Every finding on record at Whittier Westborough Transitional Care Unit

Based on observations, interviews, and record reviews, the facility failed to maintain an effective infection control and prevention program to stop the spread of organisms and infections for two Residents (#59 and #159) out of a total sample of nine residents, and during the medication administration process related to fingerstick blood glucose testing. Specifically, 1. For Resident #59, the facility staff failed to implement appropriate hand hygiene during wound care for the Resident on Enhanced Barrier Precautions (EBP: infection prevention practice of wearing gown and gloves to reduce transmission of multi-drug-resistant organisms [MDRO's-bacteria that are resistant to three or more types of antimicrobial drugs]) during high contact resident care) as ordered by the Physician. 2. For Resident #159, the facility staff failed to don (put on) appropriate Personal Protective Equipment (PPE: items such as gown and glove worn to minimize exposure to hazards, contaminants, and organisms) when changing the Resident's bed linens with the Resident in the bed, and the Resident was ordered on EBP for open skin areas on bilateral arms. 3. The facility failed to ensure that staff performed hand hygiene after doffing (removing) PPE and before donning new PPE to prevent the potential for cross contamination during medication administration and fingerstick blood glucose testing for two residents. Findings include: 1. Review of the facility's policy titled, Hand Hygiene, dated June 2012, revision date January 2025, included but was not limited to: -It is the policy of this facility to follow the Centers for Disease Control and Prevention (CDC) guidelines for hand hygiene .and reduce the risk of health care associated infections. <wash hands with soap and water when they are visibly dirty or contaminated <if hands are not visibly soiled, use an alcohol-based hand rub . -Appropriate hand hygiene should be performed: <after removing gloves. Resident #59 was admitted to the facility in April 2025 with diagnoses including fall and skin tears. Review of Resident #59's May 2025 Physician orders included: -Maintain EBP, effective 4/24/25. -Monitor left upper arm skin tear and apply a dry protective dressing (DPD) every three days, effective 4/25/25. Review of Resident #59's Person-Centered Care Plan included but was not limited to: -Problem: Impaired skin integrity related to skin tear, initiated 4/23/25. >Goal: Area will improve with decreased risk for . infection through next review, with interventions that included treatments to be provided as ordered by the Physician. On 5/1/25 at 8:20 A.M., the surveyor observed signage posted in Resident #59's doorway that indicated: >STOP ENHANCED BARRIER PRECAUTIONS STOP >EVERYONE MUST: -clean their hands including before entering and when leaving the room. -wear gloves and a gown for the following high contact resident care activities: *Wound Care: any skin opening requiring a dressing. On 5/1/25 at 9:09 A.M., the surveyor observed Nurse #1 perform wound care for Resident #59's left upper arm skin tear as follows: -Nurse #1 cleansed her hands with hand sanitizer and donned clean gloves and a gown. -Nurse #1 entered the Resident's room, introduced herself and educated the Resident about wound care. -Nurse #1 removed the old dressing from the Resident's left upper arm. -Nurse #1 discarded the old dressing into the trash receptacle. -Nurse #1 cleansed the Resident's skin tear with Normal Saline Solution (NSS) and a gauze pad. -Nurse #1 used a clean gauze pad to dry the skin tear wound area on the Resident's left upper arm. -Nurse # 1 doffed her gloves and discarded the gloves into the trash receptacle. -Nurse #1 donned a new pair of gloves without performing hand hygiene prior to applying the new pair of gloves. -Nurse #1 placed a dry protective dressing over the Resident's left upper arm skin tear. During an interview at the time, Nurse #1 said that Resident #59 required EBP because the Resident had a wound. Nurse #1 said that she did not cleanse her hands between her glove change, but she should have. Nurse #1 said that her hands should be cleansed with hand sanitizer or soap and water every time gloves are changed because not cleansing her hands between glove changes could spread infection to the Resident. During an interview on 5/1/25 at 3:44 P.M., the Infection Preventionist (IP) Nurse said that Nurses were educated on wound care and hand hygiene upon orientation and then competencies are conducted throughout the year. The IP said that Nurse #1 should have cleansed her hands when gloves were removed and prior to putting on new gloves. The IP said that the failure to cleanse hands between glove changes could spread infections to the Resident. 3) Review of the facility policy titled Hand Hygiene, revised 1/2025, indicated the following: -appropriate hand hygiene should be performed: >after removing gloves Review of the facility policy titled Personal Protective Equipment, revised 1/2025, indicated the following: -[Putting on] Unsterile Gloves >perform hand hygiene >obtain glove(s) . -Removing gloves > .discard glove . >perform hand hygiene -Putting on the Gown: >wash hands >unfold the gown with opening facing you . -Removing the gown > .discard the gown in the appropriate receptacle >wash hands . On 5/1/25 at 8:05 A.M., the surveyor observed the Infection Preventionist (IP) during a medication administration as follows: -The IP completed control testing on a glucometer. -The IP set up to complete a finger stick blood glucose test on a resident. -without performing hand hygiene, the IP donned a gown and gloves and entered the resident's room, and completed the finger stick blood glucose test. -The IP doffed (removed) gloves and gown without performing hand hygiene. -The IP cleaned and disinfected the glucometer and moved the medication cart to the next resident's room. On 5/1/25 at 8:08 A.M.,the surveyor observed the IP during a medication administration for another resident as follows: -The IP set up the glucometer for testing without performing hand hygiene after leaving the previous resident's room. -The IP donned a gown and gloves without performing hand hygiene and entered the next resident's room where the IP completed a fingerstick blood glucose test on the second resident. -The IP doffed the gown and gloves and exited the second resident's room to the medication cart where he cleaned and disinfected the glucometer. During an interview on 5/1/25 at 2:16 P.M., the surveyor reviewed the IP observations at 8:05 A.M. and 8:08 A.M. with the IP. The IP said after touching potentially contaminated items on the medication cart and after doffing gloves, he should have performed hand hygiene before donning PPE to prevent potential contamination. 2. Resident #159 was admitted to the facility in April 2025 with diagnoses including psoriasis, specified fracture of left pubis and metabolic encephalopathy. Review of the facility policy titled Enhanced Barrier Precautions, effective 4/1/24, indicated: -It is the policy of this facility that all staff providing high-contact resident care activities will implement Enhanced Barrier Precautions (EBP) for residents with any of the following: <Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a multidrug resistant organism (MDRO). -EBP refers to an infection control intervention designed to reduce transmission of multidrug resistant organisms that employs targeted gown and glove use during high contact resident care activities. -High contact resident care activities are defined to be: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use such as central lines, urinary catheter, feeding tube and tracheostomy/ventilator and wound care: any skin opening requiring a dressing. -A sign indicating the need for EBP will be placed conspicuously to alert staff before approaching the resident for care. Review of the Minimum Data Set (MDS) Assessment, dated 4/15/25, indicated the following for Resident #159: -was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of a possible score of 15. -he/she was understood by others and understands others. Review of Resident #159's May 2025 Physician orders indicated: -EBP for open areas to upper extremity due to severe Psoriasis and is being treated, initiated 5/1/25. Review of Resident #159's May 2025 Medication Administration Record (MAR) indicated: -Apply [NAME] (topical anesthetic) to patient bilateral upper extremity (BUE) due to redness and itching every shift, initiated 4/20/25. -Triamcinolone Acetonide cream (corticosteroid), 0.1%, amount to administer: small amount topical twice a day to BUE, initiated 4/19/25 On 5/1/25 at 8:00 A.M., the surveyor observed signage posted outside of the Resident's door that indicated: >STOP ENHANCED BARRIER PRECAUTIONS: >EVERYONE MUST: -clean their hands including before entering and when leaving the room. >Providers and staff must also: -wear gloves and a gown for the following high contact resident care activities: -changing linens On 5/1/25 at 8:05 A.M., the surveyor observed Resident #159 lying in bed with the head of the bed elevated to 90-degrees. The surveyor observed several open skin areas on the Resident's bilateral arms. Resident #159 said that he/she scratches at his/her arms because his/her arms were itchy. Resident #159 said that staff typically would apply a sleeve on both of his/her arms when he/she was assisted with care. On 5/2/25 at 9:14 A.M., the surveyor observed Certified Nurses Aide (CNA) #1 enter the Resident's room without donning a gown and then exited the room. CNA #1 approached the surveyor and asked the surveyor if she must wear a gown to change Resident #159's bed linens. When the surveyor asked CNA #1 what was the facility policy for residents requiring EBP, CNA #1 said that the facility policy did not require staff to use a gown when changing bed linens for the residents on EBP. The surveyor observed CNA #1 re-enter Resident #159's room without donning a gown. CNA #1 was observed changing Resident #159's bed linens while the Resident remained in the bed. During an interview on 5/2/25 at 9:26 A.M., the Director of Nursing (DON) said she was the staff member that placed an EBP sign and supplies outside Resident #159's bedroom door because the Resident had open areas to both arms. The DON said that staff are not required to wear PPE when changing bed linens for Resident #159 if the bed linen was not soiled. The surveyor and the DON reviewed the facility's EBP sign, and the DON said that CNA #1 should have worn a gown when changing the bed linens because the Resident had open areas on the arms.

