**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility's policies, the facility failed to prepare food safely to prevent cross-contamination. Dietary Aide (DA) 2 was observed on 10/01/2024 preparing a puree brownie with gnats flying around the uncovered blender and gnats were observed flying in and around the trash can in the dining area. The deficiency had the potential to affect all residents that received meals from the kitchen. The findings include: Review of the facility's policy titled, Resident Rights, revised on 08/01/2013, revealed the facility must care for its residents in a manner and in an environment that promoted maintenance or enhancement of each of the resident's quality of life. Review of the facility's policy titled, Food and Preparation and Service, revised 07/01/2014, revealed the food services employees shall prepare and serve food in a manner that complied with safe preparation and handling. Review of the facility's policy titled, Pest Control, revised 05/01/2008 revealed the facility shall maintain an effective pest control program. Per the policy, the facility maintained an on-going pest control program to ensure the building was kept free of insects and rodents. Review of the facility's Commercial Pest Control Agreement revealed it was dated 10/23/2006. Observation on 10/01/2024 at 11:35 AM, revealed DA2 was preparing puree brownie with gnats flying around the uncovered blender. Observation on 10/01/2024 at 11:49 AM, revealed there was a heavy presence of gnats flying in and around the trash can sitting inside the dining room with residents present for lunch. In an interview on 10/03/2024 at 8:56 AM with DA3, she stated she had received training in the kitchen. DA3 stated she had been educated on cross contamination. DA3 stated she had not seen any gnats, bugs, or rodents. She stated if she saw any gnats, bugs, or rodents she would notify the Dietary Manager (DM). In an interview with DA1 on 10/03/2024 at 9:02 AM, she stated she was educated on cross contamination. DA1 stated she had seen gnats around the trash can, and when she did, she changed the trash bag and cleaned the trash cans. DA1 stated she had not seen nearly as many as she did during the hot humid days of summer. DA1 stated she normally worked the morning shift, and she reported issues to the Dietary Manager (DM) or PM [NAME] , who were always on shift. In an interview with the PM [NAME] on 10/03/2024 at 11:57 AM, he stated cross contamination was taught to him at the facility. He stated gnats were in the kitchen. He stated he reported the issue to maintenance, and people came out and sprayed. He stated if a gnat got into the food, it was cross contamination. In an interview with the DM on 10/03/2024 at 9:03 AM, she stated she trained new staff on cross contamination. The DM stated when she was not working or out of the building, the cooks were responsible for the kitchen. The DM stated she had seen gnats in the building. The DM stated having gnats in the kitchen caused cross contamination, and the food could not be served and would need to be discarded if gnats were in the food. In an interview with Housekeeping Aide (HA) 1 on 10/03/2024 at 8:01 AM, she stated gnats were an issue in the building. HA1 stated she mostly saw the gnats around the residents' sinks. HA1 stated housekeeping sprayed bleach in the sinks, and she reported the sighting of gnats to maintenance. In an interview with Maintenance 1 on 10/03/2024 at 8:21 AM, he stated commercial pest control company came to the facility once a month. Maintenance 1 stated the last visit was last Tuesday, September 24, 2024, to spray the building for spiders and rodents, but not for gnats. Maintenance 1 stated he had not had any reports of gnats reported to him at the time of the campus visit made by the pest control company. Maintenance stated Housekeeping 1 told him this morning she had a sighting of gnats. He stated he had not received any reports of gnats being in the kitchen. In an interview with the Director of Nursing (DON) on 10/03/2024 at 1:45 PM, she stated she did see gnats in the building, in the generalized areas. She stated there was a resident in the facility that ate snacks up and down the hallway, dropping food. The DON stated housekeeping would clean up after the residents, as her [NAME] was, We work in their home, and it needed always to be clean. She stated she reported any sighting of gnats to the Administrator or the Maintenance Department. The DON stated her expectations for staff in the facility was to respect residents and follow safety guidelines. In an interview with the Administrator on 10/03/2024 at 12:15 PM, she stated she did see gnats in the building, but the pest control company was at the facility last week to spray. She stated she would call for a revisit from the company and have them visit more often. The Administrator stated she had the expectation for staff to follow all the policies and procedures while they were working inside the facility. The Administrator stated she wanted all staff to treat the residents with respect, love, and dignity as this was their home and needed to be treated as such, as soon as staff entered the facility.

Based on interview and review of the facility's policy, the facility failed to ensure all residents had the right to send and receive mail on Saturdays. The findings include: Review of the facility's policy titled, Residents Rights, revised 07/01/2014 revealed the resident had the right to privacy in written communications, including the right to send and promptly receive mail. During the Resident Council meeting on 10/01/2024 at 10:00 AM, Resident (R) 46 stated residents did not receive or send mail on Saturdays at the facility. R46 stated he did receive packages unopened the day they were delivered to the facility. The rest of the resident attendees confirmed there was no Saturday mail delivery. In an interview with the Business Office Manager (BOM) on 10/03/2024 at 12:21 PM, she stated she was unaware it was against residents' rights not to have their mail being delivered on Saturdays. The BOM stated her work schedule was Monday through Friday 7:30 AM to 4:00 PM, and she was not on the campus during the weekends to sort the mail and give it to the Activities Department. In an interview with Activities 1 on 10/03/2024 at 12:35 PM, she stated only department heads had keys to the mailbox which required a key to retrieve the mail. Activities 1 stated packages delivered by carriers were given to the resident as soon as they were delivered to the facility. Activities 1 stated the only time a resident would receive an opened box was if it was a delivery error by the carrier or if a resident asked for a staff member to help them open the package. In an interview with the Director of Nursing (DON) on 10/03/2024 at 1:45 PM, she stated the mailbox was checked by the BOM. The DON stated the BOM got the mail from the mailbox and sorted out the business mail from the residents' mail. The DON stated the Activities Department was at the facility seven days a week, and they gave the residents the mail everyday, including on Saturdays. The DON stated packages were given to residents the day they were delivered to the facility from the carrier. She stated her expectations for staff was to respect residents. In an interview with the Administrator on 10/03/2024 at 12:15 PM, she stated the BOM was responsible for getting the mail, sorting it, and distributing it to department heads. The Administrator stated the Activities Department would distribute the mail to the residents. The Administrator stated that the department heads only worked Monday through Friday, and they were the only ones who had the keys to the mailbox. The Administrator stated a few residents had subscriptions to the newspaper, and they gave those to residents as soon as they were delivered to the facility.

Based on interview and review of the facility's policies, the facility failed to establish written standards, policies, and procedures for a documented water management program based on nationally accepted standards for all residents (census 76). The facility did not have a water management program that included a description of the building's water systems where Legionella and other opportunistic waterborne pathogens could grow and spread, flow diagrams, measures to prevent growth, testing protocols, acceptable ranges, and established ways to intervene when control limits were not met. The findings include: Review of the facility's policy titled, Infection Control Policy, dated 02/02/2021, revealed the policy's purpose is to prevent, detect, investigate, and control infections in the facility and maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and general public. Review of the facility's policy titled, Prevention of Legionella Growth and Exposure, dated 06/2017, revealed the facility had an established water management program in an effort to prohibit and/or reduce the exposure to Legionella. Further review revealed a text and diagram model of the facility's water system would be maintained and the facility would implement and monitor control measures that might include but was not limited to environmental rounds to identify areas that might promote water stagnation or biofilm, water temperature monitoring, and lab testing of residents with healthcare associated pneumonia. Review of the facility's policy titled, Infection Preventionist, revised 03/2017, revealed the Infection Preventionist was responsible for coordinating the implementation and updating of the facility's established infection prevention and control policies and practices. Review of the facility's Infection Preventionist Job Description, undated, revealed the infection preventionist conducted oversight of the infection prevention and control program including maintaining a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services and following accepted national standards. Review of the facility's . Maintenance Director Job Description, undated, revealed duties and responsibilities included following established safety and infection control procedures and actively participating in the facility's Quality Assurance/Continuous Quality Improvement program to assure departmental activities were conducted in a manner consistent with local, state, and federal regulations. In an interview with the Maintenance Director on 10/03/2024 at 9:10 AM, he stated he had been maintenance director for just a few months and prior to that he worked in maintenance at an apartment building. He stated he was not able to speak to information related to the facility's water management system and had not received training for anything that related to Legionella. The Maintenance Director stated he was unsure if the facility performed chlorine testing. He further stated he had not performed any chlorine tests on the water. The Maintenance Director stated he did not have a description or diagram of the building's water flow system and was not aware that one existed. In an interview with the Administrator on 10/03/2024 at 10:22 AM, she stated she was not aware of a schematic or description of the facility's water flow system. She further stated the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) shared the responsibility of Infection Preventionist. In an interview with the ADON on 10/03/2024 at 11:57 AM, she stated as part of her Infection Preventionist (IP) responsibilities, she reviewed policies and reported disease outbreaks that included, but was not limited to influenza, COVID, and bed bugs. She stated the facility's infection control and prevention policies were reviewed yearly and as needed. The ADON stated she was not involved in the facility's water management system and believed it was maintenance's responsibility. She further stated, if cases of Legionella were identified in the facility, it was her responsibility to track those cases. In an interview on 10/03/2024 at 12:14 PM with the DON, she stated she assumed the role of DON and IP approximately 17 months ago and shared IP duties with the ADON. The DON stated the Maintenance Director worked with the local water department regarding the water system. She further stated the IP reported and tracked communicable diseases such as Legionella. The DON stated since she started at the facility, she had not reported any cases of Legionella. The DON stated she did not know if the facility conducted chlorine testing on the water. She further stated it was important to monitor the water to prevent sickness and spread of potential diseases. During an interview with the Administrator on 10/03/2024 at 2:18 PM, she stated there was not a current facility water management system in place, and it was not something that had been discussed in their Quality Assessment and Performance Improvement (QAPI) meetings. She further stated it was important to monitor the facility's water system to prevent pathogens like Legionella from entering the facility in efforts to protect residents, staff, and visitors. The Administrator stated she was not aware of any reported cases of Legionella. She further stated tracking and surveillance of potential disease outbreaks were the responsibility of the IP, but she was ultimately responsible as well.

