Every finding on record at Villa Haven Health and Rehabilitation Center

Based on record reviews and interviews, the facility failed to maintain a training program to ensure staff were trained for 17 of 17 staff (ADMN, DON, SW, AD, DM, MAINT, DOT, HKS, RN C, RN D, LVN B, LVN E, CNA F, CNA G, CNA H, CNA I and CNA J) reviewed for behavioral health training. The facility failed to ensure the ADMN, DON, SW, AD, DM, MAINT, DOT, HKS, RN C, RN D, LVN B, LVN E, CNA F, CNA G, CNA H, CNA I and CNA J upon hire were trained for Behavioral Health or an assessment tool to behavioral health. This failure could place residents at risk of receiving care from incompetent/untrained staff. Record review of Personnel Files revealed the following staff had no behavioral health training:-ADMN had a hire date of 03/20/2023, -DON had a hire date of 10/06/2025, -SW had a hire date of 07/04/2023, -AD had a hire date of 08/29/1988, -DM had a hire date of 09/12/2022, -MAINT had a hire date of 10/18/2022, -DOT had a hire date of 06/16/2025, -HKS had a hire date of 08/01/2025, -RN C hire date of 10/20/2020, -RN D hire date of 09/17/2025, -LVN B hire date of 07/20/2017, -LVN E hire date of 09/19/2025, -CNA F hire date of 02/16/2025, -CNA G hire date of 01/25/2025, -CNA H hire date of 12/20/2018, -CNA I hire date of 02/17/2026, and -CNA J hire date of 01/25/2017, and.During an interview on 03/13/2026 at 3:34 PM, the ADMN stated she was responsible for insuring staff were trained on resident needs that included behavioral health. She stated she also assisted in fulfilling the facility assessment which included behavioral health. The ADMN stated the facility resident census included behavioral or mental health status and all staff should have been trained on behavioral health. She stated she was not aware there was a facility policy and was fulfilling it going forward. She stated she was the ADMN and should have monitored the needs of the population closer. The ADMN stated the negative effect for residents could have been staff could not assess residents correctly and/or have caring hearts for resident needs. The ADMN stated her expectations were that all staff should have been trained in what the regulations required. She stated the failure to do so, was not knowing that training in behavioral health was available. Record review of facility policy titled Behavioral Health Services dated 03/11/2026 revealed: Policy; It is the policy of this facility to ensure all residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning and wellbeing.Policy Explanation and Compliance Guidelines; 1. Behavioral health encompasses a residence whole emotional and mental well-being, which includes, but is not limited to., the prevention and treatment of mental and substance use disorders, Psychosocial adjustment difficulty, and trauma or post-traumatic stress disorders.5. Behavioral health care and services shall be provided in an environment that is conducive to mental and psychosocial well-being.12. Social Services Director shall serve as the facilities contact person for questions regarding behavioral services provided by the facility and outside sources such as physician, attaches, or neurologist.Record review of facility assessment tool signed by the ADMN and dated 10/03/2025 revealed facility cared for 2 residents with behavioral health needs. General care requirements of patient population included mental health and behavior with specific care of Manage the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/PTSD, other psychiatric diagnoses, intellectual or developmental disabilities.

Based on observations, interviews, and record review the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 1 of 1 medication room reviewed for drugs and biologicals.The facility failed to ensure five 30G x 5/16 syringes with needles (insulin administration syringes with needles) had been removed from the medication room when they had expired on May, 31st 2025.This failure could place residents at risk of not receiving the therapeutic benefit biologicals used for testing and treatment of residents.Findings included:During an observation on [DATE] at 8:34 a.m., of medication room reflected -5 sealed sterile packages with a 30G x 5/16 1ml insulin safety syringe permanent needles expired on [DATE].During an interview on [DATE] at 8:34 a.m., LVN B stated expired needled insulin syringes could have caused residents to get an infection if the nurse had not seen the expiration date and used the product to administer insulin. She stated she did not know why there were expired syringes in the medication room, in a drawer. She stated the nurses were responsible for making sure all expired products were disposed of. She stated the supply aid (staff who reordered and stocked the medication room) looked for expired goods as well. She stated the syringes with needles should have been disposed of. During an interview on [DATE] at 10:25 a.m., the DON stated her expectation was for expired needled syringes to be disposed of when they reached the expiration date. She stated she had just gone through the medication room a week or two ago and those needled syringes were not in the medication room at that time. She clarified that she and the ADON would go through the medication room on the first of the month and the fifteenth of the month to make sure all stored items were not expired. She stated the nurses do not use those needled syringes and did not know why they were in the medication room. She stated it was the nurse's responsibility to look at expiration dates and dispose of goods when they were expired. She stated there was an agency nurse that worked and stated that nurse may have left those syringes in the medication room, but she was not sure. She stated having expired needled syringes could cause infection due to cross contamination from the package not being effective and could cause the resident to have adverse effects if expired needled syringes were used to administer insulin. Record review of the facility's policy titled Infection Prevention and Control Program, dated [DATE], reflected: 11. Supplies Protocol: a. Sterile supplies shall be appropriately packaged and sterilized or purchased prepackaged and sterile from the manufacturer. B. Sterile supplies are routinely checked for expiration dates and are replaced as necessary.Record review of the facility's policy titled Medication Storage, dated [DATE], reflected: 1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. There was no evidence that the policy addressed expired biologicals.Record of review of facility document titled Expired Products, with no date, reflected: An expired product is any medical supply, medication or sterile item that has passed the manufacturer's labeled expiration date. Expiration dates ensure: Product Safety, effectiveness and sterility. After this date, the manufacturer cannot guarantee the quality of the product. Risks of Using Expired Products: Using expired products can cause: Reduced medication effectiveness, Infection risk from non-sterile supplies, Patient Harm, Medication errors, and Legal Liability for the facility. Staff Responsibilities: Check expiration date prior to use. Inspect medications during Med pass, check supplies during treatment preparation, remove expired products immediately and dispose of them, Notify DON/ADON. To Prevent expired products: Performed monthly supply checks, Rotate stock (use oldest items first) Check expiration dates when stocking, assign staff to inspect medication room and treatment carts two times a month. Areas to be checked Medication carts, treatment carts, Medication room and treatment room, and crash cart.

Based on observation, interviews, and record review, the facility failed to provide written notice to the State Agency responsible for licensing the facility at the time of change, for a change in the facility's administrator for 1 of 1 facility. The facility failed to notify the State Agency of a change in the facility's administrator. This failure could result in the inability to connect with the appropriate leadership of the facility. Findings included: Record review of TULIP on 12/27/2025 at 8:30 a.m., reflected the name of the administrator of the facility did not match the ADM of the facility. In an observation on 12/27/25 at 12:11 p.m. of the facility posting on the wall near the nurse's station, the Administrator, abuse coordinator, named as ADM, was not the name in TULIP. In an interview on 12/27/25 at 12:27 p.m. with the ADM, she introduced herself as the facility Administrator. This was not the name of the individual named in TULIP. The ADM stated she started as the Administrator of this facility in March 2023. In an interview on 12/27/25 at 3:21 p.m. with CNA A, she stated that she started work at the facility in the past two to three months and the ADM is who she reported to with any report of abuse or neglect because ADM was the abuse coordinator. In an interview on 12/27/25 at 5:42 p.m. with the DON, she stated she started work at the facility on 10/6/25 and the ADM had been the only administrator since she had been there. The DON stated she thought it would be the ADM that is responsible for letting the state agency know who the administrator was.In a follow-up interview on 12/27/25 at 6:43 p.m. with the ADM, she stated the change in TULIP of the facility's administrator should have been made by the previous owners because she had filled out a form and given it to them. The ADM stated she knew she had to update the name of the administrator in TULIP because it was part of her license, and she would get it done. Record review of the Facility Summary Report undated revealed the name of the administrator did not match the ADM.

48883 Based on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 3 of 5 staff (LVN-A, CNA-B, CNA-C) reviewed for infection control procedures. 1. The facility failed to ensure the CNA-B and CNA-C performed proper hand hygiene in between changing gloves during incontinent care. 2. The facility failed to ensure the LVN-A performed proper hand hygiene in between changing gloves during wound care and prior to reaching into medication cart. 3. The facility failed to ensure the CNA-B and CNA-C wore gown during foley catheter care. These failures could place residents at risk for the transmission of communicable diseases. Findings included: Record review of Resident #9's electronic face sheet dated 12/19/2024 revealed she was a [AGE] year-old female admitted into the facility on [DATE] and most recently on 12/11/2024 with diagnoses to include urinary tract infection and urinary incontinence. Record review of Resident #9's quarterly MDS dated [DATE] revealed: BIMS score of 14 which indicated cognitively intact. Further review of MDS indicated that Resident #9 was incontinent to urine and bowel and she was dependent on staff for bed mobility and to transfer from bed to chair. During on observation on 12/18/2024 at 7:28 a.m., CNA B and CNA C entered Resident #9's room and performed hand hygiene and placed on gloves. Resident #9 was lying in her bed and CNA C assisted CNA B with incontinence care. CNA C stood on left side of bed to assist with bed mobility as CNA B removed tabs of the brief and cleansed Resident #9's front with wipes and disposed of wipes after every wipe starting on left side, then right side, then down middle of perineal area. Resident #9 assisted in turning to her left side by CNA C. CNA B wiped her rectal area with wipe and discarded wipe. Soiled brief was removed from Resident #9 then discarded into lined trash receptacle. CNA B removed her gloves and put on new gloves without performing hand hygiene. She placed a clean brief under resident and helped CNA C roll the resident to situate clean brief under resident along with Hoyer sling. After positioning, CNA B and CNA C took off the gloves and CNA B opened a drawer to get socks for Resident #9. CNA B put socks and shoes on Resident #9 while not wearing gloves and then placed gloves on her hands to move the mechanical sling lift over to Resident #9's bed. CNA C saw the soiled wipe on floor and put a glove on right hand to pick up the item and then disposed of both into the trash receptacle. CNA C put on gloves and assisted CNA B with mechanical sling transfer of resident into wheelchair. Both CNAs then assisted Resident #9 with removal of shirt and bra to change into clean clothes. CNA C then took trash and soiled linen out of room in plastic bag and put into covered bins in the hall. Both CNAs then performed hand hygiene for the first time since entering Resident #9's room. During an interview on 12/18/2024 at 7:33 a.m., CNA B stated she had been trained on infection control. She stated she should have sanitized her hands in between glove changes and after removal of gloves. She stated she just had a brain slip and forgot to sanitize hands. She stated no sanitizing hands could cause infection from spreading bacteria. Record review of Resident #228's electronic face sheet dated 12/19/2024 revealed she was an [AGE] year-old female admitted into the facility on [DATE] with diagnoses to include encephalopathy (swelling of the brain). Record review of Resident #228's admission MDS dated [DATE] revealed: BIMS score of 8 which indicated moderate cognitive impairment. Further review of MDS revealed Resident #228 had one or more unhealed pressure ulcers and was at risk of developing pressure ulcers. Record review of Resident #228's electronic physician orders dated 12/10/2024 revealed Resident #228 had wound to right upper thigh, left heel and right sacrum. During an observation on 12/18/2024 at 8:52 a.m., LVN A carried in wound care supplies into Resident #228's room and sat opened items onto wax paper on bedside table. She assisted Resident #228 into recliner and washed hands with soap and water prior to placing on her gloves. LVN A removed the heel dressing and cleaned the skin with wound cleanser and gauze. She removed her gloves and used ABHR to sanitize her hands prior to putting on new gloves to place dressing to heal wound. She disposed of the gloves and used ABHR prior to putting on clean gloves. LVN A removed dressing from the sacral wound and cleansed the wound with wound cleanser and gauze. She removed gloves and did not perform hand hygiene before placing new gloves. She dressed sacral wound and then removed gloves and did not perform hand sanitizing. LVN A then reached into the medication cart and removed a bottle of cream for another treatment. She came back into room and washed her hands with soap and water then put on gloves before continuing with Resident #228's treatments. During an interview on 12/18/2024 at 9:40 a.m., LVN A stated she had training on infection control. She stated she should have sanitized her hands in between glove change and after removing gloves. She did not know why she did not perform hand hygiene. She stated not performing hand hygiene could cause cross contamination infections. Record review of Resident #19's electronic face sheet dated 12/19/2024 revealed she was a [AGE] year-old female admitted into the facility on [DATE] and most recently on 11/4/2024 with diagnoses to include retention of urine. Record review of Resident #19's quarterly MDS dated [DATE] revealed: BIMS score of 12 which indicated moderate cognitive impairment. Further review of MDS revealed Resident #19 had an indwelling catheter appliance for bladder and urinary continence was not rated because resident had a catheter. Record review of Resident #19's electronic physician orders dated 9/25/2024 revealed an order for indwelling foley catheter and an order for foley catheter care to be completed by CNA every shift. During an observation on 12/18/2024 at 9:34 a.m., CNA B and CNA C performed foley catheter care for Resident #19. There was no EBP signage outside of Resident #19's door or PPE outside of door. CNAs entered the room and performed hand hygiene and placed on gloves. They performed foley catheter care without using a gown. CNA B and CNA C disposed of gloves and performed hand hygiene after foley catheter care. During an interview on 12/19/2024 at 10:26 a.m., LVN B stated she was the IP. She stated her expectation would be for staff to perform hand hygiene with ABHR or soap and water in between glove changes and after gloves were removed. She stated not sanitizing hands could cause infections from cross contamination. LVN B stated staff had been educated on hand hygiene and are responsible for carrying out hand hygiene. She stated both she and the DON performed in-services and boot [NAME] to teach staff how to perform hand hygiene appropriately. She stated boot [NAME] are held every 3 months and all direct care staff were required to attend. She stated both her and the DON watch staff perform tasks during boot camp to make sure they are knowledgeable about infection control. She stated facility does utilize EBP for residents that have indwelling catheters such as foley catheter. She stated there should have been an EBP sign outside of Resident #19's door to let staff know how to use PPE during care including gown. She stated charge nurses were responsible for making sure EBP sign and PPE were available outside of residents' rooms when EBP should be used during resident's care. She stated she and the DON monitored that EBP sign and PPE were outside of rooms when required. She stated Resident #19 had a EBP sign and PPE outside of her room, but they were removed when she went to the hospital. She stated EBP sign and PPE should have been placed outside of door when Resident #19 returned and that was an oversite by nursing and her. She stated not following EBP or performing hand hygiene when removing gloves could cause infection spread. During an interview on 12/19/2024 at 11:51 a.m., the DON stated she expected staff to sanitize their hands after gloves were removed including during glove changes. She stated gowns should be used during foley catheter care as part of EBP. She stated CNAs and nurses were responsible for performing hand hygiene when appropriate. She stated she and the IP monitored that CNAs and nurses used appropriate hand hygiene when providing care to residents. The DON stated both her and the IP were responsible for training staff on infection control. She stated EBP sign and PPE should be outside of rooms that staff should use EBP when providing care to residents that have an indwelling catheter. She stated not sanitizing hands when removing gloves and now wearing gown when caring for a foley catheter could increase risk for infection. Record review of facility policy titled Hand Hygiene/Hand Washing dated May 15, 2023 revealed: Hand hygiene is the most important component for preventing the spread of infection. Proper hand washing technique will be used when hand washing is indicated .2. Wash Hands: A. When hands are visibly soiled. B. Before starting work. C. Before putting on gloves, when changing into a fresh pair of gloves, and immediately after removing gloves. Review of facility policy titled Infection Prevention and Control Policies and Procedures dated May 15, 2023 revealed: Enhanced Barrier Precautions (EBP) 1. Enhanced Barrier Precautions expand the use of PPE (gowns and gloves) during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. a. EBP will be implemented for All residents with the following: i. Infection or colonization with an MDRO when Contact Precautions do not otherwise apply ii. Wounds and/or indwelling medical devices (central lines, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of MDRO colonization status b. EBP will be implemented during the following high-contact resident care activities: i. Dressing ii. Bathing/showering iii. Transferring iv. Providing hygiene v. Changing linens vi. Changing briefs or assisting with toilet vii. Device care or use: central lines, urinary catheter, feeding tube, tracheostomy/ventilator c. EBP requires the following PPE: i. Gloves ii. Gown iii. Face protection is performing activity with risk of splash or spray iv. All PPE is donned and doffed with appropriate hand hygiene and disposable after individual use or when visible soiled