Based on observations, interviews, and record reviews, the facility failed to provide an environment free from accidents and hazards related to the storage of medications for one Resident (#63) out of a total sample of nine residents. Specifically, for Resident #63, the facility failed to: -safely and properly store prescribed topical medications when the medications were left within reach at the Resident's bedside, and he/she had a diagnosis of Dementia, putting the Resident at risk of inappropriately accessing and using the medications. -ensure the medications was not readily accessible to the Resident and other unauthorized individuals, when Resident #63 did not have an assessment or Physician's order for self-administration of medications and the medications were observed unattended and within close proximity of the Resident in his/her bedroom. Findings include: Review of the facility policy titled Storage of Medication, revision date December 2019, included but was not limited to: -Medications and biologicals are stored safely, securely and properly . -The medication supply is accessible only to licensed nursing personal, pharmacy personal or staff members lawfully authorized to administer medications. Review of the facility policy titled Self Administration of Medication, dated June 2012, revision date March 2022, included but was not limited to: -Each resident who desires to self administer medications may do so if the facility's interdisciplinary team (IDT) has determined that the practice would be safe for the resident and other residents of the facility. -The resident may request to self administer medications at any time during their stay. -An assessment is conducted by the IDT of the residents cognitive, physical and visual ability to carry out this responsibility. -The results of the IDT assessment are recorded on the Self Administration of Medications document in the resident's medical record. Resident #63 was admitted to the facility in April 2025 with diagnoses including Dementia, anxiety, insomnia, fall and left femur fracture. Review of Resident #63's Medical Record included but was not limited to: -Resident #63's Minimum Data Set (MDS) Assessment had not yet been completed. Review of Resident #63's May 2025 Physician's orders indicated: -Venelex (topical medicated ointment for wound healing) apply to bilateral heels twice a day, effective 4/29/25. -Cleanse buttocks/perianal area with soap and water, then apply Antifungal cream twice a day until healed, effective 4/29/25. On 5/1/25 at 11:14 A.M., the surveyor observed that Resident #63 was alone in his/her room, lying in bed with the head of the bed elevated and an over-the-bed table positioned in front of him/her. The surveyor observed two tubes of medications located on the Resident's over-the-bed table and within the Resident's reach. The surveyor also observed that there were no staff members within the immediate vicinity of the Resident's room. The surveyor observed the medications located on the Resident's over-the-bed table prescription labels read as follows: -Venelex Wound Dressing ([NAME]/Castor Oil) Ointment 30 gm (grams) apply topically twice a day to bilateral heels. -Miconazole Nitrate (antifungal cream) 2% apply topically twice a day to buttocks/perianal area. On 5/2/25 at 9:10 A.M., the surveyor observed Resident #63 alone in his/her room, seated in a wheelchair and eating breakfast. The surveyor did not observe any facility staff to be within the immedicate area. The surveyor observed two tubes of medications (Venelex Ointment and Miconazole Nitrate) on the Resident's nightstand and within the Resident's reach. During an interview at the time, Resident #63 said he/she did not know what the two tubes were. During an interview on 5/2/25 at 9:15 A.M., Nurse #1 said that medications kept at a Resident's bedside required an assessment for self-administration and a Physician's order. The surveyor and Nurse #1 observed the two prescription medication tubes (Venelex Ointment and Miconazole Nitrate) remained on Resident #63's nightstand. Nurse #1 said that Resident #63 did not have a Physician's order or assessment to keep medications at the bedside. Nurse #1 said that the medications should not had been left at the bedside because the Resident had Dementia and could use the medications inappropriately. During an interview on 5/2/25 at 10:16 A.M.,Unit Manager (UM) #1 said that Residents required a Physician's order and a Self-Administration of Medications Assessment in order to keep medications at the bedside. UM #1 said that when medications were kept at the bedside the medications should be kept in a drawer for safe keeping and not out in the open or within a Resident's reach. UM #1 said that Resident #63 did not have a Physician's order or a Self-Administration of Medications Assessment to keep ointments at the bedside. UM #1 said that Resident #63 would be unlikely to pass the Self-Administration of Medications Assessment due to the Resident's diagnosis of Dementia. UM #1 said that the ointments should not have been left in the Resident's room and within the Resident's reach.