Based on observation, interview, record review, review of facility policy, and review of the Centers for Medicare and Medicaid Services (CMS), Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to implement a person centered Comprehensive Care Plan (CCP) for each resident to meet a resident's medical, and nursing needs identified in the comprehensive assessment for one (01) of nineteen (19) sampled residents (Resident #69). Resident #69 had pressure ulcers/injuries to his/her right ankle and left heel, and the CCP, dated 10/23/19, revealed an intervention to provide heel protection. However, observation on 11/12/19, 11/13/19 and 11/14/19, revealed Resident #69 was in bed without heel protection. The findings include: Review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated October 2016, revealed the Comprehensive Care Plan is an interdisciplinary communication tool and must include measurable objectives and time frames and must describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Further review revealed the services provided or arranged must be consistent with each resident's written Plan of Care. Review of Resident #69's clinical record revealed the facility admitted the resident on 09/10/19, and re-admitted the resident on 10/23/19, with diagnoses including Respiratory Failure, Cognitive Communication Deficit, Deep Vein Embolism of right lower extremity, Muscle weakness, and Wedge Compression Fracture of the Lumbar Vertebra. Review of Resident #69's admission Minimum Data Set (MDS) Assessment, dated 09/17/19, revealed the facility assessed the resident as having a Brief Status for Mental Status (BIMS) score of twelve (12) indicating moderately impaired cognition. Continued review revealed the facility assessed the resident as requiring extensive assistance of two (02) staff with bed mobility, transfers, ambulation, toileting, personal hygiene, and dressing. Further review revealed the resident was at risk for pressure ulcers/injuries and had no unhealed pressure ulcers. Continued review revealed the resident was assessed as having receiving pressure-reducing devices for his/her bed. Review of the Comprehensive Care Plan, dated 10/23/19, revealed the resident was re-admitted from the hospital with a Stage I Pressure area to the left heel. The goal stated the Stage I Pressure area to the left heel would heal with no signs of symptoms of infection. The interventions included, but were not limited to: monitor for signs and symptoms of infection, dated 10/23/19; provide pressure relief to area as ordered, dated 10/23/19; treatments and medications as ordered and monitor for effectiveness and for adverse side effects, dated 10/23/19; and heel protection, dated 10/23/19. Review of the Monthly Physician Order's for October 2019, revealed an order to Cleanse Stage I Pressure injury to the left heel with Normal Saline, pat dry and apply skin prep every day for skin management, dated 10/23/19. Further, there was no documented evidence of an order for heel protection. Continued review of the Monthly Physician's Order's dated November 2019, revealed an order to Cleanse Stage II ulcer on the Right ankle with Normal Saline, pat dry, and apply hydro-cellular dressing daily and as needed (PRN) one (01) time a day, dated 11/11/19. Review of the Weekly Wound Assessment, dated 11/11/19, revealed Resident #69 had a right ankle, Pressure ulcer with measurements 1.2 centimeters (cm) length by 1.3 cm width, with 0.01 cm depth. Additionally, the date of onset was 11/11/19. Further, pressure relief device included float heels. Observation of Resident #69, on 11/12/19 at 3:17 PM, revealed the resident was in bed, lying on his/her back in semi-Fowler_position under a sheet. The outline of the resident's lower extremities was noted and the resident had no devices on his/her feet. The resident's left heel was resting flat on the mattress/sheet and his/her right outer ankle was resting flat on the mattress/sheet. The resident's eyes were closed and he/she did not wake to verbal stimuli. Review of the Weekly Wound Assessment, dated 11/13/19, revealed Resident #69 had a left heel, Stage I Pressure ulcer with measurements 3.0 cm length by 3.0 cm width, with no depth. Additionally, the date of onset was 10/23/19. Further, pressure relief device included float heels. Observation of Resident #69, on 11/13/19 at 9:29 AM, revealed he/she was in bed, lying on his/her back in semi-Fowler_position under a sheet. The resident's bilateral feet were uncovered and the resident's left heel was resting flat on the mattress/sheet and his/her right outer ankle was resting flat on the mattress/sheet. The resident stated he/she had wounds to his/her feet that were treated by the nurse daily. Additionally, Resident #69 stated he/she did not like wearing heel boots; however. he/she wore them when staff prompted and assisted with applying them. Observation of Resident #69's wound care and assessment, on 11/14/19 at 9:20 AM, revealed the resident was lying in bed on his/her back in semi-Fowlers position under a sheet, with feet uncovered. The resident's left heel was resting flat on the mattress/sheet and his/her right outer ankle was resting flat on the mattress/sheet. No heel boots were noted. Additionally, the resident's right outer ankle had a hydro-cellular dressing in place with no date or initials to indicate placement. When the dressing was removed from the resident's right outer ankle wound, the wound bed was pink with macerated edges and there was a moderate amount of yellow exudate noted prior to wound cleansing. Further, the resident's left heel skin was intact, dry and peeling. During this observation of wound care, Registered Nurse (RN) #1 stated the resident should have had bilateral heel boots/protection on his/her feet to decrease the risk for further skin breakdown. Further, during this observation Resident #69 stated he/she would wear the heel boots if someone would put them on. Interview with Licensed Practical Nurse (LPN) #2, on 11/14/19 at 10:12 AM, revealed she had worked at the facility for one (01) year and four (04) months, and was working on Resident #69's hallway for the day/shift. Per interview, heel protection meant heel boots for Resident #69. Additionally, Resident #69 was to wear heel boots to protect his/her heels from skin breakdown and to promote healing of the wounds on his/her heel/ankle. However, LPN #2 stated the resident refused to wear them at times. Continued interview revealed the CCP was used by all nursing staff as a guide in providing care to each resident and following/implementing the CCP was essential to ensure the residents' needs were met. Further, per the CCP Resident #69 should have heel boots on to decrease the risk for further skin breakdown. Interview with State Registered Nursing Assistant (SRNA) #1, on 11/14/19 at 4:00 PM, revealed she had worked at the facility for twenty (20) years. Per interview, she implemented the care plan to provide necessary care to residents. Additionally, Resident #69 wore heels boots because he/she had ulcers on his/her feet. Further, it was important for Resident #60 to wear heel boots to protect his/her heels from further skin breakdown. Interview with the Director of Nursing (DON), on 11/14/19 at 4:16 PM, revealed it was her expectation RAI Manual Guidelines were to be followed related to implementation of the CCP. Additionally, if a resident was care planned for heel protection, she expected nursing staff to ensure the CCP was followed unless the resident refused the intervention. Further, it was important for the CCP to be implemented to ensure the Interdisciplinary team provided necessary care to residents to prevent complications such as skin breakdown. Interview with the Administrator, on 11/14/19 at 4:30 PM, revealed he expected the interventions developed on the CCP to be implemented per RAI guidelines. Further interview revealed it was important to ensure CCP interventions such as heel boots were implemented to prevent skin breakdown and to provide safe care to meet residents' needs.

Based on observation, interview, record review, review of the facility policy, and review of the Centers for Medicare and Medicaid Services (CMS), Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to ensure the Comprehensive Care Plan (CCP) was reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs for one (1) of nineteen (19) sampled residents (Resident #35). Resident #35 had a Physicians Order; dated 07/19/19 for heel boots when in bed; however, there was no documented evidence the CCP was revised to include the heel boots. Further, observations on 11/13/19 revealed the resident was in bed for approximately one (01) hour without heel boots on his/her feet. The findings include: Review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated October 2016, revealed the care plan must be reviewed and revised periodically, and the services provided or arranged should be consistent with each resident's written plan of care. Continued review revealed the care plan was driven not only by identified resident issues and/or conditions, but also by a resident's unique characteristics, strengths, and needs. Furthermore, a care plan based on a thorough assessment and effective clinical decision making, was compatible with current standards of clinical practice that provide a strong basis for optimal approaches to quality of care and quality of life needs of individual residents. A well developed and executed assessment and care plan: re-evaluates the resident's status at prescribed intervals (quarterly, annually, or if a significant change in status occurs) using the RAI and then modifies the individualized care plan as appropriate and necessary. Review of Resident #35's clinical record revealed the facility admitted the resident on 07/11/19 with diagnoses including, but not limited to Abnormalities of gait, Cognitive Communication Deficit, Dementia, Atrial Fibrillation, Pressure Ulcer of the Buttock, Weakness, and Cerebral Infarction. Review of Resident #35's Physician's Orders, dated November 2019, revealed an order for heel boots when in bed, with a start date of 07/19/19. Review of the Comprehensive Care Plan (CCP), revised 09/20/19, revealed Resident #35 had impaired skin integrity and was at risk for further impairment related to decreased mobility, required assistance with turning and repositioning; admitted to facility with two (02) Stage II pressure ulcer to buttocks; and an Unstageable pressure ulcer on right heel acquired on 07/02/19. The goal revealed the resident would exhibit signs and symptoms of healing without signs of symptoms of infection and have no further open areas. The interventions included, but were not limited to: pressure reduction mattress to bed, dated 07/11/19; dietitian consult as needed for recommendations, dated 07/15/19; turn and reposition every two (02) hours, dated 07/11/19; weekly wound assessment, dated 07/11/19; and treatments as ordered and monitor wound for any signs and symptoms of infection/deterioration, dated 08/01/19. However, there was no documented evidence the CCP was revised to include heel boots in bed ordered on 07/19/19. Review of Resident #35's Quarterly Minimum Data Set (MDS) Assessment, dated 10/07/19, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of four (04) indicating severe cognitive impairment. Further, the facility assessed the resident as requiring extensive assistance or total assist of two (02) staff for bed mobility. Additional review revealed the resident ambulated in his/her room with limited assistance of two (2) staff and was independent with setup for locomotion in the wheelchair. Per the MDS Assessment, the resident had unsteady balance, and was only able to stabilize with staff assistance during transition from surface to surface. Continued review revealed the resident was at risk of pressure ulcers/injuries and had two (02) stage II pressure injuries and an Unstageable pressure ulcer/injury. Further, the resident was receiving pressure ulcer/injury care and had a pressure-reducing device for the bed. Observation of Resident #35, on 11/13/19 at 10:15 AM, revealed the resident was attempting to self-transfer to bed from wheelchair. Continued observation revealed the wheelchair alarm sounded and State Registered Nurse Aide (SRNA) #2 responded. The resident stated he/she wanted to lay down in bed. Resident #35 was assisted to bed; however, heel boots were not placed on the resident's feet after his/her shoes were removed. Additional observation, on 11/13/19 at 11:02 AM, revealed the resident remained in bed with no heel boots on his/her feet; and his/her bilateral heels were lying on the mattress. Observation of Resident #35 during wound care and assessment, on 11/14/19 at 10:12 AM, revealed the resident was lying in bed without heel boots on prior to wound care. Further observation revealed State Registered Nursing Assistant (SRNA) #1 brought heel boots into the resident's room from central supply. Interview with Licensed Practical Nurse (LPN) #2, on 11/14/19 at 10:12 AM, revealed she had worked at the facility for one (01) year and four (04) months, and usually worked on B side, Resident #35's hallway. Per interview, Resident #35 wore heel boots to protect his/her heels from skin breakdown and to promote healing of the wound on his/her right heel. Additionally, the