**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of the facility's Infection Prevention and Control Program, the facility failed to ensure Employee Identifier (EI) #3, laundry staff, changed gloves and sanitized her hands between residents during delivery of resident clothing, and did not place small baskets on the residents' dressers and return them to the clean laundry cart. This occurred on 10/6/21, one of three days of survey, and was observed while EI #3 was delivering clothing to four resident rooms. Findings Include: The facility's Infection Prevention and Control Program dated 9/12/17 documented . D. Hand Hygiene Protocol: 1. All staff shall wash their hands when coming on duty, between resident contacts, after handling contaminated objects, . J. Linens: 1. Laundry and direct care staff shall handle, store, process, and transport linens so as to prevent spread of infection. On 10/6/21 beginning at 3:26 PM, EI #3, housekeeping/laundry aide, was observed delivering clothing to four resident rooms while wearing the same gloves. EI #3 had on gloves prior to entering room [ROOM NUMBER]. She placed the hanging clothes in the closet, exited the room, got two baskets with folded clothes, and entered the same room. EI #3 placed a basket on each dresser, removed the clothes from the baskets and placed them in the drawers. EI #3 stacked the empty baskets and exited the room. With the same gloves on (no hand sanitizing or washing performed), EI #3 went to room [ROOM NUMBER], took the hanging clothes and placed them in the closet. EI #3 brought out the hangers from the closet, then took the basket of folded clothes in the room and placed them in the dresser drawers and exited the room. EI #3 then entered room [ROOM NUMBER] with the same gloves on. EI #3 took hanging clothes into the room, exited the room with empty hangers and then entered room [ROOM NUMBER] while wearing the same gloves. EI #3 took the hanging clothes in the room and placed them in the closets and brought the empty hangers out. EI #3 took the basket of folded clothes, entered the room and placed the clothes in the dresser, then exited the room. On 10/6/21 at 3:36 PM, EI #3 was asked, how should she deliver resident clothing. EI #3 replied, take hanging clothes in, put in the closet, bring empty hangers out, then take the basket of folded clothes into the room and put them in the dresser. EI #3 was asked, what did she do with the empty hangers when she brought them out of each room. EI #3 replied, she put them on the laundry cart. EI #3 was asked, what did she do with basket when she took it into each resident room. EI #3 replied, she put it on the dresser top then put the clothes in the drawers. EI #3 was asked, what did she then do with the baskets. EI #3 replied, she took the baskets out and put them on the laundry cart. EI #3 was asked if the laundry cart was clean. EI #3 replied, yes. EI #3 was asked, what happens when you place hangers you have taken from residents' rooms and place them on the clean laundry cart. EI #3 replied, the hangers could be contaminated from someone else handling them, and could contaminate the cart. EI #3 was asked, when should she put on gloves and sanitized her hands. EI #3 replied, after each resident's clothes. EI #3 was asked, when did she change gloves or sanitize her hands. EI #3 replied, she did not. EI #3 was asked, what was the harm in not changing gloves and sanitizing hands and going to four different resident rooms. EI #3 replied, cross contamination. On 10/6/21 at 4:53 PM, an interview was conducted with EI #2, Housekeeping Supervisor. EI #2 was asked, how should housekeeping/laundry staff deliver personal clothing. EI #2 replied, they should take each individual hanging clothes in, then the basket, hang the clothes in the closet, then take the basket in one at a time not sitting the basket down, hold the basket with one hand, take the clothes with other and place them in drawers. EI #2 was asked, when should housekeeping/laundry staff change gloves and sanitize hands. EI #2 replied, prior to entering a resident room with a new basket and hangers of clothing. EI #2 was asked, what should staff do with the basket with folded clothes when they enter a resident room. EI #2 replied, hold the basket in one hand use the other hand to put clothes in the drawer. EI #2 was asked, what was the harm in the staff placing the basket on residents' dressers then returning the basket to the laundry cart. EI #2 replied, potentially transferring germs from an unsanitized surface to a clean surface. EI #2 was asked, what was the harm of the staff person bringing the empty hangers from residents' closets and placing them on the laundry cart. EI #2 replied, could carry potential germs from hangers to the clean cart. EI #2 was asked, what was the harm of the staff wearing the same gloves to deliver clothing to four different rooms. EI #2 replied, potential of transporting harmful bacteria and germs from a resident room to the clean cart.

