Every finding on record at West Gables Health Care Center

Based on observation and interviews and record review, the facility failed to ensure that emergency bathroom call-light systems were properly installed, maintained, and accessible to residents to prevent accidents and ensure timely assistance for three rooms (Wing A (North) room [ROOM NUMBER] and 428, and Wing D (East), room [ROOM NUMBER]) out of sixty rooms on the facility's 4th floor. As evidenced by missing toilet-side emergency call-light cord in room [ROOM NUMBER] and missing shower call-light cords in rooms [ROOM NUMBERS]. This deficient practice significantly increased the risk of potential accidents and injuries. Fifty-four residents resided in the facility at the time of the survey. The findings include. Observations during the environmental tour on 12/22/2025 revealed the emergency shower call-light cords were missing in the bathrooms of the 4th Floor, Wing A (North) rooms [ROOM NUMBERS], and Wing D (East), room [ROOM NUMBER]. In room [ROOM NUMBER], the toilet-side emergency call-light cord was missing, and the shower call-light cord was across the bathroom doorway, crossing over from the shower side to the toilet side. (Photographic evidence)On 12/22/2025 at 12:16 PM, Staff A Certified Nursing Assistant (CNA) acknowledged that they had crossed over the call-light cord from the shower side to the toilet side and was unaware of the reason behind its position, assuming it had been moved so the resident could reach it while using the toilet. On 12/22/2025 at 1:07 PM, The Maintenance Director reviewed photographic evidence and toured the affected rooms, noting that the toilet call-light cord in room [ROOM NUMBER] had been ripped off. He confirmed that additional rooms (rooms [ROOM NUMBERS]) were missing shower call-light cords and required immediate repair.On 12/22/2025 at 2:50 PM, the Director of Nursing (DON), revealed she was not aware the toilet call-light cord in room [ROOM NUMBER] had been ripped off and rooms [ROOM NUMBERS] were missing shower call-light cords and acknowledged the condition was hazardous.The facility's undated Policy and Procedures state in item 4-A: The call system is accessible to residents in each toilet, bath, or shower facility, including when a resident is lying on the floor.

Based on observations, interviews and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety as evidenced by kitchen staff (Cook) not wearing a beard restraint while in the kitchen assisting with food services. There were 53 residents who ate by mouth residing in the facility at the time of survey. The findings included: Record review of the facility's policy titled Food and Nutrition dated 4/1/2015 revised 1/1/2021 indicate-Policy: Defines Food Service personnel standards regarding personal hygiene. Procedure: 7. Wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that cover all hair, including body hair. Wearing false eyelashes is not permitted, as they may become a physical contaminant. Observation on 09/10/25 at 11:04 AM during the kitchen tour revealed Staff A (Cook) pushing a cart in the kitchen. He wore a surgical mask and a hat, and parts of his beard was visible. When asked about the beard net, he stated, I don't wear a beard net because it makes me allergic. He then walked to the back of the kitchen, took off the mask, and put on a beard net. On 09/10/25 at 11:09 AM, the Kitchen Director stated, I have been the Director for a month. Anyone who enters the kitchen is required to wear a hairnet or beard net. Wearing a mask as opposed to the beard net is acceptable. Interview on 09/10/25 at 2:51 PM Staff A, stated: I have been The [NAME] for 18 years. I have received in-service about wearing hairnets and beard nets. The purpose of wearing it is to prevent contamination of the food and any possible infection transmission. It is appropriate to wear a mask and not a beard net if it is clean and covers my beard. The reason I did not wear a beard net is because it causes allergies and brings Asthmatic episodes. I reported my allergy to my previous supervisor, and he told me it was fine to wear a mask as long as my mouth and beard are covered.On 9/10/25 at 4:38 PM the Kitchen Director stated, I was aware that Staff A, [NAME] had an allergy to the beard restraint. If a mask is worn; that covers facial hair it is ok. I believe the mask prevents any hair from falling into the food.On 9/10/25 at 4:42 PM, the Administrator was notified about identified concern and stated, It is okay to wear the mask to prevent any hair from falling into the food.On 09/11/25 at 2:38 PM The Registered Dietician stated, I have been employed for about a year. I do rounds in the kitchen that include sanitation audits, expiration dates, temperature logs, and storage. I observe the passing of the trays on the floors to ensure all supplements and diet orders are correct. I looked at the vents and noticed condensation and the employee wiped the vents. Before entering the kitchen, hair nets, hats, beard guards and sanitize hands.

Based on observations records reviewed and interviews the facility failed to ensure a safe homelike environment, as evidenced by water dripping from ceiling and vents on the facility's fourth floors Wing A, D into large bins, one of the five bins was noted blocking the hallway; there was water on the floor next to the bin in front of the nurse's station closest to the elevator .This deficient practice increases the risk for safety hazard due to potential slip and fall accidents that could lead to injuries. There were 53 residents residing in the facility at the time of the surveys. The findings include. Observations on September 09, 2025, at 10:59 AM on the 4th floor near the elevator, there were dark brown stains on the ceiling tiles. The stains looked like watermarks and were about 3x5 inches, 1x3 inches, and 1x½ inch in size. One ceiling tile with a security camera was sagging and not in place correctly. (Photographic evidence) On 9/9/2025 at 11:18 AM, in Wing A, North hallway, 13 ceiling tiles near the Wi-Fi router had dark brown stains that looked like watermarks (Photographic evidence) Observation on 9/9/2025 at 11:20 AM, in Wing D, East hallway, water was on the floor. A large yellow bin was placed in the hallway to catch water dripping from the ceiling. (Photographic evidence) Observation on 9/9/2025 at 11:21 AM, in the North hallway, water was also on the floor. Another large yellow bin was catching water. A second bin was at the nurse's station doing the same. (Photographic evidence) Observation on 09/09/2025 at 11:22 AM, in Wing B, East hallway, water droplets (condensation) were seen on the ceiling. Observation in 09/9/2025 at 12:10 PM, water damage and a black substance were seen around the edges of the air vents near the wall on the fourth floor. (Photographic evidence) Observation on 09/09/2025 at 2:43 PM revealed ceiling tiles that were replaced had new watermarks were already forming on them. (Photographic evidence) Observation on 09/10/2025 at 10:56 AM, revealed the ceiling tiles near the elevator that were replaced the day before now had new watermarks that were getting bigger. (Photographic evidence) Interview on 09/10/25 at 11:09 AM, the Kitchen director was asked about the condensation dripping onto tray line; he stated: I have been the director for a month. I recently noticed that condensation forming and dropping onto the tray line more this week due to the rain and we have been wiping the vent with cloth. We kept the tray line in the same position because we thought we could control the dripping with wiping. I informed the Maintenance department before this week, and they came looking at it informed us it was due to the machines and weather. We noticed the dripping on Monday, and we didn't know the vent could be moved until maintenance moved it yesterday from above tray line. On 9/10/2025 at 11:11 AM, the Kitchen Director showed a clean green cloth used to wipe the water. On 09/11/25 at 2:38 PM The Registered Dietician stated, I have been employed about a year. I do rounds in the Kitchen that include sanitation audits, expiration dates, temperature logs, and storage. I observe the passing of the trays on the floors to ensure all supplements and diet orders are correct. I have looked at the vents and noticed condensation and the employees wipe the vents. On 09/11/25 at 2:57 PM Staff C, Licensed Practical Nurse stated: I noticed dripping from the vents in July in the hallways and a resident's room when it rains. I notified the Maintenance or Administration. Ensure the safety of the residents by making sure no residents are in the area. On 09/11/25 at 1:45 PM Staff B, Certified Nursing Assistant stated, Today I noticed there are buckets to catch the dripping from vents. I haven't seen any water on the floors. I asked other staff why the buckets were there, and they informed me water was dripping from the vents. On 9/11/25 at 3:05 PM, the Environmental Service Supervisor stated, I check the fourth floor three times a day. I check the floors, walls and A/C Vents. When I check the vents, I ensure there is no dust. While checking the vents last week was the first time, I noticed condensation and dripping from the vents in the hallways and I reported to the Plant of Operation who is the Maintenance Director and my staff cleaned the vents with microfiber towels. I did not log the vent observation and cleaning. On 9/11/25 at 3:12 PM: the Director of Plant Operations stated, I am responsible for repairing any machinery. I noticed last week that there were condensation and dripping coming from the vents in kitchen last week due to the rain. This is caused by the high humidity coming into a cold place that causes condensation. I called the company that fixed our a/c to come and see why there is so much humidity and condensation in the vents. They came yesterday and informed us that there is a lot of air exchange and humidity into the building due to the opening and closing of the elevator doors. We have three elevator shafts because the hot air is getting caught in the shaft and bringing it to each floor. The kitchen would be affected due to the hot machinery inside and I moved some of the vents in the kitchen this week to avoid water from falling on the tray line. Some of the vents were moved last week but we didn't notice the vent directly over the tray line was dripping so much until this week. On 9/11/25 at 3:26 PM, the Surveyor showed the Director of Plant Operations a black stain observed around the vent in the dining area where residents have activities and meals. The Director of Plant Operations revealed that it could be caused by water dust or mildew. On 09/11/25 at 3:41 PM, the Maintenance Director stated, I first noticed condensation and dripping from the vents in the hallways about a month or two ago. The heat and the humidity determine how much condensation. When I noticed The Director of Plant Operations. I placed buckets and cones under the vents that had condensation. I have not received any reports of condensation or dripping in residents' rooms. I replaced the ceiling tile on front of the elevator due to condensation. I cleaned the vents in the dining room last month. On 09/11/25 at 3:36 PM, the Administrator stated: I do frequent rounds with Maintenance. The condensation varies depending on the weather; the frequency of the use of the elevator can cause an increase due to the shaft.

Based on records reviewed and interview, the facility failed to accurately code the Minimum Data Set (MDS) for one resident (Resident #49) out of four residents reviewed for discharges. As evidenced by Resident #49 was discharged home but the MDS coded the resident was discharged to a short-term general hospital. hospital. The findings included: Record review of admission records revealed Resident #49 was admitted to the facility on [DATE] and discharged home on 04/04/202. Record review of Resident # 49's medical records revealed the resident's diagnoses included, but not limited to, muscle wasting and atrophy and depression. Review of the resident's Care Plan initiated on 2/13/2024, Next Review Date 04/14/2024 documented that the resident is at a facility for short term skilled rehab; and plan to discharge to home with supportive care services. Record review of progress notes dated 3/12/2024 13:45 documented in the Discharge Summary: Patient with new order to be discharged home. Patient and family members that were present at the time of teaching verbalized understanding of discharge instructions received from the nurse. Record review of Section C of the MDS for cognitive pattern dated 03/12/2024 revealed the Brief Interview for Mental Status Summary score was 15 out of 15 to suggest the resident is cognitively intact, Record review of the MDS section for Discharge Return Not Anticipated dated 03/12/2024 revealed in Sections A-Identification Information indicated the resident was discharged to a Short-term General Hospital. During an interview on 04/30/24 at 12:54 PM the MDS Coordinator was asked about the coding concerns. The MDS Coordinator stated: Oh, oh, I just realized, it was a mistake, I will correct it immediately.

Based on record review and interview, the facility failed to ensure a level one Pre-Admission Screening and Resident Review (PASRR) was revised following admission for one resident (Resident #7) out of 17 sampled residents. There were 58 residents residing in the facility at the time of the survey. The findings Included: During multiple observations starting on 04/29/2024 to 05/02/2024, Resident #13 was observed in the room in bed or seated in a geriatric chair the resident was noted receiving enteral nutrition running at 50 Milliliters per hour (ml/hr.) with water flush of 40 ml/hr. Record Review of Resident #7's most recent Level I PASRR dated 11/15/2022 documented in Section I: PASRR Screen Decision Making: A: Mental Illness (MI) or suspected MI (check all that apply) - other-insomnia. Findings based on documented history were-Section II Other indicators for PASARR screening Decision-Making: All checked - no. Does individual have validating documentation to support dementia or related neurocognitive disorder - no. Section III Not a provisional admission. Section IV. No diagnosis or suspicion of Serious Mental Illness (SMI) or Intellectual Disability (ID) indicated. Level II PASRR evaluation not required. PASRR Level I was completed by the Social Service Director at the facility on 11/15/2022. Review of the Clinical Documentation Physician Query Form dated 01/09/2024 documented: Based on the documentation in the medical record, this resident has the following conditions: Psychotic Disorder, unspecified dementia, gastronomy status and dysphagia. Record review of Resident # 7's Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section A 1500 resident is currently considered by the state level II PASRR process to have a SMI (Serious Mental Illness) or ID (Intellectual Disability) or a related condition-Not available. Section C for Cognitive Patterns documented Brief interview for mental status score (BIMS), unable to determine. Section I for Active diagnosis documented Psychiatric/Mood Disorder-Psychotic disorder. In addition, the resident was coded for Psychotic disorder in Section I for Active diagnosis on the Annual MDS dated [DATE] and the Quarterly MDS 's dated 11/17/2022, 2/15/2023, 5/14/2023,11/12/2023, and 2/15/2024- Psychotic Disorder. Section N for Medications documented no medications received from the high-risk drug class. Section O for Special Treatments documented the resident received no special treatments or procedures. Record Review of Resident #7's most recent Psychological Consultation dated 02/17/2022 documented: Mental status examination performed. Recommendations: Discontinue Seroquel 12.5 milligrams and new order for Melatonin 5 milligram at bedtime for the patient. Reassurance was provided to the patient, case discussed with staff. Physician will continue to monitor the patient throughout his hospital course as needed. Further recommendations will follow accordingly. Review of the medical records for Resident #7 revealed, the resident was admitted to the facility on [DATE] and readmitted on [DATE]. Clinical diagnoses included but not limited to: Psychotic disorder with delusions due to known physiological condition. Unspecified psychosis not due to a substance or known physiological condition. Insomnia, unspecified and Unspecified Dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the Physician's Orders Sheet for April 2024 revealed Resident #7 had orders that included but not limited to: 08/16/2022- Consult Psychiatry on Admission & as needed. Record review of Resident #7's Care Plans Reference Date 04/03/2024 revealed: Resident has an alteration in neurological status r/t (related to) Dementia, dysphagia following other nontraumatic intracranial hemorrhage. Interview on 05/01/24 at 08:00 AM. The Social Services Director (SSD) stated: The resident's most recent PASRR was completed on 11/15/2022, at that time, the resident was not taking any medications for psychosis, so he would not have been coded for psychotic disorder. The resident was admitted on [DATE], readmitted on [DATE], so I have to check his paperwork, the other PASRR dated 8/10/2022 the resident was not coded for psychotic disorder either. The surveyor informed the SSD that the resident was coded for a psychotic disorder on the most recent MDS and also the prior Minimum Data Sets in addition, psychotic disorder is listed on the resident's current medical diagnosis documentation. The SSD then stated she will review the resident's chart and get back to the surveyor. On 05/01/2024 at 09:40 AM; the SSD a PASRR dated 7/27/2020 to the surveyor which indicated diagnosis checked of on the mental illness list-Psychotic Disorder. On 05/01/2024 at 10:03 AM; the Director of Nursing (DON) brought documentation revealing the resident has an active diagnosis of a Psychotic disorder based on the physician's clinical documentation dated 1/9/2024 and stated: That is why the diagnosis is coded on the MDS. Review of the facility's policies and procedures titled Admission Criteria revision date March 2019 states: Our facility admits only residents whose medical and nursing care needs can be met. All new admissions and readmissions are screened for mental disorders (MD), Intellectual Disabilities (ID) or related disorders per the Medicaid Pre-Admission Screening and Resident Review (PASRR) process.

