**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility's policy, the facility failed to provide written notification of a facility-initiated transfer to the resident and responsible party (RP) for 2 (Resident (R) 27 and R46) of 4 residents reviewed for hospitalization in the sample of 28. The failure had the potential to affect the residents and/or their representatives concerning the reason for the transfer and the resident's appeal rights. The findings include: Review of the facility's policy titled, Transfer and Discharge, revised 03/09/2024 revealed, .4. The facility's transfer/discharge notice will be provided to the resident and the resident's representative in a language and manner in which they can understand. The notice will include all of the following at the time it is provided: a. The specific reason and basis for transfer or discharge. b. The effective date of transfer or discharge. c. The specific location (such as the name of the new provider or description and/or address if the location is a residence) to which the resident is to be transferred or discharged . d. An explanation of the right to appeal the transfer or discharge to the State. e. The name, address (mailing and email) and telephone number of the State entity which receives such appeal hearing requests. f. Information on how to obtain an appeal form. g. Information on obtaining assistance in completing and submitting the appeal hearing request. h. The name, address (mailing and email), and phone number of the representative of the Office of the State Long-Term Care Ombudsman. i. For nursing facility residents with intellectual and developmental disabilities (or related disabilities) or with mental illness (or related disabilities), the notice will include the name, mailing and e-mail addresses and phone number of the state agency responsible for the protection and advocacy of these populations. 1. Review of R27's undated admission Record, located in the resident's electronic medical record (EMR) under the Profile tab revealed the facility admitted the resident on 10/13/2017. Review of R27's annual Minimum Data Set (MDS), with an assessment reference date (ARD) of 07/14/2024 and in the EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. Review of R27's nursing Progress Note, dated 07/23/2024 and located in the resident's EMR under the Progress Notes tab revealed, Per resident request, resident asked to be sent to [Name of Hospital] to be checked out R/T [related to] vomiting and pain under her left breast and through to her back. 911 called . Review of R27's nursing Progress Note, dated 07/23/2024 and located in the resident's EMR under the Progress Notes tab revealed EMS [emergency medical service] arrived to pick up resident . Review of R27's EMR revealed no documented evidence the resident and the resident's representative received a writing notice for the 07/23/2024 hospital transfer. During an interview on 08/19/2024 at 3:13 PM, R27 stated she did not remember getting anything in writing about her hospital transfer on 07/23/2024. Review of R27's EMR under the Miscellaneous tab revealed no transfer notice for 07/23/2024 was included. Review of R27's Transfer to Hospital summary, located in the EMR under the Evaluation tab, dated 07/23/2024, revealed the reason for the transfer, location to which the resident was transferred, and effective date. The summary did not include the resident's appeal rights, ombudsman information, and if the resident/representative was provided with a written Notice of Transfer. 2. Review of R46's annual MDS with an ARD of 06/13/2024 located in the EMR under the MDS tab revealed an admission date of 04/01/2023 and a BIMS score of 11 out of 15, which indicated his cognition was moderately impaired. a. Review of R46's Health Status Note, dated 02/17/2024, located in the EMR under the Progress Note tab revealed [name of transport] .call given to [name] at [hospital] e.r. [emergency room] .was sent with res [resident]. Review of R46's Health Status Note, dated 02/20/2024, located in the EMR under the Progress Note tab revealed, Resident arrived to facility . from [hospital] . Review of R46's EMR under the Miscellaneous tab revealed no transfer notice for 02/20/2024 was included. Review of R46's Transfer to Hospital summary, located in the EMR under the Evaluation tab, dated 02/17/2024, revealed the reason for the transfer, location to which the resident was transferred, and effective date. The summary did not include the resident's appeal rights, ombudsman information, and if the resident/representative was provided with a written Notice of Transfer. b. Review of R46's Health Status Note, dated 03/08/2024, located in the EMR under the Progress Note tab revealed, Resident admitted to [hospital] for further testing. Review of R46's EMR under the Miscellaneous tab revealed a hospital transfer on 03/08/2024, but no transfer notice was included. Review of R46's Transfer to Hospital summary, located in the EMR under the Evaluation tab, dated 03/08/2024 revealed the reason for the transfer, location to which the resident was transferred, and effective date. The summary did not include the resident's appeal rights, ombudsman information, and if the resident/representative was provided with a written Notice of Transfer. c. Review of R46's Health Status Note, dated 06/16/2024, located in the EMR under the Progress Note tab revealed, Resident admitted to [hospital] with pneumonia and sepsis. Review of R46's EMR under the Miscellaneous tab revealed a hospital transfer on 06/16/2024 but no transfer notice was included. Review of R46's EMR revealed no transfer notice was found for R46's 06/16/2024 hospitalization. During an interview on 08/22/2024 at 9:18 AM, the Regional Nurse Consultant (RNC) was asked about transfer notices when R27 and R46 were sent to the hospital and for any resident transferred out of the facility that included the reason for the transfer, location to which the resident was transferred, effective date, resident's appeal rights, and ombudsman information. The RNC stated they did not do the transfer notices for any residents. The RNC stated they were unaware of the requirement. During an interview on 08/22/2024 at 8:28 PM, the Administrator stated he was unaware of the requirement.

Based on interview, record review, and review of the facility's policy, the facility failed to ensure a resident who had a negative Preadmission Screening and Resident Review (PASARR) Level I and then later had a significant change in status and a new serious mental illness diagnosis was accurately and timely referred for a PASARR Level II referral for 1 of 6 residents (Resident (R) 32) reviewed for PASARRs out of 28 sampled residents. This failure placed the resident at risk of qualifying for specialized services but not receiving the services due to the inaccuracy of the PASARR Level II referral. The findings include: Review of the facility's policy titled, Resident Assessment-Coordination with PASARR Program, revised 12/24/2023 revealed, Policy: This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs .1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities .in accordance with the State's Medicaid rules for screening .b. PASARR Level II-a comprehensive evaluation by the appropriate state-designated authority that determines whether individual has MD [Mental Disorder] .and recommends any specialized services .the individual needs .8. Any resident who experiences a significant change in status will be referred promptly to the state mental health or intellectual disability authority for additional review .9. Any resident who exhibits a new evident or possible serious mental disorder .will be referred promptly to the state mental health or intellectual disability authority for a Level II resident review . Review of R32's undated admission Record, located in the resident's electronic medical record (EMR) under the Profile tab revealed the facility admitted the resident on 04/08/2022 with diagnoses which included anxiety disorder. The admission Record also revealed on 08/22/2022 the resident received a new serious mental disorder diagnosis of Psychotic Disorder With Delusions . Review of R32's Preadmission Screening and Resident Review program summary, provided by the facility revealed on 07/06/2023 the facility initiated a significant change in status PASARR Level II referral due to a new added diagnosis (psychotic disorder). The summary documented the resident received the diagnosis on 08/22/2022, 11 months prior to the Level II referral. During an interview on 08/22/2024 at 10:09 AM, the PASARR Specialist (PS) and the PASARR Nurse Coordinator (PNC) with the State's PASARR Agency both stated R32's significant change in status Level II referral was not completed timely. The PS stated the referral for a Level II should have been completed within 14 days of receiving the new mental illness diagnosis. The PNC stated when reviewing the Level II referral, the facility did not describe the diagnosis, who gave the diagnosis, or how it impaired the resident's functioning. The PS agreed and stated the facility did not correctly complete the Level II for a referral to be completed. During an interview on 08/22/2024 at 5:55 PM, the Regional Nurse Consultant (RNC) verified R32's PASARR significant change in status referral for a new diagnosis was not completed timely or fully. The RNC stated it was her expectation PASARRs be completed accurately and timely. During an interview on 08/22/2024 at 7:42 PM, the Administrator stated it was his expectation residents' PASARRs would have been completed correctly and timely.