CCP was used by all nursing staff to provide guidance related to residents' care needs. Per interview, all nurses could revise the care plan to include preventative interventions such as heel boots. Continued interview revealed residents who wore heel boots had Physician's orders to do so, and the CCP should include the intervention for heel boots as per the Physician's order. Further, Resident #35 should have had heel boots on while in bed on 11/13/19 at 10:15 AM, and prior to wound care on 11/14/19, as per physician orders. Interview with SRNA #1, on 11/14/19 at 4:00 PM, revealed she had worked at the facility for twenty (20) years. Per interview, she used the care plan as a guide for providing care to residents. Additionally, the CCP should be accurate related to residents' needs and should include devices they such as heel boots. Further, it was important for Resident #35 to wear heel boots to protect his/her heels from further skin breakdown and he/she should have been wearing heel boots while in bed on 11/13/19 and 11/14/19. Interview with the Director of Nursing (DON), on 11/14/19 at 4:16 PM, revealed it was her expectation for the RAI Manual Guidelines to be followed related to revision of the CCP. Additionally, if a resident had an order for heel protection, the CCP should be revised by the nurse, to include heel boots. Further, it was important for the CCP to be revised to ensure the Interdisciplinary team provided necessary care to residents to prevent complications such as skin breakdown. Interview with the Administrator, on 11/14/19 at 4:30 PM, revealed he expected the CCP to be revised with interventions as necessary per RAI guidelines. Further interview revealed it was important to ensure the CCP was revised to include preventative interventions such as heel boots to prevent skin breakdown and to provide safe care to meet residents' needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of facility Policy, it was determined the facility failed to provide reasonable accommodation of resident needs for three (3) of twenty-three (23) sampled residents (Resident #20, Resident #36 and Resident #53). Observation on 09/11/18, revealed call lights were not in reach and accessible for Residents #20, #36 and #53. The findings include: Review of the facility Call lights Policy, undated, revealed it is the policy of the facility to respond promptly to a resident's call and to assure the call system is in proper working order. Continued review revealed the call lights were to be positioned on the bed or close to the resident so that it is within easy reach. 1. Review of Resident #20's medical record revealed the facility admitted the resident on 07/24/17 with diagnoses including Chronic Obstructive Pulmonary Disease, Peripheral Vascular Disease and Repeated Falls. The facility assessed Resident #20 in an Annual Minimum Data Set (MDS) Assessment, dated 07/10/18, as having a Brief Interview for Mental Status (BIMS) score of eight (8) out of fifteen (15) indicating moderate cognitive impairment. Review of Resident #20's Comprehensive Care Plan, initiated 08/03/17, revealed the resident was at risk for falls with a goal stating the resident would remain free from falls/injury. There were several Interventions including keep call light in reach at all times. Observation on 09/11/18 at 1:00 PM, 3:20 PM, and 4:40 PM, revealed Resident #20 was in his/her room sitting in the chair beside the bed and the call light cord was behind the chair inaccessible to the resident. Interview with Resident #20, on 09/11/18 at 4:40 PM, revealed he/she was in no distress, and had no current needs but was unaware of the exact location of the call light. Per interview, staff usually placed the call light on the bed, but it was not currently on the bed. Continued interview revealed the resident did use the call bell to notify staff of needs at times 2. Review of Resident #36's medical record revealed the facility admitted the resident on 09/05/14 with diagnoses including Alzheimer's disease, Dysphagia, and Difficulty Walking. The facility assessed the resident in an Annual Minimum Data Set (MDS), dated [DATE], as having a BIMS score of fourteen (14) out of fifteen (15) indicating the resident was cognitively intact. Review of Resident #36's Comprehensive Care Plan, dated 09/18/14, revealed the resident was at high risk for falls with a goal stating the resident would not sustain falls or injury through the next review date. There were several interventions including ensure call light is within reach and encourage to use it for assistance as needed; and promptly respond to all requests for assistance. Observation of Resident #36, on 09/11/18 at 11:30 PM, and at 3:10 PM, revealed the resident was in his/her room sitting in the chair by the bed. The call light was noted to be on the floor behind the resident's chair and out of reach of the resident. Interview with Resident #36 on 09/11/18 at 3:10 PM, revealed he/she denied distress and did not need anything at this time. Observation of Resident #36 on 09/11/18 at 4:20 PM, revealed the resident was sitting on his/her bed. The call light was on the floor behind the resident's chair out of reach of the resident. Interview with Resident #36 during this observation revealed he/she was in no distress, and had no current needs, but was unaware of the location of the call light. Per interview, staff usually placed the call light on the bed, but it was not on the bed today. Continued interview revealed Resident #36 did use the call bell to notify staff of needs at times. 3. Review of Resident #53's medical record revealed the facility admitted the resident on 12/05/11 with diagnoses including Polyosteoarthritis, Recurrent Depressive Disorders, Difficulty Walking, and Transient Ischemic Attack. Review of the Annual Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident as having a BIMS score of twelve (12) out of fifteen (15) indicating moderate cognitive impairment. Resident #53's Comprehensive Care Plan revised 08/22/17, revealed the resident was at risks for falls with a goal stating the resident would be free from falls. There were several interventions in place including ensure the call light was within reach and encourage to use call light for assistance as needed. Observation of Resident #53, on 09/11/18 at 1:40 PM, and at 3:15 PM, revealed the resident was sitting in the chair by the bed. The call light was located behind the chair with the cord hanging toward the floor inaccessible to the resident. Observation of Resident #53 on 09/11/18 at 4:35 PM, revealed the resident was in the doorway of his/her room sitting in a wheelchair speaking to another resident. The resident's call light was located behind the chair in the resident's room, with the cord hanging toward the floor. Interview with Resident #53, on 09/11/18 at 4:35 PM, revealed he/she was in no distress, and had no current needs, but was unaware of the location of the call light. The resident tried to locate the call light, but was unable to find it. Per interview, the call light was usually placed on the bed and accessible. Continued interview revealed the resident did use the call bell to notify staff of needs at times. Interview with State Registered Nursing Assistant (SRNA) #1, on 09/11/18 at 4:40 PM, revealed she had been working on the A unit where Resident #20, Resident #36 and Resident #53 resided. Per interview, she usually completed rounds on all the rooms on the hallway to ensure residents had access to call lights and the call lights were in reach. Per interview, housekeeping may have moved the call lights in the rooms for those residents while cleaning. Continued interview revealed, per policy and to ensure resident needs were met, all residents should have access to call lights and the call lights should be in reach of the residents at all times. Interview with Kentucky Medication Aide/SRNA #2, on 09/11/18 at 5:00 PM, revealed she had been working on Unit A all shift. Per interview, all residents should have call lights within reach at all times. Continued interview revealed this was important for the safety of the residents. Further interview revealed she tried to check for call lights while passing medications; however, had not noticed call lights being inaccessible to the residents. Interview with the Assistant Director of Nursing (ADON), on 09/13/18 at 11:50 PM, revealed it was her expectation for all residents to have access to their call lights at all times as per facility policy. Per interview, this was to ensure the residents' needs were met and to prevent negative consequences such as increased risk of falls, increased incontinence and dehydration. Continued interview revealed it was facility policy for all residents, no matter their cognitive status or capability, to have call lights accessible. Interview with the Director of Nursing (DON), on 09/13/18 at 4:45 PM, revealed it was important to make sure the residents were able to communicate with staff in requesting care. The DON stated all residents should have access to the call lights no matter their cognitive ability or physical capacity. Continued interview revealed residents needed to be able to reach the call bell to prevent negative outcomes for the resident such as falls and incontinence. Interview with the Administrator, on 09/13/18 at 5:30 PM, revealed it was his expectation for all residents to have access to call lights as per policy. Per interview, the call light was the residents' form of communication and could possibly prevent negative outcomes such as choking, falls and skin breakdown. The Administrator revealed it was important for staff to check to ensure call lights were in reach when exiting the resident rooms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility Policy, it was determined the facility failed to establish mechanisms for documenting and communicating the resident's Advanced Directive choice to the interdisciplinary team and to staff responsible for the resident's care for one (1) of twenty-three (23) sampled residents (Resident #70). Resident #70's medical record was inaccurate and inconsistent related to code status. The findings include: Review of the facility Code Status Identification Policy, dated [DATE], revealed it was policy to support the decision of the resident (and/or) the person(s) they have appointed to make decisions on their behalf for resuscitation wishes should the need arise for life saving measures. Per Policy, the only place to find the resident choice for code status would be in the hard chart in the very front, on the signed and dated Consent Form indicating choice. Review of Resident #70's medical record revealed the facility admitted the resident on [DATE] with diagnoses including History of Falls, Muscle Weakness, and Spinal Stenosis. Review of Resident #70's Face Sheet under the admissions information tab of the hard chart, revealed the resident's code status was Full Code. Review of the Code Status Consent Form, dated [DATE], signed by the resident's Power of Attorney located in the front of the hard chart, revealed the resident's code status was Do Not Resuscitate. Review of the Electronic Medical Record [DATE] Physician's Orders, revealed orders for Do Not Resuscitate (DNR) code status. Interview with Licensed Practical Nurse (LPN) #5, on [DATE] at 4:00 PM, revealed it was important for all information in the chart related to code status to be consistent in order to provide accurate care for the resident and honor their wishes regarding Advanced Directives. Per interview, she checked the Code Status Consent Form when checking for code status; however, the Face Sheet was one of the documents sent when a resident was transferred out of the facility for hospitalization or appointments and should provide accurate information related to code status. Interview with the Assistant Director of Nursing (ADON), on [DATE] at 11:50 AM, revealed it was her expectation for the Face Sheet and other information in the chart related to code status to be accurate and consistent to ensure residents' wishes concerning code status were followed during emergency situations and transfers. Interview with the Director of Nursing (DON) on [DATE] at 4:45 PM, revealed it was important for residents' wishes to be honored for code status, and therefore the medical record should be consistent and accurate related to code status. Per interview, this was important to ensure a resident's wishes were clearly communicated to staff. The DON revealed if there was an error in the medical record related to code status, a resident may not receive care according to their wishes related to Advanced Directives. Continue interview revealed there should not be ambiguity in the medical record. Interview with the Administrator, on [DATE] at 5:30 PM, revealed it was important for residents' wishes to honored related to code status. Per interview, all documentation related to code status should be consistent in all areas of the medical record. The Administrator stated if there was a discrepancy in the medical record related to code status, a resident who desired Do Not Resuscitate code status could be coded or a resident who desired to be have Cardiopulmonary Resuscitation (CPR) performed could have it withheld resulting in negative consequences. Per interview, if the medical record