Based on observation, interview and review of a facility policy Maintaining a Sanitary Tray Line, the facility failed to ensure: 1. a Certified Nursing Assistant (CNA) did not touch a resident wheelchair with gloves then with the same gloves cut a resident's sandwich in quarters; and 2. a laundry aide did not deliver the resident clothing to the unit uncovered, did not take a small basket into multiple resident rooms then return it to the clean clothes cart and did not allow resident clothing to touch the floor as she carried them from the cart to the resident closet. This had the potential to affect one of one residents in the dining room and 41 residents whose laundry was done by the facility. Findings Include: 1. A review of a facility policy Maintaining a Sanitary Tray Line with effective date of 11/10/17 revealed Policy: This facility prioritizes tray assembly to ensure foods are handled safely . Compliance Guidelines: . 3. During tray assembly, staff shall: . c. Wear gloves when handling food items, particularly when direct contact between the hands and food occurs . such as .sandwiches . f. Change gloves when activities are changed . On 3/26/19 at 5:00 PM, EI # 4, CNA was observed in the dining room with gloves on placing drinks at residents places. With the same gloves EI #4 unlocked a resident wheelchair and moved the resident, holding to the wheelchair handles and then locked the wheelchair. EI #4, with the same gloves, served another resident's tray. The resident asked for the sandwich to be cut. EI #4 with the same soiled gloves touched the sandwich with her left hand, held the knife in her right hand and cut the sandwich in to quarters. On 3/27/19 at 3:12 PM, an interview was conducted with EI #4. EI #4 was asked what was the procedure for using gloves during passing meal trays. EI #4 replied, they are to have on gloves to pass the food then remove them before they feed a resident. EI #4 was asked when should she touch a resident wheelchair then handle resident food with the same gloves. EI #4 replied, never. EI #4 was asked when should she touch a resident sandwich with a glove she had on to unlock an resident wheelchair with. EI #4 replied, never. EI #4 was asked what was the harm in handling a resident wheelchair then with the same gloves touching a resident's sandwich. EI #4 replied, you would contaminate the sandwich. 2. On 3/27/19 at 11:00 AM, the surveyor observed EI #5, laundry aide, delivering resident clothing to the unit. The personal clothing cart was not covered. EI #5 was observed taking a small basket type container from the clothing cart with small clothing items in it into multiple resident rooms. EI #5 would place the basket on the resident dresser, remove the clothing and place in the resident dresser, then take the basket and enter the next resident room, place the basket on the dresser and remove the clothing, placing in the resident's dresser, then return the basket to the clean clothing cart in the hall. EI #5 was also observed taking a piece of clothing into a resident; the piece of clothing was observed touching the floor in the hall and in the resident room. On 3/27/18 at 11:20 AM, an interview was conducted with EI #5, the laundry aide. EI #5 was asked what was the procedure when delivering resident clothing to the unit. EI #5 replied, it should be covered. EI #5 was asked if the clothing cart was covered. EI #5 replied, no. EI #5 was asked what was in the small basket. EI #5 replied, resident clothes like socks and underclothing. EI #5 was asked if each resident had their own basket. EI #5 replied, no they have several residents' clothes in each basket. EI #5 was asked how did she handle the baskets when taking clothes into resident rooms. EI #5 replied, she took the basket in each room. EI #5 was asked when should the basket be taken in each room. EI #5 replied, it should not. EI #5 was asked why should the basket not be taken into each resident room. EI #5 replied, the basket could have germs where she placed it on the resident dresser then took to another resident room; it could cause contamination. EI #5 was asked when should clean clothing touch the floor. EI #5 replied, never because the floors may not be clean then the clothes could be contaminated. On 3/28/19 at 8:31 AM, an interview was conducted with EI #3, Registered Nurse, Infection Control. EI #3 was asked what was the policy on staff touching