**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of a facility policy titled Notification of a Change in Medical Condition of Residents, the facility failed to ensure Resident Identifier (RI) #71's family representative was notified promptly of resident's fall on 4/16/19 at 5:00 AM. This affected one of three residents reviewed for falls. Findings Include: A review of a facility policy titled Notification of a Change in Medical Condition of Residents, with a date of 2/1/07 revealed: .STANDARD Notification of the physician, resident's representative, should occur promptly .when there is a change in the resident's condition. This would include but is not limited to: .An accident involving the resident which results in injury and has the potential for requiring physician intervention. RI #71 was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of Alzheimer's Disease. A review of a facility report titled Resident Incident Report revealed: date/time 4/16/19 05:00 AM . resident was found sitting in the floor by bed. Resident was hollering out It hurts It hurts Resident guarding right wrist/forearm . Family notified : 4/16/19 08:59 AM . On 4/16/19 at 10:36 AM during an interview with RI #71's representative, it was revealed the representative was notified at 9:00 AM of RI #71 having a fall at 5:30 AM on 4/16/19. The staff reported to her that RI #71 was found on the floor at 5:30 AM, yelling in pain and pointing to right lower arm. The family representative revealed RI #71 had falls before and the staff had notified her timely. The representative was concerned that the fall occurred at 5-5:30 and she was not notified until 9 AM. A review of nurses notes, dated 4/16/2019 at 8:59 AM, revealed resident was found in the floor at 5:00 AM, the nurse assessed, nurse documented resident saying it hurt and she broke her arm, MD notified and Family notified. On 4/16/19 at 11:00 AM, a phone interview was conducted with Employee Identifier (EI) #3 , the Licensed Practical Nurse on duty during the fall. EI #3 was asked when did RI #71 fall. EI #3 replied, RI #3 was heard yelling and staff entered the resident's room around 5:00 AM and found the resident on the floor. EI #3 was asked how the fall occurred. EI #3 replied, she did not know, the resident was found on the floor and was saying it hurts, it hurts, my arm is broke. EI #3 revealed she assessed RI #71 and notified the Doctor. EI #3 was asked why was the Doctor notified. EI #3 replied, it was their policy to notify the Doctor. EI #3 was asked what time was the Doctor notified. EI #3 replied, somewhere between 6 and 7 AM. EI #3 was asked if the Doctor gave new orders. EI #3 replied, yes get an X-ray and she called for the X-ray service. EI #3 was asked when was the family representative notified. EI #3 replied, around 9:00 AM. EI #3 was asked why the family representative was not notified earlier. EI #3 replied, after she assessed the resident and the resident was not complaining of pain, it was early so she did not bother the family. EI #3 was asked if receiving an order for an X-ray after a fall, was that considered a reason to notify a family of a significant change in a resident. EI #3 replied, when she assessed RI #71 and did not see swelling or bruising and RI #71 was not complaining of pain or in any acute distress, she felt it could wait. EI #3 was asked when she found RI #71, what was RI #71 saying. EI #3 replied, it hurts, it hurts, my arm is broke. EI #3 was asked if RI #71 saying it hurt, was an indicator that there could be injury. EI #3 replied, yes, she guessed so. EI #3 was asked when there was a change in resident status how long of time frame before she should notify a family. EI #3 replied, if life or death right away, her assessment did not reveal a life or death matter. On 4/18/19 at 9:01 AM, an interview was conducted with EI #2 Director of Nursing. EI #2 was asked what was the incident on 4/16/19 with RI #71. EI #2 replied the nurse EI #3 heard RI #71 yelling and found the resident on the floor in the resident room. EI #2 was asked what time the resident was found. EI #2 replied 5:00 AM. EI #2 was asked if there was an accident with possible injury. EI #2 replied, yes. EI #2 was asked when should a representative be notified. EI #2 replied, notify the representative as soon as the resident was stabilized. EI #2 was asked what was the policy on notification. EI #2 replied as she read from the policy, should occur promptly. EI #2 was asked if a resident fell at 5:00 AM and the family representative was notified about 9:00 AM, was that a reasonable time frame. EI #2 replied, no, but not speaking for EI #3 it may have been and she stayed late to get all her work done. EI #2 was asked what was a prompt time for notifying a family of a change or incident involving a resident. EI #2 replied, once the resident was stabilized. EI #2 was asked what time was RI #71's family notified. EI #2 replied, 8:59 AM. EI #2 was asked if the incident involving RI #71 required physician intervention. EI #2 replied, yes. EI #2 was asked what was the intervention. EI #2 replied, yes the physician was called and he ordered an x ray of the right wrist and forearm. EI #2 was asked what was the risk of not notifying a family representative of a resident's changes. EI #2 replied, we want to keep the family involved in what was going on with their loved one.