Every finding on record at Westminster Place

Based on observation, interview, and record review the facility failed to implement its protocol on Enhanced barrier precaution. This deficiency affects all four (R42, R45, R108, and R110) residents in the sample of 14 reviewed for Infection Control Management. Findings include: 1.) On 10/15/24 at 9:34AM, Observed V12 (Certified Nursing Assistant/CNA) came out from the room donning off gown, gloves and face shield then disposed it to the garbage container outside the room. The he performed hand hygiene. Observed isolation set up outside the R42's room. On 10/15/24 at 9:37AM, V11 (Registered Nurse/RN) said that R42 is on Enhanced Barrier Precaution (EBP), but she does not know the reason. V11 is wearing surgical mask, she donned gown and gloves. V11 administered medications to R42 orally and subcutaneous injection. After administration of medication. V11 removed the gown and placed it on garbage outside the door. V11 removed her gloves and placed it in her medication garbage cart. Then she performed hand hygiene. On 10/15/24 at 9:49AM, V4 (Infection Preventionist) said that Personal Protective Equipment (PPE) use inside the EBP room should be disposed inside the room garbage container not outside. Hand hygiene should be performed inside the room after removing the PPE. V4 said, staff should follow their infection control protocol. Requested for policy. R42 was admitted on [DATE] with diagnosis listed in part but not limited to Fracture of Right lower leg, Dislocation on right ankle, History of falling. Active physician order sheet indicates that she is on Enhanced Barrier Precautions due to history of MRSA (Methicillin-Resistant Staphylococcus Aureus) nares. 2.) On 10/15/24 at 12:03PM, Observed R110 on Enhanced Barrier Precaution. V11 (RN) was wearing a surgical mask. She donned gown and gloves, then administered medications to R110. After medication administration, V11 removed the gown outside the room and disposed the gown to the garbage container located outside the room. V11 removed gloves and discarded it into the medication cart garbage. Then she performed hand hygiene. On 10/16/24 at 1:00PM, V4 (Infection Preventionist) said, there should be an order in R110's chart for resident on enhanced barrier precaution. R110 was admitted on [DATE] with diagnosis listed in part but not limited to Fracture of base skull, Intracranial injury, History of falling, Nontraumatic subarachnoid hemorrhage, Moderate protein calorie malnutrition. Active physician order sheet indicates daily wound care and as needed on sacrum due to pressure ulcer. There was not an enhanced barrier precaution order found in medical record. 3.) On 10/16/24 at 9:12AM, Observed R108 is on Enhanced Barrier Precaution. Observed V18 (R108's Private Caregiver) performing personal hygiene to R108 without using PPE- no mask, gown, and gloves. He was cleaning R108's face using wash cloth. He said that he was informed by the staff to wear PPE when providing care to R108, but he forgot. On 10/17/24 at 11:41AM, V2 (Director of Nursing/DON) said that per V1 (Administrator) they won't allow surveyor to access R108's paper hospital transfer record from the admission of 9/4/24. Surveyor inquired about history of UTI (urinary tract infection) or if a urinalysis and/or urine culture was done at the hospital. V2 said R108 does not have history of UTI, no urinalysis and urine culture were done at the hospital. R108 was admitted on [DATE] with diagnosis listed in part but not limited to Pneumonia, Gastrostomy due to dysphagia, Alzheimer's disease, Dementia, Transient Ischemic attack, and Cerebral infarction. Active physician order sheet indicates that she is on daily wound care and as needed for pressure ulcers on sacrum and left buttocks. Bolus G-tube feeding. R108 has order for Enhanced Barrier Precaution. There was no documentation in R108's care plan of V18 (Private caregiver) non-compliance on infection control management to her care. Facility's policy on Enhanced Barrier Precaution (EBP) revision dates: 9/3/24 indicates: Purpose: EBP are an infection control intervention designed to reduce transmission of resistant organism that employs targeted gown and glove use during high contact resident care activities. Procedures: 6. Ensure an order for EBP is written on the chart. 8. Post clear signage on the door or wall outside of the resident room indicating the type of precautions and required PPE (e.g., gown and gloves) 9. Make PPE, including gowns and gloves, available immediately outside of the resident room. 11. PPE, gloves, and gowns will be required for all staff providing high contact care activities 12. Position a trash can inside the resident room and near the exit for discarding PPE after removal prior to exit of the room or before providing care for another resident in the same room. 49871 4.) On 10/15/2024 at 10:50 AM, during initial round R45's room did not have Enhance Barrier Precaution (EBP) signage, set-up, and Personal Protective Equipment (PPE) available to the staff and visitors. R45 was in the room, sitting down on a chair. R45 said he has a wound on his back and staff comes to treat and do his dressing daily. On 10/15/2024 at 10:52 AM, V4 (Infection Preventionist) said there should be a set-up, PPE, and EBP signage outside R45 room for staff and visitors' information. On 10/16/2024 at 1:50 PM, V2 (DON) said there should have been a set-up, PPE, and EBP signage on R45's room. This should have been done on admission. Order Summary Report: Diagnoses: Sepsis, Unspecified Organism, Type 2 Diabetes Mellitus without Complications, Multiple Sclerosis Enhanced Barrier Precautions: Complex Wound every shift Enhanced barrier precaution R/T multiple wounds. Care Plan: Focus: (R45) has multiple stage 3's to Torso, left lateral aspect and multiple pressure ulcers to left hip, left lateral thigh, left knee. lateral aspect and or potential for pressure ulcer development r/t Immobility, poor appetite. Intervention: Observe enhanced barrier precaution per protocol

