinfecting wipe) . squeeze the wipe slightly to remove excess liquid. Step 4. Wipe the glucose meter thoroughly . Step 5.allow the surface of the meter to remain wet for the contact time listed on the disinfecting wipe's instructions . The User Instruction Manual for the Assure Platinum device instructed: Cleaning and Disinfecting Guidelines: Option 1 -Cleaning and disinfecting can be completed using a commercially available EPA-registered disinfectant detergent or germicide wipe. -Many wipes act as a cleaner and a disinfectant, though if blood is present on the meter, two wipes must be used. use one wipe to clean and a second wipe to disinfect. Option 2 -To clean the outside of the blood glucose meter, use a lint free cloth dampened with soapy water or [MEDICATION NAME] alcohol . -To disinfect the meter, dilute 1 ml of household bleach with 9 milliliters (ml) of water then thoroughly wipe down the meter. Please note there are commercially available 1:10 bleach wipes . On 6/13/19 the facility began retraining and measuring licensed nurse competencies for the proper use of the blood glucometers. Based on a review of the records provided, 55 licensed nurses were assessed for competency from a total pool of 64 nurses employed by the facility. A revised one-page New Competency form was now being utilized which included the following criteria to be observed: a. Disinfected the glucometer prior to use . h. Lancet/finger stick devices and test strip disposed of in sharps container. j. Brought glucometer to cart with barrier and disinfected with bleach wipes . Employee D, Registered Nurse (RN) Employee L, RN, and Employee G, Licensed Practical Nurse (LPN), were included in the training and were deemed competent. On 6/13/19 at 4:32 PM, an observation of blood glucose monitoring was made with Employee D, RN, for the resident in room [ROOM NUMBER]. After obtaining the blood glucose reading, the nurse returned to the cart and cleansed/disinfected the glucometer with a germacidal bleach wipe. After cleansing the glucometer, it was visibly wet, and she stated if it was not dry in one minute, that she could then wipe it dry. The unit manager confirmed that she could wipe it dry after one minute. On 6/14/19, the facility began retraining and assessing competencies again for proper handling of the glucometers. Based on a review of the records provided, 26 of 64 licensed nurses had been reassessed for competency on this day. Employees D, L, G and N (RN) were included. On 6/14/19 at 2:23 PM, an interview was conducted with Employee D, RN, regarding the education that she received yesterday related to cleaning/disinfecting glucometers. She stated she had been re-educated yesterday and corrected regarding the fact that she could not dry it; it had to air dry. She was then asked to demonstrate cleaning/disinfection of the glucometer, and she failed to complete the task appropriately. After cleaning the device, she placed it back down on a soiled barrier. On 6/14/19 at 2:27 PM, an interview was conducted with the DON. She confirmed that nursing management was only using the new checklist to provide re-education to the nurses about glucometer disinfection. When asked whether the facility had incorporated information from the manufacturer's instructions or the disinfecting wipes package regarding disinfection of the devices, she confirmed that they were not. On 6/14/19 at 4:39 PM, blood glucose monitoring was conducted with Employee L, RN, for Resident #86. The nurse cleaned/disinfected the glucometer prior to use. She entered the resident's room, sanitized her hands, donned gloves, cleansed his finger on the left hand with an alcohol wipe, pricked his finger, inserted the test strip into the glucometer, and the glucometer was not working. She explained that she had to get another glucometer. She placed the lancet in the sharps container, removed her gloves, did not perform hand hygiene, and exited the room. She returned to the cart, donned clean gloves without performing hand hygiene, and cleansed the glucometer that was not working. She placed it down on a soiled tissue. She then removed her gloves, failed to perform hand hygiene, reached into the cart and obtained a second glucometer. She entered the resident's room, used hand sanitizer, donned clean gloves and obtained his blood glucose reading using the second glucometer. She did not clean/disinfect the device first. Prior to cleaning/disinfecting the first glucometer, the nurse stated, I am new on this cart, so I do not know if these are clean or not, so I have to clean them before I use them. On 6/14/19 at 4:53 PM, Employee L, RN, confirmed she had failed to clean/disinfect the second glucometer prior to use. On 6/14/19 at 5:03 PM, blood glucose monitoring was observed with Employee M, LPN, for Resident #191. No concerns were identified with infection control; however, when asked whether she had received any training on the new glucometer that she was currently using, she confirmed she had not. On 6/14/19 at 5:38 PM, blood glucose monitoring was observed with Employee N, RN, for Resident #23. The nurse obtained the blood glucose reading, then disposed of the second lancet in the regular trash can in the room. During an interview with Employee N at 5:57 PM, she confirmed that she should have disposed of the soiled lancet in the sharps container. An interview was conducted with the Medical Director Designee (MDD) at 2:05 PM on 6/14/19. The MDD confirmed alcohol wipes should not have been used, saying I don't know why they used alcohol. We must try to avoid this from ever happening again. The MDD stated he did not know why there was blood on the glucometers. He said he expected the glucometers to be cleaned before and after each use, referring to it as common sense. The MDD reviewed the photographs of the soiled glucometers and stated, We definitely need retraining. That should not ever happen again. An interview was conducted on 6/15/19 at 3:55 PM with the Director of Nursing (DON). She reviewed the three different competency forms used by the facility for assessing nurses, the facility's policy and procedure, and the user guides for the two blood glucose meters being used by the facility. She confirmed the discrepancies regarding the cleaning and disinfecting of the devices, and the lack of consistency regarding the cleaning/disinfection of the meters before the initial use and after the final use. She confirmed knowledge that the policy and procedure in use failed to address cleaning the device after removal from the medication cart and prior to use on the first resident. The DON agreed the competencies did not make it clear that the nurses were aware the glucometer should be cleaned and disinfected after use on the last resident and prior to storage. She acknowledged that the lack of consistent information and instruction may have contributed to the discrepancies observed during the course of the survey.

Based on observation, staff interview, resident interview, clinical record review and policy and procedure review, the facility failed to identify hazard risks, assess the resident's risk of an accident and prevent avoidable accidents for one (Resident #31) of five residents sampled for accidents out of a total sample of 38 residents. Resident #31 sustained wounds in both lower extremities requiring transfer to the hospital for sutures on two occasions. The findings include: During an observation of Resident #31 on 06/11/19 at 12:00 PM, she was lying on her bed breathing heavily and moaning loudly. Both of her lower legs were [MEDICAL CONDITION] and wrapped in dressings. Two Emergency Medical Services (EMS) personnel were waiting outside the resident's room with a rolling stretcher. During a 06/11/19 interview at 12:00 PM with Employee P, Registered Nurse (RN), she stated Resident #31 had run into the hardware on her dresser with her electric wheelchair and had sustained a puncture wound. She was bleeding from the wound, and the nurse could not get the bleeding to stop. Employee P stated she had wrapped the leg very tightly with a dressing, but it was still bleeding through. She had called 911 after she obtained a physician's orders [REDACTED]. She stated Resident #31 was receiving an anticoagulant (blood thinner), and this was the second time Resident #31 had run into her dresser in a week. The hardware on the dresser in Resident #31's room was made of metal measuring approximately seven inches in length. It extended 1.5 to 2.0 inches out from the side of the dresser. There were six handles on the front of the dresser. The ends of the hardware protruded approximately one inch, creating an accident hazard. The dresser was situated across from the end of the bed. There were approximately three feet of space between the handles on the dresser and the end of the bed. A review of the nursing notes revealed the resident was transferred to the hospital on [DATE] at 2:00 PM and returned on 06/11/19 at 9:52 PM. The resident returned with five staples to the right shin. During an observation of Resident #31's room on 06/12/19 at 11:19 AM, the same handles were on the dresser. During an interview with Resident #31 on 06/13/2019 at 10:41 AM, she was observed sitting on side of her bed eating breakfast. The bandages on both of her lower legs were saturated with blood/drainage. The dressings were dated 6/13/2019. Resident #31 stated the nurse had already changed the bandages this morning. Her right leg hurt when she bent it because of the staples in her leg. She stated she ran into her dresser while maneuvering in her electric wheelchair. She felt embarrassed about it, but she thought she was moving the wheelchair joy stick to move the chair in a reverse motion when she inadvertently moved it in the forward position and ran into the handle on her dresser. She stated she also ran into the dresser handle a few days ago, and that was how she sustained the wound on her left leg. It had sutures in it too. She confirmed the handles on the dresser were the same as when she ran into it last week on 05/24/19 and again on 06/11/19. She stated, They may need to be removed. A review of the clinical record revealed the resident was admitted to the facility on [DATE], then readmitted on [DATE]. She was [AGE] years old. Her [DIAGNOSES REDACTED]. A review of the nursing notes dated 05/24/19, revealed that the resident rolled into her bed with the electric wheelchair and bumped her left lower leg leaving a 3.5 cm (centimeter) laceration. The doctor was notified and staff were advised to send the resident to the emergency room (ER). The note was written by Employee M. A review of the facility's incident report dated 05/24/19 at 10:50 PM, revealed the Certified Nursing Assistant (CNA) informed the nurse the resident's leg was bleeding. The nurse found the patient holding her left leg with blood flowing from the laceration. The resident was taken to the hospital and returned with sutures in her left leg. A review of the incident report dated 06/11/19 at 14:56 PM, revealed Resident #31 was found with a wound to her right leg after running herself into the handle on her dresser while in the electric wheelchair. A review of the Daily Nursing Documentation (V4) form dated 05/29/19 at 11:06 AM, revealed Employee P documented a full assessment of Resident #31 and services provided were noted to include: management/evaluation of resident care plan; observation/assessment of resident's condition; teaching/training to manage resident's treatment regimen; proper care of specialized dressings/skin treatments; therapy. A review of Resident #31's care plan revealed no care plan for risk of accidents, training/use of electric wheelchair or wound care to the wound she had sustained on 06/11/2019. During an observation on 06/13/19 at 11:10 AM, Employee Q, LPN, provided wound care to Resident #31's legs. Staples were observed in the wound on the right leg. Employee Q