Based on observation, interviews, and record review it was determined that the dish machine wash temperature did not reach the minimum manufacturer's recommended wash temperature as posted on the dish machine's face plate. Findings included: At 9:30 AM on 12/12/2022, a diet aide was observed running racks of dirty dishes through the dish machine. The wash and rinse temperature gauges were observed to read 150 degrees Fahrenheit (F) for the wash cycle and 180 degrees F for the rinse cycle. Observation of the manufacturer's face plate posted on the dish machine indicated the required temperature for the wash cycle should be at a minimum of 160 degrees F and the rinse cycle temperature should be at a minimum of 180 degrees F. Several racks of dishes were observed that had been run through the machine without the wash temperature reaching the manufacturer's required minimum of 160 degrees F. The Dietary Manager reported that he had been told by the service company for the dish machine that the surface of the dish would be at 160 degrees F but the ambient air in the dish machine would reduce the wash water temperature to below 160 degrees F. When it was suggested that the water temperature could be increased to ensure the wash temperature remained at or above 160 degrees F, as the rinse temperature was being maintained at 180 degrees F, there was no response from kitchen staff. A review of the dish machine temperature log revealed that for every shift on the December 2022 log, the temperatures were documented at 160 degrees F for the wash temperature and 180 degrees F for the rinse temperature. The dish machine service company provided service to the dish machine on 12/12/2022, with their service report documented at 1:47 PM, for the request description (of the visit) of temperature issue. Service comments on the service call document read: Replace gauge for security, machine work perfect in range temperature. The summary of the visit read: The dishwasher is in perfect condition; the washing temperature reaches 160 degrees F, and the final rinse exceeds 180 degrees F. The service report indicated a photograph had been taken of the temperature gauge during the wash cycle. Observation of the photograph of the wash temperature gauge revealed the temperature was at approximately 152 degrees F, which is approximately 8 degrees below the manufacturer's guidelines for the minimum temperature during the wash cycle. The photograph of the rinse temperature showed the gauge was at 180 degrees F, which is at the minimum temperature indicated by the manufacturer's guidelines.

Based on observations, staff interview and facility record review, the facility failed to ensure call lights were maintained and working effectively in three of thirty-three resident rooms, on three of three halls (wing A, wing B, and wing D). It was determined when pressing the pneumatic plastic bulbs, the call system did not activate. Findings included: 1. On 12/12/2022 at 10:28 AM the A wing was toured. Upon entering resident room [ROOM NUMBER] at 10:50 AM., both bed (a) and bed (b) call lights were tested for working maintenance. room [ROOM NUMBER] bed (a) was observed with a pneumatic bulb button. Upon pressing/squeezing the pneumatic bulb, it was determined the system did not trigger. Further observations revealed the light out in the hallway above the room door did not illuminate. The pneumatic bulb was pressed/squeezed four times and still the light did not trigger out in the hallway. At 10:55 AM, an interview with Certified Nursing Assistant (CNA) employee C, revealed that all call lights regardless even if the resident is able to use it or not, are to be placed within their reach when in bed and when in the room. Employee C also confirmed that the lights should always be in working order and that she did not know who was responsible for the general maintenance of the call lights. On 12/13/2022 at 10:00 AM, an interview with the Nursing Home Administrator (NHA) and the Maintenance Director, both revealed that all call lights in rooms and bathrooms are checked monthly per their [] maintenance system, and that this month's (December's) check has not been conducted as of yet. The NHA also indicated that floor staff to include nurses and aides would be responsible to notify maintenance or himself if call lights were not working appropriately. He also confirmed that it is facility policy for all call lights to be functioning, even for the residents who are not able to use them. The Maintenance Director revealed he would go ahead and do a building-wide check of all the resident rooms and bathrooms to ensure all are working. He provided the last four months (8/2022, 9/2022, 10/2022, 11/2022) of Nurse Call Checks audits for review. Review of the 8/2022 Nurse Call Check audit, revealed all rooms were checked and passed. Review of the 9/2022 Nurse Call Check audit, revealed all rooms were checked and passed. Review of the 10/2022 Nurse Call Check audit, revealed all rooms were checked and passed. Review of the 11/2022 Nurse Call Check audit, revealed all rooms were checked and passed. During the survey on 12/14/2022, the Maintenance Director performed a call light audit, after the 12/13/2022 observations of call lights not working. The maintenance director and Nursing Home Administrator also revealed that staff should be letting his maintenance department know if there are any lights not working, as they see them. He did not have any current work orders that reflected the above listed non-working lights. 2. On 12/12/22 at 12:06 PM; room [ROOM NUMBER] bed (a) call light was tested and the light outside of the room did not come on. Staff A, CNA tested the call light and confirmed the call light was not working. Staff A stated yesterday it was working and confirmed the resident could use the call light if she needed to. A second test on the call light was conducted for functionality for room [ROOM NUMBER] bed (a) on 12/15/2022 at 10:00 AM and it was discovered that the call light was still not functioning as intended. A third test was conducted for functionality on 12/15/22 at 11:45 AM after the facility was made aware by the survey team, and room [ROOM NUMBER] bed A's call light was tested with Staff A, CNA and she confirmed the call light system was functioning as intended. Staff A reported that maintenance told her that the cord gets kinked, so we have to make sure that does not happen. 16723 3. On 12/13/2022 at 12:10 PM, Resident # 100 was observed lying in bed. He agreed to a visit and reported that usually call bell response was good. He activated the call bell to demonstrate and when the surveyor stepped into the hall to see if the light above his door was lit because no sound was heard from the bell, observation revealed the light above the door was not lit. Resident #100 tried to activate the bell several times but the light above his door was not turning on. A request was made to Staff I, CNA who was present in the hall to try the bell and she had the same results. After confirming that the bell was not working Staff I left the room. The surveyor remained to speak with the resident who reported that he did not know the call bell was not working. After approximately five minutes, the surveyor left the room and approached Staff I, CNA to determine what her next step was related to the call bell. Staff I reported she had already notified maintenance that the bell was not functioning. At 12:35 PM, staff were observed approaching Resident #100's room pushing a small cart which was carrying multiple replacement call bells. The staff was able to replace the call bell and the call bell was functioning. On 12/15/2022 at 10:00 AM, the Nursing Home Administrator provided the facility's Call System, Resident policy and procedure for review. The undated policy heading revealed; Residents are provided with a means to call staff for assistance though a communication system that directly calls a staff member or a centralized workstation. The policy further revealed to include but not limited to: (1) Each resident is provided with a means to call staff directly for assistance from his/her bed or other sleeping accommodations. (2) The call system communication may be audible or visual. The system may be wired or wireless. (3) The resident call system is routinely maintained and tested by the maintenance department. (4) Calls for assistance are answered as soon as possible. (5) If the call system requires repair, an alternate means of communication is implemented for the affected resident(s). (6) Call light function and response should be reviewed as part of the QAPI program.

Based on observation of residents at meals, interview with facility staff, and review of residents' diet orders as ordered by the Physician, the facility failed to ensure 15 residents ( Resident #1, Resident #3, Resident #6, Resident #7, Resident #18, # Resident 20, Resident #24, Resident #28, Resident #50, Resident #53, Resident #100, Resident #103, Resident #104, Resident #105, Resident #251) of 47 residents who were receiving nourishment by mouth, were receiving the correct Physician ordered diets. Observations of Resident #100 and Resident # 3 while at lunch were made to confirm the Physician ordered diet had not been served. Findings included: 1) Resident #100 was admitted to the facility on [DATE] with multiple diagnoses including End Stage Renal Disease (ESRD). An admission note dated 12/07/2022, written at 00:40, included the resident's cognitive status as alert and oriented times 3, and ESRD as one of his diagnoses. An admission Nutrition assessment dated [DATE], written at 15:00 reviewed the resident's diagnoses, medications, labs from the hospital dated 11/30/2022, and skin concerns (unstageable pressure injury to left heel). The Assessment documented the resident's diet was 2-gram sodium, regular texture, thin consistency fluids. There was no supplement ordered. Intake at meals was 50-75%. The resident was 66 tall and weighed 165 pounds (lbs.) / 75 kilograms (kg) on 12/06/2022. The Dietitian recommended a renal with dialysis diet with a liquid high calorie, high protein supplement to better meet the resident's needs. An observation of Resident #100 at lunch on 12/13/2022 at approximately 12:30 PM; revealed he had received a large, breaded pork chop, roasted potatoes, and green beans with vanilla pudding for dessert. The resident reported he was enjoying the meal. The resident also had received and had consumed most of a bowl of chicken broth. He confirmed he had eaten most of the broth but reported it was very salty. A review of the resident's diet slip revealed he had been provided with a 2-gram sodium diet. A review of the menu for 12/13/2022 revealed the Renal Chef Select Menu was planned to provide residents with a turkey burger on a bun, a garden salad without tomato, carrot and celery sticks and a cookie for dessert. An alternate menu was planned for the Renal Chef Select diet which would have provided the resident with Chicken and Mozzarella, no tomato, with spaghetti, green beans, and a garden salad. Resident #100 had received neither of those planned meals, which would have corresponded to his recommended Renal with dialysis diet. An interview was conducted on 12/15/2022 at approximately 11:30 AM; with the Dietary Manager who reported that the facility's planned Heart Healthy Diet included the sodium modified to 2 grams. The Dietary Manager confirmed that the 2-gram sodium diet was based on the Heart Healthy Diet. The Registered Dietitian's recommendation to change Resident #100's diet from 2-gram sodium ordered at admission to a renal with dialysis diet had not been implemented seven days later. Resident #4 Physician ordered diets was reviewed and compared to the diet slips used to guide the tray line in preparing the meal trays for the residents revealed the wrong diet provided. Further review revealed of the 47 residents who had Physician ordered diets for by mouth nourishment, 15 residents (32%) had received the wrong diet, related to either the Therapeutic modification or the texture modification. The following identifies the diet received on 12/13/2022 at lunch as compared to the Physician ordered diet: Resident #7 received a 2-gram sodium diet at lunch, but her Physician's ordered diet was a regular. Resident # 100 received a 2-gram sodium diet at lunch, but his Physician's ordered diet was a renal with dialysis diet. Resident # 18 received a minced and moist, 2-gram sodium, carbohydrate-controlled diet but her Physician's ordered diet was a soft & bite sized, 2-gram sodium, carbohydrate-controlled diet. Resident #103 received a 2-gram sodium diet, but her Physician's ordered diet was 2-gram sodium, carbohydrate-controlled diet. Resident # 20 received a 2-gram sodium diet, but her Physician's ordered diet was an easy to chew diet. Resident # 1 received a heart healthy diet, but his Physician's ordered diet was regular. Resident # 104 received a soft & bite sized with carbohydrate-controlled diet, but her Physician's ordered diet was soft & bite sized. Resident # 3 received a soft & bite sized diet with moderately thick liquids, but her Physician's ordered diet was pureed with mildly thick liquids. Resident # 251 received an easy to chew diet, but her Physician's ordered diet was easy to chew with high protein high calorie foods. Resident # 105 received a heart healthy, 2-gram sodium, carbohydrate-controlled diet but her Physician's ordered diet was a heart healthy, 2-gram sodium, fat restricted, carbohydrate-controlled diet. Resident # 28 received a renal without dialysis diet, but his Physician's ordered diet was a renal with dialysis diet. Resident # 50 received a 2-gram sodium, easy to chew diet, but his Physician's ordered diet was a soft and bite sized diet. Resident # 24 received a heart healthy, 2-gram sodium, fat restricted diet but her Physician's ordered diet was a heart healthy, fat restricted diet. Resident # 6 received a heart healthy diet, but her Physician's ordered diet was a heart healthy, easy to chew diet. Resident #53 received a 2-gram sodium diet, but her Physician's ordered diet was a heart healthy, 2-gram sodium diet. 39866 2) Review of Resident #3's admission record revealed she is a [AGE] year-old resident admitted on [DATE] from and acute care hospital with diagnosed that include but are not limited to Dementia, nonspecific abnormal finding of lung field, pneumonia, Gastroesophageal reflux disease (GERD) dysphagia, and Alzheimer's disease. Review of Resident #3's physician order summary revealed an order for regular diet, pureed texture, nectar consistency for aspiration started on 11/8/2022. Further record review revealed a chest x-ray dated 11/5/2022 revealed IMPRESSION: Patchy opacity is seen in both lungs, stable. A meal observation was conducted on 12/13/22 at 12:25 PM; the lunch cart came to Resident #3's hallway. The Assistant Director of Nursing (ADON) was observed taking lunch trays out of tray cart and passing the trays to other staff members, staff sanitized their hands in between each resident. On 12/13/22 at 12:32 PM, Resident #3 was observed to be sitting in her wheelchair at her bedside with her lunch tray in front of her. The resident was observed to have her fork in her hand picking at a pile of potatoes that were cut in half. The resident had fish cut into pieces, cut green beans, and potatoes cut in half with Nectar thick lemon water with a chunk of fish in her water cup. Review of her meal ticket revealed MO3, EC7 Fish, Lemon, Chateau Potatoes, Green Beans cut, Lemon water-MO3 Review of the facility's Select Medical Food and Liquid Conversion to IDDSI [International Dysphagia Diet Standardization Initiative] undated, revealed MO3= moderately thick (old term honey). EC7=easy to chew. An interview was conducted with Staff E, Registered Nurse (RN) on 12/13/22 at 12:33 PM; Staff E stated she was taking care of Resident #3. She believed the resident was on a puree diet. Staff E reviewed the electronic medical record and confirmed the resident is on a regular diet with puree consistency and thickened liquids. Staff E, RN went into Resident #3's room, removed the lid on Resident # 3's food plate and confirmed the food the resident received was not a puree consistency. Staff E was unsure as to why Resident #3 needed the puree diet. The meal tray was removed from the room by Staff F, a Certified Nursing Assistant (CNA) at this time. An interview was conducted with the Assistant Director of Nursing (ADON) on 12/13/22 at 12:36 PM. The ADON reviewed Resident #3's medical record and stated the resident was on puree diet then changed to a diet that was regular diet, easy to chew with thickened liquids. So, I don't know why they would downgrade her diet again to puree. An interview was conducted on 12/13/22 at 12:34 PM with Staff E, RN. Staff E stated when a new diet order gets put in, they change the order in the computer, print out the new order and take the order down to the kitchen office. Or they can give it to the unit secretary, and they can take it down or fax it down to the kitchen office. During a further interview conducted on 12/13/22 at 4:45 PM, Staff E, RN stated I am the nurse, so I am responsible for making sure the residents receive the correct diet. Normally I am the one passing out the meal trays and I look at the tickets and the orders and make sure the food matches. I'm not sure why the ADON was passing the meal trays today, but I am the nurse for [Resident #3] so I am responsible. During an interview on 12/13/22 at 4:50 PM, Staff D, RN stated if a physician wants to change a diet order, we input the order he requests and print out the new order provide it to the unit secretary, and they bring it down to the kitchen managers office. If a family wants a diet changed then I have to have speech therapy come and do an evaluation and then the speech therapist will input the order and take down the order or give it to the unit secretary. An interview was conducted on 12/13/22 at 4:53 PM with Staff B, Receptionist she stated the nurses will let me know when a diet order changes, I will print out the order and I can either fax it to the kitchen office or bring it down to their office. If it is after the office closes, then I just slide it under their door, and they will get it in the morning. On 12/13/22 at 4:14 PM, an interview was conducted with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) the DON indicated based on review of [Resident #3's] lunch meal ticket and review of what MO3 and EC7 means [Resident #3] did not receive her ordered diet for lunch. Her lunch meal ticket indicates moderately thick, easy to chew. We did ask the kitchen to review the diets. An interview was conducted with the Director of Food Services on 12/13/22 at 4:55 PM. The Director of Food Services stated he does not have access to the patient electronic medical record. The secretary's will come down to my office drop off the new diet orders, my diet clerks who work in my office will update our electronic menu software system, with the new diet order, the system will take the diet order and their preferences and create a menu for the day. I have staff here from 5:00 AM to 7:30 PM. Every morning my diet clerks review new orders that were faxed or slid under the door overnight and input them into the system and then print out the menus for each resident for the day and provide them to the line assistants who put the food trays together. The facility provided me with a diet order list for all the residents and I updated our system so the dinner meal tickets reflect their correct diet orders. An interview was conducted on 12/13/22 at 10:21 AM with Staff J, Respiratory Therapist he stated [Resident #3] is stable from a respiratory standpoint she does receive albuterol twice a day. pulmonology is on board and following her. She is currently stable and doing well 96% on room air. An observation was conducted on 12/13/22 at 3:06 PM. Resident #3 was observed to be in the activities room working on picking up pegs and placing them on a peg board with other residents and staff members. She was observed without cough, congestion, or respiratory distress on room air. During a phone interview conducted on 12/13/22 at 1:30 PM, the facility's Speech Therapist indicated she has been consulted for Resident #3 since her admission due to her history of pneumonia, GERD, dementia, and she came to the facility on a puree diet with honey thick liquids. She did an initial evaluation on Resident #3 and determined she would be a good candidate for speech therapy. Resident #3 was able to consume mechanical soft diet with nectar thick liquids. The speech therapist confirmed the residents current order was a pureed because; someone must have been concerned and downgraded her diet. Pulmonology consulted me but I was already on board. Due to the residents age and her fluctuation of tolerance I left the diet order at pureed texture because it seemed the safest for the resident. The speech therapist was informed Resident #3 received an easy to chew diet for lunch; and the Speech Therapist stated in her professional opinion the resident is able to tolerate the easy to chew diet but if there were inconsistencies throughout the day with coughing, pocketing food or tiredness puree diet is the safest consistent diet to be ordered but not unsafe with an easy to chew diet. At the time of this interview the DON was present and stated the Registered Dietitian typically prints out orders from the electronic medical record and delivers it to the kitchen. A phone interview was conducted with Resident #3's Pulmonology Advanced Registered Nurse Practitioner (ARNP) on 12/14/22 at 10:55 AM. The ARNP stated I first came on board for [Resident #3] when she was coughing and had bilateral pneumonia, when I see an elderly lady with coughing and pneumonia I think she may be aspirating so I changed her diet to puree diet because that is the safest and I ordered a speech evaluation, but speech was already working with her. I don't know what speech suggested her diet should be, but puree is definitely the safest. The ARNP was told the resident did not receive pureed food for lunch on 12/13/22. The ARNP stated: if speech recommended a mechanical soft diet, then I am fine with that too. I saw [Resident #3] on Sunday [12/11/22] her lungs were clear she was on 98% on room air I did not hear her coughing, but I am not there all the time. I don't remember ordering a chest x-ray for her but typically what I do is change the diet and give the patient 2-3 weeks then take another x-ray. I cannot remember when her last chest x-ray was. The ARNP was told the last chest x-ray was on 11/5/2022 which read bilateral opacities (a radiological term that refers to hazy gray areas on the images made by CT scans or X-rays). The ARNP stated: I may do another x-ray on her next week but clinically she is doing much better than she was when I came on board. Review of Resident #3's care plan revised on 10/21/22 revealed- Focus: I have a nutritional problem or potential nutritional problem r/t need for altered texture diet, need for thickened liquids . BMI (Body mass index) < (less than) 23, poor PO (by mouth) intake Goal: I will consume > (greater than) 50% of meals, snacks and supplements offered to me I will maintain my CBW w/ no sig wt. [significant weight] changes I will tolerate my ordered altered texture diet and thickened liquids Interventions: Provide and serve diet as ordered . Review of the facility's Therapeutic Diets policy undated revealed Policy statement Therapeutic diets are prescribed by the attending physician to support the resident treatment and plan of care and in accordance with his or her goals and preferences. Policy Interpretation and Implementation 1. Diet will be determined in accordance with the resident's informed choices, preferences, treatment goals and wishes. Diagnosis alone will not determine whether the resident is prescribed a therapeutic diet. 2. A therapeutic diet must be prescribed by the resident's attending physician (or non-physician provider). The attending physician may delegate this task to a registered or licensed dietitian as permitted by state law. 3. Diet order should match the terminology used by the food and nutrition services department. 4. A therapeutic diet is considered a diet ordered by a physician, practitioner or dietitian as part of the treatment for disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet, for example: a. diabetic/calorie-controlled diet. b. low sodium diet. c. cardiac diet; and d. Altered consistency diet Review of the facility's policy Interdepartmental Notification of Diet undated revealed Policy Statement Nursing services shall notify the food and nutrition services department of a resident's diet order, including any changes in the resident's die, meal service, and food preferences. Policy Interpretation and Implementation 1. When a new resident is admitted or a diet has been changed, the licensed nurse or designee shall ensure that the food and nutrition services department receive written notice of the diet order. 2. The food and nutrition services department will be notified verbally if the diet change or report occurs one hour or less before a scheduled meal, or if circumstances indicate that the written procedure will not be adequate to ensure services at the next meal