Based on observation, interview, and record review the facility failed to limit layers of linens when using a low air loss (LAL) mattress for residents with pressure ulcers. The facility also failed to follow a physician's order and failed to implement a wound prevention intervention. This deficiency affects two (R108 and R110) of three residents in the sample of 14 reviewed for Wound Care management. Findings include: 1.) On 10/15/24 at 10:16AM, Observed R108 lying in bed on Low air loss (LAL) mattress. R108 has fitted sheet covering the LAL mattress. V6 (Wound Care Nurse/WCN) lifted the top sheet linen to check the LAL mattress. Observed cloth pad and folded linen in quarters underneath R108. R108 wears disposable brief. V6 said that R108 should have only a flat sheet over the LAL mattress, no cloth pad, and folded linens. V6 said that multi layers of linen over the LAL mattress will impede its function and purpose. R108 does not have bilateral heel protectors. On 10/15/24 at 11:06AM, V13 (Certified Nursing Assistant/CNA) said that he is assigned to R108, but he has not seen and provided care to R108. V13 said, R108 has private care giver who provides care and makes the bed for her. R108 left around 8AM or 9AM. Reviewed R108's wound care plan with V6 (WCN). There was no documentation in care plan indicating R108's caregiver noncompliance with wound care treatment and prevention. There was no documentation of caregiver education in the chart. On 10/14/24 at 11:09AM, Observed V6 (WCN) and V13 (CNA) preparing to provide wound care to R108. Observed thick pad lining inside the disposable brief. V13 CNA said that R108's caregiver has been applying the pad lining inside the disposable brief because R108 poops a lot. V13 said that he did not report this to his nurse and to V6 WCN. V6 said that V13 should report to the floor nurse of R108's caregiver noncompliance to wound care management because they don't allow pad lining inside the disposable brief in the facility. The CNA should be checking the resident every 2 hours for incontinence. On 10/15/24 at 11:16AM, V6 (WCN) checked R108's disposable brief while V13 (CNA) assisting R108 to left side lying position. Observed large amount of soft brown fecal matter. V6 took the wet disposable wash cloth and wiped R108's rectal to perineum (back to front). V6 continued to wipe several times from rectal to perineum. Surveyor informed observation to both V6 and V13. V13 (CNA) said that it should be wipe from front to back to avoid infection (UTI). V6 asked V13 to clean R108, and they switched position. On 10/15/24 at 11:20AM, V6 (WCN) removed the foam dressing on sacral area. V6 said that R108 has moderate yellowish wound drainage from sacrum and has blood stained from left buttocks. V6 cleansed left buttocks and sacrum with wound cleanser. V6 said that R108 has unstageable pressure ulcer on sacrum due to 100% yellowish slough formation. Stage 3 on left buttocks covering with dried blood. She applied (brand name ointment) to sacrum and left buttocks and cover with foam dressing. Observed non-blanchable redness on entire sacral area. V6 applied zinc cream to affected area. On 10/16/24 at 9:12AM, V18 (R108's Private Caregiver) said that they have been in the facility for more than 1 month. V18 said he does not do incontinence care to R108. V18 said, he called the CNA for incontinence care as needed. V18 said that R108's son is a lawyer, and he was told to let the staff do the care for R108 for liability issues. V18 said the staff is aware that he is applying pad lining inside the disposable brief to R108, and the staff is aware, and they are using it too. On 10/16/24 at 11:49AM, Informed V2 (Director of Nursing) of above concerns. V2 said, LAL mattress recommendation of using flat sheet over the mattress. V2 said, the floor nurse should check resident on LAL appropriate cover when making rounds or during medication administration. V2 said that they follow physician's orders in wound care prevention and management. V2 provided Medication Administration general guidelines policy. V2 said that they used the same policy for Treatment administration. On 10/16/24 at 1:58PM, Review R108's wound assessment dated [DATE] with V6 (WCN). V6 said that she completed the wound assessment, and she did the measurement. Informed V6 that her wound assessment dated [DATE] has worsened compared to wound observation made with surveyor on 10/15/24. V6 said, it will still have the same treatment. Informed V6 (WCN) that R108 does not have bilateral heel protectors as ordered by physician. R108 is admitted on [DATE] with diagnosis listed in part but not limited to Pneumonia, Gastrostomy due to dysphagia, Alzheimer's disease, Dementia, Transient Ischemic attack, and Cerebral infarction. Active physician order sheet indicates: Bilateral heel protectors while in bed. LAL mattress, Sacrum and Left Buttocks- cleanse with NSS (normal saline solution). Apply (brand name ointment) cover with 4x4 foam daily and as needed. Most recent Braden scale for predicting pressure ulcer risk assessment done on 9/25/24 indicated at high risk. Most recent wound assessment dated [DATE] indicated: Sacrum- date identified 9/5/24, present on admission, Pressure ulcer Stage 3 measures 1cm x 0.4cm x 0.2cm, Red and yellow color wound bed, granulation 40%, 60% pink non-granulated, erythema on surrounding tissue, small serosanguineous drainage, wound edge distinct and attached. Left buttocks- date identified, present on admission, Pressure ulcer, unstageable, measures 2cm x 1.5cm x 0cm, red and yellow tissue wound bed, 30% slough non adherent, 70% red beefy granulation, erythema tissue surrounding, small serosanguineous drainage, distinct and attached wound edge. Peri anal area- 9/5/24, present on admission, MASD (moisture associated skin damage), excoriation, measures 0cm x 0cm x 0.1cm, red wound bed, 100% non-blanchable erythema, erythema on surrounding tissue. Comprehensive care plan indicates R108 has multiple pressure ulcer: Stage 3 to sacrum, UTS (unstageable) to left buttock and or potential for pressure ulcer development related disease process, Braden scale, contractures, and immobility. R108 has potential impairment to skin integrity related to reduced mobility, incontinence, generalized body weakness secondary to COVID, Pneumonia, Dysphagia status post PEG tube placement. Interventions: Low air loss (LAL) mattress. Heel protectors. 2.) On 10/15/24 at 10:49AM, Observed R110 lying in bed on LAL mattress. V6 (WCN) lifted R110 top sheet linen to check the mattress. Observed flat sheet and cloth pad over the mattress. R110 is wearing disposable adult brief. V6 said that R110 should have only flat sheet over the LAL mattress. R110 is admitted on [DATE] with diagnosis listed in part but not limited to Fracture of base skull, Intracranial injury, History of falling, Nontraumatic subarachnoid hemorrhage, Moderate protein calorie malnutrition. Active physician order sheet indicates LAL mattress. Sacrum-cleanse with NSS. Apply skin prep around wound. Santyl and wet gauze packing in undermining area. Then cover with 4x4 gauze or abdominal pad then secure with med fix daily and as needed. Most recent Braden scale for predicting pressure ulcer risk assessment done on 8/8/24 indicated at high risk. Most recent wound report dated 10/14/24 indicated: Sacrum- dated identified 7/18/24, present on admission, Stage 4 pressure ulcer, measures 4cm x 3cm x 0.3cm, red and yellow wound bed tissue, 100% granulation, 12 o'clock to 12 o'clock undermining with 1.3 depth, erythema on surrounding tissue, small serous drainage, distinct and attached wound edge. Comprehensive care plan indicates he has pressure injuries, sacrum unstageable, 10/4/24 knee abrasion, 107/24 sacrum unstageable to stage 4. R110 is at risk for further skin impairment related to pressure injuries upon admission, generalized body weakness, reduced mobility, on and off pain, abrasion on left knee secondary to subarachnoid, subdural, intraventricular hemorrhage, left temporal bone fracture due to unwitnessed fall, hypertension, ETOH. Intervention: LAL mattress. Facility's policy on Use of Support Surfaces Policy: Support surfaces will be in accordance with evidence-based practice for residents with or at risk for pressure injuries. Facility's policy on Prevention and Healing of Pressure injuries and non-pressure related injuries review date: 3/31/24. Provides care and services to: *Promote the prevention of pressure injury development *Prevent infection and promote the healing of pressure injuries that are present *Prevent development of additional pressure injuries *Residents with Non-pressure-related Skin injury/wound. B. Plan/Intervention: a. Prevention iii. Provide appropriate, pressure-redistributing, support surfaces. Facility's policy on Medication Administration-General Guidelines March 2021 indicates: B. Administration 2) Medications are administered in accordance with written orders of the prescriber.

Based on observation, interview, and record review the facility failed to ensure proper perineal care is provided during incontinence care. This deficiency affects one (R108) of three residents in the sample of 14 reviewed for Incontinence care. Findings include: On 10/15/24 at 11:09AM, Observed V6 (Wound Care Nurse/WCN) and V13 (Certified Nursing Assistant/CNA) preparing to provide wound care to R108. Observed thick pad lining inside the disposable brief. V13 said that the caregiver has been applying the pad lining inside the disposable brief because R108 poops a lot. V13 said that he did not report this to the floor nurse and to V6 (WCN). V6 said that V13 should report noncompliance of R108's caregiver to the nurse because they don't allow pad lining inside the disposable brief in the facility. CNA should be is checking resident every 2 hours for incontinence. On 10/15/24 at 11:16AM, V6 (WCN) checked R108's disposable brief while V13 (CNA) assisting R108 to left side lying position. Observed large amount of soft brown fecal matter. V6 took the wet disposable wash cloth and wiped R108's rectal to perineum (back to front). V6 continued to wipe several times from rectal to perineum. Surveyor informed observation to both V6 and V13. V13 (CNA) said that it should be wipe from front to back to avoid infection (UTI- urinary tract infection). V6 asked V13 to clean R108, and they switched position. On 10/15/24 at 11:30AM, V6 (WCN) said that she should clean from front to back when performing incontinence care to R108. Requested for policy. On 10/16/24 at 1:30PM, Informed V2 (Director of Nursing) of above concern. R108 is admitted on [DATE] with diagnosis listed in part but not limited to Pneumonia, Gastrostomy due to dysphagia, Alzheimer's disease, Dementia, Transient Ischemic attack, and Cerebral infarction. Comprehensive care plan indicates she has bladder and bowel incontinence related to impaired cognition, poor safety awareness, generalized body weakness, decreased mobility secondary to COVID, Pneumonia, Dysphagia status post PEG tube placement. She has an ADL self-care performance deficit related impaired cognition, poor safety awareness, generalized body weakness, decreased endurance, and activity tolerance, reduce dynamics balance and coordination, on and off pain. She has impaired ability to perform or complete activities of daily living for oneself, such as feeding, dressing/grooming, bathing, toileting, bed and or wheelchair mobility, transfers, and ambulation secondary to COVID, Pneumonia, Dysphagia status post PEG tube placement. Facility's policy on Perineal Care indicates: Policy: It is the practice of this facility to provide perineal care to all incontinent resident's routine bath, and as needed in order to promote cleanliness and comfort, prevent infection to the extent possible and to prevent and assess for skin breakdown. Definition: Perineal care refers to care of the external genitalia and the anal area. Policy explanation and compliance guidelines: 9. If perineum is grossly soiled, turn resident on side, remove any fecal material with toilet paper, then remove and discard. a. Cleanse buttocks and anus, front to back; vagina to anus in females, scrotum to anus in males, using a separate washcloth or wipes. b. Thoroughly dry.

