**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility policy review, it was determined the facility failed to maintain an effective pest control program to ensure the facility remained free of pests. Observations conducted from 01/21/2020 through 01/24/2020, revealed flying insects throughout the building, which included resident rooms 105, 106, 107, 108, 110, 111, 117, 120, 121,122, 124, 127, and 129. In addition, observations revealed the flying insects in the facility's corridors and kitchen area. The findings include: Review of the facility's policy titled, Pest Control, revision date of May 2008, revealed the facility maintained an effective pest control program. Continued review revealed pest control services were provided by a contracted vendor. Per the policy, the facility's maintenance services assisted, when appropriate and necessary, in provision of pest control services. Review of the facility's policy titled, Quality of Life, Homelike Environment, revised date of May 2017, revealed residents were to have a safe, clean, and comfortable environment. Per the policy, a clean, sanitary, and orderly environment was the desired characteristics for the facility. Review of the Commercial Pest Management Service Agreement, revealed services were initiated May 2019, and extended through May 2020. Review revealed the Agreement automatically renewed unless the facility allowed it to expire. Per the Agreement, flying insects were in the pest exclusions section, signed and dated 05/01/2019. Continued review revealed the Agreement service specifications and instructions included general pest control for the nursing home (facility), to include service in the kitchen, dining room, and laundry room areas on a monthly basis. In addition, the Agreeement revealed services were to be provided in individual rooms on an as needed basis. Review of the Pest Control Vendor's Details of Service document, dated 11/20/2019, revealed food debris was found on the wall outside of the dish room window, as documented in the service observations section. In addition, the Pest Control Vendor's Details of Service document also revealed the vendor's observation identified food debris were on the baseboards, and service provider documented this was a breeding environment for fruit flies. Review of the Pest Control Vendor's Details of Service document, dated 01/16/2020, revealed the service provider had documented in the service observations that food debris was identified on the wall outside of the dish room window. In addition, the Vendor's service provider noted food debris was identified against the baseboards. Per review of the Pest Control Vendor's Details of Service document the service provider had documented the food debris was a breeding environment for fruit flies. Observation, on 01/21/2020 at 11:56 AM, revealed numerous large flying insects flew in and out of the sink for room one hundred and twenty-nine (129). The large flying insects flew into the surveyor's mouth with the in section of the sink. Observation, on 01/21/2020 at 11:59 AM, revealed the north hallway contained copious large flying insects in the open area of the hall. Further, observation revealed staff swiped at the bugs during medication pass. Observation, on 01/21/2020 at 12:16 PM, revealed resident room number one hundred and eleven (111) bathroom light fixture contained numerous dead black objects. Observation, on 01/21/2020 at 12:29 PM, revealed resident room one hundred and seven (107) bathroom light fixture contained numerous black objects with wing like texture to the side. Observation, on 01/21/2020 at 12:30 PM, revealed resident room one hundred and five (105) bathroom light fixture contained numerous black objects with wing like texture to the side. Observation of resident room [ROOM NUMBER], on 01/21/2020 at 11:04 AM, revealed two (2) tiny, flying insects (which had the appearance of being gnat like) in the room. Observation of resident room [ROOM NUMBER], on 01/21/2020 at 11:19 AM revealed a black flying insect landed on the lavatory (sink) in the resident's room. Interview with Resident #40 while seated in his/her recliner, in room [ROOM NUMBER], on 01/21/2020 at 11:19 AM, revealed he/she did not like bugs being in his/her room. Resident #40 stated he/she was fearful of bugs. Continued observations of room [ROOM NUMBER] and 108's shared bathroom, on 01/21/2020 at 11:19 AM, revealed a dark colored insect on the bathroom wall, near the ceiling corner. Observation in the corridor, near the entrance of room [ROOM NUMBER], on 01/21/2020 at 11:58 AM, revealed a black flying insect in the hallway. Observation of the dining room drop lighting fixtures, on 01/21/2020 12:42 PM, revealed six (6) of the eight (8) light fixtures contained what appeared as dead insects in the fixtures. Observation of resident room [ROOM NUMBER], on 01/21/2020 at 2:29 PM, revealed two (2) black