Based on interview, observation, and record review the facility failed to revise the resident's care plan for 1 of 14 residents (Resident #16) reviewed for comprehensive care plans. The IDT team failed to revise Resident #16's care plan to include the updated diet and advanced directive orders. These failures could affect residents by placing them at risk of not having their individual needs met. Findings included: Record review of Resident #16's electronic face sheet dated 12/18/2024 revealed she was an [AGE] year-old female admitted to the facility on [DATE] and most recently on 10/21/2024 with diagnoses to include dysphagia (difficulty swallowing). Record review of Resident #16's quarterly MDS dated [DATE] revealed: BIMS score of 11 which indicated moderate cognitive impairment. Further review of MDS revealed Resident #16 had symptoms of holding food in mouth/cheeks or had residual food in mouth after meals and she coughed or choked during meals or when swallowing medications. Record review of Resident #16's electronic physician orders revealed: Code Status: DNR with start date of 10/21/2024 and Diet/Consistency: Mechanical Soft-No added salt packet-Boost w/each meal-Super Pudding w/lunch & supper with start date 12/3/2024. Record review of Resident #16's comprehensive care plan dated 12/19/2024 revealed: Resident #16 was at risk for malnutrition with an approach of Diet as ordered by physician is pureed with thin liquids No Added Salt diet. Edited: 10/24/2024. Further review revealed Resident #16 was a Full Code with an approach of Resident #16 had completed the following advanced directives and DNR not selected Edited: 12/14/2024. During an observation on 12/17/2024 at 11:53 a.m., Resident #16 sitting in wheelchair at dining room table and was served lunch that was mechanical soft texture. Her lunch meal ticket stated a mechanical soft diet. During an interview on 12/19/2024 at 8:47 a.m., LVN B stated charge nurses did not revise the resident's care plans. She stated she had access to the care plans by looking into resident's paper charts kept behind the nurses' station. During an interview on 12/19/2024 at 10:54 a.m., the SSD stated she was responsible for updating residents' advanced directive choice on care plans. She stated if a resident had chosen to be a DNR and had a physician's order for DNR, then the care plan should not state Full Code. She stated she might have forgotten to update the care plan due to Resident #16's family having been indecisive during care plan meetings and would go back and forth on the advanced directive decision. She stated Resident #16's family had signed a DNR form and it had been placed in paper chart for staff to see during an emergency situation. She stated she did not feel any negative effect would occur from the care plan not reflecting physician orders because in Resident #16's paper chart had the advanced directive DNR kept in front of chart behind tab. The SSD stated there was also red sheet labeled DNR in paper chart and nurses knew to look there for advanced directive status. She stated she did not know who monitored her care plans to ensure they were correct. During an interview on 12/19/2024 at 10:58 a.m., the DM stated she was responsible for updating resident's diet choices on care plans. She stated if a resident had a mechanical soft diet, their care plan should reflect a mechanical soft diet. She stated Resident #16 had a pureed diet ordered after returning to facility from hospitalization . She stated Resident #16's diet had changed, and she must have forgotten to update care plan when the diet changed. She stated the care plan not being accurate could have a potential cause for weight loss if Resident #16 had been served the wrong diet. She stated all staff knew how to look at tray card for diet when passing out food and there are multiple staff who check the tray cards during meal service. She stated the dietician monitored resident care plans for accuracy of dietary service. During an interview on 12/19/2024 at 11:33 a.m., the ADON stated Resident 16's care plan should have the most accurate advanced directive and diet status in it. She stated she was not responsible for dietary or social services care need in care plans. She stated the Corporate MDS coordinator did come to the facility and performed chart audits at least yearly checking that care plans were accurate. She stated she had been present during care plan meetings for Resident #16 and stated Resident #16's family had been indecisive about care decisions which may have led to care plans being not updated. She stated nurses did not look in the care plan during an emergency to look for code status because it was faster to see in front of paper charts. She stated nursing staff reviewed meal tickets during mealtime to see if diet was correct for residents. She did not feel any negative outcome would occur from care plan not being updated. During an interview on 12/19/2024 at 11:33 a.m., the ADMN stated her expectation would be that care plans reflect current diet orders and advanced directive status. She stated the SSD was responsible for updating advanced directives in the care plan and the National Social Service Director was responsible for monitoring social service care needs in the care plan were accurate. She stated the DM was responsible for updating dietary needs in the care plan and those needs were monitored by the dietician. She stated staff knew to look in paper chart for advanced directive status and at meal tickets for diet orders. She stated that even so, care plans should have accurate information on them. Review of facility policy titled Care Plan Process, Person-Centered Care revised on date May 5, 2023 revealed: Person-centered care means the facility focuses on the resident as the center of control and supports each resident in making his or her own choices .The services provided or arranged by the facility, as outlined by the comprehensive person - centered care plan, will meet professional standards of quality .Procedures: 3. Following RAI Guidelines develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment .6. The Interdisciplinary Team (IDT) will review for effectiveness and revise the person - centered care plan after each assessment. This includes both the comprehensive and quarterly assessments. For the comprehensive assessment the review will be completed with seven (7) days of V0200B2 and no more than 21 days after admission .Thru ongoing assessment, the facility will initiate person - centered care plans when the resident's clinical status or change of condition dictates the need such as but not limited to falls and pressure ulcer development.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for one (Resident #1) of three residents reviewed for infection control practices. LVN A failed to perform hand hygiene and prevent cross contamination of resident care items while providing blood sugar checks for Resident #1. These failures could affect the residents by placing them at risk for the spread of infection. Finding included: Review of Resident #1's Face Sheet dated 07/18/20, revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of retention of urine, malignant neoplasm of breast (breast cancer), constipation, and dementia (brain damage) Review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 required moderate assistance with most activities of daily living (ADLs) and was always incontinent of bladder and frequently incontinent of bowel. Review of Resident #1's care plan dated 06/26/24 revealed a plan for hypoglycemia/hyperglycemic episodes related to diabetes mellitus. Its goal was for Resident #1 to be absence of signs of hypoglycemia (diaphoretic. Rapid pulse, confusion, lethargic, etc.) or hyperglycemia (increase thirst, dry mouth, blurred vision, fatigue, etc.) over the next 90 days. Observation of blood sugar checks on Resident #1 on 07/17/20 at 11:31 a.m. revealed LVN A did not wash hands or perform hand hygiene before start of care. She did not prepare a clean field before start of care to prevent cross contamination. LVN A placed the required supplies on top of the medication cart without wiping it down. The top of the table was visibly dirty. These supplies include glucometer, diabetic pins, test strips and alcohol pads. LVN A donned her gloves and picked up the supplies from the medication cart and entered Resident #1's room. She dumped the supplies on top of the resident's dressing table. She did not wipe the dressing table down. LVN A proceeded to prick the resident's finger which resulted in a blood sugar reading of 190 mg/dl (milligrams per deciliter). LVN A picked up her supplies and walked out of the room without washing her hands or performing hand hygiene. On her way out of Resident #1's room, the glucometer fell on the floor. LVN A picked up the glucometer and placed it on top of medication cart. In an interview on 07/17/20 at 11:42 a.m. with LVN A, she said she had been employed in the facility for over 7 years. LVN A acknowledged she should have washed her hands, performed hand hygiene, and prepared a clean field while providing blood sugar checks to Resident #1. LVN A stated she had infection control training about two months ago. She said cross contamination was mixing clean with dirty and the resident could get sick if good infection practice was not followed. During an interview with the DON on 07/18/20 at 3:30 p.m. she acknowledged she was aware of some of the concerns raised about infection control practices. The DON stated he expected the nurses to follow clean procedure while checking blood sugar. Review of the facility's policy on disinfection of patient/resident care equipment: Blood sugar glucose meter, point of care testing dated May 2023 reflected, POLICY: 1. Glucometers and point of care testing devices will be maintained, cleaned and disinfected in accordance with acceptable policies. 2 Manufacturers' recommendations will be followed when cleaning or disinfecting medical equipment. PROCEDURES: LEVELS OF DISINFECTION Three levels of disinfection can be utilized in the maintenance of patient/resident-care equipment: 1. Cleaning: the physical removal of organic material or soil from objects is usually done using water with a soap or detergent. Generally, cleaning is designed to remove rather than kill microorganisms. 2. Sterilization: the destruction of all forms of microbial life, carried out with steam under pressure, liquid or gaseous chemicals, or dry heat. 3. Disinfection: intermediate measure between physical cleaning and sterilization, carried out with hot water disinfection (pasteurization) or chemical germicides. CLEANING AND DISINFECTION PROCEDURE 1. Alcohol is not approved for disinfecting items which are potentially contaminated with blood. 2. Blood glucose meters and point of care testing devices are at high risk of becoming contaminated with bloodborne pathogens such as HBV, HCV, and HIV. Transmission of these viruses from individual to individual has been documented due to contaminated blood glucose devices. According to the CDC, cleaning, and disinfection of meters between resident uses can prevent transmission of these viruses through indirect contact. Record review of The CDC infection control reviewed January 26,2016 states, Standard Precautions are used for all patient care. They're based on a risk assessment and make use of common-sense practices and personal protective equipment use that protect healthcare.

