Based on observation, interviews, record reviews, and facility policy review, the facility failed to ensure the comprehensive care plan interventions were implemented during Percutaneous Endoscopic Gastrostomy (PEG) tube care for one (1) of 19 care plans reviewed. Resident #30 Findings Include: A review of the facility's policy titled Care Plans, dated 02/20/20 revealed, Each resident will have a person-centered plan of care to identify problems, needs, and strengths that will identify how the interdisciplinary team will provides care . PROCEDURE: . 6. Staff approaches are to developed for each problem/strength/need. Assigned disciplines will be identified to carry out the intervention . A record review of Resident #30's Comprehensive Care Plan with a start date of 4/4/2019 revealed Adequate fluid/nutritional intake .Intervention .Keep head of bed elevated at all times .Cleaning peg site with normal saline. Pat the site dry with gauze .for skin protection. On 11/06/24 at 1:25 PM, during an observation of PEG site care, Licensed Practical Nurse (LPN) #1 lowered the head of the bed to a flat position while the pump continued to infuse the feeding. After cleaning the PEG site, LPN #1 did not dry the PEG tube site prior to applying the split gauze dressing. During an interview with LPN #1 on 11/06/24 at 1:35 PM, she acknowledged that she did not follow the care plan for Resident #30 when she lowered the bed of Resident #30 while the feeding continued to infuse and did not dry the PEG site before applying the split gauze dressing. On 11/07/24 at 12:48 PM, during an interview with the Director of Nursing (DON), she stated that she expects staff to follow the care plan when providing care. On 11/07/24 at 3:00 PM, during an interview with LPN #2, the Minimum Data Set (MDS)/Care Plan Nurse, she explained that staff are expected to adhere to the plan of care, as the purpose of the care plan is to guide the staff in providing appropriate care. A record review of the admission Record revealed the facility admitted Resident #30 on 03/22/19. The resident had diagnoses that included Dysphagia, Oropharyngeal Phase and Encounter for Attention to Gastrostomy. A record review of Resident #30's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/16/24 revealed a Brief Interview for Mental Status (BIMS) score of ninety-nine (99), indicating severely impaired cognition. Section K was coded for PEG tube usage.

Based on observations, interviews, record reviews, and facility policy review, the facility failed to ensure the physician orders were followed related to the care of a resident with a Percutaneous Endoscopic Gastrostomy (PEG) tube for one (1) of (19) sampled residents. Resident #30. Findings Include: A review of the facility's policy titled, Dressing Change, policy (undated) revealed, A dressing change will be done to promote wound healing, prevent infection and to provide an opportunity for wound assessment. On 11/06/24 at 1:25 PM, during an observation of PEG tube site care, Licensed Practical Nurse (LPN) #1 lowered the head of the bed to a flat position while Resident #30's feeding pump was infusing Glucerna 1.2 at 50 cubic centimeters (cc) per hour. LPN #1 then proceeded to clean the PEG site with gauze in a circular motion without drying the site afterward. On 11/06/24 at 1:35 PM, during an interview with LPN #1 , she admitted she forgot to place the feeding pump on hold before positioning the bed flat to conduct care. She acknowledged that she should have dried the site before applying a split gauze. During an interview on 11/07/24 at 12:48 PM, the Director of Nursing (DON), stated that LPN #1 should have stopped the pump. She explained that Resident #30 could aspirate if the pump continues infusing while the bed is flat. She also noted that failing to dry the site could increase the risk of infection. A record review of the admission Record revealed the facility admitted Resident #30 on 03/22/19. The resident had diagnoses that included Dysphagia, Oropharyngeal Phase and Encounter for Attention to Gastrostomy. A record review of the Order Summary Report, revealed Resident #30 had active orders as of 11/07/24 that included an order dated 1/13/24 to keep the head of the bed elevated 30-90 degrees while tube feeding was infusing and an order dated 1/31/24 to clean the PEG site with normal saline, and pat dry with gauze before applying a split gauze to the PEG site daily for skin protection. A record review of Resident #30's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/16/24 revealed a Brief Interview for Mental Status (BIMS) score of (99), indicating severely impaired cognition. Section K was coded for PEG tube use.

Based on observation, interviews, record review, and facility policy review, the facility failed to prevent significant medication errors for one (1) of six (6) residents observed for medication administration. Resident #9 Findings Include: A review of the facility's policy titled Medication Administration Guidelines, (undated), revealed, Medications are administered as prescribed .18. Prior to administration, the medication and dosage schedule on the resident's MAR/TAR or EMAR/ETAR is compared with the medication label. Information on the medication should be checked against the MAR/ETAR at least three times during the med preparation and administration process . During an observation on 11/04/24 at 8:35 AM, Licensed Practical Nurse (LPN) #3 pulled medications for Resident #9. While pulling medications for an order of Lorazepam Oral Tablet 0.5 mg (milligram) that was to be given once daily for Anxiety Disorder, LPN #3 instead pulled a tablet for Alprazolam 1 mg, 1.5 tablets (to equal 1.5 mg) to be given at bedtime. This medication was placed into the medication cup with the resident's other medications to be administered. LPN #3 confirmed she intended to administer the medication to Resident # 9. The State Agency (SA) questioned whether the Alprazolam medication was due at that time and LPN #3 confirmed that the medication was not due and verified it as the incorrect medication for that time. LPN #3 called LPN #5, and together, they wasted the medication. During an interview on 11/07/24, the Director of Nursing (DON) stated that her expectation was for staff to ensure residents receive the correct medications as prescribed. She emphasized that administering incorrect medications, especially narcotics, could result in adverse outcomes, including lethargy or oversedation, and expressed concern regarding the observed error. A record review of the admission Record revealed the facility admitted Resident #9 on 01/21/15. The resident had diagnoses that included Anxiety Disorder, Depression, and Insomnia. A record review of the Order Summary Report, with active orders as of 11/07/24 revealed Resident #9 and order for the Lorazepam Oral Tablet 0.5 mg (to be given once daily for Anxiety Disorder, unspecified), with an order start date of 10/02/24 and Alprazolam 1 mg, with an order for 1.5 tablets (to equal 1.5 mg) to be given at bedtime, with an order start date of 10/01/24.

