**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and, record review the facility failed to ensure there was a functional system in place to ensure staff could initiate /not initiate CPR (Cardiopulmonary Resuscitation lifesaving technique, aims to blood and oxygen flowing through the body) during an emergency for all 66 residents (residents were identified by the Resident Matrix provided by the Administrator on [DATE]), when they failed to: 1) Monitor the accuracy of resident's living will (legal document that helps communicate patient's wishes about medical treatment when they are not available to make their own wishes known ), 2) System for staff to immediately recognize the resident's code status (type of emergency treatment a person would or would not receive if their heart or breathing were to stop) during an emergency. 3) Ensure there was complete and ready to use crash cart equipment available for use in case of an emergency. 4) Provide advanced directive (legal document that explains how you want medical decisions about you to be made if you cannot make the decisions yourself ) to Emergency Medical Services (EMS) personal at the time of transfer for R #318. This deficient practice could likely cause confusion among the nursing staff who may not be aware of which residents are Full-Code (if the person's heart stopped beating, or stopped breathing, all resuscitation procedures will be provided to keep them alive) and those residents who wish to be a DNR (Do Not Resuscitate) (No code, allow natural death), then residents are likely to not receive the prompt initiation of CPR (Cardio Pulmonary Resuscitation) (lifesaving technique, aims to blood and oxygen flowing through the body) during a cardiac/respiratory arrest (when heart and breathing stops) nor have the availbale equipment needed which could likely result in resident death. In addition, this deficient practice likely resulted in R #318 being intubated (insert a tube into the patient's throat for giving oxygen) against his DNR code status. The findings are: A. Record review of facility Resuscitation during Cardiopulmonary Arrest Policy revision date [DATE] revealed the following: Always determine code status or DNR status in advance, while the resident is medically stable. R #20 B. Record review of R #20's Face sheet revealed the admission date of [DATE]. C. Record review of R #20's Physician Orders dated [DATE] revealed code status as Full Code. D. Record review of R #20's MOST form (Medical Order for Scope of Treatment) (voluntary end-of-life planning tool designed to give those who are ill or medically frail the opportunity to make their health care wishes known in the event they are unable to speak for themselves) dated [DATE], revealed code status as DNR. E. Record review of [name of the unit] DNR report dated [DATE] located inside of the crash cart's (code cart, set of shelves used for dispensing emergency medication/equipment at the site of an emergency) binder revealed R #20's code status as Full Code. F. Record review of R #20's current Care Plan initiated on [DATE] revealed no documentation for code status was found. G. On [DATE] at 9:08 AM, during an interview, CNA #24 stated We have a DNR report paper which shows us the code status of each resident. Medical records oversee and update any changes. I also can look at the electronic system (PCC) if I don't have access to the paper report. When asked if she has no access to the paper report or PCC what actions she can take during an emergency, she stated I refer to my charge nurse. During the same interview CNA #24 was asked about education and training regarding resident's code status, she stated We usually get an all-staff In-service, but since our staff development is new, we haven't had any training since she started her position. H. On [DATE] at 9:20 AM, during an interview about resident's code status, RN #25 stated We check the crash cart's binder for their code status. Our Medication Administration Records (MAR) and treatment books also have the code status of all our residents. We also can check it on the electronic system as well. When asked if she ever found any discrepancy with the resident's code status in medical records, she stated No, I never noticed that medical records update the system and the DNR report papers regularly for all the residents. I. On [DATE] at 9:30 AM, during an interview with RN #25, when asked about R #20's code status she stated Full Code after looking at the DNR report paper. When asked to compare the DNR report paper with electronic system and the actual MOST form signed by the resident, she confirmed that there was discrepancy between R #20's living will and the information accessible to the nursing staff. R #37 J. Record review of R #37's Face sheet revealed the admission date of [DATE]. K. Record review of R #37's Physician Orders dated [DATE] revealed code status as DNR. L. Record review of R #37's MOST form dated [DATE], revealed code status as CPR. M. Record review of [name of the unit] DNR report dated [DATE] located inside of the crash cart's binder revealed R #37's code status as DNR. N. Record review of R #37's current Care Plan initiated on [DATE] revealed no documentation for code status was found. O. On [DATE] at 12:10 PM, during an interview with RN #26 when she was asked about education and training regarding resident's code status (How would she know what to do if she found a resident unresponsive) she stated, I just started working here, I have not had any training about the resident's code status yet. P. On [DATE] at 1:56 PM, during an interview CNA #26 stated, To find the resident's code status I usually check our electronic system, the computer is located inside our Nurse station, I do not have access to the nurse's office to look at the resident's paper charts. When asked if she has no access to the PCC what actions she can take during an emergency, she stated I do not know. Q. On [DATE] at 1:59 PM, during an interview about R #37 code status, RN #23 was not able to provide the most updated code status list (DNR report), he stated I guess medical records did not leave the most updated list for this unit, the one I have here inside of the crash cart was updated last