Based on observation, interview, and record review the facility failed to provide care and treatment services in accordance with professional standards of practice as evidenced by not identifying on admission that resident had transparent dressing and providing treatment for a change in condition for two (Resident #2 and Resident # 21) out of three residents sampled for skin. Findings included: 1. On 12/12/2022 at 1:29 PM, Resident #2's left forearm was observed with an undated adhesive bandage dressing that appeared old and loosely attached. The dressing partially covered a quarter size elevated mass. The Admission Business Office Manager (BOM) asked Resident #2 about the bandage and the Resident responded, I scratched it. Medical record review of the Admission Record form revealed Resident #2 has resided at the facility for close to a year and is geriatric in age. The diagnosis listed rash and other nonspecific skin eruption dated 7/16/202. Unspecified skin changes 6/26/2021 and superficial mycosis (fungus) 1/12/2021. Review of Skin assessment dated on 12/06/2022 reflected no impairment, skin intact. Nursing progress notes were omitted of documentation related to the left forearm. Review of a dermatology consult dated 09/05/2022 did not reflect Resident #2 left forearm. On 12/13/2022 at 12:00 PM, Resident #2 was observed up in his Geri chair and smiled when approached. His left forearm contained 2 inches by 2-inches bordered dressing dated 12/13/2022. Review of nursing notes dated 12/13/2022 time stamped 09:15 Skin/Wound Note Text: Patient has been and evaluated this morning by the wound care nurse as ordered by doctor [name of doctor] due to left forearm skin lesion. Patient was noted with a pink hyper granular growth to the left posterior forearm, with slightly elevated aspect, rolled and well-defined edges, no signs of infection, patient refers itching sometimes, no drainage or bleeding noted. Doctor [name of doctor] was notified about patient's skin condition, order given for Dermatology consult. Further review of the notes dated 12/13/2022 at 9:36 Skin/Wound Note, Note Text: New order received from doctor [name of doctor] to apply dry dressing to the left forearm skin lesion until the patient is seen by Dermatology, order carried out. On 12/14/2022 at 4:20 PM, an interview was conducted with the Wound Nurse. She reported there was a doctor order for her to look at Resident #2's arm. On 12/15/2022 at 10:00 AM, an interview was conducted with Minimum Data Sheet staff member who at that time, confirmed there was no Physician order in place for the Wound Nurse to assess Resident #2's arm. On 12/15/2022 at 10:30 AM, during an interview the BOM confirmed she had notified the nurse on the unit about Resident #2's bandage. She stated, On Monday (12/12/2022) right after you (surveyor) asked him about the band aid (R). 2. On 12/12/22 at 12:35 PM, Resident #21 was alert and receptive to an interview. Both of his forearms presented with large areas of petechia (pinpoint, round spots) and small scattered scabs. The right forearm contained a 4 inch by 4-inch transparent dressing that started just above his ID bracelet. Under the dressing the skin reflected dark red ruby-colored patches. No lumps, bumps, lesions, and nor open areas were present. No date was on the dressing. Resident #21 stated the dressing to his right arm was from the hospital. He stated, they put it on. Medical record review revealed Admission Record form that Resident #21 was admitted to the facility on [DATE] for short term rehabilitation. The form contained diagnosis information that included other specific disorders of the skin and subcutaneous tissue, chronic kidney disease (CKD), rash and other nonspecific skin eruptions. Review of progress notes dated 12/12/2022 2:15 PM (14:15) Skin/Wound Note Text: Patient is [age] male, alert and oriented times 3 (AOx3), readmitted to the facility from [local hospital. Readmission skin assessment done by the wound care nurse. Patient has significant ecchymosis discolorations with dry scabs and venipuncture sites to bilateral upper extremities (BUE's). Revealed omission of the transparent dressing on Resident #21's right arm. Further review of the note read the Physician [Physician name] was notified of current patient's skin condition, order given for treatment, consult with [physician name], air mattress, offloaded heels while in bed, incontinence care as needed, barrier cream to bilateral lower extremities (BLE's), turn and reposition every 2 hours and as needed (PRN). Patient is at risk for skin breakdown related to advanced age, impaired mobility, unsteady gait, difficulty walking, muscle weakness, declining in functions, diabetes mellitus (DM), heart failure (HF), hypertension (HTN), CKD, aortic stenosis. Responsible party, [ name of responsible party] aware of patient skin condition and interventions in place, no concerns. On 12/13/2022 at 10:20 AM Resident #21 received a midline catheter to his left arm, just below the antecubital area. The transparent dressing remained in place. The center of the dressing now revealed a small area reflecting the size of a pencil eraser that was green to yellow in color. On 12/14/2022 at 9:50 AM, Resident #21 was lying in bed and recalled the surveyor's name while he smiled when approached. The transparent dressing remained in place to his right arm. The center of the dressing contained a yellow-colored thick drainage, that now reflected the size of a five-cent piece (nickel) (photographic evidence obtained). At 10:00 a.m. Staff E, a Registered Nurse was asked about Resident # 21 and the left arm transparent dressing, she looked at it and stated, It's from the hospital, I will have to check with wound care. At 11:30 AM an interview was conducted with the Wound Care Registered Nurse that confirmed she had performed an admission skin assessment for Resident #21. The Wound Nurse confirmed she had documented in Resident #21 medical record the bilateral upper extremities with significant ecchymosis, discolorations, with dry scabs, and venipuncture sites. The Wound Nurse confirmed she knew about the transparent dressing being in place at the time of her assessment. She stated, It was from a line removal. It was bumpy, and elevated. If I were to remove it there is a risk for skin break down. When asked about the monitoring of the dressing she stated, there is an order in place to monitor for bruising or bleeding to the upper arms. The Wound Nurse confirmed the admission skin assessment, nor the medical records reflected that a transparent dressing was is in place. She went on to say that she had seen his arm this morning, I didn't see yellow tissue. The Wound Nurse along with the Director of Nursing (DON) observed Resident #21's arm. The arm no longer contained the transparent dressing. She stated, it's not open it was closed all the time. The DON confirmed that the medical record should contain an accurate assessment and description of the skin to include dressings that are in place for 7 days. Review of Physician orders dated 12/14/2022 Monitor for bruising and bleeding/thromboembolism every shift. Review of the facility's policy titled Assessment of Skin Condition and Integrity that did not contain a date, Policy, and Procedures: The purpose of this policy is to provide information regarding the assessment of skin condition and integrity. Skin Assessment 1. Conduct a comprehensive head to toe skin assessment upon admission, at least weekly, and as needed. A. During the skin assessment, inspect for; i. Presence of skin impairment(s); ii. Type of skin impairment (s; and iii. Location of skin impairment(s); 2. Observed the skin daily when performing or assisting with personal care or ADLs. Documentation: The following information should be recorded in the resident's medical record: 1. The findings of the skin assessment. 2. The date and time of type of skin care provided, if applicable. 3. The condition of resident's skin. 4. Any change(s) in the skin condition, if applicable. Reporting: 2. Notify the physician of new skin alteration(s) noted. 3. Notify family, guardian or residents responsible party of new skin alteration(s) noted. 4. Report other information in accordance with facility policy and professional standards of practice.