Based on observations, interviews, record reviews, and facility policy review, the facility failed to ensure proper infection control practices were implemented during Percutaneous Endoscopic Gastrostomy (PEG) tube site care and wound care for two (2) of (19) sampled residents. Residents #14 and #30 Findings Include: A review of the facility's policy titled Hand Hygiene, dated 06/12/22 revealed, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors . If your task requires gloves, perform hand hygiene prior to donning gloves, and sanitize or wash hands after removing gloves . Resident #14 On 11/06/24 at 1:08 PM, during an observation of wound care, Licensed Practical Nurse (LPN) #1/Wound Care Nurse, performed a dressing change on Resident #14's right elbow. After removing the soiled dressing from the resident's arm, she placed it on the resident's bedside table without using a barrier and did not use a red biohazard bag for disposal. LPN #1 then proceeded to apply a new dressing without removing her soiled gloves. On 11/06/24 at 1:10 PM, LPN #1 admitted that she did not use a barrier or a red biohazard bag for the soiled dressing, acknowledging failure to do so could lead to infection. During an interview with the Infection Preventionist on 11/07/24 at 9:55 AM, she stated that all staff are expected to follow infection control guidelines, including using appropriate containers for disposing of soiled dressings to prevent the spread of infection. During an interview on 11/07/24 at 10:00 AM, the Director of Nursing (DON) emphasized her expectation that staff adhere to infection prevention protocols when performing wound care. She stated that failure to change gloves or using clean surfaces for soiled dressing could increase the risk of the spread of infection. A record review of Resident #14's admission Record revealed the facility admitted the resident on 07/16/24. The resident had diagnoses that included Dementia, and Pressure Ulcer of Right elbow, Stage 3. Resident #30 On 11/06/24 at 1:25 PM, during an observation of LPN #1 providing PEG tube site care for Resident #30 revealed LPN #1 entered the room without washing her hands or using hand sanitizer. She held one pair of clear gloves upon entry and did not perform hand hygiene before donning the gloves. After lowering the head of the bed with her bare hands, she applied gloves, removed the soiled split gauze from the PEG site, placed it in a red bag, and cleaned the site with gauze and normal saline and applied a new split gauze to the site. During the procedure, she did not wash her hands, use hand sanitizer, or change gloves. During an interview with LPN #1 at 1:35 PM on 11/06/24, she admitted that she failed to wash her hands or use hand sanitizer upon entering the room and acknowledged she should have performed hand hygiene and changed gloves at different stages of the care. She recognized that her actions could lead to cross-contamination and infection. At 12:48 PM on 11/06/24, the DON confirmed that LPN #1 should have performed hand hygiene before and during the procedure. The DON noted that failure to follow these infection control protocols could lead to the spread of infection. A record review of the admission Record revealed the facility admitted Resident #30 on 03/22/19. The resident had diagnoses that included Dysphagia, Oropharyngeal Phase and Encounter for Attention to Gastrostomy.

Based on observations, record review, interviews, and facility policy review, the facility failed to provide care and services to promote healing and prevent infection for one (1) of four (4) residents that required wound care. Resident #2 Findings Include: Record review of the facility policy titled DRESSING CHANGE, (undated), revealed, A dressing change will be done to promote wound healing, prevent infection and to provide an opportunity for wound assessment. On 5/23/24 at 3:50 PM, an observation of Resident #2 revealed she was lying on her back in bed. The resident's incontinence brief was wet and had fecal matter present. There were two small open areas on her sacral area, with no bandage present. On 5/23/24 at 4:55 PM, an interview with the Assistant Director of Nurses (ADON) revealed she was assigned to the care of Resident #2 on 5/23/24. She stated she had not provided wound care to Resident #2. She explained that she intended to wait because evening meal trays had just been delivered to the hall and she had to assist with meal deliveries. She stated, when trays come out, everyone stops doing what they're doing and passes trays, as she continued to retrieve meal trays from the cart. On 5/23/24 at 5:25 PM, an interview with the ADON revealed that Resident #2 had not yet had wound care to her sacral area on . She confirmed that the resident had not had a dressing in place from 3:50 PM until 5:25 PM. She also confirmed that Resident #2 was always incontinent of bowel and bladder. On 5/24/24 at 5:55 PM, in an interview with the ADON, she revealed Resident #2 received sacral wound care and her sacral dressing had been replaced after 5:30 PM, by Registered Nurse (RN) #1. On 5/24/24 at 2:00 PM, an interview with RN #1 revealed that she had performed wound care for Resident #2 on 5/23/24 after 5:30 PM. She confirmed that the resident had not had a dressing in place at the time, however, she did not know why. The nurse confirmed that it was important for incontinent residents, with open wounds, to have dressings in place according to physician orders to reduce the risk of infection. On 5/24/24 at 2:10 PM, an interview with Medical Doctor (MD) #1 revealed he it was important for physician orders for dressings to open areas to the sacral area be followed to provide a barrier to prevent exposure to urine and fecal matter in residents that are incontinent of bowel and bladder. He stated that this was important to prevent infection. On 5/24/24 at 2:30 PM an interview with the facility Administrator revealed he expected physician orders for wound care to be carried out in a manner to protect residents' skin and prevent infection. He stated that there was no facility policy in place that stated resident needs could not be provided during meal times. Record review of the Face Sheet for Resident #2 revealed the facility admitted the resident on 2/10/21. The resident had diagnoses of Chronic Kidney disease, Venous Insufficiency, and Stage 2 pressure Ulcer of Sacral Region. Record review of the Physician Orders, dated May 2024, for Resident #2, revealed an order, dated 4/16/24, to Cleanse stage 2 pressure injury to sacrum with normal saline. Pat dry with gauze. Apply foam dressing. Change daily and PRN until healed. Record review of the Electronic Treatment Administration Record (ETAR), for May 2024, revealed RN #1 performed wound care for Resident #2 on 5/23/24.