Based on interview, record review, and review of the facility's policy, the facility failed to ensure residents' Preadmission Screening and Resident Review (PASARR) Level I accurately reflected their current mental illness diagnoses for 3 of 6 residents (Resident (R) 32, R36, and R50) out of 28 sampled residents. This failure inaccurately produced negative PASARRs Level I and placed the residents at risk for unmet psychosocial needs and services had the PASARR triggered for a Level II referral. The findings include: Review of the facility's policy titled, Resident Assessment-Coordination with PASARR Program, revised 12/24/2023, revealed Policy: This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs .1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities . i. Negative Level I Screen-permits admission to proceed and ends the PASARR process unless a possible serious mental disorder .arises later . 1. Review of R32's undated admission Record, located in the resident's electronic medical record (EMR) under the Profile tab revealed the facility admitted the resident on 04/08/2022 with a diagnosis of anxiety disorder. Review of R32's Preadmission Screening and Resident Review Level I, dated 04/11/2022 and provided by the facility, revealed for question, 2a. Diagnosis, Identify whether the individual has a current or suspected mental illness . The diagnoses listed were Anxiety Disorder and Dementia without Behavioral Disturbance [neurocognitive disorder]. 2. Review of R36's undated admission Record, located in the resident's EMR under the Profile tab revealed the facility admitted the resident on 06/28/2021 with diagnoses which included paranoid personality disorder and anxiety disorder. Review of R36's Preadmission Screening and Resident Review Level I, dated 06/30/2021 and provided by the facility, revealed for question, 2a. Diagnosis, Identify whether the individual has a current or suspected mental illness ., the question was left blank which indicated the resident had no mental illnesses. 3. Review of R50's undated admission Record, located in the resident's EMR under the Profile tab revealed the facility admitted the resident on 03/09/2021. The admission Record did not list any mental health diagnoses upon admission. Review of R50's hospital Discharge Summary, dated 03/09/2021 and located in the resident's EMR under the Misc [Miscellaneous] tab, revealed the resident was discharged to the facility with diagnoses which included schizoaffective disorder, bipolar type . Review of R50's Preadmission Screening and Resident Review Level I, dated 03/11/2021 and provided by the facility, revealed for the PASARR Level I question, 2a. Diagnosis, Identify whether the individual has a current or suspected mental illness ., the question was left blank which indicated the resident had no mental illnesses. During an interview on 08/22/2024 at 10:09 AM, PASARR Specialist (PS) and PASARR Nurse Coordinator (PNC) with the State's PASARR Agency both stated R32, R36, and R50's Level I PASARRs were not completed accurately. The PS stated R32's diagnoses section was completed inaccurately as dementia was a neurocognitive disorder, and this section was specifically for mental illness diagnoses only. Continued interview revealed R36's and R50's PASARRs were incorrect as the diagnoses sections were left blank and should have included both R36 and R50's mental illness diagnoses. During an interview on 08/22/2024 at 5:55 PM, the Regional Nurse Consultant (RNC) verified the above PASARRs were inaccurate. The RNC stated it was her expectation PASARRs be completed accurately. During an interview on 08/22/2024 at 7:42 PM, the Administrator stated it was his expectation the residents' PASARRs would have been completed correctly.

Based on interview, record review, and review of the facility's policy, the facility failed to ensure 1 of 28 sampled resident, Resident (R) 31, was provided with activities of his interest. The failure to provide these activities placed R31 at risk for isolation. The findings include: Review of the facility's policy titled, Activities, dated 02/01/2024 revealed, It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Facility-sponsored group, individual, and independent activities will be designed to meet the interest of each resident, as well as support their physical, mental, and psychosocial well-being. Activities will encourage both independent and interactive within the community .activities refers to any endeavor other than routine . Activities of Daily Living (ADL) in which a resident participates that is intended to enhance his/her sense of wellbeing and promote or enhance physical, cognitive, and emotional health. These include, but are not limited to, activities that promote self esteem, pleasure, comfort, education, creativity, success, and independence. Activities will be designed with the intent to enhance the resident's sense of wellbeing, belonging, and usefulness, reflect residents' interest and reflect cultural and religious interests of the resident and reflect choices of the resident. Space and equipment necessary are provided to ensure the residents care plan is followed. Activities will include individual, small, and large group activities as well as indoor and outdoor activities, religious programs. The facility will consider accommodation in schedules, supplies, and timing in order to optimize a resident's ability to participate in activities of choice. Review of R31's Face Sheet located in the Admission tab of the electronic medical record (EMR) revealed the facility admitted R31 on 09/26/2017 with diagnoses of Huntington's Disease, cognitive communication disorder, and contracture of the left hand Review of R31's Minimum Data Set (MDS) located under the MDS tab of the EMR with an Assessment Reference Date (ARD) of 06/25/2024, revealed R31 had a Brief Interview for Mental Status (BIMS) score of one out of 15 which indicated his cognition was severely impaired. Review of the MDS revealed R31 liked trivia, discussions, reading, puzzles, television, movies, bingo, cards, video games, tablet, church, nature, and musicals. The preferences further revealed R31 enjoyed church services, gospel music, and he face-timed with his wife multiple times a day. Review of R31's preferences revealed it was very important to him to go to religious services and to listen to gospel music. Review of the MDS indicated that R31 was usually understood. Review of R31's comprehensive Care Plan, dated 03/22/2024 with a target date of 07/16/2024 located in the EMR under the Care Plan tab revealed a problem for activities. Review of the care plan further revealed R31 preferred independent activities or spending time with his family on the Facebook portal. Review of the interventions included: resident was to be invited to activities, spend time with his family on the Facebook portal, television, country music, reading, cards, and he was to receive in-room activities three times a week. Review of R31's July 2024 Activity Calendar revealed on 07/02/2024 he was people watching in the hallway; on 07/03/2024 he was people watching; on 07/05/2024 he had aroma therapy and was read to; on 07/08/2024 he had aroma therapy, and his leg was massaged; on 07/10/2024 he had aroma therapy, and his arm was massaged; on 07/11/2024 he had aroma therapy, and his leg was massaged; on 07/15/2024 his television was turned on, and the Activity Assistant (AA) 1 talked to him; on 07/17/2024 AA1 set up Facebook; on 07/19/2024 AA1 turned the television on and talked to him; on 07/24/2024 AA1 read to him and massaged his legs; on 07/25/2024 and 07/26/2024 AA1 talked with R31 and did aroma therapy; on 07/29/2024 AA1 talked and read to him; on 07/30/2024 he had aroma therapy, and his legs were massaged. Review of the July 2024 Activity Calendar for all residents revealed on 07/07/2024, 07/14/2024, 07/21/2024, and 07/28/2024 gospel music and church services were offered. However, review of the documentation from these activities revealed R31 did not attend any of them. Review of R31's August 2024 Activity Calendar, through 08/21/2024, revealed on 08/02/2024 R31 was up in the hallway; on 08/07/2024 he was talked to; on 08/08/2024 he was talked to, and the television was turned on; on 08/09/2024 he was talked to, and the television was turned on; on 08/14/2024 he was up in a chair in the common area; on 08/15/2024 his wife visited, and he was read to; on 08/16/2024 he was up in a chair in the common area; on 08/19/2024 his wife visited; and on 08/21/2024 the television was turned on. Review of the August 2024 Activity Calendar, through 08/21/2024, for all residents revealed on 08/04/2024, 08/11/2024, and 08/18/2024 all day gospel music and church services were offered. Further review revealed on 08/06/2024, outdoor time and snacks were done. Also, on 08/03/2024, 08/10/2024, and 08/17/2024 the review revealed Saturday morning news was offered. Further review revealed Bible study was offered on 08/21/2024. Review of the documentation from these activities revealed R31 did not attend any of them. During an interview on 08/22/2024 at 10:38 AM, R31 stated he would like to go to musicals and church if the facility had those activities. R31 stated he was not able to get up himself and depended on staff to get him up for activities. During an interview with R31's wife on 08/19/2024 at 2:42 PM, she stated she and R31 had gone to a July 4th singing activity in the dining room. She stated she was not sure what activities the facility did with the resident. During an interview on 08/21/2024 at 4:11 PM with AA1, she stated staff did one-on-one reading, hand massages, leg massages, and talking with R31. AA1 stated she gave him things he might need for independent activities like turning on the television or radio. AA1 stated R31 was contracted and could not do puzzles, but he liked being read to and massaging his legs. She stated she tried to make sure the television or radio was on, and R31 had a Facebook portal, but it had to be set up for him because he was unable to set it up himself. AA1 stated she had not set the Facebook portal up for him in a couple of months because he had not asked her to set it up. AA1 stated she did not document that she asked him if he wanted to set up the Facebook portal. During an interview on 08/21/2024 at 3:50 PM, the Activity Director (AD) stated staff usually got R31 up daily, and he went to activities three times a week. The AD stated R31 used the Facebook portal to talk to his wife. The AD further stated staff had to set the computer up for the resident to use the Facebook portal because he was unable to set it up himself. During an interview on 08/22/2024 at 8:24 PM, the Administrator stated residents should have activities while in the facility.