2. Review of the facility policy titled Psychotropic (medication that effects mental processes, emotions or behaviors) Medication Management and Informed Consent, dated April 2014 with revision date of March/2025, included but was not limited to: -Psychotropic medications shall not be administered to a resident without an informed written consent. -Documentation of Informed Consent is required for any medication that is used in the treatment of a psychiatric diagnosis or symptoms. This includes drugs to treat depression, anxiety disorders, attention deficit/hyperactivity disorders or other psychiatric indications. -The written informed consent shall be kept in the resident's medical record. -Behaviors or symptoms will be monitored and documented each shift. -Potential adverse drug reactions and side effects will be monitored and documented. Resident #65 was admitted to the facility in April 2025 with diagnoses including Depression. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #65: -was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of a total possible score of 15. -was understood by others and understands others. -was taking Antidepressants medication. -the Resident had signed an informed consent for antidepressant medications, Duloxetine and Trazodone, dated 4/12/25 with risks (side effects) including: sedation, drowsiness, dry mouth, blurred vision, urine retention, tachycardia (heart rate over 100 beats per minute), muscle tremors, agitation, headache, skin rash, photosensitivity (skin sensitivity to sunlight), excess weight gain, heart disease, glaucoma, chronic constipation, seizure disorder, edema (swelling). Review of Resident #65's May 2025 Physician orders included but were not limited to: -Duloxetine capsule, delayed release 60 mg (milligram) one capsule, oral once a day 9:00 A.M., effective 4/12/25. -Trazodone tablet, 50 mg, two tablets (total =100 mg), oral at bedtime 9:00 P.M., effective 4/12/25. -No evidence of intervention for side effects monitoring of the Psychotropic medications. Review of the Resident #65's April 2025 and May 2025 MARs indicated: -The Resident had been administered Duloxetine and Trazodone, as ordered by the Provider for a 21-day period. Review of the Pharmacist's Monthly Medication Record Review for Resident #65 dated 4/26/25, indicated: -Medications reviewed. No irregularities noted at this time. Review of Resident #65's Person Centered Care Plan included but was not limited to: -Problem: ADL's functional status/Rehabilitation potential, initiated 4/12/25. >Goal: Avoid significant decline or adverse changes in status related to my (the Resident's) continued placement over the next 30 days, target date 5/12/25. >Goal: My immediate needs will be met and care needed will be provided based on admission physician orders and professional standards of quality care through my next review date, target date 5/12/25. >Approach: Physician orders for care include prescriptions for: *Duloxetine capsule, delayed release 60 mg (milligram) one capsule; oral once a day, 9:00 A.M., effective 4/12/25. *Trazodone tablet, 50 mg; two tablets -100 mg; oral at bedtime 9:00 P.M., effective 4/12/25. *No evidence that Psychotropic medication side effect monitoring had been in place. During an interview on 5/2/25 at 3:18 P.M., the Director of Nursing (DON) said that Resident #65 was being administered psychotropic medications as ordered by the Physician. The DON said that Resident #65 was being monitored for behaviors but not for the side effects for psychotropic medications. The DON said that the facility Nurses should be monitoring and documenting psychotropic medication side effects, like the facility policy indicated, but they were not. The DON said that not monitoring the Resident for psychotropic medication side effects could place the Resident at risk for unwanted side effects or complications. Based on interview, and record review, the facility failed to provide care consistent with professional standards of practice relative to the management and monitoring of psychotropic medications (medication that affect how the brain works and causes changes in mood, awareness, thoughts, feelings and behaviors) for two Residents (#159 and #65), of five applicable residents reviewed for unnecessary medications, out of a total sample of nine residents. Specifically, the facility failed to: 1. For Resident #159, ensure monitoring of potential side effects of Lexapro (antidepressant medication) medication, placing the Resident at risk for unidentified medication side effects and/or complications. 2. For Resident #65, ensure the monitoring of potential side effects of Duloxetine (antidepressant medications) and Trazodone (antidepressant medication) use in accordance with professional standards of practice, placing the Resident at risk for unidentified medication complications and/or side effects. Findings include: Review of the facility policy titled Psychotropic Medication Management and Informed Consent, effective 4/2014 and last revised 3/2025, indicated: -Psychotropic medications is any medication that may affect brain activities associated with mental processes and behavior. -When psychotropic medications are used in the facility, the facility will identify target behaviors or symptoms. -Behaviors and symptoms will be monitored and documented each shift. -A care plan targeting these behavior(s) or symptoms will be initiated. The care plan will identify both non-pharmacological and pharmacological interventions. -Potential adverse drug reactions and side effects will be monitored and documented. Resident #159 was admitted to the facility in April 2025 with diagnoses including Depression. Review of the Minimum Data Set (MDS) Assessment, dated 4/15/25, indicated for Resident #159: -was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of a possible score of 15. -was understood by others and understands others. -was taking an Antidepressant Medication -has a diagnosis of Depression Review of Resident #159's May 2025 Physician orders indicated: -Lexapro (Escitalopram Oxalate) tablet, 10 milligrams (mg), Amount to Administer: 1 tab, oral once a day, initiated 4/9/25. Review of Resident #159's April 2025 and May 2025 Medication Administration Records (MARs) indicated the Resident was administered Lexapro daily as prescribed by the Physician. Review of Resident #159's Signed Informed Consent Form dated 4/9/25, for Antidepressant Medication Administration indicated: -Lexapro 10 mg for Depression -Common side effects included: sedation, drowsiness, dry mouth, blurred vision, urinary retention, tachycardia (an abnormal heart rhythm with a fast heart rate of more than 100 beats per minutes at rest), muscle tremor, agitation, headache, skin rash, photosensitivity (an increased sensitivity of the skin to sunlight or other types of light, causing an unusual reaction like a rash or sunburn) (skin), excess weight gain. *Special Attention: Heart disease, glaucoma, chronic constipation, seizure disorder, edema. -Consent Form was signed by the Resident. Further review of Resident #159's medical record failed to indicate Physician orders or nursing interventions to monitor for potential side effects from Lexapro medication use. During an interview on 5/2/25 at 9:05 A.M., Nurse #2 said that a Resident who received Lexapro medication had to be monitored for medication side effects that include nausea, anxiety, headaches, confusion, dizziness, and sleepiness. Nurse #2 said that she knew the side effects of Lexapro because she is familiar with the medication. Nurse #2 said that Lexapro side effects should have been monitored and documented for Resident #159 every shift on the Residents MAR, but they were not. During an interview on 5/2/25 at 9:40 A.M., the Director of Nursing (DON) said that there should have been a Physician order for Resident #159 to be monitored for antidepressant side effects. The DON said that Resident #159 should have had a care plan addressing the need for care and services related to Lexapro use, but there was not.

Based on interview, and record reviews, the facility failed to notify the Physician of a significant change in condition for one Resident (#60) out of a total sample of nine residents. Specifically, the facility failed to notify Resident #60's Physician of a significant weight loss prior to his/her discharge from the facility. Findings include: Review of the facility policy titled, Weighing and Measuring, dated June 2022 and revised November 2024, included but was not limited to: -Residents are weighed and measured per the following protocol to provide a baseline and an on-going record of the resident's body weight: *To determine and monitor nutritional status and medical condition. -Residents are weighed: >On admission. >Weekly for the first 4 weeks after admission. >Monthly thereafter. >Per physician ' s order. -Procedure: >Record weight in the vital signs section of the Electronic Medical Record (EMR). >Check current weight against prior recorded weight. >Notify the licensed nurse if weight is 3 or more pounds different. >Re-weigh the resident within 72 hours to verify the accuracy of the weight. >Record the re-weight in the vital signs section of the EMR. >Changes of 5% in 30 days, must be evaluated for significant change. Review of the facility policy titled Change in Resident Condition or Status, dated June 2006, and revised March 2025, included but was not limited to: -It is the policy of this facility to immediately notify the resident . consult with his/her attending physician .of changes in the resident's condition or status. -The licensed nurse will notify the resident's physician .when: *There is a significant change in the resident's physical status that is a deterioration in health. Resident #60 was admitted to the facility in April 2024 with diagnoses including fall, right femur fracture and fracture of the right radius. Review of the medical record indicated Resident #60: -was cognitively intact as evidence by a Brief Interview of Mental Status (BIMS) score of 15 out of a total possible score of 15. -was prescribed a No Added Salt diet of regular texture and thin liquids. -Meal consumption for 4/9/25 - 5/2/25, was recorded 75-100%. -A Physician's order for weekly weights, effective 4/16/25 -Weight recordings for the Resident in the Vital Signs EMR section included: >4/10/25: 123.2 pounds (lbs.). >4/11/25: 122.4 lbs. >No weight documented the week of 4/13/25 - 4/19/25 >4/23/25: 116.4 lbs. (6.8 lbs. weight loss = 5.52% weight loss in 13 days = significant weight loss). >No evidence of a re-weight obtained on or after 4/23/25. -No evidence of Physician notification of the Resident's significant weight loss. Review of the Resident's Person-Centered Care Plan included but was not limited to: >Problem- Nutrition Intake Documentation, start date 4/9/25. >Goal: Record Resident's food consumption at every meal and snack, target date 5/9/25. >Approach: Record Resident's food consumption at every meal and snack, start date 4/9/25. Review of Resident #60's Nutritional Evaluation dated 4/14/25, indicated but was not limited to: -ideal body weight (IBW): 116 lbs. -usual body weight (UBW): 120-122 lbs. -had increased nutritional needs due to healing. Review of the Nutrition Note dated 4/28/25, included but was not limited to the following: -weight was 116.4 lbs. -has been eating 75-100% of meals. -No new recommendations. -No evidence of Physician notification pertaining to weight loss. During an interview on 5/2/25 at 12:18 P.M., the Director of Nursing (DON) said that the Registered Dietician (RD)was not available in the facility today. During an interview on 5/2/25 at 2:39 P.M., the surveyor and the DON reviewed Resident #60's medical record and the DON said the Resident had experienced a 5% weight loss in 13 days according to the documented weights in the Resident's medical record. The DON said a 5% weight loss was a significant weight loss in 13 days. The DON said that she was unaware of when a re-weight should be done. The DON said that there was no re-weight recorded in the Resident's medical record. The DON said that a 5% weight loss was a significant change and should have been reported to the Resident's Physician for possible interventions needed or to determine why weight loss had occurred. The DON said that Nurses should document Physician notification for a change in condition in the Resident's EMR. The DON said she was unable to provide evidence that the Resident's Physician or Nurse Practitioner (NP) had been made aware of the Resident's significant weight loss. The DON said that Resident #60 was discharged home earlier that day.