Based on observation, interviews, record review, and facility policy review, the facility staff failed to provide treatment and services in a manner to promote the healing and prevent complications of a pressure ulcer for one (1) of three (3) sampled residents with pressure ulcers. (Resident #2) Findings include: Review of the facility's policy, titled Dressing Change undated, revealed, Policy: A dressing change will be done to promote wound healing, prevent infection and to provide an opportunity for wound assessment . Review of the facility's policy, titled Hand Hygiene, reviewed 6/12/22, revealed Policy: All staff will perform hand hygiene procedures to prevent the spread of infection .Policy Explanation and Compliance Guidelines: 6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. On 3/13/24 at 11:55 AM, an observation revealed the facility Treatment Nurse provided wound treatment for a Stage 2 pressure ulcer, with non-intact skin on the left upper back of Resident #2. After the Treatment Nurse removed the dressing from the wound, she removed her gloves and donned (put on) clean gloves without performing hand hygiene. During the procedure, the Treatment Nurse dropped the sterile calcium alginate dressing on the mattress, picked the dressing up and applied the dressing to the wound. The Calcium Alginate dressing was larger than the wound. The adhesive and edge of the Calcium Alginate bordered dressing used to cover the wound protruded past the wound margins. Record review of the Instructions For Use on the Calcium Alginate dressing package revealed .Make sure the dressing DOES NOT overlap the wound margins . On 3/13/24 at 12:30 PM, during an interview with the Treatment Nurse, confirmed she had not performed hand hygiene after removal of the dressing from the resident's wound and removing her gloves, prior to donning fresh gloves and applying the calcium alginate dressing. The Treatment Nurse stated that she did not perform hand hygiene because the hand sanitizer was in a wall mounted dispenser, located next to the door, and she did not want to leave her clean field to use the hand sanitizer or the bathroom sink. The Treatment Nurse did not respond regarding the application of the Calcium Alginate dressing to the resident's wound, after being dropped on the mattress, nor did she respond to the Calcium Alginate dressing overlapping the wound margins. On 3/13/24 at 4:55 PM, in an interview the Director of Nurses (DON) confirmed that the facility policy on hand hygiene stated that hand hygiene was to be performed upon removal of used gloves and prior to the donning of clean gloves. A record review of the Face Sheet for Resident #2 revealed the facility admitted the resident on 9/15/23. The resident had diagnoses that included Pressure Ulcer of Unspecified Part of Back, Stage 2, Venous Insufficiency, and Type 2 Diabetes Mellitus. A record review of the March 2024 Physician Orders, for Resident #2 revealed an order dated 3/05/24 Clean Left upper back Stage 2 pressure ulcer with normal saline, apply Aquacel AG (Calcium Alginate) and cover with outer dressing. Change daily and PRN (as needed).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review, and facility policy review, the facility failed to provide care and services for a resident with an indwelling urinary catheter in a manner to prevent the potential for a urinary tract infection (UTI) for one (1) of two (2) sampled residents with indwelling urinary catheters. (Resident #6) Finding include: Record review of the facility policy titled, UTI Prevention with Indwelling Catheter Use, dated 1/27/2015, revealed, Policy: A resident with an indwelling catheter is susceptible to urinary tract infections . Policy Explanation . 3. Urinary drainage tubing should be positioned so as not to touch the floor . On 3/12/24 at 12:40 PM, an observation revealed Certified Nursing Assistant (CNA) #1 answered the call light for Resident #6, who was seated on the toilet in her room. The resident's catheter drainage bag and approximately three (3) inches of drainage tubing were lying on the floor next to the toilet. On 3/12/24 at 12:45 PM, in an interview with CNA #1, she confirmed the catheter drainage bag and tubing should not have been on the floor due to the risk of urinary tract infection. On 3/13/24 at 4:20 PM, an interview with Medical Doctor (MD) #1, he confirmed that catheter drainage bag and tubing should be kept off of the floor due to the risk of urinary tract infection. On 3/13/24 at 4:55 PM, during an interview the Director of Nurses (DON) confirmed that catheter drainage bags and drainage tubing should not be on the floor and that bags and tubing laid on the floor could increase the risk of a urinary tract infection. Record review of the Face Sheet for Resident #6 revealed the facility admitted the resident to the facility on [DATE], with diagnoses that included Unspecified Hydronephrosis and Cognitive Communication Deficit. Record review of the March 2024 Physician Orders revealed, an order dated 11/21/23 Insert 16F (French, size of catheter) 10cc (centimeter) bulb indwelling foley catheter r/t (related to) hydronephrosis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and facility policy review, the facility failed to honor the resident's right to make choices, as evidenced by residents having to remain out of bed during mealtimes for two (2) of four (4) residents reviewed for choices. Resident #15 and #24 Findings include: Review of the facility policy titled, Residents Rights, with the date reviewed/revised of 4/18/18, revealed . 6. Self-determination. The resident has the right to, and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to: . b. The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident. A record review of a signed letter provided by the Administrator, on the facility's letterhead, dated 2/23/23, revealed There is no written policy that care is not to be given during mealtimes. During an interview on 2/21/23 at 11:03 AM, Resident #24, revealed she preferred to lay down at lunch time, as this is something she has done in the past. However, she revealed staff have told her that no one is allowed to go back to bed during lunch time, so she is required to stay up. An interview and observation on 2/21/23 at 12:40 PM, revealed Resident #15 was tired of sitting up, but could not get help to get in bed until all the lunch trays were picked up. Although the resident was observed to have completed her lunch, and her tray had been removed from her room, she revealed there was a rule that no one could ask to get back in bed during mealtime. An interview on 2/21/23 at 12:44 PM, Certified Nurse Aide (CNA) #4, revealed she had been told no resident can get back in bed until all the trays for a meal are passed out, all residents that need to be fed are fed, and all trays are picked up after the mealtime was over. She commented she did observe Resident #15 and asking to get in bed, but the resident had to wait until the trays were picked up before she could go to bed. CNA #4 revealed she was not aware of a past request from Resident #24 to go to bed during a mealtime. During an interview on 2/21/23 at 12:48 PM, with Licensed Practical Nurse (LPN)#2, and the Registered Nurse (RN)/Wound Care Nurse, they both revealed that residents are not to be put to bed during mealtimes. They reported that the meal trays must be passed out, the CNAs must feed the residents that require assistance with their meals, and the CNAs must then pick up all the trays prior to assisting residents to bed. They noted they were unaware of past requests from Resident #24 to go to bed during mealtime. Both nurses revealed that they were not aware if this was facility policy or if is information that had been passed on to them by other staff in their training. An interview on 2/21/23 at 2:00 PM with the Director of Nursing (DON), revealed residents are aware, during mealtimes, the CNAs pass out meal trays, feed the residents that require assistance, and must pick up the meal trays before residents are placed back in bed. The DON also revealed she could not recall if this practice was based on facility policy. However, confirmed that residents have the right to choose when they want to go to bed, and that preferences were not being honored for Resident #15 and Resident #24. An interview on 2/21/23 at 09:20 AM, with the Administrator, revealed the CNAs are to complete the mealtimes, breakfast, lunch, and dinner, before assisting resident, to avoid cross contamination. She added that the nurses are available and should have assisted with putting Resident #15 back to bed. She noted Resident #15's and Resident #24's rights were not being honored, if they requested to be put in bed. The Administrator revealed the facility did not have a policy preventing residents from going to bed during mealtimes. She stated this was a directive from lead staff. Record review of the Face Sheet for Resident #15, revealed the facility admitted the resident to the facility on 4/8/22. Current diagnoses include Hemiplegia and Dementia. Record review of Section C of the Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 1/9/23, for Resident #15, revealed a Brief Interview for Mental Status (BIMS) score of 11, indicating the resident had moderate cognitive impairment. Record review of the Face Sheet for Resident #24, revealed the facility admitted the resident to the facility on [DATE]. Current diagnoses include Type 2 Diabetes Mellitus and Acute Transverse Myelitis. Record review of Section C of the Annual MDS Assessment, with an ARD of 11/14/22, for Resident #24, revealed a BIMS score of 15, indicating Resident #24 is cognitively intact.

Based on observations, interviews, record reviews, and facility policy review, the facility failed to shave a resident that required assistance with shaving for one (1) of 18 residents reviewed for Activities of Daily Living. Resident #48 Findings include: Review of the facility policy titled, A.M. Care revealed, A.M. care will be given to residents daily . Responsibility: All Nursing Assistants. Equipment: . 7. Razor, shaving cream . An observation on 2/21/23 at 9:01 AM, revealed Resident #48 unshaven with facial hair about ½ inch long. He stated he hasn't been shaved in a month, but when he was able to do it for himself, he shaved daily. An observation on 2/21/23 at 10:00 AM, revealed Resident #48 receiving a bed bath. In an interview on 2/21/23 at 3:15 PM, Certified Nursing Assistant (CNA) #1 confirmed she had given Resident #48 a bath this morning. She confirmed that she had washed his face but didn't offer him a shave, because she didn't think he needed it. However, after looking at the resident again, she stated he had needed to be shaved. During an interview on 2/22/23 at 4:00 PM, the Director of Nursing (DON) revealed Resident #48 did need to be shaved. She confirmed the hair on the face of Resident #48 was about approximately ½ inch long and he should have been offered a shave. An interview on 2/23/23 at 12:23 PM, CNA #5 revealed the residents are assigned shower days on a schedule at the nurse's desk. She confirmed that shaving is part of that care. An interview with the DON on 2/23/23, at 10:45 AM, revealed CNA's have a list of residents scheduled for showers and that care includes all care required by the residents, including shaving. A record review of the Face Sheet, for Resident #48, revealed the facility admitted the resident on 11/1/22. The diagnoses of Resident #48 included Type 2 Diabetes Mellitus with Diabetic Neuropathy, Peripheral Vascular Disease, Muscle Weakness, and Lack of Coordination. A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/20/23, revealed Resident #48 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact.