on [DATE]. I would follow the code status list [on the crash cart]. R. On [DATE] at 2:10 PM, during an interview with RN #23, when asked about R #37's code status he stated DNR after looking at the outdated DNR report paper located inside of the crash cart. When asked to compare the DNR report paper with electronic system and the actual MOST form signed by the resident, he confirmed that there was discrepancy between R #37's living will and the information accessible to the nursing staff. S. On [DATE] at 9:50 AM, during an interview with the DON, when asked about the discrepancies between the most updated DNR report papers dated [DATE] and the MOST forms signed by resident/resident's representative, she stated medical records are in charge of updating the resident's code status, I do not know why it was not updated. She confirmed that the code status of R #20 and R #37 did not match with their living will. During the same interview, when asked about the issue with resident's incorrect code status and staff not having quick access to the most updated code status information, she stated delay to start the process of CPR can affects resident's life. Initiating the code process for a resident who is DNR is against his/her will. R #318 T. Record review of R #318's Face Sheet no date revealed the admission date of [DATE]. U. Record review of R #318's Medication Administration Records (MAR) dated [DATE] revealed the code status as DNR. V. Record review of R #318's Medical Orders for Scope of Treatment (MOST) forms revealed the following: 1XXX[DATE] Do Not Resuscitate (do not attempt chest compression). W. Record review of [ name of the facility] Fall Incident Report revealed the following: 1XXX[DATE] at 4:40 AM .Resident was attempting to get up from bed unassisted (without help), he stated, my foot slip and I slide off bed onto my butt . X. Record review of R #318's Transfer to hospital summary revealed the following: 1. [DATE] at 8:37 AM .Responded to the resident's room at 8:00 AM, Resident in power chair (electric wheelchair) leaning to the left, unresponsive (not responding to stimulations). Nurse performing sternal rub (painful stimulation with knuckles of closed fist to the center of the chest) with no response. Right pupil (middle of the eye) dilated (open), both pupils unresponsive (not reacting to light). Unwitnessed fall (no one observed the fall) reported by night shift. Neuro checks were initiated (started) and had been with in normal range thus far. No apparent head injury at that time, no physical evidence of a head injury. Order to transfer resident to the emergency room for evaluation for sudden change in Level of conciseness (person's awareness and understanding). Resident transferred to the hospital at 0830 [8:30 am]. Y. Record review of the Hospital's Medical Records revealed the following: 1XXX[DATE] at 11:18 AM ' . R #318 found unresponsive, patient found sitting on the floor, stating he did not hit his head or any injuries. Staff put the patient back to bed, and at around 7:30 AM when they went to see the patient, he was not responsive. EMS (ambulance) was called, and the patient was intubated about an hour prior to arrival to the hospital [EMS intubated R #318 on the way from facility to the hospital] . Z. On [DATE] at 4:59 PM, during an interview DON stated, the facility has a list of documents to send with residents to the hospital and the advanced directive form is part of that list. She confirmed the facility failed to send R #318's advanced directive with the ambulance transported the resident to the hospital, as the result resident was intubated during transport to the hospital which is not consistent with R #318's DNR status identified on his advanced directive. Crash Carts AA. Record review of the facility Policy Resuscitation during Cardiopulmonary Arrest, revision date [DATE] revealed the following: .Equipment/supplies needed: b. This equipment will be on a red plastic bag marked Emergency Resuscitation Equipment. The bag will be sealed, and it contents verified weekly for proper function by the respiratory therapist, a white label with the date of inspection and initials will seal the bag. [Per DON/ and record review of Emergency Supplies Inspection Record, facility was performing inspection daily, two times a day instead of weekly]. c. Oxygen tanks and suction machines should be available at every nursing section and dining room. O2 (Oxygen) tank should have a minimum of 1500 PSI (unit of pressure) and verified weekly . BB. Record review of ACLS (Advanced Cardiac Life Support) website updated [DATE], revealed the following: .Any environment in which a patient may unexpectedly experience a medical emergency needs to have the equipment to deal with that emergency efficiently. That's the job of a crash cart. A crash cart contains the equipment and medications that would be required to treat a patient in the first thirty minutes or so of a medical emergency .Any facility that treats patients who have the potential to have a sudden deterioration (become progressively worse) in their condition should have a crash cart available. Nursing homes who provide treatment for patients in cardiac arrest until EMS (Emergency Medical Services) arrives would also have a need for a crash cart . Dining room CC. On [DATE] at 9:40 AM, an observation of Dining room's crash cart (no nurse station inside of dining room) revealed the following: 1. The oxygen tank was 1/3 full. 2. One open to air Nasal Canula (NC) (Exposure to elements). 3. One suction machine tubing (tube designed to remove small amounts of secretions from the mouth, nose, and throat), Four NC, two yankaer suctions (curved catheter used to prevent aspiration (chocking) and clear airway) and three suction catheters (tube use to prevent chocking) that were undated. 