Based on interviews, the facility failed to ensure its staff designated an Infection Preventionist (IP) who had completed specialized training in infection prevention and control prior to assuming the role of IP at the facility. Specifically, the facility designated an IP who had not completed specialized training in Infection Prevention and Control before assuming the IP role and continued to work as the designated IP at the facility. Findings include: During an interview on 5/15/24 at 7:54 A.M., the Director of Nurse (DON) said that the facility had a designated IP (Nurse #1) who has been an IP in the facility for two years and would provide proof of specialized training. During an interview on 5/16/24 at 10:00 A.M., the DON said she was not able to provide evidence of the IP's specialized training and or certification. The DON said the IP was working on the floor as a nurse. The facility failed to provide the surveyors with any evidence of the IP's specialized training in infection prevention and control prior to their exit from the facility.

Based on observations, interviews, and policy review, the facility failed to maintain an infection prevention and control program designed to help prevent the potential transmission of communicable diseases and infections within the facility for four Residents (#80, #121, #124, and #126), out of a total sample of 17 residents. Specifically, the facility failed to clean and disinfect multi-use equipment after use between Resident #126 and Resident #80 and who were on Enhanced Barrier Precaution (an infection control strategy that uses personal protective equipment (PPE) to reduce the spread of multidrug-resistant organisms between residents) prior to using the same equipment on two other Residents (#121 and #124). Findings include: Review of the facility's policy titled Cleaning of Reusable Equipment, revised October 2020, included the following: -Reusable items that come in contact with skin, but no mucous membranes should be cleaned using the approved facility disinfectant wipes or spray and dried thoroughly before re-use. Review of the facility's policy titled Enhanced Barrier Precautions, dated 4/1/24, included the use of Personal Protective Equipment (PPE) and refer to the use of gown and gloves during high-contact care that provide opportunities to transfer Multi-Drug Resistant Organisms (MDROs: infection causing bacteria that have become resistant to antibiotics and are easily transmitted to others). On 5/16/24 at 8:25 A.M., the surveyor observed Nurse #1 taking the blood pressure of Resident #126. There was a sign outside the Resident's door indicating he/she was on Enhanced Barrier Precaution. The Nurse removed the blood pressure cuff from the Resident, placed the cuff in the blood pressure machine, without cleaning or disinfecting the cuff or the machine, and left the blood pressure machine in the hallway. On 5/16/24 at 8:31 A.M., the surveyor observed Nurse #1 enter Resident #121's room with the blood pressure machine that was in the hallway. He checked the Resident's blood pressure, exited the room with the blood pressure cuff and machine, and left the blood pressure machine in the hallway, without cleaning or disinfecting the cuff and the machine and continued with his medication pass. On 5/16/24 at 8:47 A.M., the surveyor observed Nurse #1 enter Resident #80's room, with the same blood pressure machine and cuff. There was an Enhanced Barrier Precaution sign outside the Resident's door. Nurse #1 applied the blood pressure cuff to the Resident, obtained the Resident's blood pressure, removed the cuff, and placed it in the blood pressure machine. Nurse #1 came out of the room, did not clean or disinfect the cuff or the machine and left it in the hallway, sanitized his hands and continued with his medication pass. On 5/16/24 at 8:59 A.M., the surveyor observed Nurse #1 enter Resident #124's room with the same blood pressure machine and cuff. The Nurse obtained the Resident's blood pressure, removed the cuff, placed the cuff in the blood pressure machine, came out of the room and left the cuff and machine in the hallway, and did not clean or disinfect the machine and the cuff. During an interview on 5/16/24 at 9:08 A.M., Nurse #1 said he should have cleaned and disinfected the blood pressure cuff and the blood pressure machine before and after using it on the Residents but he did not. During an interview on 5/16/24 at 10:48 A.M., the Director of Nurses (DON) said Nurse #1 was the Infection Preventionist and should have cleaned and disinfected the blood pressure cuff and machine per the facility's policy.

Based on interview and record review the facility staff failed to ensure the Medical Director attended the quarterly Quality Assurance (QA) meetings for 2 out of the last 4 quarters. Findings include: Review of the last 4 quarterly QA sign in sheets indicated the Medical Director, or his designee, was not in attendance on 10/30/18 or 1/31/19. During an interview on 9/4/19 at 5:10 P.M., the Director of Nurses said she did not have any evidence that the Medical Director attended the 2 quarterly meetings as required.

Based on observation, record review and interview the facility staff failed to provide care and services for 1 resident (#121) with a Peripherally Inserted Central Catheter (PICC) out of a total sample of 8 residents. Findings include: Resident #121 was admitted to the facility in 8/2019. Review of the undated PICC Flushing Policy indicated: -Flushing is performed to ensure and maintain cannula patency and to prevent the mixing of incompatible medications/solutions -A physician's orders [REDACTED]. The order must include the flushing agent, the amount and the frequency -Flushing with 0.9% sterile saline shall be performed before and after administration of incompatible medications/solutions, followed by [MEDICATION NAME] saline per physician order Review of the admission orders [REDACTED] -[MEDICATION NAME] (an antibiotic) 2 Grams intravenous, once a day, -Change PICC line dressing weekly, and -Flush PICC line every shift per facility protocol. Continued review of the admission orders [REDACTED]. Review of the Medication Administration Record [REDACTED].M. every evening and the MAR indicated [REDACTED]. On 9/4/19 at 9:12 [NAME]M. the surveyor observed Resident #121 in bed. The surveyor observed a PICC line was inserted in his/her right upper extremity. On 9/4/19 at 1:56 P.M. during an interview with Nurse #1 the surveyor asked if she had flushed the resident's PICC line today. Nurse #1 answered yes. The surveyor asked what she used to flush the PICC line and she said she flushed the line with 5 milliliters (ml) of [MEDICATION NAME] followed by 10 ml of normal saline. The surveyor asked if there were any physician orders [REDACTED]. Nurse #1 said there should be specific orders in place, but there not. The surveyor then asked what strength [MEDICATION NAME] she used to flush the PICC line and Nurse #1 said she did not know. On 9/4/19 at 2:52 P.M., during an interview with the Director of Nurses (DON), she said that the orders for the care of the PICC line were incomplete. She said when the resident was admitted the specific physician orders [REDACTED]. The DON said that she was not able to tell the surveyor how the PICC line was cared for.