Based on observation, interview, record review and review of the facility's policy, the facility failed to maintain acceptable nutritional parameters by not assessing the reason for significant weight loss for 1 of 6 sampled residents, Resident (R) 34, reviewed for nutrition in the sample of 28 residents. This had the potential to cause further weight loss without a root cause analysis and/or additional interventions put in place. The findings include: Review of the facility's policy titled Nutrition Management, dated 02/01/2024, revealed, 2. Identification/assessment . c. A comprehensive nutritional assessment will be completed by a dietitian within 72 hours of admission, annually, and upon significant change in condition. Follow-up assessments will be completed as needed. Components of the assessment may include but are not limited to vi. Presence of persistent hunger, poor intake, or continued weight loss. Review of R34's annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 05/30/2024, located in the MDS tab of the electronic medical record (EMR), revealed an admission date of 08/17/2022. R34 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating R34's cognition was intact. R34 had diagnoses of diabetes mellitus, schizophrenia, and unspecified hallucinations, and the MDS was marked as having no weight loss. Review of R34's diet order, dated 04/09/2023, located in the EMR under the Order tab revealed a Controlled Carb [carbohydrate] diet, Regular texture, Regular/Thin consistency, Large protein portions only @ [at] all meals. May have small serving from dessert cart. May have special occasion meals. Review of R34's Care Plan, revised 05/29/2024, located in the EMR under the Care Plan tab revealed Nutritional Risk r/t [related to]: -dx [diagnoses] DM II [type two diabetes mellitus], schizophrenia, HTN [hypertension], HLD [hyperlipidemia] -need for therapeutic diet -potential side effects of antipsychotic medications: increased wt [weight] and obesity -obesity status with no interest in weight reduction at this time. The goal included R34 will maintain current level of PO [oral] intake at 76-100%/meal. An intervention for complications of R34's diabetes mellitus included, Monitor/document/report PRN [as needed] any s/sx [sign/symptom] of hyperglycemia .weight loss . Review of R34's weight history, located in the EMR under the Weight/Vitals tab, revealed R34 had lost nine percent of his body weight in five months (151 days). This included: 08/05/2024 at 237.8 Lbs. [pounds] standing; 07/05/2024 at 243.0 Lbs. standing; 06/06/2024 at 246.2 Lbs. standing; 06/05/2024 at 247.6 Lbs. standing; 05/03/2024 at 259.2 Lbs. standing; 04/03/2024 at 259.4 Lbs. standing; 03/07/2024 at 261.6 Lbs. standing. Review of the Registered Dietician (RD)'s Comprehensive Nutritional Evaluation in the EMR under the Evaluation tab, dated 05/29/2024, revealed R34 had an elevated A1C (blood test that reflected the average blood sugar level for the past two to three months). Further review, in the RD's Dietary Quarterly Evaluation, dated 02/22/2024, revealed the RD noted R34 had an elevated albumin level (blood test that checked your liver and kidney function), Fasting Blood Sugar (FBS), A1C, Blood Urea Nitrogen (BUN), BUN/Creatinine ratio, and Potassium (K+) blood level. Review of R34's Nutrition/Dietary Note, dated 06/12/2024, located in the EMR under the Progress Notes revealed, Reweight was obtained 06/06/2024 of 246.2# [pounds], indicating a true significant weight loss of 13# (5.0%) has occurred x 30 days. Resident remains within obese BMI [body mass index] class (BMI=33.4). Has orders for CCD [controlled carbohydrate diet] diet, regular textures, thin consistencies, and large portion protein q [every] meal. Intake records show he has been eating 51-75%/meal on average over the last [seven] 7 days. Informed resident of weight change. Resident states he has not been intentionally trying to lose weight, but also is not concerned with weight loss. He voices no weight related goals at this time. Weight loss is considered beneficial due to obesity status but should be achieved at a safe/controlled rate of < [less than] 5% [percent]/month. Will continue with current plan at this time. RD will monitor and follow up with resident routinely and remains available PRN [as needed] via consult. Review of R34's Nutrition/Dietary Note, dated 08/07/2024, located in the EMR under the Progress Notes revealed, R34 triggers for a significant weight loss of 21.4# (8.3%) x 90 days. CBW= 237.8#. He remains within obese BMI class (BMI= 32.2). Resident has orders for CCD diet, regular textures, thin consistencies, and large portion protein q meal. Intake records show he has been eating 76-100%/meal on average over the last [seven] 7 days. Due to obesity status and resident continuing to have excellent PO intake, weight reduction is considered beneficial. No new recs [recommendations] at present time. RD will continue to monitor and follow up routinely and remains available PRN [as needed] via consult. Review of R34's meal intake documentation, dated 08/03/2024 to 08/21/2024, located in the EMR under the Task tab revealed R34 consumed 76-100% of the meals. Observation on 08/20/2024 at 12:50 PM revealed R34 was served his lunch in his room. R34 ate 100% of his meal that consisted of a large serving of baked fish, rice, vegetables, bread, and a dessert. Observation on 08/21/2024 at 9:09 AM revealed R34 was served his breakfast in his room. R34 ate 100% of his meal that consisted of cereal, a large serving of scrambled eggs, sausage, toast, milk, and juice. R34 was asked if he got enough to eat at meals. R34 did not answer the question. During a telephone interview on 08/21/2024 at 5:50 PM, the RD was asked if she was aware of R34's weight loss. The RD stated she was aware of significant weight loss but it's beneficial due to his obese status. The RD was asked why R34 was losing weight, and the RD stated she was not sure because R34 ate well, and he was not active. The RD was asked if it was acceptable for R34 to continue to have unplanned weight loss, and if no, what was in place to address it. The RD stated, Although weight loss could be beneficial for his obese status, the reason he's losing weight may not be beneficial should it continue. Observation on 08/22/2024 at 7:58 AM revealed R34 was served his breakfast in his room. R34 ate 100% of his meal that consisted of a large portion of scrambled eggs mixed with sausage, toast, cereal, orange juice, and milk. During an interview on 08/22/2024 at 8:25 AM, the Dietary Manager (DM) was asked why R34 was losing weight. The DM stated she did ask R34 if he wanted more food this morning and he said yes. The DM stated she was not sure why R34 was losing weight but would talk to the RD about it and see if R34 needed large portions for all food items. During an interview on 08/22/2024 at 10:53 AM, the Nurse Practitioner (NP)1 was asked about R34's weight loss. NP1 stated she was not aware of any significant weight loss. NP1 reviewed the EMR and stated, R34's BMI is high but I see what you mean about R34's weight is trending down. NP1 stated the RD oversaw R34's nutrition. During an interview on 08/22/2024 at 6:07 PM, the Unit Manager (UM) was asked if the facility had a weight committee. The UM stated they had a NAR [nutrition at risk] committee. The UM was asked if she was aware of any significant weight loss for R34. The UM stated, No, R34 gets large protein at meals but that's all. The UM stated R34 was not discussed during their NAR for significant weight loss in the 08/22/2024 meeting, 08/15/2024 meeting, or 07/31/2024 meeting. The UM was asked how a resident got on the list on the NAR meetings. The UM stated the RD sent a list of residents with significant weight loss. The UM stated R34 would take more food at times when offered and would also ask for more food. The UM stated the RD documented weight loss as beneficial but no cause for the weight loss was determined. The UM asked if a root cause analysis was completed, and the UM stated she did not think so. The UM stated if there was no reason for R34 to lose weight, it could not be labeled as planned and could be a symptom of something wrong. During an interview on 08/22/2024 at 8:26 PM, the Administrator was asked about R34's weight loss and his expectations. The Administrator stated to ensure R34 was provided the correct nutrition, a root cause analysis should be done to determine why R34 was losing weight.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure 2 out of the 3 residents with a gastrostomy tube (G-tube) had the tube placement verified and the residual determined prior to any fluids or medications being administered, Resident (R) 46 and R80. This failure had the potential for these residents to be at risk for aspiration pneumonia. The findings include: Review of the facility's policy titled, Medication Administration via Enteral Tube, dated 02/14/2024, revealed, It is the policy of the facility to ensure the safe and effective administration of medication via enteral feeding tube by utilizing best practice guidelines .enteral tube placement must be verified prior to administration of fluids or medication . 