Based on observation, interview, and record review the facility failed to document count verification of controlled substances during nurses' shift change for one of three medication carts reviewed for Medication storage of controlled substances. Findings include: On 10/15/24 at 9:35AM, Checked medication cart with V11 (Registered Nurse/RN). Observed controlled substances count verification form for October 2024 has several missing initials of nurses dated 10/1/24, 10/2/24, 10/3/24, 10/11/24, and 10/15/24. V11 said that incoming nurse and outgoing nurse will sign the controlled medication verification form after counting the medications. V11 RN said that she counts the narcotic medications with the 11-7 shift nurse this morning around 7:30AM but she forgot to sign after counting. On 10/15/24 at 12:08PM, V14 (Nursing Supervisor) informed of above observation. V14 said that at each shift change, both nurses incoming and outgoing should sign the controlled medication verification form after counting the medications. Requested for policy. On 10/16/24 at 11:49AM, Informed V2 (Director on Nursing) of above concern. V2 said, the incoming and outgoing nurses during shift change should sign the controlled substance count verification after counting the medications. Facility's policy on Medication Storage in the facility: Controlled Substance Storage Policy: Medications included in the drug enforcement administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and record keeping in the facility in accordance with federal, state, and other applicable laws and regulations. Procedures: E. At each shift change, or when keys are transferred, a physical inventory of all controlled substances (CII-CV) that are stored in locked compartments, including refrigerated items as conducted by two licensed nurses and is documented.

Based on observation, interview and record review the facility failed to ensure ongoing assessment, identifying, and reporting of new skin impairment for a resident that is at risk. The facility also failed to follow manufacturer recommendation when using a low air loss mattress. This deficiency affects one (R12) of three residents in the sample of 20 reviewed for Wound/Skin Prevention Management. Findings include: On 10/31/23 at 11:50AM, observed R12 lying in low air loss (LAL) mattress bed. R12 said that his buttocks hurt. Called V9 (Registered Nurse/RN) to check and assess resident's back. Observed multi-layer linen over the LAL mattress. There was a flat sheet, folded linen in quarter, 2 cloth pads and disposable chucks over the LAL mattress. R12 is wearing disposable brief. V9 said that R12 should only be on flat sheet over the LAL mattress. There should not be multi-layers of linen because it depletes the purpose of the LAL mattress. On 10/31/23 at 12:07pm, informed V2 (Director of Nursing/DON) of above observation. V2 said that R12 should only be on a flat sheet over the LAL mattress. There should not be multi layers of linen. Requested the policy on wound care prevention and LAL mattress protocol. On 11/1/23 at 10:30AM, V14 (Wound Care Nurse/WCN) said that R12 has history of MASD (Moisture Associated Skin Disorder) that was healed months ago. Observed V13 (Certified Nursing Assistant/CNA) reposition R12 so V14 could do a skin assessment on the sacral area. Observed R12 had MASD with open wounds on both the right and left buttocks with white paste medication applied. V14 cleansed the sacral area, assessed, and measured the open wounds. V14 said that R12 has MASD with open wound on left para sacral measures 6cm x 3.5cm x 0.2cm and right para sacral measures 4cm x 3.5cm x 0.2cm. V14 said that both has superficial open wound. V14 said that he was not aware that R12 had re-opened his MASD. He has not seen him since he healed the MASD months ago. V14 said that nurses and CNAs should notify him if they observed the open wound or any skin impairment. Any skin impairment should be assessed, notify the physician to obtain appropriate treatment and update family member for wound treatment and management. On 11/1/23 at 10:35AM, V13 (CNA) said that she did not report it to the nurse because she has seen R12 with the open wound on sacral area since last week. On 11/2/23 at 10:22AM V14 (WCN) said that he is responsible for skin assessment to all residents, to prevent and treat wound, and to implements wound care interventions. V14 said that R12 was initially admitted on [DATE] with admission Braden scale/skin assessment indicating at high risk for skin impairment. R12 had facility acquired MASD on 3/29/23. It was healed on 5/26/23. R12's most recent Braden scale/skin assessment done on 10/26/23 indicating at high risk for skin impairment. V14 has not seen and assessed R12 since wound healed. He did not do weekly skin assessment for R12 because he does not have skin impairment. He only does weekly assessment if resident has active wound. Weekly skin assessment should be done be nursing and documented in progress notes. There was no skin impairment reported to him by the nurses and CNAs for R12. He only found out about R12's re-opened MASD when the surveyor asked him to do the skin assessment. V14 said that nurses and CNAs should notify him if they observed open wound or any skin impairment. Any skin impairment should be assessed, notify the physician to obtain appropriate treatment and update family member for wound treatment and management. V14 said that there should be no multilayers of linen over the LAL mattress. Only a flat sheet and 1 cloth pad. V14 is not sure if they have policy or protocol for using LAL mattress. On 11/2/23 at 10:57AM, V2 (DON) said that when CNAs observe any open wound or skin impairment, they notify the nurse. The nurse then should assess the skin impairment, call the physician or Nurse Practitioner, and update the family member. R12 is admitted on [DATE] with diagnosis listed in part but not limited to Muscle weakness, Post polio syndrome, Noncompliance with medical treatment regimen, Malignant neoplasm of prostate. Active physician order sheet indicates: Remedy Phytophex Z-Guard (Zinc Oxide)17-57% topical paste applies to sacral/buttocks/groin/perineal/scrotal areas post soap and water wash two times daily and as needed. Weekly skin assessment. Low air loss mattress by shift. Care plan indicates: R12 is at risk for pressure ulcer related to weakness, impaired mobility, incontinence, history of comminuted fracture of posterolateral aspect of humeral head and a fracture line at anatomic neck of left humerus, history of polio lifelong with left side weakness/flaccid. He prefers to stay in bed and refused to get out of bed when encouraged. R12's wound assessment completed by V14 (WCN) on 11/1/23 indicates: Left para sacral MASD measures 6cm x3.5cm x0.2cm, 75% bright red, 25% non-granulating tissues. Right para sacral MASD measures 4cmx 3.5cmx 0.2cm, 80% bright red, 20% non-granulating tissues. Facility's policy on Prevention and healing of pressure injuries and non-pressure related injuries indicates: I. Purpose: Residents at this facility will not develop clinically avoidable pressure injuries. Resident admitted with pressure injuries will receive care and services to promote healing and prevent further injuries. Residents with non-pressure related injuries will receive care and services according to current standards of practice. II. Statement of policy: Provides care and services to: *Promote the prevention of pressure injury development Procedure: c. Weekly physical assessment of skin throughout stays. C. Monitor/evaluate: a. Nursing assistant observes and reports alteration in skin integrity. Notify nurse of any change in skin condition. b. Nurse evaluate skin condition weekly or more often if indicated. Facility's policy on Use of Support Surfaces indicates: Policy explanation and compliance guidelines: 6. Support surfaces will be utilized in accordance with manufacturer recommendation. 8. Limit the amount of linen and pads placed on the bed.