Based on observation, interview, and record review the facility failed to coordinate care related to dialysis for two residents (Resident #28 and Resident #100) out of 2 residents reviewed for dialysis related to medication administration, weights, and diet orders. Findings included: 1) Review of Resident #28's admission record revealed he was admitted to the facility on [DATE] from an acute care hospital with diagnoses that included but not limited to encounter for orthopedic aftercare following surgical amputation, acquired absence of right leg below the knee, acquired absence of left leg below the knee, type 2 diabetes mellitus with diabetic chronic kidney disease, end stage renal disease, and dependence on renal dialysis. Review of Resident #28's physician order summary report revealed an order to start on 9/19/2022 with no end date for hemodialysis (inhouse) TX Freq [treatment frequency]: T, TH, S [Tuesday, Thursday, Saturday] . Review of Resident #28's physician orders revealed an order for Mircera Solution prefilled syringe 100 mcg/0.3 ml (100 micrograms per 0.3 milliliters). Inject one dose subcutaneously one time a day every 14 days related to end stage renal disease with a start date of 9/20/22. Further review revealed another physician order for Mircera solution prefilled syringe 100 mcg/0.3 ml. Use 100 mcg intravenously one time a day every 2 weeks on Thu (Thursday) for anemia dialysis to administer. Review of Resident #28's Interim Medication Regimen Review dated 12/13/2022 revealed Medication: Mircera Recommendation: There are 2 active orders in the med [medical] record. During an interview with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) conducted on 12/14/22 at 3:47 PM, it was brought to the DON and NHA attention that there are two Mircera orders, one to be administered subcutaneous and one to be administered intravenously. The intravenous order indicated to be administered by dialysis. The DON did not know why there were 2 orders for Mircera . in her opinion she thinks the two orders were a transcription error .The DON was not able to answer if dialysis provides all medications. The DON was not able to answer if her staff were expected to administer the physician ordered Mircera to be administered subcutaneously given it did not indicate that dialysis was to administer it. A phone interview was conducted with Staff G, Nurse Manager for dialysis center on 12/15/22 at 9:14 AM. Staff G confirmed coordination of care should occur between the dialysis center and the facility. Staff G stated: We have Dietitians and Social Workers; they go and see the patients every month. We do monthly labs, the Dietitian at the dialysis center communicates the labs with the facility's Dietitian and that is documented in our EMAR [Electronic Medical Record]. We do not share our documentation with the facility. We don't share our notes with them. They have their notes, and we have ours. It is expected that our nurses do a verbal pre and post handoff report to the facility's floor nurse .we administer Mircera because that is part of the bundle, The bundle includes Erythropoietin stimulating's hormone (Mircera) and Epogen, we also get paid by Medicare as a bundle on dialysis labs, treatment, and supplies. Everything is paid together and in that bundle fee medications are included so we have to provide medications for the patients. The facility should keep the Mircera order on their MAR to give every 2 weeks. On the hand off report medications that were administered should be reported to the floor nurse. We do not have access to the facility's medical record, but we are trying to get access. In dialysis, typically Mircera is given IV [intravenous] during treatment but it can also be given Sub Q [subcutaneous]. The facility is responsible for weighing the patient before dialysis and after but sometimes the patient after dialysis is hard to weigh. She confirmed they would just guess the weight if they were hard to weighed afterwards based on the amount of fluid they took off during dialysis. 16723 A review was conducted of the Provider's Monthly Dietitian Note dated 11/23/22 for Resident #28. The note revealed the resident's lab values and noted that the resident's albumin was not within target as 3.6, as the target was a value higher than 3.8. The Interventions were noted to be education to the resident on how to increase protein and/or calorie intake. Also, a protein supplement was checked as an intervention. Comments were documented at the end of the note which indicated the dietitian met with the patient to review his lab report. A recommendation was made by the dietitian to start the patient on a dialysis liquid supplement and add double protein portions to each meal. A review of the facility's quarterly nutritional assessment dated [DATE] revealed the resident's diet order was renal with dialysis, regular texture, thin consistency diet with no supplements. The resident's diagnoses included Type 2 Diabetes, End Stage Renal Disease, and a below the knee amputation of the right leg. The resident's weight was 176 lbs. (80 kg) with a comparison of weights from November and September. The note included that the comparison was based on post dialysis weights, but there was no reference to the resident's estimated dry weight determined by the dialysis provider. The resident's weight had remained consistent from September until current, based on the post weights. A review of the diet orders for Resident #28 revealed he had been ordered and was receiving a Renal with Dialysis Diet, Regular texture, thin consistency. The diet order did not reflect the recommendation made by the Dialysis Dietitian to add extra protein portions to the meals or the liquid supplement. A prior note by the facility dietitian, dated 12/05/2022 reviewed the resident's weight gain to 181 lbs., post dialysis. The note included the current diet as CCHO (consistent carbohydrate) renal with dialysis diet, with no supplement. There was no obvious coordination of care between the facility and the provider dietitian to reflect the need for the consistent carbohydrate diet, the extra protein at meals and the additional protein and calories provided by the liquid supplement as recommended by the provider dietitian. A review of Flow Sheets provided by the dialysis provider revealed pre and post weights did not match the facility's weights. In interviews with the facility DON and the provider's Nurse Manager, the protocol was for the provider to use facility obtained weights pre and post dialysis. On 12/01/2022 the facility pre dialysis weight was documented as 182.4 (82.9 kg) and the post weight was 180.2 (81.9 kg). The provider Flow Sheet used the pre dialysis weight of 82 kg and the post dialysis weight of 80 kg. On 12/03/2022 the facility obtained pre dialysis weight was 183 lbs. (83.18 kg) and the post dialysis weight was 181.2 lbs. ( 82.36 kg). The provider Flow Sheet used the pre dialysis weight of 82 kg and the post dialysis weight of 80 kg. On 12/06/2022 the facility obtained pre dialysis weight was 183.4 lbs. (83.36 kg) and the post dialysis weight was 181 lbs. (82.27 kg). The provider Flow Sheet used the pre dialysis weight of 81.5 kg and the post dialysis weight of 80 kg. Care plans were reviewed and noted for the care plans related to the resident's dialysis treatment did not include coordinating care between the facility and the provider. 2 ) A review was conducted of Resident #100's progress notes to identify documentation related to the resident's dialysis status and coordination of care between the facility and provider. Resident #100 was admitted to the facility on [DATE] with multiple diagnoses including End Stage Renal Disease (ESRD). An admission note dated 12/07/2022, written at 00:40, included the resident's cognitive status as alert and oriented times 3, and ESRD as one of his diagnoses. The note read: Resident has a dialysis port to the upper left portion of chest, scheduled days are MWF (Monday, Wednesday, Friday) for dialysis. Port is patent and thrill and bruit present. A review of the progress notes written by the nurses did not include any references to the resident while he was receiving dialysis on 12/08/2022, 12/10/2022, and 12/13/2022. An admission Nutrition assessment dated [DATE], written at 15:00 reviewed the resident's diagnosis, medications, labs from the hospital dated 11/30/2022, and skin concern (unstageable pressure injury to left heel). The Assessment documented the resident's diet at 2-gram sodium, regular texture, thin consistency fluids. There was no supplement ordered. Intake at meals was 50-75%. The resident was 66 tall and weighed 165 lbs. (pounds)/ 75 kg (kilograms) on 12/06/2022. The dietitian summarized her assessment to include concerns of the unstageable pressure injury to the left heel for which she recommended a multivitamin, zinc sulfate, and a high protein supplement to promote wound healing. The resident was taking a diuretic and on ESRD, so weight fluctuations were expected. The Dietitian recommended a renal with dialysis diet with a liquid high calorie, high protein supplement to better meet the resident's needs. A nephrology consult was obtained on 12/09/2022 with the note written at 14:51. The Nurse Practitioner documented the resident's use of a tunneled dialysis catheter. The plan included to continue with hemodialysis treatment, two hours three times a week. Care plans were developed from the resident's admitted with focus areas of renal failure, hemodialysis received in house, the resident's nutritional status related to multiple diagnoses including ESRD and hemodialysis, and the resident's risk for skin breakdown and the presence of a catheter for hemodialysis. None of these care plans identified the need to coordinate care with the outside provider. A review of Resident #100's dialysis weight log documented by the facility listed the resident's pre-dialysis weight on 12/08/2022 as 152.4 lbs. (pounds)/ 69.27 kilograms (kg) and the post-dialysis weight as 150.2 lbs. (68.27 kg). Weights used on the Hemodialysis Flowsheet were 76 kg pre dialysis and 75 kg post dialysis. Duration (length of dialysis treatment) was documented at 180 minutes or three hours. The resident was dialyzed on 12/10/2022 for 180 minutes. The facility's dialysis weight log listed the resident's pre-dialysis weight on 12/10/2022 as 153 lbs. or 69.545 kg and the post dialysis weight on 12/10/2022 as 150.8 lbs. or 68.545 kgs. Pre dialysis weight as listed on the Flow Sheet on 12/10/2022 was documented as 76 kg and post dialysis weight was documented as 75 kg. A note at the end of the treatment session documented that the blood flow rate had been decreased by the Nephrologist from 400 to 350. On 12/13/2022 the resident was dialyzed for 180 minutes with the BFR (blood flow rate) as 350 according to the new order from 12/10/2022. The pre-dialysis weight was documented as 69.30 kgs which matched the facility's pre-weight of 152.6 lbs. or 69.3 kgs. The post dialysis weight was documented as 69.3 kg which was not the same weight as the facility had documented post dialysis. The facility had documented 150.4 lbs. or 68.36 kgs. The provider's documentation during dialysis compared to the facility's documentation of weights differed on two of the three days that the resident received dialysis. A Nephrologist's consult dated 12/09/2022 ordered the duration of the dialysis treatment sessions as 2 hours or 120 minutes. The three dialysis sessions that the resident received had a duration of 180 minutes. During the Quality Assurance (QA) interview held on 12/15/2022 at approximately 11:00 AM., there was no reference to residents receiving dialysis by an outside contractor. A review was conducted of the facility's policy related to the Care of a Resident with End-Stage Renal Disease. The Policy statement read: Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care. Under Policy Interpretation and Implementation, point #3 read: Agreements between this facility and the contracted ESRD facility include all aspects of how the resident's care will be managed, including: a. how the care plan will be developed and implemented. b. how information will be exchanged between facilities. A review of the agreement between the facility and the provider of dialysis at the facility. The agreement listed the provider's responsibilities which included coordination between the ESRD IDT (interdisciplinary team) and the facility's IDT; dialysis treatments provided for facility residents based on the written orders by the Nephrologist; consultation provided by the Social Worker and Dietitian regarding the dialysis resident; and incorporation of services provided to the facility's residents into the facility's Quality Assessment and Performance Improvement Program. Shared responsibilities between the provider and the facility included: written communication to include treatment orders, medication orders, patient assessments, and any change in the resident's condition. In addition, shared responsibilities included a collaborative review and revision of care plans. An interview was conducted on 12/14/2022 beginning at 9:14 AM with the Director of Nurses (DON) about the coordination of care between the facility and the dialysis provider. The DON reported that the resident's nurse would check vitals before treatment to ensure the resident was okay for dialysis and after treatment to assess the resident's condition. She confirmed the nurses work 12-hour shifts, but there would be additional notes related to the additional vitals and assessments conducted pre and post dialysis. The DON reported that she would obtain documentation from the dialysis provider for the residents' dialysis treatments as she confirmed the facility did not receive the documentation otherwise. The DON reported that the facility weighed the resident before and after treatment and the dialysis nurse would use those weights for the treatment. The DON added that it was a verbal handoff of the resident's status between the facility nurse and the dialysis nurse that occurred prior to and after dialysis. An interview was conducted by phone with the Nurse Manager of the contracted dialysis service provider (provider) on 12/15/2022 beginning at 9:26 AM. When asked about how patient care was coordinated between the facility (the nursing home) and the dialysis center, she revealed that the dialysis provider's Dietitian and Social Worker monitor the patients monthly with a documented note and they attend care plan meetings with the dialysis center interdisciplinary team monthly. She confirmed that the facility does not attend the dialysis provider's care plan meetings, and notes and care plans from the meetings are not shared with the facility. She reported that the facility nurse and the dialysis provider's nurse conduct a verbal handoff before and after the resident's dialysis treatment.

Based on observation, interview, and medical record review the facility failed to ensure that outside services were collaborated for one (Resident #2) out of three residents sampled with Hospice services. Findings included: 1. On 12/12/2022 at 1:29 PM. Resident #2 indicated that hospice services are following him. He did not recall how often they see him on a weekly basis. He appeared comfortable and in no distress, an adhesive bandage was present to his left forearm that was not dated nor firmly attached to his skin. The area that was not attached revealed a quarter size elevated mass. Resident #2 indicated it was covered because, I scratched it. Review of nursing notes dated 12/13/2022 09:15 Skin/Wound Note Text: Doctor [name of doctor] was notified about patient's skin condition, order given for Dermatology consult. Notes dated 12/13/2022 at 9:36 Skin/Wound Note, Note Text: New orders received for a treatment until the patient is seen by Dermatology. Medical record review of the Admission Record form revealed Resident #2 has resided at the facility for close to a year and is geriatric in age. The diagnosis listed metabolic encephalopathy, respiratory failure, encounter for palliative care dated 7/18/2022. Review of Hospice Initial Certification, date of admission to Hospice 07/18/2022 Primary Hospice Diagnosis; Alzheimer's disease unspecified. Review of Resident #2 care plan Focus: I have terminal prognosis r/t (related to) end stage pulmonary disease, patient it under [name of service] hospice care DX (diagnosis) end stage Chronic obstructive pulmonary disease (COPD), end stage Alzheimer's dementia 07/19/2022 start continuous care. Interventions: Work cooperatively with hospice team to ensure the residents spiritual, emotional, intellectual, physical, and social needs are met. Review of IDT Care Plan Meeting Review dated 10/25/2022 at 11:00 Meeting Attendance did not reflect any Hospice members were in attendance. Review of the Hospice Health Care Binder did not reflect a care plan. On 12/15/2022 at 8:30 AM the Director of Social Services (DSS) was interviewed and asked about Resident #2 hospice care plan. The DSS indicated it was in the Hospice Care Binder. The DSS reviewed the binder and pointed out the Nursing -Updated Comprehensive Assessments and stated, it was the resident care plan. The DSS confirmed she is responsible for coordinating the care conferences and indicated part of the process it to notify hospice. She indicated she had notified hospice about Resident #2's conference that was scheduled but failed to document the notification. On 12/15/2022 at 8:50 AM, the DSS provided a copy of the sign in sheet for Resident #2's Interdisciplinary Care Conference Attendance Record dated 10/25/2022. The DSS pointed to a signature next to attendees listed as other and stated it was from Hospice. The signature was not legible, nor did it contain a title that would indicate who had attended. On 12/15/2022 at 8:55 AM, the Minimum Data Sheet Coordinator indicated she had attended Resident #2's Interdisciplinary Care meeting and she did not remember if a Hospice nurse had attended. Further review of Hospice Nursing -Updated Comprehensive assessment dated [DATE], revealed the nurse had reviewed facility report and had received report from [facility nurse name] nurse. The Comprehensive Assessment was omitted of Resident #2 change in skin condition that was identified on 12/13/2022, nor did it reflect new orders for treatment, and a Dermatology consult. On 12/15/22 at 9:00 AM, an interview was conducted with the Director of Nursing (DON)she confirmed she was not able to identify the signature on the Interdisciplinary Care Conference Attendance Record dated 10/25/2022. The DON additionally confirmed hospice care plans were not in the Hospice Health care Binder. The DON indicated at that time she made a call out to the provider. Review of the policy titled Hospice Program that did not contain a date Policy statement: Hospice services are available to resident at the end of life. Policy Interpretation and Implementation 1. Our facility has an agreement in place with at least one Medicare-certified hospice to ensure that residents who wish to participate in a hospice program may do so. 5. Hospice providers who contract with this facility: a. must have a written agreement with the facility outlining (in detail) the responsibilities of the facility and the hospice agency; and b are held responsible for meeting the same professional standards and timeliness of services as any contracted individual or agency associated with the facility. 9. In general, it is the responsibility of the hospice to manage the residents care as sit relates to the terminal illness and relates to conditions, including the following. A. determining the appropriate hospice plan of care. 10 In general it is the responsibility of the facility to meet the residents personal care and nursing needs in coordination with the hospice representative and ensure that the level of care provided is appropriately based on the individual resident's needs. These responsibilities the following c. notifying the hospice about the following: 1) a significant change in condition in the resident's physical, mental. Social or emotional status. 12. Our facility has designated the social services department to coordinate care provide to the resident by our facility staff and the hospice staff. He or she is responsible for the following a collaborating with hospice representatives and coordination facility staff participation in the hospice care planning process for residents receiving these services. d. Obtaining the following information from hospice: (1) the most recent hospice plan of care specific to each resident. 13. The coordinated car plan will reflect the resident goals and wishes, as stated I his or her advanced directives and during ongoing communication with the resident or representative, including c. medical treatment and diagnosis tests. Review of the Agreement for Nursing Facility, Inpatient and Inpatient Respite Services dated 4/27/21. 1.7 Hospice plan of Care means a written care plan established. Maintained, and modified as necessary) for each Hospice patient by the appropriate Interdisciplinary team. 2.1.7 Plan of Care. Per section 2.1 of Appendix C and Section 2.2 of Appendix D of the agreement, [name of provider] shall establish, modify as appropriate, and provide facility with a copy of Hospice Plan of Care for each Hospice Patient admitted to facility.