1. Review of R46's Face Sheet located in the admission Record of the electronic medical record (EMR) revealed the facility admitted R46 on 04/01/2023 with diagnoses of malignant neoplasm of larynx, dementia, and dysphagia that required enteral feedings. Review of R46's annual Minimum Data Set (MDS) located in the MDS tab of the EMR, with an assessment reference date (ARD) of 06/13/2024, revealed R46 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated the resident's cognition was moderately impaired. Review of R46's comprehensive Care Plan located in the Care Plan tab of the EMR revealed a problem was listed for enteral feeding, and staff was to check for tube placement and gastric contents/residual volume according to the facility's protocol. Observation on 08/20/2024 at 4:45 PM of Licensed Practical Nurse (LPN) 4 revealed R46 was in the bed in his room. R46 was to receive a bolus of water through the G-tube. LPN4 did not check for placement of the G-tube prior to flushing it. LPN4 attempted to flush the G-tube, but the water would not go down the tube, so she used the plunger to get the water to flush. During this observation, LPN4 started R46's tube feeding of Two Cal formula at 50 milliliters per hour. 2. Review of R80's Face Sheet located in the admission Record of the EMR revealed the facility admitted R80 on 03/18/2024 with diagnoses of dysphagia, gastrostomy status, dementia with psychotic features, diabetes, and malnutrition. Review of R80's significant change MDS, with an ARD of 07/25/2024, revealed a BIMS score of zero which indicated the resident was not able to complete the assessment. Review of R80's Physician Orders, dated 08/22/2024 at 7:03 AM in the EMR revealed a stat (immediate)abdominal x-ray was ordered to check for G-tube placement. Observation on 08/22/2024 at 4:55 PM of LPN4 revealed R80 was in the bed in his room. LPN4 did not check for placement or residual before flushing the tube. LPN4 flushed R80's G-tube with water, then a Glucerna bolus, flushed with water again, gave a Glucerna bolus, and ended the administration with a bolus of water. During an interview on 08/21/2024 at 11:24 AM, LPN4 revealed the G-tube placement should have been checked before she administered any fluids or feeding, but she forgot to check placement. LPN4 further revealed if the G-tube was not in the right place there was a possibility the feeding or fluids could go into the lungs which could cause aspiration pneumonia or an infection. During an interview with LPN3 on 08/21/2024 at 9:45 AM, LPN3 stated staff should check for placement of the G-tube before administering anything down the tube. LPN3 stated staff should instill about 30 ml of air, listen with your stethoscope for the air, and then check for residual before administering any fluids or medications. LPN3 stated if the G-tube was not in the right place, the fluid or medication instilled could go into the resident's lungs. During an interview on 08/21/2024 at 11:49 AM, the Director of Nursing (DON) stated that placement and residual of the G-tube should be verified before instilling anything down the tube. The DON stated the nurse should instill air into the tube and listen with the stethoscope for the air and then pull back on the syringe to check for residual. The DON revealed if the nurse did not check for placement it put the resident at risk of aspiration pneumonia. During an interview on 08/22/2024 at 5:07 PM, the Administrator stated that placement of the G-tube should be verified before any fluids or medication were administered. The Administrator further stated that fluids could go into the wrong place if the tube was misplaced.

Based on observation, interview, record review, and review of the facility's policy, the facility's nursing staff failed to use appropriate Personal Protective Equipment (PPE) for 1 out of 28 sampled residents who were on Enhanced Barrier Precautions (EBP), Resident (R) 237. Specifically, nurses did not wear a gown when performing R237's wound treatment. This failure had the potential to cause an infection of the resident's wound. The findings include: Review of the facility's policy titled, Enhanced Barrier Precautions, dated 02/01/2024, indicated, It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multi drug resistant organisms [MDRO]. Enhanced Barrier precautions refer to the use of gown and gloves for use during high contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices) all staff are expected to comply with all designated precautions . high contact resident care activities that require the use of gown and gloves .include wound care, any skin opening requiring a dressing . Review of R237 Face Sheet located in the admission Record tab of the electronic medical record (EMR) revealed the facility admitted R237 on 08/12/2024 with diagnoses of Parkinson's, neurofibromatosis, malignant neoplasm skin, and disorder of skin and subcutaneous tissue. Review of R237 admission Minimum Data Set (MDS) located under the MDS tab of the EMR, with an assessment reference date (ARD) of 08/19/2024, revealed R237 had a Brief Interview for Mental Status (BIMS) score of 99 which indicated the assessment was unable to be completed. Review of R237 Physician Orders, dated 08/12/2024, located under the Orders tab of the EMR revealed an order for wound care to be done to the left neck. Observation on 08/21/2024 at 3:04 PM of Registered Nurse (RN) 3 and Licensed Practical Nurse (LPN) 1 revealed neither RN3 or LPN1 put on a gown prior to entering R237's room to perform the wound treatment and dressing change. Observation further revealed signage on the door stated Enhanced Barrier Precautions (EBP) was to be utilized. Observation of the signage revealed a gown, mask, and gloves were to be worn if wound care was being done. During an interview on 08/22/2024 at 3:23 PM, RN3 stated PPE should have been used with R237 because the resident had an open wound. RN3 stated that anyone with an open wound, catheter, or any opened areas should be on EBP. RN3 stated she should have put on a gown prior to performing R237's wound treatment. RN3 stated not wearing a gown during the wound treatment put other residents at risk for spreading an infection. During an interview on 08/22/2024 at 3:23 PM, LPN1 confirmed there was an isolation cart on the outside of R237's room and signage that indicated the resident was on EBP. During an interview on 08/22/2024 at 5:34 PM, the Regional Nurse Consultant (RNC) stated when EBP signage was on the door and a wound treatment was to be done, nurses should have worn a gown, mask, and gloves when doing care. The RNC stated if fluids were present then goggles should be worn. The RNC stated there was a risk for contamination with MDROs and carrying them to other residents. During an interview on 08/22/2024 at 5:00 PM, the Administrator stated that if a resident was on EBP then a gown, gloves, and mask should be worn from an infection control standpoint. The Administrator further stated failure to wear PPE would pose a risk of bringing an infection into the facility or spreading the infection to others.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined the facility failed to ensure the Office of the State Long Term Ombudsman was notified of a resident transfer/discharge for one (1) of three (3) sampled residents reviewed for discharge requirements out of a total sample of twenty-four (24) residents (Resident #95). Resident #95 was discharged to an acute care hospital on [DATE] with return anticipated; however, the resident did not return to the facility and was admitted to the hospital Hospice Unit. There was no documented evidence the State Long Term Care Ombudsman was notified of the transfer/discharge. The findings include: Review of the facility Transfer or Discharge Notice Policy, undated, revealed the facility shall provide a resident and/or the resident's representative with a notice of an impending transfer or discharge from the facility as soon as it is practicable if an immediate transfer or discharge is required by the resident's urgent medical needs. A copy of the notice will be sent to the Office of the State Long Term Ombudsman. Review of Resident #95's medical record revealed the facility admitted the resident on 03/28/19 from an acute care hospital setting with diagnoses to include Type 2 Diabetes Mellitus with Diabetic Nephropathy, and Unspecified Cirrhosis of the Liver. Review of the Change of Condition Nurse's Note, dated 04/23/19, revealed Resident #95's skin was jaundiced, the resident was noted to be lethargic during medication pass, and the resident's family was notified. Further review of the Note, revealed the Physician was notified and new orders were received to transfer the resident to an acute care hospital. Review of the Nurse's Note, dated 04/24/19, revealed there was contact between the acute care hospital and the facility on 04/24/19, and Resident #95 had been admitted to the hospital's hospice unit. However, further review of Resident #95's medical record, revealed there was no documented evidence the Office of the State Ombudsman had been contacted and informed of the resident's transfer and subsequent discharge from the facility. Interview on 07/12/19 at 9:04 AM, with the facility Administrator, revealed he disagreed with the interpretation of the regulation regarding reporting of non facility-initiated discharges to the Office of the State Ombudsman. He stated he understood the need for the Ombudsman to be involved in the case of facility initiated discharges, but did not understand the reason for reporting non facility initiated transfers to the Ombudsman. Further interview revealed he was unaware residents who were discharged with intent to return, but did not return were considered facility-initiated discharges. He further stated he was unaware of the need to report Resident #95's transfer/discharge to the State Ombudsman's Office.