4. Oxygen Concentrator Machine (medical device that gives extra oxygen) last service date was [DATE]. DD. Record review of daily crash cart's inventory list review (process to check that all required supplies were available and functioning) for the month of [DATE] revealed [DATE] was not documented as being reviewed. All other dates were identified that the crash cart had been reviewed and was complete. EE. On [DATE] at 9:50 AM, during an interview, DON confirmed that the Oxygen tank was not full, there was contaminated and undated supplies inside of the crash cart with an outdated Oxygen Concentrator Machine. She also confirmed that the crash cart's inventory list was not properly filled out on [DATE]. Secured Unit I FF. On [DATE] at 11:01 AM, an observation of Secured Unit #I's crash cart (crash cart located inside of the nurse manager's office) revealed the following: 1. One oxygen tubing, one suction and yankaer tubing and two trach masks (allows delivery of oxygen to patients with tracheostomy [open cut on the front of neck to create a direct airway for the patient]) that were open to the air. 2. One oxygen tubing, one face mask (mask to reserve oxygen and delivers it directly to patient), two oral airways (device to keep the airway open by stopping the tongue from closing it), two yankaer and three suction tubing that were undated. 3. There was no daily crash cart's inventory list review for the month of [DATE]. GG. On [DATE] at 11:09 AM, during an interview, RN #25 confirmed there was contaminated and undated supplies inside of the cart and no crash cart's inventory list was found. Secured Unit II HH. On [DATE] at 11:011 AM, an observation of Secured Unit #II's crash cart (crash cart located inside of the nurse manager's office) revealed the following: 1. Nonfunctional oxygen tank, unsealed tank (releasing oxygen with pressure). 2. One open to air Trach mask. (Exposure to elements) 3. Three suction tubing, one face mask, four yankaers and three suction catheters that were undated. II. Record review of daily crash cart's inventory list for month of [DATE] revealed [DATE] was not documented as being reviewed. All other dates were identified that the crash cart had been reviewed and was complete. JJ. On [DATE] at 11:20 AM, during an interview, RN #23 confirmed the oxygen tank was not functioning properly, it was releasing oxygen and was not safe to use. She also confirmed there was contaminated and undated supplies inside of the cart and the crash cart's inventory list was not properly filled out for [DATE]. Independent Unit KK. On [DATE] at 12:10 PM, an observation of Independent Unit's crash cart (located inside of day room) revealed the following: 1. The oxygen tank was 1/4 full. 2. One open to air face mask (Exposure to elements). 3. Three oxygen tubing, five suction tubing and four suction catheters were undated. LL. Record review of daily crash cart's inventory list for month of [DATE] revealed [DATE] was not documented as being reviewed. All other dates were identified that the crash cart had been reviewed and was complete. MM. On [DATE] at 12:15 PM, during an interview, RN #26 confirmed the oxygen tank was not full, there was contaminated and undated supplies inside of the cart and the crash cart's inventory list was not properly filled out and was missing multiple dates. These resulted in an Immediate Jeopardy identified on [DATE] at 4:46 pm. A final Plan of Removal was approved on [DATE] at 1:22 pm. The facility was verified to have fully implemented this approved plan on [DATE] at 5:00 PM. Plans of Removal related to Code Status 1.Resident # 37 and Resident # 20's records were reviewed, and the families/POA's for both were contacted to verify advanced directives by physician and verified by Social Services Department. Once verified, the orders in PCC were updated to reflect that the MOST Form information was correct and the most current information available for the resident. This was completed on [DATE]. A review of all remaining resident documentation and PCC orders for all residents began on [DATE], and audit will be completed by [DATE], and audit will be completed by [DATE], taking into account POA's not immediately available. Upon admission or change to MOST form, Social Services Department will receive a copy of the resident MOST form and verify that physician orders match MOST forms. Will contact physician if order is incorrect or missing. Nursing may enter this information if physician is absent. Quarterly, all MOST forms will be reviewed in Care Plans for updates, corrections, changes, verification that orders match Most Forms. An alphabetized folder will be maintained at each nurse's station with each resident's Code Status. This will prevent delay in looking in computer for information. A resident list with code status will also be maintained on the Crash Carts. When staff member comes upon a downed resident, will use radio system to call for nurse STAT Code Blue, responding nurse or CNA will go to nurses' station check for code status and relay information to CNA who is with resident to prevent delay in life saving efforts. In-Service training for Social Services, Physician, MDS Coordinator and Nursing Department began immediately on [DATE] and will continue at start of each shift, to ensure all staff are trained as soon as possible, and expected to be completed by [DATE] which will include any staff out on vacation or leave. Training will be completed with all new hires during orientation. Plan of Removal related to Crash Carts 2.All 5 crash carts/suction carts were reviewed on [DATE]. All oxygen tanks were examined and found to be working. On [DATE] the Oxygen Contractor [NAME] in Las [NAME], changed out all oxygen tanks on all carts, ADON and [NAME] Oxygen Technician verified that all O2 tanks were full, working, and ready to use. Nursing Department will inspect crash carts biweekly to verify oxygen tanks remain working and filled. All supplies on every cart were discarded and replaced and dated than placed in crash carts biweekly to verify oxygen tanks remain working and filled. All supplies on every cart were discarded and replaced and dated than placed in crash carts. To ensure this does not happen again, the facility will discard and replace all tubing and disposable products every 6 months to prevent contamination. Additionally, all supplies and equipment will be examined bi-weekly to ensure products remain non-contaminated. Nurses will maintain a log of inspections and items replaced, to ensure equipment is available for immediate use. Training began immediately on [DATE] and will continue at start of each shift (prior to starting