was inaccurate, errors could be made related to code status in an emergency situation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure a Comprehensive Person-Centered Care Plan was developed and implemented for one (1) of twenty three (23) sampled residents, Resident #11. Resident #11's Care Plan revealed 1:1 individual activities were to be offered three (3) times per week. The resident received one individual activity in August and two (2) individual activities from 09/01/18 through 09/13/18. The facility failed to provide resident centered one to one (1:1) activities to meet the interests and support the physical, mental, and psychological well-being of Resident #11 according to the resident's Comprehensive Care Plan. The findings include: Review of the facility policy titled, Care Plans, undated, revealed each resident would have an individualized care plan to guide staff as to the care needed by each resident. The policy further revealed the initial care plan was completed by the nurse within twenty four (24) hours of admission and updated with changes in resident conditions. Review of the facility document titled Activities Policy, undated, revealed it was the facility's policy to provide an ongoing program of activities designed to meet residents' needs, in accordance with the comprehensive assessment, the interest and physical, mental and psychological well-being of each resident. Review of the facility document titled Activities Procedure, undated, revealed it was the responsibility of the Activities Director to complete resident activity assessments, maintain updated lists of resident preferences, and to provide 1:1 individual resident activities according to the Policy and Procedure. Review of the facility document titled, 1:1 Policy and Procedure, undated, revealed 1:1 individual activities would be provided three (3) times per week if a resident did not attend group activities. Record review revealed Resident #11 was admitted to the facility on [DATE] with diagnoses to include: Dementia, Unspecified Urinary Tract Infection, Alzheimer's Disease, Anorexia, and Osteoarthritis of Hip, Unspecified. His/Her Brief Interview for Mental Status (BIMS) score was 00 on the Quarterly Minimum Data Set (MDS) completed on 07/02/18. The cognitive assessment in the MDS revealed Resident #11 did not exhibit inattention or disorganized thinking at the time of assessment. Review of the Comprehensive Care Plan with admission date of 11/08/17, revealed a focus area updated 07/02/18, for decreased social interaction due to anxiety and Alzheimer's Disease. Resident centered preferences included singing, church, ball games, horseshoes, checkers, and movies. The goal was updated on 07/21/18 and stated the resident would participate in three (3) weekly 1:1 individual activities. Interventions included: offering activity consistent with intellectual and physical capabilities, staff conversation when delivering care, inviting the resident to attend activities, praise for participation in activities, provision of an Activity Calendar to the resident, and thanking the resident for participation. Observations, on 09/11/18 at 2:13 PM and 09/11/18 at 3:59 PM, revealed Resident #11 remained in his/her room, in bed with eyes closed, and no movement noted. Further observations on 09/12/18 at 10:12 AM and throughout the day revealed the resident remained in bed in his/her room with eyes closed. Continued observations on 09/13/18 at 8:05 AM, 8:35 AM, and 9:45 AM revealed Resident #11 was in the room in bed, with eyes closed. Review of the facility 1:1 List dated 09/01/18, revealed Resident #11 was on the list to provide individual activities. Review of the Pioneer Trace Nursing Home Follow Up Question Report dated 08/01/18 through 09/13/18 revealed Resident #11 only received one (1) 1:1 activity on 08/01/18 and 09/02/18 that included current events. Further review of the report revealed on 09/05/18 an additional 1:1 church visit occurred; however there were no other group or 1:1 activities documented as occuring during the report time frame. Interview on 09/13/18 at 3:11 PM with State Registered Nursing Aide (SRNA) #6, revealed the resident did not leave the room for activities. The SRNA stated Resident #11 liked candy which she gave to him/her when she was in the room providing care. SRNA #6 stated she was unaware of any one to one (1:1) activities provided to the resident. She stated sometimes the family came to visit. Interview on 09/13/18 at 3:18 PM with SRNA #4, revealed the resident generally did not get out of bed. She further stated Resident #11 did not attend any group activities. SRNA #4 stated she had never observed any 1:1 activities with Resident #11 as per the Care Plan. Interview with Licensed Practical Nurse (LPN) #4, who cared for Resident #11, on 09/13/18 at 3:25 PM, revealed Resident #11 rarely got out of bed. She stated the resident did not attend group activities nor had she ever observed staff engaged in a 1:1 activity with the resident. Interview with Registered Nurse (RN) #1 on 09/13/18 at 3:36 PM, revealed Resident #11 never left the room for group activities. She further stated she had never observed a 1:1 activity with the resident as per the resident's Comprehensive Care Plan. Interview with LPN #5 on 09/13/18 at 3:51 PM, revealed the resident did not attend group activities nor had she ever observed 1:1 activity interactions with the resident as per the resident's Care Plan. Interview with the Activity Director on 09/12/18 at 3:57 PM, revealed Resident #11 did not attend group activities. She stated the 1:1 Activity Plan for the resident included looking at pictures on the wall in his/her room. The Activity Director stated she was unaware of an Activity Policy. She did maintain a listing of residents who were to receive 1:1 activities. She stated Activities Staff used the listing to provide individual activities two (2) to three (3) times per week for residents not attending group functions. Further interview with the Activity Director, on 09/13/18 at 10:40 AM, revealed Resident #11, according to facility documentation, received one (1) 1:1 activity in August, 2018 and two (2) in September, 2018. She stated the resident should have received more individual activities and one activity per month was not good. The Director stated she was not sure if Resident #11 refused an activity or if no activities were offered. Upon continued interview, she stated the activities delivered for the resident were not consistent with the Activity Care Plan and the Care Plan was not followed related to provbiding activies for Resident #11. She further stated she was working on an inservice for her staff to better educate about expectations for service delivery in accordance with the Comprehensive Care Plan and required documentation the Activity staff should complete. Interview with the Director of Nursing (DON), on 09/13/18 at 4:18 PM, revealed Resident #11 normally did not attend group activities because he/she called out and was disruptive. The DON stated the resident should receive activities in accordance with the Comprehensive Care Plan. Continued interview with the DON revealed she had not observed any 1:1 activities with Resident #11 and one activity offering in a month was not sufficient for resident care. The DON stated participation in resident centered activities was important and improved the quality of life for residents. Interview with the Administrator, on 09/13/18 at 5:29 PM, revealed Resident #11 appeared to be declining and rarely came out of the room. The Administrator further stated his expectation for staff to document participation or declination of activities by a resident to ensure residents were not isolated and functioned at the highest possible level. He stated he did not think Resident #11 went to group activities very often but stated his/her family did come to visit. The Administrator stated the Comprehensive Care Plan should be adhered to for the provision of activities. His expectation was for Activity Staff to ensure resident centered activities were offered to each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of faciltiy Policy, it was determined the facility failed to provide, based on the comprehensive assessment, care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for one (1) of twenty three (23) sampled residents (Resident #11). The facility failed to provide resident centered one to one (1:1) activities to meet the interests and support the physical, mental, and psychological well-being of Resident #11. The findings include: Although, interview with the Activity Director, on 09/12/18 at 3:57 PM, revealed she was unaware of an Activity Policy, the facility provided an undated document on plain paper during the survey. Review of the facility document titled Activities Policy, undated, revealed it was the facility's policy to provide an ongoing program of activities designed to meet residents' needs, in accordance with the comprehensive assessment, the interest and physical, mental and psychological well-being of each resident. Review of the facility document titled Activities Procedure, undated, revealed it was the responsibility of the Activities Director to complete resident activity assessments, maintain updated lists of resident preferences, and to provide 1:1 individual resident activities according to the Policy and Procedure. Review of the facility document titled, 1:1 Policy and Procedure, undated, revealed 1:1 individual activities would be provided three (3) times per week if a resident did not attend group activities. Review of Resident #11's medical record revealed the facility admitted the resident on 11/08/17 with diagnoses to include: Dementia, Unspecified Urinary Tract Infection, Alzheimer's Disease, Anorexia, and Osteoarthritis of Hip. Reveiw of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident as having a Brief interiew for Mental Status (BIMS) score of 00. The facilty further assessed the resident as not exhibiting inattention or disorganized thinking at the time of assessment. Review of Resident #11's Comprehensive Care Plan, initiated 11/08/17, revealed a focus area updated 07/02/18, stating the resdient had decreased social interaction due to Anxiety and Alzheimer's Disease. Resident centered preferences included singing, church, ball games, horseshoes, checkers, and movies. The goal was updated on 06/21/18 and stated the resident would participate in three (3) weekly 1:1 individual activities. Interventions included: offering activities consistent with intellectual and physical capabilities; staff conversation when delivering care; inviting the resident to attend activities; praise for participation in activities; provision of an Activity Calendar; and thanking the resident for participation. Review of the facility 1:1 List dated 09/01/18, revealed Resident #11 was on the list to be provided individual activities. Review of the Pioneer Trace Nursing Home Follow Up Question Report dated 08/01/18 through 09/13/18, revealed Resident #11 received one (1) 1:1 activity on 08/01/18 and 09/02/18 that included current events. On 09/05/18 an additional 1:1 church visit occurred. However, there was no documented evidence of other group or 1:1 activities attended or provided during the report time frame for this resident. Observation on 09/11/18 at 2:13 PM and 3:59 PM, revealed Resident #11 remained in his/her room, in bed with eyes closed. Further observation on 09/12/18 at 10:12 AM and throughout the day, revealed the resident remained in bed in his/her room with eyes closed. Continued observation on 09/13/18 at 8:05 AM, 8:35 AM, and 9:45 AM, revealed Resident #11 was in the room in bed, with eyes closed. Interview on 09/13/18 at 3:11 PM, with State Registered Nursing Aide (SRNA) #6, revealed the resident did not leave the room for activities. The SRNA stated Resident #11 liked candy which she gave to him/her when she was in the room providing care. SRNA #6 further stated she was unaware of any one to one (1:1) activities provided to the resident. She stated sometimes the family came to visit. Interview on 09/13/18 at 3:18 PM, with SRNA #4, revealed the resident generally did not get out of bed. She further stated Resident #11 did not attend any group activities. SRNA #4 stated she had never observed any 1:1 activities with Resident #11. Interview on 09/13/18 at 3:25 PM, with Licensed Practical Nurse (LPN) #4, who was assigned to Resident #11, revealed Resident #11 rarely got out of bed. She stated the resident did not attend group activities nor had she ever observed staff engaged in a 1:1 activity with the resident. Interview with Registered Nurse (RN) #1, on 09/13/18 at 3:36 PM, revealed Resident #11 never left the room for group activities. She further stated she had never observed a 1:1 activity being provided to the resident. Interview with LPN #5, on 09/13/18 at 3:51 PM, revealed Resident #11 did not attend group activities nor had she ever observed 1:1 activity interactions with the resident. Interview with the Activity Director, on 09/12/18 at 3:57 PM, revealed she was unaware of an Activity Policy. She stated she maintained a listing of residents who were to receive 1:1 activities, and staff used the listing to provide individual activities two (2) to three (3) times per week for residents who did