Based on record review and interview the facility staff failed to meet professional standards of quality for 1 resident (#19) out of a total sample of 8 residents. Findings include: For Resident #19, the facility staff failed to monitor the resident's intake to ensure the 1.5 liter (L) fluid restriction was maintained. Resident #19 was admitted to the facility in 8/2019 with a [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the Intake Report, dated 8/28/19 through 9/4/19, indicated the Certified Nurses Aids (CNAs) were documenting the resident's intake, but the nurses were not. Therefore, the totals were inaccurate. On 9/4/19 at 11:22 [NAME]M., during an interview with Unit Manager (UM) #1, the surveyor asked if there was any other documentation that included the fluids the nurse gave the resident. UM #1 said no, and the Intake Record that she had given the surveyor was the only record of the resident's intake. The surveyor asked if the nurses should have included the fluids that were given with the medication pass and liquid supplements that the nurses were responsible to administer. UM #1 said that the record should include all fluids given to the resident. She said the Intake Record was not accurate because the nurses did not document the fluids that they gave to the resident. UM #1 said that she was unable to assess if the fluid restriction was maintained. On 9/4/19 at 2:58 P.M., during an interview with the Director of Nurses, she said that the computer system totals the input at the end of the day. She said the 11:00 P.M. to 7:00 [NAME]M. nurse was responsible to review the totals to ensure that the orders were followed. The DON said that the nurses who were responsible to review the intake should have recognized that the nurses had not documented the fluids they had given to the resident.

Based on record review and interview, the facility staff failed to provide a written bed hold notice that specified the duration of the bed hold, for 1 resident (#8) when he/she required 3 separate transfers to a hospital, from a total sample of 8 residents. Findings include: Review of the facility's Bed Hold Policy and Notice, dated 1/2016, indicated the following; -It is the policy of the facility to inform the resident and/or their representative of the bed hold policies upon admission and prior to a resident being transferred to a hospital or allowed to go on a non-medical leave. -A bed hold policy reminder is given to the resident or responsible party upon their transfer to the hospital by the social worker or, in his/her absence, the nurse on duty. Resident #8 was admitted to the facility in 7/2019 with [DIAGNOSES REDACTED]. Review of a nurse's note, dated 7/22/19, indicated resident had an acute transfer to the hospital. A nurse's note, dated 7/28/19, indicated the resident was readmitted to the facility on [DATE]. Review of a nurse's note, dated 7/31/19, indicated the resident was experiencing medical changes and was seen by the physician. The note indicated the resident was transferred to the hospital and the family member was notified when he came into the facility to see the resident. A nurse's note, dated 8/11/19, indicated the resident was readmitted to the facility. Review of a nurse's note, dated 8/21/19, indicated the resident was transferred to the hospital for surgery. A nurse's note, dated 8/29/19, indicated the resident was readmitted to the facility. During an interview on 9/4/19 at 8:21 [NAME]M., Resident #8 said he/she had been very sick recently and was hospitalized several times during his/her stay at the facility. During an interview on 9/4/19 at 4:36 P.M., the Administrator said there was no bed hold notices provided to the resident and/or his/her representative for the 3 hospital transfers the resident required. He said the bed hold policy should have been provided by the staff as required, but were not.

Based on record review and interview, facility staff failed to notify a resident and/or the resident's representative for 2 of 3 transfers or discharges, including the reasons for the move, in writing and failed to ensure the Office of the State Long-Term Care Ombudsman was notified, for one Resident (#8) in a total sample of 8 residents. Findings include: Review of the facility's policy for Notice upon Resident's Transfer or Discharge Including Expedited Appeal, dated 1/2017, indicated the following: -It is the policy of this facility to provide residents and/or the residents' representatives with a written notice of impending transfer or discharge. -A resident, and or representative, will be given a 30 day advance notice of an impending transfer or discharge from the facility if .the resident required an immediate transfer or discharge due to urgent medical needs . -At the time of discharge or transfer, a copy of the written notice will also be sent to a representative of the Office of the State Long Term Care Ombudsman. Resident #8 was admitted to the facility in 7/2019 with [DIAGNOSES REDACTED]. Review of a nurse's note, dated 7/22/19, indicated the resident had an acute transfer to the hospital. Review of a nurse's note, dated 7/28/19, indicated the resident was readmitted to the facility on [DATE]. Review of a nurse's note, dated 7/31/19, indicated the resident was experiencing medical changes and was seen by the physician. The note indicated the resident was transferred to the hospital and the family member was notified when he came into the facility to see the resident. Review of a nurse's note, dated 8/11/19, indicated the resident was readmitted to the facility. Review of a Notice of Intent to Discharge or Transfer A Resident Within 30 Days form, dated 7/31/19, indicated the resident was notified that an immediate transfer was required due to his/her urgent medical needs. Review of a nurse's note, dated 8/21/19, indicated the resident was transferred to the hospital for surgery. Review of a nurse's note, dated 8/29/19, indicated the resident was readmitted to the facility. During an interview on 9/4/19 at 8:21 [NAME]M., Resident #8 said he/she had been very sick recently and was hospitalized several times. He/she hoped to be going home in the next day or 2 as his/her health had improved. During an interview on 9/4/19 at 4:36 P.M., the Administrator said there was only one transfer notice (7/31/19) provided for the 3 hospital transfers the resident required. He said there should have been notices issued for the other 2 transfers, but they were not. He said there was no evidence a representative of the Office of the State Long-Term Care Ombudsman was notified of the 3 transfers as required, but there should have been.