confirmed that Resident #31 ran into her dresser twice causing the wounds in both legs. The sutures had been removed from the left leg. The electric wheelchair was not observed in the room. The dresser the resident ran into was in the room. During an interview on 06/13/19 at 12:11 PM with the Assistant Director of Nursing (ADON), she was asked what happened to Resident #31's legs, and how she sustained the wounds. She stated the resident ran into the dresser in her room twice. She was asked what was done to prevent the resident from running into the dresser again,and she stated Therapy had screened the resident and determined the power chair was appropriate for her. The chair was removed from her room yesterday and taken to the hospital across the street to be evaluated for safety. She confirmed the dresser with the handles the resident ran into was still in the resident's room. The staff wanted her to remain in bed with her legs elevated to reduce the [MEDICAL CONDITION] in her lower legs. During an interview with Employee I, Assistant Director of Rehabilitation, on 06/13/19 at 2:26 PM, she stated the therapy department had been working with this resident for the past few months. They removed her electric wheelchair from her room yesterday, and took it across the street to the main hospital to have it tested and make sure it was safe. A review of the Occupational Therapy (OT) progress note, dated 05/29/19, read: Patient to maneuver power wheelchair, however does require moderate-maximum verbal cues to avoid running into objects, especially in narrow spaces such as bathroom doorway. A note dated 5/30/19 read: Patient required assistance and verbal cues for managing power wheelchair in tight spaces. Patient would benefit from further training with chair. The OT progress notes through 06/11/19, revealed the resident was receiving therapy to learn to maneuver her electric wheelchair in tight spaces so she would not run into objects. A note dated 06/11/19 read: (Resident #31) requires cues on location of cones, as she is unable to see them at times. She reports I can navigate if I go slow. At the end of the session, (Resident #31) was navigating in her room around her dresser, and she accidentally pushed the joy stick forward instead of backward and she ran into the side of the dresser. She hit her right leg with a skin tear to the right leg and bleeding. During an interview with Resident #31 on 06/13/19 at 1:22 PM in her room, she was lying in bed covered with a sheet and blanket. She stated her power wheelchair was being tested for safety. The dresser was observed in the resident's room with the same handles that were on the dresser when she ran into it on 05/24/19 and 06/11/19. During an interview with the Director of Nursing (DON) on 06/14/19 at 1:26 PM, she stated anyone could identify an accident hazard - therapy staff, nursing staff, the social worker or anyone. When the hazard was identified, it should be addressed immediately. When asked about the dresser in Resident #31's room, she stated she had not noticed the handles on the dresser sticking out or being a problem. She would go look at it. During an observation of Resident #31's room on 06/14/19 at 10:32 AM, the dresser was still in the resident's room and the same handles were on the dresser. During an interview with the administrator on 06/14/19 at 2:45 PM, he held up the handle that he had taken off the dresser in Resident #31's room, and stated they were going to remove the handles and put something else on the dresser for handles that did not protrude out so far. He indicated he was not aware that the resident had two wounds from running herself into the handles of the dresser. On 06/14/19 at 2:50 PM, the administrator went to Resident #31's room to find the maintenance director who had taken one of the handles off the dresser. Resident #31 was seated in a non-electric wheelchair with her legs extended in front of her. The administrator explained to Resident #31 that the maintenance director was going to put diffierent knobs on her dresser. She stated Oh, that will be good. They won't be as sharp. During a second interview with Employee I on 06/14/19 at 4:11 PM, she stated that the therapy department had not considered moving the dresser out of the resident's room or providing a different dresser with smaller or different handles for the resident. They were working with her to increase her ability to use the power wheelchair in tight spaces such as between her bed and dresser. During an interview with Employee M, LPN, on 06/15/19 at 04:00 PM, she stated that when the resident was injured on 05/24/19, she was the nurse on duty, but she did not witness the incident. The resident was not sure what she ran into and could not confirm what she hit. She told the nurse she was trying to maneuver herself in her electric wheelchair around her bed when it happened. The nurse stated the resident went out to the hospital the next day (05/25/19) with altered mental status, was found to have a UTI, and was being treated for [REDACTED]. A review of the facility's policy and procedure entitled Safety and Supervision of Residents, dated 05/2015, revealed: Our facility strives to make the environment as free from accident hazards as possible. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes: Quality Assessment and Assurance (QA&A) reviews of safety and incident/accident reports; and a facility-wide commitment to safety at all levels of the organization. When accident hazards are identified, the QA&A/Safety Committee shall evaluate and analyze the cause(s) of the hazards and develop strategies to mitigate or remove the hazards to the extent possible. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for that resident. The care team shall target intentions to reduce the potential for accidents.

Based on observation, resident interview, staff interview and clinical record review, the facility failed to develop a comprehensive, person-centered care plan for a risk for accidents and use of an electric wheelchair for one (Resident #31) out of five residents sampled for accidents, out of a total sample of 38 residents. The findings include: During an observation of Resident #31 on 06/11/19 at 12:00 PM, she was lying on her bed breathing heavily and moaning loudly. Both of her lower legs were [MEDICAL CONDITION] and wrapped in dressings. Two Emergency Medical Services (EMS) personnel were waiting outside the resident's room with a rolling stretcher. During a 06/11/19 interview at 12:00 PM with Employee P, Registered Nurse (RN), she stated Resident #31 had run into the hardware on her dresser with her electric wheelchair and had sustained a puncture wound. She was bleeding from the wound, and the nurse could not get the bleeding to stop. Employee P stated she had wrapped the leg very tightly with a dressing, but it was still bleeding through. She had called 911 after she obtained a physician's orders [REDACTED]. She stated Resident #31 was receiving an anticoagulant (blood thinner), and this was the second time Resident #31 had run into her dresser in a week. A review of the nursing notes revealed the resident was transferred to the hospital on [DATE] at 2:00 PM, and returned on 06/11/19 at 9:52 PM. The resident returned with five staples in her right shin. During an interview with Resident #31 on 06/13/19 at 10:41 AM, she stated she ran into her dresser while maneuvering her electric wheelchair. She felt embarrassed about it, but she thought she was moving the wheelchair control stick to move the chair in a reverse motion, when she accidentally moved it in the forward position and ran into the handle on her dresser. She stated she also ran into the dresser handle a few days ago, and that was how she sustained the wound on her left leg. It had sutures in it as well. She confirmed the handle on the dresser was the same as when she ran into it on 06/11/19. She further stated they may need to be removed. A review of the facility incident report dated 05/24/19 at 10:50 PM, revealed the Certified Nursing Assistant (CNA) informed the nurse the resident's leg was bleeding. The nurse found the resident holding her left leg with blood flowing from the laceration. The resident was taken to the hospital and returned with sutures in her left leg. A review of the Daily Nursing Documentation (V4) form, dated 05/29/19 at 11:06 AM, revealed Employee P documented a full assessment of Resident #31, and services provided were noted to include: management/evaluation of resident care plan; observation/assessment of resident's condition; teaching/training to manage resident's treatment regimen; proper care of specialized dressings/skin treatments, and therapy. A review of the incident report dated 06/11/19 at 14:56 PM, revealed Resident #31 was found with a wound to her right leg after running herself into the handle on her dresser. A review of Resident #31's care plans revealed no care plan for a risk for accidents, training/use of her electric wheelchair, or wound care to the wound she had sustained on 06/11/19. The last update to the care plan was on 06/03/19 under the focus area of moderate to high nutrition/hydration risk related to obesity, [MEDICAL CONDITIONS], comorbidities, weight gain, need for therapeutic diet, open skin area, altered labs and polypharmacy. During a 06/13/19 interview at 12:11 PM with the Assistant Director of Nursing (ADON), she was asked what had happened to Resident #31's legs and how she had sustained the wounds. The ADON stated Resident #31 ran into the dresser in her room twice. She was asked what had been done to prevent the resident from running into the dresser again, and she replied that the therapy department had screened the resident and determined the power chair was appropriate for her. The chair was removed from her room yesterday, and was taken to the hospital across the street to be evaluated for safety. She confirmed the dresser with the handle the resident ran into was still in the resident's room. The staff wanted her to remain in bed with her legs elevated to reduce the [MEDICAL CONDITION] in her lower legs. During a 06/13/19 interview with Employee I, Assistant Director of Rehabilitation, at 2:26 PM, she stated the therapy department had been working with this resident for the past few months. They removed the electric wheelchair from her room yesterday, and took it across the street (to the main hospital) to have it tested to ensure it was safe. A review of the Occupational Therapy (OT) progress note, dated 05/29/19, read: Patient to maneuver power wheelchair, however does require moderate-maximum verbal cues to avoid running into objects, especially in narrow spaces such as bathroom doorway. A note dated 5/30/19 read: Patient required assistance and verbal cues for managing power wheelchair in tight spaces. Patient would benefit from further training with chair. The OT progress notes through 06/11/19, revealed the resident was receiving therapy to learn to maneuver her electric wheelchair in tight spaces so she would not run into objects. A note dated 06/11/19 read: (Resident #31) requires cues on location of cones, as she is unable to see them at times. She reports I can navigate if I go slow. At the end of the session, (Resident #31) was navigating in her room around her dresser, and she accidentally pushed the joy stick forward instead of backward and she ran into the side of the dresser. She hit her right leg with a skin tear to the right leg and bleeding. During an interview with the Director of Nursing (DON) on 06/14/19 at 1:26 PM, she stated anyone could identify an accident hazard - therapy staff, nursing staff, the social worker or anyone. When the hazard was identified, it should be addressed immediately. When asked about the dresser in Resident #31's room, she stated she had not noticed the handles on the dresser sticking out or being a problem. She would go look at it.