not attending group functions. Further interview revealed Resident #11 did not attend group activities; and the 1:1 Activity Plan for Resident #11 included looking at pictures on the wall in his/her room. Further interview with the Activity Director, on 09/13/18 at 10:40 AM, revealed Resident #11, according to facility documentation, received one (1) 1:1 activity in August, 2018 and two (2) in September, 2018. She stated the resident should have received more individual activities and one (1) activity per month was not good. The Activity Director stated she was not sure if Resident #11 refused an activity or if no activities were offered. Continued intervirew revealed the activities delivered for the resident were not consistent with the Activity Care Plan. She further stated she needed to educate her staff about expectations for service delivery in accordance with the Comprehensive Care Plan as well as required documentation of Activities completed. Interview with the Director of Nursing (DON), on 09/13/18 at 4:18 PM, revealed Resident #11 normally did not attend group activities because he/she called out and was disruptive. Continued interview with the DON, revealed she had not observed any 1:1 activities provided to Resident #11. The DON stated the resident should receive activities in accordance with the Comprehensive Care Plan and his/her preferences. Per ineriew, one (1) activity offering in a month was not sufficient for resident care. The DON stated participation in resident centered activities was important and improved the quality of life for residents. Interview with the Administrator, on 09/13/18 at 5:29 PM, revealed Resident #11 appeared to be declining and rarely came out of the room. He stated he did not think Resident #11 went to group activiies very often, but stated his/her family did come to visit. The Administrator stated the Comprehensive Care Plan should be adhered to for the provision of activities. Per interview, it was his expectation the Activity Staff ensure resident centered activities were offered to each resident. The Administrator further stated his expectation for staff to document participation or declination of activities by a resident to ensure residents were not isolated and functioned at the highest possible level. [NAME]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of facility Policy, it was determined the facility failed to ensure proper storage of drugs and biologicals. Observation of the Medication Storage Area on the Hall for Rooms 20 through 40, on 09/11/18, revealed two (2) tubes of Silvasorb Gel with no resident label and an expiration date of 06/2018; a vial of Humulin R Insulin with an open date of 08/01/18; a vial of Humalog Insulin with an open date of 08/01/18; a vial of Lantus Insulin with no open date; a Novolog Flex Pen with expiration date of 09/06/18; and an open vial of Novolin R with expiration date of 08/25/18. In addition, observation on the Hall for rooms 20-40 on 09/11/18, revealed Assure Prism Glucometer Control Solution bottles were opened but undated. Furthermore, observation of the Medication Cart for Upper B Hall, on 09/12/18 at 2:19 PM, revealed two (2) expired medications including Opthalmic Eye Drops Systane Gel 0.3% with expiration date of 01/2018 and Fluticasone 50 micrograms Nasal spray with expiration date of 08/08/18. The findings include: Review of the facility document titled, Med Care Pharmacy - Medication Expiration Dating, with revision date of 09/26/16, revealed a listing of medication expiration dates by type of drug. Further review revealed once opened, Humulin R insulin expired in thirty one (31) days; Humalog, Novolin Flex Pen, and Lantus insulin expired twenty-eight (28) days after opening; and Novolin R expired forty-two (42) days after opening. The reference guide further noted ear drops, eye drops, and nasal sprays generally expired one hundred eighty (180) days after opening. The guide also stated if a medication was unopened staff was to rely on the expiration date on the original bottle/package. Review of the [NAME] Lilly (major producer of insulin products) Manufacturer Recommendations, revealed never use insulin beyond the expiration date. Review of the American Diabetes Association's Healthy Living Magazine, dated January 2018, revealed a recommendation to discard expired insulin. The article further stated use of expired insulin was unsafe. Review of the facility Policy titled, Specific Medication Administration Procedures, undated, revealed staff was to check the expiration date on a package/container prior to administering medication to residents. Review of the facility document titled Administration of Insulin, undated, revealed the insulin expiration date should be checked prior to administering. 1. Observation of the Medication Storage Area on the Hall for Rooms 20 through 40, on 09/11/18 at 2:44 PM, revealed two (2) tubes of Silvasorb Gel with no resident label and an expiration date of 06/2018; a vial of Humulin R Insulin with an open date of 08/01/18; a vial of Humalog Insulin with an open date of 08/01/18; a vial of Lantus Insulin with no open date; a Novolog Flex Pen with expiration date of 09/06/18; and an open vial of Novolin R with expiration date of 08/25/18. Interview with Licensed Practical Nurse (LPN) #1, on 09/11/18 at 2:44 PM, revealed insulin vials and Flex pens should be dated at the time of first use. She stated insulin was to be discarded thirty (30) days after opening. LPN #1 further stated the Medication Storage Room was a mess and discarded all expired insulin and the Silvasorb Gel at the time of discovery by the State Agency Representative. 2. Review of the facility policy titled, Cleaning and Disinfecting Glucose Meter Policy, undated, revealed the policy did not provide guidance to staff for control testing. The facility had no other policies available for Glucometer Testing and Maintenance. Review of Arkray USA, Incorporated manufacturer's package insert for Assure Prism Glucometer Control Solution titled, Assure Prism Control Solution REV3, dated 04/2015, revealed the solution should have a discard date recorded on the label at the time the solution was opened. The instructions further stated the control solution was not to be used ninety (90) days after opening. Observation on the Hall for rooms 20-40 on 09/11/18 at 2:44 PM, revealed Assure Prism Glucometer Control Solution bottles were opened but undated. The control solutions were discarded by LPN #1 at the time of discovery by the State Representative. Interview with LPN #1 on 09/11/18 at 2:44 PM, revealed night shift nursing staff generally performed the glucometer control testing. LPN #1 stated the control solution bottles should have been dated when opened in order to ensure they were not expired. She further stated control testing of the glucometers using control solution ensured accurate finger stick blood sugar results which determined sliding scale insulin dosage. Interview with LPN #4, on 09/13/18 at 3:25 PM, revealed she did not routinely perform glucometer testing; however, she stated glucometer control testing solution should always be dated when initially opened and should be discarded when expired. Interview with Registered Nurse (RN) #1, on 09/13/18 at 3:36 PM, revealed night shift staff usually performed the glucometer control testing. She stated the glucometer control solutions were to be dated upon opening and discarded when expired. RN #1 further stated accurate glucometer control testing with glucometer control solution helped ensure correct calibration of the glucometer, which in turn, helped ensure accurate finger stick blood sugar (FSBS) results. Per interview, nursing staff relied on the FSBS readings to determine correct sliding scale insulin dosages. Interview with LPN #5, on 09/13/18 at 3:51 PM, revealed glucometer testing with glucometer control solution was important for accuracy of insulin administration. She stated glucometer control solutions should be dated when first opened and discarded when expired. 3. Observation of the Medication Cart for Upper B Hall, on 09/12/18 at 2:19 PM, revealed two (2) expired medications including Opthalmic Eye Drops Systane Gel 0.3% with expiration date of 01/2018 and Fluticasone 50 micrograms Nasal spray with expiration date of 08/08/18. Interview on 09/12/18 at 2:19 PM, with RN #1, revealed nursing was expected to check for expired medications daily with monthly oversight by the pharmacy. RN #1 discarded the expired medications at the time of discovery by the State Agency Representative. Further interview with RN #1 on 09/13/18 at 3:36 PM, revealed she always dated new multidose medications at the time of opening. She stated she also marked an expiration date on the vial or bottle when opening a new medication. RN #1 stated she relied on the Med Care Pharmacy reference sheet if she was unsure of how long the medications were stable after opening. Interview with LPN #4, on 09/13/18 at 3:40 PM, revealed new medication vials of Insulin and new bottles of eye drops or Nasal Spray were to be dated when opened and discarded when expired. She stated the expiration date was usually thirty (30) days from the open date for Insulins; however, she used the Med Care Pharmacy cheat sheet on the Medication Cart to check for expiration dates if she was unsure. LPN #4 further stated the purpose of discarding expired medications was to help ensure medication effectiveness. Interview with LPN #5, on 09/13/18 at 3:51 PM, revealed she always marked the date after opening a new vial or bottle of medication. She stated she knew the correct expiration dates by using the reference card for expired medication provided by Med Care Pharmacy. LPN #5 stated she discarded expired medications because they may not be effective administered. Interview with the Assistant Director of Nursing (ADON), on 09/13/18 at 11:45 AM, revealed medication carts should be checked daily by nursing staff for outdated medications. Per interview, staff were expected to discard outdated medications and reorder as needed. She further stated staff should mark an open date on multidose medications at the time of first use/opening. Per interview, expiration dates for multidose medications was usually twenty- eight (28) to thirty (30) days after opening. The ADON revealed if expired medications were administered, they may not be effective. Additional interview with the ADON, revealed nursing staff was to date glucometer control solution bottles when initially opened and discard the bottles when expired. Continued interview revealed use of expired glucometer control solution could result in inaccurate readings on the glucometers, which in turn could cause errors in sliding scale insulin administration. Interview with the Director of Nursing (DON), on 09/13/18 at 4:18 PM, revealed the proper procedure when opening a new Insulin vial, flex pen, bottle of eye drops, Nasal Spray, or topical medication was to mark the medication with the open date. She further stated insulin was to be discarded thirty (30) days after opening. Continued interview revealed Medication Carts were to be checked weekly for expired medications by the nursing staff and Pharmacy checked for expired medications on a monthly schedule. The DON stated staff could use the Med Care Pharmacy Guide, kept on the Medication Carts, as a reference to determine expiration dates. She further stated use of expired medications could result in residents receiving less effective medications. Additional interview with the DON, revealed glucometer testing solution should be dated when opened. She stated the solution was good for ninety (90) days from the date of opening and should be discarded when expired to ensure accurate glucometer readings. The DON stated glucometer results drove accurate insulin dosages for residents on sliding scale insulin. Interview with the Administrator, on 09/13/18 at 5:29 PM, revealed nursing staff was responsible for ensuring expired medications were discarded. He further stated it was important to ensure expired medication was not accessible for use, because if administered, the medication may not be effective. The Administrator stated sliding scale insulin dosages could be adversely affected if expired insulin was administered. Further interview with the Administrator, revealed nursing was to ensure glucose control solutions which were not marked with an open date upon opening, were discarded and not accessible for use. Per interview, the DON had overall responsibility for the glucometer testing process. He stated the importance of accurate testing with the control solutions was to ensure reliable testing results and correct sliding scale insulin dosing for residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of facility Policy, it was determined the facility failed to store food and drink items in accordance with professional standards for food service safety. Observation on 9/12/18 at 8:40 PM, of the B Hall Nourishment refrigerator, revealed an opened, unlabeled, and undated bottle of Mountain Dew carbonated soft drink; and an unlabeled and undated bottle of [NAME] Blue water. The B Hall Nourishment refrigerator freezer had an unlabeled and undated container of Breyers Strawberry Ice Cream in the freezer. The findings are: Review of the facility Use and Storage of Foods Brought to Residents