Based on observation interview, record review, and review of the facility's policies, it was determined the facility failed to ensure Tracheostomy Care (Trach Care) was provided in accordance with facility policy and professional standards of care for one (1) of one (1) sampled resident observed for Trach Care out of a total of twenty-four (24) sampled residents (Resident #75). Observation of Tracheostomy Care for Resident #75 on 07/11/19 , revealed Registered Nurse (RN) #1 did not follow the facility Infection Control Policy, Tracheostomy Care Procedure, or professional standards as the nurse failed to utilize proper hand hygiene and glove usage prior to, during, and after the procedure. In addition, RN #1 set up the trach kit for the procedure on the resident's abdomen instead of using a bedside table. Further observation revealed RN #1 cleansed the skin at the stoma site with Hydrogen Peroxide instead of using Normal Saline. Furthermore, after the nurse was questioned by the State Survey Representative about the need for Normal Saline during the procedure, the nurse took a Q-tip which was wet with Normal Saline, lifted the dressing she had applied at the stoma site, and cleaned under the dressing, leaving the then wet gauze in place against the resident's skin. (Refer to F-880) The findings include: Review of the facility's Infection Control Policy, revealed the facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of disease and infections and these policies apply to all personnel. Further review revealed all personnel will be trained on the infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control. Review of the facility Tracheostomy Care Procedure, undated, revealed the steps included: remove old dressings, pull soiled gloves over dressing and discard into appropriate receptacle; and wash hands. 1) Open tracheostomy kit; 2) set up supplies on sterile field; 3) maintain sterile field while pouring Hydrogen Peroxide in one compartment of opened kit and pour Normal Saline in another compartment.; 4) don sterile gloves; 5) secure the outer neck plate with non-dominate gloved hand; 6) Unlock the inner cannula with gloved dominate hand; 6) remove the clean removable inner cannula, while rotating clockwise while lifting away from the resident and soak the cannula in Hydrogen Peroxide, clean with brush, and rinse with Saline and dry with pipe cleaners; 7) remove and discard gloves, wash hands and don clean gloves; 8) replace the cannula and lock in place. For Site and Stoma Care: Apply clean gloves; clean the Stoma with Normal Saline soaked gauze pads; rinse Stoma with saline soaked gauze pads; wipe with dry gauze; allow to air dry or wipe with clean, dry gauze; remove neck ties and replace with clean ones as needed; apply a gauze pad around insertion site; remove gloves and discard; and wash hands. Review of Resident #75's clinical record revealed the facility admitted the resident on 04/17/19 with diagnoses to include Acute Respiratory Failure, Tracheostomy Status, and Gastrostomy Status. Review of Resident #75's admission Minimum Data Set (MDS) Assessment, dated 04/24/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of thirteen (13) out of fifteen (15) indicating the resident was cognitively intact. Further review of the MDS Assessment, under Section O , revealed the facility assessed the resident as having a Tracheostomy requiring care and suctioning. Observation of Resident #75's Trach Care on 07/11/19 at 1:35 PM, revealed RN #1 failed to wash hand prior to donning gloves. After donning gloves, RN #1 set-up the Trach-Care kit with the sterile field on the resident's abdomen instead of setting up the kit on the bedside table. RN #1 then poured the Hydrogen Peroxide from the kit into one compartment and the Normal Saline into the second department of the tray. Clean gauze and Q-tips were noted on the sterile field area. RN #1 secured the outer neck plate at the site and removed the disposable inner cannula and discarded it. She then removed her soiled gloves and without washing her hands, donned sterile gloves and applied a new sterile inner cannula. She then cleaned the outer area of the stoma with Hydrogen Peroxide Q-tips making several swipes. The nurse then removed her soiled gloves, but failed to wash her hands before donning clean gloves. RN #1 applied a split gauze with a single piece of tape over the split gauze. When RN #1 was questioned related to the need for the Normal Saline, she stated she forgot to use the Normal Saline. RN #1 then lifted the sterile gauze from the stoma site, and used Q-Tips and Normal Saline to clean around the stoma, never removing the split gauze dressing completely. Further observation, revealed after the procedure was completed, RN #1 removed her soiled gloves and without washing her hands, donned clean gloves stating she was going to provide Gastrostomy Tube (G-Tube) site care. After the State Survey Representative questioned RN #1 about the need to wash her hands between procedures, she went to the sink in the resident's room, and rinsed her hands under water. However, RN #1 failed to use soap or wash her hands before drying her hands. (Refer to F-880) Interview with RN #1 on 07/11/19 at 2:23 PM, revealed she did not wash her hands prior to Trach Care and further verbalized she was aware of the policy guidelines related to washing hands or using hand sanitizer prior to providing Trach Care. RN #1 stated she did fail to wash her hands or use hand sanitizer with glove changes during trach care. Further interview revealed she did clean the skin around Resident #75's trach stoma site with Hydrogen Peroxide; however, she stated she should have cleaned the site with Normal Saline instead. Per interview, after the dressing was applied around the stoma she should not have cleaned under the dressing with a saline Q-tip, but should have removed the dressing first, and then reapplied the dressing after the area was dry. Further interview revealed after the trach care procedure, she only rinsed her hands and should have washed her hands with soap and water prior to initiating Gastric tube care to prevent cross contamination from the resident's tracheostomy area and gastrostomy site area. Interview with Licensed Practical Nurse (LPN) #2, on 11/12/19 at 2:05 PM, revealed handwashing was required prior to performing Trach Care. Per interview, the old dressing should be removed using clean gloves, and then the gloves removed and hands washed again. Per interview, hands should be washed between glove changes with soap and water. Further interview revealed the stoma site should be cleaned with Normal Saline and not Hydrogen Peroxide. Continued interview revealed after the dressing was applied around the stoma it would not be good nursing practice to clean under the dressing with a saline Q-tip, because at that point the gauze would be wet and wet gauze should not be left on the skin. Per interview, after performing Trach Care, the stoma area should be left to air dry or dried with gauze. Per interview, after the procedure soiled gloves should be removed and hands washed with soap and water, as rinsing hand with just water was not acceptable. Interview with the Assistant Director of Nursing (ADON), on 07/12/19 at 2:33 PM, who also served as the Infection Control Nurse (ICN) and Staff Development Coordinator, revealed the seasoned nurses taught other nurses how to perform Trach Care. Per interview, nurses should wash their hands with soap and water prior to starting care, and between glove changes during the procedure. Further interview revealed the stoma of the tracheostomy was to be cleansed with Normal Saline, not Hydrogen Peroxide. Continued interview revealed after Trach Care, hands should be washed with soap and water as just rinsing hands with water was unacceptable practice. Interview with the Director of Nursing (DON), revealed it was her expectation nurses wash their hands with soap and water prior to performing Trach Care, prior to glove changes during the procedure, and after the procedure. Further interview revealed when providing Trach Care, the Hydrogen Peroxide in the kit was to be used to clean the inner cannula if the cannula was not disposable. The DON stated the skin around the stoma should be cleaned with Normal Saline. Per interview, cleaning the skin of the stoma site with Hydrogen Peroxide, applying the gauze dressing and then going back up under the dressing to rinse with Normal Saline using a Q-tip was not acceptable. Continued interview revealed staff was to wash hands between tasks and to use universal precautions. Per interview, if universal precautions and good hand washing was not followed, this could result in a resident acquiring an infection that could possibly lead to death. Interview with the Administrator on 07/11/19 at 3:26 revealed, he would expect staff to follow the facility's infection control policies and the tracheostomy care Procedure for the well being of the residents.