winged bugs located on the privacy curtain located at the entrance to the room. Observation of resident room [ROOM NUMBER], on 01/22/2020 at 8:45 AM and at 9:06 AM, revealed flying insects in the room. Observation of resident room [ROOM NUMBER], on 01/22/2020 at 8:50 AM, revealed winged insects located on the bathroom door. Continued observation revealed additional winged insects flew out of the bathroom as the resident re-entered his/her room from the bathroom. Observation of resident room [ROOM NUMBER], on 01/21/2020 at 11:04 AM, revealed two (2) flying insects (which appeared gnat like) in the resident's room. Further observation of resident room [ROOM NUMBER], on 01/22/2020 at 08:57 AM, revealed a black flying insect which had landed on the ceiling. Interview with Resident #28, who resided in room [ROOM NUMBER], during the Resident Council meeting, on 01/22/2020 at 1:39 PM, revealed the resident had experienced gnats flying into his/her mouth while he/she was sleeping. Continued interview revealed Resident #28 stated it was terrible when the gnats had flown into his/her mouth. Per interview, the resident stated he/she had spit the gnats out, and rinsed his/her mouth. According to Resident #28, he/she had told the nurse about the gnats, and asked her to do something about it. Further interview revealed however, the nurse never returned to do anything about the gnats. In addition, Resident #28 stated I have to try to keep my mouth closed to keep the gnats out of my mouth. Interview with Resident #38 during the Resident Council meeting, on 01/22/2020 at 1:39 PM, revealed he/she continued seeing gnats in the building. Interview with Resident #127 during the Resident Council meeting, on 01/22/2020 at 1:39 PM, revealed the gnats were still in his/her room. Interview with Resident #23 during the Resident Council meeting, on 01/22/2020 at 1:39 PM, revealed the gnats were also in his/her room. Observations in the bathroom of resident room [ROOM NUMBER], on 01/23/2020 at 8:51 AM, revealed four (4) insects, flying from the waste container, and into the toilet bowl area. Continued observation revealed flying insects landed on the ceiling, and upper walls in the bathroom. Further observation revealed a strong, urine-like odor was in the bathroom. In addition, observation revealed the sealer on the floor around the base of the toilet bowl was discolored with dried orange, yellow, and brown stains. Interview with Certified Nursing Assistant (CNA) #3, on 01/23/2020 at 8:55 AM, revealed gnats were frequently found in the bathroom of resident room [ROOM NUMBER]. She stated the gnats were an ongoing issue in the residents' room. Per interview, the bathroom smelled of urine, which did not help the situation with the gnats. Further interview revealed housekeeping staff cleaned the resident bathrooms every day, but the urine smell stayed. Interview with Registered Nurse (RN) #1, on 01/23/2020 at 9:15 AM, revealed there were gnats continually flying around inside the facility. She stated the gnats were usually in the sink areas. According to RN #1, she and other staff usually let the housekeepers know about where the gnats were located and they cleaned up those areas. She reported the facility had a resident friendly spray the housekeeping or maintenance staff used to get rid of the gnats. Further interview revealed she had seen many gnats during the holiday season with all the fruit present. Observation of resident room [ROOM NUMBER], on 01/23/2020 at 9:30 AM, revealed flying insects located on the curtains. Continued observations revealed resident rooms 124, 125 and 126 also had flying insects located within the rooms. In addition, observation of resident room [ROOM NUMBER] revealed the bathroom light fixture contained an which appeared as dead. Interview with Housekeeper (HSKP) #1, on 01/23/2020 at 10:25 AM, revealed the facility had an ussue with gnats. She stated if cited she would spray the area and then she notified her supervisior. Interview with the Housekeeping Supervisor, while in the soiled utility room, on 01/23/2020 at 10:25 AM, revealed gnats were here and there throughout the facility. She revealed the housekeepers and herself had sprayed for the insects in attempt to get rid of them. Per interview, she only used the spray for the gnats when residents were not in the same location. Interview with HSKP #2 on 01/23/2020 at 10:35 AM, revealed she cleaned offices, the lobby, the Nurse's Station, and resident rooms. She stated she did see a few gnats in the facility. Per interview, she had a product they used on the flying insects when she saw them. According to HSKP #2, she had seen the gnats in resident rooms before. Continued interview revealed she had not reported anything about the flying insects, she had observed in the facility, in the maintenance binder located at the Nurse's Station. She stated she just tried to take care of the situation