by Family and Visitors, Policy, dated October 2017, revealed food items will be labeled with the resident's name, date and a discard or use by date. Observation on 9/12/18 at 8:40 PM, of the B Hall Nourishment refrigerator, revealed an opened, unlabeled, and undated bottle of Mountain Dew carbonated soft drink and an unlabeled and undated [NAME] Blue water which had not been opened. The B Hall Nourishment refrigerator freezer had an unlabeled and undated container of Breyers Strawberry Ice Cream in the freezer which had not been opened. Interview with Licensed Practical Nurse (LPN) #3, on 9/12/18 at 8:45 PM, revealed the Mountain Dew in the nourishment refrigerator on Hall B was hers. Per interview, LPN #3 was aware of the facility policy concerning labeling and dating of food in the nourishment refrigerator and stated all food in the refrigerator was to be for the residents' use. She stated she did not know who the [NAME] Blue water in the freezer belonged to, but did not think it belonged to a resident. Continued interview revealed LPN #3 did not know who the strawberry ice cream belonged to, but stated the container should be labeled and dated to maintain proper food storage. Interview with the Dietary Manager, on 9/13/18 at 3:00 PM, revealed the dietary department was not involved with maintaining the nourishment refrigerators on the units and that task was the responsibility of the nursing department. Continued interview revealed the dietary department was only responsible for labeling and dating the facility supplied snacks that were kept in the nourishment refrigerators. Further interview revealed it was her expectation all staff involved in handling food and nourishments for the residents followed facility policy related to food storage to ensure residents received food and drinks which had been stored appropriately. Interview with the Assistant Director of Nursing (ADON), on 9/13/18 at 11:50 PM, revealed it was her expectation all nursing staff followed facility policy related to labeling and dating the food and drinks in the nourishment refrigerators. Per interview, only residents' food and drink items were to be stored in the nourishment refrigerators. The ADON revealed labeling the food and drinks which were stored in the refrigerator was important in order to identify which residents the items belonged. The ADON further stated it was important for the food and drink items to be dated to ensure residents did not consume expired food or drinks. Interview with the Director of Nursing (DON), on 9/13/18 at 4:45 PM, revealed it was her expectation all staff followed policy related to outside food and fluids brought in by family and visitors. Per interview, the food and drinks stored in the nourishment refrigerators were to be labeled with the residents' name, and dated at the time the items were brought into the facility. She stated nourishments should be dated in order for staff to know when to dispose of the items, and labeling the items with the resident's name was important in order to identify to whom the items belonged. Further interview revealed the employees were not to use these refrigerators for their food and drinks. Interview with the Administrator, on 9/13/18 at 5:30 PM, revealed the nourishment refrigerators were to be used for resident nourishment only and employees should not have their personal food or drinks in these refrigerators. Per interview, all items in the refrigerator or freezer should be labeled and dated. Continued interview revealed this was important to ensure food was discarded when expired and to ensure residents received the right diet to maintain safety. The Administrator stated all staff was to follow facility policy related to food storage and labeling.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of facility policy, it was determined the facility failed to provide nourishing snacks to residents at bedtime, and failed to have juice available on request. Interview during Group Interview, conducted by the State Agency Representative on 9/12/18, revealed Residents #20, #29, #38, #51, #53, #60, and #66 complained the facility failed to offer bedtime snacks and did not have juice available when requested. In addition, observation and interview with staff and Residents #12, #23, #36, and #57, on the evening of 9/13/18, revealed the facility failed to offer bed time snacks. The findings include: Review of the facility Hydration and Nutrition Policy, revised 9/25/15, revealed snacks are offered between meals and at bedtime according to resident desire or need, and fluids are always available to residents. 1. Group Interview conducted by the State Survey Agency Representative on 9/12/18 at 10:59 AM, revealed Resident #20, #29, #38, # 51, #53, #60, and #66 were not being offered bedtime snacks at night, and would enjoy being offered nourishments and fluids other than water at bedtime. The residents also expressed during Group Interview the facility did not have juice available which used to be offered in the daytime and at bedtime. Further Group Interview revealed they had not expressed these concerns to the facility. Review of Resident #20's medical record revealed the facility assessed the resident in a Quarterly Minimum Data Set (MDS) dated [DATE], as having a Brief interview for Mental Status (BIMS) score of eight (8) out of fifteen (15) indicating moderate cognitive impairment. Review of Resident #29's medical record revealed the facility assessed the resident in an Annual MDS assessment dated [DATE], as having a BIMS of fifteen (15) out of fifteen (15) indicating the resident was cognitively intact. Review of Resident #38's medical record revealed the facility assessed the resident in a Quarterly MDS assessment dated [DATE], as having a BIMS score of fifteen (15) out of fifteen (15), indicating the resident was cognitively intact. Resident #51 had a facility assessed BIMS score of fourteen (14) out of fifteen (15), on the Annual Minimum Data Set (MDS) assessment dated [DATE], indicating the resident to be cognitively intact. Resident # 53 had a facility assessed BIMS score of twelve (12) out of fifteen (15), on the Annual Minimum Data Set (MDS) dated [DATE], indicating moderate cognitive impairment. Resident #60 had a facility assessed BIMS score of thirteen (13) out of fifteen (15), on the Quarterly Minimum Data Set (MDS) dated [DATE], indicating the resident to be cognitively intact. Resident #66 had a facility assessed BIMS score of fifteen (15) out of fifteen (15), on the admission Minimum Data Set (MDS) dated [DATE], indicating the resident to be cognitively intact. 2. Review of Resident #36's medical record revealed the facility assessed the resident as having a BIMS score of eleven (11) out of fifteen (15) per the Quarterly MDS assessment dated [DATE], indicating moderate cognitive impairment. Observation on 9/12/18 at 8:00 PM, revealed Resident #36 was sitting in a chair in his/her room. Interview with the resident at the time of observation, revealed if he/she asked for snacks at bedtime staff would say they did not have any. Per interview he/she had stopped asking for snacks from the facility and his/her family would bring in snacks for him/her. 3. Resident #57 had a facility assessed BIMS score of thirteen (13) out of fifteen (15), on the Quarterly Minimum Data Set (MDS) dated [DATE], indicating the resident was cognitively intact. Observation on 9/12/18 at 8:06 PM, revealed Resident #57 was in his/her room lying in bed. Interview with the resident during the observation revealed staff never offered snacks at bedtime. Per interview, he/she would occasionally like to have snacks at bedtime. 4. Review of Resident #13's medical record revealed the facility assessed the resident as having a BIMS score of fifteen (15) out of fifteen (15) on the Annual Minimum Data Set (MDS) dated [DATE], indicating the resident was cognitively intact. Observation on 9/12/18 at 8:11 PM, revealed Resident #13 was lying in bed in his/her room on Hall A. Interview with the resident during the observation revealed snacks were never offered at anytime, and definitely not offered at bedtime. Per interview, the facility used to offer juice several times a day and now never offered juice. Resident #13 stated he/she would like to have juice and snacks offered to him/her at bedtime and at other times of the day. Continued interview revealed when the facility did have snacks the only snacks available were cheese and crackers which were not offered, but staff would get them if requested. 5. Review of Resident #23's medical record revealed the facility assessed the resident as having a BIMS score of ten (10) out of fifteen (15) on the Annual Minimum Data Set (MDS) dated [DATE], indicating moderate cognitive impairment Observation on 9/12/18 at 8:13 PM, revealed, Resident #23 was sitting in his/her room. Interview with Resident #23 during the observation, revealed nursing staff did not offer snacks at bedtime or anytime. Per interview, he/she would ask for snacks; however, staff did not offer them. Per interview, staff never offered any nutrition or fluids between meals other than ice and water. Observation of staff on 9/12/18 from 8:00 PM- 9:00 PM, on A Hall and B Hall, revealed staff did not offer snacks or nourishments to residents other than passing ice and water. Observation on 9/12/18 at 8:15 PM, of the A Hall refrigerator, and at 8:45 PM, of the B Hall refrigerator, revealed cranberry juice, sandwiches and assorted labeled resident drinks. The Nurse's station for both A and B Hall had peanut butter and cracker, cheese crackers, and graham crackers as well as assorted condiments. Interview with Licensed Practical Nurse (LPN) #5, on 9/13/18 at 8:15 PM, revealed she was assigned to the A Unit. Per interview, she did not offer bedtime snacks to all residents routinely each night. Continued interview she would give snacks to the residents known to want night snacks and she would give snacks to certain residents during medication pass. Per interview, if resident's asked for snacks she would obtain a snack per resident request. However, LPN #5 stated she did not ask the State Registered Nursing Assistants (SRNA) if they had passed snacks at night and did not know if they offered snacks to all residents. Per interview, all resident's should be offered a bedtime snack because some residents may want a snack and not ask for it, and some residents were unable to ask for a snack due to cognitive impairment. Per interview, there were sandwiches as well as cheese and crackers from the kitchen which were always available on the unit. Interview with SRNA #8, on 9/13/18 at 8:40 PM, revealed she sometimes offered bedtime snacks to residents, but not every evening. Per interview, snacks were available at the nursing station in the nourishment refrigerator and cabinet. Continued interview revealed the facility did not have a snack cart to make rounds or a list indicating each resident's diet orders in order to provide snacks to each resident. Interview with SRNA #9, on 9/13/18 at 8:45 PM, revealed she was aware of some residents' preferences for bedtime snacks and delivered these residents snacks, but she did not offer each resident a bedtime snack. Further interview revealed there was no snack and hydration cart or list to indicate the residents' diet in order to offer each resident a snack in the evenings. Per interview, SRNAs or nurses should be offering a bedtime snack to all residents each night to help ensure adequate nutrition and hydration and for resident enjoyment. Interview with the Assistant Director of Nursing (ADON), on 9/13/18 at 11:50, revealed all residents should be offered a bedtime snack. Per interview, it was important for staff to offer snacks because all residents may not voice or be able to voice being hungry or thirsty, but may enjoy a snack at bedtime. Further interview revealed it was important staff ensured residents with a diagnosis of Diabetes received an evening snack as well to maintain their blood sugar levels. Continued interview revealed there may be times when residents may not have eaten much at dinner and that would make offering a bedtime snack even more important. Interview with the Dietary Manager, on 9/13/18 at 3:00 PM, revealed the dietary department did send snacks to the unit to stock the nourishment refrigerators, but the kitchen did not individually label snacks with the residents' name. Per interview, there was no unit snack lists. Interview with the Director of Nursing (DON), on 09/13/18 at 4:45 PM, revealed all residents if allowed PO (by mouth) food and fluids should be offered snacks at bedtime to maintain optimal nutrition. Per interview, the facility maintained snacks for the residents at the nurse's station. Further interview revealed the time period after supper until breakfast was the longest period between meals, and the SRNAs should be offering nutrition and hydration upon nightly rounds. Interview with the Administrator, on 09/13/18 at 5:50 PM, revealed all residents if allowed PO dietary nutrition should be offered snacks at bedtime each evening. Per interview, this was important to maintain nutrition, hydration, satisfaction, and quality of life for the residents. Per interview, the facility needed to put a quality assurance plan in place as a priority to give residents options in snacks at bedtime.