Based on observation, interview and record review the facility staff failed to follow infection control measures when completing procedures that have potential exposure to blood. Findings include: Review of the Facility Policy Blood Glucose Monitoring System dated as revised 1/2016 indicated under Infection Control: The glucometer unit must be wiped down between each resident with a sani-wipe (germicidal) product and before being replaced in the kit. During the medication pass observation on 8/1/18 at 4:23 P.M. with Nurse #2, she was observed to obtain a plastic case from behind the Nurses station and place it on the medication cart. Nurse # 2 gathered supplies from the the case to obtain a finger stick blood sugar (FSBS) including a lancet , 2x2 gauze and alcohol wipe and the Glucometer. The Nurse brought the supplies into the resident's room and was observed to do the following: -donn gloves -placed a test strip into the glucometer -place the glucometer onto the resident's overbed table in front of the resident -clean the resident's finger with alcohol -using a lancet stick the resident's finger to obtain a blood sample and gently squeeze the resident's finger to initiate blood flow -pick up the meter and place the test strip into the blood on the resident's finger to obtain the blood sample holding the meter with gloved hands -removed and disposed of the test strip and lancet -removed her gloves and brought the meter back to the medication cart placing it into the plastic case that contained the FSBS supplies -Closed the case and returned the case back to the shelf behind the Nurses station Nurse #2 cleaned her hands with alcohol and proceeded to prepare the resident's medication for administration. On 8/01/18 at 4:30 P.M. the surveyor observed Nurse #1 had picked up the glucometer case with the uncleaned glucometer, put it on his medication cart and begin to move the medication cart down the hall. The surveyor stopped the nurse before he could proceed and asked what is the process for using the glucometer. Nurse #1 said he was going to complete FSBS on his assigned residents. He said you use the red top wipes to clean the FSBS machine after each use. During an interview on 8/01/18 at 4:33 P.M., Nurse #2 said I used FSBS check machine and did not clean it after use. I handled the meter with gloved hands and returned it to the case case containing the FSBS supplies. Nurse #2 disposed of the contents of the glucometer case and cleaned the glucometer and case before it was used on any other resident. During an interview on 8/02/18 at 7:27 A.M., the Director of Nurses (DON) said Nurse #2 should have cleaned the glucometer between residents after use, that is the policy. The contents of the glucometer case were contaminated due to putting the glucometer in without cleaning it.

Based on record review and interview, the facility staff failed to ensure that one resident (#10) from a sample of 8 residents, received a written notice of transfer. Findings include: Review of the Notice Upon Resident's Transfer or Discharge Policy, revision date, 1/2/17, indicated the following, It is the policy of the facility to provide residents and/or the resident's representatives (sponsors) with a written notice of an impending transfer or discharge. Resident # 10 was admitted in 5/2018 with [DIAGNOSES REDACTED]. Review of a nurse's note, dated 6/7/18, indicated the resident was experiencing worsening respiratory symptoms and shortness of breath. Review of physician's orders [REDACTED]. Review of the clinical record indicated there was not a written notice of transfer provided to the resident and/or the representative. During an interview on 8/02/18 at 2:20 P.M., the Director of Nurses(DON)she said a written notice of transfer was never provided to the resident or the representative as required.

Based on observation, record review and interview, the facility staff failed to follow the plan of care for 1 resident (#1) relative to safety interventions in a total sample of 8 residents. Findings include: For Resident #1, the facility staff failed to follow the plan of care relative to the use of a chair alarm. Resident #1 was admitted to the facility in 4/2017 with [DIAGNOSES REDACTED]. Review of the resident's Patient Care Card, dated 4/27/17, indicated the following Fall/Safety Measures/Devices; bed and chair alarms. Review of the 5/2017 signed physician's orders [REDACTED]. Review of the 5/2017 Treatment Administration Record indicated the following; bed and chair alarm. Check placement and function every shift. On 5/2/17 at 11:50 A.M. and 1:50 P.M., the resident was observed sitting in a wheel chair in his/her room. The resident was clean, dressed and had on slipper socks. There was not an alarm on the chair. During an interview on 5/2/17 at 3:45 P.M., the Unit Manager (UM) observed the resident's wheel chair and she said there was not an alarm on the chair. The Surveyor reviewed the resident's 5/2017 physician's orders [REDACTED]. On 5/3/17 at 8:45 A.M., the resident was observed sitting in a straight back chair in his/her bedroom. The resident was wearing a bathrobe and slipper socks, no alarm was on the chair. The chair pad alarm was in the wheel chair which the resident was not sitting in.

Based on record review and interview the facility staff failed to rotate injection sites for 2 residents (#2 and #5) out of a total sample of 8 residents. Findings include: Review of the facility's policy for subcutaneous (sc) medication administration procedures, dated 3/3/09, indicated the following: -Document the injection on the Medication Administration Record (MAR) along with site used, as follows: Site/Code: Left Buttock/LB Right Buttock/RB Left Arm/LA Right Arm/RA Left Thigh/LT Right Thigh/RT Left Abdomen/LS Right Abdomen/RS 1. Resident #2 was admitted to the facility in 4/2017 with [DIAGNOSES REDACTED]. Review of 2016 Nursing Drug Handbook indicated the following: For Insulin Gargline and Humalog Insulin, administer by subcutaneous (sc) only in the thigh, abdominal wall, or upper arm. Rotate sites within same region (abdomen, thigh, or deltoid) from one injection to the next to reduce risk of [DIAGNOSES REDACTED] (a lump in the skin that forms when injections are repeatedly administered in the same spot). Review of the 4/2017 signed physician's orders [REDACTED]. Review of the 4/2017 MAR indicated the resident was administered Insulin [MEDICATION NAME] 26 u sc on 4/26, 4/27, 4/28, and 4/29. Further review indicated injection sites were not documented for any of the injections listed above. During an interview on 5/2/17 at 1:45 P.M., the Unit Manager (UM) reviewed the 4/2017 MAR and said the nurses should have documented the injection site to ensure rotation of sites. 2. Resident #5 was admitted to the facility in 4/2017 with [DIAGNOSES REDACTED]. Review of the 2016 Nursing Drug Handbook indicated the following: For [MEDICATION NAME] sodium subcutaneous injections, give low-dose injections sequentially between iliac crests in lower abdomen deep into subcutaneous fat .alternate sites every 12 hours-right for morning, left for evening. Record location. Review of the signed physician's orders [REDACTED]. Review of the 4/2017 MAR indicated the Resident was administered [MEDICATION NAME] 5,000 u sc every 12 hours from 4/18/17 to 4/30/17. Further review indicated that 16 out of 25 doses were administered in abd referring to the abdomen but omitting which side or quadrant it was administered in to ensure injection sites were rotated. During an interview on 5/2/17 at 1:45 P.M., the UM said the documentation for injection sites should have been more specific to ensure rotation of injection sites and that the key code for injection sites should have been used.

Based on record review and interview the facility staff failed to maintain complete and accurate, fluid intake and output records for 2 residents (#3 and #5) out of a total sample of 8 residents. Findings include: Review of the facility's policy for initiating, maintaining and removing residents from intake and output recording, dated 1/2016, indicated the following: A. Intake and Output (I+O) monitoring may be ordered by a Physician. B. Conditions for which a resident must be put on I+O include but are not limited to, the following: - Fluid Restriction (FR) C. Daily I+O worksheets for residents being monitored will be kept with the Medication Administration Record. These forms will be discarded after the totals have been entered onto the Monthly I+O Record. D. 11-7 nurse will transcribe 24 hour totals to the Monthly I+O Record. Any discrepancies or incomplete recordings will be reported to the Charge Nurse at that time. The person entering the totals onto the form will initial them in the appropriate box. At the end of the month, the Monthly I+O Record will be maintained in the medical record. 1. Resident #3 was admitted to the facility in 3/2017 with [DIAGNOSES REDACTED]. Review of the 4/5/17 physician's orders [REDACTED].>Review of the 4/2017 Monthly Intake and Output Record indicated the daily fluid intake was recorded for 1 out of 3 shifts on 4/5, not recorded at all on 4/6, and was recorded 2 out of 3 shifts from 4/8-4/9. Further review indicated the daily fluid intakes were not totaled from 4/6-4/9. Review of the 4/10/17 physician's orders [REDACTED]. Review of the 4/19/17 physician's orders [REDACTED]. Review of the 4/2017 Monthly Intake and Output Record indicated the daily fluid intake was not recorded at all from 4/20-4/23, 4/28, and 4/30; was recorded 1 out of 3 shifts on 4/19, 4/25, and 4/29; and was recorded 2 out of 3 shifts on 4/24. Further review indicated the daily fluid intakes were not totaled at all in 4/2017. During an interview on 5/2/17 at 3:20 P.M., the Unit Manager (UM) reviewed the 4/2017 Monthly Intake and Output Record and said the I+O documentation was incomplete. She said the daily fluid intakes should have been totaled by the 11:00 P.M.-7:00 A.M. nurse. 2. Resident #5 was admitted to the facility in 4/2017 with [DIAGNOSES REDACTED]. Review of the 4/26/17 physician's orders [REDACTED]. Review of the 4/2017 Monthly Intake and Output Record indicated the fluid intakes were recorded for 1 out of 3 shifts on 4/27 and 4/28, 2 out of 3 shifts on 4/30. Further review indicated the daily fluid intakes were not totaled from 4/26/17-4/30/17. During an interview on 5/2/17 at 2:55 P.M., the UM reviewed the 4/2017 Monthly Intake and Output Record and said the record was incomplete and that was the only I+O record they had for this Resident.