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure Hospice was coded on the Quarterly Minimal Data Set (MDS) dated [DATE], for Resident Identifier (RI) #46. This affected one of three residents sampled for Hospice. Findings Include: RI #46 was admitted to the facility on [DATE]. A review of RI #46's Quarterly MDS with an Assessment Reference Date of 1/22/19 did not have Hospice marked in Section O. A review of RI #46's Physician Orders dated April 2019 revealed RI #46 was admitted to Hospice services on 08/09/18. On 4/18/19 at 8:39 AM an interview was conducted with Employee Identifier (EI) #5, [NAME], LPN, MDS Coordinator and EI #6, [NAME], RN. EI #5 was asked, what were her responsibilities there. EI #5 replied, MDS assessments and care plans. The surveyor asked for the most recent MDS which was a Quarterly MDS dated [DATE], which did not have Hospice coded. The surveyor informed EI #5 that the MDS had a corrected version with a form titled, Changes in computer system with a date of 4/17/2019, attached to the end of the MDS. EI #5 was asked, what was the correction. EI # 5 replied, Section J for prognosis and Section O for list treatments specifically Hospice. EI #5 was asked, when the MDS was submitted for the most recent Quarterly with Assessment Reference Date of 1/22/2019 was it coded accurately in Section O for Hospice. EI #5 replied, no. E I #5 was asked, who was responsible for coding this section for Hospice on the Quarterly MDS with an assessment reference date of 1/22/2019. EI #5 replied, at that time it was EI #6, RN. EI #6 was asked what was her title. EI #6 replied MDS manager. EI #6 was asked why was this not coded accurately in Section O on the Quarterly with ARD of 1/22/2019. EI #6 replied, punch error, overlooked. E I #6 was asked, what was the potential harm in submitting a MDS that was not coded accurately. EI #6 replied, it would not accurately reflect RI #46's condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of facility policies titled, Dressings, Clean (Wound Care) and Hand Washing (Infection Control), the facility failed to ensure: 1. licensed staff changed gloves during wound care for Resident Identifier (RI) #94 and RI #111 after cleaning the wound and before placing the treatment and 2. licensed staff changed gloves during incontinent care after cleaning the resident and before placing the clean brief for RI #94 . This affected two of two residents observed for wound care and one of one resident for incontinent care. Findings Include: 1. A review of a facility policy titled, Dressings, Clean (Wound Care) with an effective date of 3/2018 revealed: .PROCESS: 4. Wash hands and put on clean gloves 5. Remove existing dressing 6. Pull your glove off .7. Wash hands and put on clean gloves 8. Cleanse the wound as ordered . 10. Wash hands put on clean gloves 11. Apply treatment as ordered . RI #94 was admitted to the facility on [DATE] with a diagnosis of Pressure Ulcer of Sacral Region, Stage 3. A review of RI #94's April Physician Orders revealed . 3/25/19 . Right Lower Buttock Pressure Ulcer . Clean with wound cleanser, pat dry, shurprep, periwound, Apply Medi honey . Cover with Bordered Gauze . On 4/16/19 at 11:30 AM, the surveyor observed wound care for RI #94, performed by Employee Identifier (EI) #2, Director of Nursing. EI #2 gathered the needed supplies and entered the resident's room. EI #2 washed her hands put on gloves placed the barrier to the over bed table and prepared the area. EI #2 then removed her gloves, washed her hands and put on clean gloves. EI #2 removed the old dressing and measured the wound. EI #2 then removed her gloves, washed her hands and put on clean gloves. EI #2 opened the packages, sprayed wound cleanser on the 4 x 4's gauze and opened the medihoney tube and placed some in a small medication cup. EI #2 cleaned the wound with the wound cleanser. EI #2 then, with the same soiled gloves, applied the skin prep, medihoney and outer covering. She did not remove the soiled gloves and wash her hands prior to applying the treatment to the wound. RI #111 was admitted to the facility 3/20/17. A review of RI #111's April 2019 Physician Orders revealed: .4/10/19 Clean Stage 2 Pressure Ulcer on Right Heel with Cara Klenz wound cleaner, skin prep wound edges. Apply Xeroform gauze cover with border gauze. On 4/16/19 at 3:18 PM, EI #2 was observed performing wound care for RI #111. EI #2 gathered the needed supplies and entered RI #111's room. EI #2 washed her hands, put on gloves, prepared the overbed table with a towel barrier and and placed supplies on the table. EI #2 opened the border gauze taped a dated strip to the outer cover, opened packages of 4 x 4's and sprayed cleanser to them. EI #2 opened the Xeroform and skin preps. EI #2 removed her gloves washed her hands and put on clean gloves. EI #2 removed the old dressing from the right heel, measured the wound then removed her gloves washed hands and put on new gloves. EI #2 cleansed wound with pre-wet 4 x 4's. EI #2, wearing the same soiled gloves, then applied the skin prep. EI #2 picked up the Xeroform folded it in half and applied to RI #111's heel. EI #2 placed the outer dressing. EI #2 then removed her gloves and washed her hands. On 4/16/19 at 3:45 PM, an interview was conducted with EI #2. EI #2 was asked what was the policy for cleaning a wound during wound care. EI #2 replied, clean the wound then change gloves before applying clean treatment. EI #2 was asked when should you wash hands and change gloves during wound care. EI #2 replied, before starting and after finishing. EI #2 was asked when does she wash her hands and change gloves during cleaning of a wound. EI #2 replied, after cleaning it. EI #2 was asked if she washed her hands after cleaning RI #94 and RI #111's wounds, before placing the ordered treatment. EI #2 stated, I guess not. EI #2 was asked what was the procedure after cleaning a wound. EI #2 replied, clean the wound with wound cleanser then place the ordered treatment. EI #2 was asked when was it acceptable to clean a wound then with same gloves apply skin prep and the ordered treatment. EI #2 replied, it was not acceptable. EI #2 was asked what was the harm in not changing gloves and washing hands after cleaning the wound and before placing the ordered treatment and outer dressings. EI #2 replied, cross contamination. 