resident food with gloves used to touch a resident wheelchair. EI #3 replied, once staff touches a resident wheelchair they should remove those gloves and wash hands and put on clean gloves before they touch any resident food. EI #3 was asked when should staff touch a resident food with same gloves they had on to unlock a resident wheelchair. EI #3 replied, never. EI #3 was asked what would the harm be in staff touching a resident wheelchair then with same gloves touch a resident sandwich. EI #3 replied, they could pass bacteria or germs from the resident wheelchair to the other resident sandwich. EI #3 was asked how should laundry staff transport resident clean clothing. EI #3 replied, they are to bring the clothing to the unit on a covered cart. EI #3 was asked how should laundry aide handle the small baskets for small laundry. EI #3 replied, leave on the cart and remove the clothing and take into the resident room. EI #3 was asked when should the laundry aide take the small basket of clothing from one resident room to another. EI #3 replied, they should not, because they could pick up bacteria from one resident and take to the next resident room. EI #3 was asked when should resident clean clothes touch the floor. EI #3 replied, never because they could pick up germs from the floor that would get on the clothes then to the resident.

Based on observations, interviews, and a review of facility policies titled, FOOD Safety Requirements, Handwashing Guidelines Dietary Employees, Maintaining a Sanitary Tray Line, and Monitoring of Cooler/Freezer Temperatures, the facility failed to ensure: 1. food temperatures were taken prior to serving food from the tray line to residents on the skilled unit; 2. hands were washed by the kitchen worker serving tray line on the skilled unit while multi tasking; 3. refrigerator temperature was maintained to keep frozen food frozen solid; 4. employees hair was fully restrained and 5. green beans were not served to residents after a foreign object was removed from the green beans. These deficient practices had the potential to affect all 53 residents served meals from the kitchen. Findings Include: 1. Food temperatures were not taken prior to serving food from the tray line to residents on the skilled unit. A review of a facility policy titled, Maintaining a Sanitary Tray Line dated 11/10/2017, revealed: POLICY: This facility priorities tray assembly to ensure foods are handled safely and held at proper temperatures in order to prevent the spread of bacteria that may cause food borne illness. Compliance Guidelines: . 3. During tray line assembly, staff shall: .k. Periodically monitor food temperatures throughout the meal service to ensure proper hot (at or above 135 degrees) or cold holding temperatures (at or below 41 degrees) are maintained. A review of the temperature logs for the skilled unit revealed there were twelve days with no entries of food temperatures taken. The temperature logs also revealed multiple days were not documented that food temperatures were checked for one or two meals severed on those dates, however, not all three meals had temperatures documented on the logs. On 3/26/2019 at 4:50 PM, an observation was made of food coming from the second floor kitchen in portable oven warmers. The evening meal was observed being served from the tray line on the skilled unit. The surveyor observed none of the food items checked for temperatures prior to being served to the residents. The temperatures for the food were never observed being checked during the entire serving process on 3/26/2019. An interview was conducted on 3/27/2019 at 4:09 PM, with EI (Employee Identifier) #6, kitchen staff and tray line server for the skilled unit. EI #6 was asked if she checked any food temperatures prior to serving the evening meal on 3/26/2019. EI #6 replied she did not recall. This surveyor shared with EI #6 the observation she made on 3/26/2019 of the evening meal. The food being served to the residents was placed on the steam table and there were no temperatures checked prior to serving the food. EI #6 was asked what the concern was if foods that are supposed to be hot and maintain a certain temperature are not checked. EI #6 replied, germs she guessed. EI #6 was asked what she was trained to do when food was placed on steam table. EI #6 replied to check the temperature of the food. EI #6 was asked why she did not check the temperatures on 3/26/2019 prior to serving the evening meal. EI #6 replied she was running late. EI #6 was asked why was it important to check the temperature of the food being served. EI #6 replied because of contamination and germs. 