Based on observation, interview and record review the facility failed to use appropriate PPE (Personal protective equipment) for a resident on droplet and contact isolation. The facility also failed to perform hand hygiene after removing and donning gloves during incontinence care. This deficiency affects one (R42) of three residents in the sample of 20 reviewed for infection control. Findings include: On 11/1/23 at 10:00am observed R42's door with a posting of Special Droplet/contact precautions. On 11/1/23 at 10:20AM, observed V13 (Certified Nursing Assistant/CNA) after providing incontinence care to R42. V13 rolled the soiled linen toward R42 and tucked it underneath her while V14 (Wound Care Nurse/WCN) was holding R42 in a side lying position. V13 removed her soiled gloves, took a clean flat sheet, and covered the mattress with her bare hands. V13 realized that she was not wearing gloves. She donned gloves without hand hygiene. On 11/1/23 at 10:35AM, informed V13 (CNA) and V14 (WCN) of the observation made while observing incontinence care and wound care to R42. V13 said that she should wear gloves when making the bed for a resident on isolation precaution. She should have washed her hands after removing and before wearing gloves during incontinence care. On 11/1/23 at 10:55AM conducted an interview with V3 (Infection Preventionist). Informed V3 of the observation made with V13 (CNA). V3 said that V13 should perform hand hygiene after removing gloves and donning gloves during incontinence care. Facility's policy on Isolation for Infectious Diseases 7/18/23 indicates: Purpose: To prevent transmission of infectious disease. Special Droplet/contact precaution- Residents who are suspected to be infected with microorganism transmitted by droplets (large-particle droplets) that can be generated by the resident coughing, sneezing talking or procedures such as suctioning: 11. Sets up isolation equipment as follows: c. Places bedside cabinet or isolation cart outside resident's room and ensures stock of clear garbage bags, red plastic infectious waste bags, yellow or blue plastic linen bags (depending on color used at community), gloves, gowns, eye protection, and masks and single use thermometers, stethoscope, and sphygmomanometer as appropriate. Facility's poster for Special droplet/contact precautions from CDC posted outside R12's door indicates: In addition to standard precautions. Only essential personnel should enter this room. If you have questions, ask nursing. Everyone must: including visitors, doctors, and staff. 1. Clean hands when entering and leaving the room. 2. Wear Mask. (Fit tested N95 or higher required when performing aerosol-generating procedures) 3. Wear eye protection. (Face shield or goggles) 4. Gown and glove at the door. 5. Keep door closed. 6. Use patient dedicated or disposable equipment. Clean and disinfect shared equipment. Facility's policy on Hand hygiene 9/21/21 indicates: I. Purpose: To prevent the spread of infection and to maintain asepsis. II. Statement of policy: Hand hygiene is essential for preventing the spread of infectious organism in health care settings. The center for Disease Control and Prevention (CDC) and Illinois Department of Public Health (IDPH) recommend the routine use of alcohol- based hand rubs (ABHR) over soap and water due to improved adherence, effectiveness, and accessibility except in situations where soap/water handwashing is specifically recommended. This table below provided by the CDC summarizes the recommended uses of the two forms of hand hygiene.

Based on observation, interview, and record review the facility failed to follow physician's order to apply medicated cream to relieve discomfort and itching for one (R15) of one resident reviewed for quality of care in the sample of 18. Findings include: R15 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . According to MDS (Minimum Data Set) dated 09/07/2022 under section C, R15 has BIMS (Brief Interview of Mental Status) score of 11 indicating moderately impaired cognition. On 10/24/22 at 11:08 AM the surveyor observed R15 lying in bed, dressed in a hospital gown. The surveyor asked if R15 usually stays in bed past breakfast. R15 stated, I usually stay in the common area and participate in activities, but I have had a rash in my private area for months now and it itches terribly. I stayed in bed because of it in the last two days because it gets worse when I'm sitting down. I would like to know more about it. V7 (Certified Nursing Assistant) told me that I talk about it too much. Nobody cares about what I say here. This condition keeps me up at night and it causes pain and itchiness. On 10/24/22 at 11:38 AM V7 (CNA) stated, I didn't see any rash on her skin. I changed her this morning, around 7.30 AM. I usually change her every two hours. Surveyor asked if R15 usually stays in bed at this time. V7 stated, R15 wasn't feeling good yesterday, so today she still didn't feel good and wanted to stay in bed. Surveyor clarified if V7 discouraged R15 from talking about itchiness in her private area. V7 stated, I never told her to stop talking about itching, when she mentions something, I always tell her that the nurse will put some medication on. On 10/24/22 at 11:45 AM V7 changed R15's briefs and called V6 (Register Nurse) to apply skin barrier cream into affected area. The surveyor did not note any rash in R15's private area. V7 washed and dressed R15 and put her into a wheelchair. V7 proceeded to propel R15 into a common area for upcoming lunch. On 10/24/22 at 12:07 PM V6 (RN) stated, R15 just told me about the itching this morning. I'll notify the doctor when they do rounds on the unit. We've been using skin barrier cream every time R15 gets her briefs changed. V6 indicated that she forgot that there was an order of [MEDICATION(S)] cream for R15 private area itchiness. On 10/24/2022 at 02:05 PM Surveyor observed V8 (Nurse Practitioner) at R15's bedside. V8 completed assessment and inquired about the discomfort in R15's private area. Upon completion of R15's assessment, surveyor asked V8 about R15's private area itchiness. V8 stated, This has been an on and off going issue. R15 has an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . It has been ordered for a while. V8 indicated that she is not sure why V6 did not offer it to R15 for symptom relief. Point of Service plan dated 02/24/2022 reads in part, [MEDICATION(S)] 0.01% (0.1mg/gram) vaginal cream (Cream with Applicator) Notes: Dx Vaginal Dryness. Frequency: as needed. R15's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, interview and record review, the facility failed to discard food items after reaching their good thru dates; failed to wear hair net(s) while in the kitchen; and failed to follow policy and procedure regarding food storage. These deficient practices have the potential to affect 48 residents receiving food prepared from the kitchen. Findings include: On 9/28/21 at 9:37AM, during the initial kitchen observation, V12 (Dining Services staff) was observed preparing vegetable salad without a hair net. V10 (Dining Services staff) was observed working at the baking station preparing cookies to be baked without a hair net. V11 (Dining Services staff) was observed pushing a cart with food items to the refrigerator without a hair net on. On 9/28/21 at 9:43AM, the facility refrigerators were inspected with V9 (Clinical Nutrition Manager) and found the following: Inside the walk-in refrigerator number two was four big trays of cooked potatoes with white sauce. The yellow label stated, Today's date: 9/14/21, Good thru: 9/14/21. There was one tray of hard-boiled eggs with a label that said good thru 9/26/21. Three large food containers of potatoes had a label that said good thru date of 9/21/21. The walk-in refrigerator number three had one tray of chocolate truffle with a label that said good thru date of 9/19/21. Inside the one cooler that contained vegetables was pesto sauce labeled with preparation date of 9/14/21 and a good thru date of 9/17/21. On 9/29/21 at 10:26AM, the surveyor observed the walk-in refrigerator number one. Located on the top shelf was a box of chocolate pudding, a large black tray containing boxes of assorted juice and a jug of milk, and a tray of meat balls. These food items were stocked a foot (12 inches) below the ceiling. The walk-in refrigerator number three had on the top shelf boxes that contained vegetables and a box of pie shells. These food items were stocked a foot below the ceiling. V9 (Clinical Nutrition Manager) was asked if these boxes were supposed to be located at that height. V9 said No, they are not supposed to be there. On 9/28/21 at 12:01PM, V9 said All staff entering the kitchen should wear a hair net. Staff with a beard would wear the beard guard. V9 said regarding the food storage, If the date was 9/26 (good thru) it should have been discarded on 9/26 pm ideally, it should be discarded at the end of the day. Facility Policy and procedure titled, titled Uniform and Grooming Guidelines dated 1/6/21 state in part: 4. General Hygiene, Grooming and Sanitation for FOH and [NAME] -Hair must be clean, secured away from the face or placed in hair net when handling food. Facility Policy and procedure titled, Storage of Food and Supplies dated 12/15/2020, state in part: Method/How to/Procedure: Products are good through the close of business on the date noted on the label. Refrigerated Foods Store food items 6 above the floor, 2from the walls, and 18 from the ceiling, consistent with local food protection codes.