Based on interview, and record review the facility failed to prevent unnecessary medication administration for one resident ( Resident #28) out of 4 residents reviewed for unnecessary medications. Related to the administration of a blood pressure medication (Clonidine) out of physician ordered parameters. Findings included: Review of Resident #28's admission record revealed he was admitted to the facility on [DATE] from an acute care hospital with diagnoses that included but not limited to encounter for orthopedic aftercare following surgical amputation, acquired absence of right leg below the knee, acquired absence of left leg below the knee, type 2 diabetes mellitus with diabetic chronic kidney disease, end stage renal disease, dependence on renal dialysis, and hypertension. Review of Resident #28's physician orders revealed an order for Clonidine HCL tablet 0.2 mg (milligrams) give 1 tablet by mouth every 6 hours for HTN SBP (hypertension systolic blood pressure) greater than 160 mm HG (millimeters of mercury) with a start date of 9/15/2022 and discontinued on 12/14/2022. Review of Resident #28's medication administration record (MAR) for December 2022, revealed 0.2 mgs of Clonidine was administered out of the physician ordered parameters 21 times out of 54 opportunities. Further review of Resident #28's MAR for the month of November revealed 0.2 mgs of Clonidine was administered out of the physician ordered parameters 55 times out of 120 opportunities. An interview and record review with the facility's Assistant Director of Nursing (ADON) was conducted on 12/14/22 at 1:00 PM; The ADON reviewed the Clonidine order and stated the resident should get Clonidine when his systolic blood pressure is above 160. The DON reviewed the December MAR and confirmed Resident #28 received Clonidine when his systolic blood pressure was below 160. An interview was conducted with the Director of Nursing (DON) on 12/14/22 at 1:38 PM, the DON revealed that after she was asked to print out the pharmacy recommendations she recognized the Clonidine was given out of parameters and the facility started education with all the nurses. The physician was called, and he came in early and evaluated the resident to ensure there was no adverse reactions. The DON stated: I take this very seriously and there will be disciplinary action for the nurses who administered the medication out of parameters. Review of the physician note dated 12/14/22 at 1:31 PM revealed: Patient was reevaluated today to clarify Clonidine orders. Pt (patient) is hemodynamically stable, Pt is oriented about his diagnosis, prognosis, treatment, and medication s/e [side effect]. All labs test results reviewed. Pt . discussed with staff to D/C [discharge] planning. I ordered to change Clonidine order to (0.1 mg) PO (by mouth) every 6 hours PRN [as needed] if BP [blood pressure] equal or more than 160/90. The RN [Registered Nurse] was advised call me if any abnormality occurs. Review of Resident #28's care plan initiated on 9/15/2022 revealed: Focus: I have altered cardiovascular status r/t [related to] hypertension, PVD [peripheral vascular disease], hyperlipidemia. Goal: I will be free from s/sx [signs/symptoms] of complications of cardiac problems through the review date. I will exhibit reduction of my cardiac symptoms through the review date. Interventions include but are not limited to Administer medications as ordered. Monitor effectiveness and for side effects . The facility's unnecessary medications policy provided revealed Psychotropic Medication Use undated, revealed Policy statement Residents will not receive medications that are not clinically indicated to treat a specific condition .