herself when she saw the gnats flying around. Further interview revealed she had not documented in the maintenance binder when other staff had also reported seeing the flying insects. Telephonic interview with Licensed Practical Nurse (LPN) #6, on 01/24/2020 at 11:07 AM, revealed she frequently took care of the residents residing in resident room [ROOM NUMBER]. She stated the bathroom in room [ROOM NUMBER] had both odors and gnats located there. In addition, she stated she worked nights and had not seen anyone spraying for gnats on night shift. Observation during the environmental tour on 01/24/2020 at 2:30 PM, revealed the dish washroom had flying insects located in it. Continued observation revealed a pan which contained water located under the dishwasher drain pipe. Interview with the Administrator on 01/24/2020 at 4:31 PM, revealed the facility currently had a pest control contract. He stated they were aware resident rooms had gnats and bugs present. He stated they had especially had a problem during the holiday season with the gnats, as there was more fresh fruit in the building at that time. According to the Administrator, the facility had not be able to identify the source or cause of the gnats.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, it was determined the facility failed to implement the care plan for one (1) of twenty-one (21) sampled residents, Resident #1, related to falls. The findings include: Review of the facility's policy, Comprehensive Person-Centered Care Plans, revised December 2016, revealed each resident's care plan would be consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to receive the services and/or items included in the plan of care. The policy revealed the care plan would describe the services that would be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Record review revealed the facility admitted Resident #1 on 10/19/17, with diagnoses to include Alzheimer's Disease and Type 2 Diabetes Mellitus. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident required extensive assistance with transfers. Review of a Fall Investigation, dated 10/08/18, revealed Resident #1 fell on [DATE] in another resident's room when he/she attempted to transfer from the wheelchair to the bed. There had been two (2) other falls in other resident rooms, on 09/23/18 and 08/31/18. The investigation into all three (3) falls indicated the resident was unsupervised when the falls occurred. Review of Nurses' Notes revealed Resident #1's falls occurred on 08/31/18 at 2:00 PM, 09/23/18 at 9:30 AM, and 10/06/18 at 8:40 PM. Review of the Care Plan for Resident #1, dated 06/22/18, revealed the resident was at risk for elopement with an intervention to check the location of the resident frequently. The Falls Risk Care Plan, dated 11/05/18, revealed the resident was at risk for falls related to attempts to transfer unassisted. The care plan included an intervention, initiated on 11/16/18, to redirect the resident away from other resident rooms to easily observed areas. Observation, on 12/05/18 at 10:09 AM, revealed Resident #1 was not in his/her room and the Certified Nursing Assistant (CNA) did not know where the resident was. Interview, on 12/06/18 at 1:35 PM, with CNA #5 revealed Resident #1 was a fall risk and staff placed a wheelchair alarm to alert staff when he/she tried to stand from the chair unassisted. The CNA stated staff seated the resident near the nurses' station because he/she wandered and there was usually someone there to keep an eye on him/her. She revealed there was a CNA hall partner to monitor all residents on the hall when a CNA was off the unit during breaks. She revealed it was difficult to monitor all the residents when she was alone on the hall. She stated she looked at the care plans to determine if residents were at risk for falls. Interview, on 12/06/18 at 2:20 PM, with CNA #4 revealed she checked on Resident #1 typically every hour or two (2). In addition, CNA #4 stated the hall partner and the nurse were responsible for monitoring her assigned residents while she was on break. She stated it was important to monitor residents to prevent falls. The CNA stated interventions to prevent falls were listed on the care plan. Interview, on 12/06/18 at 2:42 PM, with the CNA Team Leader revealed she was not aware of any trends related to Resident #1's falls. According to the Team Leader, staff tried to ensure the resident was in a well-observed area such as the nurses' station, but there was not always someone at the nurses' station and sometimes he/she just wheeled off. The Team Leader stated she monitored care plan interventions were implemented by going room-to-room and ensuring safety equipment, cushions, mattresses, and boots were in place. Interview, on 12/06/18 at 3:12 PM, with Licensed Practical Nurse (LPN) #2 revealed Resident #1 wandered the hallways and into other resident rooms. The