2. A review of a facility policy titled, Hand Washing (Infection Control) revealed, . STANDARD: Hand washing should be performed between procedures with residents. RI #94 was readmitted to the facility on [DATE] with a diagnosis of Need for Assistance with Personal Care. On 4/16/19 at 12:10 PM, after providing wound care for RI #94, EI #2 provided incontinent care for RI #94. EI #2 removed the gloves she had on doing the wound care and put on clean gloves, not washing her hands between glove change or between procedures. EI #2 rolled the soiled brief in away from the resident and wiped the front area. EI #2 turned the resident on the left side and placed the clean brief. EI #2 did not wash her hands or change her gloves and placed the clean brief and moisture barrier, then secured the brief. EI #2 pulled RI #94's shirt down and placed the top covers with same soiled gloves. After RI #2 had completed the care she was interviewed. EI #2 was asked when did she change gloves during incontinent care. EI #2 replied, if gloves get soiled and after finishing. EI #2 was asked if she changed her gloves after cleaning RI #94 and before applying moisture barrier and placing the clean brief. EI #2 replied, no. EI #2 was asked when should she touch a clean brief, resident clothing and linens with the same soiled gloves she wore to clean the resident. EI #2 replied, she should not have done that. EI #2 was asked when should she hold the tube of moisture barrier cream and apply moisture barrier cream with same gloves she wore to clean the resident. EI #2 replied, you should not do that. EI #2 was asked what was the harm in wearing the same gloves to clean a resident then place a clean brief and moisture barrier. EI #2 replied, contamination.

Based on observations, interviews and review of facility's policies titled, Food Receipts and Storage, Food, Leftover -Storage and Use, Service ware/Silverware, Handling and, Hand Washing (Infection Control), the facility failed to ensure: 1. supplements in the resident's refrigerator were not expired; 2. utensils and plates at the tray line was not wet nesting; 3. dietary staff washed hands when entering the kitchen and; 4. roast beef in the reach in refrigerator was labeled with an open and use by date. This had the potential to affect 138 of 138 residents who received meals from the kitchen. Findings Include: 1) A review of a policy titled, Leftover-Storage and Use with an effective date of 7/2016, revealed: PURPOSE: To assure that food borne illnesses are avoided. PROCESS: . 9.bulked items that requires refrigeration .may be stored .not beyond the best by or expiration date then discarded . On 4/17/2019 at 9:57 am, the survyor observed on the South hall supplement refrigerator one Nepro Therapeutic Nutrition Butter pecan eight fluid ounces supplement drink, with an expiration date of 4/1/2019. On 4/17/2019 at 10:20 a.m., the surveyor observed in the East dining hall supplement refrigerator door four butter pecan magic cups four fluid ounces, with an expiration date of March 14, 2019. On 4/17/2019 at 2:59 pm, the surveyor conducted an interview with (Employee Identifier) EI # 8, Dining Service Manager. EI # 8 was asked what was expired in the resident's supplement refrigerators on the South and East hall. EI #8 replied on the South hall Glucerna with a date of April 1, 2019 and on the East hall honey thick mighty shake with a date of March 14 2019. EI #8 was asked why were the expired items in the refrigerators. EI #8 replied, the refrigerator on the South hall someone else was responsible for, but dietary over looked items on the East side. EI #8 was asked who was responsible for making sure items were not expired in the resident supplement refrigerators. EI #8 replied, dietary aides. EI #8 was asked what did the facility policy say regarding expired items in the supplement refrigerators. EI #8 replied, they need to be disposed off. EI #8 was asked when was the refrigerator checked last for expired items. EI #8 replied, last night. EI #8 was asked when should expired items be taken out of the resident supplement refrigerators. EI #8 replied, immediately. 2) A review of a facility policy titled, Service ware/Silverware, Handling with an effective date of 6/2017 revealed: PURPOSE: To prevent the spread of bacteria that may cause food borne illnesses.PROCESS: .8. Service ware should be air dried and stored turned upside down, or covered. On 4/17/2019 at 10:51 am, the surveyor observed wet silverware in a tray. The surveyor observed EI #11, Dietary Aide wrapping wet utensils. She was wiping the utensils off with a coffee filter. She dried forks, knives and spoons and wrapped them. She wrapped several sets of spoon, knives and forks in napkins. She changed her coffee filter one time. She reached down in her smock pocket for a marker and continue to dry and wrap utensils. On 4/17/19 at 11:43 am, the surveyor observed EI #12 Dietary Aide, bringing wet plates from the dish room to the tray line. The surveyor observed wet plates in the plate warmer. The dietician moved plates from one slot to another slot in the plate warmer. EI #7 turned 20 plates over in the plate