Based on observation, interviews and record review, the facility's staff failed to ensure infection control prevention measures and policies were implemented resulting in immediate jeopardy, as evidenced by 1) Failure to appropriately disinfect the multiple patient use glucometer, during observation of routine blood glucose testing Staff failed to properly disinfect the multi patient glucose monitoring device resulting in the likelihood of cross contamination and infection of a blood-borne pathogen and /or virus for 7 out of 18 residents observed (Residents #8, #12, #21, #28, #29, #30, and #45) that required blood glucose checks. 2) Facility Staff failed to dispose of sharps appropriately. 3) Facility Staff failed to practice appropriate hand hygiene and infection prevention control measures for 10 out of 19 residents observed during the medication administration. (Residents #8, #12, #21, #28, #29, #30, #32, #45, #256, and #302). These deficient practices have the potential to affect 56 residents residing in the facility at the time of this survey. It was determined Immediate Jeopardy (IJ) existed related to infection control and prevention based on the facility's failure to appropriately disinfect the blood glucose monitoring device/glucometer that was being used for 7 (Residents #8, #12, #21, #28, #29, #30, and #45 residents) out of 18 residents observed that required blood glucose checks. The likelihood existed for cross contamination, increased risk for exposure and being infected with bloodborne pathogens through the use of contaminated blood glucose monitoring equipment. This also increased the likelihood of serious harm that could create life-threatening diseases and complications/conditions to any of the 18 residents residing in the facility with physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] On April 07, 2021 at 6:01 PM, the facility's Administrator, the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were notified that Ongoing Immediate Jeopardy existed for infection control F880-Scope and Severtiy(S/S)-K. The findings included: Review of the facility's document titled: Blood Sampling-Capillary (Finger Sticks) Policies and Procedures (undated) revealed: Policy Purpose: The purpose of this procedure is to guide the safe handling of capillary-blood sampling devices to prevent transmission of bloodborne diseases to residents and employees. Equipment and Supplies: 1-Alcohol [MEDICATION(S)]; 2-Disinfected blood glucose meter (glucometer) with sterile lancet; or single resident use spring-loaded device (Penlet) or automatic or safety type lancet; 3-Disposable lancet; 4-Personal protective equipment (e.g., gloves); 5-Sharps container; and 6-Approved Environment Protection Agency (EPA) registered disinfectant for cleaning of sampling device. General Guidelines: 1-Always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses. Single-resident use fingerstick devices (pen-like devices) should never be used by more than one resident. 2-The lancets and platforms must always be changed after use on each resident. 3-handle the lancet as a used needle. Steps in the Procedure: 1-Wash hands. 2-Don gloves. 3-Place blood glucose monitoring device on clean field. 4-Place a new lancet and disposable platform on the spring-loaded finger-stick device. 5-Wipe area to be lanced with alcohol [MEDICATION(S)]. 6-Obtain the blood sample, following the manufacturer's instructions for the device. 7-Discard lancet and platform into the sharp's container. 8-Following the manufacturer's instructions, clean and disinfect reusable equipment, parts, and/or devices after each use. 9-Remove gloves, and discard into appropriate receptacle. 10-Wash hands. 11-Replace blood glucose monitoring device in storage area after cleaning. Review of the facility's glucometer manufacturers guide (page 14) revealed instruction titled Cleaning and Disinfecting the Meter indicates: To minimize the risk of transmitting blood-borne pathogens, the cleansing and disinfection procedure should be performed as recommended in the instructions below. The meter should be cleaned and disinfected after use on each patient. The Assure prism multi Blood Glucose monitoring system may only be use for testing multiple patients when standard precautions and manufacture's disinfection procedures are followed. Cleaning and Disinfection: The cleaning procedure is needed to clean dirt, blood, and other bodily fluids off the exterior of the meter before performing the disinfection procedure. The Disinfection procedure is needed to prevent the transmission of blood borne pathogens. A variety of the most commonly used EPA-registered wipes have been tested and approved for cleaning and disinfecting of the Assure prism multi Blood Glucose Monitoring System. Manufacturer disinfectant brand name: Germicidal wipes, Super Sani - Cloth Germicidal Disposable Wipes . Note: indicates two disposable wipes will be needed for each cleaning and disinfecting procedure; one wipe for cleaning and a second wipe for disinfecting. 1. Observation on 04/06/2021 at 11:28 AM revealed, Licensed Practical Nurse (LPN), Staff A completed a blood glucose check for Resident # 45. Staff A stated that she was going to disinfect the glucometer. At 11:32 AM, Staff A proceeded to the medication cart, retrieved a small white nonglossy packet containing an alcohol swab and cleaned the glucometer then placed it back into the medication cart's top drawer. On 04/06/2021 at 11:46 AM, Resident # 45 stated that his blood glucose checks are done every day before meals and at bedtime. Resident # 45 stated that he did not need any insulin coverage today because his blood sugar was good. Review of clinical records for Resident # 45 revealed, an admitted [DATE]. The clinical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident # 45's Brief Interview of Mental Status(BIMS) revealed a score of 10 out of 15 indicating the resident is moderately impaired cognitively. Review of Resident #45's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Inject as per sliding scale:, subcutaneously before meals and at bedtime related to type 2 diabetes mellitus without complications. 2. On 04/06/2021 at 4:02 PM, observation of blood glucose monitoring and interview with Registered Nurse (RN), Staff E revealed, Staff E placed glucose testing supplies lancet, tests strips, alcohol pads and glucometer that was retrieved from the top drawer of the medication cart on a white foam tray. Staff E entered the residents' room and performed hand hygiene, donned gloves, and completed blood glucose check for Resident #30. Staff E told the resident the blood glucose result and explained no insulin coverage is needed and disposed used supplies in the sharp container, removed gloves and exited the room. Staff E returned to the medication cart donned gloves, retrieved one germicidal wipe from a white and purple container, cleaned the glucometer and placed it in the top drawer of the med cart. Removed gloves and performed hand hygiene. Staff E was asked what the procedure was for disinfecting the glucometer. Staff E stated that the blood glucose monitors should be cleaned with a bleach wipe after each use. Review of Resident # 30's clinical records revealed an admitted [DATE]. Clinical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident # 30's Brief Interview of Mental Status(BIMS) revealed a score of 15 out of 15 indicating the resident is cognitively intact. Review of Resident # 30's POS revealed orders for [MEDICATION(S)] Solution 100 unit/ml(milliters) (Insulin [MEDICATION(S)] Human) Inject as per sliding scale subcutaneously before meals and at bedtime for diabetes. On 04/06/2021 at 4:12 PM, Resident # 30 revealed during an interview that she was in the facility because of because she had diabetes and was recovering from COVID-19. 3. On 04/06/2021 at 4:16 PM observation and interview of blood glucose monitoring for Resident #21 with LPN, Staff F revealed, Staff F placed the glucose testing supplies on a white foam tray (to include lancet, tests strips in small medication cup, alcohol pads) and retrieved the glucometer from top drawer of the medication cart. Staff F entered the Resident's room identified the resident, performed hand hygiene, donned gloves, performed blood glucose testing, disposed of the lancet and test strip in the sharps container removed gloves. Staff F returned to the medication cart Staff F donned gloves and retrieved one germicidal wipe from the container located on the lowest drawer of the medication cart and wiped the glucometer and placed it directly on the top of the cart then removed gloves and performed hand hygiene. Staff F stated that the glucose meter must be disinfected with the wipe after each use. Review of clinical records revealed Resident # 21 was admitted to the facility on [DATE] with clinical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident # 21's Brief Interview of Mental Status (BIMS) revealed a score of 15 out of 15 indicating Resident #21 is cognitively intact. On 04/06/2021 at 4:40 PM Resident # 21 revealed, she was in the facility because she had shortness of breath and was in the hospital then she came to this facility and had to be treated for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident # 21's POS revealed orders for [MEDICATION(S)] Solution 100 unit/ml (Insulin [MEDICATION(S)] Human) Inject as per sliding scale subcutaneously before meals and at bedtime for diabetes. 4. On 04/07/2021 at 6:31 AM, observation of blood glucose monitoring for Resident #8 performed by Staff B, RN revealed, Staff B prepared the supplies for the blood glucose monitoring that included alcohol pads, lancets, test strips (entire bottle) and glucometer, placed supplies on disposable white foam tray and entered the room. Staff B placed the supplies on the resident's overbed table and went to wash his hands while the tray with the supplies were left unattended at the beside. The nurse donned gloves and did blood sugar test then disposed of the used lancet, used test strip that was visibly soiled with blood and alcohol pad that was visibly soiled with blood into the regular trash. Staff B then exited the resident's room and went to the medication cart and placed the glucometer directly on top of the cart. Staff B did not perform hand hygiene. Review of clinical records for Resident # 8 revealed an admitted [DATE]. Clinical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident # 8's POS revealed orders for [MEDICATION(S)] Solution 100 unit/ml (Insulin [MEDICATION(S)] Human) Inject as per sliding scale subcutaneously two times a day for diabetes. On 04/07/2021 at 6:53 AM, Staff B, RN did not perform hand hygiene and proceeded to prepare medications for Resident # 256 but the medication was not available. 5. Observation on 04/07/2021 at 6:35 AM, Staff B, RN did not perform hand hygiene and proceeded to prepare medications and blood glucose monitoring supplies for Resident #21 (to include alcohol pads, lancets, bottle of test strips) retrieved another glucometer from the top drawer of the medication cart. Staff B placed the oral medications that were in a med cup (Synthroid a [CONDITION(S)] medication and [MEDICATION(S)] a medication used for Gastro [CONDITION(S)] Reflux Disease/ GERD) and blood glucose supplies on a white foam tray. Staff B performed hand hygiene and, donned gloves, performed the blood glucose check, placed used lancet, used alcohol swabs, used test strips (visibly soiled with blood) on the tray that had the medications, proceeded with administering the resident's oral medications. Staff B then used an alcohol swab to clean the glucometer, removed gloves and disposed of the used medication cup, the used lancet, the used test strip and alcohol swab that was visibly soiled with blood was disposed into the regular trash in the resident's room. Staff B exited the room went to the medication cart, placed the bottle with the test strips on top of the medication cart. Staff B was asked what was the policy for disinfecting shared supplies such as the glucometer. Staff B stated that the equipment is disinfected with alcohol and did not perform any further disinfecting of the glucometer and did not perform hand hygiene. 6. Observation on 04/07/2021 at 7:06 AM, Staff B, RN did not perform hand hygiene, prepared medication (Levothyroxine, a [CONDITION(S)] medication) for Resident # 32, Staff B entered the resident's room and placed the medication on the overbed table located on the left hand side of the resident's bed. There was a urinal on the overbed table with yellow amber colored urine. Staff B performed hand washing, donned gloves and gave the medication by mouth to the resident. Staff B removed the gloves and threw them in the garbage along with the used medication cup and exited the room, leaving the urinal with the urine on the table with the cup containing water on the overbed table (photographic evidence). No hand hygiene was performed, Staff B returned to the medication cart did not perform hand hygiene and signed out the medication on the computer. Review of clinical records for Resident # 32 revealed an admitted [DATE]. Clinical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 7. Observation on 04/07/2021 at 7:11 AM Staff B did not perform hand hygiene and proceeded to prepare medications and blood glucose testing supplies (to include, the bottle with test strips, 1 lancet, alcohol pads and glucometer) for Resident # 12. Staff B, RN prepared the medications in a small med cup and placed the items on a white foam tray. Staff B entered the resident's room and placed the tray with medication and supplies on the overbed table, performed hand hygiene and donned gloves. Staff B then left the room stating he was going to get water and went to the medication cart, poured water into a cup and returned to the room. Staff B gave the oral medications and pricked the residents finger, Staff B stated that he needed to get another lancet to prick the resident's finger. Staff B removed his gloves and went to the medication cart and retrieved a lancet from the top drawer of the medication cart. Staff B returned to the room, performed the blood glucose check and at 7:25 AM staff B used an alcohol swab to clean the glucometer, removed gloves and disposed of the used lancets, the visibly soiled test strips with blood and used alcohol pads into the regular garbage and exited the room. Staff B returned to the medication cart and placed the glucometer directly on top of the medication cart along with the bottle of test strips and no hand hygiene was performed. Clinical record review, revealed Resident # 12 was admitted to the facility on [DATE]. Clinical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #12 POS revealed orders for [MEDICATION(S)] Solution 100 unit/ml (Insulin [MEDICATION(S)] Human) Inject as per sliding scale subcutaneously before meals and at bedtime. 8. Observation on 04/07/2021 at 7:28 AM, Staff B proceeded to prepare medications for Resident # 29. Staff B did not perform hand hygiene prior to preparing medications. Staff B poured liquid medication (Sucralfate and [MEDICATION(S)], medications for Gastroesphageal Reflux Disease [GERD]). Staff B then placed the glucometer, bottle with test strips, 1 lancet and alcohol swabs on a white foam tray entered the resident's room. The resident refused the oral medications, but agreed to have blood glucose checked. At 7:32 AM Staff B donned gloves and performed blood glucose check, wiped glucometer with alcohol pad, removed gloves, disposed gloves, used lancet, used test strip and alcohol pads in the garbage and exited room. Staff B placed the glucometer on the cart with the bottle of test strips. Staff B informed the oncoming nurse who was standing in the hallway that the resident refused the medication. Staff B then returned to Resident # 29's room and flushed the medications in the toilet, did not perform hand hygiene and returned to the medication cart and documented blood glucose results and stated that no insulin coverage was required. Resident # 29's clinical records revealed an admitted [DATE]. Review of the Brief Interview of Mental Status (BIMS) indicated a score of 15 out of 15, meaning Resident #15 is cognitively intact. Clinical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the clinical records revealed orders for [MEDICATION(S)] Solution 100 unit/ml (Insulin [MEDICATION(S)] Human) Inject as per sliding scale subcutaneously before meals and at bedtime for Diabetes. 9. Observation on 04/07/2021 at 7:40AM, Staff B did not perform hand hygiene, prepared medication (Omeprazole a medication for GERD and [MEDICATION(S)] a blood pressure medication) for Resident # 302. Staff B entered the resident's room placed medications on the overbed table, performed hand washing donned gloves gave medications, removed gloves placed all used supplies in the trash and left the room and went back to the medication cart. Review of the clinical records revealed Resident # 302 was admitted to the facility on [DATE]. Clinical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 04/07/2021 at 8:05 AM during an interview Staff B was asked to explain the blood glucose monitoring glucometer disinfecting process. Staff B stated, that the order is checked in the computer then I put the alcohol to clean the glucometer, I get the strip, the lancet with the needle, alcohol pad on the tray to test the sugar. When I finish, I take off the gloves and throw everything in the trash. Staff B was asked what was the facility's policy and what is the correct way to clean the glucometer. Staff B stated, to clean the glucometer, I use the alcohol pad, I clean the glucometer before every use. That is the facility protocol. Staff B was asked about trainings received for infection control. Staff B stated, the training was provided by the infection control nurse for hand washing. Staff B was asked to explain when should hand hygiene be performed; Staff B stated, I only have to do hand hygiene when I go to do the next patient. Staff B was asked about disposing of sharps, and biohazardous waste. Staff B stated that the sharps should be disposed of in the sharps container and Biohazards are disposed of in the red container. Staff B was asked why he did not perform hand hygiene after removing gloves, before preparing medications. Staff B responded, I only need to do hand hygiene before I put on the gloves and go to the next patient. Staff B stated that because he wore the gloves he does not have to do hand hygiene again. Staff B was asked what the facility's policy and requirements is for disinfecting shared equipment such as the glucometers. Staff B stated, we disinfect the shared equipment such as oximeter, glucometer, blood pressure equipment and thermometer with alcohol swabs. Record review of the Handwashing/Hand Hygiene Policy and Procedures (Date Written-non available; Date Revised-non available) revealed: Policy Statement: The facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation: 1-All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections 2-All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 5- Wash hand with soap (antimicrobial or non-antimicrobial) and water for the following situations: a-When hands are visibly soiled; and b-After contact with a resident with infectious diarrhea including, but not limited to infections caused by norovirus, salmonella, shigella and Clostridioides Difficile. 6- Use an alcohol-based hand rub containing at least 60% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: c-Before preparing or handling medications; m-After removing gloves. 8-The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. 9-Single-use disposable gloves should be used. Review of the facility's policy titled, Infection Prevention and Control Program (IPCP), Revised October 2018: The policy statement documented, the IPCP is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The Policy Interpretation and Implementation section included, the infection prevention and control program is developed to address the facility-specific infection control needs and requirements identified in the facility assessment and the infection control risk assessment.This program is reviewed annually and updated as necessary. The Policies and Procedures section indicated these items: a. Policies and procedures are utilized as standard of infection prevention and control program. b. Policy and procedure reflect the current infection and control standard of practice. c. The infection prevention and control committee, Medical Director, Director of Nursing Services, and other key clinical and administration staff review the infection control policies at least annually. Assessment of staff compliance with existing policies and regulations. Prevention of Infection section, Item #8 indicated that the important facets of infection prevention includes following established general and disease-specific guidelines such as those of the Centers for Disease Control (CDC). The section for Monitoring Employee Health and Safety item #2, a protocol is in place for managing those who stick themselves with a needle that was possibly or actually in contact with blood or body fluids. 10. On 04/07/2021 at 11:19 AM observation of blood glucose check performed by Staff A, LPN revealed, Staff A stated she had 8 blood glucose checks to be completed and Resident # 28 was the last one. Staff A prepared supplies (to include 2 test strips placed in small medication cup, 1 lancet, 3 alcohol swabs and the glucometer). Staff A entered the resident #28s room, verified the correct resident, and explained to the resident what would be done. Staff A placed the supplies on the overbed table and performed hand hygiene, donned gloves, and completed the blood glucose check. Staff A revealed the blood glucose level was 301 and required insulin coverage. Staff A disposed of the test strips, and used lancet in the sharp container and removed gloves. Staff A went to the medication cart performed hand hygiene and cleaned the glucometer with a germicidal wipes. Staff A then placed the glucometer into the top drawer of the medication cart. Staff A retrieved the insulin quick pen containing [MEDICATION(S)], two alcohol pads and placed them on a white foam tray. Staff A re-entered the resident's room cleaned the pen with an alcohol pad and dialed up six units of insulin, wiped the area on the upper right quadrant of the resident's abdomen and removed the needle from the quick pen and discarded it in the sharp container. Staff A was not wearing gloves during the insulin administration. Staff A performed hand washing and returned to the cart. Review of the clinical records revealed, Resident # 28 was admitted to the facility on [DATE]. Clinical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] = 0 units; 201 - 250 = 2 units; 251 - 300 = 4 units; 301- 350 = 6 units; 351 - 400 = 8 units; 401+ = 10 units . Call MD if BG>401, subcutaneously before meals and at bedtime for type 2 Diabetes Mellitus without complication. Record review of Subcutaneous Insulin Policy and Procedures (Nursing Care Center Pharmacy Policy and Procedures Manual 2007; Date Revised-non available) revealed: Policy: To administer subcutaneous insulin as ordered and in a safe, accurate and effective manner. Equipment: 1- Safety insulin syringe or pen device and sterile safety needle of appropriate gauge. 2-Insulin as ordered. 3-Antimicrobial agent for medication product (such as alcohol swab). 4- Antimicrobial agent for resident's skin (such as alcohol swab). 5-Gloves. 6-Antimicrobial agent for hand hygiene. Procedures: 11-Put on gloves. On 04/07/2021 at 1:05 PM, Staff A was asked if training was provided for infection control, what is the procedure for blood glucose monitoring, blood glucose machine disinfecting, hand hygiene, glove use and administering injectables. Staff A stated that for blood glucose checks she verified the order, take the glucometer, place it on the tray, put test strips in a cup, and put lancet and alcohol swabs on a tray; verify the patient, put the tray on the table, wash hands, put on gloves, and do blood sugar. Staff A stated, after I finish, I put the dirty stuff in the sharp container, take off gloves, wash my hands, clean the glucometer with the towels and leave it to dry. Staff A was asked why the glucometer was not disinfected with the germicidal wipes on 04/06/2021 after she completed blood glucose check. Staff A explained that each cart has two glucometers and the glucometer should be cleaned with the germicidal wipes. Yesterday after the blood sugar test I made a mistake when I cleaned it with an alcohol pad. Staff A was asked what the facility policy is for administering injections, Staff A stated, when giving the injection sub [subcutaneous] q I clean the skin with alcohol and give the injection. Staff A was asked if gloves are required when administering an injection and what is the policy after administering an injection. Staff A stated, when giving an injection I am supposed to wear gloves and I made a mistake removing the needle from the pen, I made a mistake. On 04/07/2021 at 1:35 PM during an interview with the the Director Of Nursing (DON) and the Infection Preventionist (IP) it was revealed by the DON that each medication cart has two glucose testing machines available on the cart. After use one is cleaned and left to dry and the other is available for use. All the machines are cleaned with Sani Wipes and left to dry for 3-4 to minutes After accuchecks, the nurse should clean the machine thoroughly with the Sani Wipes and leave it to dry. After the machine is rubbed with the Sani Wipes chemical they are to put it on a tray or in a cup to air dry in the cart. The nurses are not supposed to leave the glucometer unattended on the cart. For injectables, standard protocol is to wear gloves. The insulin quick pen needles are retractable and during removal of needles the nurse should wear gloves at all times and wash hands after. The DON was asked, when were the last trainings related to injectables and infection control. The DON stated that trainings are done as soon as issues are identified and that recent trainings were done for injectables. The DON was asked about the facility's policy related to sharps disposal including used blood glucose testing supplies. The DON stated that the facility's policy on sharps disposal indicates anything that is considered sharp should be placed in the sharps disposal in the room. The supplies after the blood glucose check, the lancet should be disposed of in the sharps either in the room or on the cart. The Infection Preventionist revealed that she completed the CDC modules in October 2020 for the Infection Control Preventionist. The IP revealed that she is responsible for the trainings for infection control that includes COVID-19 training, handwashing [Personal Protective Equipment] PPE, blood borne pathogen training was completed and disinfecting of shared equipment and reusable equipment. The DON stated that because the Infection Preventionist was new in her role, she worked along with the Infection Preventionist. The Infection Control Preventionist stated that the facility has not had any residents with any blood-borne infections in house at this time. Review of the facility's Infection Control training records for 2020 with the IP revealed, the in-service covered disinfection of reusable equipment and blood-borne infections/transmission. OSHA: Occupational Exposure to blood borne pathogens October 13, 2020 and included blood-borne infections and how it is transmitted. March 6, 2020 biohazard training to include sharps disposal. The Infection Preventionist revealed that the most recent training for handwashing was on February 2, 2021. The infection control preventionist presented training provided related to the glucometer and stated that the glucometer training and handwashing training was done on April 01, 2021. The Infection Preventionist was asked what the expectation and facility policy is for disinfecting of the glucometer. The Infection Preventionist stated, the nurses are supposed to clean the machine with alcohol before and after each use. Each cart has two blood glucose machines. After each blood glucose check the used supplies (sharps, lancets) should be disposed of in the Biohazard sharp container in the room. The nurse should get a tray and place the machine the alcohol get the strips and lancet the nurse should take the entire bottle into the room. After finished they should clean the machine wash hands before and after including after removing gloves. On 04/07/2021 at 5:54 PM the identified concerns related to infection control was discussed with the Administrator (NHA), the DON, and the Assistant Director of Nursing. It was revealed that the facility will immediately conduct trainings to address the identified concerns. On 04/07/2021 at approximately 6:32 PM, the DON and the Infection control Preventionist stated that the Infection Preventionist made a mistake and meant to say that the glucometer is disinfected with the wipes and presented a packet with the germicidal wipes. The Infection Preventionist stated, they are the same. The DON and the Infection Preventionist were informed that the alcohol wipes/pads and the germicidal wipes are not the same and the active ingredients are not the same. The Immediate Jeopardy Removal Plan provided by the facility on 4/8/21 included: Measures put in place: Staff Training on the policy for disinfection and utilizing the correct infection control procedures. Competency with return demonstration. Nurses to be trained on competency and self-test for glucometer cleaning. Medication carts would be audited to assure that two blood glucose meters are present. Medication carts would be audited to assure that Germicidal Wipes are present. Thereafter - On 4/7/21 the nurses (Staff A) and (Staff B) identified were provided one on one education by the Director of Nursing with return demonstration on proper cleansing and disinfection of glucometers. On 4/7/21, licensed nursing staff were in-serviced by the Director of Nursing on the policy and procedure for cleaning and disinfection of the glucometer, instruction on proper glucometer use and performed returned demonstration to ensure c