Based on observation, interview, record review and review of the facility policies, it was determined the facility failed to implement procedures for acquiring, receiving, dispensing and administering medications for one (1) of twenty-four (24) sampled residents (Resident #75). Observation on 07/11/19 at 2:05 PM, revealed Resident #75 was administered a liquid per nebulizer treatment via tracheotomy by Registered Nurse (RN) #1, while the State Agency Representative was in Resident #75's room observing other care being provided. Interview with RN #1 at the time of administration, revealed she could not recall the name of the medication she had just administered. The State Agency Representative accompanied RN #1 back to the medication cart to identify the medication and RN #1 revealed the medication she had just administered to Resident #75 was Ipratropium Bromide/Albuterol 0.5-2.5 (3) milligrams (mg)/3 milliliters (ml), 3 mg. RN #1 further explained she had retrieved the medication from Resident #28's medication supply due to Resident #75's medication being unavailable. RN #1 had not utilized the facility Emergency Kit to obtain the needed medication for Resident #75, as per Policy. The finding included: Review of the Facility's Long Term Care Facility Pharmacy Services and Procedures Manual revised, 10/31/16, revealed If medication is needed before the next scheduled delivery and is not available in the Emergency Medication Supply, facility staff should: Fax or transmit the order to the pharmacy and notify the pharmacy of the exact time by which the medication is needed. Further review of the Manual; under the section titled, Emergency Medication Supplies (Emergency Kits), revealed facility staff may record the name of the nurse who accessed the emergency kit (E-Kit) medication, the date and time the E-Kit was accessed and the serial number of the tamper-evidence lock or seal replaced on the E-Kit. The same authorized nurse who removes the dose from the E-Kit shall administer doses of medication. Review of the facility's Administering Medications Policy, undated, revealed Medications shall be administered in a safe and timely manner, and as prescribed. Further review revealed medications ordered for a particular resident may not be administered to another resident, unless permitted by State law and facility policy, and approved by the Director of Nursing Services. Review of Resident #75's Medical Record revealed the facility admitted the resident on 04/17/19 with diagnoses to include: Acute Respiratory Failure, and Tracheostomy Status. Observation of Registered Nurse (RN) #1, on 07/11/19 at 1:57 PM, revealed she poured a clear tube of liquid medication in Resident #75's Nebulizer Machine while the State Agency Representative was in the resident's room making observations related to other care being provided. When the State Agency Representative asked the nurse for the name of the medication, she stated it was a medication starting with the letter I. The State Agency Representative accompanied RN #1 to the medication cart to identify the medication. RN #1 checked the medication cart and then stated, I got the medication from Resident #28's package. Observation of the medication cart with RN #1, revealed there was no Ipratropium Bromide/Albuterol 0.5/2.5 (3) mg/3 ml in the cart for Resident #75. Review of Resident #75's Order Summary Report, dated July 2019, revealed current orders for Ipratropium-Albuterol Solution 0.5-2.5 (3) mg/3 ml, 3 mg via trach every six (6) hours related to Tracheostomy. Further review revealed current orders for Ipratropium-Albuterol Solution 0.5-2.5 (3) mg/3 ml, 3 mg via trach every six (6) hours PRN (as needed) for Shortness of Breath related to Tracheostomy Status. Review of Resident #28's Order Summary Report, dated July 2019, revealed an original order date of 09/07/19 for Ipratropium-Albuterol Solution 0.5-2.5 (3) mg/3 ml, one (1) inhale orally three (3) times a day related to chronic Obstructive Pulmonary Disease. Per the Summary the order status was current as of 07/12/19. Further interview with RN #1, on 07/11/19 at 2:03 PM, revealed she had poured the Ipratropium/Albuterol Solution belonging to Resident #28, into Resident #75's nebulilzer machine for administration to Resident #75 because she could find no Ipratropium/Albuterol Solution prescribed for Resident #75 in the medication cart. Further interview revealed RN #1 was aware of facility policy related to not borrowing medications with the rationale that residents paid for their medication and the medication should not be borrowed without consent. Further interview with RN #1, on 07/12/19 at 4:51 PM, revealed Licensed Practical Nurse (LPN) #1, had called pharmacy prior to RN #1's shift on 07/11/19 related to the need for a refill of Resident #75's Ipratropium/Albuterol Solution and the pharmacy stated they would have the medications to the facility by noon on 07/11/19. Per interview, pharmacy did not deliver the medication (Ipratropium/Albuterol) on 07/11/19. Continued interview revealed the Ipratropium/Albuterol Solution medication was available in the Emergency Box (E-Kit), but she did not utilize the E-Kit on 07/11/19 at 1:57 PM to obtain the medication for Resident #75. Review of Resident #75's Medication Administration Record (MAR) dated 07/10/19, and 07/11/19, revealed all doses of Ipratropium-Albuterol were administered as scheduled at 12:00 AM, 6:00 AM, 12:00 PM, and 6:00 PM. Review of the MAR, dated 07/12/19, revealed doses were administered at 12:00 AM, 6:00 AM, and 12:00 PM prior to the end of the survey. Post survey phone interview, with the facility Consulting Pharmacist, on 07/15/19 at 1:25 PM, revealed the nursing staff was not allowed to borrow or use medications for one resident that belonged to another resident in any circumstance. Per interview, the nurses had access to the Emergency Box (E-Kit) if a situation were to arise related to a resident running out of a particular medication and Ipratropium/Albuterol Solution was stocked in the E-Kit. Further interview revealed staff could request refills on medications from pharmacy by re-ordering the medication through Point Click Care (computerized electronic system); or by faxing a reorder sheet; or by calling the Pharmacy. Per interview, Pharmacy was in the facility six (6) days a week and E-Boxes were delivered each day Monday through Saturday. Interview with the Assistant Director of Nursing (ADON), on 07/11/19 at 2:30 PM, revealed she was aware of RN #1 having borrowed Ipratropium/Albuterol Solution from Resident #28 for Resident #75. She stated Resident #28's dose was replaced from the E-Kit on 07/11/19. Further interview revealed the nurse involved would be re-educated and this issue would be discussed in the Quality Assurance meeting. Continued interview revealed, RN #1 understood she was not to borrow medications from another resident as this was against the facility policy. Interview with the Director of Nursing (DON,) on 07/12/19 2:57 PM, revealed when a resident runs out of a medication, the proper procedure was to notify the pharmacy and retrieve the medication if available out of the E-Box. Per interview, when a medication was removed from the E-box, a refill slip was filled out and sent to the pharmacy by fax and then pharmacy would bring a new E-box that night. Further interview revealed pharmacy came to the facility twice a day to deliver medications at 1:00 PM and again about Midnight. The DON stated, It is never acceptable for a nurse to use one resident's medications for another resident. Interview with the Administrator, on 07/12/19 at 9:00 PM, revealed the nurse involved in borrowing medications had been educated on the proper way for her to obtain medications for a resident on 07/11/19. Per interview, he was informed of the nurse borrowing medication from Resident #28 for Resident #75 by the ADON and the medication was replaced for Resident #28 yesterday. Further interview revealed it was his expectation for the nursing staff to follow the facility's policies related to obtaining medications for residents. He stated this concern would be run as a Quality Assurance issue.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of the facility Tuberculosis Screening Policy, dated October 2017, revealed the facility shall screen all residents for Tuberculosis (TB) infection and disease. The policy further stated any resident admitted to the facility will have a Tuberculin Skin Test (TST), blood assay for Mycobacterium Tuberculosis (BAMT) or chest X-ray (CXR). Any resident without documented negative TST, BAMT or CXR or (one step) in the previous twelve (12) months will receive a baseline (two-step) TST or (one step) BAMT upon admission. If the first TST is negative, a follow-up TST will be administered one (1) to three (3) weeks after the initial test is read. The Policy submitted for review did not include information related to Annual Tuberculin Skin Tests. In addition, the Policy submitted for review did not include information related to the need for the TST results to be recorded in date of measurement, and millimeters of induration. Review of Resident #23's medical record revealed the facility admitted the resident on 03/09/18 with diagnoses including Alzheimer's Disease, and Diabetes Mellitus. Review of Resident #23's Immunization Report from the Electronic Health Record (EHR), revealed the resident received an admission TST on 03/09/18, with negative results; however, the date of the results and the millimeters (mm) of induration was not recorded. Per the Immunization Report, the second step of the initial screening for TB was completed on 03/23/18, with negative results; however, the date of the results and the mm of induration was not recorded. Resident #23's Physician's Orders dated 05/12/19, revealed orders to administer and read the resident's annual TST. Further review of the Immunization Report, revealed the annual TST was not repeated until 05/13/19, fourteen (14) months after