**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide documentation of communication between the facility and the dialysis (a process for removing waste and excess water from the blood) center for one resident (Resident #2) out of one sampled resident. The facility census was 25. Review of the facility's policy titled, Dialysis Care, undated, showed: - Adequately assess resident needs and provide care goals which achieve the highest practicable level of care to residents with end stage renal disease receiving dialysis; - Risk factors related to potential for bleeding, alterations in fluid volume, potential for infection, alteration in nutrition, skin integrity, risk for adverse medication effects and psychosocial needs should be identified, assessed and interventions to manage addressed in the individualized care plan; - An individual care plan should be developed and followed in coordination with the comprehensive assessment. 1. Review of Resident #2's Physician's Order Sheet (POS), dated March 2025, showed: - admitted on [DATE]; - Diagnosis of end-stage renal disease (ESRD - a medical condition where the kidneys can no longer function to filter wastes or excess fluids from the blood); - An order for dialysis one time a day, every Monday, Wednesday and Friday, dated 05/21/24; - An order to assess the dialysis site for bleeding or signs or symptoms of infection every shift, dated 05/21/24; - An order to check the dialysis site for a thrill (a palpable vibration felt on the skin over a blood vessel) and the bruit (an audible sound heard through a stethoscope) every shift, dated 05/21/24. Review of the resident's quarterly Minimum Data Set (MDS - part of a federally mandated process for clinical assessment of all residents in certified nursing homes), dated 12/18/24, showed: - The resident received dialysis. Review of the resident's Care Plan, dated 12/30/24, showed: - The resident needs dialysis related to renal failure; - Do not take a blood pressure or draw blood from the arm with the fistula (a connection between an artery and a vein used for dialysis); - Monitor labs and report to the physician as needed; - Encourage the resident to go to scheduled dialysis appointments every Monday, Wednesday and Friday; - Monitor, document, and report as needed any signs and symptoms for infection to the access site, any signs and symptoms of bleeding. Review of the resident's medical record showed: - No Dialysis Communication Reports between the facility and the dialysis unit. During an interview on 03/07/25 at 09:11 A.M., the Director of Nursing (DON) said the facility should be sending a form to the dialysis unit with the resident's information and the dialysis facility should be filling out the dialysis portion and returning it to the facility with the resident. This was not being done. During an interview on 03/07/25 at 10:28 A.M., Registered Nurse (RN) A said he/she had not used a dialysis communication sheet at this facility.

Based on interview and record review, the facility failed to limit the use of an as needed (PRN) order for psychotropic (medications that affect how the brain works and causes changes in mood, awareness, thoughts, feelings, or behaviors) medication to 14 days for two residents (Residents #8 and#11) out of four sampled residents. The facility census was 24. The facility did not provide a policy for PRN psychotropic medication use. 1. Review of Resident #8's March 2025 Physician Order Sheet (POS) showed: - Diagnoses of Alzheimer's disease (progressive mental deterioration), dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning) with other behavioral disturbance, and cognitive communication deficit; - An order for lorazepam (an antianxiety medication) 0.5 milligram (mg) by mouth every two hours PRN for anxiety, dated 02/25/25, with no stop date; - The facility failed to provide a 14 day stop date order for the lorazepam PRN order. 2. Review of Resident #11's March 2025 POS showed: - Diagnoses of mild cognitive impairment, major depressive disorder (long-term loss of pleasure or interest in life), and insomnia (difficulty sleeping); - An order for lorazepam 0.5 mg by mouth every 12 hours PRN for anxiety, dated 09/25/24, with no stop date; - The facility failed to provide a 14 day stop date order for the lorazepam PRN order. During an interview on 03/07/25 at 10:53 A.M., the Director of Nursing (DON) and Registered Nurse (RN) E said the first order for a psychotropic PRN was for 14 days and then it was re-evaluated by the physician. The physician determined the duration and indication for the use of the medication. During an interview on 03/07/25 at 11:00 A.M., the Administrator said he would expect guidelines to be followed.