Based on observation, interview and record review, the facility failed to follow its policy regarding the use of gloves and hand hygiene. This deficiency affects two residents (R245 and R249) out of a total sample of 22 residents reviewed for infection control. Findings include: R245 was admitted to the facility 9/10/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R245 was placed on special precaution droplet and contact isolation for symptom monitoring and testing due to close exposure from someone with COVID-19. R249 was admitted to the facility 9/14/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She is alert and oriented and requires one person assistance with activities of daily living. R249 is on contact isolation for C-Diff. On 9/27/2021 at 12:50PM, V13 (Dietary Assistant) was observed entering into R245's room with lunch tray. V13 had on a pair of translucent vinyl gloves. V13 was not seen performing any hand hygiene prior to removing tray from the food cart and did not perform hand hygiene prior to entering room. R245 has a sign posted at the door that indicates Droplet/Contact isolation. An isolation 3 bin system is located outside of the room entrance that contains gloves, gowns, face shields and N95 masks. At 12:52PM, V14 (Dietary Assistant) was observed taking a lunch tray from the food cart while wearing gloves and entering into R249's room. An isolation station is located outside the door and a Droplet/Contact isolation sign posted at the door. No hand hygiene was observed prior to entering the room. At 12:53PM, V13 exited R245's room and did not perform hand hygiene before going back to the food cart and did not change gloves. At 12:55PM, V14 exited R249's room wearing the same gloves and did not perform hand hygiene. On 9/27/2021 at 12:53PM, V13 said that he did not perform hand hygiene prior to going into and exiting R245's room and did not know about the isolation. At 12:55PM V14 said, It's an isolation room. Normally I should wear full gear, cap, gown, and gloves before going in the room. All of the equipment is here outside the room. I didn't wash my hands after coming out of the room or before I reached for another tray. I should have washed my hands. Now, I don't know what type of infection the resident has for isolation. On 9/27/21 at 12:58PM during the medication observation, V4 Registered Nurse said that R249 came from the hospital with C-Diff. R249 is currently on contact isolation precautions for C-Diff. I washed my hands with soap and water inside the resident's room because it is required for this infection. And now that I have left the room, I use hand sanitizer at the cart. On 09/29/21 11:45AM V7 (ADON/Assistant Director of Nursing) and Infection Preventionist said, R249 was on isolation for C-Diff until 9/28/21. The dietary staff is not tested for competency in donning and doffing of PPE because they don't have contact with the residents inside of their rooms. It is not an expectation for dietary staff to go into the rooms especially for people on isolation. The (CNAs/Certified Nursing Assistants) should do the passing of the trays. For people on isolation, I don't think it would be appropriate for dietary to go in rooms for people on quarantine or isolation. C-diff infection requires hand hygiene to be conducted with soap and water and not alcohol-based hand rub because of the high risk of transmission. On 9/29/2021 at 1:30PM, the facility policy was reviewed titled Isolation for Infectious Diseases which states in in part; Gloves and Hand Hygiene- In addition to following Standard Precautions, wear gloves when entering room, change gloves after contact with infective material and remove and dispose of gloves before leaving room and perform hand hygiene. On 9/29/2021 the surveyor reviewed R245's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/30/2021 at 12:10PM, V1 presented physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, record review, and interview, the facility failed to label and date food items, remove expired food items, ensure food was prepared under sanitary conditions, and ensure equipment was air dried before use. This had the potential to affect all 69 residents receiving food prepared in the kitchen. Findings Include: On [DATE] at 10:55am during the initial kitchen observation with V6 (Clinical Nutrition Manager), the following was observed in 3 of 6 refrigerators, 2 of 2 freezers, and 1 of 1 dry storage areas. Refrigerators: 15 pieces of uncovered baked chicken in a metal pan unlabeled. 32 ounce (oz.) carton of egg whites with an expiration date of [DATE]. 32 oz. carton of egg yolks with an expiration date of [DATE]. Open boxes of butter, egg yolks, and egg whites unlabeled. Brown pureed contents in a metal tray unlabeled. 33 eggs out of their original box unlabeled. 48 apple juices in an open box unlabeled. 3 plates of macaroni salad on a cart unlabeled. ,[DATE] gallon of nonfat yogurt unlabeled. 101.4 milliliter (ml) container of opened orange juice unlabeled. 6 (32 oz.) containers of horseradish unlabeled. 1 container of horseradish was opened and unlabeled. Open 10.1lb box of fully cooked pork sausage patties unlabeled. 2 rolls of salami in a metal pan unlabeled. Freezers: 7 cooked then frozen flank steaks with a freeze date of [DATE] and an expiration date of [DATE]. 2 frozen dough loafs opened unlabeled. 1 box of opened dough unlabeled. 1 open bag of French fries out of the original box and unlabeled. Dry Storage Area: 2 loafs of bread unlabeled. Open containers of salt (48 oz.), kosher salt (3 pound), white Pepper (5 pound), thyme Leaves (11 pound), and olive oil (1 gallon) unlabeled. During the initial kitchen tour V6 stated, all food received and stored should be labeled with a receive date and open foods should have an open date on them. V6 also stated the expired egg yolks and eggs whites should have been discarded. V7 (Executive Chef) stated, All food should be labeled with a receive date and all food should be labeled when it is taken out of its' packaging. On [DATE] at 12:04pm 4 (177 ml) containers of orange nutritional drinks were found in the third floor unit fridge unlabeled. On [DATE] at 1:00pm 2 apple juices, 2 cranberry juices, and 2 orange juices, and an opened 32oz apple juice with no labels were found in the second floor unit fridge. On [DATE] at 10:36am V6 was interviewed and she stated, It is the collective responsibility of nursing and kitchen staff to maintain and date opened items in the unit fridges. V6 also stated, An in-service was done for nurses and kitchen staff on labeling open food products. Policy: A facility policy #B003 and titled, Food and Supply Storage, was received from V6. The policy had a revision date of ,[DATE]. The policy read, . Cover, label and date unused portions and open packages Discard food past the use-by or expiration date .Food prepared in-house, and stored frozen should be kept no longer than 3 months .If a case of food is partially used, and the remaining food is exposed to the air (ex: 20# case of frozen vegetables), re-label when the product is opened, to use within 3 months .Use manufacturer's expiration date for products before they are opened. If there is no expiration date on the package, add the time listed here to the date the food is received. Findings Include: On [DATE] at 09:34 AM V9 (Resource Chef) was observed drying out blender bowl with a paper towel after washing in the three compartment sink , then pureed and placed the tuna in a bowl. At 09:42AM, V9 place blender bowl on rack to be washed, then returned with second blender bowl and dried it out with a paper towel. V9 pureed vegetables in blender bowl. V9 said we air dry equipment as long as it takes. I dry it with a paper towel or air dry it more. On [DATE] at 10:09 AM V10 (Baker) was observed preparing monkey bar desserts with gloves on. V10 dried out a 4 liter pitcher with a paper towel then poured brown sugar into the pitcher for measurement. Brown sugar was poured into the mixer bowl and residual of the brown sugar was observed at the bottom of the pitcher. V10 said the pitcher had water in it and I did not want the brown sugar to stick on the bottom. It was wet and that is the reason I had to dry it. V10 then went in storage room to get bananas, returned to the preparation table and changed gloves. V10 threw the banana peelings in the garbage, removed gloves, added flour to the 4 liter pitcher that was use for the brown sugar. V10 put on gloves, obtained a large bowl, pour flour added salt, baking soda on sifter and sifted it into the bowl. V10 removed and applied gloves, went to walk in refrigerator obtained a quart carton of butter milk and 32 ounce carton of egg whites then poured the egg whites into a pitcher. V10 poured bananas into mixer bowl then removed gloves, obtained and poured the butter milk into a measuring cup then put on gloves. V10 then added vanilla flavor, butter milk, egg whites and flour to the mixer bowl. V10 used the gloved left hand to scrape the remaining flour from bowl into the mixer bowl. V10 removed gloves returned egg whites and butter milk to walk in refrigerator, obtained pans and applied gloves. V10 sprayed non-stick spray in pans, removed mixer blade, poured mixture into pans, removed gloves, obtained spatula, applied gloves, spread mixture in pans, removed gloves then placed pans in oven. V10 was observed using gloved hands after touching multiple surfaces to prepare food and did not perform hand hygiene. V10 said when I remove my gloves I supposed to wash my hands. Clover, ginger, nutmeg, baking powder, baking soda, salt, cinnamon, all spice and cream of tartar observed in spice drawers with no dates. V10 said I put it in there last Friday. I am supposed to date it when I put it in there. On [DATE] at 10:39 AM V11 (Food Service) prepared a grilled sandwich and hamburger with gloved hands, wrapped each in plastic wrap and placed in warmer. V11 returned to preparation table and wiped out 3 plates with a paper towel, placed salmon on 2 of the plates touching on piece of salmon with the gloved hand. V11 touched his pants with left gloved hand, took chicken tenders out of oven, removed and applied gloves. V11 placed 6 chicken tenders on plate with gloved hand then placed them in the warmer. V11 proceeded to obtain bread, put 3 pieces in toaster, picked up lettuce and tomatoes with gloved hands, spread mayonnaise on each piece of bread, picked up bacon and ham with gloved hands then put the lettuce, tomatoes, bacon and ham on the bread with gloved hands. Rinsed off knife with water and dried it with a paper towel. V11 was observed using gloved hands after touching multiple surfaces to prepare food and did not perform hand hygiene. V11 said I think someone had splashed water on the plates and I wipe them off with a paper towel. I am supposed to wash my hands after changing gloves. On [DATE] at 11:15 AM V12 open the oven with gloved hands to check temperature of tuna croquette them proceeded to prepare sheared fried vegetables. V12 poured carrots, mushrooms and onions into tilt skillet added salt with gloved hands then added vegetable seasoning. Removed vegetables and place into pan. Poured cabbage, pea pods into tilt skillet, added salt with gloved hands then added vegetable seasoning. Removed and applied gloves then combined all vegetables, checked temperature while in tilt skillet. V12 placed vegetables into pans rechecked temperature at 162 degrees and placed pans into warmer. 12:04 PM V12 said I should wash my hands when I take the gloves off. On [DATE] at 10:36 AM V6 (Clinical Nutrition Manager) said equipment must be air dried and you cannot use equipment if it's wet. They monkey bar desserts were prepared for the entire facility. Record review of Product Specification Document dated [DATE] reads to sanitize food contact surfaces, food processing equipment and other hard surfaces. Allow equipment to drain thoroughly and air dry. Policy: Titled Safety and Sanitation Glove Usage revised (MONTH) (YEAR) Always wash and dry hands before and after gloving. Wash and sanitize hands before gloving. Remove gloves when: Going into storage room Going into walk-in or reach in coolers Wash and sanitize hands prior to re-gloving as needed

