**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, it was determined that the facility failed to provide services that met professional standards of quality for one (1) of twenty (20) sampled residents (Resident #65). Record review revealed a physician's order dated 06/28/19 to discontinue a protein nutritional supplement. However review of the monthly orders for June and July 2019 revealed the protein supplement had continued to be administered. The findings include: Review of the policy titled Protocol for Physician Orders, no date, revealed that any new physician's order received will be noted and transcribed to the appropriate place and the orders shall be followed accordingly until changed; e.g., Medication Administration Record (MAR), and Treatment Administration Record (TAR), etc. Observation on 07/25/19 at 2:00 PM revealed that Licensed Practical Nurse (LPN) #1 administered a protein nutritional supplement to Resident #65. Review of the record revealed the resident was admitted on [DATE] with diagnoses that include Aphasia, Gastrostomy, and Dysphagia. Record review further revealed that a physician's order had been written to discontinue the protein nutritional supplement on 06/28/19. Further review of the record revealed that although the supplement had been discontinued, the order remained on the July 2019 monthly orders. Further review of the MAR for 07/01/19 revealed the protein nutritional supplement had been given three (3) times a day up to 07/25/19. Interview on 07/25/19 at 3:40 PM with LPN #1 revealed that she was new to working with Resident #65 and was unaware that the protein nutritional supplement had been discontinued; therefore, she administered the supplement. Interview on 07/25/19 at 3:47 PM with Registered Nurse (RN) #2 revealed that she was the nurse to take off the new order that stated to discontinue the protein nutritional supplement. However, she stated that she did not transcribe the order nor did she remove the order from the MAR. RN #2 stated that she should have followed up with the order and transcribed it herself. Interview on 07/25/19 at 3:55 PM with RN #1 revealed she was the Unit Manager and stated there was a process to verify that orders from the previous day have been transcribed properly. RN #1 stated that she had not identified any concerns, that this was an oversight. Interview on 07/25/19 at 4:26 PM with the Director of Nursing (DON) revealed there is a process for transcribing physician's orders and that she had not identified any concerns related to the transcription of orders up to this time and that this was an oversight.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of twenty (20) sampled residents (Resident #65) received treatment and services to prevent complications of enteral feeding. Observation on 07/25/19 at 2:00 PM revealed that Licensed Practical Nurse (LPN) #1 gave medications through a gastrostomy tube (G-tube) and failed to flush the G-tube prior to administering the medications. The findings include: Review of the facility policy titled Medication Administration Policy, undated, revealed that G-tubes should be flushed with at least 30 cubic centimeters (cc) of water before and after completing the medication administration. Observation of medication administration on 07/25/19 at 2:00 PM for Resident #65 revealed LPN #1 administered the following medications: Lisinopril 2.5 milligrams (mg) (medication for blood pressure), Metoprolol 25 mg (medication for blood pressure), Multi-Vitamin tablet, Nexium 40 mg (medication to treat gastroesophageal reflux disease), and Hydrocodone/APAP 5/325 mg (medication to treat pain). Further observation revealed that LPN #1 did not flush the G-tube with 30 cc of water prior to administering the medication per facility Medication Administration Policy. Interview conducted with LPN #1 on 07/25/19 at 4:00 PM revealed she should have flushed the G-tube with 30 cc of water. LPN #1 stated she was nervous and forgot to flush the G-tube. Interview conducted with the Director of Nursing (DON) on 07/25/19 at 4:10 PM revealed that the LPN should have flushed the G-tube before giving medications with 30 cc of water and afterwards. She further revealed that she had not had any concerns before this issue occurred.

Based on observation, interview, record review, and review of the facility policy, it was determined the facility failed to maintain an effective infection control and prevention program for one (1) of twenty (20) sampled residents (Resident #136). Observation of Resident #136 revealed staff served a meal tray to the resident after touching her own hair multiple times. State Registered Nurse Aide (SRNA) #1 did not wash her hands before serving the meal tray. Staff then proceeded to prepare the resident's meal tray by opening the corn on the cob that was wrapped in aluminum foil and applying butter. Staff also continued to touch other food items on the resident's tray without washing/sanitizing her hands. The findings include: Review of the facility's Guidelines For Hand hygiene policy, undated, revealed that indications for hand washing included that before eating, staff wash their hands with a non-antimicrobial soap and water or with an antimicrobial soap and water. Review of the facility's Meal Pass Tips policy, undated, revealed that hands should be washed and sanitized between meal trays. Review of Resident #136's medical record revealed the facility admitted the resident on 07/17/19 with diagnoses that included Atherosclerotic Heart Disease, Dementia, Essential Primary Hypertension, and Gastro-Esophageal Reflux Disease. Review of Resident #136's Plan of Care, revealed the resident required the assistance of staff to set up meal trays. Observation of Resident #136 on 07/23/19 at 12:05 PM, revealed SRNA #1 was providing meal service to residents. As SRNA #1 walked down the hall to the meal cart to retrieve a meal tray, SRNA #1 was observed brushing her hair back with her ungloved hands multiple times before providing meal service. SRNA #1 retrieved a tray from the meal cart and delivered it to Resident #136. SRNA #1 did not wash or sanitize her hands after touching her hair multiple times. Further observations revealed SRNA #1 prepared Resident #136's food by opening the corn on the cob and putting butter on the corn and opened other packages for the resident that were on the resident's tray without washing or sanitizing her hands. An interview with SRNA #1 on 07/23/19 at 12:20 PM, confirmed she did not wash or sanitize her hands before setting up Resident 136's meal tray. The SRNA stated she was aware she should have washed her hands prior to setting up the meal tray and that she was unaware that she had touched her hair. SRNA #1 stated she guessed she did it out of habit. Interview with the Director of Nursing on 07/25/19 at 3:00 PM, revealed that SRNAs received infection control training upon hiring, every six (6) months, annually, and as needed. She stated the Handwashing Observation Tool training form had been completed by SRNA #1 on 06/27/19. She then stated SRNA #1 should have washed her hands before and after serving a resident's meal tray. The Director of Nursing stated SRNA #1's practice was a break in the infection control process because she was touching her hair and did not wash her hands. She also revealed she had no concerns prior to this incident.