Based on staff interview and clinical record review, the facility failed to revise the care plan for one (Resident #31) of three residents sampled for urinary tract infection [MEDICAL CONDITION], or for one (Resident #297) of five residents reviewed for accidents, from a total sample of 38 residents. The findings include: 1. A review of Resident #31's electronic medical record revealed she was admitted to the facility on [DATE] and then readmitted on [DATE]. She was [AGE] years old. Her [DIAGNOSES REDACTED]. During a 06/12/19 interview at 12:00 PM with Employee F, Infection Control Nurse, she stated Resident #31's specimen for a urinalysis (UA) and culture and sensitivity (C&S) was collected on 06/11/19, and results were not yet available. She further stated the resident had leukocytosis (elevated white blood cell count, a frequent sign of [MEDICAL CONDITION] response, most commonly resulting from infection), but they were not sure what the organism was yet. They were waiting for the lab results. The physician started the resident [MEDICATION NAME]([MEDICATION NAME] - antibiotic) [MEDICATION NAME]. A review of Resident #31's (MONTH) 2019 Medication Administration Record [REDACTED]. She received [MEDICATION NAME] 500 mg (milligram) tablets three times a day until 06/04/19. The resident received nine doses [MEDICATION NAME] 06/11/19 and 06/14/19, when the physician discontinued the medication. A review of the physician's orders [REDACTED]. Another order dated 06/10/19 read:[MEDICATION NAME] milligrams (mg) by mouth twice a day for infection for 7 days. The end date was 06/18/19. A review of the laboratory results, dated 06/14/19, revealed more than 100,000 colony-forming units/milliliter flora of gram-negative rods predominant of Escherichia coli (E-coli) (Isolate 1) and [NAME]ell morganii ssp morganii (Isolate 2). The sensitivity analysis indicated that Isolate 1 was resistant to the antibiotic Cipro, and Isolate 2 was sensitive to Cipro. The sample was collected on 06/11/19 at 11:25 AM. A review of Resident #31's care plans revealed a focus area that read: (Resident #31) admitted with [MEDICAL CONDITION] and E-coli in urine - receiving antibiotic therapy. At risk for bladder incontinence r/t (related to) requires assistance with toileting. Initiated 05/09/18, Revision 08/13/18. 2. A review of Resident #297's clinical record revealed an [AGE] year-old male who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Further review of the record revealed he had three falls in the facility since his admission; one on 5/25/19, 6/1/19, and 6/4/19. A review of his care plans revealed that his fall care plan had not been updated with all of his fall interventions. The facility had an order for [REDACTED]. On 6/15/19 at 1:40 PM, an interview was conducted with Employee O, MDS Coordinator regarding the resident's falls. She reviewed the fall care plan and confirmed she had missed capturing the floor mats at bedside on the care plan. .

Based on a review of resident records and interviews with staff, the facility failed to ensure each resident's drug regimen was adequately monitored and had clear indications for one (Resident #25) of five residents reviewed for unnecessary medications, out of a total sample of 38 residents. The findings include: A review of Resident #25's 30-day minimum data set (MDS) assessment with an assessment reference date of 4/29/19, revealed the resident was assessed with [REDACTED]. Resident #25 was sometimes able to understand others and was sometimes able to make herself understood. She required extensive assistance with transfers and activities of daily living. Active [DIAGNOSES REDACTED]. Resident #25 was care planned on 2/23/19 for altered cardiovascular status related to aryrthmia and hypertension. The goal was to be free from complications from cardiac problems through the review date. Interventions included administration of medications as ordered. A review of Resident #25's physician's orders [REDACTED]. There were no specific parameters or definitions as to what was considered high blood pressure. An interview was conducted with Employee D, Registered Nurse (RN), on 06/14/19 at 10:38 AM. When asked to review the order for Resident #25's [MEDICATION NAME] and define when the blood pressure was considered high, she did so and explained that typically, a systolic blood pressure reading of 160 was considered high blood pressure. A review of the (MONTH) 2019 through (MONTH) 2019 Medication Administration Records (MARs), revealed Resident #25 was given her [MEDICATION NAME] with a systolic blood pressure (SBP) of 160 or higher on: 3/15/19 - SBP was 163 3/24/19 - SBP was 164 5/11/19 - SBP was 167 5/12/19 - SBP was 160. As of 6/14/19 at 10:38 AM, [MEDICATION NAME] had not been administered during the month of (MONTH) 2019. A review of the vital signs record for Resident #25, revealed her systolic blood pressure was measured at or exceeded 160 on the following days in (MONTH) 2019: 6/5/19 - SBP was 160 6/6/19 - SBP was 166. Further review of the record found no blood pressures were recorded for Resident #25 between 6/6/19 and 6/14/19. Employee D, who was still present, reviewed the MAR at this time and confirmed no [MEDICATION NAME] had been administered in June. She reviewed the vital records and the MAR, and could not find any blood pressures recorded since 6/6/19. She stated she was preparing to enter hers for today, 6/14/19. Employee D further stated vital signs were usually measured weekly, but for this resident they were recorded every day. Employee F, RN/Staff Educator, entered the conversation at 10:43 AM on 6/14/19. She asked what was being reviewed, and explained high blood pressure was any systolic measurement above 160. She reviewed the electronic batch order, which did specify [MEDICATION NAME] was to be administered for a systolic blood pressure (SBP) exceeding 160. When asked if it should be given for a SBP of 160, she confirmed it would be given for a SBP of 160 and above. Employee F reviewed the MAR and confirmed that the medication was last given in (MONTH) 2019. She confirmed there were two instances in (MONTH) 2019 that Resident #25's SBP was 160 or greater, and the [MEDICATION NAME] was not given. She confirmed the MAR did not instruct the floor nurses of the parameters for when the medication should be given, and that there was no readily available instruction accessible to floor nurses for when to give and when to hold the [MEDICATION NAME]. Employee F stated she would need to correct it.

Based on observations, facility record reviews and interviews, the facility failed to ensure a medication error rate of less than 5%. There were twenty-five (25) opportunities and two (2) errors for a medication error rate of 8.0%. The findings include: On 6/12/19 at 5:20 PM, administration of medication was observed with Employee S, Licensed Practical Nurse (LPN), for Resident #56. He had an order for [REDACTED]. tablets of [MEDICATION NAME] (sleep aid) that was scheduled for 9:00 PM. She removed the [MEDICATION NAME] instead of the Tamsulosin and placed it in the medication cup. She picked up the medication cup and locked her cart. As she approached the resident's doorway, she was asked to stop and return to her cart. When she was made aware that she had pulled [MEDICATION NAME] instead of Tamsulosin, she stated, No, I did not. I am not giving him that until later. She was asked to remove the packet from the cart that contained the Tamsulosin and check the medication. She removed the packet and verified that she had indeed pulled the [MEDICATION NAME] instead of the resident's Tamsulosin. On 6/13/19 at 12:42 PM, administration of medication was observed with Employee A, Registered Nurse (RN), for Resident #301. She removed the resident's insulin pen and applied a needle. She then removed the needle, discarded it in the sharps container, cleansed the top of the pen and applied a new needle. She confirmed the pen was dialed up to 11 units of insulin. She performed the blood glucose monitoring and received a result of 227 mg/dl (milligrams/deciliter). She stated she needed to administer four (4) more units for coverage and dialed the insulin pen to 15 units, then verified the dose. She administered the resident's insulin. After administering the insulin, she disposed of the needle and the lancet in the sharps container on the wall. She then removed the test strip from the glucometer, and disposed of it in the regular trash can with her gloves. On 6/13/19 at 1:05 PM, an interview was conducted with Employee A regarding whether she had ever received education on priming a needle for insulin pen administration, and she replied, Yes, I know I was supposed to prime it with two units, but I forgot.

Based on observations, resident and staff interviews, and resident record review, the facility failed to promote the resident's choice to wear a postural support for a sense of safety, security and emotional well-being for one (Resident #302) of one sampled residents reviewed with a seatbelt in use, from a total sample of 38 residents. The findings include: An interview was conducted with Resident #302 on 6/11/19 at 2:54 PM. He stated he had a safety strap he always wore when he was up in his wheelchair, however the facility told him he could not wear it in the facility, because it was considered a restraint. Resident #302 explained he could apply and remove the device independently and at his leisure. An interview was conducted with Resident #302 in his room on 6/13/19 at 10:51 AM. He was up in his wheelchair and attempted to demonstrate the use of the safety strap. He reiterated that he was told he could not use it while in the facility. He explained that the device kept him in his wheelchair and secured his legs when they spasm in the mornings. He searched for the strap, but was not able to locate it. He explained it was a buckling strap (a seatbelt) that he could unfasten himself. Employee J, Certified Nursing Assistant (CNA), was interviewed on 6/14/19 at 8:15 AM. She stated Resident #302 had a seatbelt on his wheelchair that he could put on and take off by himself. Employee A, Registered Nurse (RN), stated during an interview on 6/14/19 at 8:33 AM that Resident #302 had a seatbelt that he could remove on his own, and would like to wear it. She explained he had no use of his lower body, and he felt the seatbelt kept him upright and safe in his wheelchair. Employee A further stated the facility staff had discussed the seatbelt the other day and decided it was a restraint, therefore it was not to be utilized. Employee A confirmed this by asking Employee K, CNA, if this was correct. Employee K replied yes, the device had been deemed a restraint. A record review for Resident #302 found an Admission Minimum Data Set (MDS) assessment with a reference date of 6/5/19. The resident had a brief interview for mental status (BIMS) score of 15 out of a possible 15 points, indicating no cognitive impairment. He required extensive assistance from two staff members with transfers, dressing, toilet use and personal hygiene. He used a wheelchair as a mobility aid. His [DIAGNOSES REDACTED]. Resident #302 was care planned on 6/10/19 as at risk for falls related to weakness and impaired strength. Interventions did not address the use of the seatbelt Resident #302 desired to use. A review of physician's orders [REDACTED]. An interview was conducted on 6/14/19 at 3:25 PM with the Director of Nursing (DON). When asked about Resident #302's preference to use a seatbelt when up in his wheelchair, she stated the facility was restraint-free, therefore Resident #302 was not using the seatbelt. The DON was not aware that since Resident #302 could apply and remove the device at will and wanted the device for safety reasons, it did not meet the definition of a restraint. She acknowledged the resident's choice to wear the seatbelt for his own security. An interview was conducted with the Rehabilitation Director on 6/14/19 at 3:27 PM. She confirmed she had tested Resident #302, and he could independently apply and remove his seatbelt. She stated this resident felt safer using the device, since he had no use of his lower extremities and had limited upper body use/strength to prevent falling forward from his chair. She confirmed with this resident, the risk of falling was possible. .