2. Hands were not washed by the kitchen worker serving tray line on the skilled unit while multi tasking. A review of a facility policy titled, Maintaining a Sanitary Tray Line dated 11/10/2017, revealed: . Compliance Guidelines: . 3. During tray assembly, staff shall: .e. Wash hands before and after wearing or changing gloves. f. Change gloves when activities are changed, . or when the type of food being handled is changed, or when leaving the work station. g. Change gloves after sneezing, coughing, or touching face . An observation was made on 3/27/2019 at 12:15 PM, of Employee Indentifer (EI) #6, tray line food server multi tasking while plating for the lunch meal on the skilled unit. She was observed handling notebooks, dome covers and meal tickets, wearing the same gloves. EI #6 was also observed going to the plates to continue serving the residents meal plates after going to the sink to wash a pair of tongs. Another observation was made of EI #6 leaving the tray line, going to sink and washed a scoop, and returning to the tray line without removing her gloves and washing her hands. EI #6, while standing at the tray line, was then observed rubbing her upper chest area with her gloved left hand while holding a plate with food with her right hand. She then added more food to the plate without removing her gloves or washing her hands. In addition, EI #6 was observed picking up and holding meal cards while serving food from the tray line onto plates. EI #6 was never observed removing her gloves and washing her hands during the time of the tray service. On 3/27/19 at 4:09 PM, an interview was conducted with EI #6. EI #6 was asked when she was serving lunch that day, stepped to the sink to rinse utensils off, returned to the steam table and started serving again, was that the appropriate process to follow. EI #6 replied no she should have changed gloves and washed her hands. EI #6 was asked why should she have washed her hands and changed her gloves. EI #6 replied because of germs. An interview was conducted 3/28/2019 at 1:31 PM with EI #7 (Dietary Manager). EI # 7 was asked when hand washing should occur when serving food. EI #7 replied before serving food and then put on gloves, also, stating anytime something was touched away from the steam table, gloves should be removed and hands should be washed then clean gloves should be put on. EI #7 was asked about the following and what should be done by the tray line server: Serving plates and scratching chest area with a gloved hand, taking utensils to a sink washing them and returning to the tray line. EI #7 replied all of these scenarios would require the removal of the gloves, washing of the employees hands and re-gloving before returning to the tray line. 3. Freezer temperature was not maintained to keep ice cream frozen solid. A review of the facility policy titled, Monitoring of Cooler/Freezer Temperature, dated 03/14/2018. Policy: It is the policy of the facility to maintain temperatures and freezers at the appropriate temperature to promote food safety. Policy Explanation and Compliance Guidelines: 1. Logs for recording temperatures for each refrigerator or freezer will be posted in a visible location outside the freezer or refrigerator unit. a. Temperatures will be checked and logged at least twice per day . b. logs will be changed out and filed each month. 2. Thermometers shall be placed inside each cooler/freezer . 4. All freezer storage must be maintained at or -4* (degrees) F (Fahrenheit), unless otherwise specified by law. 5. If .or 10*F for freezer,the supervisor will be notified . b. Internal temperature readings of all perishables of potentially hazardous food shall be taken and discarded if not in an acceptable range 11. Refrigerated food shall be labeled, dated, and monitored so that it is used by the use by date, frozen, or discarded as applicable. On 03/27/19 at 9:19 AM, an observation was made of the refrigerator freezer in the kitchen area on the first floor skilled nursing unit. No thermometer was located in the freezer section and there were no temperature logs found for the freezer posted in a visible area. An observation was made of three single serving cups of sherbet with two of the individual cups soft to squeeze and not frozen solid. In addition, there were four single serving size ice creams that were soft to touch, as well as, two ice sandwiches soft to touch. On 03/27/19 at 11:29 AM, a second observation was made of the 1st floor kitchen refrigerator and freezer unit and all the findings observed on 03/27/19 at 9:19 AM remained the same. On 3/28/19 at 9:21 AM, an observation was made of the refrigerator log posted on the outside of the refrigerator unit on first floor and there no temperatures recorded for the