Based on observation, interviews, record review, and facility policy review, the facility failed to provide appropriate catheter care of for one (1) of three (3) residents reviewed for a catheter care. Resident #29 Finding's include: Review of the facility policy titled, Catheterization Policy, with no revision date, revealed, . Reminders -Tubing and bag should be properly positioned below hip level . An observation on 2/21/23 at 8:45 AM, revealed Resident #29 lying in bed with a nephrostomy bag attached to the head of the bed on her right side. The head of the bed that was elevated to approximately 30 degrees. An interview on 2/22/23 at 8:40 AM, with Certified Nurse Assistant (CNA) #2, revealed that Resident #29 gets turned every two hours. The CNA stated the urine catheter bag does not affect her turning, because it always stays at the head of the bed. An observation on 2/22/23 at 9:22 AM, revealed, Resident #29 was lying in bed with her nephrostomy bag at the head of the bed, that was elevated approximately 30 degrees. An observation and interview on 2/22/23 at 1:41 PM, with the Registered Nurse (RN)/Wound Care Nurse and CNA #3, confirmed that Resident #29's nephrostomy bag was laying at the head of her bed, that was elevated to approximately 30 degrees. An interview with the Wound Care Nurse revealed that a urine catheter bag needs to be kept below the kidneys to help with flow, but Resident #29's has always been kept at the head of the bed, but she is not sure why. CNA #3 confirmed that the resident's nephrostomy bag is always at the head of her bed, but she is also not sure why. An interview on 2/22/23 at 1:54 PM, with Licensed Practical Nurse (LPN) #2, confirmed that urine drainage bags should be kept below the bladder, but Resident #29's nephrostomy bag was always kept on the resident's right side at the head of the bed. She revealed she usually moves the bag lower, but it gets moved back up. An interview on 2/22/23 at 2:00 PM, with the Director of Nurses (DON), confirmed that Resident #29's nephrostomy bag should be kept lateral or below the kidneys to prevent back flow, which could lead to kidney stones or bacteria flowing back into her kidneys. An observation on 2/23/23 at 7:50 AM, revealed Resident #29's nephrostomy bag was laying above the resident's pillow at the head of the bed, with the head of the bed elevated to approximately 30 degrees. Record review of Resident #29's Face Sheet, revealed the facility admitted the resident to the facility on 3/22/19, with medical diagnoses that included Unspecified Dementia, personal history of Urinary Tract Infections and Calculus of Kidney. Record review of then Minimum Data Set (MDS) for Resident #29, with an Assessment Reference Date (ARD) of 11/02/22, revealed in Section C a Brief Interview for Mental Status (BIMS) score of 99, which indicated the resident was severely cognitively impaired and Section H revealed the resident had an indwelling catheter.

Based on interviews, record reviews and facility policy review, the facility failed to ensure as-needed (PRN) psychotropic medications were discontinued after 14 days, for one (1) of six (6) residents reviewed for unnecessary medications. Resident # 9 Findings include: Review of the facility policy titled, Psychotropic Medication Policy and Procedure with a revision date of 3/21/17, revealed Policy: Physicians//providers will use psychotropic medications appropriately working with the interdisciplinary team to ensure appropriate use, evaluation and monitoring. Standards: 1. The facility will make every effort to comply with state and federal regulations related to the use of psychopharmacological medications in the facility to include regular review for continued need, appropriate dosage, side effects, risks and or benefits . 9. Orders for PRN psychotropic medications will be time limited (i.e., times 2 weeks) and only for specific clearly documented circumstances. PRN orders for anti-psychotic drugs are limited to 14 days unless the prescriber evaluates the resident for the appropriateness of that medication . A record review of the February 2023, Physician Orders, for Resident #9 revealed, . Lorazepam (Ativan) 0.5 mg (milligram) tablet give one tablet by mouth every eight hours as needed for anxiety .Order Date 4/21/22 and Start Date 4/21/22 . the order did not include a stop date. A record review of the past ten (10) months of Resident #9's Electronic Medication Administration Record (EMAR) revealed that the resident has continued to receive the PRN medication beyond the required 14 day limit, for the past ten (10 months. This PRN order was continuous, without the required reassessment, documentation of rationale for continued use, and new orders. Resident #9's EMAR documentation revealed since the order was written on 4/21/22, the resident has received Lorazepam 0.5 mg tablets seven (7) times in April 2022, 20 times in May 2022, 16 times in June 2022, ten (10) times in July 2022, four (4) times in August 2022, three (3) times in September 2022, two (2) times in October 2022, two (2) times in November 2022, four (4) times in December 2022, ten (10) times in January 2023, and 11 times thus far in February 2023. A record review of the Face Sheet, revealed the facility admitted Resident #9 on 07/30/19. The resident's current diagnoses include Major Depressive Disorder and Anxiety Disorder. A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/2/23, revealed in Section C a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident's cognition was moderately impaired. An interview on 2/22/23 at 2:35 PM, with the Pharmacy Consultant revealed that Ativan would need a 14 day stop date, unless the physician documents the indications for use, why it needs to be extended and the time for when to review again. An interview on 2/22/23 at 2:45 PM, with the Administrator revealed that a resident taking a psychotropic medication, without a stop date, could have an increase in their potential for falling, changes in behavior, and many other complications. An interview on 2/22/23 at 3:00 PM, with the Director of Nurses (DON), confirmed that Resident #9 did not have a stop date for Ativan. She revealed that she is aware that most psychotropic medications should have a stop date.