warmer that were wet. EI #13, Cook, observed wet plates at the tray line and used a coffee filter to dry wet plates that were stacked on top of each other. On 4/18/2019 at 8:15 am, an interview was conducted with EI #11. EI #11 was asked what was she wrapping wet. EI #11 replied, silverware. EI #11 was asked what type of container were the spoons, forks, and knives in. EI #11 replied, silver ware rack. EI #11 was asked why were the utensils wet. EI #11 replied, they were not dry. EI #11 was asked who was responsible for making sure utensils were dry. EI #11 replied, she assumed it was her. EI #11 was asked how should utensils be allowed to dry. EI #11 replied, air dry. EI #11 was asked what was the facility policy on drying utensils. EI #11 replied, air dry. EI #11 was asked why was it important that utensils air dry. EI #11 replied, so the napkin would not be wet when the utensils were served. EI #11 was asked did she use a coffee filter to dry spoons, forks and knives. EI #11 replied, yes ma'am. EI #11 was asked why did she use a coffee filter to dry utensils. EI #11 replied, she was told by EI #7, Dietician, to use a coffee filter. EI #11 was asked should she have used a coffee filter. EI #11 replied, she would have used a napkin. EI #11 was asked what was the potential harm to the residents when utensils were wet in a tray. EI #11 replied, contamination from the water. EI #11 was asked how many times did she change her coffee filter when drying utensils. EI #11 replied, twice. On 4/18/2019 at 8:28 am, an interview was conducted with EI #12, Dietary Aide. EI #12 was asked who was responsible for bringing the plates out of the dish room on 4/17/2019 to the plate warmer. EI #12 replied, she was. EI #12 was asked were the plates dry. EI #12 replied, no ma'am. EI #12 was asked why should plates be dry. EI #12 replied, if you send them out wet, dust was out there and could stick on the plates and they did not want to put food on wet plates. EI #12 was asked what was the facility policy on serving food to resident on wet plates. EI #12 replied, cross contamination. On 4/18/2019 at 8:34 am, an interview was conducted with EI # 13, the Cook. EI #13 was asked what was stacked on top of each other wet in the plate warmer on 4/17/2019. EI #13 replied, she had a couple of plates that still had water on them. EI #13 was asked how many were wet. EI #13 replied, about ten. EI #13 was asked why were they stacked on top of each other wet. EI #13 replied, they were not letting them dry before they brought them from the dish room. EI #13 was asked how should plates be allowed to dry. EI #13 replied, stack to the side at least face down. EI #13 continued to say if there was not enough room, leave the dishes in the rack. EI #13 was asked did she dry plates with a coffee filter at the tray line. EI #13 replied yes ma'am. EI #13 was asked why did she dry plates with a coffee filter. EI #13 replied, it helped absorb the water quicker. EI #13 was asked what was the facility policy on drying plates. EI #13 replied, they should leave them in the rack in the dish room/stack to the side before bringing to the plate warmer. On 4/18/19 at 11:05 am, an interview was conducted with EI #7 Dietician. EI #7 was asked how many plates did she move from one plate warmer to the other plate warmer. EI #7 replied, she did not count them, she just turned them upside down. EI #7 was asked why were the plates wet. EI #7 replied, the dishes just came out of the dishwasher and they were stacked incorrectly. EI #7 was asked why did she tell staff to use a coffee filter to dry utensils and plates. EI #7 replied, they were on the line and all of it was wet and there was no bacteria in a coffee filter. EI #7 was asked how should plates and utensils be allowed to dry. EI #7 replied, air dry. EI #7 was asked what was the potential harm to the resident when utensils were wet in a utensil tray and plates were stacked on top of each other, wet. EI #7 replied, potential for bacteria grow. 3) A review of a policy titled, Hand Washing (Infection Control) with an effective date of 4/2018 revealed: Purpose: To provide guideline to employees for proper and appropriate hand washing techniques that will aide in the prevention of the transmission of infections. On 4/17/2019 at 11:43 am, the surveyor observed EI #11 returning to the kitchen without washing her hands. She came back in the kitchen with the resident meal tickets. She was also observed touching a brown box pulling the tape off the box. On 4/18/2019 at 8:22 am, an interview was conducted with EI #11. EI #11 was asked when entering the kitchen with the resident meal tickets did she wash her hands. EI #11 replied, no ma'am she did not. EI #11 was asked why not. EI #11 replied she was rushed. EI #11 was asked why was it important that she wash her hands in the kitchen. EI #11 replied, because of cross contamination. EI #11 was asked did she touch a box and pull the tape off the box. EI #11 replied, yes. EI #11 was asked when should she wash her hands in the kitchen. EI #11 replied every time she changed what she were doing. EI #11 was asked what was the facility policy on hand washing in the kitchen. EI #11 replied, wash hands every time you do a new task. On 4/18/2019 at 11:35 am, an interview was conducted with EI #2, DON (Director of Nursing). EI #2 was asked should staff wash their hands when entering the kitchen. EI #2 replied, yes. EI #2 was asked why should staff wash their hands when entering the kitchen. EI #1 replied, she did not know what they may have touched out on the hall. EI #2 was asked what was the potential harm to residents when staff did not wash their hands when entering the kitchen. EI #2 replied, cross contamination. 