Based on interviews and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, by failing to follow physician's orders [REDACTED].#1) of 3 sampled residents. This resulted in discomfort for Resident #1. The findings include: A review of the medical record revealed that Resident #1 was admitted on [DATE], and was then discharged on [DATE] with a [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. A second order read, 'Please give [MEDICATION NAME] twice a day with meals, breakfast and dinner', ordered on [DATE]. During an interview with Resident #1 on 4/20/18 at 11:57 AM, the resident stated that they had not received their [MEDICATION NAME] with meals, which was causing stomach upset. The resident's concern had been communicated to the nursing staff on 3//6/18, however the problem had not been addressed. The result was stomach discomfort. Resident #1 stated that when at home, the [MEDICATION NAME] was taken during meals, which did not result in stomach upset. During an interview with Nurse A on 4/23/18 at 11:33 AM, the nurse stated that breakfast started at 'around 7:30 AM' and dinner started at 'around 5:30 PM'. During an interview with Nurse B on 4/23/18 at 11:51 AM, the nurse stated that the breakfast breakfast trays were delivered to the unit 'between 7:00 AM and 7:30 AM'. During an interview with the Assistant Director of Nursing (ADON) on 4/23/18 at 12:49 PM, the ADON and this surveyor reviewed Resident #1's clinical record including the Medication Administration Record [REDACTED]. Scheduled times of administration were 9:00 AM and 5:00 PM. There was nothing noted, indicating that the medication should be given with meals. The second order for '[MEDICATION NAME] twice a day with meals, breakfast and dinner', added on 3/8/18, was not located on the MAR. The ADON stated that when a physician wrote an order, the nurse took off the order, and it was put into the system. If an order had been put into the system, the nurse would have signed and dated the order. During a review of Resident #1's clinical record, the order dated 3/8/18 for '[MEDICATION NAME] twice a day with meals, breakfast and dinner', was not signed or dated by a nurse, indicating that the order had not been put into the system. The original order had not been discontinued, and the new order had not been transcribed to the MAR. The facility nursing staff continued to sign off the medication on the original order, which did not specify 'with meals, breakfast and dinner'. Whether or not the medication had actually been given with meals could not be ascertained based on the documentation. The ADON checked the computer for the order, but was unable to find one in the computer or on the MAR. She stated that when she reviewed the MAR, she was unable to tell the exact time the medication was given. The medication could have been given between 8:00 AM and 10:00 AM or between 4:00 PM and 6:00 PM, as the nursing staff had up to one hour before and one hour after the scheduled time to administer the medication. The ADON was unable to confirm that Resident #1 received the [MEDICATION NAME] with meals as was ordered by the physician.

Based on observation, record review and staff interview, the facility failed to (1) implement infection control practices during wound care for one (Resident #61) of 2 sampled residents with pressure ulcers; (2) failed to wear Personal Protective Equipment (PPE) in isolation rooms for residents with [MEDICAL CONDITIONS] for 4 of 5 observations; (3) failed to wear Personal Protective Equipment (PPE) in an isolation room for a resident with Extended Spectrum Beta-Lactamases (ESBL), and failed to perform proper hand hygiene when exiting the isolation room for the resident with ESBL for 5 of 5 observations, and (4) failed to report 8 (#2, #7 ,#15 #41 #80, #131, #133 and #384) of 13 residents with gastrointestinal symptoms to the local Health Department. The findings include: 1. Observation of Resident #61 on 3/7/18 at 10:00 am during dressing change of a pressure area to the sacrum. Employee A, a Licensed Practical Nurse (LPN), gathered supplies to initiate wound care on top of the treatment cart in the hallway. Employee A placed the dressings and supplies required to complete wound care on top of foil paper. Then she grabbed the dressings and other supplies in her hand touching the clean open bandages to transport them into the resident's room. Employee A donned gloves and removed the soiled dressing from the resident's sacrum. She stated she forgot to bring the garbage can to the bedside to discard the soiled dressing. There was a small amount of clear drainage on the dressing. She placed the contaminated dressing on the resident's bedside table that touched the foil paper/clean barrier with the supplies and the bedside table. She cleaned the wound with normal saline and applied the prescribed medication to the wound with application of the new dressing. She did not washed her hands and don a new pair of gloves before initiating the clean dressing change. Upon completion of the dressing change, Employee A folded up the contaminated wound supplies and dumped them in the garbage can in the room. She washed her hands in the bathroom and closed the conversation with the resident. Once outside the room, Employee A was asked to clean down the resident's bedside table. She stated, I have some Clorox wipes on my cart and will clean it. Interview with Employee A, Staff Nurse LPN on 3/7/18 10:23 am revealed she could improve. She stated she did not have a survey since 2010 and should have dated the dressing. The Staff Nurse was unaware that she had to change her gloves, sanitize her hands and don a new pair of gloves after removing the soiled dressing and before doing wound care. On 3/7/18 at 3:00 pm, the Education Coordinator/Infection Control Nurse presented writer with an In-service document to show that the nurse signed the In-service record to indicate that she was re-educated in infection control techniques in wound care. The Education Coordinator stated that Employee A told her what happened and it was not the process to do dressing changes. Review of the policy and procedure for Clean Dressing Change with an effective date of 8/17/16 revealed the pertinent steps to take to perform a clean dressing change. Staff were to: Bring necessary supplies to Guest's room Prepare a clean, dry work area at bedside: Cover work surface barrier (tin foil) to prevent contamination of supplies. Place trash bag at end of bed or within easy reach of working area. Use biohazard bag as necessary for saturated dressings. Perform hand hygiene and apply gloves. Prepare/open dressing items on table/work surface. Place initials and date on a piece of tape or on the dressing. Remove soiled dressing and place in trash bag or biohazard bag as necessary. Remove gloves, wash hands, and apply new gloves 2(a). On 3/5/18 at 2:42 pm, Employee B, Therapy Aide, opened the door to room [ROOM NUMBER] to enter. There was a sign on the door that read, Stop, please see the nurse before entering. There was a box of gloves hanging on the door. The employee touched the knob of the door, walked into the room, and placed an activity schedule on the bedside table. He came out touching the doorknob without washing his hands. Interview with Employee B on 3/5/18 at 2:43 pm, revealed that normally he went into isolation rooms with the therapists. He stated that they wore gloves. He was asked, What happened this time? The employee stated that he was just trying to get in and out of the room to deliver schedules. When asked if he had Infection Control Education, he stated that he received Infection Control education last year and a month ago. Interview with Employee C, Unit Manager, on 3/8/18 at 10:56 am, revealed that if you are not in contact with the resident, not providing resident care, and not touching anything inside the resident's room, you would wash your hands with soap and water. Review of the Policy and Procedure for [MEDICAL CONDITION] revealed, it is a spore forming gram-positive anaerobic bacillus producing toxins that cause mucosal inflammation and damage. In step 3 of the Procedure for preventing the spread of [MEDICAL CONDITION], staff were to wear clean, non-sterile gloves when entering the room of a [MEDICAL CONDITION] infected resident/patient. 2. (b) On 03/06/18 at 09:20 AM, this surveyor observed Resident #333's room entrance with the door open about 18. Physical therapist D was observed inside the room. Surveyor could hear the conversation between the resident and therapist while waiting on the opposite side of the hallway to interview the resident. At 09:37 AM therapist D stated he would take off his gown and gloves and leave. The sound of the gown being compressed and placed in the waste container was heard and, within three seconds, the therapist appeared at the doorway, paused to use the hand sanitizer on the wall, tucked what appeared to be a note pad under his left arm and left the room. No hand washing (with water and antimicrobial soap) had taken place as required by facility policy and procedure and no wiping of the item placed under his arm had been completed as per standard procedure for infection control. Therapist was observed to walk down the hallway to within 50 feet of the therapy gym's entrance at the other end of the hall. 2. (c) Employee C, unit manager, was interviewed on 03/06/18 at 02:58 PM. She described the process for entering and leaving the room of a resident diagnosed with [REDACTED]. One should knock and announce yourself, put on a gown and gloves. Enter the room. When exiting, remove the gown and gloves and dispose these items in the waste can provided in the room. Wash hands with soap and water. Use sanitizer after leaving the room. Asked why you should wash hands instead of just using hand sanitizer, she stated because the infection is [MEDICAL CONDITION] and requires soap and water to assure removal of spores. 