Based on resident and staff interviews, record reviews, and facility policy review, the facility failed to document and act promptly to resolve grievances and recommendations from Resident Council Meetings for six (6) of 6 months of resident council meeting minutes reviewed. Findings include: A review of the facility policy titled, Resident and Family Grievances, with a date reviewed of 2/3/23, revealed, Policy: It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal. 2. The Grievance Official, Administrator or Director of Nursing is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion; leading any necessary investigations by the facility . Policy Explanation and Compliance Guidelines: .8. Grievances may be voiced in the following forums . d. Verbal complaint during resident or family council meetings 10. Procedure: . b. The staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form or assist the resident or family member to complete the form. d. The Grievance Official will take steps to resolve the grievance, and record information about the grievance, and those actions, on the grievance form. e. The Grievance Official, or designee, will keep the resident appropriately apprised of progress towards resolution of the grievances. 12. The facility will make prompt efforts to resolve grievances. A record review of the Resident Council Meeting Minutes for 9/28/22, 10/19/22, 11/23/22, 12/7/22, 1/25/23, and 2/15/23, revealed there were no documented grievances or review from concerns voiced during the previous month's meeting. During the Resident Council Meeting held on 2/22/23, at 2:30 PM, Resident #36 revealed that she became the Resident Council President six (6) months ago. In an interview with the President, she revealed she did not remember seeing the staff member present at the meetings writing down any of the resident complaints made during the meetings or reporting feedback to the group on responses or actions taken regarding the previous month's complaints. During the meeting, at 2:40 PM, Resident #68 was interviewed regarding her Resident Council Meeting attendance. Resident #68 revealed she used to regularly attend the meetings but stopped due to there being no resolution to any issues brought up in the meetings. She confirmed complaints were discussed, but nothing was ever done. An interview, during the meeting at 2:56 PM, with Resident #1, revealed she too had once regularly attended the Resident Council Meetings, but had grown tired of going to the meetings to discuss her complaints, listen to the complaints of other residents, and returning to the meeting the next month realizing that nothing was being done about their complaints. She voiced she could not remember if anyone wrote down what was being said in the meetings, but none of the staff followed up with her about any of the complaints she had made. An interview on 2/22/23, at 3:30 PM, with the facility's Social Services Director, revealed she was responsible for monitoring the Resident Council Meetings. She revealed, at the beginning of the meetings, the residents are informed that she was aware they may have a lot of complaints, but they should keep them to a minimum and concentrate on what can be done to make things better. She stated that she sat in the back at the meetings, allowed the Resident Council President to conduct the meeting and keep the Resident Council Meeting minutes, and had no further input. She also noted there had been complaints by the residents in the meetings, but she did not write formal grievances for the complaints. Instead, she stated she would call the departments involved and allow them to handle the complaints. An interview on 2/22/23 at 03:55 PM, with the Administrator, revealed the residents have the option to report grievances to Social Services at times other than in Resident Council Meetings. She noted that Social Services have a Grievance Log and residents were aware they could file a Grievance with Social Services. The Administrator did not confirm that Social Services should have documented and followed up for resolution of grievances from the Resident Council Meetings. An interview on 2/23/23 at 11:40 AM, with the Assistant Activities Director, revealed she was present in the January and February 2023, Resident Council Meetings, and the mediator for the residents. She noted the Resident Council President conducted, as well as documented the meetings. She confirmed she did not write down the resident grievances from the meeting, as it was the responsibility of the Resident Council President to document the grievances. A record review of the Grievance Log for September 2022, through February 2023, did not reveal grievances from any of the Resident Council Meetings. A record review of the Face Sheet for Resident #1, revealed the facility admitted the resident on 5/14/21. A record review of Section C of the Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 2/9/23, for Resident #1, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #1 is cognitively intact. A record review of the Face Sheet for Resident #36, revealed the facility admitted the resident on 8/5/16. A record review of Section C of the Quarterly MDS Assessment, with an ARD of 2/1/23, for Resident #36, revealed a BIMS score of 15, indicating Resident #36 is cognitively intact. A record review of the Face Sheet for Resident #68, revealed the facility admitted the resident on 11/23/22. A record review of Section C of the Quarterly MDS Assessment, with an ARD of 2/21/23, for Resident #68, revealed a BIMS score of 15, indicating Resident #68 is cognitively intact.

Based on observation, staff interviews, and facility policy review, the facility failed to maintain a clean ice machine for the residents as evidenced by white, red, and black residue build up on the inside and outside of the ice machine, observed on one (1) of five (5) kitchen tours. Findings include: Review of the facility policy titled, Cleaning Instructions Ice Maker and Dispenser, dated 9/04, revealed, Policy: Equipment shall be maintained in a clean and sanitary condition . Procedure: . The ice making system can be cleaned in place without disassembling the water system. The cleaning process should be performed at least every 6 months or more often if local water conditions dictate . An observation and interview on 2/21/23, at 8:08 AM with the Dietary Cook, revealed the ice machine to have streaks of white residue running down from the door covering the ice machine and down the left outer side of the ice machine. There were also observations of the following: 1. Streaks of faded white residue on the inside of the door covering the ice machine. 2. Red residue on the inside ledge, under the door covering the ice machine. 3. Buildup of red residue that extended across the full length of the bottom edge of a white plastic guard, located inside the ice machine, which hung over the ice. 4. Condensation dripping off the white plastic guard and running through the red residue onto the ice located below it. 5. Buildup of red residue inside the machine, on the metal hinges on the right side of the door, located above the ice. 6. Buildup of red residue on a black, outward curved, rubber flap that hung on the right inside area of the ice machine, located under the right-side metal hinge. 7. Thick black build up on a black, outward curved rubber flap that hung inside the machine The Dietary [NAME] used a wet, white, towel and wiped away the red residue on the inside ledge of the ice machine, located under the door and the red residue on the white plastic guard, that had condensation dripping through it onto the ice. The Dietary [NAME] confirmed that the ice machine was not clean, but the Dietary Manager is responsible for keeping it clean. An observation and interview on 2/21/23, at 8:30 AM with the Dietary Manager, revealed he was responsible for cleaning the ice machine. He stated that it was last cleaned in January 2023, however, he does not keep a cleaning log for the ice machine, but he makes sure it is cleaned every month. He confirmed that he observed the white streaks, as well as the red and black buildup located inside the machine. He too was observed using a wet, white, towel to wipe more of the red and black residue off the rubber flap. The Dietary Manager confirmed the ice machine was not clean. He revealed that an unclean ice machine could contaminate the ice and cause the residents to become sick. An interview on 2/22/23, at 4:00 PM with the Administrator, revealed the ice machine should have been clean, as it could contaminate the ice that was being served to the residents. He confirmed that contaminated ice had the potential to cause illness.

Based on staff interviews, record reviews, and facility policy review, the facility failed to accurately complete the Level I Preadmission Screening (PAS) for one (1) of four (4) resident preadmission screenings reviewed, Resident #78. Findings include: A review of the facility's email statement, dated 10/4/19, revealed the facility follows the state guidelines for completing the PAS. Review of the Pre-admission policy, dated August 26, 2016, revealed the facility conducted a Mental Illness (MI)/Mental Retardation (MR) screening if the diagnosis required. Review of the Preadmission Screening (PAS) Summary and Physician Certification with a PAS date of 6/5/19, indicated Resident #78 did not have a diagnosis of a major mental illness or a history of a mental illness. A review of the facility's Face Sheet revealed the facility admitted Resident #78 on 6/7/19, with diagnoses of Major Depressive Disorder and Delusional Disorders. Review of the most recent quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 9/3/19, revealed Resident #78 was coded for Psychotic Disorder (other than Schizophrenia) and Depression. The most recent Admission/Discharge MDS assessment, for Resident #78, with an ARD of 6/9/19, was coded to include Manic Depression (Bipolar Disorder) and Psychotic Disorder (other than Schizophrenia). On 10/02/19 at 3:32 PM, an interview with Social Service Worker #1 revealed, upon review of the Diagnosis List from Resident #78's admission, she verified the admission diagnosis of Major Depression Disorder and Delusional Disorder. She confirmed the PAS was inaccurately documented and the resident should have been referred for a Level II. She stated she did not refer the resident for a Level II review after the completion of the MDS, with an ARD of 6/13/19.

Based on staff interviews, record reviews, and facility policy review, the facility failed to refer the resident for a Level II review after a significant change in condition for one (1) of four (4) residents reviewed for preadmission screening, Resident #78. Findings include: A review of the facility's statement dated 10/4/19, revealed the facility follows the guidelines for a Level II referral. Review of Resident #78's medical record revealed no referral for a Level II. Review of the Preadmission Screening (PAS) Summary and Physician Certification with a PAS, dated 6/5/19, indicated the resident did not have a diagnosis of a major mental illness or a history of a mental illness, however, Resident #78 had admitting diagnoses on 6/7/19, of Major Depressive Disorder and Delusional Disorder. Review of a Significant Change (SC) Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 6/13/19, revealed Resident #78 had Diagnoses of Manic Depression (Bipolar Disorder) and Psychotic Disorder (other than Schizophrenia). Review of the most recent quarterly MDS, with an ARD of 9/3/19, was coded to include Psychotic Disorder (other than Schizophrenia) and Depression. On 10/02/19 at 3:18 PM, an interview with Registered Nurse (RN) #1 revealed she has not communicated to Social Service Worker #1 the need for a Level II review of this resident when completing the SC MDS. On 10/02/19 at 3:26 PM, an interview with Licensed Practical Nurse (LPN) #5 revealed she have not talked to Social Services Worker #1, regarding a Level II review after Resident #78's MDS. She stated Social Services Worker #1 participated in the completion of the SC MDS. On 10/02/19 at 3:32 PM, an interview with Social Services Worker #1 revealed if the resident had changes in behaviors, and/or a new psychotropic medication introduced, she would refer the resident for a Level II review. She stated this is the only time that she knows of to refer the resident for a Level II review. She stated a Major Mental Illness is, for example, Depression and Anxiety. Upon review of the Diagnosis List from the resident's admission, Social Service Worker #1 verified the admission diagnosis of Major Depression Disorder and Delusional Disorder. She stated she did not refer the resident for a Level II review after the completion of the SC MDS, with an ARD of 6/13/19. A review of the facility's Face Sheet revealed, the facility admitted Resident #78 on 6/7/19, with diagnoses of Major Depressive Disorder and Delusional Disorders.