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for 1 of 1 kitchen's reviewed for food service safety. The facility failed to properly label food items in the refrigerators. The facility failed to separate spoiled food from other food items in the refrigerators. The facility failed to seal items to protect them from freezer burn in freezers. The facility failed to discard expired food items in the dry food storage areas. The facility failed to wash dishes at a safe temperature in a low temperature setting dishwashing machine. The facility staff failed to practice good hand hygiene while preparing and serving food. These failures placed residents at risk of food borne illnesses that ate from the facility kitchen. Findings included: During an observation and interview on [DATE] at 10:10 AM revealed: Refrigerator #2 1 package of meat in a deep-dish metal pan that had no label to identify the food item. The DM said it was stew meat for tomorrow ([DATE]). 3 bags containing 16 heads of lettuce that had brown and/or black spots on them. The DM said they came in like that, but the vendor would not take them back without seeing them again. Freezer #1- 1 box of popsicles with frozen water on and inside the box. The DM said they needed to be thrown away and they were the Activities Department. Freezer #2 1 box of puff pastries that was not sealed and exposed to air. The DM said the packaging should have been closed as well as the box. Dry Food Storage ,d+[DATE]gal tub of pinto beans with dates [DATE]-[DATE]. ,d+[DATE]gal tub of rice with the dates of [DATE]-[DATE]. ,d+[DATE]gal tub of cornmeal with dates of [DATE]-[DATE]. The DM said the first date was when the items were put in the tubs and the second date was when they should have been thrown out. The DM said the beans, rice and cornmeal should have already been thrown out. During an observation on [DATE] at 11:03 AM, of the preparation of mixed moist and pureed meal, the DC was observed to not wash her hands prior to putting on gloves, and when removing her gloves not washing her hands. Then while wearing gloves she would adjust her facemask and her clothing then go back to mixing the altered food items. The DC went outside of the kitchen to the steam table in the dining room several times then back into the kitchen wearing the same gloves, having touched the doorknobs and would again begin mixing the altered food items. The DA was observed to not wash his hands and wore the same gloves, going in and out of the kitchen to the steam table and back touching the doorknob with his gloved hands; then coming back into the kitchen and preparing residents' drinks wearing the same gloves having never removed his gloves or washed his hands. During an observation and interview on [DATE] at 11:35 AM the DC utilized the dishwasher to clean the blender during the altered meal food items. The dishwasher came up to 120 degrees F after running the machine 3 times. She said when the dishwasher wasn't in use for a while, it needed to be ran a few times before it would come to temp. The machine had a sticker on it that reflected to wash/rinse at 120 degrees Fahrenheit. Review of the dishwasher temp log revealed steady morning temperatures of 110F. The DA said the wash temp was 110 F and the rinse temp was 120F. Review with DA the paper log for the month of [DATE] reflected to wash/rinse at 120 degrees F and sticker on the dishwasher reflected to wash/rinse at 120 degrees F. Later the DM verified that the paper log had 110 degrees F written routinely but the paper log and dishwasher both clearly identified to wash/rinse at 120 degrees F. The DM said the sanitation company told her it was a low temp dishwasher, and it was ok to run at a lower temperature. The DM said she had an email from the sanitation company that stated the dishwasher could be ran at a lower temperature. During an observation on [DATE] at 11:51 AM, while awaiting meal service the DA was observed with his gloved hands inside his pants pockets. Then as meal service began, he did not remove his gloves, wash his hands and put on new gloves. The DC was observed to change her gloves just prior to the meal service due to hands being very moist inside her gloves. She rubbed her hands off on her uniform top and then she put new gloves on without washing her hands and began meal service. During an interview on [DATE] 12:09 PM, the DM said they were supposed to wash hands and change gloves between each task. She said they were supposed to wear gloves at all times when handling the food. She said they were supposed to wash their hands between removing gloves and putting new gloves on. The DM said they were not supposed to touch their clothing, adjust their hair or facemasks and keep the same gloves on then handle the food. The DC verified that she had not washed her hands when she changed her gloves and that she had adjusted her mask, hair and clothing while wearing the same gloves and went back to preparing food items. During an exit interview on [DATE] at 2:30 PM with all facility management, the DM could not provide an email from the sanitation company. Record review of facility policy labeled Nutrition Policies and Procedures Safe Food Handling revised [DATE]. Hand Hygiene/Hand Washing. Hand hygiene is the most important component for preventing the spread of infection. Proper hand washing technique will be used when hand washing is indicated. Employees keep their hands and exposed portions of arms clean. Wash hands: When hands are visibly soiled. Before starting work. Before putting on gloves, when changing into a fresh pair of gloves, and immediately after removing gloves. Before handling or eating food . After contact with soiled or contaminated articles, such ass, dirty dishes. After contact with an object or source where there is a concentration of microorganisms, such as, mucous membranes, non-intact skin, body fluids or wounds . Antimicrobial gels cannot be used in place of proper hand washing techniques in a food service setting. (This refers to in the kitchen and food preparation but not to passing of trays.) . Check expiration dates and use-by dates to assure the dates are within acceptable parameters . Refuse contaminated food and return to the vendor for credit. If the food cannot be returned immediately, store it away from other food and supplies to prevent contamination .Food safety in Receiving and Storage. Place food that is repackaged in a leak-proof, pest-proof, non-absorbent, sanitary container with a tight-fitting lid. Label both the container and its lid with the common name of the contents, the date it was transferred to the new container, and the discard date. It is recommended that food stored in bins (e.g., flour or sugar) be removed from its original packaging . Refrigerated condiments and salad dressings are properly covered, labeled, and clearly marked to indicate a use by date two months from the date opened. Food acquisition, storage and distribution will comply with accepted food handling practices. Proper food handling is essential in preventing foodborne illness. Employees wash their hands, and patients or residents are given the opportunity and necessary equipment to wash their hands prior to handling or consuming food. Follow all local, State, and Federal Regulations when handling food. Food/Beverages Prepared and Swerved by Facility Staff for Patients or Residents: All facility staff (culinary, nursing, therapy, activities, etc.) involved in the preparation and service of food adheres to safe food handling techniques. Plates are handled by the edge or bottom; cups by the handles or bottom; and utensils by the handles. All foods are stored, prepared and served at temperatures that prevent bacterial growth. Hot foods are maintained at 135 F or higher and cold foods are maintained at 40 F or below at point of service. At point of delivery, hot foods and cold foods should be palatable and consumed within 2 hours or discarded . Refrigerated Time/Temp Control for Safety (TCS) leftover foods are properly covered, labeled and dated and marked with a use by date TCS leftovers are discarded after 3 days unless otherwise indicated. Items that cannot be used within 3 days may be placed in the freezer . Food is served with clean, sanitized utensils. There is no bare hand contact . All foods removed from the original packaging are stored in a closed container or tightly wrapped package and labeled with the common name of the item and the date it was opened. Review of FDA Food Code 2022 Chapter 3 Food Subsection ,d+[DATE] Preventing food and ingredient contamination revealed: (A) FOOD shall be protected from cross contamination by: (1) Except as specified in (1)(d) below or when combined as ingredients, separating raw animal FOODS during storage, preparation, holding, and display from: (a) Raw READY-TO-EAT FOOD including other raw animal FOOD such as FISH for sushi or MOLLUSCAN SHELLFISH, or other raw READY-TO-EAT FOOD such as fruits and vegetables,P (b) Cooked READY-TO-EAT FOOD, P and (c) Fruits and vegetables before they are washed; P (d) Frozen, commercially processed and packaged raw animal FOOD may be stored or displayed with or above frozen, commercially processed and packaged, ready-to-eat food. (2) Except when combined as ingredients, separating types of raw animal FOODS from each other such as beef, FISH, lamb, pork, and POULTRY during storage, preparation, holding, and display by: (a) Using separate EQUIPMENT for each type, P or (b) Arranging each type of FOOD in EQUIPMENT so that cross contamination of one type with another is prevented, P and (c) Preparing each type of FOOD at different times or in separate areas; P (3) Cleaning equipment and utensils as specified under ,d+[DATE].11(A) and sanitizing as specified under S ,d+[DATE].11; (4) Except as specified under Subparagraph ,d+[DATE].15(B)(2) and in (B) of this section, storing the food in packages, covered containers, or wrappings; (5) Cleaning hermetically sealed containers of food of visible soil before opening; (6) Protecting food containers that are received packaged together in a case or overwrap from cuts when the case or overwrap is opened; (7) Storing damaged, spoiled, or recalled food being held in the food establishment as specified under S ,d+[DATE].11; and (8) Separating fruits and vegetables, before they are washed as specified under S ,d+[DATE].15 from READY-TO-EAT FOOD. Review of FDS Food Code 2022 Chapter 3 Food Subsection ,d+[DATE] Labeling revealed: (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. (B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement; (2) If made from two or more ingredients, a list of ingredients and sub-ingredients in descending order of predominance by weight, including a declaration of artificial colors, artificial flavors and chemical preservatives, if contained in the FOOD; (3) An accurate declaration of the net quantity of contents; (4) The name and place of business of the manufacturer, [NAME], or distributor; and (5) The name of the FOOD source for each MAJOR FOOD ALLERGEN contained in the FOOD unless the FOOD source is already part of the common or usual name of the respective ingredient. Pf (6) Except as exempted in the Federal Food, Drug, and Cosmetic Act S 403(q)(3) - (5), nutrition labeling as specified in 21 CFR 101 - Food Labeling and 9 CFR 317 Subpart B Nutrition Labeling. Review of FDA Food Code 2022 Annex 3 revealed: Time/temperature control for safety refrigerated foods must be consumed, sold or discarded by the expiration date.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive and person-centered care plan, including measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment for 3 of 3 (Resident #6, Resident #19, and Resident #30) residents reviewed for comprehensive care plans. 1. The facility failed to develop care plans based on assessed needs with measurable objectives and timeframes in areas such as risk for dehydration, exposure to infections, falls, skin breakdown, pain, and impaired nutrition, decline in psychosocial wellbeing, PASRR positive status, incontinence, presence of an ostomy, decreased vision, inability to perform ADL's, impaired communication, depression, memory loss, advanced care planning, and participation in activities for Resident #6. 2. The facility failed to develop care plans based on assessed needs with measurable objectives and timeframes in areas such as risk for dehydration, exposure to infection, high or low blood sugar levels, skin breakdown, pain, and falls, psychotropic drug use, mood distress, behaviors (refusing care and threatening others), hallucinations, altered psychosocial wellbeing, impaired communication, depression, memory loss, paranoid behaviors, inability to perform ADL's, advanced care planning, weight loss, participation in activities, incontinence, and COVID positive status for Resident #19. 3. The facility failed to develop care plans based on assessed needs with measurable objectives in areas such as risk for falls, skin breakdown, pain, dehydration, malnutrition, exposure to infection, and decreased psychosocial wellbeing, psychotropic drug use, advanced care planning, depression, impaired cognition, impaired communication, inability to perform ADL's, incontinence, and participation in activities for Resident #30. Findings included: Resident #6 Record review of Resident #6's electronic face sheet revealed a [AGE] year-old male, admitted to the facility on [DATE] with medical diagnoses of brain damage due to lack of oxygen, severe intellectual disabilities, ileostomy (an opening in the abdomen for draining stool from the small intestines), and difficulty walking. Resident #6's Quarterly MDS dated [DATE], Section C 0500 BIMS Score Summary revealed the resident scored 03 out of 15 indicating severe cognitive impairment. Record review of Resident #6's Comprehensive Care Plan reviewed and revised 09/19/2023 revealed objectives lacking ability to be evaluated or quantified were: [resident] will not exhibit signs of dehydration ., [resident] will have interventions in place to reduce possible exposure to COVID-19. , [resident] will not experience any social isolation and will have no impact on interpersonal relationships . as evidenced by verbalization or documentation of contentment with routine, facility will ensure [resident] receives referrals and assessments to identify his needs related to the diagnosis of IDD. Identified resources will be coordinated and incorporated into his daily care to allow him to achieve optimal functioning, [resident] will remain clean, dry, and odor free and no occurrence of skin break down will occur., ostomy care will be managed appropriately: (e.g., appropriate amount type, color, odor of drainage; stoma the correct size, pink, free of breakdown, or infection; surrounding skin free of breakdown, rash, or infection, stool will not leak.) ., [resident] will be able to use the environment with little or no difficulty . , [resident] will maintain a sense of dignity by being clean, dry, odor free and well groomed ., [resident] will have interventions in place to reduce the risk of major injuries with falls ., [resident] will have interventions to prevent skin breakdown., [resident] will verbalize & show signs of relief of pain ., Staff will anticipate and meet all needs that [resident] is not able to communicate effectively ., [resident] will be able to function in current environment . His needs will be anticipated and met by staff, [resident] will be informed of his right to complete advanced directives to direct his medical care and make his values and treatment goals known. His stated desires will be honored, Will have interventions in place to maintain a stable weight., [resident] will actively engage in music activity . Further review of the comprehensive care plan revealed no evidence of timeframes for evaluating the effectiveness of the planned interventions in the areas of PASRR positive status and advanced care planning. Resident #19 Record review of Resident #19's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with medical diagnoses of Parkinson's disease, dementia, and dysphasia (difficulty speaking). Resident #19's Annual MDS dated [DATE], Section C 0500 BIMS Score Summary revealed the resident scored 01 out of 15 indicating severe cognitive impairment. Record review of Resident #19's Comprehensive Care Plan reviewed and revised 09/13/2023 revealed objectives lacking ability to be evaluated or quantified were: maintain airway and oxygen exchange as evidenced by O2 SATS and Respiratory Rate WNL, [resident] will not exhibit signs of dehydration . , [resident's] use of medication will result in maintenance or improvement in his functional status as evidenced by: less sadness, crying, greater participation in social and leisure activities, [resident's] use of medication will result in improvement in his functional status as evidenced by fewer behavioral episodes, [resident] will verbalize feelings underlying difficulty concentrating, [resident] will have interventions in place to reduce possible exposure to COVID-19 ., [resident] will return to his/her usual pattern of behavior, [resident] will not harm self or others secondary to hallucinations ., [resident] will not experience any social isolation and will have no impact on interpersonal relationships . as evidenced by verbalization or documentation of contentment with routine ., Resident will have better control of his behaviors with the help of coping skills and or/new medication management, Minimize risk for hypoglycemia/hyperglycemia ., Staff will anticipate and meet all needs that [resident] is not able to communicate effectively ., [resident] will not exhibit signs of isolation, such as, dull affect, withdrawn, or inattention to self-care, [resident's] use of medication (Nuplazid) will result in maintenance in his functional status AEB reduced paranoid behaviors and stable cognitive status ., [resident] will achieve the highest level of functioning .,[resident] will increase active joint range of motion in BLE & BUE. AROM up to 7 days per week. To maintain extensive assist with dressing and transfers, [resident] will transfer self with extensive assistance ., [Resident] will be informed of his right to complete advanced directives to direct his medical care and make his values and treatment goals known. [Resident's] stated desires will be honored ., [resident] will express an improved mood or behaviors ., He will engage in activities of his interest and begin to develop social relationships at facility, intervention in place to keep a stable weight ., [resident] will have socialization and stimuli thru daily care routine and actively engage in one on one activity, [resident] will remain clean, dry, and odor free and no occurrence of skin break down ., [resident] will have interventions to prevent skin breakdown ., [resident] will verbalize relief of pain ., [resident] will maintain sense of dignity by being clean, dry, odor free and well groomed ., [resident] will have interventions in place to prevent major injuries with falls. Further review of the comprehensive care plan revealed no evidence of timeframes for evaluating effectiveness of the planned interventions in the areas of psychotropic drug use, mood distress, behaviors, depression, inability to perform ADL's, advanced care planning, and participation in activities. Resident #30 Record review of Resident #30's electronic face sheet revealed an [AGE] year-old female, admitted to the facility on [DATE] with medical diagnoses of dementia, asthma, difficulty communicating, and diabetes type 2. Resident #30's Quarterly MDS dated [DATE], Section C 0500 BIMS Score Summary revealed the resident scored 01 out of 15 indicating severe cognitive impairment. Record review of Resident #30's Comprehensive Care Plan reviewed and revised 08/24/2023 revealed objectives lacking ability to be evaluated or quantified were: Resident will be informed of her right to complete advanced directives to direct her medical care and make her values and treatment goals known. Residents stated desires will be honored, [resident] will not exhibit any further decline in her mood or her signs of depression. She will be able to make decisions based on her wants and desires ., [resident] will have interventions in place to minimize distress d/t cognitive impairment ., Staff will anticipate and meet all needs that [resident] is not able to communicate effectively ., [resident] will maintain a sense of dignity by being clean, dry, odor free and well groomed ., [resident] will remain clean, dry and odor free and no occurrence of skin break down will occur ., [resident] will have interventions in place to reduce the risk of major injuries with falls ., [resident] will have interventions to prevent skin breakdown ., Minimize risk for hypoglycemia/hyperglycemia (low or high blood sugar) ., [resident] will verbalize relief of pain ., [resident] will not exhibit signs of dehydration ., will maintain nutritional status as evidenced by no significant weight change . Will receive appropriate diet as ordered by physician, [resident] will actively engage in bingo ., [resident] will not experience any social isolation and will have no impact on interpersonal relationships . as evidenced by verbalization or documentation of contentment with routine, [resident] will have interventions in place to reduce possible exposure to COVID-19 ., [resident] will be capable of performing personal hygiene with limited assist from staff, [resident] will maintain joint range of motion in BLE & BUE. AROM up to 7 days a week. To maintain extensive assist with transfers and dressing, Resident will achieve the highest level of functioning. Further review of the comprehensive care plan revealed no evidence of timeframes for evaluating effectiveness of the planned interventions in the areas of advanced care planning, inability to perform ADL's, and participating in activities. During an interview on 11/02/2023 at 12:50 PM, the ADON/MDS Coordinator stated she was responsible for creating the baseline and comprehensive nursing care plans. The ADON stated the SW was responsible for addressing the social services problems identified on the comprehensive care plans. She stated the effect on a resident when a goal was not met or was not measurable would depend on what the problem was. The ADON stated an unmeasurable goal could lead to a resident experiencing a physical or emotional decline, harm, or loss of function. The ADON explained training for her position included learning on the job during her 15 + years working at the facility, computer-based training, and training meetings with the corporate case mix director. During an interview on 11/02/23 at 1:09 PM, the SW stated her expectations on care plans was guidance for measurable progress by a certain goal date. The SW stated the care plan and measurable goals were the basis for evaluation on whether to change, discontinue, or continue with the current plan. The SW stated this was her first position in a long-term care facility. She explained her previous work experience included IDD and ICF where she was responsible for all aspects of care planning. The SW stated the effect a goal without a means to measure effectiveness for residents was not knowing if a goal was met or if a resident was improving. She stated if there was nothing to measure against it was difficult to determine the effectiveness of interventions. During an interview on 11/02/23 at 1:20 PM, the Admin stated her expectation of care plan goals was for the statement to be measurable in order to know if goal had been achieved. She stated goals were the guidelines to evaluate if a resident did not improve or declined. The Admin stated her expectations for developing care plan goals was for the goals to align with current guidelines and standards of care. Review of facility policy titled Care Plan Process, Person-Centered Care revision date May 5, 2023, revealed The facility will develop and implement a baseline and comprehensive care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. Procedures, item #3. Revealed Following RAI Guidelines develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.