on floor), to ensure all staff are trained as soon as possible, and expected to be completed by [DATE] which will include any staff out on vacation or leave. A current copy of code status will be kept on each cart and updated by Medical Records team weekly, with new admissions, with discharges or as status changes occur. DON/ADON will audit cart logs monthly to ensure ongoing compliance and report to OAPI. Surveyor: Bostinto, Bo

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to provide quality of care for 1 (R #27) of 1 (R #27) resident reviewed for diabetes, when R #27 who is insulin dependent (a chronic condition in which the pancreas produces little or no insulin) went out on leave (out of the building) and was provided by the facility short acting insulin to self-administer but was not provided a glucometer to check his blood sugar levels. This deficient practice likely resulted in R #27 being admitted to the hospital for DKA (diabetic ketoacidosis: a serious complication of diabetes that can be life-threatening. DKA develops when your body doesn't have enough insulin to allow blood sugar into your cells for use as energy) and likely puts other residents who need insulin but are unable to monitor their blood sugar levels and self administer insulin when they leave the facility in life threatening situations. The findings are: A. Record review of the R #27's Medication Administration Record for April, May, and June 2022 revealed the following: 1. LANTUS SOLOSTAR (a long acting insulin) 100 UNIT/ML INJECT 40 UNITS SUB-Q (applied under the skin) DAILY AT BEDTIME FOR DIABETES MELLITUS 2. Humalog INSULIN 100 UNIT/ML PEN INJECT SUB-Q BEFORE MEALS THREE TIMES DAILY . < (less than) 100 0U (unit) 101-160=4U 161-200=6U 221-280=8U 281-340=10U 341-400 =10U > (greater than) 401 call MD (medical doctor). 3. Blood Sugar Check BG (blood glucose) according to Humalog sliding scale 15 to 20 mins before meals B. Record review of R #27 Physician's Orders revealed the following: 1. 02/04/22 R #27 may go out of the facility with brother. 2. 02/14/22 Give am PO (by mouth) meds on 02-15-22 @ (at) 05:00 (5:00 am) prior to departure for appointment, also sliding scale with snack for am. 3. 03/08/22 Res (resident) may go out on pass (1) overnight. Give 20 units reg insulin now for bs >400 provide pill planner c [with] meds for pass. 4. 05/02/22 Resident may go with c (with) brother to Las [NAME] for day for son court date. Meds (medications) for day to go c (with) resident. Go am RTN (return) pm. 5. 05/10/22 Resident may go with brother to Las [NAME] for day leaves 5/10/22 to return 5/11/22. Current PO meds, insulin and wound care supply sent with resident. 6. 05/22/22 Ok to go out on pass 5.24.22 Tuesday and back 5.25.22. Rx (Prescriptions) ready, 2 days of meds to go c (with) resident. C. Record review of the Progress Notes for R #27 revealed the following: 1. Social Services (SS) 03/08/22 at 8:23 AM Resident left for appointment 3/8/2022 at 0800 . in [name of local city] and will stay (1) overnight with sister. There was no documentation of education to R #27 or his family regarding blood sugar checks or need for insulin. 2. Medical Doctor 03/10/22 at 3:29 pm, Type: Health Status Note Note Text: Called [name of R #27] . He has been out of the facility in [Name of local city] x 2 more days than he had told us therefore we expressed our concern about his wellbeing. We offered to go get him or send someone to check on him but he would not give us his address. He was asked if he was checking his glucose and he said it was low (he states he has a glucometer) but would not give me a number. He has no insulin at this time, therefore we will call insulins to [name of local pharmacy] and he promised to go pick it up tonight. I have told him that without insulin his health could suffer greatly, leading to death. He stated he would come back to us tomorrow. 4. Nursing 03/13/22 at 10:12, the facility documented receiving information from the local hospital after R #27 was admitted Resident was admitted in the hospital [03/12/22] . with admission diagnosis of DKA . D. Record review of R #27 Hospital Records 03/12/22 to 03/15/22 revealed the following: .Upon presentation to the ER here, he was found to have an initial serum glucose greater than 600 however on lab work his glucose was 497 . E. On 06/07/22 at 1:23 PM, during an interview the Social Services Director confirmed that R #27 has gone out on pass (overnight away from the building) a few times this year. F. On 06/08/22 at 8:38 AM, during an interview, R #27 stated that when he goes out on leave from the facility, the facility does send him with medication (including his insulin). They pack you that much medication (for time he was expected to be out of the facility). R #27 confirmed that the facility they does not provide him a glucometer. R #27 stated I can't take insulin without knowing my blood sugar. And then they tell me 'you didn't take insulin'. They never send me with a meter (glucometer). I have told them I need a meter. I am not going to just take the insulin. I bottom out (blood sugar drops) real fast. Especially when I don't eat. They say I am noncompliant because I don't take the insulin but I don't take it when I don't eat. I am not doing it just to not take the insulin. I don't want to bottom out. When asked what staff's response to his request for a glucometer, R #27 stated They don't say anything just don't get a meter. R #27 was asked if the facility had ever evaluated him for self-administering his insulin or using a glucometer, he stated No. When asked about his leave on 03/08/22, R #27 stated he had to take care of his banking and that he was only suppose to be gone for (1) night. R #27 stated the facility dropped him off at his appointment and that family picked him up. R #27 stated that he was at the mercy of family and friends because they had the vehicles and was staying different places due to this. R #27 also stated that he did not have charger for his phone so when staff tried to call him, his phone was dead. R #27 reported that during this outing and after several days without his medication when he was preparing to return to the facility, he was instructed instead go to the hospital where