3. On 03/05/18 at 12:22 PM Employee E, certified nursing assistant (CNA), was observed to don a gown for personal protective equipment (PPE) but did not don latex gloves. She took a lunch tray into Resident #231's room. She touched the tray table to adjust it in front of the resident and then put the tray on the tray table. She set up the tray. The tray did not have disposable utensils, plates or cups on it. Employee E then took the gown off, threw it into the wastebasket for PPE, sanitized her hands and left the room. She walked to the nurses' station approximately 30 feet down the hall touched the handles of the faucet while turning it on, washed her hands, and touched the handles while turning it off, in the hand sink located behind the desk. Resident #231 was observed on 03/05/2018 at 03:42 PM to be in an isolation room. At 03:45 PM, she was interviewed in her room. She was sitting upright in her wheelchair covered with a blanket. Her eyes were closed. She voiced no complaints. A female private sitter was observed in the room with her, sitting in a side chair next to the window. The private sitter was not wearing any PPE. The private sitter stated she was educated about wearing PPE. She waved her hand to indicate she did not care about wearing it. A pair of latex gloves were laying on a side table near the door. She came over, picked them up, and put them in the garbage. She did not wash her hands or sanitize her hands. She went back to the chair and sat down. On 03/06/18 at 11:26 PM Employee E was observed taking a lunch tray into Resident #231's room. She did not put on any PPE. She set it down on the tray table. The private sitter was in the room with the resident. The private sitter had no PPE on. The meal tray had no disposable utensils, plate, glasses or cups. Employee E sanitized her hands when she left the room. She did not wash her hands with soap and water. She continued to pass meal trays. 03/06/18 at 12:35 PM Employee E checked with the private sitter to see if meal tray was still in Resident #231's room. It was already on the meal cart. She opened the cart and took it out for this surveyor to see how much food was consumed. She did not don gloves. The resident's meal tray was on the tray cart with all the other meal trays. The cart was taken from the hallway to the kitchen at 2:57 PM. At 3:10 PM, the tray cart was observed sitting in the kitchen. Not in the dirty dish room. It had not been unloaded. On 03/07/18 at 8:59 AM, Resident #231 had been calling out for help for 3 minutes. She sounded agitated and yelled out Come here. Help me! Why won't anyone help me? No staff went to her room. This surveyor went down the hall to investigate. The call light was not on. The Social Services Director, Employee H, and the Assistant Director of Nursing (ADON) were observed standing further down the hall near the dining room talking to each other. At 9:04 AM Employee H and the ADON came down the hall and entered Resident #231's room. Employee H entered with no PPE on. The ADON stopped to don gloves. The resident kept yelling out Why doesn't someone help me? Where is everyone? Employee H was observed to put her hands on Resident #231 and on her chair in an attempt to calm her down. When Employee H and the ADON left the room, they did not wash their hands with soap and water. On 03/07/18 at 9:31 AM, Employee R, Speech Therapist was observed to enter Resident #231's room with no PPE on. She went to the resident, who was seated in her chair, and put her hands on the resident. She left the room without washing her hands with soap and water. She was observed to walk down the hall in the direction of the therapy gym. On 03/07/18 at 10:55 AM, the call light was observed to come on above door to Resident #231's room in the hallway. At 10:57 AM, Employee E was observed to go into Resident #231's room with only latex gloves on. She was observed to be pulling the bedcovers off the resident. The resident was heard to say, I need to use the bathroom. Review of the electronic medical record for Resident #231 revealed she was admitted on [DATE]. [AGE] year old with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Contact precautions for ESBL in urine with start date of 03/06/2018 with no end date. an order for [REDACTED]. Start date 03/06/2018 and end date 03/09/2018. Dietician progress note dated 03/07/2018 8:39 AM read: Resident experiencing bouts of [DIAGNOSES REDACTED], often in early morning times. Discussed with resident and husband. Agreeable to (bedtime) snack of Ensure [MEDICATION NAME] (1.5 CHO) for weight maintenance and BG control throughout the night. Intermittent bouts of loose stools this week. MD ordered stool testing for [MEDICAL CONDITION]. Noted fall last night. Resident has baseline AMS, however it is increasingly worse this review d/t UTI will continue to monitor closely due to high risk status. Review of the MDS dated [DATE] revealed the resident was assessed as being frequently incontinent of bowel and bladder. She did not have a urinary catheter. Review of the care plan dated 02/12/2018 with revision date of 03/06/2018 revealed a focus are of activities of daily living (ADL) care performance deficit related to altered mental status, decreased mobility and [MEDICAL CONDITION]. Interventions included TOILET USE: Provide limited to extensive staff assist x 1 to complete tasks of toileting as needed. During an interview with Employee E on 03/07/18 at 02:52 PM, regarding Resident #231, she stated that she tries to provide personal care in the mornings after breakfast. She tries to provide incontinence care at that time as well, otherwise Resident #231 gets upset and starts calling out for help. She puts Resident #231 on the toilet. Resident #231 will let her know when she needs to use the restroom. Resident #231 was experiencing loose stools overnight last night. She wears a brief due to incontinence. She was given orientation when she started her a year ago. It covered isolation precautions. She was taught to use a gown only when she was going to be providing personal care. She could use just gloves otherwise. She asked the other CNA at lunch today if she needed to wear the gown to assist her with lunch and the other CNA told her to wear one just in case she needed to provide personal care while she was in the room. She stated that she was never given another in service on isolation precautions since she started. During an interview with the Infection Control Nurse on 03/08/18 at 03:49 PM She stated that no audits for hand washing have been completed. She educates staff during orientation. She stated, We do not put residents on isolation, but precautions, if suspected of (an infectious disease). If a resident is continent of bowel and bladder, it is contained, they would be on precautions. 4. On 3/7/18 at 5:42 PM, an interview was conducted with Employee I, Licensed Practical Nurse (LPN), regarding ill residents on her assignment. Employee I stated, I have 5 or 6 people complaining of nausea, vomiting and diarrhea. One resident was sent to the hospital, and she was vomiting too. We have had a lot of sick residents lately with a gastrointestinal bug. On 03/08/18 at 2:13 PM, a brief review of progress notes and physicians orders was conducted for all residents currently residing on the third floor due to outbreak concern with gastrointestinal symptoms which revealed the following: room [ROOM NUMBER] - Resident #2 had a progress note on 3/4/18; 2 loose stools, and emesis x2, admitted was 8/23/17. room [ROOM NUMBER] - Resident #384 was ordered [MEDICATION NAME] (for nausea) on 3/1/18, had loose stools on 3/2/18, admitted was 2/15/18. room [ROOM NUMBER] - Resident #382 - positive [MEDICAL CONDITIONS] on isolation, admitted [DATE]. room [ROOM NUMBER] - Resident #386 - [MEDICATION NAME] ordered 3/6/18, admitted [DATE] room [ROOM NUMBER] - Resident #15 - Pre-cautions for [MEDICAL CONDITION] 3/6/18, admitted [DATE], Vanco started for [MEDICAL CONDITION] on 3/2/18, contact precautions started on 3/6/18, stool culture ordered on [DATE] (no lab available). room [ROOM NUMBER] - Resident #80 - [MEDICAL CONDITION] stool 3/5/18, [MEDICATION NAME] 3/5/18, admitted [DATE] room [ROOM NUMBER] - Resident #131 - [MEDICATION NAME] on 3/5/18, [MEDICAL CONDITION] stool on 3/6/18 (- results), admitted [DATE] room [ROOM NUMBER]- Resident #134, [MEDICATION NAME] on 3/1/18, 3/4/18 loose stool and [MEDICAL CONDITION] precautions (- [MEDICAL CONDITION] culture), admitted [DATE]. room [ROOM NUMBER] - Resident #9 - [MEDICAL CONDITION] positive, + for [MEDICAL CONDITION] on 2/28/18 and 3/2/18, no isolation started until 3/6/18 room [ROOM NUMBER] - Resident #133 - 3/7/18 loose stools room [ROOM NUMBER] - Resident #7, stool/[MEDICAL CONDITION] on 3/7/18, [MEDICATION NAME] on 3/7/18, admitted [DATE] room [ROOM NUMBER] - Resident #34, 3/7/18 progress note complained of nausea room [ROOM NUMBER] - Resident #35, stool for [MEDICAL CONDITION] on 3/7/18 and [MEDICATION NAME] on 3/7/18, admitted [DATE] room [ROOM NUMBER] - Resident #41, stool for [MEDICAL CONDITION] on 3/5/18 An interview was conducted with Employee N, Registered Nurse/Infection Control Nurse, on 3/8/18 at 4:15 PM regarding Resident #15's isolation for [MEDICAL CONDITION], and she stated that the facility would typically put the resident on precautions if they suspected [MEDICAL CONDITION], and discontinue it if the lab results were negative. However, Resident #15 was not put on isolation until 4 days after antibiotic therapy was started for [MEDICAL CONDITION]. On 3/8/18 at 4:24 PM, an interview was conducted with the Director of Nursing (DON) regarding the 14 residents with GI symptoms. The DON stated that she was aware of only two (2) residents who had possible gastrointestinal (GI) symptoms to report (Residents #34 and #35). The DON then stated that she had a list of 5 residents that they were concerned with (Resident's #9, #34, #35, #134, and #386). She was then asked specifically about each resident. Resident #9, was of no concern, because she had frequent diarrhea; Resident #134 - I can't remember why we ruled him out.; Resident #386 - because she has had diarrhea in the past. The DON was unaware of any concerns with Residents #2, #384, #80, #131, #133, #327, and #47. She was asked whether she had enough cases to call the Department of Health (DOH), and she replied, Yes, Correct. She was then asked if she had a current list of infections that should be reported to the DOH, and she replied, No, I do not have a list. On 3/8/18 at 4:42 PM, an interview was conducted with Employee N, RN/Infection Control Nurse regarding her and the Director of Nursing not being aware of all the residents that were sick with the gastrointestinal (GI) symptoms. Employee N stated, We have a stand up meeting in the morning, but that is not something that we look at. On 3/8/18 at 5:53 PM, an interview was conducted with the Administrator during completion of the Quality Assurance task, and he stated that the facility was only aware of a few cases of diarrhea, and some cases of [MEDICAL CONDITION]. The Administrator stated that the facility had not identified any clusters. He was then shown a map of infections, and he then stated that they had now notified the health department, and the doctor there said the nurse would follow up with it. The third floor of the facility consisted of three hallways; Rooms 1-15 (front hallway), 16-25 (middle hallway), and 26-37 (back hallway). The infections were noted on the third floor facility maps, and revealed 4 rooms involved on the front hallway (2 rooms that were adjacent to one another), 6 rooms involved in the middle hallway (4 adjacent rooms on one side of the hallway, and directly across from those, 2 adjacent rooms), and 5 rooms involved on the back hallway. Mapping of the rooms, indicated a cluster.