refrigerator for 3/27/19 and 3/28/19. Also, there was no freezer temperature log posted and there was no thermometer located in the freezer unit. An interview with EI #7, the Dietary Manager was conducted on 3/28/2019 at 1:31 PM. EI #7 was asked why there were no temperatures entered on the refrigerator temperature log on the skilled unit for 3/27/2019 and 3/28/2018. EI #7 replied he did not know, the kitchen staff did not take care of that refrigerator, the nursing staff did. EI #7 was asked who provided the training for the nurses related to refrigerator and freezer temperatures. EI #7 replied he did not know who was responsible, he guessed it would be the kitchen staff, but he was not sure. 4. Employees hair was not fully restrained. A review of a facility policy titled, Maintaining a Sanitary Tray Line, dated 11/10/2017, revealed, Compliance Guidelines . 3. During tray line assembly, staff shall: . h. Wear hair restraints (bonnets, caps, nets to cover hair) when preparing or handling food. On 03/26/19 at 5:00 PM, an observation was made of the supper meal delivery in dining the room on skilled unit. The tray line server, EI #6 was observed with her hair not completely covered with a hair net. On 03/27/19 at 7:55 AM, another observation was made of EI #6. Her hair was observed not completely contained in a hair net. Another kitchen worker who was assisting EI #6 did not have her hair completely restrained in the hair net. 03/27/19 at 4:12 PM, an interview was conducted with EI #6. EI #6 was asked what was the facility's policy/ procedure for hair covering. EI #6 replied all of the hair should be covered. EI #6 was asked when would hair not be contained in a hair restraint. EI #6 replied never, it (hair) should always be covered when handling food. EI #6 was asked what was the harm if all hair was not contained in a hair restraint. EI #6 replied hair could fall in the food and contaminate it. 5. [NAME] beans were served to residents after a foreign object was removed from the green beans. A review of a facility policy titled, Food Safety Requirements, dated 03/14/2018, revealed, Policy: . Food will also be stored, prepared, and served in accordance with professional standards for food service safety Definitions: . Contamination means the unintended presence of potentially harmful substance including, but not limited to . or physical objects. Policy Explanation and Compliance Guidelines: 1. Food safety practices shall be followed throughout the facility's entire food handling process. The process begins when food is received from the vendor and ends with delivery of the food to the resident. An observation was made on 3/27/19 at 12:06 PM, of the skilled nursing unit dining room/ kitchen on the first floor. During the serving of lunch from the tray line, an observation was made of a piece of foreign object that was removed from the green beans by EI #6. It appeared to be some type of plastic material. EI #6 removed the foreign object from the green beans and continued to serve additional residents. The dietitian entered the area and was asked to look at the foreign object removed from the green beans. She was told it was in the green beans and was removed by EI #6 and she continued to serve residents the green beans. An additional 14 residents had been served green beans from the pan. The dietitian was asked what the object was. She replied plastic. The surveyor asked if the green beans should have continue to be served. The surveyor was informed no, as the green beans were still being served. Later the dietitian was asked why were the green beans pulled from the tray line and a fresh pan brought from the main kitchen. She said the green beans with the plastic substance in them was contaminated. The green beans with the foreign object was removed and replaced with another pan of green beans. An interview was conducted with EI #6 on 03/27/19 at 4:09 PM. EI #6 was asked what was found in the green beans at the lunch meal. EI #6 replied it looked like a piece of plastic that maybe the green beans were in prior to cooking them. EI #6 was asked what should have been done when she found the plastic type material in the green beans. EI #6 replied she should have called the manager or chef. EI #6 was asked if there was any concern about continuing to serve the green beans she removed the plastic type material from. EI #6 replied she should have not continued serving those green beans because there could have been germs in the green beans from whatever that was she removed and if a resident received a piece of the material they possibly could have choked. An interview was conducted on 03/28/19 at 1:31 PM with EI #7. EI #7 was asked if a foreign object was found in a food being served to residents' what should be done. EI #7 replied the object should be removed and the food item would also be replaced. EI #7 was asked why the food would need to be replaced. EI #7 replied they would not know where the object came from and would not know if there was more in the food. EI #7 was asked why was it important to remove the food where the object was found. EI #7 replied because the food was considered contaminated at that time therefore serving more residents would be unsafe.