Based on observation, interview, and record review, the facility failed to establish and maintain an Infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 2 of 5 residents (Resident #30 and Resident #21) reviewed for infection control, in that: The facility failed to remove COVID-19 negative Resident #30 and Resident #21 away from COVID-19 positive Resident #4 and Resident #19 to the prevent spread of infection. The facility failed to COVID-19 test Resident #30 after a confirmed exposure to COVID-19 positive Resident #4 within 2 days per facility policy. This deficient practice could place residents at-risk for infection due to improper care practices. The findings included: Review of Resident #30's electronic face sheet revealed an [AGE] year-old female admitted to facility on 05/19/2023 with diagnoses to include: dementia, asthma, and pneumonia. Further review revealed no diagnosis of COVID-19. Review of Resident #30's Quarterly MDS, dated [DATE], revealed Section C: Cognitive Patterns: BIMS score 11 (indicating mild cognitive impairment). Review of Resident #30's Comprehensive Care Plan, revised 09/05/2023, revealed: Problem: is at risk for possible exposure to COVID-19 & prefers to not social distance or wear a face covering. Res declines COVID vaccine, educated on risks expressed understanding. Goal: will have interventions in place to reduce possible exposure to COVID-19 over the next 90 days. Approach: is encouraged to wear a mask when out of room and encourage social distancing. Encourage hand hygiene. COVID-19 testing per policy. Staff to DON/DOFF PPE per policy. Review of Resident #30's MAR, dated October 2023 and November 2023, revealed no evidence of COVID-19 testing from 10/30/23-11/01/23. Review of Resident #21's electronic face sheet revealed an [AGE] year-old male admitted to facility on 07/24/2020 with diagnoses to include: anxiety, high blood pressure, and heart disease. Further review revealed no diagnosis of COVID-19. Review of Resident #21's Annual MDS, dated [DATE], revealed Section C: Cognitive Patterns: BIMS score not performed. Review of Resident #21's Comprehensive Care Plan, revised 09/19/2023, revealed: Problem: is at risk for possible exposure to COVID-19 & prefers to not social distance or wear face covering. Goal: will have interventions in place to reduce possible exposure to COVID-19 over the next 90 days. Approach: is encouraged to wear a mask when out of room and encourage social distancing. Encourage hand hygiene. COVID-19 testing per policy. Staff to DON/DOFF PPE per policy. Res family request res eat & have activities with multiple other residents & roommate, educated family on COVID-19 risks & states understanding. Review of Resident #21's MAR, dated October 2023, revealed COVID-19 test performed on 10/31/2023 with a negative result. Review of Resident #4's electronic face sheet revealed a [AGE] year-old female admitted to facility on 09/16/2019 with diagnoses to include: dementia, high blood pressure, and heart failure. Review of Resident #4's Quarterly MDS, dated [DATE], revealed Section C: Cognitive Patterns: BIMS score 03 (indicating severe cognitive impairment). Review of Resident #4's Comprehensive Care Plan, revised 10/30/2023, revealed: Problem: Resident with COVID - 19 Test Positive with Symptoms. Goal: Maintain airway and oxygen exchange as evidenced by oxygen saturation and Respiratory Rate within normal limits. Approach: Observe for respiratory distress. Observe for signs and symptoms of pneumonia. Observe and document presence of sputum, color, viscosity, odor, amount. Observe for signs and symptoms of dehydration. Encourage and record fluid intake. Observe for signs and symptoms of pain. Medications as ordered (Lageviro). Labs/XRay as ordered. Oxygen at 2LPM/NC PRN. Vital Signs, O2 SAT. Turn and Reposition. Encourage Cough and Deep Breathing Exercise. Oral Care. Maintain an environment conducive to rest and sleep/raise upper body for sleep. Notify provider if symptoms worsen. Review of Resident #4's MAR, dated October 2023 revealed COVID-19 test performed on 10/30/2023 with a positive result. Review of Resident # 19's electronic face sheet revealed a [AGE] year-old male admitted to facility on 02/28/2023 with diagnoses to include: dementia, diabetes, and COVID-19. Review of Resident #19's Annual MDS, dated [DATE], revealed Section C: Cognitive Patterns: BIMS score 01 (indicating severe cognitive impairment). Review of Resident #19's Comprehensive Care Plan, revised 10/31/2023, revealed: Problem: Resident with COVID - 19 Test Positive with Symptoms. Goal: Maintain airway and oxygen exchange as evidenced by oxygen saturation and Respiratory Rate within normal limits. Approach: Observe for respiratory distress. Observe for signs and symptoms of pneumonia. Observe and document presence of sputum, color, viscosity, odor, amount. Observe for signs and symptoms of dehydration. Encourage and record fluid intake. Observe for signs and symptoms of pain. Medications as ordered (Lageviro). Labs/XRay as ordered. Oxygen at 2LPM/NC PRN. Vital Signs, O2 SAT. Turn and Reposition. Encourage Cough and Deep Breathing Exercise. Oral Care. Maintain an environment conducive to rest and sleep/raise upper body for sleep. Notify provider if symptoms worsen. Review of Resident #19's MAR, dated October 2023 revealed COVID-19 test performed on 10/31/2023 with a positive result. During an interview on 10/31/23 at 10:29 AM, the Administrator stated the facility had 3 residents who tested positive for COVID-19. She stated a CNA tested positive for COVID-19 on 10/26/23. She stated the CNA tested at home and had not been in the facility since 10/23/23. She stated all residents were tested on [DATE] and 10/27/23 with only Resident #15 testing positive. She stated Resident #15 was already in a private room, so he was left in place and placed on transmission-based precautions. She stated all staff began wearing a mask and provided source control. She stated in-services were provided regarding infection control. She stated Resident #4 had signs and symptoms of COVID-19 and was tested on [DATE] with a positive result and Resident #19 had signs and symptoms of COVID-19 and was tested on [DATE] with a positive result. She stated Resident #30 who was Resident #4's roommate and Resident #21 who was Resident #19's roommate were both tested with negative results. She stated the COVID-19 positive residents were not isolated from the COVID-19 negative roommates. She stated the facility just isolated all 4 residents to their rooms since the residents had already been exposed. During an observation on 10/31/23 at 12:00 PM, revealed Resident #30 and Resident #4 were in the same room with a privacy curtain drawn between them and Resident #21 and Resident #19 were in the same room with a privacy curtain drawn between them. Review of the facility COVID-19 testing log revealed: Resident #4 was tested on [DATE] with a positive result; Resident #19 was tested on [DATE] with positive result' and Resident #21 was tested on [DATE] with negative result. Further review revealed no evidence of Resident #30 being tested after exposure was confirmed by Resident #4 testing positive on 10/30/23. During an interview on 11/02/23 at 10:24 AM, the DON stated she did not separate Resident #30 from Resident #4 or Resident #21 from Resident #19 because they had already been exposed. She stated she was trying to minimize spreading COVID-19 across the facility. She stated privacy curtains were drawn between the residents to prevent the spread of infection and new PPE was changed in between each resident's care. She stated she was instructed by corporate not to separate the residents. She stated Resident # 30 was not tested because she had no COVID-19 symptoms. She stated per policy the facility was only supposed to test if resident was symptomatic. During an interview on 11/02/23 at 10:40 AM, the IP stated Resident #30 should have been tested and she thought it had been done. She stated all at risk or exposed residents should have been tested within 2 days of a confirmed or suspected exposure. During an interview on 11/02/23 at 11:00 AM, the DON stated after review of the facility policy, Resident #30 should have been tested . She stated after review of the facility policy she could not find a definite answer on separating the COVID-19 positive residents from the COVID-19 negative residents. She stated that since she was unclear, she would separate the residents now. Record review of the facility policy, titled Infection Prevention and Control Policies and Procedures, complete revision 05/12/2023, revealed SUBJECT: CORONAVIRUS DISEASE (COVID-19): POLICY: In the event of a suspected or actual case of SARS-CoV-2/COVID-19, the Facility provides notification to the Clinical Services Director (CSD) and Regional [NAME] President (RVP) and initiates involvement of federal, state, and local health agencies for direction regarding current recommended strategies for prevention of spread of the disease and treatment methods. PROCEDURES: .6. Facility will test those residents identified by root cause analysis and contact tracing if they were a high-risk exposure to the positive individual. Testing will be completed via Point of Care Antigen test and/or PCR test. The test will be performed within 2 days of the positive individual .14. The facility will place residents who test positive for COVID-19 in transmission-based precautions until criteria is met to discontinue transmission-based precautions. The facility will implement the Coronavirus Disease 2019 Pandemic Prevention and Response Plan if multiple residents are identified with COVI D-19 infection. The facility may open a hall/unit to cohort like infections to a designate area of the facility to reduce the spread of infection. Review of Centers for Disease Control and Prevention accessed on 11/15/2023 at https://www.cdc.gov/coronavirus/2019-ncov/your-health/isolation.html revealed If you have COVID-19, you can spread the virus to others. There are precautions you can take to prevent spreading it to others: isolation, masking, and avoiding contact with people who are at high risk of getting very sick. Isolation is used to separate people with confirmed or suspected COVID-19 from those without COVID-19. Review of Centers for Disease Control and Prevention accessed on 11/15/2023 at https://www.cdc.gov/coronavirus/2019-ncov/your-health/if-you-were-exposed.html revealed If you develop symptoms: isolate immediately, get tested

Based on observation, interview and record review, the facility failed to ensure the menu was followed, for 1 of 1 observed lunch meal on 09/07/2022 The facility failed to ensure residents received a fresh baked role or an approved alternative during the lunch meal. The facility failed to ensure residents received an approved alternative; residents received a cookie instead of Strawberry Delite during the lunch meal. These failures could place residents that eat out of the kitchen at risk of poor intake, chemical imbalance and/or weight loss. The findings include: Record review on 09/06/2022 of week 3 facility menu revealed: Lunch: Cornflake Chicken 3 oz, Confetti Rice 1/2 Cup, Season Peas 1/2 cup, Fresh baked roll 1 oz, Whipped Strawberry Delite 1/2 cup. Observation of the noon meal on 09/06/2022 at 11:30 AM revealed residents were served Cornflake Chicken, Confetti Rice, Seasoned Peas, and a cookie. During an interview on 09/06/22 at 3:02 PM the DM stated Cook A should have used sliced bread to replace the roll, because there was plenty of bread. The DM stated she realized Cook A replaced the Strawberry Delite with a cookie, she did not know why he switched the desserts. The DM stated there was a substitution record that Cook A should have completed. The DM stated he did not complete the substitution record. During an interview on 09/08/22 at 1:58 PM the DM stated her expectation was that menus should have been followed. The DM stated it was important to follow the menus because they were calculated with specific calories, to ensure residents received the correct diet. The DM stated what led to failure was staff were in the habit of doing it their own way and making what they want for long time. During an interview on 09/08/22 at 2:08 PM the ADM stated her expectation was that the posted menu be followed and there should have been a paper trail for substitutions. The ADM stated if Cook A was out of rolls then there should have been another item substituted for the roll. The ADM stated the DM was responsible for monitoring the substitution record and talking with the Dietitian. The ADM stated not following the menu could affect residents by their diet being thrown off and residents would not receive the minerals and vitamins their diets required. The ADM stated what led to failure of the menu not being followed was staff was nervous and/or forgetful. Record review of the Substitution Record on 09/08/22 revealed no documentation had been entered for the changed menu on 09/06/2022 Record review of facility policy titled, Nutrition Polices and Procedures dated 08/01/2020 revealed: Make appropriate substitutions when items on the menu are not available. Record these substitutions and keep the records on file with menus.

Based on interviews and record reviews, the facility failed to develop and implement a baseline care plan for 1 of 3 (Resident #86's) resident reviewed for baseline care plans. Resident #86's did not have a baseline care plan This failure placed new residents at risk for continuity of care and adverse events that are most likely to occur right after admission. Findings included: Record review of Resident #86's Facesheet dated 9/8/22 revealed an [AGE] year-old female with an admitted [DATE]. Her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #86's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #86's Nursing Admission assessment dated [DATE] revealed: [CONDITION(S)], [CONDITION(S)], [CONDITION(S)] within last 30 days, [CONDITION(S)]. Impaired short-term memory modified independent decision making meaning some difficulty in new situations. Wears glasses. Use of antipsychotic medication. Use of a walking device, lower extremity knee impairment both sides. Full set of dentures. Continent of bowel and bladder. Record review of Resident #86's Care plan dated 9/6/22 revealed no care areas with goals and/or interventions began prior to 9/6/22 except Activities that began 8/31/22. During an interview on 9/8/22 at 8:58AM with RN-A, she said the ADON did the baseline care plan based off of the admission assessment the nurses completed. She said it was a specific form that was labeled Baseline Care Plan. RN-A said it should be completed within 48 hours of admission and included any types of medications, diet, ADL care needs, therapies such as OT and PT, as well as activities. During an interview on 9/8/22 at 9:30AM with ADON, she said she had looked through Resident #86's's file and could not find the form for the base line care plan. She said the resident had been admitted to the facility on a Saturday (8/27/22) and that she had worked on the floor as a nurse on Friday (8/26/22) and she had forgotten to leave the baseline care plan out for the admission nurse to begin. ADON said as she had been auditing Resident #86's's file and seen that there had not been a baseline care plan completed within 48 hours of admission, she began a comprehensive care plan on Tuesday (9/6/22), and the facility had a teleconference with Resident #86's's family to discuss the care plan yesterday (9/7/22). Record review of facility policy labeled Person Centered Care Plan Process last revised 7/1/16 revealed: The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care . summary of the baseline care plan that includes but is not limited to: initial goals of the resident, summary of the resident's medications and dietary instructions, any services and treatments to be administered by the facility and personnel acting on behalf of the facility . Develop and implement the baseline care plan within 48 hours of a resident's admission.

Based on observation, interview, and record review the facility failed to employ sufficient staff with the appropriate competencies, skills set and accreditations to carry out the functions of the food and nutrition service department for 1 of 1 (Dietary Manager) reviewed for qualified dietary staff. The facility failed to ensure the facility's only Dietary Manager (DM) met the requirements for a dietary manager. This failure could place residents at risk of not having their nutritional needs met and place them at risk for food born illnesses. Findings: In an observation and interview at 06/01/2021 at 9:34 AM of the facility's only kitchen revealed Texas Food Handler Certificates were displayed and there was no certificate for a Dietary Manager. There was A Food Handler Certificate displayed for the DM stated, I'm enrolled in online classes for dietary manager. The DM then stated he had become DM One and half years ago. I was taking the DM class and then I ran out of time which is why I am paying for the classes now. I signed up for classes two months ago and should be done by 04/2022. The DM also stated that the Dietician only comes to the facility on e time a month. In an interview and observation at 06/02/21 at 3:30 PM with HR/BOM, the DM was designated DM 04/17/2019. Interview with DM revealed that he is currently enrolled in DM classes. When asked HR/BOM for a copy of DM job description she stated: I don't have a new one for the DM, but I will get it for you. The HR/BOM was then observed on 06/02/2021 at 3:40 PM printing out the DM job description then took to the Administrator for signature who then had the DM sign and date the job description on 06/02/2021 at 3:40 PM. Review of DM's transcript record, on 06/03/2021 at 9:20 AM, revealed the DM was enrolled in an online Nutrition & Foodservice Professional Training Program online course. Transcript record also revealed that the DM was enrolled on 03/22/2021 with an expected completion date of 03/22/2022. Review of CMS 672 dated 06/01/2021, 1 of 32 residents received nutrition via PEG Tube. Review of facility policy titled Department Leadership dated 10/2/2017 revealed: . 1 . If a qualified Dietitian is not employed full time, a person is designated to serve as the Nutrition/Culinary Services Directory (NSD) who receives frequently scheduled consultation from a qualified Dietitian. 2. An NSD who is not a registered dietitian functions collaboratively with a qualified dietitian to meet the nutritional needs of the patients/residents. A qualified Nutrition/Culinary Services Director is as follows; A certified dietary manager; or a certified food service manager, who has obtained certification from an accredited school according to federal and state guidelines .

Based on observation, interview, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety, for one of one facility kitchen. The facility failed to prepare and serve food in sanitary conditions by not covering dinner rolls while they were rising; not having the facility's only ice machine be free of pink slime and mold; not donning beard covers in the kitchen and during food service; not ensuring dishes were washed and dried in a sanitary manner; not using dishware that is free of chips; not labeling, dating, and resealing multi use food items; and not safely distributing drink ware and dishware. This failure could place residents at risk of not having their nutritional needs met and placing them at risk for food born illnesses. The findings include: In an observation on 2/24/20 at 10:20 am in the kitchen revealed dinner rolls were observed uncooked and rising on a shelf above the stove with no cover; the facility's only ice machine was observed to have pink slime and black mold on the inside; Cook C, who had a beard, did not have a beard cover; and the dishwashing machine temperature was at 105 degrees Fahrenheit. In the dry food storage area there was Devils food cake mix sitting open in a zip lock bag that was not sealed and it had no date indicating when it was opened. In the refrigerator there was a container of Lemon thicken liquid and a container of thickened Cranberry without dates indicating when they were opened. In an observation on 2/24/20 at 11:00 am Cook B was preparing pureed deserts and placed the deserts in small stoneware bowls for service. At least 5 out of the 40 bowls observed had visible chips. In an observation on 2/24/20 at 11:24 am Cook C was observed without a beard cover, washing dishes then passing out open cups of thickened liquids to residents. Cook C was holding the cups, two per hand, by the drinking rim of each glass with no gloves on or hand hygiene performed just prior to the handling of the glasses. In an observation on 2/24/20 at 11:31 am Cook B was taking the temperatures of chilled chicken salad and pimento cheese. While doing so, her arm was laying across plates for food services. Cook B then began making plates, for residents, using plates that where damp with water. Cook B placed food on the plate her arm had lain across and was going to use it for food service until she was informed she had contaminated the plate by this surveyor. In an observation on 2/24/20 at 2:15 pm a styrofoam cup of water and ice was sitting uncovered at the kitchen hand washing sink. Dishwashing crates were discolored and appeared unclean with a brown buildup on them. Two of the 8 dishwashing crates were on the floor under the sink. Cook D was observed placing dishwashing crates on the ground during dishwashing. In an interview on 2/24/20 at 2:40 pm Administrator stated she does have a Dietary Consultant that comes at least monthly and during her time in the facility she does an inspection of the kitchen. Currently the Administrator does not have a cleaning schedule for the kitchen, but she inspects the kitchen weekly. The Administrator was unaware of the condition of the ice machine and stated it would be cleaned by the end of the day and the facility would start using their emergency ice supply. The Administrator also stated dishes should not be stored wet, they should be left to air dry after washing, and the dish washing machine should be running at 120 degrees Fahrenheit. In an interview on 2/26/20 at 1:58 pm Cook C stated he was aware he should wear a beard cover and they are available but don't fit well like the old ones did. Cook C stated he has told the Dietary Manager (DM) and the DM told him he will order the old ones once they are available again. Cook C stated if he sees a broken dish he would throw it away and leave a note for DM. Cook C stated he had not noticed any broken dishes. In an interview on 2/26/20 at 2:04 pm DM stated he was ok with Cook C not having a beard cover because his beard is not long. DM stated if dishes are broken or chipped they should be thrown away and if they have broken dishes they must have just been over looked. DM also stated dishes should be put up dry and not wet. DM stated if a dish had been touched by an arm it should not be used. Review of facility policy dated 10/2/2017 revealed a policy for Safe Food Handling . 4. Handle food carefully to avoid contamination with potentially harmful debris, such as broken glass or glass chips, sweepings and the Like. 5. Dishes, flatware, and glassware are free from chips, cracks or stains. Glaze intact on plastic and china dishes. 6. Follow all local, State, and Federal Regulations when handling food . 8. Anyone working in the kitchen during normal food productions hours is expected to wear appropriate hair restraints (such as hats, hair covers or nets, beard restraints) . 1. All Facility staff (culinary, nursing, therapy, activities, ect.) involved in the preparation and service of food adheres to safe food handling techniques . 3. Plates are handled by the edge or bottom; cups by the handles or bottom; and utensils by the handles . 6. Food is served with clean, sanitized utensils. There is no bare hand contact . 3. All foods removed from the original packaging are stored in a closed container or tightly wrapped package and labeled with the common name of the item and the date it was opened . 4. Food and beverages are consumed by employees/contract personnel in designated areas such as break rooms. Eating and drinking is not permitted in the kitchen .