Based on record review and staff interview, the facility failed to inform the Ombudsman in writing that Resident #9 was transferred/discharged to the hospital. The findings include: A record review revealed that Resident #9 was discharged on [DATE] with a Discharge Return Anticipated MDS (minimum data set) assessment completed. The resident returned to the facility on [DATE]. A review of the nursing progress notes revealed that on 11/17/2017 at 10:59 p.m., Resident #9 had episodes of nausea/vomiting and loose stools. A call was placed to the attending physician, who ordered [MEDICATION NAME] q6h (every 6 hours) PRN (as needed), [MEDICATION NAME] 40 mg (milligrams) daily, with the first dose now, a CBC (complete blood count - laboratory test), CMP (comprehensive metabolic panel), Lipase lab work, and a UA C/S (urinalysis with culture and sensitivity). The resident required physical assistance of one person for completion of activities of daily living (ADLs). The resident stated that she did not feel well. She was noted as cooperative with care. On 11/18/17 at 12:53 a.m., the nurse received a report that the resident was having loose stools and vomiting. Assessment of the resident found bloody stool with blood clots. The physician was contacted. An order was received to send the resident to the acute care hospital. The resident's family was contacted. Transportation was contacted. The resident left for the hospital. A review of the discharge papers sent with resident during transfer to the hospital revealed that the resident left with the following information: a bed-hold policy for Long Term Care Patient, a face sheet, history and physical, current progress notes, current laboratory results and a medication list. However, there was no written information that the family, or the resident had been notified in writing of the reason for the transfer/discharge to the hospital. There was no evidence that a copy of the written notice had been sent to the Ombudsman regarding this transfer. An interview with the Director of Nursing on 3/8/2018 at 4:00 p.m., revealed that the facility was not aware of the above requirement.

Based on observations, record reviews and interviews, the facility failed to provide care and treatment in accordance with professional standards of practice by failing to provide appropriate care and treatment for 1 (Resident #231)of three residents reviewed for falls (neurological assessments), for 1 (Resident #238) of 1 residents reviewed for skin concerns (untreated rash), and for 1 (Resident #31) of 1 residents reviewed for [MEDICAL TREATMENT] (medications not scheduled around [MEDICAL TREATMENT] schedule, inaccurate and incomplete [MEDICAL TREATMENT] and fluid restriction charting). The findings include: 1. During an interview with Employee F, Licensed Practical Nurse (LPN), on 3/5/2018 at 10:42 AM, she stated that Resident #231 was on contact isolation for Extended Spectrum Beta-Lactamases (ESBL) in her urine. An observation of Resident #231 was made on 3/7/2018 at 9:02 AM. She had been calling out for help for 3 minutes. The resident was agitated and calling out Come here. Help me! Why won't anyone help me? No staff went to her room until this surveyor went down the hall to investigate. The Social Services Director (SSD), Employee H, and the Assistant Director of Nursing (ADON) were observed standing further down the hall near the dining room talking to one another. The resident kept yelling out, Why doesn't someone help me? Where is everyone? Employee H and the ADON attempted to calm the resident for several minutes. Review of the medical record for Resident #231 revealed the resident was diagnosed with [REDACTED]. A progress note dated 3/7/2018 at 5:06 AM, revealed she had an unwitnessed fall on 3/7/2018 at 4:00 AM. The note was written by Employee G. Resident #231 was found on the floor in her room. She suffered a scrape to her left knee, an abrasion to the back of her left shoulder, and an abrasion to her lower left back. Her vital signs were taken at that time. Her blood pressure was 131/75, pulse was 83, temperature was 98.2 and respirations were 20. (copy obtained) A review of the medication administration record/treatment administration record (MAR/TAR) on 3/7/2018 at 10:15 AM, revealed the resident's vital signs had been taken after the resident was found on the floor at 4:00 AM, however no neuro-checks (assessment of the resident's neurological status) had been done since that time. (copy obtained) During an interview with Employee F on 3/7/2018 at 10:22 AM, she stated that she was not sure if neuro-checks were being done for Resident #231 after her fall. She stated she would check with the Unit Manager. At 10:35 AM, she stated that they would be doing neuro-checks for the resident for 72 hours due to the fall having been unwitnessed. She stated the Unit Manager had to call the nurse from the 11p-7a shift (Employee G) to see if she had done them. Her understanding was that the nurse had done them, but had not entered them into the system. She stated that Employee G was asked to come to the facility and enter them into the system. During an interview with the Director of Nursing (DON) on 3/7/2018 at 11:10 AM, she stated that Employee G had been called and was asked to come to the facility to enter the neuro-checks into the e-chart (electronic clinical record). She was asked to have Employee G speak with the surveyors prior to entering any data into the electronic chart (e-chart). She stated she would send her to the unit where the surveyors were located when she arrived. During an interview with Employee G on 3/7/2018 at 12:39 PM, she stated she failed to enter the vital signs into the system while on duty. She came back to do so, and was told that a surveyor wanted to talk to her. She was asked if she had the vital signs. She produced a piece of paper with vital signs on it. (photographic evidence obtained) She stated she came in on her own to enter the vital signs. If you don't do it, they will call you to come in and do it. She was asked if she used the monitor in the hallway near the nurses' station and she stated she did. That monitor did not enter the vital signs into the electronic MAR (e-MAR) automatically. She did not measure the resident's oxygen saturation level. She stated she did not enter them into the e-chart, because it was harder/more complicated than entering just regular vital signs. She had worked at this facility for a year, and had not had any resident who required neuro-checks during that time. Review of the facility policy and procedure #1.0 Fall: Assessment & Documentation effective 09/2016 revealed that it read, Purpose: to prevent further complication of fracture or injury if such has occurred as a result of a fall. Charting: 2. Vital signs including Neuro-check, if unwitnessed. (copy obtained) 2. Resident #238 was observed on 3/6/2018 at 10:46 AM with a rash on both forearms. Red, raised welts were observed. The resident was brushing his teeth at the time of the observation, so he was not available for an interview. Review of the electronic medical record for Resident #238 revealed no orders for skin treatment or care plan focus for the observed rash. Further review revealed no skin assessments indicating a rash. (copies obtained) Resident #238 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED].>[MEDICAL CONDITION], dehydration, unspecified injury of head, altered mental status, hypertension, [MEDICAL CONDITION]-fibrillation, [MEDICAL CONDITIONS], obstructive sleep apnea, nausea with vomiting, gastrointestinal hemorrhage, acute [MEDICAL CONDITION] infarction, pain, major [MEDICAL CONDITION], and [MEDICAL CONDITION] reflux disease without esophagitis. The list of [DIAGNOSES REDACTED]. (copy obtained) During an interview with Resident #238 on 3/8/2018 at 9:45 AM, when asked if the surveyor could look at his arms, he stated, Yes, please do! He held up both arms and stated that they itched. He stated that he had the rash on his arms for at least a week. He stated it was on his legs, abdomen and chest. He stated, It itches like crazy! He could not sleep last night due to itching so badly. He stated, I almost cried, because all I could think about was the itching. He pointed to a red area on his inner arm and started to pick at it. I like to pick at them. When asked if he was being treated for [REDACTED]. He stated he told the nurse last night, but he did not know if anything was being done about it. When told that his doctor would be notified, he stated Oh good. Do something! He held up his fingers approximately five inches apart and said, Even if you have to give it to me in a big needle, just bring it! During an interview with Employee F, LPN, on 3/08/18 at 10:04 AM, she stated that the night nurse told her that Resident #238 had informed her that he had a rash on his arms. Employee F stated that when she passed his medications this morning, he did not tell her about the rash or complain about itching. She stated she was going to inform the resident's physician who is at the facility today. She had not done so yet. A review of the nursing progress notes from 2/19/2018 through 3/7/2018 revealed a note dated 2/19/2018 at 4:15 PM, that read, Resident A & O x 3 (alert and oriented), respirations even & unlabored, able to make needs known, skin warm & dry with [MEDICAL CONDITION] noted to bilateral upper & lower extremities also noted on back and chest area. A review of the Minimum Data Set (MDS) assessment dated [DATE], section M revealed no category for assessment of rashes and no indication the resident had a rash at the time of the assessment. A review of the care plan dated 3/6/2018 with a target completion date of 3/12/2018 revealed a focus area for potential impairment to skin integrity relate to decreased mobility and [MEDICAL CONDITION]. Goal: The resident will maintain intact skin by the review date. Interventions included: Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Encourage good nutrition and hydration in order to promote healthy skin. Keep skin clean and dry. Use lotion on dry skin. Use a draw sheet or lifting device to move resident. Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface During an interview with Employee P, Minimum Data Set (MDS) Coordinator, on 3/8/2018 at 5:20 PM, she stated that the care plan should have been updated/developed when the nurse identified the rash upon admission. The nurse should have called the physician and gotten an order for [REDACTED]. 