he was admitted [from 03/12/22 to 03/15/22] for high blood sugar levels. G. On 06/08/22 at 11:18 AM, during an interview House Supervisor (HS) #3 was asked if the facility issues glucometers to diabetic residents going out on pass, she stated, No we don't release glucometers. HS #3 was asked if R #27 had been out of the building recently and she stated that R #27 went to an appointment that the facility had taken him to in [NAME] on 06/07/22 from 6:00 or 7:00 am to 3:00 pm [approximately 8 hours]. HS #3 was asked if R #27 was sent with his insulin and a glucometer, she stated that the facility had not sent him with insulin or a glucometer. The HS #3 stated that the facility would administer insulin before and after R #27 returned. HS #3 stated No one is available to check his blood sugar (on facility transport), they (transportation staff) don't carry a glucometer. I think we need to [provide staff glucometers during outings]. HS #3 was asked if R #27 had received insulin prior to his leaving on 06/07/22, HS #3 stated, No, [he] refused. H. On 06/08/22 at 12:06 PM, during an interview Transportation Worker (TW) confirmed that R #27 did go to an appointment on 06/07/22 for about 7 hours in [NAME] . TW also confirmed that staff do not take insulin or glucometers during transport because they are not qualified to administer insulin or conduct blood sugar checks. I. On 06/08/22 at 2:30 pm, during an interview, the DON confirmed that if residents go out of the facility on pass they take insulin with them but are not issued glucometers. The DON continued that it was her understanding that the Power of Attorney (POA) will have the glucometer. Usually, we talk to the POA and we will go over the medication. It should be documented talking education with the family. The DON was asked about resident who need insulin and go to appointments, if staff take insulin or glucometers, she confirmed that the facility does not, The transportation team are CNA not CMAs . When they (residents) get back, we will check their blood sugar. We have an instruction if they (residents) show any sign of hyper or hypoglycemia (during transport or at appointments) to go to the nearest hospital. We have been doing that practice. J. Record review of R #27's Medical Record revealed no documentation of a conversation between the facility staff and R #27 or his family about ensuring that they (resident or family) have a glucometer when he goes out on pass. K. On 06/08/22 at 3:48 pm, during an interview the Medical Doctor (MD) confirmed that R #27 requires insulin to live. When asked if R #27 should have insulin and a glucometer when out of the building, the MD stated, He is supposed have blood sugar checks and insulin. He needs the glucometer [to check his blood sugar level and determine how much insulin is needed], or he should not administer [the Insulin]. The above findings resulted in an Immediate Jeopardy that was called on 06/08/22 at 4:46 pm. A final Plan of Removal was submitted and approved on 06/10/22 at 10:35 am. The facility was verified to have fully implemented this approved plan on 06/10/22 at 5:00 PM. Upon implementation of the Plan of Removal the Immediate Jeopardy was lifted on 06/10/22. Plan of Removal The resident identified in this citation was given self-administration assessment for proper use of glucometer and insulin administration on 6/9/2022 and passed all areas of assessment and return administration. New Protocols implemented 6/9/2022 Every resident with diabetes required to have blood glucose checks and insulin administration will have a glucometer and insulin available on every transport, with a nurse to provide administration while out of facility, unless resident is able to perform self-administration. Residents going out of facility on extended leave of absence who are dependent on insulin will be given instruction and assessed for self-administration to ensure resident is aware and able to give him/herself appropriate insulin doses and use glucometers. If resident is unable to perform glucose testing or insulin administration, facility will train family members or friend to perform assessment with return demonstration prior to taking them out of facility, to endure that a competent person is with resident and able to provide insulin administration safely. Transportation will still be instructed to go to nearest hospital if resident became critical. Training on new protocols began immediately on 6/9/2022, with transportation staff, nursing staff, and physician and will continue at start of each shift, to ensure all staff are trained as soon as possible, and expected to be completed by 6/17/2022 which will include any staff out on vacation or leave. All new staff will be trained on protocols during orientation.

Based on observation, interview, and record review, the facility failed to ensure they maintained an Infection Prevention and Control Program (IPCP) when they failed to: 1. Provide process surveillance (techniques of observation and monitoring to evaluate infection control practices) for tracking the infections, 2. Repeated antibiotic use for R #66 without verification of effectiveness of the treatment before prescribing it again. 3. Follow contact precautions (used when patients have an infection that can be spread by contact with patient's skin including mucous membranes, vomit, urine, feces, and wound drainage) protocols when staff failed to use proper PPE [Personal Protective Equipment: gloves and gown for all interactions that may involve contact with the patient or the patient's environment] for R #66 who was on contact precautions, 4. Use the Hoyer lift only for R #66 who was on contact precautions, 5. Ensure that staff perform appropriate hand hygiene when: a. RN #21 touched her face mask, b. The Receptionist in between screening visitor's temperatures, c. RN #22 performed R #3's blood sugar check, and d. Before CMA #21 administered medication to R #3, 6. Ensure staff assist residents to perform proper hand hygiene prior to their meals, 7. Ensure that staff wear their face masks properly in patient care areas, 8. Ensure resident's Nebulizer masks (nebulizer is a device that turns the liquid medicine into a mist which is then inhaled through a mouthpiece or a mask) and Nasal cannulas (flexible tubing that sits inside the nostrils and delivers oxygen.) tubing were covered when not in use, 9. Ensure that staff are trained in infection control practices, 10. Did not have functional Infection Control Program, including assurance that the facility assessment was utilized as part of the infection control program and that reviews were conducted on an annual basis. 