4) A review of a facility policy titled, Food Receipts and Storage with an effective date of 6/2018 revealed: PURPOSE: Food should be . stored properly to prevent food borne illnesses. PROCESS: . 2. Storage: .b. Items should be dated (month, day and year) should not be stored greater than one year or by Best by Date whichever is sooner n. Refrigerated and frozen items removed from original packaging should be labeled , covered and dated. On 4/15/2019 at 6:27 pm, the surveyor and EI #10 observed roast beef in the reach in refrigerator was opened and not in a zip loc bag. The roast beef was opened with no opened or use by date on the meat wrapping. The wrapping was ripped opened. On 4/18/2019 at 8:44 am, an interview was conducted with EI #10, Cook. EI #10 was asked what did she observe in the reach in refrigerator that was not in a plastic bag. EI #10 replied, roast beef. EI #10 was asked to describe the item. EI #10 replied, it was partially opened, it was in a small mixing bowl along with two other packages of meats that were in a plastic container. EI #10 was asked did the roast beef have an open and use by day on it. EI #10 replied, no it did not. EI #10 was asked was it in a zip loc bag. EI #10 replied, no, it was in an opened package of meat. EI #10 was asked why was it not in a zip loc bag. EI #10 replied she did not know. EI #10 was asked what was the facility policy on items once they were opened. EI #10 replied, once opened they put in a zip loc bag, write down the date they were opened and a use by date. EI #10 was asked why was it important that food items have an opened and use by date on them. EI #10 replied, so they will know when to discard them and know when they food would go bad.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and review of a facility document titled Incident Report a facility policy titled Medication, Oral/Sublingual Administration and FUNDAMENTALS OF NURSING, NINTH EDITION, the facility failed to ensure a licensed nurse administered the correct medication to Resident Identifier (RI) # 96 on 5/6/18. This affected 1 of 3 residents sampled for medication concerns. Findings Include: Complaint #AL00035689 alleged an unknown resident had received the wrong medication and was sent to the hospital. Additional information received during the survey identified RI #96 as the resident who received the wrong medication. A review of a policy titled Medication, Oral/Sublingual Administration, with an effective date of 5/2014, documented: Purpose: To administer oral medications in an organized and safe manner . A review of FUNDAMENTALS OF NURSING, NINTH EDITION Chapter 32 Medication Administration, page 625, documented: .Box 32-4 Steps to Take to Prevent Medication Errors *Prepare medications for only one patient at a time *follow the six rights of medication administration (Right Patient, Right Drug, Right Dose, Right Route, Right Time, and Right Documentation) *Be sure to read labels at least 3 times (comparing medication administration record (MAR) with label) before administering the medication . RI # 96 was admitted to the facility on [DATE] with diagnoses to include Chronic Obstructive Pulmonary Disease and Malignant Neoplasm of Lung. A review of RI # 96's most recent Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/4/18 documented a Brief Interview of Mental Status (BIMS) score of 15, which indicated RI # 96 was cognitively intact. A review of an incident report dated 5/7/18 documented RI # 96 was found in his/her room around 4:45 a.m. He/she reported, I was dizzy and stumbled. I haven't felt right since that nurse gave me that cup full of medicine. RI # 96's skin was pale and clammy. No injuries or pain reported upon assessment. Further review of the incident reported determined RI # 96 received RI # 91's medication on 5/6/18 during the 5:00 p.m. medication pass. On 5/21/18 at 10:51 a.m., an interview was conducted with RI # 96 in his/her room. RI # 96 reported he/she received the wrong medication and was sent to the hospital. RI #96 reported the hospital told him/her that he/she had received a sedative. RI #96 reported he/she felt sleepy after receiving the wrong medication. RI #96 further stated he/she received blue, yellow, pink and white pills on 5/6/18. A review of RI # 96's current Physician's Order for May 2018 documented RI # 96 should have received the following medication by mouth at 5:00 p.m. daily: Coreg 3.125 MG (milligrams), Lasix 40 MG, Gabapentin 100 MG, Glucophage 1,000 MG and Prednisone 10 MG. However, review of the physician's orders for RI # 91 revealed RI # 96 received the following medications instead: Divalproex DR (delayed-release) 500 mg .pnk (Pink) .tab (tablet) (antiepileptic), Gabapentin 300 mg .yel (yellow) (antiepileptic), Glimepiride 4mg .bl (blue) (hypoglycemic), Pravastatin 40 mg .yel (statin) and Quetiapine 50 mg .wht (white) (antipsychotic). RI # 96 received 3 times the dose of Gabapentin that he/she normally would have received. RI # 91 was RI # 96's roommate. An interview was conducted with Employee Identifier (EI) #7, Licensed Practical Nurse (LPN) on 5/21/18 at 7:35 p.m. EI #7 stated she was familiar with RI # 96. She further stated the facility told her she gave him/her the wrong medications. EI #7 stated she did not remember giving RI #96 the wrong medication. EI #7 was asked what are the possible side affects of a resident receiving the wrong medications. EI #7 stated the resident could get sick. An interview was conducted with EI #1, Administrator, on 5/22/18 at 11:46 