3. Resident #58 was an [AGE] year-old female admitted with [DIAGNOSES REDACTED]. A record review revealed the following orders; - [MEDICAL TREATMENT] every Monday, Wednesday, and Friday - pickup at 5:15 AM - 1600 ml (milliliter) fluid restriction: Total nursing 300 ml (each shift 100 ml), Dietary 720 ml, Nepro TID (three times daily) 516 ml daily. A review of the Medication Administration Record [REDACTED]. Medications were ordered to be administered while Resident #58 was at [MEDICAL TREATMENT]. Further review revealed that multiple medications on multiple days had been signed for and documented as having been administered to Resident #58, however, Resident #58 was out of the facility at [MEDICAL TREATMENT] on those days at those times. On 3/7/18 at 6:17 PM, an interview was conducted with Employee K, Willow Unit Manager, regarding [MEDICAL TREATMENT] residents. Employee K was asked whether or not the facility scheduled medication times around a resident's [MEDICAL TREATMENT] schedule. Employee K stated, Yes, absolutely. We have to look at their schedule for [MEDICAL TREATMENT], and then schedule their medications accordingly. On 3/7/18 at 6:18 PM, an interview was conducted with the physician regarding the standard protocol for medication scheduling for [MEDICAL TREATMENT] residents. The physician was asked whether it was his expectation that the facility schedule a resident's medications around their [MEDICAL TREATMENT] times, and the physician replied, Of course, you do not want to give them medications such as blood pressure medications before they go to [MEDICAL TREATMENT], because it can drop their blood pressure too low. You would want to hold any blood pressure medications on [MEDICAL TREATMENT] days. You have to be careful with a [MEDICAL TREATMENT] patient's medications. On 3/8/18 at 10:05 AM, an interview was conducted with Employee J, Cherry Unit Manager, regarding Resident # 58's [MEDICAL TREATMENT] and medication times. Employee J stated that the facility should schedule the resident's medication times around her [MEDICAL TREATMENT] schedule, and that she usually left the facility for [MEDICAL TREATMENT] very early in the morning, at approximately 5:30 AM. Employee J stated Resident #58 went to [MEDICAL TREATMENT] every Monday, Wednesday, and Friday. Employee J and this surveyor reviewed Resident #58's current Medication Administration Record [REDACTED]. Employee J stated, Those should not be documented as given. Employee J was asked if medications were sent to [MEDICAL TREATMENT] with Resident #58, and she stated no, they were not. Further review of Resident #58's Medication Administration Record [REDACTED]. Resident #58 had an order for [REDACTED]. Upon further review of the MARs it was determined that the nursing department had been documenting too much fluid, and had not been following the fluid restriction order as follows: February 5, (YEAR) 7-3 = 240cc 3-11=360cc 11-7=60cc Total daily intake =660cc (cubic centimeters) February 6, (YEAR) 7-3 = 120cc 3-11= 100cc 11-7= 120cc Total daily intake = 340cc February 13, (YEAR) 7-3 = 480cc 3-11=300cc 11-7=720cc Total daily intake = 1500cc February 14, (YEAR) 7-3 = 600cc 3-11= 120cc 11-7= 30cc Total daily intake = 750cc February 15, (YEAR) 7-3 = 600cc 3-11= 240cc 11-7= 100cc Total daily intake = 940cc February 17, (YEAR) 7-3 = 450cc 3-11= 480cc 11-7=240cc Total daily intake = 1170cc February 18, (YEAR) 7-3 = 350cc 3-11= 480cc 11-7= 100cc Total daily intake = 930cc March 3, (YEAR) 7-3 = 550cc 3-11= 100cc 11-7= 50cc Total daily intake = 700cc March 4, (YEAR) 7-3 = 550cc 3-11= 100cc 11-7= 100cc Total daily intake = 750cc March 5, (YEAR) 7-3 = 350cc 3-11=0 11-7= 100cc Total daily intake = 450cc Fluid amounts listed above are examples of the facility's documentation. The documentation for Resident #58's fluid restriction was incorrect on 28 out of 30 days (Feb. 5th through (MONTH) 6th, (YEAR)). On 3/8/18 at 10:05 AM, an interview was conducted with Employee K, Cherry Wing Unit Manager, regarding Resident #58's orders for fluid restriction. Employee K and this surveyor reviewed the orders and documentation, and discovered a discrepancy in the amount ordered and the amount actually given. Employee K stated, That is because they have to include the Nepro in the amount that they give. Employee M, Licensed Practical Nurse (LPN), intervened and stated, No, dietary includes the Nepro; nursing does not do that. Employee M then called the dietitian and had her come to the unit. On 3/8/18 at 10:27 AM, the dietician entered the room to speak with the surveyor. The dietician and this surveyor reviewed the documentation for Resident # 58's fluid restriction order. The dietician confirmed that nursing did not include the Nepro in the amount that they gave. She stated that they should only be documenting the percent (%) of Nepro that the resident consumed. Further review of the documentation was conducted, and the dietician confirmed that nursing was not currently following Resident # 58's fluid restriction orders. She stated, We are going to have to revisit this. She confirmed that nursing was only supposed to provide and document 300cc per day, 100cc per shift. A review the Resident #58's [MEDICAL TREATMENT] communication book revealed that the resident took it with her to [MEDICAL TREATMENT] and that it contained a communication form between the nursing facility and the [MEDICAL TREATMENT] center as noted below: The [MEDICAL TREATMENT] Communication Form consisted of 3 sections: Section #1- Pre-[MEDICAL TREATMENT] (to be completed by skilled nursing facility) Vital Signs, lung sounds, conditions of catheter site, patient on antibiotics, Bruit/Thrill present, Any meds given to take to the [MEDICAL TREATMENT] center, Meal given to the resident to take to the [MEDICAL TREATMENT] center, additional notes, signature/title of staff completing, date and time. Section #2 -[MEDICAL TREATMENT] Center (to be completed by [MEDICAL TREATMENT] staff) [MEDICAL TREATMENT] Center Name, Nephrologist Name, telephone number, contact person, vital signs, pre-[MEDICAL TREATMENT] weight, post-[MEDICAL TREATMENT] weight, condition of access/site, Bruit/Thrill present, type of vascular site, additional notes, if any medication was given or if any instructions for skilled nursing facility, please indicate in note section, signature/title of staff completing, date and time. Section #3 - Post [MEDICAL TREATMENT] (to be completed by skilled nursing facility) Vital signs, weight, condition of access/site, Bruit/Thrill present, change of site, if changed; specify location of new site, signature/title of staff completing, date and time. A review of Resident #58's [MEDICAL TREATMENT] communication forms was conducted and revealed the following: 2/9/18 - all three areas were blank, no documentation completed at all. 2/16/18 - Section #3 was not completed, facility failed to assess Resident #58 after returning from [MEDICAL TREATMENT]. 2/23/18 - Sections #1 and #3 were incomplete, Facility failed to send any information to [MEDICAL TREATMENT], and failed to assess Resident #58 upon her return from [MEDICAL TREATMENT]. 2/28/18 - Section #1 was incomplete, facility failed to provide [MEDICAL TREATMENT] center with necessary information. 3/1/18 - Section #2 was blank, and no communication was provided back to the nursing center from [MEDICAL TREATMENT]. Section #3 was blank, facility failed to evaluate Resident #58 after returning from [MEDICAL TREATMENT]. 3/2/18 - Section #2 was blank and no communication was provided back to the nursing center from [MEDICAL TREATMENT]. On 3/7/18, a review of the facility's policy and procedure for [MEDICAL TREATMENT] revealed the following: [MEDICAL TREATMENT] Infection Control Practice, policy #1, Created on (MONTH) 2014, last review/update 5/2017, approved by Administrator, Director of Nursing, and Medical Director, effective 5/2014. Purpose: To ensure proper communication between nursing and the [MEDICAL TREATMENT] provider. Policy: Patient [MEDICAL TREATMENT] is provided through an outside contracted service. Procedure: 2. The [MEDICAL TREATMENT] communication form is utilized to communicate updates to the nursing personnel regarding the residents status. 4. If central line site is not within normal limits, i.e. redness, drainage, pain, and/or tenderness, the [MEDICAL TREATMENT] nurse and/or staff nurse is responsible for notifying the physician. See Appendix 1: [MEDICAL TREATMENT] Communication Form

Based on resident record reviews and staff interviews, the facility failed to provide necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent worsening of pressure ulcers, by failing to provide care for one (Resident #31) of two sampled residents with pressure ulcers. The findings include: Based on a review of the clinical record, Resident #31 was a [AGE] year-old male who was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the nursing admission evaluation revealed that Resident #31 was readmitted with an open area in the center of his coccyx, measuring approximately 1 cm x 1 cm (centimeter). A review of the nutritional assessment completed for Resident #31 upon readmission revealed documentation of the pressure ulcer to the coccyx as well. A review of the physician's orders [REDACTED]. A review of the Treatment Administration Record (TAR) revealed the following: Cleanse sacrum with normal saline, pat dry, apply [MEDICATION NAME] dressing, every evening shift for wound care, order started on 2/7/2018. A review of Resident #31's weekly wound documentation, revealed that the wound had increased in size on 2/7/2018 to 1.5 cm x 1.5 cm and a depth of 0.2 cm. On 3/7/18 at 2:30 PM, an interview was conducted with Employee J, Unit Manager (UM), regarding the wound. The UM stated that the wound was not an in-house acquired wound, but that Resident #31 had gone out to the hospital and returned with the wound. The UM stated that Resident #31 was readmitted from the hospital on [DATE] with the wound. On 3/7/18 at 3:20 PM, a second interview was conducted with Employee J, Unit Manager (UM), regarding the treatment order put in place for Resident #31's pressure ulcer after returning from the hospital. Employee J reviewed the electronic medical record and stated, There is no way that he did not have something in place until 2/7/18. Employee J continued to review the record, and this surveyor asked that she please let the surveyor know if she located a wound care order written prior to 2/7/2018. On 3/8/2018 at 9:57 AM, a third interview was conducted with Employee J regarding treatment orders for Resident #31's pressure ulcer. Employee J confirmed that no treatment order was put into place for his coccygeal pressure ulcer until 2/7/18. Employee J stated, That usually does not happen.