Based on observation, interview and record review, the facility failed to provide safe, sanitary and comfortable environment to prevent the developement and transmission of communicable diseases and infections during meal service and for resident care for 3 of 3 residents, (resident# 26, 31, 5) observed for infection prevention and control. 1. CNA A did not perform hand hygiene while passing food trays during dining observation. 2. LVN A did not perform proper hand hygiene during administration of protein powder for resident # 26. 3. LVN A did not perform proper hand hygiene during personal care of resident # 31 and #5. This failure could cause risk of adverse effects of infections for residents of the facility. Findings include: During observation of meal service in the dining room on 02/24/20 at 11:43 AM, CNA A did not use any type of hand sanitation. She was observed touching her hair, scratching her head, then placed a used tray back on top of other clean trays. She then pulled her hair back behind her ear, then scratched inside of right ear. She was observed assisting a resident with protective clothing cover, re-centered wheelchair and applied brakes. She was then observed repositioning another resident. Then observed using sanitizing wet wipes on hands and arms for the only time during meal service. She was observed passing more meal trays, then again scratching hairline, and passing more meal trays. She was observed picking up items off the floor. CNA A was observed serving several trays to multiple residents. In an interview with the DON on 02/24/20 at 12:08 PM, she said that she expects that the staff use Sani-hands (sanitizing wet wipes) before passing trays and each time a tray is passed to a resident. She said, if touching face or hair she expects that the staff would go wash hands with soap and water. Resident #26 Record review of Resident #26 facesheet printed 02/26/2020 revealed a [AGE] year-old male admitted on [DATE] with most recent hospital readmission on 10/13/2019. [DIAGNOSES REDACTED]. Record review of Resident #26 quarterly MDS dated [DATE] revealed a BIMS of 9 meaning moderate cognitive impairment. Feeding tube, PEG tube, with 51% or more of total calories received through [MEDICATION NAME] tube feeding and average of 501 or more fluid ounces per day intake through feeding tube. Record review of Resident #26 careplan last reviewed 01/24/2020, revealed: Feeding tube d/t [DIAGNOSES REDACTED] and dysphagia. Goal to not exhibit signs of complications from feeding tube or enteral feeding solution. Change irrigation set, bag, tubing every day. Date, time and initial every day. In an observation on 02/25/20 at 11:19 AM, LVN A did not wash hands prior to administering protein powder via PEG tube. In an interview on 02/25/2020 at 11:30 AM with LVN A, she stated she would wash her hands before preparing supplement at the medication cart. Upon entering the room, she would set up everything she needed, wash her hands and don gloves. She would then check for placement and administer supplement. When completed she would clean equipment and staging area then wash her hands. When asked about the failure to wash hands prior to administration she stated she got side tracked and forgot. Resident #31 Record review of Resident #31 facesheet printed 02/26/2020 revealed an [AGE] year-old male admitted [DATE]. [DIAGNOSES REDACTED]. Record review of Resident #31 most recent Significant change in status MDS dated [DATE] revealed a BIMS of 5 out of 15 which would indicate a severely impaired cognition. Section G Functional States indicated Resident #31 needed extensive assistance with ADLs requiring 1 to 2-person assistance for all ADLs. Resident #31 had limited range of motion in his lower extremities and used a wheelchair for mobility. Section H Bladder and Bowel revealed Resident #31 is always incontinent of bladder and bowel. Record review of Resident #31 careplan revised on 01/29/2020 revealed: Urinary incontinence, with approach to monitor for incontinence every 2 hours and as needed. Change promptly, monitor for signs and symptoms of skin breakdown, monitor for signs and symptoms of infection. Resident #5 Record review of Resident #5 facesheet printed 02/26/2020 revealed a [AGE] year-old male admitted on [DATE]. [DIAGNOSES REDACTED]. Record review of Resident #5 most recent Quarterly MDS dated [DATE] revealed a BIMS of 3 out of 15 which would indicate a severely impaired cognition. Section G Functional Status revealed extensive assistance was needed for all ADLs except for walking in his room which required limited assistance. Resident #5 required only one person assist for ADLs except for toileting in which he required a 2 person assist. Resident #5 also used a wheelchair for mobility. Section H Bladder and Bowel indicated Resident #5 has an [MEDICAL CONDITION] and is frequently had urinary incontinence. Record review of Resident #5 careplan revised 12/9/2019 revealed: Urinary incontinence, with approach to monitor for incontinence every 2 hours and as needed. Change promptly, monitor for signs and symptoms of skin breakdown, monitor for signs and symptoms of infection. Ostomy, with approach to monitor the stoma and surrounding skin and observe the size, color of stoma; presence/absence of skin breakdown; presence/absence of infection. Provide full staff performance assistance for ostomy care every shift and as needed. In an observation on 02/26/20 at 09:45 AM, of peri care for Resident #31 revealed buttocks had a healed 0.5-inch area of pink skin. LVN A did not wash her hands after peri care and grabbed gloves from a glove dispenser in the hall. LVN A then went into Resident #5 room, washed her hands but then donned the gloves she obtained with dirty hands. She then proceeded to look at stoma and buttocks of Resident #5 with the dirty gloves. In an interview on 02/26/20 at 11:10 AM with LVN A, she said she had been working in the facility for five years. She said they should wash their hands after each resident if they had been touching them. She was unsure if hand hygiene was completed after the first resident. She said if it was not, that was not the expectation of the facility. In an interview with the administrator on 02/26/20 at 11:26 AM, she said they should wash hands or use Sani hands sanitizing wet wipes after resident care. She said that she expected employees should get gloves with clean hands, and gloves should not be placed in a pocket. Record review of policy labeled Hand hygiene/Hand washing revised 10/2/2017, revealed: wash hand before handling food . before/after resident contact . before putting on gloves, when changing into a fresh pair of gloves, and immediately after removing gloves . after personal grooming . after contact with an object or source where there is a concentration of microorganisms.

Based on observation, interview, and record review, the facility failed to maintain 1 of 1 AED in safe operating condition. The facility did not perform routine maintenance checks on the AED. The battery status light had a red X and when turned on the AED voiced instructions to change the batteries. This failure could place residents who wished to be resuscitated in the event of a [MEDICAL CONDITION] at risk of not receiving emergency interventions. Findings included: Observation on 02/25/2020 at 10:00 AM revealed the AED had a red X on battery status. Interview with LVN A on 02/25/20 at10:01 AM she stated she didn't know who was supposed to check AED and crash cart. When she checked the AED, it revealed it needed new batteries. Interview with Administrator on 02/25/20 at 10:10 AM revealed she was unsure of how to check or change batteries in AED. She stated the previous Director of Nursing was responsible for the checks. Record review of AED monitoring log revealed the last documented check was on 09/19/2019. Record review of Nursing Policies and Procedures dated 7/1/2016 Automatic External Defibrillator. Procedures: #3. Quality checks for battery life, appropriate functioning of the unit and the presence of required [MEDICATION NAME] and other equipment are performed on a routine basis.

Based on observations, interviews and record reviews, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for one (1) of one (1) resident reviewed for enteral nutrition (Resident #26). The facility failed to label and date Resident #26's feeding tube and bag to ensure the product had not exceeded the expiration date, after it was hung for infusion. These failures could place Resident #26 (the only resident who received tube feeding) at risk for malnutrition or gastro-intestinal illness from expired formula. Findings Included: Record review of Resident #26 face sheet printed [DATE] revealed a [AGE] year-old male admitted on [DATE] with most recent hospital readmission on [DATE]. [DIAGNOSES REDACTED]. Record review of Resident #26 quarterly MDS (Minimum Data Set) dated [DATE] revealed a BIMS of 9 meaning moderate cognitive impairment. Feeding tube, PEG tube, with 51% or more of total calories received through [MEDICATION NAME] tube feeding and average of 501 or more fluid ounces per day intake through feeding tube. Record review of Resident #26 care plan last reviewed [DATE], revealed: Feeding tube due to [DIAGNOSES REDACTED] and dysphagia. Goal to not exhibit signs of complications from feeding tube or enteral feeding solution. Change irrigation set, bag, tubing every day. Date, time and initial every day. Review of Physician order [REDACTED].\2020- 02\29\2020 revealed Enteral Feeding: Change bag, tubing, date, time, & initial once a day: 05:00PM Observations on: [DATE] at 10:31 AM feeding and flush hanging from IV pole not labeled and not connected to resident. The feeding bag was one-third full, and the flush bag was over half full. The feeding bag and tubing were not dated or timed. [DATE] at 09:19 AM feeding running at prescribed rate, no label on feeding or flush solution. The feeding bag and tubing were not dated or timed. Interview with LVN A on [DATE] at 02:48 PM she stated she prepares feeding and flush bags as ordered, then labels both bags with date, time and initials. Stated once the feeding time is completed at 11:00 am it is removed and disposed of. Interview with the DON on [DATE] at 02:51 PM she stated she expects the bags to be labeled per policy. Review of policy Nutrition Policies and Procedures (Enteral Feeding-Documentation) #7 (B) dated 10\02\2017 Revealed Label the feeding set with the date, time, patient\resident's name and nurse's initials.

Based on observation, interview, and record review the facility failed to employ sufficient staff with the appropriate competencies, skills set and accreditations to carry out the functions of the food and nutrition service department for 1 of 1 (Dietary Manager) reviewed for qualified dietary staff. The facility failed to ensure the facility's only Dietary Manager (DM) met the requirements for a dietary manager. This failure could place residents at risk of not having their nutritional needs met and placing them at risk for food born illnesses. Findings: In an observation on 2/24/20 at 10:20 am of the facility's only kitchen revealed Texas Food Handler Certificates were displayed and there was no certificate for a Dietary Manager. There was a Food Handler Certificate displayed for the Dietary Manager. In an interview on 2/24/20 at 10:28 am Dietary Manager stated he had started a Dietary Manager course in (MONTH) of 2019 and should complete it in (MONTH) of 2020. He has been the acting DM since (MONTH) of 2019. Record review of facility policy dated 10/2/17 revealed a policy for Department Leadership . 1 . If a qualified Dietitian is not employed full time, a person is designated to serve as the Nutrition/Culinary Services Directory (NSD) who receives frequently scheduled consultation from a qualified Dietitian. 2. An NSD who is not a registered dietitian functions collaboratively with a qualified dietitian to meet the nutritional needs of the patients/residents. A qualified Nutrition/Culinary Services Director is a as follows; A certified dietary manager; or a certified food service manager, who has obtained certification from an accredited school according to federal and state guidelines .

Based on observations, interviews, and record review the facility failed, based on a comprehensive assessment, to ensure 1of 2 residents (Resident #4) reviewed for enteral nutrition, received the appropriate care and services to prevent complications of enteral feedings as evidenced by: LVN A failed to measure liquids used to prepare the Protein powder and to flush before and after the administration of the Protein powder through [DEVICE] for Resident #4. This failure affected Resident #4's quality of life and placed him at risk for life-threatening complications and possible death due to aspirating his [DEVICE] feedings. Findings Included: Review of Resident #4's electronic Face Sheet printed on 8/29/18 revealed he was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. His [DIAGNOSES REDACTED]. Review of Resident #4's Quarterly MDS (Minimum Data Set) dated 3/8/19 revealed that Resident #4 was unable to complete the BIMs (Brief Interview for Mental Status) score of 0 which indicated his cognitive function was severely impaired. Resident #4's annual MDS dated [DATE] revealed a BIMS score of 12 indicative of a moderate cognitive impairment He required extensive assistance with his ADLs (Activities of Daily Living). The assessment indicated he had a feeding tube and that he received 51% or more of his total calories through the feeding tube and his average daily intake of fluid through the feeding tube was 501 cc (cubic centimeters) or more per day. Documented [DIAGNOSES REDACTED]. Record review of hospital records dated 2/23/17 revealed: admitted [DATE], Chief complaint: aspiration pneumonia, history of recurrent pneumonia . Record review of hospital records dated 6/1/17 revealed: admitted [DATE], Chief complaint: aspiration pneumonia, history of recurrent pneumonia . Record review of hospital records dated 01/22/18 revealed: admitted d 01/22/18, Chief complaint: aspiration pneumonia, acute hypoxemic [MEDICAL CONDITION]. In patient Diagnoses: [REDACTED]. History: Patient coming in for respiratory distress . He has a long history of aspiration pneumonia .cat scan of chest revealed probably left sided aspiration pneumonia . Review of Resident #1's care plan last reviewed on 6/28/18 revealed: Problem Start Date: 3/1/17. Category: Nutritional Status. (Resident #4's name) has a history of/risk for aspiration pneumonia. He receives all nutrition via peg tube. [MEDICATION NAME] 2.0 per physician order. History of weight gain. Nutrition order changes 11/15/18. Monitor weight weekly .Long Term Goal Target Date: 3/5/19 Weight will remain stable 214.9 +/- 4% q month with no sign or symptoms of aspiration pneumonia . Approach Start Date: 3/1/17 -1. Provide [MEDICATION NAME] 2.0 per physician order. 2. Flush tube per physician order [REDACTED].>Review of Resident #4's recapitulated electronic physician's orders [REDACTED]. Enteral Feeding: Flush tube with 60 cc's warm water before and after medication administration. Every shift. Shift 1; Shift 2. Enteral Feeding: Flush tube with 60 cc's warm water before and after tube feeding. Once a day; 6:00 am- 6:00 pm. Enteral Feeding: 275 ml flush every 4 hours to provide 1650 ml water every shift; Shift 1; Shift 2. Enteral Feeding: Formula [MEDICATION NAME] Strength 2.0 flow rate; 40 ml/hour for 18 hours/day. Off 11:00 am- 5:00 pm on 5:00 pm to 11:00 am via pump. Diagnosis- dysphagia. Every shift, shift 1, shift 2. Protein powder- 2 scoops in 200 ml water via PEG tube once a day; 11:00 am. Observation and interview on 03/18/19 @ 11:20 AM of medication administration to Resident #4 revealed LVN A prepare 2 scoops of Protein powder mixed with approximately 200-ml water, and flushed with approximately 180 ml free water. LVN A did not measure the liquids. There was only one type of measuring cup, a 1 ounce (30 ml) medication cup. LVN A said that she did not have a measuring cup available and that she would use a 240-ml cup and eyeball the amount of fluids that she needed for Resident #4. In an interview on 3/18/19 with the Administrator and DON at 3:30 pm the Administrator said that she expected the staff to be following the physician orders [REDACTED]. Record review of Dietary Progress Note dated 3/13/19 revealed (MONTH) weight 217 pounds, body mass index (BMI): 27.9, ideal body weight (IBW): resident weight is stable for last 6 months. Diet: nothing passing orally (NPO), tube feeding (TF)- [MEDICATION NAME] 2.0 at 40 ml/hour for 18 hours plus Protein powder 2 scoops in 200 ml of water every day. 60 ml water medication flushes and water flush of 275 ml every 4 hours. TF, Protein powder, and flushes provide 1500 Kcal, 72 g protein, and 2708 ml of water . Record review of Nutritional evaluation tool dated 3/15/17 revealed admission diagnosis- admit status [REDACTED]. Record review of Gastrostomy Tube Flush/Irrigation policy dated 7/1/2016 revealed the following: Policy: The nursing staff will take measures to maintain or establish patency of the gastrostomy tube. Flushing of the tube with thirty (30) ml of water will be performed: 1. Before & after each intermittent feeding. 2. Before and after administration of medication* 3. According to physician's orders [REDACTED]. 4. Whenever feeding is interrupted .