Resident #3 A review of Resident #3's care plan, initiated 4/6/18, revealed the resident had an indwelling catheter, related to a diagnosis of Benign Prostatic Hyperplasia (BPH) and was at Risk for Infection. An intervention included catheter care every shift. An observation on 10/01/19 at 05:11 PM, revealed CNA #3 performed catheter care on Resident #3. CNA #3 washed her hands, gloved and touched her uniform as if she was wiping her hands. CNA #3 obtained a cloth and wiped the head of the penis moving the cloth from place to place around the head of the penis. CNA #3 using the same cloth, and without turning the cloth, wiped up and down the shaft of the penis. CNA #3 removed her gloves, and re-gloved without washing her hands. CNA #3 dried the groin area and the penis with the same area of towel. During an interview on 10/02/19 at 03:04 PM, CNA #3 revealed that she should have wiped the head of the penis once, discarded the cloth, and gotten a clean cloth to wipe the penis again. CNA #3 stated that she remembered wiping the head of the penis more than once with the same cloth. CNA # 3 stated she should have not wiped the shaft of the penis with the same cloth that she used to wipe the head of the penis, and she should have dried each area separately, instead of wiping the whole area with the same towel. CNA #3 stated that she should have washed her hands after removing her gloves and before gloving again. During an interview on 10/01/19 at 1:50 PM, LPN #5 stated the she expected the care plan to be followed and updated by the staff when needed. During an interview on 10/03/19 at 12:55 PM, the Director of Nursing stated Resident #3's care plan was not followed for the correct procedure to provide catheter care. MS #16115 Based on observation, staff interview, record review, and facility policy review, the facility failed to follow the care plan for two (2) of 23 resident care plans reviewed, Resident #9 for the use of a full body lift, and Resident #3 for catheter care. Findings include: Review of the facility's Care Plans policy, not dated, revealed: Each resident will have a plan of care to identify problems, needs, and strengths that will identify how the interdisciplinary team will provide care. The Certified Nursing Assistant (CNA) Daily Care Guide is part of the comprehensive care plan and used as the tool to make staff aware of the resident's daily care needs. Assigned disciplines will be identified to carry out the interventions. Review of Resident #9's comprehensive care plan, dated 3/19/19, revealed that a total lift with two (2) person assist and medium sling were required for transfers, related to her risk for falls and history of falling, Review of a Resident Incident Report, dated 7/20/19 at 6:00 AM, revealed Resident #9 was found lying on her right side on the floor in her room. The incident report documented that CNA #2 stated she was using the sit-to-stand lift and Resident #9 didn't stand up, so she lowered her to the floor. The incident report was documented by Licensed Practical Nurse (LPN) #4. Review of the summary and conclusion to the investigation provided by the facility, dated 7/26/19, revealed the facility determined CNA #2 did transfer Resident #9 with the incorrect lift, resulting in a fall for Resident #9. Review of the Departmental Notes, dated 7/20/19 at 7:17 AM, documented by LPN #4, revealed a CNA stated she was getting Resident #9 up with the sit to stand lift and the resident didn't stand up, so she assisted her to the floor, lying on her right side. Resident #9 then complained of pain in her right shoulder, according to the nurses notes. LPN #4 note documented she notified the physician with new orders for a stat X-ray of the right arm and Tylenol 650 milligram (mg) was given for pain. Review of the X-ray report, dated 7/20/19, revealed no fracture, however there was a dislocation of the right shoulder. Resident records revealed Resident #9 returned with orders for a sling, which she refused to wear. An attempt to call CNA #2 at 10/01/19 at 02:59 PM, resulted in no answer, with a message left to return the call. During an interview on 10/01/19 at 3:46 PM, LPN #4 stated CNA #2 called for help after Resident #9 had been placed on the floor. LPN #4 said the stand-up lift was used for Resident #9, and was still in the room. LPN #4 stated she helped assist Resident #9 back to the bed, by using the lift pad. She said Resident #9 complained of pain in her shoulder and she notified the physician, who ordered an x-ray of the arm. During an interview on 10/03/19 at 11:05 AM, Registered Nurse (RN) #1 stated Resident #9's care plan matched the Resident Assessment and the need for a total lift. RN #1 said the expectation was to follow the care plan according to the evaluation of the resident assessment, which for Resident #9 included using the full body lift and using two (2) people at all times during the lift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint #MS #16115 Based on staff interview, record review, and facility policy review, the facility failed to provide adequate supervision and assistance, related to the use of mechanical lifts, to prevent falls with minor injury for one (1) of four (4) residents reviewed for accidents, Resident #9. Findings include: Review of the facility's Modified Lifting Policy, revised 5/29/15, revealed the staff would follow the documented lifting protocol deemed appropriate for each resident. The policy also revealed the information related to the lift would be documented in the smart charting and a sticker system, which was located on each lift. Review of a Resident Incident Report, dated 7/20/19, and the facility investigative report, dated 7/26/19, revealed Resident #9 was found lying on her right side on the floor in her room. The incident report documented that Certified Nurse Aide (CNA) #2 used the wrong lift to transfer the resident; she used the sit-to-stand lift and the resident had been assessed for the total lift. The CNA reported Resident #9 didn't stand up, while using the lift, so she lowered her to the floor. Resident #9 was transferred to the hospital, where X-rays revealed a dislocation of the right shoulder. Treatment included a shoulder immobilizer. Review of Resident #9's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/26/19, revealed the resident needed extensive assist of two (2) persons to transfer. The care plan, initiated 3/19/19, revealed Resident #9 required the use of the total lift with two (2) person assistance. Review of the Departmental Notes, dated 7/20/19 at 7:17 AM, documented by LPN (Licensed Practical Nurse) #4, revealed a CNA reported she was transferring Resident #9 with the sit-to-stand lift and the resident was unable to stand up, so she assisted her to the floor, lying on her right side. Resident #9 complained of pain in her right shoulder, the physician was notified and a new order received for a stat X-ray to the right arm. Tylenol 650 milligram (mg) administered for pain. Interview on 10/01/19 at 09:46 AM, with the Administrator revealed the facility policy was to use two (2) people for all lifts, and to transfer residents according to the resident assessment. The Administrator stated CNA #2 was terminated after the investigation on 7/21/19, for failure to follow the facility policy. An attempt to call CNA #2 at 10/01/19 at 02:59 PM, was unsuccessful, with a message left to return the call. Review of CNA #2's personnel file revealed she was terminated on 7/21/19, for wrong or improper lift with a resident causing an injury. During an interview on 10/01/19 at 3:46 PM, LPN #4 said she first became aware of the incident after CNA #2 called for help and Resident #9 was already on the floor. LPN #4 said the stand-up-lift was still in the resident's room. LPN #4 stated Resident #9 complained of pain in her shoulder, so she notified the Physician, received orders for an X-ray, and gave the resident Tylenol. Review of the Departmental Notes dated 7/20/19 at 11:25 AM revealed Resident #9 was transferred to the hospital for evaluation. Review of the Radiology Report, dated 7/20/19, revealed the humerus of Resident #9's right shoulder was anteriorly and inferiorly dislocated, with respect to the glenoid. There was no fracture. Conclusion: Anterior shoulder dislocation. Review of the Emergency Department form, dated 7/20/19, revealed the reason for visit was shoulder pain-swelling, shoulder dislocation/fall. The final Diagnosis: shoulder dislocation, unspecified subluxation of right shoulder joint. Review of Nurse's Notes, dated 7/20/19 at 11:25 AM, revealed Resident #9 returned to the facility at 8:00 AM with a should immobilizer in place, however the care plan addressed the resident's refusal of the care. An observation on 10/02/19 at 10:55 AM, revealed Resident #9 was transferred with a full body lift and two (2) staff, without difficulty or distress. There was no noted injury to Resident #9. Interview on 10/02/19 at 03:18 PM, with the Director of Nursing (DON), revealed she was not working at this facility when the incident happened with Resident #9. The DON said the check off with the lifts, for CNA #2, could not be located. There was a documented New Hire Orientation Video Checklist, dated 10/31/18, signed by CNA #2, for a 25 minute video completion for [NAME] and Vera lifts. Review of facility Face Sheet revealed Resident #9 was admitted on [DATE], with a diagnosis of Dementia, Unspecified.