Based on observation, interview, and record review, the facility failed to maintain an error rate of less than five percent (%) during medication administration. There were 30 opportunities with four errors made, for an error rate of 13.33%, which affected four residents (Residents #2, #5, #13, and #17) out of 16 sampled residents. The facility's census was 24. The facility did not provide a policy in regards to insulin administration. Review of the facility instruction sheet, Priming Insulin Pens Quick Reference, undated, showed: - Every insulin pen requires priming with each injection. Doing so ensures the correct amount of insulin is given to the patient. It removes air from the needle and cartridge that can collect during normal use and confirms the pen is working correctly. - Fiasp (insulin aspart - a rapid-acting insulin) dial two units when priming; - Lispro (Humalog - a rapid acting insulin) dial two units when priming, recommended to hold the dose button down five second when priming. Review of the Fiasp Flex Touch Pen Instructions, revised July 2023, showed: - To prime the pen, turn the dose selector to select two units; - Hold the pen with the needle pointing up; - Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge; - Keep the needle pointing upwards, press the push-button all the way in; - The dose selector returns to zero; - A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than six times; - Select your dose; - Give injection. Review of the Insulin Lispro KwikPen Manufacturer Instructions for Use, revised July 2023, showed: - Priming the pen means removing the air from the needle and cartridge that may collect during normal use and ensures the pen is working correctly; - Not priming before each injection may result in too much or too little insulin; - Turn the dose knob to select two units; - Hold the pen with the needle pointing up, tap the cartridge holder gently to collect air bubbles at the top; - With the needle pointing up, push the dose knob until it stops and zero is seen in the dose window, hold and count to five slowly; - There should be insulin at the tip of the needle, if not, repeat no more than four times. 1. Review of Resident #2's POS, dated March 2025, showed: - An order for insulin aspart inject per sliding scale before meals for a blood sugar of 251-300 - give three units, dated 11/14/24. Observation of the resident on 03/06/25 at 10:31 A.M., showed: - Registered Nurse (RN) A administered insulin aspart four units subcutaneously (an injection into the fatty layer of tissue just beneath the skin) to the resident per sliding scale for a blood sugar of 243; - RN A failed to prime the aspart pen prior to the administration of the insulin to the resident per the manufacturer's instructions for use. 2. Review of Resident #5's Physician's Order Sheet (POS), dated March 2025, showed: - An order for Fiasp FlexTouch Pen inject as per sliding scale subcutaneously before meals and at bedtime for a blood sugar of 111-140 - give two units, dated 08/08/24. Observation of the resident on 03/06/25 at 10:28 A.M., showed: - Certified Medication Technician (CMT) B administered Fiasp two units subcutaneously to the resident per the sliding scale order for a blood sugar of 130; - CMT B failed to prime the Fiasp pen prior to the administration of the insulin to the resident per the manufacturer's instructions for use. 3. Review of Resident #13's Physician's Order Sheet (POS), dated March 2025, showed: - An order for Fiasp FlexTouch Pen inject as per sliding scale subcutaneously before meals and at bedtime for a blood sugar of 201-250 - give four units, dated 12/04/24. Observation of the resident on 03/06/25 at 10:31 A.M., showed: - CMT B administered Fiasp four units subcutaneously to the resident per the sliding scale order for a blood sugar of 243; - CMT B failed to prime the Fiasp pen prior to the administration of the insulin to the resident per the manufacturer's instructions for use. 4. Review of Resident #17's POS, dated March 2025, showed: - An order for Humalog inject per sliding scale subcutaneously before meals for a blood sugar of of 141 - 180 - give four units, dated 07/24/24; - An order for Humalog inject five units subcutaneously before meals, dated 09/24/24. Observation of the resident on 03/06/25 at 10:36 A.M., showed: - Registered Nurse (RN) A administered Humalog nine units for a blood sugar of 148 subcutaneously to the resident per sliding scale and the Humalog insulin order; - RN A failed to prime the Humalog pen prior to the administration of the insulin to the resident per the manufacturer's instructions for use. During an interview on 03/07/25 at 10:19 A.M., RN A said the insulin pen should be primed when it was new, not after it had already been used. He/she didn't usually administer insulin in the facility, During an interview on 03/07/25 at 10:11 A.M., CMT C said the insulin pen should be primed with each use. During an interview on 03/07/25 at 10:13 A.M., CMT D said the insulin pen should be primed with each use, the facility had a sheet on the medication cart showing how each kind of insulin should be primed. During an interview on 03/07/25 at 11:08 A.M., the Director of Nursing said insulin pens should be primed based on the type of insulin. During an interview on 03/07/25 at 11:15 A.M., the Administrator said it was expected that staff follow the proper procedures.