LPN stated she monitored Resident #1 while she documented at the nurses' station or passed medication. According to LPN #2, it was important to monitor Resident #1 to prevent potential falls and stated the facility did not follow the care plan related to monitoring of the resident. Interview, on 12/06/18 at 3:35 PM, with the Unit Manager (UM) revealed staff attempted to keep Resident #1 near the nurses' station because he/she wandered into other resident rooms. According to the UM, Resident #1 was fast and could not be monitored every second. Interview, on 12/06/18 at 3:56 PM, with the Director of Nursing (DON) revealed staff monitored Resident #1's whereabouts frequently and redirected him/her as needed. The DON revealed she had not identified any concerns related to monitoring the resident to prevent falls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility's policy, Medication Administration-General Guidelines, revised 12/18/12, revealed medications were administrated in accordance with written orders of the attending physician and once a medication was removed from a package or container, unused doses should be discarded. Further record review revealed Resident #1's Annual MDS, dated [DATE], revealed the facility assessed Resident #1 with a Brief Interview for Mental Status (BIMS) score of five (5) of fifteen (15) and determined the resident was not interviewable. Review of Resident #1's Physician Order, dated 11/25/18, revealed an order for Miconazole (antifungal) Nitrate 2% Powder to the peri area every shift and as needed to maintain skin integrity. Review of Resident #1's Medication Administration Record (MAR), dated December 2018, revealed an order, with a start date of 11/26/18, for Desenex 2% Powder (antifungal), apply topically to peri area every shift and as needed (for external use only). Further review of Resident #1's Care Plan, updated 11/25/18, revealed the resident's peri area was noted as red related to moisture with a goal to maintain skin integrity. Interventions included applying antifungal Miconazole Nitrate 2% powder to the peri area every shift and as needed. Observations of Resident #1's bathroom, on 12/04/18 at 2:30 PM and 12/05/18 at 10:09 AM, revealed a small clear medication cup containing white powder with peri groin marked on it located on top of the sharps container that was secured to the wall. LPN #2 was alerted by the surveyor and the LPN removed the medication cup from Resident #1's bathroom. LPN #2 identified the white powder in the medication cup as Miconazole Nitrate. Interview with CNA #6, on 12/05/18 at 10:18 AM, revealed she had not identified the medication cup in Resident #1's bathroom. She stated she assisted Resident #1 to the bathroom, as well as the resident used the bathroom on his/her own. Interview with LPN #2, on 12/05/18 at 10:25 AM, revealed she did not provide care to the resident on 12/04/18 when the medication cup was found in Resident #1's bathroom; however, LPN #5 worked that day and was responsible for medication administration for Resident #1. Additionally, she stated residents that had access to the bathroom could have ingested the medication and it could have caused harm. Interview with the Staff Development Nurse, on 12/06/18 at 8:59 AM, revealed on 10/18/18 at 3:00 PM, a medication administration training was scheduled but was cancelled by their contract pharmacist. Continued interview revealed LPN #5 completed new employee orientation on 11/08/18. She stated LPN #5 forgot to discard the medication in the bathroom, which was a human error. She stated she provided medication administration in-services annually. Review of LPN #5's LPN Competency Skills Checklist, dated 11/08/18, revealed she successfully performed transcribing and administering medications according to the facility policy and procedures. Interview with the Regional Director of Clinical Services, on 12/06/18 at 9:23 AM, revealed medication administration should be performed according to the medication administration policy. Interview with the DON, on 12/06/18 at 3:32 PM, revealed she contacted LPN #5 at home on [DATE], and the LPN told her she pulled Resident #1's medication, entered the resident's room, assisted the resident to the bathroom, applied some of the powder to the resident's perineal area, then placed the medication cup on the sharps container. LPN #5 further revealed she forgot to discard the medication cup after placing the resident in the bed. Interview with the Administrator, on 12/06/18 at 09:16 AM, revealed the facility had not identified any issues with medication administration. He expected medications to be administered and disposed of properly. Further interview revealed LPN #5 was toileting Resident #1 in the bathroom and the medication was accidentally left in the bathroom. 