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review and a review of the facility's policy titled, Personal Cell Phones Policy, the facility failed to ensure staff did not use a personal cell phone during resident care. This affected Resident Identifier (RI) #207, one of 15 residents who were observed during the provision of care. Findings Include: A review of a facility's policy titled, Personal Cell Phones dated 04/22/2016, documented: . Cell phones are to be kept in your handbag or vehicle while on duty. They may not be kept on your person or work area . while working.You may not use your cell phone in any residential area . even if you are on break or off duty . RI #207 was readmitted to the facility on [DATE] with a diagnosis of Fracture of Unspecified Part of Neck of Right Femur. On 03/21/2018 at 12:10 p.m., the surveyor entered RI #207's room. RI #207 stated around 10 a.m. that morning, Employee Identifier, (EI) #2, the Certified Nursing Assistant (CNA), came in the room to change him/her brief because the resident had a bowel movement (BM). RI #207 stated before he/she was changed, the CNA stood in his/her room and talked on the cell phone. RI #207 stated when the CNA finished her conversation, she then changed his/her brief. The surveyor asked how did that make his/her feel. RI #207 stated he/she felt like he/she was not getting the attention he/she needed. An interview was conducted on 03/21/2018 at 2:33 p.m. with Employee Identifier (EI) #2 CNA. The surveyor asked EI #2 was she taking care of RI #207. EI #2 said yes she was. The surveyor asked EI #2 was RI #207 alert and oriented. EI #2 said yes. EI #2 was asked what was the facility's policy on cell phone usage. EI #2 said if staff have a cell phone, they should have it on silent mode. The surveyor asked EI #2 was she on the cell phone that morning when she went into RI #207's room. EI #2 said no, she was talking to EI #3, another CNA, in the adjoining bathroom about the cushion between RI #207's legs. The surveyor asked how would it make the resident feel if she was on the cell phone during resident care. EI #2 said the resident would feel like she did not want to take care of them. An interview was conducted on 03/21/2018 at 2:50 p.m., with EI #3, CNA. The surveyor asked EI #3 was she in the adjoining bathroom to RI #207's room that morning or anytime earlier today. EI #3 said no. The surveyor asked EI #3 when did she have a conversation with EI #2 regarding RI #207. EI #3 said after lunch she informed EI #2, that RI #207 was the resident she had previously taken care of. The surveyor asked EI #3 did she ever discuss the cushion between RI #207's legs. EI #3 said no. The surveyor asked EI #3 what was she doing at approximately 10:00 a.m. that morning. EI #3 said she was providing resident care, and it was not the resident with the adjoining bathroom to RI #207. An interview was conducted on 03/21/2018 at 3:01 p.m. with EI #1, Director of Nursing (DON)/Registered Nurse (RN) ). EI #1 was asked what was the facility's policy on cell phones. EI #1 said staff were not to be on personal cell phones during work hours. The surveyor asked EI #1 should staff be on the cell phone while in a resident's room. EI #1 said no. EI #1 was asked why should staff not talk on cell phones in the residents' room while providing care. EI #1 said because it was against the facility's policy. EI #1 was asked how would it make a resident feel if staff were talking on a cell phone in the resident's room. EI #1 said it would make the resident feel they had to wait. The surveyor asked EI #1 what issue did she think it was with staff talking on the cell phone in a resident's room while providing care. EI #1 said a dignity issue.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review and a review of the facility's policy titled, Medications Administration and a review of [NAME] and Perry's Fundamentals of Nursing, the facility failed to ensure staff obtained Resident Identifier (RI) #12's heart rate before administering Metoprolol Tartrate. This affected one of 11 residents observed during medication administration observation. Findings Include: A review of the facility's policy titled, Medications Administration dated 11/19/12 revealed the following: Policy Medications are administered as prescribed, in accordance with good nursing principles and practices. Procedure: . 