Based on observation, interview, and record review, the facility staff failed to maintain appropriate infection control practices by not performing proper hand hygiene and glove changing techniques during wound care for two residents (Residents #5 and 13) out of two sampled residents and during catheter (a tube inserted into the bladder to drain urine) care for one resident (Resident #13) out of two sampled residents. The facility also failed to correctly screen five residents (Residents #4, #8, #13, #17, and #20) for tuberculosis (TB - an infectious disease characterized by the growth of nodules in the tissues, especially the lungs) out of five sampled residents required by state regulation 19 CSR 20-20.100. The facility census was 25. The facility did not provide an infection control policy. Review of the facility policy titled, Catheter Care, Urinary, revised September 2014, showed: - The purpose of this procedure is to prevent catheter-associated urinary tract infections; - Place the clean equipment on the bedside stand or overbed table; - Wash and dry your hands thoroughly; - Put on gloves; - Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site to approximately four inches outward; - Secure catheter utilizing a leg band; - Remove gloves and discard into designated container. Wash and dry your hands thoroughly; - Reposition linens, make resident comfortable; - Clean area and discard items; - Wash and dry your hands thoroughly. Review of the facility's policy titled, Handwashing/Hand Hygiene, revised August 2019, showed: - Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: before and after direct contact with residents; before preparing or handling medications; before handling clean or soiled dressings, gauze pads, etc.; before moving from a contaminated body site to a clean body site during resident care; after contact with a resident's intact skin; after handling used dressings, contaminated equipment, etc.; after removing gloves; and is the final step after removing and disposing of personal protective equipment (PPE). Review of the facility policy titled, Enhanced Barrier Precautions (EBP), dated August 2022, showed: - EBPs are utilized to prevent the spread of multi-drug-resistant organisms (MDROs) to residents; - EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply; - Gloves and gown are applied prior to performing high contact resident care activity; - PPE is changed before caring for another resident; - Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include dressing, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (urinary catheter), and wound care (any skin opening requiring a dressing); - EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk; - Signs are posted on the door or wall outside the resident room indicating the type of precautions and PPE required; - PPE is available outside of the resident rooms. Review of the facility policy titled, TB, Screening Residents for, revised August 2019, showed: - This facility shall screen all residents for TB infection and disease; - The admitting nurse will screen referrals for admission and readmission for information regarding exposure to or symptoms of TB; - Screening of new admissions or readmissions for tuberculosis infection and disease is in compliance with state regulations; - The facility will conduct an annual risk assessment to determine risk of exposure; - Residents who have risk factors for exposure to active TB are re-tested for latent tuberculosis infection (LTBI) and symptoms of active TB. 1. Observation on 03/05/25 at 10:28 A.M., of Resident 313's catheter care showed: - No EBP signage on or around the door; - Certified Nursing Assistant (CNA) F and CNA G entered the room, performed hand hygiene, put on gloves, and did not put on gowns; - CNA F uncovered the resident, unfastened the top of the brief, and sat the wipes beside the resident on the bed without a clean barrier; - CNA F wiped toward the insertion point of the catheter twice with the same area of the wipe; - CNA F failed to wipe away from the insertion point and failed to use a clean wipe or clean side of the wipe with each cleaning motion; - CNA F removed the gloves and failed to perform hand hygiene. 2. Observation on 03/05/25 at 1:45 P.M., of Resident #13's wound care showed: - No EBP signage for the resident; - Registered Nurse (RN) A gathered supplies, performed hand hygiene, entered the room, put on gloves, and did not put on a gown; - The resident sat on the toilet in the bathroom with CNA F and CNA G assisting the resident to stand using a sit-to-stand lift (a device that assist individuals with limited mobility to transition from a seated to a standing position). CNA F and CNA G had gloves on, did not wear gowns, and rolled the resident out of bathroom into the room; - RN A cleaned the wound to left buttock with Dermaklenz (a wound cleanser) and gauze, changed the glove on the right hand, did not perform hand hygiene, applied Triad Paste (a wound treatment) to the left buttock, covered with a 2 inch (in.) x 2 in. silicone foam dressing (type of dressing), removed the gloves, exited the room, and performed hand hygiene; - CNA G pulled the resident's pants up and assisted CNA F to transfer the resident to the recliner; - CNA G hung the resident's Foley (type of catheter) catheter drainage bag covered by a privacy bag on the outside of the trash can by the recliner; - CNA F and CNA G removed the gloves, exited the room, and performed hand hygiene. 