3. Review of the facility's policy, Oxygen Administration, dated October 2010, revealed the following equipment and supplies were necessary when performing this procedure: portable oxygen cylinder (strapped to the stand); nasal cannula, nasal catheter, mask (as ordered); humidifier bottle; No Smoking/Oxygen in Use signs; regulator; and personal protective equipment (e.g., gowns, gloves, mask, etc., as needed). Record review for Resident #24 revealed the facility admitted the resident on 06/06/17, and the resident had a diagnosis of Acute Upper Respiratory Infection. Review of Resident #24's Physician Order, dated 11/12/18, revealed supplemental oxygen at 2 liters (L) per minute via nasal cannula as needed to keep the resident's blood oxygen saturation above 90%. Observation, on 12/06/18 at 11:04 AM, revealed Resident #24 resting in bed receiving oxygen per nasal cannula. There was no signage at the doorway or within view of the entryway to the resident's room to alert staff and visitors of oxygen usage in the resident's room. Record review revealed the facility admitted Resident #153 on 11/13/18, with a diagnosis of Pneumonia. Review of a Physician Order, dated 11/13/18, revealed oxygen at 2L per minute per nasal cannula, continuous. Observation and interview, on 12/04/18 at 9:02 AM, with Resident #153 revealed he/she had been on oxygen for years and was utilizing oxygen during the interview. There was no sign on the resident's doorway alerting staff and visitors that oxygen was in use. Observation of Resident #153's room, on 12/04/18 at 11:38 AM, revealed an oxygen concentrator in the room; however, no signage alerting staff or visitors regarding the use of oxygen was within view of the entryway to the resident's room. Resident #153 entered his/her room in a wheelchair with portable oxygen attached. Record review revealed the facility admitted Resident #7 on 02/25/12, with diagnoses that included Congestive Heart Failure (CHF), Toxic Encephalopathy, and Rhabdomyolysis. Review of Resident #7's December 2018 Physician Orders revealed the resident was ordered oxygen at 2L/minute per nasal cannula to maintain oxygen saturations above 88%, as needed. Observation, on 12/04/18 at 8:51 AM, 12/05/18 at 10:12 AM, and 12/06/18 at 11:02 AM, revealed Resident #7 in bed with oxygen administered by nasal cannula; however, there was no oxygen sign posted at the doorway to the resident's room. Interview with LPN #2, on 12/06/18 at 11:07 AM, revealed there should have been an oxygen sign posted at Resident #7's door, per facility policy. Resident #7 had been receiving oxygen since the start of LPN #2's employment, March 2018, and she had not noticed there was no oxygen sign posted on the door. Further interview revealed nursing staff was responsible for setting up the resident's oxygen and placing the oxygen sign on the door. Interview with the DON, on 12/06/18 at 11:09 AM, revealed Resident #7 did have an oxygen sign posted at the door at one time. The DON stated there should have been an oxygen sign posted at Resident #7's door at all times, per facility policy. Interview with the Administrator, on 12/06/18 at 11:13 AM, revealed nursing staff was responsible for ensuring the oxygen sign was posted on the door. The Administrator further stated the Maintenance Director had been painting in the 100 hallway recently. Interview with the Maintenance Director, on 12/06/18 at 11:20 AM, revealed he removed the oxygen signs from resident rooms last week while he painted the outside doorframes and did not reapply them. Based on observation, interview, record review, and facility policy review, it was determined the facility failed to prevent accidents and hazards for four (1) of nine (9) sampled residents, Resident #1, #7, #24, and #153. The facility failed to supervise Resident #1 to prevent falls and failed to ensure medicated cream was not left in the resident's bathroom, accessible to residents. Resident #7, #24, and #153 received oxygen therapy and the facility failed to ensure a No Smoking/Oxygen in Use sign was posted on the entryways of the residents' rooms to alert staff and visitors that oxygen was in use. The findings include: 1. Review of the facility's policy, Fall Risk Assessment, revised March 2018, revealed staff, with the support of the attending physician, would evaluate functional and psychological factors that may increase fall risk, including ambulation, mobility, gait, balance, excessive motor activity, Activities of Daily Living (ADL) capabilities, activity tolerance, continence, and cognition. The policy further revealed staff and the attending physician would collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that were not modifiable. Review of the facility's policy, Managing Falls and Fall Risk, revised March 2018, revealed based on previous evaluations and current data, staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. Review of the clinical record revealed the facility admitted Resident #1 on 10/19/17, with diagnoses of Alzheimer's Disease and Type 2 Diabetes Mellitus. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident required extensive assistance of two (2) staff for transfers. Per the MDS, the resident had no falls since the previous assessment. Review of a Fall Investigation for Resident #1, dated 10/08/18, revealed the resident attempted to transfer unassisted from the wheelchair to the bed, in another resident's room, on 10/06/18, and fell. Continued review of fall investigations for Resident #1 revealed he/she had two (2) previous falls in other resident rooms, on 09/23/18 and 08/31/18. Review of Resident #1's Nurses' Notes revealed the resident fell on [DATE] at 2:00 PM, on 09/23/18 at 9:30 AM, and on 10/06/18 at 8:40 PM. Review of the Care Plan, dated 06/22/18, revealed Resident #1 was at risk for elopement and included an intervention to check his/her location frequently. In addition, the resident was at risk for falls related to attempts to stand, transfer, or walk alone unsafely, Dementia, gait problems, history of falls, impaired judgement, and impaired safety awareness. The care plan included an intervention, initiated 11/16/18, to redirect the resident away from other resident rooms to easily observed areas. Observation of Resident #1's room, on 12/05/18 at 10:09 AM, revealed Resident #1 was not in his/her room and the Certified Nursing Assistant (CNA) did not know where the resident was. Interview with CNA #5, on 12/06/18 at 1:35 PM, revealed Resident #1 was a fall risk and had a wheelchair alarm to let staff know when he/she tried to stand from the chair unassisted. The CNA stated the resident also wandered and staff seated him/her near the nurses' station because there was usually someone there to keep an eye on him/her. She revealed the facility assigned two (2) CNAs to a hall and the hall partner was responsible for monitoring all residents on the hall when the other CNA took a break. She stated she did not feel she could adequately monitor the residents when she was alone on the hall. Interview with CNA #4, on 12/06/18 at 2:20 PM, revealed she typically took breaks after resident meals and signed out on a sheet kept at the nurses' station. The CNA stated the hall partner and the nurse were responsible for monitoring her assigned residents while she was on break. She stated it was important to monitor residents to prevent falls. Interview with the CNA Team Leader, on 12/06/18 at 2:42 PM, revealed CNAs were responsible for signing out and notifying the nurse and hall partner when taking a break. The Team Leader stated she did not review the break sign out sheets and turned them in to the Director of Nursing (DON). She stated she participated in the interdisciplinary team (IDT) standards of care meeting and was not aware of any trends related to Resident #1's falls. According to the Team Leader, staff tried to keep the resident in a well-observed area such as the nurses' station, but there was not always someone at the nurses' station and sometimes the resident just wheeled off. Interview with Licensed Practical Nurse (LPN) #2, on 12/06/18 at 3:12 PM, revealed Resident #1 wandered the hallways and into other resident rooms. The LPN stated the CNAs were busy answering call lights and getting residents to bed so she monitored Resident #1 while she documented at the nurses' station or passed medication. Additionally, LPN #2 revealed it was important to monitor Resident #1 to prevent a potential fall. Interview with the Unit Manager (UM), on 12/06/18 at 3:35 PM, revealed Resident #1 had chair/bed alarms due to frequent falls and wandering in the halls, including other resident rooms. She stated staff attempted to keep the resident at the nurses' station when he/she was out of bed. The UM revealed the falls recorded for Resident #1 occurred in other residents' rooms when he/she attempted to get into their bed. According to the UM, Resident #1 was fast and could not be monitored every second. Interview with the Director of Nursing (DON), on 12/06/18 at 3:56 PM, revealed staff monitored Resident #1's whereabouts frequently and redirected him/her as needed. The DON stated she had not identified any trends related to the times of Resident #1's falls and was not aware of any issues related to staffing during breaks or shift change. She revealed CNAs were responsible for notifying the nurse and hall partner when leaving for break. She stated the facility used the break sign out sheet as an extra communication tool and CNAs did not always sign out. The facility did not provide a copy of the CNA break sign out sheets.