Based on observation interviews and record reviews the facility failed to prepare foods at safe holding temperatures to prevent the possibility of food borne illnesses. This failure has the potential to affect 8 (R4, R10, R12, R25, R38, R44, R49, R56) of 16 residents being served lunch on the first floor. Findings Include: On 09/03/19 at 12:12 PM V8 (Wait Staff) checked macaroni salad temperature at 57 degrees. V8 said it should be between 36-38 degrees. R4, R10, R12, R25, R38, R44, R49 and R56 were served the macaroni salad for lunch. V8 said if the temperatures are incorrect I report it to the managers and they follow up on the temperatures. I served the residents anyway and it can cause illness. On 09/05/19 at 10:36 AM V6 (Clinical Nutrition Manager) said If food is served at incorrect temps there is potential risks for illness. It is the expectation that a manager or supervisor be notified. The salad would have been pulled. No policy provided.

Based on observations, interviews, and record reviews, the facility failed to follow physician orders [REDACTED]. This has the potential to effect resident's wound healing. Findings include: On 9/3/19 at 12:09 P.M., Found G.T. (Gastrostomy Tube) dressing dated 9/1/19. V13 LPN (Licensed Practical Nurse) removed the G.T. gauze dressing and found redness on the skin, brown drainage around the G.T. site and brown drainage on the gauze. The dressing was out dated. On 9/3/19 at 12:18 P.M., V13 stated The dressing change is supposed to be changed daily. I don't take care of R7 all the time, the last time I worked with R7 I didn't see any drainage. On 9/4/19 at 11:26 V2 stated, We have a standard policy to change it anyway. I think we have an order for [REDACTED].>On 9/5/19 at 1:24 P.M., EMR (Electronic Medical Records) reads Physician orders [REDACTED]. V13 documented old dressing noted brown drainage. Facility Policy titled Gastrostomy/Jejunostomy site care dated (MONTH) -2011 Purpose: The purposes of this procedure are to promote cleanliness and to protect the Gastrostomy or Jejunostomy side from irritation, breakdown and infection

Based on observation, interview, and record review, the facility failed to ensure that respiratory equipment and tubing used to deliver oxygen were labeled and dated. This deficient practice affected 2 residents (R263and R264) of two residents reviewed for specialty care in a total sample of 18. Findings Include: On 9/3/19 at 9:45am, R264 is in bed, asleep with oxygen administering via nasal cannula. Caregiver at bedside. Observed oxygen concentrator in R264, with humidifier bottle not labeled and no date written on the bottle. Also observed oxygen tubing not dated and not labeled. On 9/3/19 at 10:00am, R263 is in bed, awake, alert and able to answer questions. Observed oxygen concentrator in R263's room not in used, with humidifier bottle not dated or not labeled and with oxygen tubing dated 8/18/19. On 9/3/19 at 11:00am, V5 RN (Registered Nurse) stated, We change oxygen tubing and humidifier bottle weekly and as needed. We date them for infection control, so we know when to change it. We keep the oxygen concentrator in their room for oxygen with PRN (as needed) orders, but we still have to label, put dates on humidifier and oxygen tubing, and change it weekly. On 9/5/19 at 10:30am, V2 DON (Director of Nursing) stated, Our policy states for the oxygen tubing and humidifier to be labeled, dated and change weekly and PRN. Oxygen Therapy policy with review date of 8/6/17 reads in part: Oxygen will be administered in accordance with safety and sanitary principles. Replaces pre0filled humidifier bottle at lest every week and as needed. Dates bottle when opened. Changes cannula tubing at least weekly on 11-7 shift. Label tubing with date.

Based on observation, interview and record review, the facility failed to follow Medication Storage policy; failed to write open date on insulin vial once opened and failed to write the expiration date. This deficiency was observed in 1 of 3 medication carts reviewed in the facility. Findings Include: On [DATE] at 1:03pm, first floor medication cart was reviewed with V4 RN (Registered Nurse). One [MEDICATION NAME] (insulin) vial for R50 was observed to have a broken seal, opened, and without opened and expired date written on the insulin vial or on insulin box. On [DATE] at 1:05pm, V4 stated, We supposed to put the open date and the expired date when nurses open the insulin vial, so we would know when to discard it. We discard the vial 28 days after the opened date. On [DATE] at 10:30am, V2 DON (Director of Nursing) stated, We follow our policy, the nurses need to write opened and expired date on insulin vials when they open a vial. Medication Storage policy with revision date of [DATE] reads in part: Medication and biologicals are stored safely, securely and properly following the manufacture or supplier recommendation. Insulin (non-refrigerated). Once the insulin seal is broken the vial/prescription label is initialed and dated.