the initial test, thus the test was performed two (2) months past the twelve month period required per regulation. Interview on 07/10/2019 at 2:03 PM, with Licensed Practical Nurse (LPN) #2, who worked on the 100 Hall where Resident #23 resided, revealed all residents were to receive a two (2) step TST upon admission and a TST yearly and the results were to be recorded with date of results and millimeters (mm) of induration. She stated she was unaware Resident #23 had not received the annual TST timely. LPN #2 further stated there was no shortage of TST solution in March 2019 to her knowledge. When questioned related to the process to ensure residents receive their annual TST, she stated the orders were in the Electronic Health Record (EHR). Per interview, the orders would pop up on the computerized electronic Medication Administration Record (eMAR) when they were due. She re-iterated the need for the orders to first be entered in order to populate on the eMAR. Further interview revealed the admission orders for Resident #23 must not have been entered to include an annual TST. Interview on 07/10/19 at 2:20 PM, with LPN #3, revealed the facility staff nurses tracked the TST via a paper in the back of the resident's hard chart and in the EHR. LPN #3 further stated the Physician's Order was entered into the EHR to administer the TST and a second order must be entered in the EHR to read the TST. Per interview, the results of the TST were then entered into in the medical record. LPN # 3 stated the eMAR of the EHR , indicted the date and time the TST was to be administered and read. Interview on 07/10/19 at 2:28 PM, with the ADON/ICN/SDC, revealed sometimes new nurses did not know the correct procedure for entering admission orders into the EHR. She confirmed there were several new staff nurses working during the time of Resident #23's admission, and the admitting nurse must have missed entering Resident #23's orders for annual TST in the EHR. Per interview, the former Director of Nursing (DON) had a tracking system to ensure TSTs were administered on admit and annually; however, she was unaware of a tracking system in place at this time. Further interview revealed TST results must be recorded by the date of measurement, and millimeters of induration. Interview with the Director of Nursing (DON), on 7/12/19 at 3:00 PM, revealed she did not know how or why the annual TST was missed on Resident #23. The DON confirmed, to her knowledge, there was no facility shortage of TST solution during March 2019, which may have caused the TST to be missed. She further stated it was her expectation Tuberculin Skin Tests be administered on admission and annually as per the regulations. Further interview revealed the TST results were to be recorded as per regulation. Further interview with the DON, revealed if a nurse dropped a pill on the medication cart, the nurse should dispose of the medication. Per interview, if a narcotic, two (2) nurses would need to dispose of the medication and sign off on the disposal. Further interview revealed staff should wear gloves to handle medications as it was not acceptable to handle medications with bare hands. Continued Interview with the DON, revealed as per standards of nursing practice and the facility policy, nurses were to wash their hands prior to performing Trach Care. Further, during the Trach Care procedure when soiled gloves were removed, hands should be washed prior to donning clean gloves. Additional interview with the DON, revealed after performing a procedure such as Trach Care, hands should be thoroughly washed with soap and water, as just rinsing hands with water was not sufficient or acceptable. Further interview revealed hand were to be washed with soap and water between procedures such as after Trach Care and prior to G-Tube site care in order to prevent the transfer of an organism from one site to another. Per interview cross contamination could result in the resident getting an infection and even death could occur as a result of the infection. Per interview, staff was expected to follow the facility policies regarding infection control and procedures for performing G-Tube care. Interview with the Administrator on 07/11/19 at 3:26 PM, revealed it was his expectation staff follow the facility infection control policies. He stated staff should be using good hand hygiene and proper infection control protocols during medication pass, during trach care, and during G-tube site care in order to prevent cross contamination and the spread of infection and disease. Further interview revealed it was his expectation regulations be followed related to the Tuberculin Skin Tests and the failure to follow facility policies and regulations related to TB was an infection control issue. Additional interview revealed facility staff received training routinely related to infection control and he would need to implement auditing to ensure infection control polices were followed. Based on observation, interview, record review, and review of facility policies, it was determined the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three (3) of twenty-four (24) sampled residents (Resident #23, #69 and #75). Observation of Medication Administration for Resident #69, on 07/11/19, revealed Registered Nurse (RN) #1 handled pills and capsules with her bare hands. In addition, observation of Tracheostomy Care for Resident #75, on 07/11/19 , revealed RN #1 failed to ensure proper hand hygiene and glove usage prior to, during, and after the procedure. Furthermore, observation on 07/11/19, revealed after RN #1 completed Trach Care for Resident #75, she failed to wash her hands before donning clean gloves and setting up to provide Gastrostomy Tube (G-Tube) site care. The State Agency Representative intervened and questioned the RN about handwashing between procedures, and RN #1 then stopped, and went to the sink to rinse her hands under water, instead of washing her hands with soap and water. RN #1 then proceeded to don clean gloves and perform Gastric Tube (G-Tube) site care, even though she did not properly wash her hands prior to the procedure. Moreover, Resident #23's Immunization Report from the Electronic Health Record (EHR), revealed the resident received an admission Tuberculin Skin Test (TST) on 03/09/18, with negative results; however, the date of the results and the millimeters (mm) of induration was not recorded. In addition, the Immunization Report, revealed the second step of the initial screening for TB was completed on 03/23/18, with negative results; however, the date of the results and the mm of induration was not recorded. Further review of the Immunization Report, revealed the annual TST was not repeated until 05/13/19, fourteen (14) months after the initial test, thus the test was performed two (2) months past the twelve (12) month period required per regulation. The findings include: Review of the facility's Infection Control Policy, revealed the facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of disease and infections and these policies apply to all personnel. Further review revealed all personnel will be trained on the infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control. 1. Review of the facility's Administering Medications Policy, undated, revealed staff shall follow established facility infection control procedures (e.g. handwashing, antiseptic technique, gloves, isolation precautions, etc.) for administration of medications, as applicable. Observation of Medication Administration for Resident #69, on 07/11/19 at 8:00 AM, revealed RN #1 dropped the resident's Sertraline HCL 25 milligram (mg) Tablet on the medication cart. RN #1 retrieved the medication with ungloved hands placing it in the cup. When the State Agency Representative asked if this was appropriate, she stated, well, it is the 10 second rule. She then proceeded to put her finger in the medication cup and stated the medication was sticking to the bottom of the cup. At that time, she did discard the medication and retrieved another Sertraline HCL 25 mg Tablet and put it in the cup without handling the medication. Further observation during this same medication pass for Resident #69, revealed RN #1 removed an Omega-3 Capsule ([NAME] Oil) 1000 mg from the package and placed it into the medication cup. She then wiped off her nursing scissors with a Sani-wipe, removed the Omega-3 capsule from the cup with her ungloved hand and cut a whole at the end of the capsule to release the liquid. RN #1 released the liquid from the capsule into the thirty (30) millimeter (ml) medication cup and then poured the medication into the Hi-Cal supplement to administer. The State Agency Representative then asked if it was appropriate to handle medications without gloves, to which RN #1 responded, I did not touch the liquid, so there is no problem. Continued interview with RN #1, on 07/11/19 at 2:23 PM, revealed she felt it was okay to retrieve a medication off the top of the medication cart as long as it was not nasty. Further interview revealed she did understand she should not handle medications with ungloved hands for infection control purposes. Interview was conducted, on 07/12/19 at 2:33 PM, with the Assistant Director of Nursing (ADON), who also was the Infection Control Nurse (ICN) and Staff Development Coordinator (SDC) for the facility. Per interview, if a medication tablet was dropped on a medication cart, staff should discard it in the proper manner. Continued interview revealed staff were not allowed to handle oral medications without gloves due to the potential for cross contamination. 2. Review of the facility Tracheostomy Care Procedure, undated, revealed the steps included: remove old dressings, pull soiled gloves over dressing and discard into appropriate receptacle; and wash hands. 