Based on observations, interviews and record review the facility failed to ensure the corridors were equipped with firmly secured handrails. A loose handrail was located between Country Lane and Hummingbird Road halls and a loose handrail was located in the Cactus Trail hall. This failure placed residents and visitors at risk for falls and injuries due to the handrails giving way when pressure was applied. Findings included: Observation on 3/19/19 at 11:00 a.m. revealed the handrail at the corner across from the nurse's station between the Country Lane and Hummingbird Road halls was loose. The brackets on one end were pulled out of the wall and the rail could easily be raised up and moved out of place and gave way when downward pressure was applied. Observation on 3/20/19 at 9:30 a.m. revealed the handrail between Country Lane and Hummingbird Lane remained loose. Observation on 3/20/19 at 11:30 a.m. revealed the handrail to the left of the medication room door on the Cactus Trail hall was loose. Review of the maintenance log from 12/31/18 through 3/16/19 revealed no documentation to indicate staff reported the handrails needed repair. In an interview on 3/20/19 at 11:30 a.m. the Maintenance Director said the staff had not notified him that the handrails were loose. He said the staff was supposed to document needed repairs in the maintenance log. In an interview with the Administrator and Maintenance Director on 3/20/19 at 11:40 a.m., the Administrator said the facility had a maintenance log that she checked daily and her expectation was for staff to document any needed repairs on the log. The Maintenance Director said he also checked the log daily and that it was his hope that the staff would write needed repairs on the log to notify him. Review of the facility's Maintenance/Housekeeping Policies and Procedures dated 2006 revealed: Subject: Routine Maintenance Policy: The center performs routine maintenance on floors, walls, fixtures and equipment. Procedures: 1. Each center maintains a standard work order system with employee in-service training and a designated area where work order requests are to be prepared and picked up. 2. A work order log is maintained by the Maintenance Department. 3. The Director and/or Executive Director/Administrator is responsible for initiating work order requests for all special project work and work that may result from preventive maintenance inspections.

Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety from 1 of 1 facility kitchens: a. Hand hygiene procedures were not followed by staff This failure could place 36 residents who reside at the facility and eat meals prepared and served by the facility's kitchen at risk of contracting a foodborne illness. The findings included: In an observation on 1/30/18 at 11:12 am, Cook A exited the kitchen, went into the dining room, returned to the kitchen, proceeded to puree black-eyed peas, gathered items to throw away, lifted the lid on the trash barrel, retrieved a piece of aluminum foil from the roll, covered a steam table pan with the foil and returned to puree food prep and did not wash hands or wear gloves. In an interview on 1/30/18 at 11:17 am, Cook A said he would wash his hands if he touched anything outside the kitchen and if he didn't touch anything. He said he doesn't think he needed to wash his hands upon returning to the kitchen. In an interview on 1/30/18 at 12:17pm Dietary Manager said she expected staff to wear gloves when handling raw meat or ready to eat foods. She said she expected staff to wash their hands after using the bathroom, taking a break, touching their face or body and when entering the kitchen. Dietary Manager said she expected staff to wash their hands upon returning to the kitchen even if they had just been at the buffet serving area or the dining room. She said all staff had recently been in-serviced on hand washing technique and policy. Dietary manager provided staff education policies and procedures (in-service) in the competency area of hand washing for Cook A dated 2/23/17 which revealed Cook A met performance criteria for hand washing. In an interview on 1/30/18 at 5:00 pm, Administrator said kitchen staff should be washing their hands upon entering the kitchen. Upon explaining surveyor observation, administrator said she would expect staff to wash their hands even if they went from the kitchen to the buffet area or dining room because their hand would still make contact with the doorknob and residents are able to access that door. Review of facility policy titled Nutrition Policies and Procedures Complete Revision 9/2012 Subject: Hand Hygiene/Handwashing Policy: Hand hygiene is the most important component for preventing the spread of infection. Proper hand washing technique will be used at all times that hand washing is indicated. Employees shall keep their hands .clean. Review of the policy did not address hand washing when entering the kitchen. In an interview on 1/29/18 at 12:05 pm, dietary manager said 36 residents eat food prepared from the facility's kitchen.

Based on observation, interview and record review, the facility failed to ensure one (Residents #16) of 16 residents, who were reviewed for medication regimen, were free of significant medication errors. On 5/20/15 LVN A administered 7 medications prescribed for another resident to Resident #16. Resident #16 ' s blood pressure dropped and the resident became very sleepy and required transfer to the emergency room for treatment of [REDACTED].#16 required 500 milliters of normal saline intravenously and was diagnosed with [REDACTED]. An Immediate Jeopardy (IJ) was identified on 06/01/15. While the IJ was removed on 06/05/15, the facility remained out of compliance at a severity level of Actual harm that is not Immediate Jeopardy and a scope of isolated, because the facility was monitoring the implementation of the Plan of Removal. This failure to administer medications as ordered by the physician could affect the facility's 14 residents medicated by LVN A on South Hall and placed them at risk for a change in their condition, exacerbation of current health issues, development of new health issues, prolonged healing time and the possibility of hospitalization . Findings included: Resident #16's Admission record dated 04/07/15, reflected an admission date of [DATE] and a readmission date of [DATE]. The resident was a [AGE] year old female with [DIAGNOSES REDACTED]. Record review of Resident #16's MDS assessment dated [DATE] reflected she was alert and disoriented no behaviors, she was cognitively impaired. Resident #16 was also assessed as requiring extensive assistance by one staff for bed mobility, transfers, toileting and bathing, dressing and personal hygiene and for eating. Resident #16 had clear speech, was Spanish speaking only and was usually understood and could understand, she was able to follow commands. Record review of Physician orders [REDACTED].#16 had MEDICATION ORDERS FOR [REDACTED]. daily fluid for constipation and [MEDICATION NAME] 50 mg daily for pain. Record review of Medication Flow Sheet for Resident # 16 dated 04/01/15-4/30/15 revealed an order for [REDACTED].<95/65 mm/Hg. Documented B/P were as follows- 4/09/15- 162/64 4/23/15- 134/64 4/30/15- 128/68 Record review of Medication Flow Sheet for Resident # 16 dated 05/01/15-5/31/15 revealed an order for [REDACTED].<95/65 mm/Hg. Documented B/P were as follows- 5/07/15- 119/53 5/28/15- 128/78 Record review of Medication/Treatment Error investigation worksheet dated 5/20/15 3:00 p.m. entry revealed that at 8:15 a.m. LVN A administered the wrong medication to Resident #16. Resident #16 was given the following 7 medications; Vital signs after incident: blood pressure- 119/48 pulse 88 respirations 18. 1. [MEDICATION NAME] D ([MEDICATION NAME] HCL {[MEDICATION NAME]} 60 mg /[MEDICATION NAME] 120 mg {nasal decongestant})1 tablet used for allergy & congestion. 2. Aspirin 81 mg chewable 1 tablet by mouth, used for [MEDICAL CONDITION]. 3. [MEDICATION NAME] 10 mg 1 tablet by mouth, used for hypertension (4 times the dose usual to the resident). 4. [MEDICATION NAME] 40 mg by mouth used as diuretic. 5. Potassium Chloride 20 mg used as supplement. (Severe allergic reactions; black, tarry stools; chest pain; irregular heartbeat; listlessness; numbness or tingling in your skin, lips, hands, or feet; severe nausea or vomiting; stomach pain or swelling; confusion or anxiety; muscle weakness or paralysis; vomiting; weak or heavy legs) <http://www.drugs.com/sfx/potassium-chloride-side-effects.html> 6. [MEDICATION NAME] 18 mg (beta-blocker) used for hypertension. 7. [MEDICATION NAME] 50 mg (narcotic-like) used to treat pain. In an interview on 6/1/15 at 2:25p.m., LVN A said It was breakfast time (approximately 8:15 a.m.) Resident #16's daughter brought Resident #16 up to the cart. The medication cart had a cup on it with Resident #16 ' s name on it. LVN A was popping out meds for another resident and Resident #16's daughter was talking to me and questioning me. I accidently gave Resident #16 the other resident's meds. I went and told the DON and I called the Hospice nurse, talked with the daughter who was still in the facility and we got Resident #16 shipped to the emergency room . Resident #16 was out of the facility a couple of hours and then returned with orders to monitor her vital signs for the next 6 hours; her blood pressure was a little low. We also held her medications and removed her [MEDICATION NAME]. In an interview on 05/30/154 at 10:40 a.m., the Director of Nurse's said that LVN -A was setting up medications outside the dining room. Resident #16 and her daughter came to the medication cart .Resident #16 was in her wheelchair was being assisted by her daughter. The daughter interrupted the nurse and was asking questions about her mother ' s medication. The DON continued and said that she could see the nurse becoming tense and the DON tried to redirect the daughter. The DON said that she should have gone to the medication cart to see if she could help, but that she didn ' t. She said that she did not know why she had not. LVN-A turned the pages of her medication record and answered the questions for the daughter. LVN-A then gave the medications in the cup she was setting up to Resident #16. Resident #16 was administered another residents medications that included [MEDICATION NAME] D, [MEDICATION NAME] 10 mg, [MEDICATION NAME] 40 mg, potassium chloride 20 mg, [MEDICATION NAME] 18 mg, [MEDICATION NAME] 50 mg and Aspirin 81 mg. The DON said that the resident & her daughter left the medication cart and return to the resident room. The DON said she had gone to her office and LVN-A came right away to report the incident. Resident #16 ' s vital signs were obtained approximately 10 minutes after the medication was taken and were 119/45 blood pressure 84-pulse, 93% oxygen saturation on room air, and at 8:30 a.m. they were 109/42 blood pressure and 85 pulse. Dr. A was notified by cell phone and the medications were discussed and the resident current low blood pressure and sleepy state. Plan was to send to the emergency room for fluid and blood pressure/telemetry monitoring. The DON said that she discussed the error with the daughter and the plan to send to the emergency room , and she was in agreement. The ambulance was called. The resident was transferred to the hospital. Resident # 16 returned to the facility by lunch time with orders to monitor her vital signs for 6 hours. Record review of the hospital emergency room record dated 5/20/15 revealed vital signs at 9:33 a.m. blood pressure 123/51, blood pressure at 9:53 a.m. 115/43 drowsy, at 9:50 a.m. blood pressure down to 106 systolic gave 500 ml bolus of normal saline, 10:45 a.m., more alert blood pressure now 112/37 and stable, a discharge [DIAGNOSES REDACTED]. Discharge instructions included monitor Glasgow coma scale and vital signs every hour for 6 hours. Record review of hospital telemetry vital signs on 5/20/15 at 9:30 a.m. B/P 110/37 HR 72 RR 7. Record review of hospital telemetry vital signs on 5/20/15 at 9:52 a.m. B/P 96/44 HR 74 RR 10. Record review of hospital telemetry vital signs on 5/20/15 at 10:00 a.m. B/P 115/43 HR 69 RR 10. Record review of hospital telemetry vital signs on 5/20/15 10:19 a.m. B/P 120/44 HR 72. Record review of hospital telemetry vital signs on 5/20/15 10:20 a.m. B/P 120/44 HR 74. Record review of the Physician telephone order dated 5/20/15 at 12 noon (upon Resident #16's return from the hospital) revealed orders for the following: Vital signs every 1 hour for 6 hours. Hold [MEDICATION NAME] if B/P <120/60. Hold [MEDICATION NAME] if B/P < 120/60. Contact provider if [MEDICATION NAME] or [MEDICATION NAME] held 2 doses in a row. Record review of Medication Flow Sheet for Resident # 16 dated 5/01/15-5/31/15 revealed an order for [REDACTED].<95/65 mm/Hg. B/P - (no time or date) in a margin scribbled on the record were the following B/P: 105/56, 138/58, 142/68, 120/40, 131/45, 143/63. In an interview on 6/1/15 at 2:25p.m., when shown the above record, LVN A said that those were the vital signs ordered every hour after Resident # 16 returned to the facility on [DATE]. When questioned about the parameters, LVN A said she did not call the physician because he already knew the vital signs were low. Attempts were made to contact the emergency room Physician on 06/04/15 at 2 p.m. and 4 p.m., the physician was unavailable. An IJ was identified on 06/01/15 at 4:00 p.m. and the Director of Nurses was informed. At 1:00 p.m. on 06/05/15, an interview was conducted with the interim Administrator. The Administrator stated that his first dated of employment was June 2, 2015 and that the last Administrator had left on May 26th. When asked how he monitored his staff to ensure the systems were effective, he stated that he makes rounds and watches and listens to the staff and the residents. When the interim Administrator was asked why he thought the IJ had occurred he stated that he had not interviewed the nurse that had made the medication error but had been informed that it was not her typical routine, she was not very familiar with this halls meds and that might have been a contributor. The facility's Plan of Removal, 4th draft dated 6/4/15 at 2:20 p.m. and reflected the following: 1. The residents that were identified to have had medication errors have been monitored for any adverse effects from medication errors and on-going monitoring will continue for 72 hours or per physician order. The residents ' physicians have been notified of medication errors. The families have been notified of the medication errors. The residents identified were assessed by a Registered Nurse and have not had any negative outcome at this time. 2. The Licensed Vocational Nurse that made the medication error was immediately re-educated by Director of Nursing on Medication Administration. A medication administration competency observation was done with the LVN by the ADON. Then the LVN was placed on suspension pending investigation by facility administration. Incident reports/Medication Error reports have been done on all of the medication errors. 3. On 6/1/15 the facility started immediate re-education of licensed nursing staff on Medication Administration following the policy on Medication Administration. Medication pass observations were started on 6/1/15. Medication Administration education with Medication Pass Observations were completed on 6/2/15 for all 9 licensed nurses who administer medications in the facility by the DON, ADON and Clinical Services Director. Additionally 1 certified medication assistant, who works as a certified nurse assistant, and 7 licensed nursing managers, which include 4 prn weekend RN supervisors, 1 DON, 1 ADON/nurse assessment coordinator and 1 admissions coordinator working in the facility by DON, ADON, and Clinical Services Director. Re-education focused on the following: a. Preparation for Medication Administration b. Safety and security guidelines (including minimizing interruptions during medication pass) c. Administering Medication, focusing on the 8 rights (right resident, drug, dose, time, route, charting, results and reason). d. Infection control with each route of medication administration (including nasal spray administration). e. Resident Rights and Dignity in terms of privacy and the Right to refuse. 4. Random Medication Administration audits have begun with licensed nursing staff by DON, Clinical Services Director and ADON. DON and ADON will continue with random audits to validate compliance and will continue 3 times each week for 1 month and then 1 time each week for 1 month. Audits will be presented to the Quality Assurance and Performance Improvement Committee monthly for tracking and trending until substantial compliance achieved. Any area of concern will be addressed at the time of discovery. At 1:30 p.m. on 06/05/15, an interview was conducted with the Director of Nursing. When asked how she monitored her staff to ensure the systems were effective, she stated that he makes rounds and watches and listens to the staff and the residents. When the DON was asked why she thought the IJ had occurred she stated that LVN A was nervous and Resident #16 ' s daughter had come to the medication cart and interrupted LVN A and LVN A gave her mother the wrong medication. Interviews from 1:00 p.m. until 2:30 p.m. on 6/5/15 with 9 of 9 nurses on duty reflected that LVN's and RN's had been trained on medication and administration with emphasis on preventing interruptions and Medication Pass competencies, medication errors. Interviews confirmed that the staff had been trained prior to resuming duties administering medications. Record review of the training roster revealed that 9 nurses had completed the training provided by the 6/1//15.Training included- Medication Pass, Controlled Substances-Accountability and Documentation, Ways to minimize med errors, and Medication Pass observation. Record review of the training revealed that 17 of 17 nurses had completed the training in- service and 17 of 17 had completed the medication pass observation. Record review of in-service record dated 6/1/15 revealed that 17 nurses had been in-serviced on Medication Administration Policy, and Medication Management- What You Need to Know. Record review dated 6/3/15 of in-service record for Resident Rights related to medication administration revealed 17 nurses had been in-serviced. Observation on 06/03/15 from 6:45 a.m. to 8:00 p.m. of the medication passes revealed 4 of 4 licensed staff competently performed the medication pass. On 6/5/15 at 2:11 p.m., the Administrator and DON were informed the IJ was removed. While the IJ was removed on 6/5/15 the facility remained out of compliance at a severity level of Actual harm that is not Immediate Jeopardy and a scope of isolated, because the facility was still monitoring the implementation of the Plan of Removal. On 6/5/15 The Director of Nursing said that 14 Resident receive medications on the South Hall.