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to maintain an effective infection control program related to hand hygiene during wound care for one (1) of twenty-five (25) sampled residents, Resident #45. The findings include: Review of the facility's policy, Wound Care, dated October 2010, revealed the purpose of the procedure was to provide guidance for the care of wounds to promote healing. Steps in the procedure included washing hands thoroughly and donning gloves before treatment, and using a sterile tongue blade and applicators to remove ointments and creams from containers. In addition, staff was to wear sterile gloves when physically touching a wound, or holding a moist surface over a wound. Review of the facility's policy, Handwashing/Hand Hygiene, dated August 2015, revealed the facility considered hand hygiene the primary means to prevent the spread of infections. All staff was to follow hand washing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Further review of the policy revealed staff was to wash hands with soap and water or use alcohol based hand rub at multiple times including: before and after direct contact with residents; before donning sterile gloves; and before handling clean or soiled dressings, gauze pads, and additional items, (wound treatment materials including wipes used to clean). Additionally, staff was to wash hands before moving from a contaminated body site to a clean body site during resident care; after contact with resident's intact skin; and after handling used dressings and contaminated equipment. In addition, hand washing occurred after contact with objects in the immediate vicinity of the resident. Review of Physician Orders for Resident #45 revealed an order, dated 11/30/18, to discontinue house barrier cream and apply Magic Butt Cream to the peri area and buttock with each incontinent episode and each shift. Review of the Initial Wound Evaluation and Management Summary, dated 12/04/18, revealed the physician noted an open sheer wound was present to Resident #45's gluteal cleft. Observation, on 12/05/18 at 9:35 AM, revealed Licensed Practical Nurse (LPN) #1 completed a treatment to Resident #45's buttock, including gluteal cleft. The LPN, with gloved hands, pulled the privacy curtain, held a jar of Magic Butt Cream with her left gloved hand, and wiped the resident's gluteal cleft with an incontinence-cleansing wipe with her right gloved hand. The LPN discarded the used wipe, opened the jar with both gloved hands, held the jar of cream with her right gloved hand, and used her left gloved hand and dipped fingers into the jar and applied the cream to the resident's buttock and gluteal cleft. The LPN did not perform hand hygiene or change gloves after touching the curtain or the jar of Magic Butt Cream. In addition, the LPN did not perform hand hygiene before cleaning the wound on Resident #45's gluteal cleft. LPN #1 did not perform hand hygiene or change her gloves before dipping her gloved fingers into the jar of cream and applying it to the resident's open wound. Interview with LPN #1, on 12/5/18 at 9:40 AM, revealedthere was an open area of skin in the resident's gluteal cleft. The LPN stated she did not remove her gloves, wash her hands, and don clean gloves after cleaning the resident's gluteal cleft and before applying the Magic Butt Cream to the open skin on Resident #45's gluteal cleft. LPN #1 stated she contaminated the gloves she wore when she touched the privacy curtain, held the jar of Magic Butt Cream, and wiped the resident's gluteal cleft. The LPN further stated she contaminated the cream in the jar when she dipped her fingers into the jar. In addition, she stated she contaminated the resident's open wound when she applied the Magic Butt Cream to the wound without performing hand hygiene and changing gloves first. The LPN stated Resident #45 was a diabetic, and contamination of an open wound could lead to the resident developing a skin ulcer and infection. Interview, on 12/06/18 at 8:27 AM, with the Infection Prevention Nurse (IPN) revealed nurses should perform hand hygiene at several points while providing a treatment to a resident, including immediately before beginning the treatment, and whenever hands encounter contaminated surfaces. The IPN further stated LPN #1 contaminated her gloves when she closed the privacy curtain, held the Magic Butt Cream jar, and cleaned the resident's wound and gluteal cleft with a wipe, then held the jar with the same hand. She further stated when LPN #1 dipped her gloved fingers into the jar of Magic Butt Cream without performing hand hygiene and donning new gloves, she contaminated the cream. The IPN stated she preferred nurses use a tongue blade or applicator to get medicated creams and ointments out of jars, place the creams in a clean medication cup, and then use an applicator to apply the creams to the resident's skin. The IPN stated when LPN #1 applied the cream to the resident's wound; the LPN transferred any organisms that were on the curtain and the jar. She stated contaminating the wound could lead to the resident developing an infection, sepsis, and could result in death. Interview, on 12/06/18 at 9:34 AM, with the Wound Nurse revealed nurses were