3. Observation on 03/05/25 at 2:05 P.M., of Resident #5's wound care showed: - No EBP signage for the resident; - RN A entered the room with the supplies, washed hands, put on gloves, did not put on gown, opened the gauze package, sprayed Dermaklenz on the gauze, touched the resident's clothing to expose the wound area to left upper thigh, removed the gloves, discarded the gauze, did not perform hand hygiene, and exited the room; - CNA F and CNA G entered the room, put on gloves, did not perform hand hygiene, did not put on a gown, and assisted the resident to roll to the right side; - RN A performed hand hygiene, put on gloves, did not put on a gown, sprayed Dermaklenze on the wound area, wiped with a dry gauze, did not change gloves, did not perform hand hygiene, applied Silvadene cream 1% (a topical antibacterial used to prevent or treat wound infection in second and third-degree burns) to the wound, removed the gloves, did not perform hand hygiene, touched the bed control, the oxygen tubing, the pillow, the call light, and the incontinent pad to reposition the resident in bed, performed hand hygiene, and exited the room; - CNA G assisted the resident to reposition in bed, removed the gloves, performed hand hygiene, and exited the room; - CNA F removed the gloves, performed hand hygiene, placed a pillow under the resident's feet, touched the sheet, performed hand hygiene, and exited the room. 4. Review of Resident #4's medical record showed: - admit date of 10/10/12; - Annual TB screen, dated 10/11/23; - No annual tuberculin skin test (TST) or screening completed for 2024. 5. Review of Resident #8's medical record showed: - admit date of 12/19/22; - Annual TB screen, dated 06/07/24, negative 0 millimeter (mm) with no read date. 6. Review of Resident #13's medical record showed: - admit date of 04/26/24; - TST step one, dated 05/06/24, with negative 0 mm and no read date; - TST step two, dated 05/11/24, with negative 0 mm and no read date. 7. Review of Resident #17's medical record showed: - admit date of 07/02/24; - No documentation of TST or screening completed. 8. Review of Resident #20's medical record showed: - admit date of 09/06/24; - TST step one, dated 05/06/24, with negative 0 mm and no read date; - TST step one, dated 05/17/24, with negative 0 mm and no read date. During an interview on 03/06/25 at 4:15 P.M., RN A said EBP, gown and gloves should be worn when providing care for residents with indwelling catheters, MDRO infection risks, wounds, or any other open areas. He/She should have worn a gown while performing wound care. Gowns and gloves were available all the time, and he/she knew where to locate them. Hand hygiene should be completed before, between, and after resident care. Gloves should be changed and hand hygiene should be preformed when moving from a dirty to a clean task. Catheter care should be performed by using a clean wipe to clean the catheter from the insertion point out, fold the wipe to a new area with each swipe, no back-and-forth motion, and cleaning six to eight inches down the catheter. During an interview on 03/06/25 at 4:31 P.M., CNA F and CNA G said should perform hand hygiene and put on gloves for resident care. Catheter care should be completed by cleaning from the insertion point to six to eight inches down the catheter, using a new wipe each swipe for peri care and catheter care. Should change gloves and perform hand hygiene when moving to a new area, before applying barrier cream, and before placing a new brief or touching anything clean. CNA F and CNA G did not know about EBP for the residents. During an interview on 03/07/25 at 11:08 A.M., RN E said EBP should be initiated for a resident with an indwelling device, MDRO, and/or a chronic wound. Staff and the resident should be notified. There were door hangers to hold supplies, with signs for the door, and additional PPE in the clinic and staff have access to the clinic. While in the room and during high contact activities, staff will gown and glove. A gown and gloves should be worn during catheter care and wound care. For catheter care, should clean from the insertion point down several inches. After all care was done, make sure the resident was covered and wash hands. Hand hygiene should be completed anytime gloves were soiled or moving from dirty to clean care, and upon entering and exiting the rooms. TB TST or assessments should be done on admission, during an outbreak, and annually. The TST step two should be completed two-three weeks following the TST step one and both should be read 24-72 hours after testing. The admitting nurse was responsible for completing the TB testing. He/She guessed he/she was responsible for the monitoring. During an interview on 03/07/35 at 11:15 A.M., the Director of Nursing (DON) said EBP, gowns, and gloves should be worn during care of a resident if there were wounds, infections, and anytime care was performed, for residents with catheters and/or wounds. For catheter care, should clean from the insertion point down several inches, using a clean area of the wipe or a new wipe each swipe. Hand hygiene should be completed anytime gloves were soiled, moving from dirty to clean care, and upon entering and exiting rooms. TB testing should be completed upon admission, during an outbreak, and annually. The second step TST was to be completed two-three weeks following the first step TST. Both TST steps should be read 24-72 hours after testing.