Based on record reviews and staff interviews, the facility failed to ensure that one (Resident #58) out of one sampled residents for [MEDICAL TREATMENT] received care consistent with professional standards of practice by failing to ensure medications were administered in accordance with the [MEDICAL TREATMENT] chair time, failing to follow physician's orders [REDACTED]. The findings include: Resident #58 was an [AGE] year-old female admitted with [DIAGNOSES REDACTED]. A record review revealed the following orders; - [MEDICAL TREATMENT] every Monday, Wednesday, and Friday - pickup at 5:15 AM - 1600 ml (milliliter) fluid restriction: Total nursing 300 ml (each shift 100 ml), Dietary 720 ml, Nepro TID (three times daily) 516 ml daily. A review of the Medication Administration Record [REDACTED]. Medications were ordered to be administered while Resident #58 was at [MEDICAL TREATMENT]. Further review revealed that multiple medications on multiple days had been signed for and documented as having been administered to Resident #58, however, Resident #58 was out of the facility at [MEDICAL TREATMENT] on those days at those times. On 3/7/18 at 6:17 PM, an interview was conducted with Employee K, Willow Unit Manager, regarding [MEDICAL TREATMENT] residents. Employee K was asked whether or not the facility scheduled medication times around a resident's [MEDICAL TREATMENT] schedule. Employee K stated, Yes, absolutely. We have to look at their schedule for [MEDICAL TREATMENT], and then schedule their medications accordingly. On 3/7/18 at 6:18 PM, an interview was conducted with the physician regarding the standard protocol for medication scheduling for [MEDICAL TREATMENT] residents. The physician was asked whether it was his expectation that the facility schedule a resident's medications around their [MEDICAL TREATMENT] times, and the physician replied, Of course, you do not want to give them medications such as blood pressure medications before they go to [MEDICAL TREATMENT], because it can drop their blood pressure too low. You would want to hold any blood pressure medications on [MEDICAL TREATMENT] days. You have to be careful with a [MEDICAL TREATMENT] patient's medications. On 3/8/18 at 10:05 AM, an interview was conducted with Employee J, Cherry Unit Manager, regarding Resident # 58's [MEDICAL TREATMENT] and medication times. Employee J stated that the facility should schedule the resident's medication times around her [MEDICAL TREATMENT] schedule, and that she usually left the facility for [MEDICAL TREATMENT] very early in the morning, at approximately 5:30 AM. Employee J stated Resident #58 went to [MEDICAL TREATMENT] every Monday, Wednesday, and Friday. Employee J and this surveyor reviewed Resident #58's current Medication Administration Record [REDACTED]. Employee J stated, Those should not be documented as given. Employee J was asked if medications were sent to [MEDICAL TREATMENT] with Resident #58, and she stated no, they were not. Further review of Resident #58's Medication Administration Record [REDACTED]. Resident #58 had an order for [REDACTED]. Upon further review of the MARs it was determined that the nursing department had been documenting too much fluid, and had not been following the fluid restriction order as follows: February 5, (YEAR) 7-3 = 240cc 3-11=360cc 11-7=60cc Total daily intake =660cc (cubic centimeters) February 6, (YEAR) 7-3 = 120cc 3-11= 100cc 11-7= 120cc Total daily intake = 340cc February 13, (YEAR) 7-3 = 480cc 3-11=300cc 11-7=720cc Total daily intake = 1500cc February 14, (YEAR) 7-3 = 600cc 3-11= 120cc 11-7= 30cc Total daily intake = 750cc February 15, (YEAR) 7-3 = 600cc 3-11= 240cc 11-7= 100cc Total daily intake = 940cc February 17, (YEAR) 7-3 = 450cc 3-11= 480cc 11-7=240cc Total daily intake = 1170cc February 18, (YEAR) 7-3 = 350cc 3-11= 480cc 11-7= 100cc Total daily intake = 930cc March 3, (YEAR) 7-3 = 550cc 3-11= 100cc 11-7= 50cc Total daily intake = 700cc March 4, (YEAR) 7-3 = 550cc 3-11= 100cc 11-7= 100cc Total daily intake = 750cc March 5, (YEAR) 7-3 = 350cc 3-11=0 11-7= 100cc Total daily intake = 450cc Fluid amounts listed above are examples of the facility's documentation. The documentation for Resident #58's fluid restriction was incorrect on 28 out of 30 days (Feb. 5th through (MONTH) 6th, (YEAR)). On 3/8/18 at 10:05 AM, an interview was conducted with Employee K, Cherry Wing Unit Manager, regarding Resident #58's orders for fluid restriction. Employee K and this surveyor reviewed the orders and documentation, and discovered a discrepancy in the amount ordered and the amount actually given. Employee K stated, That is because they have to include the Nepro in the amount that they give. Employee M, Licensed Practical Nurse (LPN), intervened and stated, No, dietary includes the Nepro; nursing does not do that. Employee M then called the dietitian and had her come to the unit. On 3/8/18 at 10:27 AM, the dietician entered the room to speak with the surveyor. The dietician and this surveyor reviewed the documentation for Resident # 58's fluid restriction order. The dietician confirmed that nursing did not include the Nepro in the amount that they gave. She stated that they should only be documenting the percent (%) of Nepro that the resident consumed. Further review of the documentation was conducted, and the dietician confirmed that nursing was not currently following Resident # 58's fluid restriction orders. She stated, We are going to have to revisit this. She confirmed that nursing was only supposed to provide and document 300cc per day, 100cc per shift. A review the Resident #58's [MEDICAL TREATMENT] communication book revealed that the resident took it with her to [MEDICAL TREATMENT] and that it contained a communication form between the nursing facility and the [MEDICAL TREATMENT] center as noted below: The [MEDICAL TREATMENT] Communication Form consisted of 3 sections: Section #1- Pre-[MEDICAL TREATMENT] (to be completed by skilled nursing facility) Vital Signs, lung sounds, conditions of catheter site, patient on antibiotics, Bruit/Thrill present, Any meds given to take to the [MEDICAL TREATMENT] center, Meal given to the resident to take to the [MEDICAL TREATMENT] center, additional notes, signature/title of staff completing, date and time. Section #2 -[MEDICAL TREATMENT] Center (to be completed by [MEDICAL TREATMENT] staff) [MEDICAL TREATMENT] Center Name, Nephrologist Name, telephone number, contact person, vital signs, pre-[MEDICAL TREATMENT] weight, post-[MEDICAL TREATMENT] weight, condition of access/site, Bruit/Thrill present, type of vascular site, additional notes, if any medication was given or if any instructions for skilled nursing facility, please indicate in note section, signature/title of staff completing, date and time. Section #3 - Post [MEDICAL TREATMENT] (to be completed by skilled nursing facility) Vital signs, weight, condition of access/site, Bruit/Thrill present, change of site, if changed; specify location of new site, signature/title of staff completing, date and time. A review of Resident #58's [MEDICAL TREATMENT] communication forms was conducted and revealed the following: 2/9/18 - all three areas were blank, no documentation completed at all. 2/16/18 - Section #3 was not completed, facility failed to assess Resident #58 after returning from [MEDICAL TREATMENT]. 2/23/18 - Sections #1 and #3 were incomplete, Facility failed to send any information to [MEDICAL TREATMENT], and failed to assess Resident #58 upon her return from [MEDICAL TREATMENT]. 2/28/18 - Section #1 was incomplete, facility failed to provide [MEDICAL TREATMENT] center with necessary information. 3/1/18 - Section #2 was blank, and no communication was provided back to the nursing center from [MEDICAL TREATMENT]. Section #3 was blank, facility failed to evaluate Resident #58 after returning from [MEDICAL TREATMENT]. 3/2/18 - Section #2 was blank and no communication was provided back to the nursing center from [MEDICAL TREATMENT]. On 3/7/18, a review of the facility's policy and procedure for [MEDICAL TREATMENT] revealed the following: [MEDICAL TREATMENT] Infection Control Practice, policy #1, Created on (MONTH) 2014, last review/update 5/2017, approved by Administrator, Director of Nursing, and Medical Director, effective 5/2014. Purpose: To ensure proper communication between nursing and the [MEDICAL TREATMENT] provider. Policy: Patient [MEDICAL TREATMENT] is provided through an outside contracted service. Procedure: 2. The [MEDICAL TREATMENT] communication form is utilized to communicate updates to the nursing personnel regarding the residents status. 4. If central line site is not within normal limits, i.e. redness, drainage, pain, and/or tenderness, the [MEDICAL TREATMENT] nurse and/or staff nurse is responsible for notifying the physician. See Appendix 1: [MEDICAL TREATMENT] Communication Form