Based on observation, interview and record review the facility failed to protect resident's Medicare, and Social Security number from being available to the public. This failure affects 4 of 5 residents (R50, R58, R59, R257, R258) in the sample of 18 reviewed for privacy and confidentiality and 11 residents (R1, R31, R35, R38, R39, R57, R58, R59, R208, R209, R257, R258, R259, R260, R347) in the supplemental. On 8/29/18 13:32 PM V36 expressed a concern about R50 personal and medical information being available to anybody who signs the in/out book when residents are taking off the unit, including volunteer service, friends and transportation. V36 states she was looking for R50's sheet to sign, as she was taking him off the unit, and noticed that the sheet had a stamp with resident's information, including the social security number. Did talk with someone (does not remember the name) in the high level administration, with V37 who said was not aware. The person in the high level administration did not say much. Spoke with V6. On 08/30/18 09:00 AM (R1, R31, R35, R38, R39, R50, R57, R58, R59, R208, R209, R257, R258, R259, R260, R347) were reviewed for confidentiality. On 08/30/18 09:00 AM 3rd north Resident sign in/out book reviewed and shows a stamp in resident's sheet showing resident's name, Date of Birthday, Medicare number, Social Security number, resident's doctor's name, account number and room number. The book is placed on the countertop at the nursing station. On 08/30/18 09:30 V15 states the family fill out the book, or we guide them how to fill out, some family know how to write it down. If someone gets the residents of the unit they have to sign them out. We always reinforce them to sign in and out. On 08/30/18 09:36 AM V35 states she does stamps the in/out sheet. The sheet is part of the admission package. When resident comes in I get the admission package and they have this form. I stamp it and put it in this book in alphabetic order. The book is placed in the countertop in the nursing station. When resident goes off the unit we have the resident's friend, family, social worker, physical therapist, transportation, or anybody who takes resident off the unit signing the book with information where they go, with whom. On 08/30/18 11:46 AM reviewed 3rd north Resident sign in/out book again and noticed that some Social Security numbers had been scratched out. On 08/30/18 01:39 PM V2 states we encourage residents and family or anybody (transportation, Physical Therapist, friends) who is taking the resident off the unit to sign the in /out sheet/book in the floor. The book is available in the nursing station. On 08/30/18 01:42 PM V2 states sharing medical is only for Power of Authority or at the residents wishes, is about the resident choice. I trained that people I work with, Certified Nursing Assistant (CNA), nurses in the floor to protect residents information. We have training frequently on that, how to protect their information. We don't share and resident personal and medical information should be protect from other folks. We really try to avoid to expose identifying information. The unit's secretary does the sign in/out sheet/book. We have a couple opportunities for training, videos, they are mandatory, and one of than it is about how to protect the resident information. We do in services. I frequently make rounds, I have supervisors, we do every morning meetings in the floor, I go from unit to unit. When I am up there I can see if there is any problem. On 08/30/18 01:56 PM when asked about the 3rd floor in/out book showing confidential resident's information V2 stated I am not aware about that. My belief is all the books are the same. On 08/30/18 02:15 PM V2 states the secretary was following the wrong procedure and states I don't have a policy/procedure specific for that process.

Based on observation, interview and record review, facility failed to properly sanitize and dry equipment used to prepare pureed diets. This deficient practice affected 4 residents(R142, R214, R22, R229) in the supplemental sample. Findings include: Policy and procedure titled, Procedures: Pots & Pans/Cookware - Cleaning & Sanitizing, under step 8 states, Then submerge in sanitizer sink(Sink 3) for one minute or as specified by .Quat(quaternary) Sanitizer product label and/or local guidelines. Multi-Quaternary product specification document includes explanation to expose all surfaces to the sanitizing solution for a period of not less than 1 minute . On 8/29/18 at 9:10 am V20(Dietary/kitchen aide) prepared pureed food items for the lunch service. V20(Dietary/kitchen aide) washed the receptacle, blade of blender and top in the 3 compartment sink, submerging the blender parts in the sanitizer solution for 2 seconds. Blender parts did not dry before V20(Dietary/Kitchen aide) began to puree mixed vegetables. Pureed, mixed vegetables during processing in the blender came in contact with sanitizer solution. V20 also took a spatula which she washed, sanitized and immediately used to transfer the pureed vegetables into a holding container. The spatula was still wet with sanitizer solution when V20 used it on the pureed vegetables. After completing puree of the vegetables, V20 took the blender components and hand washed them in the 3 compartment sink, submerging the blender parts for less than 2 minutes and immediately used the blender to prepare pureed fish. Blender components which came in contact with the fish were wet from contact with the sanitizer solution in the 3 compartment sink. On 8/29/18 at 11:15 am V20(Dietary/Kitchen Aide) agreed she had not submerged the blender equipment used in the preparation of the puree food an adequate amount of time and did not allow the blender equipment to dry before use resulting in cross contamination.

Based on observation, interview and record review the facility failed to ensure proper infection control measures related to hand washing after cleaning an isolation room for one resident R358 on contact isolation for [MEDICAL CONDITION]-Resistant Staphylococcus Aureus (MRSA) of the wound, in a sample of 18, this has the potential to affect 4 residents (R3, R37, R157 and R210) in the supplemental sample. The facility also failed to ensure proper handling of linen and hand hygiene for one resident R9 in a sample of 18 this has the potential to affect one resident R9 in the supplemental sample. 08/28/18 12:19 PM V7 (Certified Nurse Aide) CNA dropped a face towel on floor then placed it back on linen cart with the clean linen. V7 said I don't usually put it back on the linen cart. I am sorry, I put it there to throw it in the dirty wash. 08/28/18 12:24 PM while making R9 bed V7 (CNA) proceeded to handle clean linen on linen cart. V7 said my hands are clean and the linen is clean. I washed my hands before making the bed. I needed more linen and got it off the clean linen cart, am I supposed to keep washing my hands? I did not wash my hands because they are clean. 08/28/18 12:30 PM R358 is on isolation [MEDICAL CONDITION]-resistant Staphylococcus Aureus (MRSA) of the wound. 08/28/18 01:09 PM V8 (Housekeeper) entered R358 isolation room. 08/28/18 01:19 PM V8 exited isolation room removed isolation gown, placing gown, gloves, microfiber mop and dust cloth in trash on cart, put on gloves swept floor near door, put gloves in trash proceeded down hallway. 08/28/18 01:22 PM V8 put on gloves without hand hygiene entered R3 room proceeded to dust room, empty garbage, replace trash bag in garbage can, cleaned bathroom, placed gloves, microfiber mop and dust cloth in trash on cart. 08/28/18 01:27 PM surveyor asked V8 about hand hygiene policy, V8 said I don't know, I am new, I did receive training for making beds, but I did not receive training for isolation. V8 reentered room mopped the floor. V8 said no I am not supposed to wash my hands because I change my gloves, the people training me said I just need to change my gloves. 08/28/18 01:35 PM V8 entered R210 room without hand hygiene, cleaned bathroom, emptied garbage exited room, threw out garbage reentered room mopped floor, exited room threw gloves, microfiber mop and dust cloth in trash on cart. 08/28/18 01:41 PM V8 donned gloves entered R157 room without hand hygiene proceeded to clean room, exited room, retrieved mop reentered room, mopped floor exited room, placed gloves, microfiber mop and dust cloth in trash on cart. 08/28/18 01:47 PM V8 donned gloves entered R37 room without hand hygiene and cleaned room, emptied trash, exited room retrieved mop, mopped floor, exited room discarded gloves, microfiber mop and dust cloth in trash on cart, did not wash hands. 08/28/18 01:57 PM V8 said I work wherever they need me, I work the other floors and the other building, and because I am new I do not have a set floor. 08/29/18 11:09 AM requested Housekeeping policies and procedures V10 (Housekeeping Supervisor) said isolation linen is put in red or melt away bags, chemical supplier. Isolation linen is washed on level 4 and only use one machine and an additional rinse with detergent is used after the wash is complete. If clean linen is dropped it goes to soiled process. Everything that touches the floor or comes out of a resident room, it returns to the soiled linen. All linen should be covered once it leaves the laundry room. 08/29/18 02:31 PM reviewed Housekeeping Policies & Procedure 08/30/18 10:54 AM V10 said housekeepers are to make sure chemicals are put away and they wash their hands. They should lock up chemicals and wash hands before going to next room. Hand sanitizer is acceptable to use. After exiting an isolation room wash hands. We have an isolation form that is signed when the isolation room is cleaned, we have different chemicals to clean an isolation room it should be cleaned twice during day shift. There are extra micro fiber rags and mops for the isolation room. The isolation micro fiber mop and rags are put in a separate bag. Fuzion is only for isolation rooms. Isolation rags and microfiber mops should be separated. Not washing hands after exiting an isolation room causes the potential for cross contamination. We have computer training and in service every 6 months and the supervisor will remind staff of hand hygiene. Everyone that is taking care of the isolation room is trained and they have 3 days in training. The isolation room should be one of the first rooms cleaned. If anything touch the floor it is put down the soiled line chute which goes to a laundry cart. The whole cart would be soiled if there is anything that fall to the floor and is placed on the clean linen cart. 08/30/18 01:01 PM V3 (Assistant Director of Nursing) said a different chemical is used to clean isolation rooms, hands should be washed or hand sanitizer used after cleaning the rooms, but if it is [MEDICAL CONDITIONS] hands should be washed with soap and water. If cleaning an isolation room the mop handle, broom handles and any supplies taken in the room should be disinfected. If this is not done there can be a transmission of disease. If a towel is dropped on floor it should go in the soiled linen, it should never be placed back on the clean linen cart, if it is everything else on the clean linen cart is soiled. The infection control policy is reviewed annually. 08/30/18 02:13 PM reviewed Infection Control Policy 08/30/18 02:25 PM reviewed Standard Precautions 08/30/18 02:47 PM V3 said the next scheduled Influenza and Pneumococcal immunizations is 09/25/18. 08/30/18 02:50 PM reviewed Isolation for Infectious Diseases 08/30/18 03:02 PM reviewed Hand washing policy Policy: Titled Infection Control revised 6/14/17 I. Purpose: to help prevent the development and transmission of disease and infection. II. Statement of Policy Prevent and control outbreaks and cross-contamination using transmission-based precautions in addition to standard precautions. Implement hand hygiene practices consistent with acceptable standards of practice, to reduce the spread of infections and prevent cross contamination. Properly store, handle, process and transport linen to minimize contamination. Title Standard Precautions revised 11/12/13 All employees who work in Presbyterian Homes' Health Care Centers will abide by the following Standard Precautions: Hand Hygiene Gloves- Hands should be washed immediately after gloves are removed. Housekeeping will use heavy-duty gloves in all housekeeping duties. Titled Isolation for Infectious Diseases revised 6/15/17 Gloves and Hand Hygiene - In addition to following Standard precautions, wear gloves when entering room, change gloves after contact with infective material and remove gloves before leaving room and perform hand hygiene Housekeeper: 20. Daily housekeeping routine is maintained in isolation room on the same schedule as all other rooms, noting the following points: a. Cleans isolation room after all other rooms. b. Places mop head in blue bag and send to laundry. c. Places disposable cloths in red plastic bags and discards in infectious waste receptacle in dirty utility room. Titled Hand Washing revised 9/4/14 Hand hygiene is to be done before and after removing gloves.