Based on observation, interview and record review, the facility failed to ensure accurate administration of medications to meet the needs of each resident for five of sixteen (Resident ' s #16, 10, 17, 1 and 4) residents reviewed for pharmacy services. The facility failed to ensure: a) Resident # 16 was free of significant medication errors On 5/20/15 LVN A administered 7 medications prescribed for another resident to Resident #16. Resident #16's blood pressure dropped and the resident became very sleepy and required transfer to the emergency room for treatment of [REDACTED]. b) LVN A did not omit two of Resident #10's medications c) LVN A did not omit two of Resident #17's medications d) LVN B administered Klor-Con to Resident #1 according to the physician's orders [REDACTED]. e) LVN B administered nasal spray to Resident #4 according to the manufacturers ' specification and current standards of practice. An Immediate Jeopardy (IJ) was identified on 06/01/15. While the IJ was removed on 06/05/15, the facility remained out of compliance at a severity level of Actual harm that is not Immediate Jeopardy and a scope of isolated, because the facility was monitoring the implementation of the Plan of Removal. This failure to administer medications as ordered by the physician could affect the facility's 14 residents medicated by LVN A on South Hall, could place the 6 residents receiving nasal spray and 13 residents receiving Potassium (Klor-Con) at risk for a change in their condition, increasing their risk of infection, blindness and exacerbation of current health issues, development of new health issues, prolonged healing time and the possibility of hospitalization . Findings included: Resident #16's Admission record dated 04/07/15, reflected an admission date of [DATE] and a readmission date of [DATE]. The resident was a [AGE] year old female with [DIAGNOSES REDACTED]. Record review of Resident #16's MDS assessment dated [DATE] reflected she was alert and disoriented no behaviors, she was cognitively impaired. Resident #16 was also assessed as requiring extensive assistance by one staff for bed mobility, transfers, toileting and bathing, dressing and personal hygiene and for eating. Resident #16 had clear speech, was Spanish speaking only and was usually understood and could understand, she was able to follow commands. Record review of Physician orders [REDACTED].#16 had MEDICATION ORDERS FOR [REDACTED]. daily fluid for constipation and Tramadol 50 mg daily for pain. Record review of Medication Flow Sheet for Resident # 16 dated 04/01/15-4/30/15 revealed an order for [REDACTED].<95/65 mm/Hg. Documented B/P were as follows- 4/09/15- 162/64 4/23/15- 134/64 4/30/15- 128/68 Record review of Medication Flow Sheet for Resident # 16 dated 05/01/15-5/31/15 revealed an order for [REDACTED].<95/65 mm/Hg. Documented B/P were as follows- 5/07/15- 119/53 5/28/15- 128/78 Record review of Medication/Treatment Error investigation worksheet dated 5/20/15 3:00 p.m. entry revealed that at 8:15 a.m. LVN A administered the wrong medication to Resident #16. Resident #16 was given the following 7 medications; Vital signs after incident: blood pressure- 119/48 pulse 88 respirations 18. 1. Allegra D (fexofenadine HCL {antihistamine} 60 mg /pseudoephedrine 120 mg {nasal decongestant})1 tablet used for allergy & congestion. 2. Aspirin 81 mg chewable 1 tablet by mouth, used for coronary artery disease. 3. Norvasc 10 mg 1 tablet by mouth, used for hypertension (4 times the dose usual to the resident). 4. Lasix 40 mg by mouth used as diuretic. 5. Potassium Chloride 20 mg used as supplement. (Severe allergic reactions; black, tarry stools; chest pain; irregular heartbeat; listlessness; numbness or tingling in your skin, lips, hands, or feet; severe nausea or vomiting; stomach pain or swelling; confusion or anxiety; muscle weakness or paralysis; vomiting; weak or heavy legs) <http://www.drugs.com/sfx/potassium-chloride-side-effects.html> 6. Coreg 18 mg (beta-blocker) used for hypertension. 7. Tramadol 50 mg (narcotic-like) used to treat pain. In an interview on 6/1/15 at 2:25p.m., LVN A said It was breakfast time (approximately 8:15 a.m.) Resident #16's daughter brought Resident #16 up to the cart. The medication cart had a cup on it with Resident #16 ' s name on it. LVN A was popping out meds for another resident and Resident #16's daughter was talking to me and questioning me. I accidently gave Resident #16 the other resident's meds. I went and told the DON and I called the Hospice nurse, talked with the daughter who was still in the facility and we got Resident #16 shipped to the emergency room . Resident #16 was out of the facility a couple of hours and then returned with orders to monitor her vital signs for the next 6 hours; her blood pressure was a little low. We also held her medications and removed her Fentanyl patch. In an interview on 05/30/154 at 10:40 a.m., the Director of Nurse's said that LVN -A was setting up medications outside the dining room. Resident #16 and her daughter came to the medication cart .Resident #16 was in her wheelchair was being assisted by her daughter. The daughter interrupted the nurse and was asking questions about her mother ' s medication. The DON continued and said that she could see the nurse becoming tense and the DON tried to redirect the daughter. The DON said that she should have gone to the medication cart to see if she could help, but that she didn ' t. She said that she did not know why she had not. LVN-A turned the pages of her medication record and answered the questions for the daughter. LVN-A then gave the medications in the cup she was setting up to Resident #16. Resident #16 was administered another residents medications that included Allegra D, Norvasc 10 mg, Lasix 40 mg, potassium chloride 20 mg, Coreg 18 mg, Tramadol 50 mg and Aspirin 81 mg. The DON said that the resident & her daughter left the medication cart and return to the resident room. The DON said she had gone to her office and LVN-A came right away to report the incident. Resident #16 ' s vital signs were obtained approximately 10 minutes after the medication was taken and were 119/45 blood pressure 84-pulse, 93% oxygen saturation on room air, and at 8:30 a.m. they were 109/42 blood pressure and 85 pulse. Dr. A was notified by cell phone and the medications were discussed and the resident current low blood pressure and sleepy state. Plan was to send to the emergency room for fluid and blood pressure/telemetry monitoring. The DON said that she discussed the error with the daughter and the plan to send to the emergency room , and she was in agreement. The ambulance was called. The resident was transferred to the hospital. Resident # 16 returned to the facility by lunch time with orders to monitor her vital signs for 6 hours. Record review of the hospital emergency room record dated 5/20/15 revealed vital signs at 9:33 a.m. blood pressure 123/51, blood pressure at 9:53 a.m. 115/43 drowsy, at 9:50 a.m. blood pressure down to 106 systolic gave 500 ml bolus of normal saline, 10:45 a.m., more alert blood pressure now 112/37 and stable, a discharge [DIAGNOSES REDACTED]. Discharge instructions included monitor Glasgow coma scale and vital signs every hour for 6 hours. Record review of hospital telemetry vital signs on 5/20/15 at 9:30 a.m. B/P 110/37 HR 72 RR 7. Record review of hospital telemetry vital signs on 5/20/15 at 9:52 a.m. B/P 96/44 HR 74 RR 10. Record review of hospital telemetry vital signs on 5/20/15 at 10:00 a.m. B/P 115/43 HR 69 RR 10. Record review of hospital telemetry vital signs on 5/20/15 10:19 a.m. B/P 120/44 HR 72. Record review of hospital telemetry vital signs on 5/20/15 10:20 a.m. B/P 120/44 HR 74. Record review of the Physician telephone order dated 5/20/15 at 12 noon (upon Resident #16's return from the hospital) revealed orders for the following: Vital signs every 1 hour for 6 hours. Hold Norvasc if B/P <120/60. Hold Lisinopril if B/P < 120/60. Contact provider if Norvasc or Lisinopril held 2 doses in a row. Record review of Medication Flow Sheet for Resident # 16 dated 5/01/15-5/31/15 revealed an order for [REDACTED].<95/65 mm/Hg. B/P - (no time or date) in a margin scribbled on the record were the following B/P: 105/56, 138/58, 142/68, 120/40, 131/45, 143/63. In an interview on 6/1/15 at 2:25p.m., when shown the above record, LVN A said that those were the vital signs ordered every hour after Resident # 16 returned to the facility on [DATE]. When questioned about the parameters, LVN A said she did not call the physician because he already knew the vital signs were low. Attempts were made to contact the emergency room Physician on 06/04/15 at 2 p.m. and 4 p.m., the physician was unavailable. Record Review of Resident #10's Admission Record dated 5/5/2015 revealed that he was admitted to the facility on [DATE], is [AGE] years old and has [DIAGNOSES REDACTED]. During an observation of a Medication pass on 06/01/15 at 2:00p.m. with LVN A, it was noted that Resident #10 had 2 medications scheduled for 2 p.m. and the medications had not been administered. The omitted medications were Calcium 600 mg + D 200 units 1 tablet 3 times a day and Gabapentin 600 mg 1 tablet 3 times a day. In an interview on 06/01/15 at 3:30 p.m. LVN A was questioned about Resident #10 ' s medication , LVN A said I must have missed them. Record Review of Resident #17's Admission Record dated 7/5/14 revealed that she was admitted to the facility on [DATE], is [AGE] years old and has [DIAGNOSES REDACTED]. During an observation of a Medication pass on 06/01/15 at 2:00 p.m. with LVN A, it was noted that Resident #17 had 2 medications scheduled for 2 p.m. that had not been administered. The medications were Cosopt 2- 0.5 % one drop in right eye 3 times a day, FreshKote 2-0.9% one drop in right eye 3 times a day. When shown the MAR indicated [REDACTED]. Review of Resident #1's face sheet, undated, revealed a [AGE] year old male admitted on [DATE] and readmitted on [DATE] with Diagnoses: [REDACTED]. In an observation on 6/2/15 at 7:20 a.m., LVN B administrated Resident #1 ' s Klor-Con 20 milliequivalent with approximately 3 oz. water and without offering food. Review of Resident #1's Consolidated Physician Order, dated 06/01/15 through 06/30/15 indicated Resident #1 had Klor-Con M20 (potassium chloride) Tab Sustained Release Particle/Crystal: 20mEq; amount 1 tab; Oral Special Instructions: **Give w/food and 4-8 oz. of water** BID-Twice a Day; 8:00 am and 5:00 pm. Klor-Con (potassium chloride) is used to prevent or to treat low blood levels of potassium ([DIAGNOSES REDACTED]).Klor-Con Dosage and Administration: To take each dose with meals and with a full glass of water or other liquid. www.drugs.com/pro/klor-con.html <http://www.drugs.com/pro/klor-con.html>. In an observation on 6/2/15 at 8:15 a.m., Resident #1 remained in the hall sitting up in his wheelchair. In an interview on 6/2/15 at 8:15 a.m., Resident #1 stated that they will bring my breakfast in a while. In an interview on 6/3/15 at 7:20 a.m., LVN B acknowledged Resident #1 received Klor-Con 20 mEq one tablet. LVN A said she that she should have offered him a snack or waited until he ate his breakfast and got him to drink a full cup of water. In an interview on 6/3/15 at 8:15 p.m., the DON stated that the nurse should have offered a snack or given the medication after he ate his breakfast and with more fluids. Review of the facility's policy, Medication Management Program, Complete Revision: 9/2011 but revised 02/2015-4/1/15, indicated, in part: C. If ordered with food administers the medication during the meal or with 4-8 ounces of semi-solid food. D. Always follows pharmacy and/or manufacturer ' s specifications. F. Offers 6-8 ounces of fluid, unless fluids are restricted. Review of Resident #4's face sheet, undated, revealed an [AGE] year old female admitted on [DATE] with Diagnoses: [REDACTED]. In an observation on 6/3/15 at 7:15 a.m., LVN B administrated Nasacort Allergy 24 (Flonase) nasal spray two puffs each nostril to Resident #4. LVN B asked the resident if she wanted to do the nasal spray herself or if she wanted the nurse to administrate the nasal spray. The resident asks the nurse to do it. LVN B then administrated the nasal spray without having resident blow her nose before and with no instruction to the resident. Flonase is a nasal spray containing fluticasone. Fluticasone is corticosteroid that prevents the release of substances in the body that cause inflammation. www.drugs.com/pro/flonase.html <http://www.drugs.com/pro/flonase.html> Review of Resident #4's Consolidated Physician Order, dated 06/01/15 through 06/30/15 indicated Resident #4 had Flonase (fluticasone) spray, suspension: 50 mcg/actuation: amount: 2 puffs each nostril: one a day: 08:00 a.m. In an interview on 6/3/15 at 7:20 a.m. LVN B stated that she should have had the resident blow her nose before she administers her nose spray. She stated that she should have told her to take a deep breath as she administered the medication. In an interview on 6/3/15 at 8:05 p.m., the DON stated that she was not aware that they needed to have resident blow nose before administering nasal spray. She stated that they are to instruct the resident to breathe in as they administer the spray. Review of a Drug Information Leaflet, provided by DON on 6/3/15 at 5:00 p.m. advises the following: How to use your Nasal Spray: Using the Spray; 3. Blow your nose to clear your nostrils; 4. Close one nostril; 5. Start to breathe in through your nose, and while breathing in press firmly .; 6. Breathe out through your mouth; Record Review on 6/4/15 at 5:00 p.m., provided by DON Potter and Perry guidelines for nasal instillations. Chapter 31 Medication Administration; Box 31-16 Procedural Guidelines 14. Instruct patient to clear or blow nose gently 16. Administer nasal spray c. Have patient spray medication into the nose while inhaling. Record review of the Facility ' s Medication Administration policy dated 4/1/14 revealed- Purpose - to administer the following: Right patient/Resident, Right drug, Right dosage form, Right time, Right route, Right charting, right results, and right reason. An IJ was identified on 06/01/15 at 4:00 p.m. and the Director of Nurses was informed. At 1:00 p.m. on 06/05/15, an interview was conducted with the interim Administrator. The Administrator stated that his first dated of employment was June 2, 2015 and that the last Administrator had left on May 26th. When asked how he monitored his staff to ensure the systems were effective, he stated that he makes rounds and watches and listens to the staff and the residents. When the interim Administrator was asked why he thought the IJ had occurred he stated that he had not interviewed the nurse that had made the medication error but had been informed that it was not her typical routine, she was not very familiar with this halls meds and that might have been a contributor. The facility's Plan of Removal, 4th draft dated 6/4/15 at 2:20 p.m. and reflected the following: 1. The residents that were identified to have had medication errors have been monitored for any adverse effects from medication errors and on-going monitoring will continue for 72 hours or per physician order. The residents ' physicians have been notified of medication errors. The families have been notified of the medication errors. The residents identified were assessed by a Registered Nurse and have not had any negative outcome at this time. 2. The Licensed Vocational Nurse that made the medication error was immediately re-educated by Director of Nursing on Medication Administration. A medication administration competency observation was done with the LVN by the ADON. Then the LVN was placed on suspension pending investigation by facility administration. Incident reports/Medication Error reports have been done on all of the medication errors. 3. On 6/1/15 the facility started immediate re-education of licensed nursing staff on Medication Administration following the policy on Medication Administration. Medication pass observations were started on 6/1/15. Medication Administration education with Medication Pass Observations were completed on 6/2/15 for all 9 licensed nurses who administer medications in the facility by the DON, ADON and Clinical Services Director. Additionally 1 certified medication assistant, who works as a certified nurse assistant, and 7 licensed nursing managers, which include 4 prn weekend RN supervisors, 1 DON, 1 ADON/nurse assessment coordinator and 1 admissions coordinator working in the facility by DON, ADON, and Clinical Services Director. Re-education focused on the following: a. Preparation for Medication Administration b. Safety and security guidelines (including minimizing interruptions during medication pass) c. Administering Medication, focusing on the 8 rights (right resident, drug, dose, time, route, charting, results and reason). d. Infection control with each route of medication administration (including nasal spray administration). e. Resident Rights and Dignity in terms of privacy and the Right to refuse. 4. Random Medication Administration audits have begun with licensed nursing staff by DON, Clinical Services Director and ADON. DON and ADON will continue with random audits to validate compliance and will continue 3 times each week for 1 month and then 1 time each week for 1 month. Audits will be presented to the Quality Assurance and Performance Improvement Committee monthly for tracking and trending until substantial compliance achieved. Any area of concern will be addressed at the time of discovery. At 1:30 p.m. on 06/05/15, an interview was conducted with the Director of Nursing. When asked how she monitored her staff to ensure the systems were effective, she stated that he makes rounds and watches and listens to the staff and the residents. When the DON was asked why she thought the IJ had occurred she stated that LVN A was nervous and Resident #16 ' s daughter had come to the medication cart and interrupted LVN A and LVN A gave her mother the wrong medication. Interviews from 1:00 p.m. until 2:30 p.m. on 6/5/15 with 9 of 9 nurses on duty reflected that LVN's and RN's had been trained on medication and administration with emphasis on preventing interruptions and Medication Pass competencies, medication errors. Interviews confirmed that the staff had been trained prior to resuming duties administering medications. Record review of the training roster revealed that 9 nurses had completed the training provided by the 6/1/15.Training included- Medication Pass, Controlled Substances-Accountability and Documentation, Ways to minimize med errors, and Medication Pass observation. Record review of the training revealed that 17 of 17 nurses had completed the training in- service and 17 of 17 had completed the medication pass observation. Record review of in-service record dated 6/1/15 revealed that 17 nurses had been in-serviced on Medication Administration Policy, and Medication Management- What You Need to Know. Record review dated 6/3/15 of in-service record for Resident Rights related to medication administration revealed 17 nurses had been in-serviced. Observation on 06/03/15 from 6:45 a.m. to 8:00 p.m. of the medication passes revealed 3 of 4 licensed staff competently performed the medication pass. On 6/5/15 at 2:11 p.m., the Administrator and DON were informed the IJ was removed. While the IJ was removed on 6/5/15 the facility remained out of compliance at a severity level of Actual harm that is not Immediate Jeopardy and a scope of isolated, because the facility was still monitoring the implementation of the Plan of Removal. According to a list of residents who have orders for medications to be given with food received from the ADON on 6/5/15, there are 13 residents with orders for Potassium (Klor- Con), 6 residents with orders for nasal spray and 14 residents that receive medications on the South Hall.