a.m., EI # 1 stated EI # 7 gave RI # 96 the wrong medication. EI # 1 stated EI # 7 should have completed the five rights of administrating medication before giving RI # 96 his/her medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, a facility document titled Incident Report and review of a facility policy titled Medication, Oral/Sublingual Administration, the facility failed to ensure Resident Identifier (RI) # 96 received the correct medication on 5/6/18. This resulted in RI # 96 being sent to the emergency room for an evaluation. This affected 1 of 3 residents sampled for medication concerns. Findings Include: Complaint #AL00035689 alleged an unknown resident had received the wrong medication and was sent to the hospital. Additional information received during the survey identified RI #96 as the resident who received the wrong medication. A review of a policy titled Medication, Oral/Sublingual Administration with an effective date of 5/2014 documented: Purpose: To administer oral medications in an organized and safe manner . RI # 96 was admitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease and malignant neoplasm of lung. A review of RI # 96's most recent Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/4/18 documented a Brief Interview of Mental Status (BIMS) score of 15, which indicated RI # 96 was cognitively intact. A review of an Incident Report dated 5/7/18 documented RI # 96 was found in his/her room around 4:45 a.m. He/she reported I was dizzy and stumbled. I haven't felt right since that nurse gave me that cup full of medicine. RI # 96's skin was pale and clammy. No injuries or pain reported upon assessment. Further review of the incident reported determined RI # 96 received RI # 91's medication on 5/6/18 during the 5:00 p.m. medication pass. On 5/21/18 at 10:51 a.m. an interview was conducted with RI # 96 in his/her room. RI # 96 reported he/she received the wrong medication and was sent to the hospital. RI #96 further stated he/she received blue, yellow, pink and white pills on 5/6/18. A review of RI # 96's current Physician's Order for May 2018 documented RI # 96 should have received the following medication by mouth at 5:00 p.m. daily: Coreg 3.125 MG (milligrams), Lasix 40 MG, Gabapentin 100 MG, Glucophage 1,000 MG and Prednisone 10 MG. However, review of the physician's orders for RI # 91 revealed RI # 96 received the following medications instead: Divalproex DR (delayed-release) 500 mg .pnk (Pink) .tab (tablet) (antiepileptic), Gabapentin 300 mg .yel (yellow) (antiepileptic), Glimepiride 4mg .bl (blue) (hypoglycemic), Pravastatin 40 mg .yel (statin) and Quetiapine 50 mg .wht (white) (antipsychotic). RI # 96 received 3 times the dose of Gabapentin that he/she normally would have received. RI # 91 was RI # 96's roommate. A review of a facility document titled Departmental Notes documented RI # 96 was transported to the emergency room on 5/7/18 at 5:25 a.m. A review of medical documents from a local hospital revealed RI # 96 arrived at the hospital emergency room with altered mental status on 5/7/18 at 5: 37 a.m RI # 96 was discharged on 5/7/18 at 9:00 a.m. Documents revealed there was a suspicion RI #96 had received another residents medication by accident on 5/6/18. RI # 96's condition at discharge was stable and he/she was transported back to the nursing home. An interview was conducted with Employee Identifier (EI) #7, Licensed Practical Nurse (LPN) on 5/21/18 at 7:35 p.m. EI #7 stated she was familiar with RI # 96. She further stated the facility told her she gave him/her the wrong medication. EI #7 stated she did not remember giving RI #96 the wrong medication. EI #7 was asked what are the possible side affects of a resident receiving the wrong medication. EI #7 stated the resident could get sick. An interview was conducted with Employee Identifier (EI) # 4, Registered Nurse (RN), Director of Nursing on 5/22/18 at 9:30 a.m. EI # 4 stated she became aware of the incident involving RI # 96 on 5/7/18 when she arrived at work. EI # 4 stated she made sure an incident report was completed. She further stated it was determined that EI #7 gave RI # 96 the wrong medication during the 5:00 p.m. medication pass on 5/6/18. EI # 4 further stated RI # 96's pill pack from the 5:00 p.m. medication pass on 5/6/18 was still on the medication cart. EI # 4 was asked if RI # 96 had any negative effects from receiving the wrong medication. EI # 4 stated he was sleepy and dizzy. An interview was completed with EI # 1, Administrator on 5/22/18 at 9:45 a.m. EI # 1 stated a nursing supervisor called her in the early morning hours of 5/7/18 and informed her RI # 96 had received the wrong medication during the 5:00 p.m. medication pass on 5/6/18. EI # 1 stated she instructed the nursing supervisor to send RI # 96 out to the emergency room for an evaluation. EI # 1 stated RI # 96 left the facility at 5:25 a.m. and returned a few hours later. EI # 1 was asked if RI # 96 had any negative side effects from taking the wrong medication. EI # 1 stated he/she was sleepy. EI # 1 further stated the emergency room found no negative side effects. EI # 1 was asked about the harm of a resident receiving the wrong medication. EI # 1 stated there could be complications because it would be a new medication. An interview was conducted with EI # 5, Medical Doctor on 5/22/18 at 10:25 a.m. EI # 5 stated he was aware RI # 96 received the wrong medication on 5/6/18 and was sent to the emergency room. EI # 5 stated RI # 96 received fluids at the emergency room and was sent back to the nursing home. EI # 5 stated he felt this was a one time error with RI # 96 and