**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that one (Resident #25) of 42 sampled residents, who was unable to carry out activities of daily living (ADLs), received the necessary services to maintain good grooming and personal hygiene. The findings include: A review of Resident #25's medical record revealed he had a Brief Interview for Mental Status (BIMS) score of 10 out of a possible 15 points, indicating moderate cognitive impairment. There were no documented behaviors, bathing was noted as very important to him, and he required extensive assistance with his ADLs, including personal hygiene (combing hair, brushing teeth, shaving, and washing/drying face and hands). On 10/18/22 at 10:13 AM, Resident #25 was observed with a contracture of the right hand and appeared to be immobile on his right side. Upon further observation it was noted that his fingernails were long with a dark brown substance beneath them. (Photographic evidence obtained) He was unshaven. When asked if he preferred his fingernails long, he stated he would like them trimmed and would also like a shave. A review of the care plan dated 8/7/2022 revealed that Resident #25 was a vulnerable resident who was at risk for abuse based on his need for assistance with transfers, toileting, transport, dressing, and other ADLs. The plan included ADL goals, which stated the resident should be clean, dry, and well groomed with assistance from staff, including assistance from staff for personal hygiene and oral care. Review of a Personal Hygiene task completion form, revealed that on a 30-day look-back period from 9/20/2022 through 10/19/2022, the resident was totally dependent requiring full staff performance for personal hygiene. Documentation indicated this was not performed on the following dates: 9/27/2022, 10/2/2022, 10/3/2022, 10/7/2022, 10/11/2022, 10/16/2022, 10/18/2022, and 10/19/2022. On 10/19/2022 at 8:52 AM, Resident #25 was observed with very long fingernails with dark brown debris beneath them. A full beard remained as well. Resident #25 reiterated that he had informed the facility that he would like to have his nails trimmed and cleaned, along with a clean shave. On 10/20/2022 at 10:28 AM, Resident #25 was again observed with dark brown debris beneath his fingernails. He remained unshaven. An interview was conducted with Certified Nursing Assistant (CNA) A on 10/20/2022 at 10:32 AM, who stated she had been working at the facility for six years as an Agency CNA, and more recently (over the last three weeks) she had been working here more often. She stated orientation training was conducted at the facility which included resident hygiene, documentation of tasks, appointments, CPR (cardiopulmonary resuscitation), falls, and personal hygiene. When asked about resident showers, she said showers were generally conducted on the 7A-3P and 3P-11P shifts, and shower sheets had to be signed and filled out to show the task had been completed. When asked to talk through the process of cleaning the residents, she said she would first wake the resident, help if needed to brush their teeth and get them ready to eat breakfast. She would wait for approximately 30 minutes after the meal so they could digest their food, and then she would shower the resident which usually occurred between 9:00 AM and 9:30 AM. During the showering process, she said she would look for skin redness, signs of injury, skin tears or anything abnormal, and she would notify the nurse of such things. She added that she would make sure the residents were clean shaven, toe nails and fingernails were trimmed and clean, and ensure the residents' eyes were clean. If the nails did need trimming, she would let the nurse know, because CNAs could not trim or cut the nails, only clean them. An interview was conducted with Licensed Practical Nurse (LPN) B, Unit Manager, on 10/20/2022 at10:43 AM, who stated personal hygiene training was provided, and she expected the CNAs to attempt to shower the residents as cleanliness was important. She continued, stating she expected residents not to have soiled hair, and for the CNAs to do their best to keep the residents clean paying close attention to perineal care, washing and cleaning fingernails, have podiatry trim toenails, and make a full-body observation from head to toe. She stated if toenails need trimming, this need was placed in the Podiatry book. When asked who trimmed residents' fingernails, she stated fingernails were done by the Activities Department staff. They had what was called a manicure day every Tuesday and on an as needed basis. When she was asked how it was known whether or not a resident needed fingernail or toenail care, she said she would know based on a visual assessment, if the resident verbalized it themselves, or through notification by the CNA. Activities Director C was interviewed on 10/20/2022 at 11:08 AM in reference to residents' fingernail and toenail care. she stated she had been employed by the facility for 15 years. She had a CNA license and would help with tasks such as fingernail care. She stated the facility had what they called Fancy Fingers activities on Thursdays, and this consisted of manicures, fingernail cleaning, nail trimming and filing, and if the resident wished, the nails would be polished. When asked about toenail care, she said her team would place information inside the Podiatrist book and the Podiatrist came to the facility on Fridays to take of the residents' feet. On 10/20/2022 at 11:24 AM, an interview with the Director of Nursing (DON) revealed that if residents needed assistance with ADLs, it would be listed on the [NAME] (brief paper-based summary of a resident's needs). If a resident needed or wanted a bath/shower, there were shower sheets that would indicate who needed showers on certain days. When asked about her expectations of staff for the provision of ADL care and personal hygiene, she said she expected showers to be given in a timely manner and CNAs to do a minimum of two-hour rounds, change residents in a timely manner, assist with brushing teeth, washing faces, combing hair, and skin observation. She further stated along with the skin observation, there should be no new bruising or skin tears/lacerations, and if something like that was observed, the CNA should report it to the nurse or herself (DON). When asked about CNA roles and capabilities when providing personal hygiene as it relates to fingernails, she stated, CNAs can clean, file, and paint fingernails but no cutting or trimming. Nurses are allowed to cut/trim fingernails, and toenail care is left for the podiatrist. She further stated her nurses should be observing as well That's their job and they should be doing weekly checks. When asked if this was just for women, she replied, Nno, men get their nails cleaned and filed, and they get shaved. A review of the facility's Assisted Daily Living Policy stated for Fingernail Care: Ensure fingernails are clean and trimmed to avoid injury and infection; Explain importance of fingernail care to the resident; assemble all necessary equipment, which may include fingernail clipper, nail file, orange sticks, wash basin, towel, and any other necessary equipment; report any abnormalities to the nurse. .