Based on observation, interview, and record review the facility failed to ensure that a resident with pressure ulcers received the necessary treatment and services to promote healing, and prevent new pressure ulcers from developing for one of two residents (Resident #7) reviewed for pressure ulcers as evidenced by: 1. Resident #7 developed an unstageable pressure ulcer to her right heel. 2. Resident #7 developed an unstageable pressure ulcer to her left heel. 3. Resident #7 developed an abrasion to her right calf. Findings include: Review of Resident #7 ' s " Resident Admission Record " revealed she was a [AGE] year old female admitted to the facility 12/26/12. Review of Resident #7 ' s " Physician order [REDACTED]. Review of Resident #7 ' s " Admission/Readmission Data Collection Tool " dated 12/26/12 revealed, " ...Reddened area/blanchable-coccyx ...bruising right shin and right great toe ... " Review of Resident #7 ' s " Admission/Readmission Data Collection Tool " dated 12/26/12 revealed the " Braden Scale for Predicting Pressure Sore Risk " score of 14. " ...Total score of 18 or below is considered a risk of developing pressure ulcers ... " Review of Resident #7 ' s admission MDS dated [DATE] revealed she needed extensive assistance for transfers, dressing, eating and hygiene, and had two Stage I pressure ulcers with [MEDICATION NAME] tissue. Review of Resident #7 ' s " Comprehensive Plan of Care " dated 12/26/12 revealed a Stage I to her right heel. The care plan was updated 01/06/13 and revealed a Stage II to her right heel. Review of Resident #7 ' s " Comprehensive Plan of Care " dated 01/16/13 revealed a Stage II to her left heel. Review of Resident #7 ' s " Physician order [REDACTED]. Review of Resident #7 ' s " Nurse ' s Notes " dated 12/27/12, 01/11/13, 01/12/13, 01/16/13, 01/17/13, 01/18/13, 01/19/13, 01/20/13, 01/22/13 and 01/31/13 revealed: 12/27/12, 7:00 a.m., " ...heels floated... Stage I to right heel and coccyx... " 01/11/13, 11:00 a.m. " Stage II fluid filled blister to right heel ruptured..." Podus? boots (Multi-purpose foot boot helps in the healing and prevention of heel and toe ulcers and safeguards against foot drop. http://www.posey.com/Products/Posey-Deluxe-Podus-Boot) in place ... " 01/12/13 3:15 a.m., " ...Podus? boots in place ... " 01/16/13, 1:00 p.m., " Stage II fluid filled blister to left heel. NS cleanse and apply [MEDICATION NAME] cream and dress with loose gauze ...Podus? boots in place ... " 01/17/13, 4:00 a.m., " Podus? boots on last night ...boots on to decrease further incidence of skin breakdown. " 01/17/13, 10:00 p.m., " Podus? boots in place ... " 01/18/13, 6:00 p.m., " Resident ' s right heel noted with 3.5 cm by 3.0 cm necrotic area in middle of Stage II-surrounding area is red and blanchable ...Podus? boots in place ... " 01/19/13, 4:00 a.m., " Podus? boots in place to BLE (bilateral lower extremities) ... " 01/19/13 7:45 a.m., " Podus? boots in place to BLE ... " 01/19/13, 3:15 p.m., " ...Podus? boots in place ... " 01/20/13, 3:15 a.m., " ...Podus? boots in place ... " 01/22/13 2:00 p.m., " Abrasion noted to right lower calf. Appears to be from Podus? boot strap- NS cleanse and apply foam dressing. Podus? boots removed and lower extremities elevated on pillow ... " 01/31/13 at 2:00 p.m., " Late entry at 10:30 a.m.-Stage II P.U. (pressure ulcer) to left heel noted 1.5 cm by 3.0 cm necrotic area changed classification to unstageable ... " Review of Resident #7 ' s " Telephone Orders " dated 01/11/13 revealed, " Stage II P.U. right heel- NS cleanse, apply [MEDICATION NAME] and 4x4 ' s with Kerlix Q.D. (every day). Podus? boots to bilateral feet. " Review of Resident #7 ' s " Telephone Orders " dated 01/16/13 revealed, " Stage II fluid filled blister, NS cleanse, apply [MEDICATION NAME] cream and dress with loose gauze QD to left heel. " Review of Resident #7 ' s " Telephone Orders " dated 01/18/13 revealed, " Change right heel P.U. to unstageable ... " Review of Resident #7 ' s " Telephone Orders " dated 01/22/13 revealed, " Change right heel drsg to [MEDICATION NAME]? Q 3-7 days and prn (as needed). Abrasion to right lower calf- NS cleanse and apply foam drsg Q (every) 1-5 days. " Review of Resident #7 ' s " Telephone Orders " dated 01/23/13 revealed, " DC (discontinue) Podus? boots. " Observation on 01/31/13 between 9:00 a.m. and 9:45 a.m. revealed Resident #7 sitting in her geri chair in her room. Resident #7 ' s calves were on a pillow. Resident #7 was noted to have dressings covering both feet from above her ankles down to the middle of her feet. The treatment nurse removed the dressings to provide wound care. Resident #7 ' s left heel was noted to have an opened blistered area approximately 3.5 cm by 4.5 cm. The center of the area was purple. The treatment nurse cleaned the wound with normal saline and applied [MEDICATION NAME] cream and a gauze dressing. Observation on 01/31/13 between 9:00 a.m. and 9:45 a.m. revealed the treatment nurse to remove the gauze dressing from Resident #7 ' s right heel. Resident #7 ' s right heel had a black area approximately 3.5 cm by 3.0 cm. The surrounding skin of approximately 3.5 cm by 3.5 cm was a dark red color. Observation on 01/31/13 between 9:00 a.m. and 9:45 a.m. revealed the treatment nurse to remove the dressing from Resident #7 ' s right calf. There was an open round area approximately 1.6 cm by 2.4 cm. In an interview with the treatment nurse on 01/31/13 at 9:00 a.m. it was revealed that Resident #7 did not have any skin breakdown on admission except for a stage I to her coccyx, which had healed. The Podus? boots had been applied at the facility to Resident #7 ' s lower extremities for pressure relief but caused Resident #7 ' s heels to break down and they looked worse than they had before. The wound on Resident #7 ' s right calf was from the Podus? boot strap rubbing on the right calf. Resident #7 had the Podus? boots on except for during showers and the staff checked her skin every shift. In an interview with the DON on 01/31/13 at 10:45 a.m., it was revelaed that Resident #7 had Podus? boots applied to help relieve heel pressure. The Podus? boots were discontinued because they were heavy and caused an abrasion to Resident #7 ' s right calf. The Podus? boots were ordered 01/11/13 and discontinued 01/23/13. Resident #7 ' s legs rotated outward while in the Podus? boots, causing the abrasion. In an interview with the DON on 01/31/13 at 11:30 a.m., it was revealed that Resident #7 ' s Podus? boots were left on after her right heel blister opened on 01/18/13 until 01/23/13. The staff did not realize that Resident #7 ' s heel was sliding out of the side of the boot and putting pressure on her heel. Shearing from the Podus? boot strap caused the open area on the back of Resident #7 ' s right calf. In an interview with the treatment nurse on 01/31/13 at 12:35 p.m., it was revealed that Resident #7 ' s feet sliding out of the boot caused the pressure ulcers. When asked by the surveyor, the treatment nurse did not know what the bar on the back of the Podus? boot ' s function was or how to use the bar. The treatment nurse said she had been trained by the previous treatment nurse. All licensed nurses were taught how to use the Podus? boot. The licensed nurses were supposed to check residents ' skin under the boot every shift. The CNA's were taught to use the Podus? boot and remove them for bathing. She said she had never seen a package insert for Podus? boots. Review of " Podus Boot Instructions " provided by the DON on 02/01/13 at 11:30 a.m. revealed, " Indicated to help prevent excessive heel pressure ...Anti-rotation bar assists with control of leg rotation. To adjust: Loose knob sufficiently to allow bar to rotate-do not remove. Move bar to desired side retighten knob ...Closely monitor condition of skin. If redness or skin irritation persists discontinue use ...Single patient use. To be used only when ordered by a physician and applied by a qualified professional ... " In an interview with the DON on 02/01/13 at 1:45 p.m., it was revelaed that staff had not had official training on the use of Podus? boots. None of the staff knew about the anti-rotation bar on the boot. There was nothing in writing about the use of the Podus? boot. The facility ' s policy was that if a wound had no progress in 2-4 weeks, the treatment was to be modified. . Resident #7 ' s heels were now being floated, and she no longer had the Podus? boots on. Review of additional information on use of the Podus? boot revealed, " ...Warning: Be sure to follow your facility ' s policies and guidelines for frequency of patient monitoring. Posey recommends that this product be removed at least every two hours to check for skin integrity, proper circulation and range of motion ...Application instructions: ...Carefully position the foot down into the splint. The sole of the foot must be flat against the liner of the splint. The back of the leg at the calf area must fit snugly against the top and back of the splint for proper fit. Ensure that the heel is completely suspended in the open curve of the splint and that the foot is flat against the liner of the splint ...verifying that a finger can be inserted between the heel and the splint for adequate heel clearance ... " (www.posey.com) In an interview with CNA A on 02/01/13 at 11:10 a.m., it was revealed that CNA A said Resident #7 had a red spot on one heel on 01/04/13. She had been off work for about two weeks, and when she returned, Resident #7 ' s left heel looked worse, like an open blister. She never removed the Podus? boot because the hospice aides bathed Resident #7. In an interview with LVN A on 02/01/13 at 11:25 a.m., it was revealed that Resident #7 ' s Podus? boots were put on in the morning or were on when she started her shift at 6:00 a.m., she was not sure. She would pick up Resident #7 ' s feet after meals because they would fall off the geri chair. She was trained on using the Podus? boot as a CNA, but had been a nurse for about a year. The hospice aides took the boots off for showers. Resident #7 had a red spot on her heel when she did a treatment one day earlier in the month. Resident #7 ' s wounds looked worse than before. In an interview with CNA B on 02/01/13 at 11:40 a.m., it was revelaed that Resident #7 ' s heels looked worse now than previously. Resident #7 used to have Podus? boots on, but now had her heels floated and dressings on her heels. She had training on using the boots, but could not remember when. When Resident #7 is transferred from bed to chair or chair to bed, it made her " cringe " and said it " looks like it ' s gonna hurt " when Resident #7 ' s " heels were dragged across the bed " . She did not know what the bar on the Podus? boot was used for. In an interview with the treatment nurse on 02/01/13 at 12:45 p.m., it was revealed that Resident #7 was admitted with areas being watched. Resident #7's right heel turned into a Stage II blister on 01/06/13. On 01/18/13, Resident #7 ' s right heel became necrotic. A clear blister was noted on Resident #7 ' s left heel on 01/16/13. During this time, Resident #7 was wearing the Podus? boots. The boots were removed for showers, clothing changes and skin checks that were done every shift. The boots were removed because Resident #7 ' s heels were worsening and the Podus? boots were not staying on. Resident #7 ' s heels turned and came out of the Podus? boots, and that the heels touched the surface of the chair or bed. The Podus? boots should have been discontinued when staff realized the boots were not staying on right. Resident #7 ' s feet slid out of the boot. She said Resident #7 ' s heels looked worse. Resident #7 ' s left heel blister came up overnight and that she " was shocked " . The treatment for [REDACTED]. On 01/18/13, Resident #7 ' s left heel had too much drainage to use Xeroform, so the treatment was changed to using Hydrogel and [MEDICATION NAME] on 01/24/13. She would have taken Resident #7 ' s Podus? boots off earlier if she had known the resident ' s heels would have gotten so bad. Review of Resident #7 ' s " Weekly Skin Documentation " revealed the following: 01/04/13: " ...Skin is not intact. Stage I P.U. right heel. Stage I P.U. left buttock ... " 01/11/13: " ...Skin is not intact. Stage II P.U. right heel. Stage II P.U. left buttock. Bruising BLE ... " 10/18/13: " ...Skin is not intact. Stage II P.U. right heel. Stage I left buttock. Excoriation to buttocks. Bruising BLE ... " 01/26/13: " ...Decub (decubitus) right and left heels. Excoriation buttocks. Review of Resident #7 ' s " Wound Treatment and Progress Record " revealed the following: 12/26/12: " ...Stage I P.U. left buttock. NS cleanse and apply [MEDICATION NAME] cream QID (four times daily) ... " 01/16/13: " ...Stage II fluid filled blister to left heel-apply [MEDICATION NAME] paste and dress with loose gauze QD... " 01/17/13: " ...Stage II P.U. 3.5cm by 4.5 cm fluid filled blister ... " No location for the blister was listed. 01/22/13: " ...Unstageable P.U. right heel- NS cleanse and apply [MEDICATION NAME] Q 3-7 days and prn ... " 01/24/13: " ...Unstageable P.U. right heel- NS cleanse and apply Hydrogel to necrotic area and [MEDICATION NAME] to surrounding area ... " 01/25/13: " ...Stage II P.U. 3.5 cm by 4.5 cm fluid filled blister ... " No location for the blister was listed. 01/31/13: " ...Unstageable P.U. to left heel- NS cleanse and apply non-adhesive foam and wrap with Kerlix Q.D ... " Review of the facility ' s policy, " Wound Care Policies and Procedures Reference " dated 12/11 revealed, " If a pressure ulcer/wound does not show some evidence of progress towards healing in 2-4 weeks, the pressure ulcer/wound and the resident ' s overall condition should be reevaluated ...Stage II: " ...1. Relieve pressure to the area either through a turning schedule, or elevation of the area. Any device used on an extremity to elevate or protect (e.g. braces), needs to be applied in a manner as to not cause additional injury. Consult manufacturer ' s guidelines ..." CMS 672 dated 01/30/13 revealed two resident with pressure ulcers.