Based on observation, interviews and record review, the facility failed to ensure a medication error rate of less than 5% during the medication administration observation. As evidenced by a medication error rate of 10% out of 50 opportunities observed 5 omission errors for 5 out of the 17 residents observed for medication administration (Resident, #8, #12, #21, #256, and #353). There were 56 residents residing in the facility at the time of the survey. The findings included: 1. On 04/07/2021 at 6:05 AM, observation revealed Staff B a Registered Nurse (RN), exiting Resident # 13's room. Staff B stated, he worked the 7:00 PM to 7:00 AM shift and had finished administering all the medications for the shift because he had an hour before and an hour after to give the medications, he started the med pass at 5:20 AM and was finished for the shift with medications, including the blood glucose checks for all the residents on the assignment. Upon review of the Electronic Health Records system, it was revealed that the medications and blood glucose checks were not all signed off as administered. At 6:10 AM Staff B was asked to show the blood glucose information and medications administered for randomly selected Resident #8. Upon review of the Electronic Health Records system, it was revealed that the medications and blood glucose checks were not all signed off as administered. Staff B stated, that the blood glucose was checked and it was 120. Staff B, was unable to show that medications and blood sugars were signed off and documented on the computer. Staff B then pulled the glucometer equipment and scrolled through and then stated he made a mistake, and the glucose level was 138 for resident #8. Furthermore, the date on the glucometer with the reading provided by Staff B was dated 04/04/2021. At 6:20 AM, in the presence of Staff B, the supervisor was asked about the facility's policy after medications are administered and when blood glucose checks are completed. The supervisor stated that the nurses are required to document and sign off in the computer immediately after the medications are administered and immediately after blood glucose checks are done. Staff B then revealed that he had not completed administering all the medications and blood sugars checks. Review of the facility's policy titled, Documentation of Medication Administration Policy and Procedures (undated) revealed: Policy Statement: The facility shall maintain a Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident # 8's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] = 0 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301- 350 = 8 units; 351 - 400 = 10 units; 401+ = 12 units. Call Medical Doctor (MD) if blood glucose is greater than (BG>) 401, subcutaneously two times a day for diabetes. Further Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of clinical records for Resident # 8 revealed and admitted [DATE]. Clinical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The [MEDICATION(S)] was omitted. 2. On 04/07/2021 at 6:35 AM, observation revealed Staff B, RN did not perform hand hygiene and proceeded to prepare medications for Resident #21. Staff B verified the orders in the computer and proceeded to prepare ordered medications; [MEDICATION(S)] Tablet Delayed Release 40 milligram (mg) Give 1 tablet by mouth one time a day related to [CONDITION(S)] (GERD). [MEDICATION(S)] Tablet 150 microgram (mcg). Give 1 tablet by mouth one time a day for low [CONDITION(S)] related to [CONDITION(S)]'s Disease to be administer at 06:00. Staff B started searching the cart for ordered respiratory medication, [MEDICATION(S)] Aerosol Solution 20-100 mcg/actuation solution (Ipratropium-Albuterol) 1 puff inhale orally every 8 hours related to shortness of breath. Administration times ordered 0600, 1400 and 2200. Staff B searched the cart for the [MEDICATION(S)] and stated it was not available. Staff B left the medication cart (screen open on computer) and went to let the night supervisor know that the [MEDICATION(S)] was not available. The supervisor went to the medication room and checked in the emergency medications and stated the medication was not available in the emergency medication supply. On 04/07/2021 at 6:50 AM, the Director of Nursing (DON) came to the medication cart and searched the cart for the missing [MEDICATION(S)] for Resident # 21. and confirmed that the medication was not available. The DON stated, the pharmacy and the doctor would be contacted. The [MEDICATION(S)] was omitted. 3. On 04/07/2021 at 6:53 AM, Staff B, RN did not perform hand hygiene and proceeded to prepare medications for Resident # 256. The ordered medication [MEDICATION(S)] 40 mg. Give 1 tablet by mouth one time a day related to [CONDITION(S)] (GERD), to be given at 0600 was not available on the cart. Staff B then notified the supervisor and checked the emergency medication supply but the medication was not available in the emergency supply. Staff B stated that the medication was a new order that is why it was not available. Review of clinical records revealed, Resident # 256 was admitted to the facility on [DATE]. Clinical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Give 1 tablet by mouth one time a day related to Gastro [CONDITION(S)] Reflux Disease with a start date 4/3/2021 to be administered 06:00. Review of the Electronic Medication Administration Records (EMAR) revealed, staff had signed off on 04/03/2021, 04/04/2021, and 04/05/2021 that the medication was administered. Staff B did not provide an explanation with the discrepancy. The [MEDICATION(S)] was omitted. 4. On 04/07/2021 at 7:11 AM Staff B did not perform hand hygiene and proceeded to prepare ordered medications for Resident #12 [MEDICATION(S)] tablet 50 milligram (mg). Give 1 tablet by mouth three times a day for anxiety scheduled to be administered at 0600. [MEDICATION(S)] tablet 20 mg. Give 1 tablet by mouth three times a day related to pulmonary hypertension, to be administered at 0600. [MEDICATION(S)] tablet delayed release 40 mg. Give 1 tablet by mouth one time a day related to Gastro [CONDITION(S)] Reflux Disease without Esophagitis. To be administered at 0600. [MEDICATION(S)] tablet 300 mcg. Give 1 tablet by mouth one time a day related to [CONDITION(S)] to be administered at 0600. Staff B stated that the [MEDICATION(S)] 300 mcg was not available. The [MEDICATION(S)] was omitted. Review of clinical records revealed Resident # 12 was admitted to the facility on [DATE]. Clinical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of facility's document titled, administering medications (Revised 09/2020); policy statement indicate: Medications are administered in a safe and timely manner, and as prescribed. The policy interpretations items included: The Director of Nursing Services supervises and directs all personnel who administer medications and /or have related functions. Medications are administered in accordance with prescribed orders, including any required time frame. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example before and after meal orders). The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. The following information is checked /verified for each resident prior to administering medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . Vital signs, if necessary. 18. Staff follows established facility infection control procedures (e.g.; handwashing, antiseptic technique, gloves, isolation precautions etc.) for administration of medications as applicable . Wash hands. Arrange supplies in medication room or move the medication cart outside the resident's room. Place the MAR [Medication Administration Record] within easy viewing distance. Check the medication dose. Recheck to confirm the proper dose. Prepare the correct dose of medication. For liquid medications. Remove the cap from the bottle and place cap upside down on the work surface. Hold the medication cup at eye level and use your thumb to mark the desired level on the cup. Fill to the bottom of the meniscus at the desired level. Place cup on a level surface and read the poured amount at eye level to check accuracy. On 04/07/2021 at 8:05 AM, during an interview with Registered Nurse Staff B regarding the identified concerns with medication administration and infection control was discussed with Staff B. Staff B was asked to explain the ordering and reordering residents' medications. Staff B stated that the medication availability is checked every shift as soon as the supply is needed because the orders are done through the computer. Staff B was asked what the timeframe is to reorder medications and stated as soon as possible but was unable to give a definite timeframe that medications should be reordered. Staff B could not explain the discrepancies related to the medications that were not available. On 04/07/2021 at 5:54 PM the identified concerns related to infection control and medication administration was discussed with the Administrator (NHA), the DON, and the Assistant Director of Nursing. It was revealed that the facility will immediately conduct trainings to address the identified concerns. 5. On 04/08/2021 at 10:18 AM, observation of medication administration for Resident # 353 performed by Licensed Practical Nurse, Staff H performed hand hygiene, prepared [MEDICATION(S)] HCI tablet 20 mg(milligram), [MEDICATION(S)] mix in [NAME] packet 17 gram 1 packet mixed with cup of water, Multivitamins with minerals 1 tablet and [MEDICATION(S)] tablet 2.5 mg 1 tablet. Staff H stated that the [MEDICATION(S)] Patch 4% was not available. Staff H was asked what the process for missing medications is. Staff H stated that the pharmacy should be notified and the doctor and document. Staff H explained that the missing medications were ordered that day and should be received later from pharmacy. Staff H explained that sometimes medications that are not available are due to new admission and usually arrive with 24 hours. Review of physicians' orders revealed [MEDICATION(S)] tablet 1 milligram, give 1 tablet by mouth one time a day related to malignant neoplasm, [MEDICATION(S)] HCI tablet 20 mg. Give 1 tablet by mouth one time a day related to major depressive disorder (0900), [MEDICATION(S)] mix in [NAME] packet 17 gram . Give 1 packet by mouth one time a day related to constipation. Multivitamins-mineral tablet. Give 1 tablet by mouth one time a day for supplement. [MEDICATION(S)] Patch 4%. Apply 1 patch transdermally two times a day related to fracture of other parts of pelvis, on 0900 off 2100. [MEDICATION(S)] tablet 2.5 mg. Give 1 tablet by mouth two times a day for DVT[Deep Vein Thrombosis]. Review of clinical records revealed Resident # 353 was admitted to the facility on [DATE]. Clinical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The [MEDICATION(S)] patch was omitted.

Based on observation, interview, and record review, the facility failed to ensure that dignity was maintained during dining as evidenced by: 1) Disposable drink ware provided in the 4th floor dining room, and 2) Staff standing up while assisting a resident (resident #309) with eating. There was a total of 117 residents present in the facility at the time of this survey. The findings included: Record review of the facility's policy and procedures titled, Resident Rights, undated, revealed, Employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a dignified existence. 1) During a dining observation of the 4th Floor Dining Room on 06/25/19 at 11:41 am revealed, out of the seven residents in the dining area, five of the residents had disposable cups with beverages in them; only two residents in the dining area had regular cups. Staff members were observed providing residents with water in the disposable cups. During a second dining observation of the 4th Floor Dining Room on 06/26/2019 at 11:33 am revealed, in the dining area at each of the tables where residents were seated there were disposable cups set up in the center of the tables. Further observation at 11:38 am revealed, a nursing staff member pouring two cups of juice in two disposable cups for a resident seated at one of the table; however, the resident had a regular cup at the table. Interview with the Nurse Supervisor (Staff E) and the Director of Nursing (DON) on 06/27/2019 at 2:34 pm revealed, Staff [NAME] reported, there was an issue in the kitchen involving the tray line related to the cups, and to avoid any inconvenience with the residents she decided to provide them with disposable cups. The DON stated, they were not supposed to be using disposable cups. 2) During the dining observation of the 4th Floor South Hallway on 06/25/2019 at 11:50 am revealed, in room [ROOM NUMBER], Registered Nurse (Staff F) was feeding resident #309 while standing up. Staff F looked and saw that she was being observed and continued feeding the resident while standing up. Observation on 06/25/2019 at 11:57 am revealed, Staff F was still feeding resident #309 while standing. Further observation at 12:09 pm revealed, Staff F was still standing while feeding the resident. Interview with Staff F on 06/27/2019 at 2:24 pm revealed, the reason she was standing up while feeding resident #309 was for safety reasons, but she could sit down while feeding the resident.

Based on interview and record review, the facility failed to support one (resident #81) sampled resident for Choices related to not being able to select the food items that they wanted to eat during their meals. There were a total of 117 residents present in the facility at the time of this survey. The findings included: Record review of the facility's policy and procedures titled, Resident Rights, undated, revealed, Employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: self-determination.be supported by the facility in exercising his or her rights. Interview with resident #81 on 06/25/19 at 10:21 am revealed, everything was good in the facility; however, she did not know why they took the menus away. Before she was given a menu for the next four days where she was able to select the items that she wanted, but about two months ago the facility stop doing this. The resident reported, now when she received her meals she did not know what she was getting. Resident #81 stated, it was not about food quality, the food was good, but she would like to know what she was getting and be able to select what she wanted or did not want. Interview with the Food Service Director, the Clinical Nutritionist, and the Consultant Dietitian on 06/27/2019 at 12:50 pm revealed, once residents were admitted , residents filled out a form about their likes and dislikes and then it was collaborated with the kitchen. Depending on the menu of the day, the Restorative Certified Nursing Assistant (CNA) or Dietitian, will go over the menu of what was being served. The resident can then say what they want, or if they want an alternative. In addition to honoring resident's preferences, residents could tell the staff and they would let the kitchen know about it; food preferences were updated frequently and honored. The Consultant Dietitian stated, before residents were given selective menus, but it was not working out; it was more of a test period. It was complicated because it took a lot of time and it was difficult for the kitchen. So, it was decided to go back to the original process of food preferences, which was what they were doing now. The menus were posted in the dining room, and activities and restorative staff went to the residents and informed them of what was being served that day, and residents could request alternatives. Record review and interview with Clinical Nutritionist on 06/27/2019 at 1:40 pm revealed, in the resident's medical record there was a patient dislike form dated 02/27/2019 with the resident's dislikes for breakfast, lunch, and dinner. There was a nutrition note dated 03/04/2019 that revealed, to continue the selective menu per resident's request. Interview with resident #81 on 06/27/2019 at 2:18 pm with Consultant Dietitian and Clinical Nutritionist present, revealed that the resident stated that she would like to have a menu again so she could select what she wanted or didn't wanted. The Consultant Dietitian stated, she would provide the resident with a menu for the week; she reported that the resident never requested a menu or told anyone about wanting one. Interview with the Director of Nursing (DON) on 06/28/2019 at 11:36 am revealed, resident #81 did not have to request a menu; a menu would be given to her for selection of her meals.