Based on observation, record review and interview, the facility failed to provide one of one applicable residents (#5) with pressure sores present on entering the facility, in a total sample of 8, with the necessary treatment and services to promote healing. Findings include; The facility policy for Pressure Ulcer Prevention and Treatment Program, dated 10/2015, indicated that wounds would be reassessed at least once a week, with accurate measurements, and documented on the Wound or Pressure Ulcer Identification and Progress Notes Sheet (facility form). This form includes information such as location of sore, wound type, date, size of wound, deepest stage, thickness, drainage, odor, wound bed undermining, tunneling, peri-wound condition, change since last assessment and present on admission. The response of the wound to the ordered treatment will be re-evaluated at east every 16 days to determine if the current treatment is effective and the physician would be notified sooner if the wound exhibits signs of infection, increased drainage, increased size or other negative outcomes. Residents will skin impairment will be reviewed by the skin team weekly. For Resident #5, the facility failed to consistently assess the pressure sores per the facility policy, failed to notify the physician when the wounds declined and failed to changed treatments when the wound failed to respond to the current treatment regime. Resident #5 was readmitted status [REDACTED]. The initial nursing assessment, dated 2/22/16, documented the presence of a 3 by 2 cm open area on the coccyx. There was an order to treat the area with a Santyl ointment and cover with [MEDICATION NAME] dressing daily. On 3/3/16 , the Wound Care consultant assessed the resident as having two small open areas measuring 2 by 3 centimeters (cm) on the left and right buttock. Review of the Wound/Pressure Ulcer Identification and Progress Notes indicated the following: 2/24/16: wound size 3 by 2 cm, Stage 2, no drainage, no documentation if odor present or not and no documentation of the condition of the wound bed, periwound intact, the assessment did not document the site of the wound. On 3/3/16, the wound care nurse consultant (WCC) assessed the resident and noted two wounds, a right buttock wound stage 2 measuring 0.7 cm by 0.3 cm with no depth filled with pale yellow fibrous material and a left buttock 0.4 by 0.3 cm wound with no depth filled with pale yellow fibrous material. This implied that the wound may have healed and split into two smaller wounds. 3/3/16: no documentation of wound size, no notation of the two wounds as per the WCC notes, Stage 2, no drainage documented, odor present or absent not documented, no condition of wound bed documented and peri-wound intact; 3/9/16: no location of the wound documented; wound size (which one not designated) only one measured at 0.7 by 0.6 cm Stage 2, no odor noted, no drainage noted, wound bed condition not assessed, peri-wound intact. Assessment tool asks if ulcer improved since last assessment and not answered. Record review indicated treatment was changed to [MEDICATION NAME] and Mediplex dressing per recommendation of the WCC on 3/9/16 due to a slight increase in size of the wounds. On 3/16/16 and 3/23/16, the Wound or Pressure Ulcer Identification and Progress Notes Sheets (facility form) were not completed per policy. Review of the treatment sheets indicated on 3/16/16, an open area on the coccyx with yellow slough, no measurements done and the peri-wound was red and the wound was draining scant serous drainage. This was a change from the previous assessment. Review of the record indicated there was no notification of the physician as required. Review of the treatment record for 3/23/16, indicated the buttock ulcer had white slough, no drainage no redness and the dressing was changed. On 3/28/16, review of the Wound or Pressure Ulcer Identification and Progress Notes Sheet indicated the wound ( now defined as coccyx) had declined in size to 2 by 1.3 cm with scant drainage, odor not assessed, wound bed not assessed with [REDACTED]. Nurses notes, dated 3/28/16, indicated an incident report was completed for a declining wound and the physician was notified. No actions were taken until the WCC saw the resident on the monthly visit on 4/7/16. The WCC note indicated that the 2 buttock wounds had appeared to coalesce into one sacral ulcer measuring 1.5 by 1.7 cm with red periwound skin. The WCC recommended to change the treatment to [MEDICATION NAME] with a foam dressing which was prescribed by the physician. On 4/7/16, review of the Wound or Pressure Ulcer Identification and Progress Notes Sheet indicated the wound had declined to a Stage 3, size 1.7 by 1.5 cm with scant drainage, no odor, wound bed not assessed and redness noted in the periwound. No signs of infection were documented. On 4/13/16 at 10:30 A.M., the Surveyor observed LPN #1 change the sacral dressing on Resident #5. LPN #1 identified the resident, set up supplies on the tray table on a clean field, performed hand hygiene, donned clean gloves and removed the old sacral dressing after positioning the resident and providing for privacy during care. The wound was observed to be at the base of the spine (sacral). It measured approximately 2 cm long by 1 cm wide and was filled with a yellow slough in the wound base. LPN #1 did not measure the wound. The periwound skin was red for one-half inch around the wound. No odor was noted. No visible granulating tissue was evident. LPN #1 completed the dressing change with good technique. There were no wounds or evidence of healed tissue observed on the buttocks or the coccyx. During an interview on 4/14/16 at 8:00 A.M., the WCC said the wound healing had stalled in early March and that is why she recommended a dressing change on 3/7/16. The WCC said, after reviewing the Wound or Pressure Ulcer Identification and Progress Notes for March and April, that the staff could improve in the assessment and monitoring of wounds and should have called her earlier when the wound began to decline in late March.