11. Ensure that Indwelling suprapubic Catheter (soft plastic or rubber tube that is inserted to the bladder through a small cut in the abdomen to drain the urine and is connected to a collecting bag) tubing was not touching the floor. This has the potential to affect all 66 residents on the facility (residents were identified by the Census list provided by the Administrator on 06/06/22). If the facility cannot determine the rate and spread of infection in the facility, and are not following infection control practices for residents with infections, then this could likely result in the spread of infections causing illness and death. The findings are: Resident's hand hygiene A. On 06/06/22 at 11:50 AM, during an observation of common area revealed staff did not offer hand hygiene to R #6, R #7, R #8, R #25, and R #46 prior to start their meal. B. On 06/06/22 at 12:30 PM, an observation of common area revealed staff did not offer hand hygiene to R #66 prior to her meal. C. On 06/06/22 at 12:30 PM, during an interview with CNA #21, when asked if staff should offer hand hygiene to R #66, she stated we did not wash her hands because she took a shower an hour ago and she did not move from this area, so we did not have to sanitize her hands anymore. D. On 06/09/22 at 12:58 PM, during an interview IP confirmed that staff should offer hand hygiene to all residents prior and after their meals. Face mask E. On 06/06/22 at 10:41 AM during an observation of common area RN #21 was observed with her face mask under her nose. F. On 06/06/22 at 10:42 AM, during an interview RN #21 confirmed she failed to wear her mask properly. G. On 06/06/22 at 2:07 PM, during an observation of common area, RN #21 observed with her mask under her nose, not covering her face. During an interview at that time, she confirmed her mask was not covering her face and was under her nose. H. On 06/09/22 at 12:58 PM, during an interview, IP confirmed that staff should wear their masks properly at all time Staff's hand hygiene I. On 06/06/22 at 2:07 PM, during an observation of medication administration, RN #21 was observed touching her face mask. She failed to perform hand hygiene before she offered the medication to the R #46. J. On 06/06/22 at 2:10 PM, during an interview, RN #21 confirmed she failed to perform hand hygiene after she touched her face mask and offered the medication to R #46. K. On 06/09/22 at 1:00 PM, during an interview, IP confirmed staff and nurses should perform hand hygiene after touching their masks and before administering medication to the residents. L. On 06/10/22 at 8:17 AM, during an observation of reception area revealed receptionist did not change his gloves between checking visitor's temperatures and failed to perform hand hygiene after he removed his gloves. M. On 06/10/22 at 8:20 AM, during an interview, receptionist confirmed he failed to change his gloves and perform hand hygiene between each temperature check. He stated, I was nervous. N. On 06/14/22 at 12:57 PM, during an interview, DON confirmed staff should change their gloves and perform hand hygiene between each visitor while they are checking their temperatures. O. On 06/14/22 at 11:08 AM, during an observation of R #3's blood sugar check, it was observed RN #22 failed to change her gloves and perform hand hygiene after she checked the resident's blood sugar. P. On 06/14/22 at 11:12 AM, during an interview, RN #22 stated, I did not have to change my gloves because they were not contaminated with blood. Q. On 06/14/22 at 11:20 AM, during an observation of medication administration, CMA #21 failed to perform hand hygiene before administering medication to R #3. During an interview at that time, she confirmed she did not sanitize her hands between each task. R. On 06/14/22 at 12:57 PM, during an interview, DON confirmed RN #22 failed to change her gloves and perform hand hygiene after blood sugar check. She stated, staff should perform hand hygiene between each task while performing medication administration. S. Record review of Handwashing/ Hand hygiene policy revision date 08/01/19 revealed the following: Policy interpretation and Implementation .1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare associated infections. 2. All personnel shall follow the handwashing/ hand hygiene procedure to help prevent the spread of infections to other personnel, residents, and visitors. 9. The use of gloves does not replace hand hygiene/ hand washing. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare associated infections. 10. Single -use disposable gloves should be used: C. When in contact with a resident, or the equipment or environment of a resident, who is on contact precautions . Nebulizer R #3 T. On 06/07/22 at 01:30 PM during observation of R #3's room revealed his Nebulizer mask was uncovered. R #10 U. On 06/07/22 at 01:31 PM during observation of R #10's room revealed his Nebulizer mask was uncovered. R #11 V. On 06/07/22 at 01:32 PM during observation of R #11's room revealed his Nebulizer mask was uncovered. R #13 W. On 06/07/22 at 01:33 PM during observation of R #13's room revealed his Nebulizer mask and Nasal cannulas were uncovered. R #14 X. Record review of R #14's physician orders dated 06/07/22 revealed, ALBUTEROL SUL[sulfate] 2.5 MG [milligram]/3 ML [milliter] SOLN [solution]- inhale orally. Y. On 06/07/22 at 1:39 pm during an interview with R #14, R #14's nebulizer was observed to be placed face down on R #14's dresser and uncovered. R #14 stated, I use it [nebulizer] in the mornings and in the evenings. Z. On 06/07/22 at 1:44 pm during an interview with RN #5 she stated, It's [R #14's nebulizer] supposed to be in a bag with a date as well. It needs some protection. RN #5 confirmed R #14's nebulizer was not dated or stored appropriately. R #18 AA. On 06/07/22 at 1:26 