2. Medications are administered in accordance with written orders of the attending physician . A review of [NAME] and Perry's Fundamentals of Nursing Eighth Edition, chapter 23, Legal Implications in Nursing Practice, page 305, revealed the following: Health Care Providers' Orders . Nurses follow health care providers' orders . RI #12 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including: Pneumonia and Unspecified Diastolic (Congestive) Heart Failure. A review of RI #12's Quarterly Minimum Data Set (MDS) dated [DATE], revealed RI #12's Brief Interview for Mental Status (BIMS) score of 12, indicating moderate impairment in cognition. A review of RI #12's care plan revealed, (RI #12) has impaired cardiovascular status related to medical diagnosis of hypertension . Approaches . Obtain . vital signs as ordered . A review of RI #12's March 2018 Physician's orders revealed the following: . Metoprolol Tartrate 25 MG (Milligram) GIVE 1 TAB (TABLET) BY MOUTH . FOR HEART RATE GREATER THAN 110 . On 03/21/18 at 1:13 PM, the following was observed during the medication administration observation: Employee Identifier (EI) #6, Licensed Practical Nurse/LPN administered Metoprolol Tartrate 25 MG to RI #12. EI #6 did not obtain the resident's heart rate before administering the medication. On 03/21/18 at 4:50 PM, during an interview with EI #6, the surveyor asked did she obtain RI #12's heart rate before giving the Metoprolol Tartrate. EI #6 said she did not, but she should have obtained the resident's heart rate before administering the Metoprolol Tartrate. The surveyor asked what was the importance of checking a resident's heart rate before administering Metoprolol Tartrate. EI #6 replied if the heart rate was below 60, the medication would decrease the heart rate more.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and a record review, the facility failed to ensure staff followed Resident Identifier (RI) #12's care plan titled, . impaired cardiovascular status related to medical diagnosis of hypertension, by not obtaining RI #12's heart rate/vital signs as ordered. This affected one of 11 residents observed during medication administration observation and one of 15 residents whose care plans were reviewed. Findings Include: RI #12 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including: Pneumonia and Unspecified Diastolic (Congestive) Heart Failure. A review of RI #12's Quarterly Minimum Data Set (MDS) dated [DATE], revealed RI #12's Brief Interview for Mental Status (BIMS) score 12, indicating moderate impairment in cognition. A review of RI #12's care plan revealed, (RI #12) has impaired cardiovascular status related to medical diagnosis of hypertension . Approaches . Obtain . vital signs as ordered . A review of RI #12's March 2018 Physician's orders revealed the following: .Metoprolol Tartrate 25 MG (Milligram) GIVE 1 TAB (TABLET) BY MOUTH . FOR HEART RATE GREATER THAN 110 . On 03/21/18 at 1:13 PM, the following was observed during medication administration: Employee Identifier (EI) #6, Licensed Practical Nurse/LPN administered Metoprolol Tartrate 25 MG to RI #12. EI #6 did not obtain the resident's heart rate before administering the medication. On 03/22/18 at 6:14 PM, during an interview with EI #6, the surveyor asked was the care plan for RI #12 followed for obtaining vital signs/heart rate before administering Metoprolol Tartrate. EI #6 replied, No ma'am.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, interviews and a review of the facility's policies titled, Wound Care and Clean Dressing Change, the facility failed to ensure staff wiped Resident Identifier's (RI) #42's wound located on mid back from the inner to the outer aspect in one continuous wipe and cleaned the peri-wound area. This affected, RI #42, one of two residents observed during wound care. Findings Include: A review of the facility's policy titled, Wound Care dated 11/16/16 revealed the following: . Purpose The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Steps in the Procedure . 11. Wash tissue around the wound that is usually covered by the dressing, tape, gauze with wound cleanser or normal saline . A review of the facility's policy titled, Clean Dressing Change dated 10/16/16, revealed the following: . Policy: It is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination . Policy Explanation and Compliance Guidelines: . 