Based on observation, review of policies and interview, the Transitional Care Unit (TCU) failed to provide services by sufficient number of licensed nursing staff to meet the needs of its residents on a 24 hour basis. Findings include: 1. On 4/14/16, during review of nurse schedules, it was noted that the facility staffed periodically staffed with one agency licensed nurse on the night shift and two certified nurses' aides. Agency staff is also used on the 3-11 shift. During an interview, on 4/13/16 at approximately 1:00 P.M, the Director of Nursing and the previous Director of Nursing, who was assisting during the survey said the house RN supervisor from the rehab hospital attached to the facility covered the facility for any supervisory needs during the night shift. The rehab hospital and the TCU (Transitional Care Unit) are owned by the same corporation but are separately licensed and certified entities functioning independently of each other. The House Supervisor per the DON is an employee of the rehab hospital. Review of the Rapid Assessment/ Medical Emergency Team Record, dated 3/2/15, indicated the Rehab hospital nursing supervisor and a respiratory therapist (RT) , both employees of the Rehab Hospital responded to the medical emergency in the TCU for a resident with an acute bleeding issue and assisted with the hospital transfer. Both the RT and the nursing supervisor signed the Team record as Rapid Assessment team members. 2. On 4/14/16 at 10:30 A.M., observation of the code cart with Licensed Nurse (LN) #2, indicated that on the cart with advanced cardiac life support medications such as intravenous (IV) [MEDICATION NAME], [MEDICATION NAME], sodium [MEDICATION NAME] and an intubation kit These medications are given in [MEDICAL CONDITION] situations under the supervision of a physician with a highly trained team of nurses and usually respiratory therapists in an attempt to resuscitate a critically ill or clinically dead patient before transfer to an acute care hospital. During an interview, LN #2 said none of the nurses in the TCU (Transitional Care Unit) were ACLS certified ( Advanced Cardiac Life Support Certified), meaning they are not trained in the use and administration of the advanced cardiac life support medications and the monitoring that is required when they are used. LN #2 said that if a cardiac or respiratory arrest occurs on the TCU, the TCU used the rapid response team from the Rehab hospital next door (TCU is a tenant inside the Rehab Hospital) and the hospital has an ACLS certified nurse who responds. On 4/14/15 at 10:45 A.M., during an interview, LN #3 said that if there was a cardiac or respiratory arrest in the TCU, staff are to dial *88, and page code blue to room [ROOM NUMBER]-- , three times. Then staff are to get the code cart, vital sign machine and start compressions until the code team from Rehab hospital arrives and then they go into ACLS mode. LN #3 said the ACLS certified nurse from the hospital will run the code until the physician arrives. Asked who calls 911 EMS services, LN #3 says that is up to the code team. During an interview on 4/14/16 at approximately 11:00 A.M., the Director of Nursing said that the Rehab Hospital provides emergency services coverage and supervisory nursing services to the TCU as the TCU does not have a night supervisor or their own code team.

Based on staff interview and documentation review the facility failed to implement an effective Infection Control Program to ensure the identification, tracking and trending of facility infections (urinary tract infections/UTIs and surgical site infections/SSIs ), and failed to implement interventions based on infection rate data analysis, to prevent the potential spread of facility acquired infections. Findings include: On 4/14/16 at 12:45 P.M. during the Quality Improvement (QI) interview, the Director of Nursing (DON) and Infection Control Nurse (ICN) were interviewed. The DON said that the facility used the McGeer Criteria for tracking infections (set of infection surveillance definitions intended to serve as the national standard for infection surveillance in long term care facilities). The Surveyor asked the ICN to discuss the facility's overall infection rates and how surveillance and performance improvement (based on national benchmarks) was conducted. The ICN could not answer the Surveyor's questions. The Surveyor asked to review the last three months of surveillance line listings of facility infections. Review of the facility's infection control line listings (from January through March 2016) indicated a line listing form which did not reflect the McGeer's Criteria Report and therefore, did not indicate a section for data analysis to differentiate between a healthcare acquired infection (HAI or in-house) versus a Community Acquired Infection (CAI) per the McGeer's Infection Report Form (page 1). McGeer Criteria indicates the following for infection surveillance purposes: Infections should be attributed to a LTCF onset if (a) there is no evidence of an incubating infection at the time of admission to the facility (on the basis of clinical documentation of appropriate signs and symptoms and not solely on screening microbiologic data) and (b) onset of clinical manifestation occurs >2 calendar days after admission. Review of the line listings for January 2016 through March 2016 indicated the following on-going infections: 1/2016: UTI-2 Residents (symptoms and medication treatments listed only with no infection resolution date) Skin- 1 Resident (no indication of location or SSI, just treatment with no infection resolution date) (*no indication of HAI or CAI for surveillance) 2/2016: Surgical Site Infections/SSI-6 Residents (symptoms and medication treatments only and no evidence of a root cause analysis) for a 33% SS infection rate with no evaluation or action plan. UTI-1 Resident (symptoms and medication treatments only) 3/2016: UTI- 5 Residents (2 from E-Coli (bacteria normally found in the human intestinal tract) from a census of 18 Residents for a 27.7% infection rate for UTIs with no action plan for possible staff re-education regarding personal hygiene care, handwashing or trending by staff/shift or resident assignment (according to McGeer Criteria). The Surveyor requested all supporting lab documentation, surveillance activity and action plans/interventions for the past 3 months for reported infections. The ICN, DON and Clinical Corporate Nurse did not provide any further infection control reports prior to the survey teams' exit conference.

Based on an incident review, internal investigation review and staff interview, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in order to control excessive bleeding from a skin tear for 1 Resident (#NS A) from a total sample of 8 residents. Findings include: For Resident #NS A, the facility failed to continuously assess and monitor for excessive bleeding, causing a delay in treatment (8 sutures), from a right lower extremity skin tear while receiving [MEDICATION NAME] (a blood thinning medication). Resident #NS A was admitted to the facility in February 2015, with [DIAGNOSES REDACTED]. ) The Resident had an Internationalized Normal Ratio (INR is a laboratory value which measures how long it takes for the blood to clot) of 2.3 (3/1/15) and 2.5 (3/3/15) (The normal range for a healthy person not using a blood thinner is 0.8-1.2 and for people on blood thinners is 2.0-3.0. Review of the Incident Report Form, dated 3/1/16, indicated that the Resident was self propelling in his/her wheel chair at approximately 9:30 P.M. when a staff nurse observed spots of bright red blood on the floor (approximately 8-12 drops/ 6-12 cm. in diameter). The Staff Nurse observed a 3 cm. x 4 cm skin flap on the right lower extremity (2.5 cm. equals 1 inch) and applied a dressing. The Resident was assisted back to bed and the staff nurse indicated that the original dressing was already saturated with blood. The covering provider was notified (9:30 P.M.) and an order to cover with a pressure dressing and to call back if continued bleeding. Further review of the Incident Report indicated that a pressure dressing was applied; the patient was encouraged to elevate his/her legs and was monitored without change in vital signs or discomfort on the 3:00 P.M.-11:00 P.M. shift. Review of the 11:00 P.M.-7:00 A.M. Nursing Progress Notes for 3/1/15 (date of incident) indicated no nursing note (no assessment of the wound, bleeding, pain, anxiety or documentation of physician notification). The incident report also indicated the following: The patient continued to bleed through dressings despite the measures put into place, and at 2:00 A.M. (4 1/2 hours later), the physician was notified. The Resident was sent out to the hospital emergency department at 2:30 A.M. (5 hours after the incident occurred) and required 8 sutures to the right lower extremity skin tear. Review of the Wound Clinic Report of Consultation on 3/12/15 and 3/24/15 indicated the following: 3/12/15 lower extremity brawny [MEDICAL CONDITION], continue to elevate leg, compression stockings when skin allows and (3/24/15) [MEDICATION NAME] gel to open area, elevate leg above heart, steri strips placed-please monitor and return to clinic. On 4/14/16 at 12:30 P.M. the Director of Nursing (DON) was interviewed. The Surveyor asked why there was no nursing progress note written from the 11:00 P.M.-7:00 A.M. shift (when the Resident was to be monitored closely for further bleeding). The DON could not answer the question, but did say that the nurse scheduled on the 11:00 P.M.-7:00 A.M. shift was from an outside agency. On 4/20/16 review of the emergency room Visit (faxed) copy indicated that the Resident's skin tear was still oozing when the dressing was removed and that 8 sutures were required to achieve hemostasis.