to perform hand hygiene by washing hands and changing gloves after they contacted any contaminated surfaces, and before completing treatments to resident's skin. She stated staff not performing hand hygiene could lead to cross contamination, which could introduce germs and cause infection, worsening an infection, or deterioration of the wound. Interview, on 12/06/18 at 1:59 PM, with the Director of Nursing (DON) revealed staff should follow facility policies related to hand hygiene. She stated nurses should wash hands before donning gloves, when they removed gloves, and after touching anything soiled or potentially contaminated, after providing direct care to a resident, and at other times as stated in the facility policies. She stated nurses should always wash hands and don new gloves in preparation for wound care. She further stated nurses should not touch anything with a gloved hand before using the gloved hand to apply ointment to a resident's skin. The DON stated she preferred nurses to wash hands, don clean gloves, and use a clean applicator, like a tongue depressor or cotton tipped applicator, to apply ointment. She additionally stated a nurse with gloved hands should not touch a curtain, hold a jar of medicated cream, and then touch a resident's wound. She stated the nurse should have stopped to perform hand hygiene before applying the cream, and when the nurse did not do so, the nurse transferred bacteria and contaminated the wound. The DON stated the contaminated wound could result in an infection; deterioration of the wound, decline in the resident's condition, or the resident could develop sepsis or worse outcomes. Interview, on 12/06/18 at 2:26 PM, with the Administrator revealed he referred to the in-services and competency training for hand hygiene during wound care, provided through nursing. In addition, all staff should practice good hand hygiene as stated in the facility policies and trainings to help prevent the spread of infection.

Based on interview, record review, and review of the Resident Assessment Instrument (RAI) 3.0 User's Manual, it was determined the facility failed to submit the Minimum Data Set (MDS) assessments to the Centers for Medicare and Medicaid Services (CMS) within the required timeframe for twelve (12) of thirty-five (35) residents, Resident #1, #2, #3, #4, #15, #24, #28, #41, #46, #51, #200, and #153. The findings include: Interview with the MDS Coordinator, on 12/05/18 at 3:30 PM, revealed the facility did not have a policy related to completing MDS assessments, but the facility followed the RAI guidelines. Review of the RAI 3.0 User's Manual, Version 1.16, dated October 2018, Chapter 5 Submission and Correction of MDS Assessments, revealed comprehensive assessments must be transmitted electronically within fourteen (14) days of the Care Plan Completion Date (V0200C2 + 14 days). All other MDS assessments must be submitted within fourteen (14) days of the MDS Completion Date (Z0500B + 14 days). Entry and Death in Facility tracking records, information must be transmitted within fourteen (14) days of the Event Date (A1600 + 14 days for Entry records and A2000 + 14 days for Death in Facility records). Review of the CMS Submission Report, MDS 3.0 NH Final Validation Report, dated 12/04/18, revealed twelve (12) of thirty-five (35) MDS records were transmitted late. The facility received warning error message -3810a, record submitted late, submission date was more than 14 days after V0200C2 on this new (A0050 equals 1) comprehensive assessment (A0310A equals 01,03 04, or 05) for Resident #24, #200 and #153. The facility received warning error message -3810b, record submitted late, submission date was more than 14 days after A2000 on this new (A0050 equals 1) death in facility tracking record (A0310F equals 12) for Resident #46. The facility received warning error message -3810c, record submitted late, the submission date was more than 14 days after V0200C2 on this new (A0050 equals 1) comprehensive assessment (A0310A equals 01, 03, 04, or 05) for Resident #1 and #3. The facility received warning error message -3810d, record submitted late, submission date was more than 14 days after the Z0500B on this new assessment for Residents #2, #3, #4, #15, #28, #41, and #51. Interview with the MDS Coordinator, on 12/06/18 at 10:29 AM, revealed a new batch was created a few weeks ago and submitted at that time. The batch was found open on 12/04/18, and then resubmitted to CMS. The batch was accepted but received late submission warnings. The Coordinator stated the batch did not go through due to possible internet issues; however, she did not check it to ensure the batch was accepted by CMS. Interview with the Director of Nursing (DON), on 12/06/18 at 10:42 AM, revealed MDS assessments should be accurate and timely. The DON stated if MDS assessments were submitted late, it was likely due to internet issues.