Based on interview and record review, the facility failed to develop a Quality Assurance and Performance Improvement Plan (QAPI - a written plan containing the process that will guide the facility's efforts in assuring care and services are maintained at acceptable levels of performance and continually improved.) The facility census was 25. Review showed the facility did not have a QAPI plan containing the necessary policies and protocols describing how they will identify and correct their quality deficiencies, track and measure performance, and establish goals and thresholds for performance measurement. During an interview on 03/07/25 at 9:11 A.M., the Director of Nursing (DON) said she just started in January 2025, and found no documentation of a previous QAPI Plan. She was trying to get everything together but did not have anything in place yet.

Based on interview and record review, the facility failed to ensure the Quality Assurance/Quality Assurance Performance Improvement (QAA/QAPI - a written plan containing the process that will guide the facility's efforts in assuring care and services are maintained at acceptable levels of performance and continually improved) committee developed and implemented an appropriate plan of action to correct identified quality deficiencies. This had the potential to affect all residents in the facility. The facility census was 25. The facility did not provide a policy for a QAPI Plan or Performance Improvement Plans (PIPs). Review showed no documentation the facility maintained the minimum required documentation for a QAPI plan or PIPs. During an interview on 03/07/25 at 9:11 A.M., the Director of Nursing (DON) said there was no documentation the facility had a QAPI Plan or PIPs in place. The facility was currently trying to get everything in place.

Based on interview and record review, the facility failed to maintain quarterly Quality Assurance and Improvement Program (QAPI - a written plan containing the process that will guide the facility's efforts in assuring care and services are maintained at acceptable levels of performance and continually improved) committee meetings with the required members. The facility census was 25. The facility did not provide a policy or any documentation related to QAPI. Review showed no documentation the facility maintained the minimum required quarterly QAA meetings with the required members. During an interview on 03/07/25 at 9:11 A.M., the Director of Nursing (DON) said the facility did not have a QAPI policy and procedure. There was not a QA committee at this time. There was no documentation to review.

Based on interview and record review, the facility failed to maintain an Infection Prevention and Control Program (ICIP) that included an antibiotic stewardship program. This deficient practice had the potential to affect all residents in the facility. The facility census was 25. Review of the facility's policy titled, Antibiotic Stewardship, revised December 2016, showed: - Antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program; - The purpose of our antibiotic stewardship program is to monitor the use of antibiotics in our residents. Review of the facility's policy titled, Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes, revised December 2016, showed: - Antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship; - As part of the facility antibiotic stewardship program, all clinical infections treated with antibiotics will undergo review by the Infection Preventionist (IP) or designee; - The IP, or designee, will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics; - At the conclusion of the review, the provider will be notified of the review findings; - All resident antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking form. The information gathered will include resident name and medical record number; unit and room number; date symptoms appeared; name of antibiotic; start date of antibiotic; pathogen identified; site of infection; date of culture; stop date; total days of therapy; outcome; and adverse events. The facility did not provide documentation for the Antibiotic Stewardship Program. Review of the facility's Antibiotics Report, from 02/01/25 To 03/31/25, showed: - Eight residents received antibiotics. Review of the facility's Matrix (a listing of all facility residents), dated 03/04/25, showed: - Two residents currently received antibiotics. During an interview on 03/04/25 at 12:35 P.M., the Director of Nursing (DON) said they were working on getting the Infection Control program up and running, but it was not fully in operation yet. The facility's pharmacy consultant company completed an antibiotic report monthly, but the facility did not do their own infection surveillance.