Based on observation, staff interview, record review, and facility policy review, the facility failed to prevent the possible spread of infection during catheter care for one (1) of two (2) resident catheter care observations, which affected Resident #3. Findings include: A review of facility's UTI Prevention with Indwelling Catheter Use policy, dated January 27, 2015, revealed A resident with an indwelling catheter is susceptible to Urinary Tract Infections. Catheter care should be provided daily or anytime an incontinent episode occurs. An observation on 10/01/19 at 5:11 PM, revealed Certified Nursing Aide (CNA) #3 entered Resident #3's room to perform catheter care. CNA #3 washed her hands, gloved and touched her uniform as if she was wiping her hands. CNA #3 obtained a cloth and wiped the head of the penis, moving the cloth from place to place around the head of the penis. CNA #3, using the same cloth, and without turning the cloth, wiped up and down the shaft of the penis. CNA #3 removed her gloves, and re-gloved without washing her hands. CNA #3 dried the groin area and the penis with the same area of the towel. During an interview on 10/02/19 at 3:04 PM, CNA #3 revealed that during Resident #3's catheter care, she should have wiped the head of the penis one time, discarded the cloth and retrieved a clean cloth to wipe again. CNA #3 stated she remembered wiping the head of the penis more than once with the same cloth. CNA # 3 stated she should not have wiped the shaft of the penis with the same cloth that she used to wipe the head of the penis; she should have dried each area separately, instead of wiping the whole area with the same towel. CNA #3 stated she should have washed her hands after removing her gloves and before gloving again. During an interview on 10/03/19 at 12:45 PM, Registered Nurse (RN) #2, Infection Control Nurse, confirmed CNA #3, not performing catheter care correctly, could be considered an Infection control issue, sending germs straight to the bladder. She stated that not washing hands and gloving properly is also an infection control issue. During an interview on 10/03/19 at 12:55 PM, the Director of Nursing (DON) stated the lack of training was an issue as well as technique with Infection Control. The DON stated that CNA #3 wiping the head of the penis and the shaft of the penis, with the same cloth, could have caused germs to enter the head of the penis, resulting in an infection. She stated it was a big UTI risk. She stated, By not doing hand hygiene/gloving properly, you can spread germs and infection. The DON stated the whole process was an infection control issue.

Based on record review, facility statement, and staff interview, the facility failed to provide a Registered Nurse (RN) Supervisor, for a facility with a census greater than 60 residents, for eight (8) of 17 days reviewed. Findings include: Review of a document on facility letterhead, undated and signed by the Administrator, revealed the facility does not have a policy for RN staffing. Review of the facility census, during survey, revealed a census of 85 residents. Review of a staffing grid and the working schedule, provided by the Director of Nursing (DON), revealed the DON served as RN Supervisor on 9/16/19, 9/17/19, 9/18/19, 9/19/19, 9/20/19, 9/23/19, 9/24/19, and 9/25/19. A written statement, provided by the DON, on 10/02/19 at 3:22 PM, revealed I served as Supervisor for all units on the following dates: 9/16/19, 9/17/19, 9/18/19, 9/19/19, 9/20/19, 9/23/19, 9/24/19, and 9/25/19. During an interview on 10/02/19 at 3:22 PM, the DON revealed a lot of times, during the week, she served as the Registered Nurse (RN) Supervisor for both units. She stated on the weekends, she had a RN Supervisor. The DON stated, To be honest, the lowest the my census has been is 80. I've done treatments, supervising, I've done it all for a while now. The DON stated she had only heard about not being able to be the DON and the Supervisor, once in the past, and had actually forgot about it. She stated she didn't have anyone else to cover the RN Supervisor position, so she did what she had to do and filled the RN Supervisor position herself. An interview on 10/03/19 at 9:50 AM, with the Administrator, revealed he knew the DON could not serve as Charge Nurse in a facility with more than 60 beds. The Administrator stated he just didn't catch the DON serving as the RN Supervisor. The Administrator stated there were other RN's at the facility some of those days, but they were in and out of the offices doing work. The Administrator stated the DON did serve as RN Supervisor on some days.