12. Cleanse the wound as ordered, taking care to not contaminate other skin surfaces or other surfaces of the wound ( . clean outward from the center of the wound). RI #42 was admitted to the facility on [DATE] with diagnoses including: Weakness, Hemiplegia and Moderate Protein Calorie Malnutrition. A review of RI #42's March 2018's Physician Orders revealed the following: . WOUND TO MID BACK . A review of RI #42's Minimum Data Set (MDS) dated [DATE] revealed RI #42's Brief Interview for Mental Status (BIMS) score of 15, indicating cognition intact. The MDS assessed RI #42 as having three pressure ulcers. On 03/22/18 at 9:50 AM, the following was observed during wound care for RI #42: Employee Identifier (EI) #4, Licensed Practical Nurse/LPN/Treatment Nurse and EI #5, Certified Nursing Assistant/CNA washed their hands and applied gloves. EI #4 removed RI #42's dressing to the resident's mid back wound. EI #4 moisten 4 x (by) 4's with Vashe wound cleanser, wiped RI #42's wound from top to bottom, in a dabbing in and out motion as she wiped the wound, loosing contact with the wound bed. EI #4 did not clean the peri-wound. EI #4 then applied Santyl ointment and mepilex border dressing to the wound. On 03/22/18 at 10:45 AM, during an interview with EI #4, the surveyor asked what direction should a wound be wiped/cleaned. EI #4 said from inner to outer, but that was not what she had done, she wiped from top to bottom. The surveyor asked when should staff lose contact with a resident's skin when cleaning a wound. EI #4 stated staff should never lose contact with a resident's skin, but that was not what she had done. The surveyor asked what did that potentially cause. EI #4 said germs could be re-entered into the wound. The surveyor asked EI #4 when did she clean the periwound. EI #4 stated she did not, but she should have cleaned the periwound. The surveyor asked what was the potential for harm related to wiping a wound from top to bottom and loosing contact with skin. EI #4 said germs could enter into the wound.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, interview and a review of the facility's policies titled, Skin Care and Gloves, the facility failed to ensure staff changed soiled gloves after cleaning Resident Identifier (RI) #42's wound and before applying a clean dressing. The facility further failed to ensure staff washed hands after removing soiled gloves and before applying clean gloves. This affected RI #42, one of two residents observed during wound care. Findings Include: A review of the facility's policy titled, Skin Care dated 11/16/12 revealed the following: . Procedure I. Dressing-Clean Technique: . 9. Remove dressing and discard . Remove gloves and wash hands. 10. Apply clean gloves. 11. Cleanse area . 12. Remove gloves, wash hands . A review of the facility's policy titled, Gloves dated 03/23/06, revealed the following: . handwashing is to be done after removal of gloves. If gloves become soiled, change during care . RI #42 was admitted to the facility on [DATE] with diagnoses including: Weakness, Hemiplegia and Moderate Protein Calorie Malnutrition. A review of RI #42's Minimum Data Set (MDS) dated [DATE] revealed RI #42 had a Brief Interview for Mental Status (BIMS) score of 15, indicating cognition was intact. The MDS assessed RI #42 as having three pressure ulcers. A review of RI #42's March 2018's Physician Orders revealed the following: . WOUND TO MID BACK . WOUND TO SACRUM . LEFT HEEL WOUND . On 03/22/18 9:50 AM, the following was observed during wound care for RI #42: Employee Identifier (EI) #4, Licensed Practical Nurse/LPN/Treatment Nurse and EI #5, Certified Nursing Assistant/CNA washed their hands and applied gloves. EI #4 cleaned and dried RI #42's left heel wound. EI #4 then applied Santyl ointment and a clean dressing. EI #4 did not remove her gloves or wash her hands after cleaning the left heel wound and before applying Santyl ointment and a clean dressing. On 03/22/18 9:50 AM, the following was observed during wound care for RI #42: EI #4 cleaned RI #42's sacrum wound and applied a clean dressing. EI #4 removed her gloves and applied clean gloves. EI #4 dated, timed and initialed the dressing. EI #4 did not wash her hands after she removed her soiled gloves and before applying clean gloves. On 03/22/18 at 10:45 AM, during an interview with EI #4, the surveyor asked after cleaning a wound and before applying a clean dressing what should be done with gloves. EI #4 said wash hands and apply clean gloves, but that was not what she had done. The surveyor asked what should be done after gloves were removed and before applying clean gloves. EI #4 stated wash hands, but that was not what she had done. The surveyor asked what was the potential for harm related to not changing gloves and washing hands. EI #4 said infection control.