PM during observation of R #18's room revealed his Nebulizer mask was uncovered. R #21 BB. On 06/07/22 at 1:27 PM during observation of R #21's room revealed his Nebulizer mask and Nasal cannulas were uncovered. R #24 CC. On 06/07/22 at 1:28 PM during observation of R #24's room revealed his Nebulizer mask and Nasal cannulas (flexible tubing that sits inside the nostrils and delivers oxygen.) tubing were uncovered. R #28 DD. On 06/07/22 at 1:29 PM during observation of R #28's room revealed his Nebulizer mask was uncovered. R #35 EE. On 06/07/22 at 1:40 PM during observation of R #35's room revealed his Nebulizer mask was uncovered. R #45 FF. On 06/07/22 at 1:47 PM during observation of R #45's room revealed his Nebulizer mask was uncovered. R #49 GG. Record review of R #49's Medication Administration Record (MAR) dated 05/01/22 revealed, Iprat-Albut [Ipratropium bromide- Albuterol] 0.5- 3 (2.5) MG/3 ML- Duo Neb, Give 3 ML Neb [nebulizer] Tx [treatment] QID [four times daily] for COPD [Chronic Obstructive Pulmonary Disease- a group of lung diseases that block airflow and make it difficult to breathe]. HH. On 06/07/22 at 1:28 pm during an interview with R #49, R #49's nebulizer was observed to be uncovered and stored in R #49's top dresser drawer. R #49 stated, I use it [nebulizer] four times a day. II. On 06/07/22 at 1:48 pm during an interview with RN #5 she stated, We use a zip lock [plastic storage bag] that should be dated. There should be a [name of tissue paper company] for mucous as well. RN #5 confirmed R #49's nebulizer was not stored appropriately or dated. R #55 JJ. On 06/07/22 at 1:55 PM during observation of R #55's room revealed his Nebulizer mask was uncovered. KK. On 06/07/22 at 2:10 PM, during an interview, IP confirmed R #11, R #35, R #45, and R #55's Nebulizer masks were uncovered. R #56 LL. On 06/07/22 at 01:26 PM during observation of R #56's room revealed his Nebulizer mask was uncovered. R #60 MM. Record review of R #60's physician orders dated 06/07/22 revealed, IPRAT-ALBUT 0.5-3(2.5) MG/3 ML 3 ml inhale orally four times a day related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE, UNSPECIFIED INHALE 1 VIAL VIA NEBULIZER FOUR TIMES DAILY FOR CHRONIC OBSTRUCTIVE PULMONARY DISEASE [COPD]. NN. On 06/07/22 at 1:26 pm during an interview with R #60, R #60's nebulizer mask observed to be uncovered and stored on R #60's dresser. R #60 stated, I use it [nebulizer] three times a day. OO. On 06/07/22 at 1:47 pm during an interview with RN #5, she confirmed R #60's nebulizer was not stored appropriately or dated. PP. On 06/09/22 at 12:59 pm during an interview with the IP, she stated, My understanding prior to this week was we [facility] were to rinse them [nebulizers] and dry them [nebulizers], but then we were to place them [nebulizers] in a bag. They [residents nebulizer and nebulizer tubing] should be dated and changed monthly. IP confirmed resident nebulizer masks should be stored in a sealed bag, dated, and not left on or in resident dressers. R #62 QQ. On 06/07/22 at 01:26 PM during observation of R #62's room revealed his Nebulizer mask was uncovered. R #167 RR. On 06/07/22 at 01:26 PM during observation of R #167's room revealed his Nebulizer mask was uncovered. SS. Record review of Departmental Respiratory Therapy- Prevention of Infection policy revision date 11/01/11 revealed the following: .Infection Control Considerations Related to Medication Nebulizers/Continues Aerosol: 7.Store the circuit in plastic bag, marked with date and resident's name, between uses . Training TT. On 06/14/22 at 2:38 PM, during an interview with the IP when asked if she has completed staff training on infection prevention she stated, Staff development does the general education and IP does the infection control ones for all staff. There has not been any specific training that applies to everyone, so we did not perform any infection control training (since the IP started). When new employees come in, we do new hire orientation and then annual training. We have some training paperwork from the previous IP, but I don't have anything from the time I started (April 2022). Infection control program UU. On 06/14/22 at 2:45 PM, during an interview with the Infection Preventionist she was asked the following: 1. If the facility assessment was used to help develop and implement the IPCP. She stated, I do not know. 2. The annual review of the infection control program. She stated, I do not know, I am sure they (facility administration) review the infection control program, but since I started this role, I have not done it. VV. On 06/14/22 at 3:00 PM, during an interview IP confirmed that facility currently has no functional Infection Control program in place, and she is in the process of establishing and completing one (since she started in April 2022). PPE/ Contact precaution for R #66 WW. Record review of R #66's H &P (History and Physical) dated 07/24/19 revealed the diagnosis of recurrent UTI (urinary tract infection). XX. On 06/06/22 at 11:01 AM, an observation of R #66's room revealed a contact precautions sign was posted on the door. YY. On 06/06/22 at 11:10 AM, during an observation of R #66's room, it was observed staff coming in and out of the resident's room without wearing their PPE. ZZ. On 06/06/22 at 12:20 PM, during an interview with RN #21, when asked why R #66 was under contact precautions she stated, R #66 has chronic MDRO (Multidrug resistant organism) (bacteria that resist treatment with more than one antibiotic). She is under contact precaution for E. coli (bacteria commonly found in the gastrointestinal tract [stomach] that can cause infection in the urine) in her urine. AAA. On 06/06/22 at 12:21 PM, an observation of the common area revealed, R #66 was brought to the dining area without any PPE on to have lunch with other residents around the same table. During an interview at that time RN #21 was asked, If R #66 is under contact precaution, why is she out of her room without proper PPE, RN #21 stated her infection is in her urine, she has an incontinence brief (adult diapers) on. We are allowed to take her out of her room. The only time we are required to have PPEs on is when we perform incontinence care for her. R #66 doesn't