Based on observations, record reviews and interviews, the facility failed to ensure a medication error rate of less than 5% for two (Residents #66 and #18) of three residents sampled for medication administration review. There were 27 opportunities for error with six medication errors identified, for a medication error rate of 22.22%. The findings include: 1. A review of Resident #66's medical record revealed current physician's orders for Potassium 20 meq (milliequivalents) by mouth two times a day, Lactobacillus by mouth every day, Prednisone 10 mg (milligrams) by mouth every day, and Ascorbic Acid 500 mg by mouth two times a day. On 3/17/21 at 8:20 AM, an observation of medication administration was made with Employee A, Registered Nurse (RN), for Resident #66. Employee A failed to administer the Potassium 20 meq, Lactobacillus, Prednisone 10 mg (milligrams) and Ascorbic Acid 500 mg per physician's orders. On 3/17/21 at 9:00 AM, an interview was conducted with Employee A. She confirmed that she missed four of Resident #66's medications during the morning medication pass. She stated she failed to scroll to the next page of the Medication Administration Record (MAR) for the medications listed there. 2. A medical record review for Resident #18 revealed that an apical pulse (a pulse site on the left side of the chest over the pointed end of the heart) check was required prior to administration of digoxin. The parameters instructed nursing to hold medication for a pulse of less than 60. The record review also revealed that rinsing the resident's mouth with water after administration of advair diskus was required. On 3/17/21 at 8:40 AM, an observation of medication administration was made with Employee A, RN, for Resident #18. Employee A failed to take an apical pulse prior to administering digoxin 125 mcg (micrograms), and she failed to have Resident #18 rinse her mouth with water after administering advair diskus aerosol powder. On 3/17/21 at 9:00 AM, an interview was conducted with Employee A. She confirmed that she failed to check the apical pulse prior to administering Resident #18's digoxin, and she failed to ensure the resident rinsed her mouth with water after she received her advair diskus. On 3/17/21 at 9:15 AM, an interview was conducted with Employee I, Regional Nurse. She confirmed that the nurse missed four of Resident #66's medications during the medication pass at 8:20 a.m. Employee I confirmed that an apical pulse should have been taken prior to administering digoxin, and she confirmed that after administering advair diskus, the resident should have rinsed their mouth with water. .

Based on observation, interviews and record review, the facility failed to appropriately store medication in one (1) (Bermuda Cart #1) of two (2) medication carts observed, from a total of four (4) medication carts in the facility. The findings include: On 03/17/21 at 9:05 AM, an observation of the medication cart was made during medication pass with Employee A, Registered Nurse (RN). An unopened insulin pen for Resident #29 was observed, and Employee A confirmed that it should have been in the refrigerator. (Photographic evidence obtained) A review of the facility's policy and procedure titled Storage and Expiration of Medications, Biologicals, Syringes and Needles, with an effective date of 12/07/07 and a revised date of 04/15/19, revealed on page 2 number 11, that the facility should ensure medications and biologicals were stored at their appropriate temperatures according to the United States Pharmacopeia guidelines for temperature ranges. Refrigerated (36 - 46 degrees F (Fahrenheit) NOT IN USE - Insulin Aspart 100 unit/ml (milliliter) Pen. Outdated, contaminated or deteriorated medication and those in containers that are cracked, soiled or without secure closures, are immediately removed from stock, locked in the medication room in a segregated area, and disposed of according to procedure for medication destruction and re-ordered from the pharmacy if a current order exists. On 03/17/21 at 9:15 AM, an interview was conducted with Employee I, Regional Nurse. She confirmed that the unopened insulin pen should have been stored in the refrigerator until it was opened. .