1) Open tracheostomy kit; 2) set up supplies on sterile field; 3) maintain sterile field while pouring Hydrogen Peroxide in one compartment of opened kit and pour Normal Saline in another compartment.; 4) don sterile gloves; 5) secure the outer neck plate with non-dominate gloved hand; 6) Unlock the inner cannula with gloved dominate hand; 6) remove the inner cannula, while rotating clockwise while lifting away from the resident and soak the cannula in Hydrogen Peroxide, clean with brush, and rinse with Saline and dry with pipe cleaners; 7) remove and discard gloves, wash hands and don clean gloves; 8) replace the cannula and lock in place. For Site and Stoma Care: Apply clean gloves; clean the Stoma with Normal Saline soaked guaze pads; rinse Stoma with saline soaked guaze pads; wipe with dry gauze; allow to air dry or wipe with clean, dry gauze; remove neck ties and replace with clean ones as needed; apply a gauze pad around insertion site; remove gloves and discard; and wash hands. Observation of Tracheostomy Care for Resident #75, on 07/11/19 at 1:35 PM, revealed RN #1 failed to wash hands prior to donning gloves before the procedure. She was observed to set up the Trach-Care kit and sterile field on the resident's abdomen instead of setting up the kit on the bedside table. RN #1 poured the Hydrogen Peroxide from the kit into one compartment and the Normal Saline in the second department. Clean gauze and Q-tips were on the sterile field area. RN #1 secured the tracheostomy neck plate and removed the disposable inner cannula and discarded it into the trash. She then removed her soiled gloves and without washing her hands, donned sterile gloves and applied a new sterile inner cannula. She then cleaned the outer area of the stoma with Hydrogen Peroxide Q-tips (instead of Normal Saline) making several swipes. Sterile gloves were removed and she failed to wash hands before donning clean gloves. RN #1 applied a split gauze with a single piece of tape over the split gauze. RN #1 then stated she forgot to use the Normal Saline in the kit. She then lifted the sterile gauze from the stoma site, and used Q-Tips and Normal Saline to clean around the stoma, never removing the split gauze dressing completely. Interview with RN #1, on 07/11/19 at 2:23 PM, revealed she washed her hands prior to entering the resident's room; however, she did not perform hand hygiene prior to setting up the equipment for Trach Care. Continued interview revealed she should have performed hand hygiene after removing her gloves and prior to donning clean gloves during the procedure. Further, she should have used the bedside table to set up the sterile field for the procedure. Interview with the ADON/ICN/SDC, on 07/12/19 at 2:33 PM, revealed the more seasoned nurses taught other nurses how to perform Trach Care at the facility. Per interview, nurses should wash their hands prior to starting Trach Care, and wash hands between glove changes with soap and water, as just rinsing the hands was not acceptable. Further interview revealed the facility Tracheostomy Care Procedure should be followed to prevent the spread of infection during the procedure. 3. Review of the facility's Gastrostomy/Jejunostomy Site Care procedure guidelines, undated, revealed the purpose of the procedure was to promote cleanliness and to protect the gastrostomy or Jejunostomy site from irritation, breakdown and infection. The following equipment and supplies will be necessary: 1) Soap and Water; 2) Gauze; 3) Cotton-tipped applicators; and 4) personal protective equipment to include gloves. Steps in the procedure will include washing hands and drying hands and donning gloves. Use gauze pads, and soap and warm water to gently clean the area immediately surrounding the tube and continue working outward in a circular fashion. After cleansing, the site will be allowed to air dry. Unless otherwise indicated, do not place a dressing over the site. Observation on 07/11/19 at 1:50 PM, revealed RN #1 completed Tracheostomy Tube care (Trach Care) care for Resident #75. RN #1 then without washing her hands, donned clean gloves stating she was going to provide Gastrostomy Tube (G-Tube) site care. The State Agency Representative intervened and questioned the RN about handwashing between procedures, and RN #1 then stopped, and went to the sink in the resident's room, and rinsed her hands under water. However, RN #1 failed to use soap or properly wash her hands before drying her hands and donning clean gloves to perform the G-Tube site care. RN #1 then cleansed the G-Tube site with Normal Saline gauze, patted the site dry, applied a split gauze, and secured the gauze with tape on the top of the split gauze dressing. After the dressing was applied, RN #1 did wash her hands. Interview with RN #1, on 07/11/19 at 2:23 PM, revealed she should have washed her hands properly with soap and water after performing Trach Care and prior to performing G-Tube site care. Per interview, if hands were not washed between procedures there was the potential for cross contamination. Interview with the ADON/ICN/SDC, on 07/12/19 at 2:33 PM, revealed infection control education was provided at least monthly, and this education included the importance of proper handwashing. Per interview, staff was taught poor handwashing or no handwashing would result in the spread of infections. Per interview, staff was to wash their hands with soap and water, as rinsing of the hands or just using water was not acceptable. Further interview revealed handwashing was required between procedures and anytime gloves were removed. Additional interview revealed RN #1 should have washed her hands with soap and water after performing Trach Care and prior to donning gloves to perform G-Tube site care for Resident #75. She stated this was to prevent cross contamination from the Trach to the G-Tube site.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility's Policy, it was determined the facility failed to ensure daily quality controls were run on glucometers (a device utilized to obtain an immediate reading of the blood glucose) for eleven (11) dates on two (2) glucometers totaling twenty-two (22) events between 03/01/19 and 07/09/19. This affected fifteen (15) residents (Residents #1, #15, #16, #17, #20, #23, #31, #37, #50, #61, #66, #67,#73, #75, and #85) on the 100 and 300 Halls. Review on 07/10/19 of the Glucometer Control Logs, for the 100 and 300 Halls, revealed there were two (2) glucometers in use for fifteen (15) residents who were diagnosed with Diabetes Mellitus. Review of the Logs, revealed missing control results for the dates: 01/18/19, 01/19/19, 03/17/19, 04/28/19, 05/12/19, 05/30/19, 06/04/19, 06/05/19, 07/01/19, 07/02/19, and 07/03/19. Notations in the logs for the dates: 05/13/19, 06/08/19, 06/09/19, 06/21/19, and 06/22/19, revealed no meter or monitor was available. The findings include: Review of the facility's Performing a Control Solution Test Policy, undated, revealed the results of the high and low control solution should be recorded in the Daily Log located at each nurse's station. In addition, the Policy stated the checks must be performed nightly by the night shift nurse on each nursing unit. Review of the Manufacturer's (Optimum by [NAME]) Recommendations, revealed the Control solution results should fall within the control solution range printed on the test strip. Check that the lot number printed on the test strip packet and instruction for use match. Observation on 07/10/19 at 2:00 PM, revealed the facility's 100 Hall and 300 Hall nurse's stations were utilizing two (2) glucometers for their diabetic residents. The Glucometer Calibration and Quality Control Logs in the binder at the nurse's station for the 100 and 300 Halls, were dated 01/01/19 through 07/10/19 for each glucometer. Further review revealed both Logs were missing data on the same dates. The dates without data recorded included: 01/18/19, 01/19/19, 03/17/19, 04/28/19, 05/12/19, 05/30/19, 06/04/19, 06/05/19, 07/01/19, 07/02/19, and 07/03/19. Notations in both Logs for the dates: 05/13/19, 06/08/19, 06/09/19, 06/21/19, and 06/22/19, revealed no meter or monitor was available. Record review revealed the residents with a diagnosis of Diabetes Mellitus on the 100 Hall and the 300 Hall who received accuchecks using the glucometers included Residents #1, #15, #16, #17, #20, #23, #31, #37, #50, #61, #66, #67, #73, #75, and #85. Interview with Licensed Practical Nurse (LPN) #2, on 07/09/19 at 3:30 PM, revealed the night shift nurses were responsible for performing the Quality Controls on the glucometers. Further interview revealed the glucometers needed to be maintained appropriately in order to ensure accurate blood glucose readings, as the dose of insulin administered depended on the blood glucose results. Interview on 07/10/19 at 3:45 PM, with LPN #4, revealed the night nurses were responsible for the logging of glucometer controls each night. She further stated the controls should be run to ensure the accuracy of the blood glucose readings so the residents receive appropriate doses of insulin. Interview on 07/11/19 at 9:30 AM, with the Assistant Director of Nursing (ADON), revealed the night shift nurses were responsible for ensuring the glucometers had controls run each night to ensure accuracy of the glucometers. The ADON stated she was responsible to monitor the logs for accuracy and completeness weekly; however, she had failed to ensure this was done. She stated if the glucometers were not accurate, a resident could receive an insufficient or excessive amount of insulin. Interview with the Director of Nursing (DON), on 07/12/19 at 2:40 PM, revealed she expected staff to perform glucometer control checks and log them per policy. She further stated there were several new nurses on the night shift, which may indicate a training need. Further interview revealed she expected the monitors to perform accurately in order to avoid potential over/ under dosing of insulin which could be dangerous for residents. Interview with the Administrator, on 07/12/19 at 3:00 PM, revealed he expected the night nurses to perform their duties, including performing glucometer control checks.