Based on interviews, observations and record review of the facility's grievance log and policy, the facility failed to support Resident's Right relating to the assurance of prompt efforts in resolving grievances for one resident (Resident #84) out twenty-six sampled residents. After he reported concerns with staff attitude that went unaddressed and unresolved. This facility practice has the potential to affect all 117 adults residing in this facility at the time of this survey. The findings included: Record review of the Face Sheet for Resident #84 revealed, he was admitted to the facility on [DATE]. A review of medical report noted resident #84 [DIAGNOSES REDACTED]. The patient is awake, alert, and oriented x3. Interview on 06/25/19 at 9:57AM with Resident #84 revealed, the resident had concerns with staff attitude. Resident #84 reported, Staff D, a Licensed Practical Nurse (LPN) attempted to intimidate him earlier that morning. The Resident explained, {Staff D} took my washcloths that I keep there (pointed to the overbed table). I use them to wash my face because I like to keep myself clean, I feel his actions were an attempt to intimidate me. I told him, I use those and want to keep them, but he threw them out anyway, saying, if the State sees that! I complained about him this morning to {the Registered Nurse (RN) supervisor and Director of Nursing (DON)}. During an interview on 06/26/2019 at 9:08 AM Resident #84 added that he had other concerns with staff that showed disrespect and he communicated those concerns during a recent care plan meeting, the meeting occurred on 6/20/2019. Since the meeting, Resident #84 waited for staff to respond and offer him the names of the staff he reported had shown him disrespect. He also reported to his nurse a recent concern that happened that morning. The concern he reported also related to staff attitude and behavior. During an interview on 6/27/2019 at 9:27 AM with Staff D, the LPN reported he was familiar with resident #84. He described the incident with Resident #84 and explained, I told him that we were going through an inspection and that we could not have wet towels on the table; because it causes bacteria. He took offense to it. He told me, I'm not afraid of the State, I do what I want . (he) continued to vent, I let him get it out, then I told him, let me know when you need the towels and we'll get it for you . I removed the towels and my gloves . after all that he got quiet. I thought he was receptive, turns out he was not . He called (pressed the call light), and the supervisor was around and answered his call . I could hear him screaming (complaining) from his room . The supervisor (Staff B) is the one providing his meds now. Staff D added, he learned about Resident #84's issues with a lot of people. Interview on 06/27/2019 at 11:20 AM with Staff B, RN and Charge Nurse for the unit revealed, the Charge nurse was aware that Resident # 84 reported concerns with staff treatment during a care plan meeting. Resident #84 also reported that it made him upset when staff D, removed some wet towels off his table. The resident reported, the incident to the Director of Nurses (DON). The RN Charge Nurse did not indicate that she followed the grievance procedure on behalf of the resident. During an interview with the Social Services Director on 06/27/2019 at 10:07 AM , she explained that she oversaw all grievances to the resident and/or family's resolution. All staff was educated on the grievance process and to immediately report all resident concerns. Resident concerns with staff attitude should be addressed as a grievance. The Social Worker was not aware that Resident #84 had concerns with staff attitude. Record review of the Grievance log and reports at this time indicated that none of Resident #84's concerns were addressed as per their grievance protocol. Interview with the DON on 6/27/2019 at 12:05 PM revealed, the DON reported she knew about Resident #84's issue with his nurse. No other issues were reported to her. The DON explained, no grievance was filed on behalf of the resident; She immediately addressed the issue to the resident's satisfaction. The DON indicated, she was not aware that Resident #84 had other concerns. She reported, if the resident had complained about anybody else, then Social Services should know. During the interview with the DON, she agreed to call the Social Worker and the Charge Nurse to plan and speak to Resident #84 and hear his concerns. During an interview on 6/27/2019 at approximately 1:15 PM, Resident #84 reported to the DON, the Social Worker, and to the Charge Nurse, his above-mentioned concerns with staff attitude. Resident #84 expressed his issues with Staff D, and others were not resolved. The resident reported, Staff D, was rude and tried to intimidate him. The resident had previously asked the supervisors that Staff D stayed away, but the nurse continued to enter his room. Resident #84 added other concerns with staff attitude and stated that he feared retaliation. During an interview on 06/27/2019 at 1:37 PM with the DON, she explained that given what I learned during the interview (with Resident #84) we will do an immediate reported because the patient used the word intimidation. The nurse is going to be removed from the floor pending investigation.

Based on observation, interview and record, the facility failed to ensure that infection control standards were met as evidenced by a staff member observed in a resident room caring for a resident on contact isolation precautions without wearing personal protective equipment for one resident (resident #1) out of one residents on contact precautions out of three residents reviewed for infections during the time of the survey. The findings included: Record review of the face sheet revealed that resident # 1 was admitted on [DATE]. The [DIAGNOSES REDACTED]. coli) / Extended Spectrum Beta Lactamase (ESBL) in urine. Record review of the Physician order [REDACTED].# 1 for (MONTH) 2019 revealed the following laboratory (Lab) orders but not limited to Complete Blood Count (CBC), Complete Metabolic Panel (CMP), Urinalysis (U/A) and Culture and Sensitivity (C & S). Record review of the Telephone Order (TO) for resident #1 dated 06/14/2019 revealed Infectious Disease (ID) consult was completed. Record review of the lab for resident # 1 dated 06/14/2019 revealed, urinalysis yellow and cloudy, bacteria plus 1, urine culture 48 hours (hrs) and isolate Escherichia coli (E. coli) / ESBL greater than 100,000. Notification of multidrug resistant organism. Medical Doctor (MD) aware and new orders in the chart. Record review of the lab for resident # 1 dated 06/14/2019 revealed an antibiotic sensitivity test was done. Record review of the Infections Disease Medical Doctor consult for resident # 1 dated (MONTH) 14, 2019 revealed, consult for E. coli / ESBL positive Urinary Tract Infection. Denied pain. Resident was awake, alert to name, place and time. Laboratory results indicated Ecoli / ESBL. Treatment Order: Meropenem 1 gram Intravenous (IV) every (Q) 12 hours (hrs.) for 7 days. Record review of the care plan for resident # 1 dated 6/14/2019 revealed Meropenem 1 gram IV Q 12 hrs. for [DIAGNOSES REDACTED]. Record review of the Telephone Order (TO) for resident # 1 dated 06/14/2019 at 3:00 PM revealed Meropenem 1 gram IV Q 12 hrs. for 7 days. Record review of the TO for resident # 1 dated 06/14/2019 revealed okay to insert Heplock, flush 10 milliliters (ml) Normal Saline (NS), before and after antibiotic treatment. Monitor heplock insertion for signs and symptoms of infection, infiltration and bleeding every shift. Record review of the TO for resident # 1 dated 06/14/2019 revealed change Heplock site with dressing every 96 hrs. and change heplock site with dressing as needed. Record review of the TO for resident # 1 dated 06/15/2019 revealed contact isolation for [DIAGNOSES REDACTED]. Record review of the nurse's note for resident # 1 dated 06/15/2019 during the 7:00 am to 3:00 PM shift revealed resident #1 was transferred to a new room for contact precautions. Observation on 6/17/2019 at 11:20 AM of resident # 1 with another State Agency representative revealed, a Personal Protective Equipment (PPE) kit was on the door with gowns, gloves and masks. The door was open and Staff A, Certified Nursing Assistant (CNA) was in the room without without wearing a gown or gloves and had a wheel chair leg rest in her hand. Staff A was assisting resident # 1 who was in a wheel chair. Interview on 06/17/2019 at approximately 11:25 AM with staff A, and staff B, a Registered nurse with Spanish translation by a State Agency representative revealed, Staff A, noted that she came from activities and had a wheel chair leg rest for resident # 1. Staff A, mentioned that she saw the stop sign and the PPE kit on the door for resident # 1, but was in a hurry to place the leg rest on the wheel chair for resident # 1. Staff A, stated that she knew the process for residents on contact isolation precautions. Staff A, acknowledged that she was not wearing any PPEs while in the room for resident # 1 who was on contact isolation precautions. Interview on 06/17/2019 at approximately 11:35 AM with staff C, a Charge Nurse and in the presence of staff B, a RN regarding staff A revealed, she will educate staff regarding residents on contact precautions. Resident #1 was currently on contact precautions. Observation and interview on 06/17/2019 at approximately 11:45 PM of the room for resident # 1 revealed, there was a stop sign on the door and a PPE kit hanging from the top of the door. The State Agency representatives sanitized their hands and donned on PPE before entering the room of resident #1. There were two red bins with red biohazard bags in the room. Resident # 1 was in a wheel chair in her room and the family member of resident # 1 was sitting in the chair and was not wearing PPE. The family member of resident #1 stated that he was told only to wear gloves when he touched resident #1. The family member of resident # 1 was never told by staff about wearing a gown or wearing anything else while in the room with resident #1. Interview on 6/17/2019 at 3:41 PM with staff B, a Registered Nurse regarding resident # 1 revealed, the labs for resident # 1 came back positive for ESBL on 06/14/2019. Resident # 1 had returned on 06/14/2019 at 2:45 PM from a medical appointment. They notified the Infectious Disease (ID) Doctor of the labs and the ID Doctor was in the facility on 06/14/2019. Resident # 1 was transferred to a new room on 6/15/2019 and placed on contact isolation for ESBL in the urine. They placed residents on contact precautions when the doctor wrote an order and then they would inform the resident and the family. Interview on 6/17/2019 at 4:05 PM with Director of Nursing (DON) revealed, on 6/14/2019 the Infectious Disease Doctor came to see resident # 1. The ID doctor had orders for IV antibiotics Q 12 hrs X 7 days. The DON noted the ID Doctor did not order contact isolation for resident # 1 at that time. The DON explained, regarding resident # 1: He is the ID Doctor and he was given the lab. The facility staff called the ID Doctor on 6/15/2019 and he stated that this is up to the primary doctor to place the resident on contact isolation precautions. The DON noted that it depended on the resident if they were continent or incontinent and this was up to the discretion of Infectious Disease Doctor. The DON acknowledged that E. Coli / ESBL in the urine was resistant to certain antibiotics and noted that resident # 1 was moved to a new room on 6/15/2019 when the Primary Doctor ordered this. Record review of the facility's policy revised, (MONTH) (YEAR) titled, Isolation Transmission Based Precautions: Transmission Based Precautions are initiated when a resident develops signs and symptoms of a transmissible infection, arrives for admission with symptoms of an infection or has a laboratory confirmed infection and is at risk of transmitting the infection to other residents. When a resident is placed on transmission based precautions, appropriate notification is placed in the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for and type of precautions. The signal informs the staff of the type of precautions, instructions for use of Personal Protective Equipment and other instructions to see a nurse before entering the room. Contact precautions may be implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident care items in the resident's environment.

Based on interview and record review, the facility failed to investigate and submit Federal immediate and five-day reports for two out of two allegations of abuse involving resident #142 and resident #314. There were a total of 114 residents present in the facility at the time of this survey. The Findings included: Record review of the facility's abuse log for the year 2016 provided on 02/13/2017 revealed two separate abuse allegations reported on 09/09/2016 and 10/28/2016 related to resident #142 and resident #314. Record review of the social service notes dated 09/08/2016 revealed a meeting conducted with resident #142 and his [MEDICATION NAME] daughter and facility staff that included the Social Services Supervisor, Social Worker, and the Administrator. The meeting was to discuss the resident's upcoming discharge; however, resident #142's [MEDICATION NAME] daughter became verbally aggressive and was noted to have yelled things in the hallway in front of the resident and staff as she left the building. Further review of the social service notes indicated that on 09/09/2016 the Social Services Supervisor notified Administration about a possible allegation of emotional and verbal abuse from the [MEDICATION NAME] daughter against resident #142. It was noted that the allegation was reported to the Department of Children and Families (DCF); however, there was no documentation to show that a Federal immediate and five-day report was submitted. Record review of the Incident Note for resident #314 dated 10/28/2016 revealed that on 10/27/2016 the resident reported to her nurse that she felt that her certified nursing assistant (CNA) touched her inappropriately when providing assistance with toileting. A statement was taken from the CNA, who stated that he provided the resident with items to clean herself and he only assisted with cleaning her backside; he dressed the resident and helped her back to bed. In a subsequent interview, resident #314 was assured that the CNA would no longer work with her and that the allegation would be reported. The resident then changed her statement stating that she may have been confused that day, and that the CNA always provided excellent care. There was no documentation to show that a Federal immediate and five-day report was submitted. Interview with the Abuse Prevention Coordinator, the Director of Nursing (DON), and the Administrator on 02/16/2017 at 6:01 pm revealed that the Abuse Prevention Coordinator did not have a username and a password to submit Federal immediate and five day reports; the previous DON had the access. There had only been two abuse allegations since the last standard survey, and both of them were reported to DCF. All of the staff members said that they did not know if the reports were submitted to the State licensing agency. They confirmed that there was no evidence to show that the Federal immediate and five day reports were sent in. Record review of the facility's policy and procedures titled, Staff treatment of [REDACTED]. mental health The facility will thoroughly investigate and document each alleged violation and will prevent further potential abuse while the investigation is in process. The Abuse Prevention Coordinator will serve as the official investigator of all incidents of alleged abuse. The Administrator shall have overall responsibility for the abuse investigation. The Abuse Prevention Coordinator or his/her designee will report all findings to the Administrator and his/her designee. In accordance to CFR Reporting of Federal 5-day incidents as required under 42CFR 483.13.

Based on interview and record review, the facility failed to implement their policy and procedures on abuse by not investigating and reporting two out of two allegations of abuse involving resident #142 and resident #314. There were a total of 114 residents present in the facility at the time of this survey. The Findings included: Record review of the facility's abuse log for the year 2016 provided on 02/13/2017 revealed two separate abuse allegations reported on 09/09/2016 and 10/28/2016 related to resident #142 and resident #314. Record review of the social service notes dated 09/08/2016 revealed a meeting conducted with resident #142 and his [MEDICATION NAME] daughter and facility staff that included the Social Services Supervisor, Social Worker, and the Administrator. The meeting was to discuss the resident's upcoming discharge; however, resident #142's [MEDICATION NAME] daughter became verbally aggressive and was noted to have yelled things in the hallway in front of the resident and staff as she left the building. Further review of the social service notes indicated that on 09/09/2016 the Social Services Supervisor notified Administration about a possible allegation of emotional and verbal abuse from the [MEDICATION NAME] daughter against resident #142. It was noted that the allegation was reported to the Department of Children and Families (DCF); however, there was no documentation to show that a Federal immediate and five-day report was submitted. Record review of the Incident Note for resident #314 dated 10/28/2016 revealed that on 10/27/2016 the resident reported to her nurse that she felt that her certified nursing assistant (CNA) touched her inappropriately when providing assistance with toileting. A statement was taken from the CNA, who stated that he provided the resident with items to clean herself and he only assisted with cleaning her backside; he dressed the resident and helped her back to bed. In a subsequent interview, resident #314 was assured that the CNA would no longer work with her and that the allegation would be reported. The resident then changed her statement stating that she may have been confused that day, and that the CNA always provided excellent care. There was no documentation to show that a Federal immediate and five-day report was submitted. Interview with the Abuse Prevention Coordinator, the Director of Nursing (DON), and the Administrator on 02/16/2017 at 6:01 pm revealed that the Abuse Prevention Coordinator did not have a username and a password to submit Federal immediate and five day reports; the previous DON had the access. There had only been two abuse allegations since the last standard survey, and both of them were reported to DCF. All of the staff members said that they did not know if the reports were submitted to the State licensing agency. They confirmed that there was no evidence to show that the Federal immediate and five day reports were sent in. Record review of the facility's policy and procedures titled, Staff treatment of [REDACTED]. mental health The facility will thoroughly investigate and document each alleged violation and will prevent further potential abuse while the investigation is in process. The Abuse Prevention Coordinator will serve as the official investigator of all incidents of alleged abuse. The Administrator shall have overall responsibility for the abuse investigation. The Abuse Prevention Coordinator or his/her designee will report all findings to the Administrator and his/her designee. In accordance to CFR Reporting of Federal 5-day incidents as required under 42CFR 483.13.