the facility immediately sent him/her for an evaluation when they became aware. EI # 5 stated the side effects of RI # 96 taking the wrong medication would be he/she would be sleepy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) RI #109 was readmitted to the facility on [DATE] with diagnoses to include, Gastrostomy Status. On 05/20/18 at 12:22 p.m., during medication pass observation for RI #109, EI # 12, Registered Nurse (RN) was observed pulling RI #109's privacy curtain wearing gloves. EI #12 then administered RI #109's flushes and medication, straightened his/her covers and rinsed and dried RI #109's syringe and plunger wearing those same gloves. On 05/22/18 at 9:14 a.m., a telephone interview was conducted with EI #12. EI #12 was asked when should she change her gloves and wash her hands during gastrostomy tube medication administration. EI #12 said every time she touched a potentially contaminated surface she should change her gloves and wash her hands. EI #12 was asked did she pull RI #109's privacy curtain while wearing gloves and then wear those same gloves when administering RI #109's gastrostomy tube flushes and medication. EI #12 replied she did and that she knew better. EI #12 was asked if she changed her gloves after administering RI #109's medication before she straightened his/her covers and rinsed and dried the syringe used during administration. EI #12 said no. EI #12 was asked what was the concern with those things. EI #12 answered infection control issues. 3.) RI #141 was admitted to the facility on [DATE] with diagnoses to include, Unspecified Chronic Ischemic Heart Disease and Shortness of Breath. On 05/21/18 at 8:26 a.m., EI #13, Licensed Practical Nurse (LPN) was observed during medication pass observation. EI #13 entered RI #141's room and laid gloves on RI #141's overbed table. EI #13 was observed applying and removing those gloves without washing her hands. Then after washing her hands to administer RI #141's inhaler, EI #13 operated the bed control on the bedrail before applying her gloves and administering the inhaler. On 05/21/18 at 10:09 a.m., an interview was conducted with EI #13. EI #13 was asked when should she wash her hands during medication administration. EI #13 said before and after. EI #13 was asked did she wash her hands before she began preparing RI #141's medications. EI #13 replied no she did not. EI #13 was asked should gloves be put on an unclean surface. EI #13 said no. When asked if she put RI #141's gloves on his/her overbed table, EI #13 replied she did. EI #13 was asked if she cleaned the overbed table before placing the gloves on it. EI #13 answered no. EI #13 was asked when should she wash her hands when using gloves. EI #13 said before she put them on and after she takes them off. EI #13 was asked did she wash her hands before putting on gloves when administering RI #141's medications. EI #13 replied no. When asked did she wash her hands after she used the control to adjust RI #141's bed before she put on gloves to administer his/her inhaler, EI #13 said no. EI #13 was asked what was the concern with those things. EI #13 answered infection control. 4.) RI #96 was admitted to the facility on [DATE] with diagnoses to include, Chronic Obstructive Pulmonary Disease With Acute Exacerbation. On 05/21/18 at 5:21 p.m., EI #11, LPN was observed during medication pass for RI #96. EI #11 placed RI #96's nebulizer treatment in her pocket before entering his/her room. EI #11 was observed taking the treatment from her pocket to administer it. On 05/21/18 at 5:31 p.m., an interview was conducted with EI #11. EI #11 was asked was her pocket considered clean. EI #11 said no. EI #11 was asked should she place medications for administration in her pocket. EI #11 replied no and she thought about it when she put the nebulizer treatment in her pocket that she should not have put it in there. EI #11 was asked what was the concern with putting medications in her pocket. EI #11 answered infection control. 5.) RI #60 was readmitted to the facility on [DATE] with diagnoses to include, Dementia In Other Diseases Classified Elsewhere Without Behavioral Disturbance. On 05/21/18 at 2:02 p.m., EI #10, LPN/Treatment Nurse was observed during wound care for RI #60. EI #10 was observed pulling RI #60's privacy curtain wearing gloves. EI #10 then removed RI #60's wound dressing wearing those same gloves. When wound care was completed, EI #10 placed the garbage bag containing the soiled dressing and supplies used during wound care on the floor of RI #60's room. On 05/22/18 at 2:54 p.m., an interview was conducted with EI #10. EI #10 was asked did she pull RI #60's privacy curtain after applying her gloves to perform wound care. EI #10 said yes. EI #10 was asked did she change gloves before removing RI #60's wound dressing. EI #10 replied no. When asked should she have changed her gloves, EI #10 said yes. EI #10 was asked did she place the garbage bag containing the soiled dressing and other items she used during RI #60's wound care on the floor. EI #10 replied yes she did. EI #10 was asked should the garbage bag have been placed on the floor. EI #10 said no. EI #10 was asked what was the concern with not changing gloves and placing the garbage bag on the floor. EI #10 answered infection control. On 05/22/18 at 3:07 p.m., an interview was conducted with EI #9, Registered Nurse (RN)/Assistant Director of Nursing/Infection Control Coordinator. EI #9 was asked when should a nurse wash her hands during medication pass. EI #9 said before and after and when coming into contact with a resident and between residents. EI #9 was