Resident #11-Stoma care Observation of Resident #11's PEG stoma care on 10/02/19 at 10:11 AM, revealed LPN #3 did not use appropriate hand hygiene practices, during the care. She did not wash her hands throughout the entire procedure, and changed gloves twice. During an interview on 10/03/19 at 10:39 AM, LPN #3 stated she should have washed her hands, when she changed gloves, and during PEG Tube care, because it could have caused cross contamination. Resident #3-Catheter care An observation on 10/01/19 at 5:11 PM, revealed Certified Nursing Aide (CNA) #3 entered Resident #3's room to perform catheter care. CNA #3 washed her hands, gloved and touched her uniform as if she was wiping her hands. CNA #3 obtained a cloth and wiped the head of the penis moving the cloth from place to place around the head of the penis. CNA #3, using the same cloth and without turning the cloth, wiped up and down the shaft of the penis. CNA #3 removed her gloves, and re-gloved without washing her hands. CNA #3 dried the groin area and the penis with the same area of towel. During an interview on 10/02/19 at 3:04 PM, CNA #3 revealed that she should have wiped the head of the penis once, discarded the cloth, and got a clean cloth to wipe the penis again. CNA #3 stated she remembered wiping the head of the penis more than once with the same cloth. CNA # 3 stated she should have not wiped the shaft of the penis with the same cloth that she used to wipe the head of the penis, and she should have dried each area separately, instead of wiping the whole area with the same towel. CNA #3 stated that she should have washed her hands after removing her gloves and before gloving again. During an interview on 10/03/19 at 12:45 PM, Registered Nurse (RN) #2, Infection Control Nurse, stated CNA #3 not performing catheter care correctly could be considered an Infection control issue, sending germs straight to the bladder and not washing hands and gloving properly is also an infection control issue. During an interview on 10/03/19 at 12:55 PM, the Director of Nursing (DON) stated that the lack of training was an issue as well as technique with Infection Control. The DON stated that CNA #3 wiping the head of the penis and the shaft of the penis with the same cloth could have caused germs to enter the head of the penis, causing an infection, which is a big UTI risk. She stated, by not doing hand hygiene/gloving properly you can spread germs and infection. Resident #3-Stoma Care An observation on 10/01/19 at 3:00 PM, revealed LPN #3 entered Resident #3's room without gloving, and wiped the over bed table with a sani-wipe germicidal wipe. LPN #3 placed a red biohazard bag on the floor beside Resident #3's bed. LPN #3 washed her hands, gloved, removed the dirty dressing from the PEG stoma, and discarded it into the red biohazard bag on the floor. LPN #3 removed her gloves, and without performing hand hygiene, applied clean gloves, cleaned and dried the stoma, discarding the gauze in the red biohazard bag on the floor. LPN #3, without changing her gloves or washing her hands, applied the clean split sponge dressing to the stoma and secured it with tape. During an interview on 10/02/19 at 3:59 PM, LPN #3 stated the she was trained to put the red bag on the floor. She stated, I didn't know that it was wrong to do it. During an interview on 10/03/19 at 12:40 PM, the Director on Nursing (DON) stated that up until now, the facility had always had a Registered Nurse (RN) to provide wound treatments. She stated the lack of training was an issue. She stated technique and proper hand hygiene/gloving appropriately is an Infection Control Issue. The DON stated that LPN #3 dragging the biohazard bag across the floor could cause germs to get on the bottom of the shoes and be transported from room to room causing other residents problems. Resident #20-Stoma care On 10/02/19 at 11:24 AM, an observation revealed LPN #1 placed her red biohazard bag on Resident #20's floor beside the resident's bed, washed her hands, and applied clean gloves. After performing stoma site care, she removed her gloves and discarded all soiled supplies. On 10/03/19 at 10:40 AM, an interview with LPN #1 revealed she should have placed her wound care bag in a container as opposed to putting it on the resident's floor. She stated it is unsanitary to put the red bag on the resident's floor. On 10/03/19 at 11:28 AM, an interview with LPN #2 revealed when performing gastric tube site care, she would expect the nurses to use aseptic technique. Based on observation, staff interview, record review, and facility policy review, the facility failed to utilize proper infection control techniques while providing care for six (6) of 10 care observations. This included wound care for two (2) of four (4) observations, Resident #41 and #83; stoma care for three (3) of four (4) Percutaneous Endoscopic Gastrostomy (PEG) tube care observations, Residents #3, #11 and #20; and catheter care for one (1) of two (2) catheter care observations, Resident #3. Findings include: A review of the facility's Infection Prevention and Control policy, dated 2016, revealed all contaminated disposable items shall be discarded in a waste receptacle lined with a red plastic bag. Review of the facility's Infection Prevention and Control Program, policy, implemented 4/17/18, revealed the Hand Hygiene Protocol: All staff shall wash their hands when coming on duty, between resident contacts, after handling contaminated objects, after Personal Protective Equipment (PPE) removal, before and after eating, before and after toileting, and before going off duty. Staff shall wash their hands before and after performing resident care procedures. Hands shall be washed in accordance with the facility's established hand washing procedure. A review of facility's Hand washing, policy, not dated, revealed, Staff will use proper hand washing technique to prevent the spread of infection. A review of facility's UTI (Urinary Tract Infection) Prevention with Indwelling Catheter Use policy, dated January 27, 2015, revealed A resident with an indwelling catheter is susceptible to Urinary Tract Infections. Catheter care should be provided daily or anytime an incontinent episode occurs. A review of a document provided by the facility, not dated and signed by the Administrator, revealed, The facility does not have a policy for PEG tube care. A review of a document provided by the facility, not dated and signed by the Administrator, revealed, The facility does not have a policy concerning gloving. Resident #83 During an observation of pressure ulcer care, on 9/30/19 at 3:50 PM, LPN #3 sat the red wound care biohazard bag on Resident #83's floor bedside the resident's bed. LPN #3 performed wound care, changing her gloves throughout the wound care procedure, but did not wash her hands at all during the wound care procedure. The red biohazard bag remained on Resident #83's floor beside her bed during the entire wound care procedure, as she placed soiled items in the bag. On 9/30/19 at 4:35 PM, an observation revealed LPN #3 performed as needed (PRN) wound care on Resident #83 after the resident's dressing had become soiled. LPN #3 sat the red biohazard bag on Resident #83's floor beside the resident's bed. She performed wound care on Resident #83, changing her gloves, but did not wash her hands. The red biohazard bag remained on the resident's floor beside her bed during the entire wound care procedure. On 10/03/19 at 10:44 AM, interview with LPN #3 revealed she should not have placed the red biohazard bag on the resident's floor but should have used a trash can to place her bag, and when finished with the wound care, she would remove the bag from the trash can. LPN #3 stated when she placed the red bag on the resident's floor, it caused contamination. She also stated she should have washed her hands when she removed her gloves and the resident's dressing. On 10/03/19 at 11:04 AM an interview with RN #1 revealed, she would expect the nurse to use clean technique when performing wound care. Resident #41 An observation on 10/01/19 at 2:13 PM, revealed LPN #3 had a red biohazard bag on the floor beside Resident #41's bed. LPN #3 cleansed and dried the wound and discarded the gauze in the red biohazard bag on the floor. Without washing her hands or changing gloves, LPN #3 applied ointment to a clean gauze dressing, and applied the dressing to the right buttock wound. LPN #3 moved to the other side of the bed to perform left heel care. LPN #3 went back to the side of the bed where the red biohazard bag lay on the floor and with her foot, she pulled the red biohazard bag across the floor to the other side of the bed. LPN #3 washed her hands, gloved and removed the soiled dressing from left heel and discarded the dressing in the red biohazard bag lying on the floor. LPN #3 removed her gloves and without washing her hands, she reapplied gloves and wiped the left heel and discarded the gauze in the red biohazard bag on the floor. LPN cleansed the wound twice more, then discarded the gauze in the biohazard bag. Without washing her hands or changing gloves, LPN #3 took ointment, and while applying the ointment to a gauze, the resident touched the clean heel to the sheet. LPN #3 stated, Don't touch it to the sheet, you gonna make me have to clean it again. LPN #3 continued the wound care, without cleaning the wound again. During an interview on 10/03/19 at 12:40 PM, LPN #3 stated the she remembered dragging the red bag with her foot and she should not have. LPN #3 stated she thought you only washed your hands and changed gloves after a sterile procedure. She confirmed not changing gloves/washing hands correctly could have caused infection. LPN #3 stated that she went home and read about wound care, hand washing, and gloving and saw where she should have done differently. She stated she even watched a you tube video of the correct technique during wound care. During an interview on 10/03/19 at 12:45 PM, RN #2 stated that not performing hand hygiene and gloving properly is an infection control issue.