Based on interview, and review of facility Policy, it was determined the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) Policy included a written Quality Plan that describes the process for conducting QAPI activities such as identifying and correcting quality deficiencies as well as opportunities for improvement. The findings include: Review of the facility Quality and Assurance Performance Improvement Policy, dated 08/01/14, revealed parameters for the development and operation of a QAPI Committee. However, there was no documented evidence of a QAPI Plan describing the process for identifying and correcting quality deficiencies including tracking and measuring performance; establishing goals and thresholds for performance measurement; identifying and prioritizing quality deficiencies; systematically analyzing underling causes of systemic quality deficiencies; developing and implementing corrective action or performance improvement activities; and monitoring or evaluating the effectiveness of corrective action/performance improvement activities. Interview with the Assistant Director of Nursing (ADON)/Licensed Practical Nurse (LPN), on 09/13/18 at 1:05 PM, revealed she was also the Director of QAPI. She stated the team met monthly; however, there was no established Quality Plan inclusive of performance measurement, goals, data analysis, or interventions based on reported outcomes. Interview with the Director of Nursing (DON), on 09/13/18 at 4:18 PM, revealed the QAPI Committee was the responsibility of the ADON. She further stated she was not aware of a Quality Plan with written policies and protocols . Further interview revealed there were no active quality initiatives other than monitoring of call light responses on the date of the interview. She stated a Quality Program was important for the facility to ensure residents achieved optimal outcomes. Interview with the Administrator, on 09/13/18 at 5:29 PM, revealed the Quality Plan should have written standards for collection of data, guidance for measurement of data, and assessment of the effectiveness of interventions. Per interview, the facility's current QAPI Policy did not contain a Quality Plan with additional policies and protocols. He stated the ADON was responsible for the Quality Program and all staff had a role in quality improvement. He further stated a well established quality plan was the structure for providing optimal resident outcomes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility's Contact Precautions Policy, dated 2007, revealed general guidelines were provided for contact isolation. Per Policy, gloves were required for entry into residents' rooms and gowns were required if clothing came into contact with the resident, environmental surface, or items in the resident's room; if the patient was incontinent; or if there was wound drainage not contained by a dressing. No other policies related to transmission precautions were submitted for review. Review of the Centers for Disease Control (CDC), Management of Multi-Drug-Resistant-Organisms in Healthcare Setting, 2006, last updated February 15, 2017, revealed once multi-drug resistant organisms (MDROs) were introduced into a healthcare setting, transmission and persistence of the organism was dependent on prevention efforts. Further review revealed recommendations for contact precautions (gown and gloves) when in contact with draining wounds. Continued review revealed educational interventions should intensify when MDROs were identified within the facility. Review of Resident #13's medical record revealed the facility admitted the resident on 05/07/18 with diagnoses to include History of Urinary Tract Infections, Spina Bifida, Bladder Disorders in diseases classified elsewhere, Neuromuscular Dysfunction of Bladder, and Extended Spectrum Beta Lactamase Resistance. Review of Resident #13's Acute Care Plan with problem onset date of 03/26/18, revealed a problem of strong odor in urine upon in/out catheterization. The goal stated the resident would be symptom free by review date with target date of 10/25/18. Interventions include antibiotics as ordered, offer and encourage fluids, provide proper peri care, and contact precautions related to Extended Spectrum Beta Lactamase (ESBL) in the Urine. Review of Resident #13's Annual Minimum Data Set (MDS) Assessment, dated 07/14/18, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of fifteen (15) out of fifteen (15) indicating the resident was cognitively intact. Review of Resident #13's September 2018 Order Summary Report, revealed an active Physician's Order for Contact Precautions, with an original order date of 5/17/18. Further review of Resident #13's September 2018 Order Summary Report, revealed Physician's Orders dated 06/12/18, with start date of 06/24/18, for Macrobid (antibiotic) 10 Milligrams one (1) by mouth one (1) time a day for Urinary Tract Infection (UTI) for three (3) months until 09/24/18. Observation on 09/12/18 at 4:15 PM, revealed there was no signage on the door related to isolation precautions or to see a nurse before entering. In addition there was no PPE noted on the door or at the entrance to the resident's room. Licensed Practical Nurse (LPN) #2 was observed to enter the resident's room without donning PPE. LPN #2 was further observed to perform In and out urinary catheterization on Resident #13 using sterile technique. LPN #2 then disposed of the used catheter in the resident's trash can beside the bed, emptied the urine from the catheterization into the resident's commode, and discarded the urine container and gloves in Resident #13's roommate's trash can. There was no biohazard receptacle in the room. LPN #2 then performed hand hygiene, donned gloves and continued to care for the resident. Interview on 09/12/18 4:50 PM with LPN #2, revealed she received infection control education in facility orientation, and had worked as a nurse for a year. Per interview if a resident was on contact precautions there would be signage on the door to warn staff and visitors to see the nurse before entering the resident's room and there would be a caddy on the door containing PPE. She stated when a lab report came back indicating the need for contact precautions the nurse would call the physician for an order for contact precautions. Per interview, the nurse would then initiate the proper precautions with signage and the PPE caddy as well as a biohazard receptacles for the resident's room for soiled gowns, gloves, and waste. She stated there would also be red biohazard bags to be used for linens and clothes. LPN #2 further acknowledged she did not utilize isolation precautions for Resident #13 as there was no indication the resident was on isolation precautions. Interview on 09/13/18 at 10:20 AM, with State Registered Nurse Aide (SRNA) #7, revealed if a resident was on contact precautions staff would receive this information during report at the beginning of the shift and there would be pockets on the resident's door containing gowns, gloves, and masks. Per interview, if a resident was on contact precautions the resident's linens will be placed in a special bag, and biohazard trash would be discarded into a red bag in the resident's room. Further interview revealed she had taken care of Resident #13 for three (3) years and the resident had not been on isolation precautions. Interview on 09/13/18 10:30 AM with LPN #5, revealed if a resident was on contact precautions staff would be informed during shift report, and there would be a yellow basket on the resident's door containing PPE. She further stated staff would put the resident's clothes and linens in a washable bag that dissolved in the wash, and biohazard trash would be placed in a red bag. Per interview, the facility did not use signage to inform visitors or staff of the need to see the nurse before entering the room. LPN #5 stated she had taken care Resident #13 a few times a month for the last two (2) to three (3) years and the resident had not been on contact precautions. Interview on 09/13/18 at 10:00 AM, with Resident #13, revealed staff wore gloves when they are provided care for him/her, but not gowns. He/she stated it had been a while since anyone had worn a gown while providing care for him/her. Further interview revealed staff usually discarded the used catheters in the beside trash can and the urine container in the bathroom trash can. 3. Review of Resident #68's medical record revealed the facility admitted the resident on 06/07/18 with diagnoses to include Methicillin Resistant Staphylococcus Aureus, and Proteus (Mirabilis) (Morganii) as the cause of diseases classified elsewhere, Urinary Tract Infection, and Pressure Ulcer of Sacral Region stage 4. Review of Resident #68's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the Resident as having a BIMS score of nine (09) out of fifteen (15) indicating moderate cognitive impairment. Review of Resident #68's Acute Care Plan, revised 08/16/18, revealed the resident was re-admitted with an unstageable sacral pressure ulcer infected with MRSA according to hospital records. The goal stated the wound would show signs of healing. However, there were no interventions for contact precautions. Review of Resident #68's Microbiology Report, revealed a wound culture was collected on 08/27/18 with report date of 08/30/18, indicating the sacral wound culture showed Methicillin Resistant Staphylococcus Aureus (MRSA) (Mutidrug Resistant Organism). Review of Resident #68's September 2018 Order Summary Report revealed no Physician's orders related to isolation precautions. However, observation on 09/12/18 at 5:00 PM, revealed signage on Resident #68's door which stated to see the nurse before entering. In addition, there was PPD hanging on the door including gowns and gloves. Continued interview on 9/13/18 11:21 AM with the ADON/ICP, revealed staff were educated on isolation precautions during orientation and as needed. She stated if a resident was on contact precautions there would be signage on the resident's door to see the nurse before entering as well as a caddy containing PPE. She further stated biohazard bags would be kept in the room for biohazard waste; however, she was not sure who picked up those bags to be discarded. Per interview, staff also passed information in shift report related to isolation precautions. Further interview revealed if the signage and the PPE was removed from the resident's door, staff could assume the resident was no longer in isolation. Continued interview on 09/13/18 4:18 PM with the DON, revealed education for nursing staff related to isolation precautions was provided by the ADON and the DON during orientation and per computer training. The DON stated if there was a Physician's Order for contact precautions, the order should be followed to prevent the transmission of disease and infection to residents and staff. Further interview revealed there should be Physician's Orders related to isolation for any resident on contact precautions for MDROs. Interview with the Administrator on 09/13/18 at 5:29 AM, revealed it was his expectation for the Nursing Department to take the lead on infection control actions. He stated the ADON had overall responsibility for the program. He further stated it was important to track, trend, and manage infectious diseases to enable the facility to prevent disease transmission among staff and residents. Continued interview revealed it was important the facility had written written infection control and surveillance policies to identify communicable diseases. Further interview with the Administrator, revealed