asked when should a nurse change gloves during medication pass. EI #9 replied any time they move from one resident to another or their gloves become visibly soiled. EI #9 was asked should a nurse change gloves and wash their hands when they touch a potentially contaminated object before administering tube medications and inhalers. EI #9 said they should change them as frequently as they need to be changed. EI #9 was asked should a nurse put a medication in their pocket. EI #9 replied no. EI #9 was asked when should a CNA change their gloves during incontinence care. EI #9 replied in between residents, any time they are visibly soiled and any time they move from a dirty item to a clean item. When EI #9 was asked should a CNA put on a clean brief wearing gloves worn during incontinence care, EI #9 said no. EI #9 was asked should a CNA take off soiled gloves and put on a clean pair of gloves without washing her hands. EI #9 replied no. When asked what was the concern with those issues, EI #9 answered cross contamination and infection control. Based on observation, interview, record review, and review of [NAME] and Perry's Fundamentals of Nursing, the facility failed to ensure: 1.) CNAs (Certified Nursing Assistant) provided incontinent care in a manner to prevent infection for RI (Resident Identifier) #72 and #10. The facility further failed to ensure licensed staff: 2.) Did not pull RI #109's privacy curtain wearing gloves, wear those same gloves while administering RI #109's medication and flushes per gastrostomy tube and then straighten RI #109's covers and rinse and dry the syringe used during administration wearing those same gloves. 3.) Washed hands prior to preparing medication for RI #141, did not place gloves on RI #141's overbed table before applying them, did not operate control of RI #141's bed after washing hands and then applied gloves to administer RI #141's inhaler. 4.) Did not place a nebulizer treatment for RI #96 in her pocket prior to administration. 5.) Did not pull the privacy curtain wearing gloves and then begin wound care for RI #60 wearing those same gloves and did not place a garbage bag containing a soiled dressing and supplies used during wound care on the floor of RI #60's room after wound care was provided. These deficient practices affected RI #72 and RI #10, two of three residents observed for incontinent care; RI #109, RI #141, and RI #96, three of five residents observed during medication administration; and RI #60 one of one resident observed during wound care. Findings include: A review of [NAME] and Perry's FUNDAMENTALS OF NURSING, Ninth Edition, Chapter 29 Infection Prevention and Control, page 459 revealed the following: . TABLE 29-6 Centers for Disease Control . Standard Precautions . for Use with All Patients . Perform hand hygiene before, after, and between direct contact with patients. Perform hand hygiene after contact with . body fluids, mucous membranes, . excretions, . after contact with inanimate surfaces or articles in a patient room; and immediately after gloves are removed. Wear gloves when touching . body fluids, .excretions, . Remove gloves and perform hand hygiene . when going from a contaminated to a clean body site. 1.) RI #72 was readmitted to the facility on [DATE]. RI #72's quarterly MDS (Minimum Data Set) assessment with an Assessment Reference Date (ARD) of 3/22/18 documented a BIMS (Brief Interview for Mental Status) score of 1, which indicated severe cognitive impairment; and RI #72 was always incontinent of bowel and bladder and was dependent of staff for toileting and personal hygiene. On 05/20/18 at 5:05 a.m., EI #8 CNA, and one assistant provided incontinent care for RI #72, and after cleaning urine and stool from RI #72 removed her gloves. Without performing hand hygiene EI #8 got a clean brief from the closet, and applied the clean brief to RI #72 before washing her hands. When asked if RI #72 was clean, EI #8 replied, no. EI #8 cleaned more stool from RI #72 and again, applied another clean brief without performing hand hygiene and while wearing the soiled gloves. RI #10 was readmitted to the facility on [DATE]. RI #10's annual MDS assessment with an ARD of 1/31/18 documented RI #10 had long and short term memory problems and severly impaired cognitive skills for daily decision making; and RI #10 was always incontinent of bowel and bladder and was dependent of staff for toileting and personal hygiene. On 5/20/18 at 5:19 a.m., EI #8 and one assistant provided incontinent care for RI #10. After cleaning urine and stool from RI #10, EI #8, while wearing the soiled gloves, applied a clean brief to RI #10, changed gloves and repositioned RI #10 in bed without performing hand hygiene. On 5/20/18 at 6:22 a.m., EI #8 was asked if the facility had a policy about when to change gloves and wash hands. EI #8 said, after and before care. When asked when she should change her gloves, EI #8 replied, after each resident or when she touched something contaminated. When asked when she should wash her hands, EI #8 said, after doing any kind of care with a resident or handling anything contaminated. EI #8 was asked what could happen if she did not change gloves when they were soiled and wash her hands after gloves were removed. EI #8 said, cross-contamination and the spread of germs. When asked what could happen when she put a clean brief on a resident while wearing soiled gloves, EI #8 replied, it transfers the germs. EI #8 was asked why she applied the clean brief and touched other items of the resident's during repositioning while wearing soiled gloves. EI #8 said, she was nervous being watched.