Based on interview and record review, the facility failed to provide a written notice of discharge to one resident (R57) and also failed to document in the medical record that the Ombudsman was notified of discharges, and transfers for three residents (R39, R57 and R158) reviewed for transfers and discharges in a total sample of 18 residents. Findings include: On 08/30/18 at 09:01 AM, surveyor reviewed R57 ' s face sheet in the electronic medical record (EMR). R57 ' s face sheet reads R57 was discharged from facility on 06/06/18. On 08/30/18 at 09:21 AM, surveyor reviewed R57 ' s Clinical Notes in the EMR. Clinical notes did not contain documentation that the facility provided a written notice of discharge to R57. Clinical notes did not contain documentation that the Ombudsman was sent a copy of the notice of discharge. On 08/30/18 at 10:32 AM, surveyor requested V4, Continuity Care Coordinator, to provide R57's discharge documentation. On 08/30/18 at 10:50 AM, V4 provided survey team with R57 ' s paper medical records. Paper medical records did not contain a written notice of discharge or documentation stating the Ombudsman was notified of the discharge. On 08/30/18 at 11:35 AM, V4 stated the facility does not document in the resident ' s medical record when they notify the Ombudsman regarding the resident ' s discharge. On 08/30/18 at 12:06 PM, V4 stated the notification of discharge is done verbally. V4 stated the facility does not provide a written notification of discharge to the residents. 08/30/18 09:57 AM record review R39 discharge to hospital on [DATE], Readmitted on [DATE]. 08/30/18 11:27 AM V4 (Continuity of Care Coordinator) said the ombudsman only require the Monthly Report of discharges not admissions. 08/30/18 11:27 AM record review notification of ombudsman dated 3/14/18 home 6/7/18 hospital no notification documented for discharge of 7/15/18 08/30/18 11:35 AM V4 said we don't put the notification in the medical record, it is just on the monthly report of discharges. 08/30/18 02:42 PM record review of Census History dated 8/30/2018 R39 was discharged [DATE] readmitted [DATE] and discharged [DATE] readmitted [DATE]. Record review of R158's medical record, no documentation of ombudsman's notification of R158 discharged to hospital. On 08/29/18 at 02:58 PM Interviewed with V4 RN Community Care Coordinator stated that the nurse on the unit will call the family member the reason of sending to the hospital and documented in nursing note. Monthly written report list of discharged residents are being sent to Ombudsman. The Evanston Ombudsman requires us to submit to them on a monthly basis. Upon admission, there is a form/contract that the family/resident have to sign. A bed hold policy is part of the contract/admission paper.

Based on interview and record review the facility failed to document in the medical record, and provide a second bed hold policy notice at the time of transfer for 2 facility initiated hospital transfers for 1 resident (R39) in a sample of 18. Findings include: 08/30/18 09:57 AM record review Resident # 39 discharged to hospital on [DATE] with [DIAGNOSES REDACTED]. Readmitted on [DATE] with [DIAGNOSES REDACTED]. 08/30/18 11:27 AM V4 (Continuity of Care Coordinator) said we call the family if they want the bed hold we remind them of the signed bed hold agreement. 08/30/18 11:35 AM V4 said the family is called and reminded of the bed hold but there is no written documentation of the notification. 08/30/18 11:43 AM V5 RN when a resident is discharged , the nurse gives, discharge instruction, medication list, notify physician of updated medications. If discharged to hospital the ambulance is called, transfer forms, med list, notify resident and family member of and reason for discharge, call to give report to ER staff, reason for get order for transfer. Family member is notified how the resident is doing at this time. If the resident is Alert and oriented x3 we will send belongings with them, once resident leave's the unit we have the room locked by public safety, we double check belonging sheet, notify supervisor, write in shift report, endorse to next shift. If the resident is expected or not expected to come back, I think based on our admission, we notify our admissions, and admissions discuss all our admission explanations with family once the resident leaves. Admissions has a time frame up to how long they can hold the bed until the resident returns, more often than not we do not discuss the bed holding policy. Notification is given with the admission package. 08/30/18 12:03 PM V6 (Director of admissions) said R39 came in as a respite patient and became Medicare after returning. The husband paid for the room while R39 was in the hospital. I can get the information from billing. 08/30/18 12:35 PM V6 said resident and family do not get an additional copy of the bed hold policy when discharged , it is in the system non bed hold. 08/30/18 02:42 PM record review of Census History dated 8/30/2018 R39 was discharged [DATE] readmitted [DATE] and discharged [DATE] readmitted [DATE]. The McGraw Care Center Bed Hold Policy revised 4/12/2018 signed by R39 representative dated 5/25/2018. Policy: Titled Bed Hold Policy revised 2/20/17 I. Purpose: Resident and a family member or resident's representative will be provided written information regarding bed-hold policy if resident is transferred to a hospital or on therapeutic leave. III. Procedure: Before Presbyterian Homes transfers a resident to a hospital or allows a resident to go on therapeutic leave, written information will be provided to the resident and a family member or resident representative

Based on observation, interview and record review, the facility failed to ensure nectar thick liquids were consumed by one resident (R48) out of 18 reviewed for therapeutic diets in a total sample of 18. Findings include: R48 face sheet has [DIAGNOSES REDACTED]. Current Physician order [REDACTED]. On 8/28/18 at 1:22 pm R48 was seated in the 1st floor dining area with lunch tray in front of her. R48 had 2 drinks including coffee of which 25% had been ingested. Coffee was tested and was of thin consistency. V15(Registered Nurse) reported initially it was dietary's responsibility to thicken liquids and then noted both staff and dietary are responsible. V15 explained a packet of thickener measuring .42 oz is added to coffee and staff need to stir the thickening powder to achieve the right consistency. V15 reported the coffee was probably not stirred sufficiently to activate the thickening. Packet titled, Thickened Coffee Drink Mix with net weight of .42 oz and labeling of nectar-like consistency, directs staff to 1. Pour contents of packet into a cup. 2. Add 6 fl(fluid) oz of hot water. Stir until dissolves. 6 fl oz of water is equivalent to 180 cc's of liquid. Amount of coffee served is approximately 240 cc's. V15 noted more thickening powder may also have needed to be used to achieve nectar thick consistency.