communication of infection control issues such as the need for isolation precautions was the most important aspect in prevention of disease and infection. The Administrator stated adhering to isolation precautions and protocols was of high importance to prevent transmission of infection to residents and staff. Based on interview, record review, and review of facility policy, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary environment and to help prevent the development and transmission of communicable disease and infections. There was no documented evidence of written policies and procedures which included a system of surveillance designed to identify possible communicable diseases before transmission to others; and when and how isolation should be used for a resident; including, but not limited to the type and duration of the isolation, and the least restrictive possible isolation for the resident. Also, review of the Facility Infection Control Risk Assessment, dated 11/17/17, revealed an assessment of the facility's infection control risks was completed; however, there was no written analysis or summary connecting the Assessment to written infection control and surveillance policies and procedures for the facility. In addition, observation on 09/12/18, revealed Resident #13 had no signage related to contact isolation, no Personal Protective Equipment (PPE) at the entry to the resident's room, and no biohazard receptacle in the resident's room. However, the resident had a Physician's Order for contact isolation related to Extended Spectrum Beta Lactamase (ESBL) in the Urine. Observation of a catheterization procedure on 09/12/18, for Resident #13, revealed the nurse did not follow contact precautions related to wearing a gown, and disposing of used supplies per a biohazard container. Furthermore, Resident #68 did not have a Physician's Order for isolation; however, PPE and signage was on the resident's door. Review of Resident #68's Microbiology Report revealed a wound culture was reported on 08/30/18, revealing the sacral wound culture showed Methicillin Resistant Staphylococcus Aureus (MRSA). The findings include: 1. Review of the Centers for Disease Control (CDC) recommendations, revealed one (1) to three (3) million infections occur in long-term facilities annually. The National Healthcare Safety Network (NHSN), a part of CDC, recommends long-term facilities track infections in a systematic way to improve care and decrease costs. Review of the Facility Infection Control Risk Assessment, dated 11/17/17, revealed an assessment of the facility's infection control risks was completed; however, there was no system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases based upon the facility Assessment. Review of the facility Unit B Antibiotic Tracking Log dated 03/26/18 through 09/10/18, revealed six (6) of twenty-eight residents did not have the antibiotic start date recorded; twenty-six (26) of twenty- eight (28) residents treated with antibiotics did not have a pathogen/organism identified; ten (10) of twenty -eight (28) residents did not have an antibiotic discontinue date; and two (2) of twenty- eight (28) residents did not have the antibiotic treatment documented. Thus, the facility lacked information to ensure resident safety from transmission of infections acquired at the facility. Also, the facility did not have written standards, policies, or procedures defining the surveillance system designed to identify possible communicable diseases before transmission to others when requested. Furthermore the facility did not have written standards, policies, or procedures defining how isolation should be used for a resident; including, but not limited to the type and duration of the isolation, and the least restrictive possible isolation for the resident, nor was there evidence the Infection Control Risk Assessment was included in policies and procedures. Interview with the Assistant Director of Nursing (ADON) (who also served as the Infection Control Preventionist) on 09/13/18 at 11:21 AM, revealed she did not track residents with infections or antibiotics over time. She stated she reviewed antibiotic orders each day but did not access laboratory reports until the end of the month to see what infections were present in the facility. Per interview, she did not maintain the information to establish any infection control risks for residents. Further interview revealed the facility had no written standards, policies, or procedures for management of infections acquired within the facility. Interview with the Director of Nursing (DON) on 09/13/18 at 4:18 PM, revealed the ADON had overall responsibility for the Infection Control Program. The DON stated it was important to review laboratory work associated with infections to enable the facility to establish common infections and implement preventive measures to protect residents and staff from disease transmission.

Based on interview, record review, review of Policies utilized by the facility, and review of the Centers for Disease Control (CDC), The Core Elements of Antibiotic Stewardship in Nursing Homes, it was determined the facility failed to have an Antibiotic Stewardship Program that was developed and implemented based on written protocols for antibiotic use in order to monitor antibiotic usage; optimize the treatment of infections by ensuring residents who required an antibiotic were prescribed the appropriate antibiotic; and reduce the risk of adverse events from antibiotic usage including the development of antibiotic-resistant organisms from unnecessary or inappropriate antibiotic use. Review of the facility Antibiotic Tracking Log and interview with the Assistant Director of Nursing (ADON)/Infection Control Nurse (ICN), revealed no antibiotic prescribing protocols were in place nor evidence of laboratory results to support antibiotic usage. Twenty six (26) of twenty-eight (28) residents did not have a culture collected to support correct antibiotic prescribing, dosing, and duration in order to reduce the development of antibiotic-resistant organisms. In addition, the Antibiotic Tracking Log was incomplete with no pathogen identified for twenty six (26) of twenty eight (28) residents on antibiotics; no start date for antibiotics for nine (9) of twenty eight (28) residents; and no antibiotic stop dates for ten (10) of twenty eight (28) residents. The findings include: Review of the Antibiotic Stewardship-Staff and Clinician Training and Roles Policy, 2001 Med Pass, Inc., revised July 2016, utilized by the facility, revealed nursing assistants, licensed nursing staff, the Assistant Director of Nursing (ADON), the Director of Nursing (DON), and the Consultant Pharmacist would receive training in antibiotic stewardship. However, there were no protocols present in the policy regarding antibiotic prescribing, review of prescribing practices, protocols for optimizing the treatment of infections, nor a process for consistent review of laboratory reports and resident signs and symptoms. Review of the Antibiotic Stewardship-Review and Surveillance of Antibiotic Use and Outcomes, Policy dated 11/27/17, revealed the Infection Preventionist should review all antibiotic starts within forty -eight (48) hours of antibiotic therapy. However, no antibiotic use protocols for consistent review of laboratory reports were included in the policy. Review of the Centers for Disease Control (CDC), The Core Elements of Antibiotic Stewardship in Nursing Homes, undated, recommended facility-specific treatment recommendations, based on national guidelines and local susceptibilities and formulary options to optimize antibiotic selection and duration. The CDC further stated residents who were unnecessarily exposed to antibiotics were placed at risk for serious adverse events with no clinical benefit. Review of the facility Antibiotic Tracking Log for Unit B, 03/26/18 through 09/10/18, revealed antibiotics were prescribed for residents; however, no prescribing protocols were in place nor evidence of laboratory results to support antibiotic usage. Further review revealed twenty six (26) of twenty-eight (28) residents did not have a culture collected to support correct antibiotic prescribing, dosing, and duration to reduce the development of antibiotic-resistant organisms. In addition, the tracking log was incomplete with no pathogen identified for twenty six (26) of twenty eight (28) residents, no start date for antibiotics for nine (9) of twenty eight (28) residents, and no antibiotic stop dates for ten (10) of twenty eight (28) residents. Review of the facility Agenda for Quality Assurance (QA) Meeting Minutes, undated, revealed pharmacy was expected to attend meetings; however, no agenda item for antibiotic stewardship was included. Further review of the Quality Assurance/Performance Improvement Committee Agenda and Minutes sign in sheet, dated 09/13/18, revealed pharmacy did not attend the meeting. Interview with the Assistant Director of Nursing (ADON), Infection Control Nurse, on 09/13/18 at 11:21 AM, revealed she was responsible for the Antibiotic Stewardship Program. She stated she did not review laboratory reports, but she reviewed Physician's Orders for antibiotics. She further stated she kept no tracking of start and stop dates for residents on antibiotics nor did she track signs and symptoms of residents with infections. The ADON stated she did not receive an antibiogram or any other information from the laboratory. She further stated during Quality Assurance and Performance Improvement Committee meetings the pharmacist reviewed how many antibiotics were prescribed to residents, but no other antibiotic stewardship information was presented. Interview with the Director of Nursing (DON), on 09/13/18 at 4:18 PM, revealed the ADON was responsible for the Antibiotic Stewardship Program. She stated it was important to track all infections to identify patterns and implement interventions to prevent the transmission of infectious disease. She further stated she realized some residents in the facility were on antibiotics for extended time periods. The DON stated the staff used an SBAR form (Form used to communicate medical concerns from the nurse to providers. The acronym means Situation, Background, Assessment and Recommendation) to notify providers of new signs and symptoms of resident infections. Per interview, the nurse then recorded residents on antibiotics on the Antibiotic Tracking Log. She stated she was unaware of any prescribing protocols to optimize antibiotic usage. She was also unaware of the lack of culture results to support antibiotic use for twenty six (26) of twenty eight (28) residents. Interview with the Administrator, on 09/13/18 at 5:29 PM, revealed protocols for antibiotic prescribing were not included in the policies utilized by the facility for antibiotic stewardship as these were older policies. He stated the Antibiotic Stewardship Program was important to the facility to ensure residents were treated for infections appropriately and to prevent the development of resistant organisms. He further stated the ADON was responsible for the organization and function of the Antibiotic Stewardship Program, and the Medical Director's role was to assist with inappropriate antibiotic usage although he did not recall any time when that had been necessary. Further interview revealed the facility's QA was not effectively tracking infections and antibiotic usage. The Administrator acknowledged the facility did not have an effective antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use.