have to use PPE because the infection is in her urine. RN #21 continued to state We only use full PPE when we perform peri-care (cleaning the private areas of the patient), changing the resident's soiled (linens dirtied from fluids from human body) clothes and her contaminated bedding. BBB. On 06/07/22 at 8:30 AM, an observation of R #66's room revealed staff left a Hoyer lift (an assistive device helps to transport residents) inside of the resident's bathroom. CCC. On 06/07/22 at 8:35 AM, during an interview with CNA #21 when asked about the Hoyer lift inside of the R #66's room, she stated That's our community lift, but we keep it inside of her room because she uses it more than others. Every time we need it for another resident, we take it out and clean it prior to use, then we take it back to her room after we are done. DDD. On 06/07/22 at 8:43 AM, during an interview RN #21 stated, Hoyer lift is specific for R#66 because she is under contact precautions, we should not remove that from her room. RN #21 did not confirm how many residents used the Hoyer lift, but stated I don't know why staff are using it for other residents. EEE. On 06/07/22 at 9:03 AM, during an interview with CNA #22 when asked about the Hoyer lift inside of the R #66's room, he stated That is our unit's Hoyer lift. We use it for every resident who needs it, but I usually use my belt instead of using the lift. FFF. On 06/07/22 at 8:45 AM, an observation of the common area revealed R #66 was sitting around the table eating her breakfast. GGG. On 06/07/22 at 8:50 AM, during an observation, CNA #21 was observed helping R #66 with removing her dignity cover and picked up her disposable breakfast plates and cup without proper Replace with what she actually was wearing PPE/gloves. She failed to disinfect the table after resident was done with her meal. Repeated antibiotic use for R #66 HHH. Record review of R #66's Physician Orders revealed the following: 1. 11/2/21: .Rocephin (antibiotics to treat infection) 1 gram intramuscularly, every day for 5 days. 2. 11/09/21: . Macrobid 100mg by mouth two times a day for 10 days for UTI, discontinue Rocephin . 3. 12/13/21: . Macrobid 100 mg by mouth, every 12 hours for 10 days to treat UTI . 4. 01/1/22: .Macrobid 100 mg, take one capsule by mouth three times a day for 7 days to treat UTI . 5. 02/27/22: .Macrobid 100 mg, take one capsule by mouth three times a day for 10 days to treat UTI . 6. 4/5/22: .Macrobid 100 mg by mouth, every 12 hours for 10 days to treat UTI . 7. 5/3/22 .Macrobid 100 mg by mouth, every 12 hours for 14 days to treat UTI . 8. 06/01/22 .Contact precautions . 9. 06/03/21: Macrobid (antibiotic to treat infection in the urine) 100 mg by mouth, two times a day to treat UTI . 10. 06/28/21: .Macrobid 100 mg by mouth, two times a day for 14 days to treat UTI . III. Record review of R #66's Care Plan dated 08/06/19 revealed the following: 1.Observe for signs and symptoms of UTI: cloudy, smelly urine, blood in urine, lower back, flank (side, between ribs and hip), or suprapubic pain (above the pubic bone), pain on urination, fever, chills, malaise (general discomfort), nausea, vomiting . JJJ. Record review of R #66's Urine Culture (test to check the bacteria in the urine) Result dated 12/18/21 revealed positive for E.coli. KKK. On 06/09/22 at 12:42 PM, during an interview with IP, she was asked the following: 1. When asked about repeated antibiotic use for R #66 with chronic UTI, with no change in type of antibiotic, she stated I talked to our Medical Director (MD) about this resident, but I did not document our conversations, I recently started working here and can't speak for the reason why DR. [Doctor] continuously giving the resident the same antibiotics. 2. The IP confirmed that treatment is complete by end of the medication regimen only. The IP also confirmed that a cutlure and sensitivty test is not conducted after each antibiotic use to confirm the infection is cleared. 3. When asked about the process of contact precaution for R #66, IP stated [Name of R #66] has MDRO and is under contact precaution. She can come out of her room, but she cannot eat with other residents around the same table and staff should be sanitizing her hands prior and after her meal and her table should be disinfected every time. 4.When IP was asked about the use of Hoyer lift, she stated Lift is only for R #66 because she is under contact precaution. Staff are not supposed to take it out of her room and use it for any other resident. LLL. 06/10/22 at 8:41 AM, during an interview with MD, he stated [Name of R #66] is chronically (persistent) colonized (germs gather in one part of the body) with MDRS (multi drug resistant strains) from Ecoli. Her urine culture (UA) shows [Name of R #66] responds well to Macrobid, but I was unable to clear her infection yet. I tried to order UA and change the antibiotic, but the daughter refused and stated, absolutely not (due to her age and cognition). So we decided to keep her under the same medication over and over. We tried to isolate her but it's difficult, putting gown and gloves on her aggravates (increase the symptoms) her dementia. Her daughter is not agreeing with this decision and the nurses are refusing to follow the order. When asked about the process of contact precaution he stated, her issue is not an open wound, the infection is in her urine, we need to place her under universal precaution (are a standard set of guidelines to prevent the transmission of bloodborne pathogens from exposure to blood and other potentially infectious materials by means of the wearing of nonporous articles such as medical gloves) instead, but about the process of contact precaution you need to refer to our IP. MMM. On 06/14/22 at 9:55 AM, during an Interview with MD he confirmed urine culture was not done based upon the family's wishes [due to resident age and congnition] and that contact precaution were not being followed. He stated we do not perform urine culture after the course of antibiotics is over. I use the clinical condition of resident to judge the situation, but to evaluate the medication in 48 hours after start of the antibiotics is something we haven't done before. Indwelling suprapubic Catheter OOO. On 06/15/22 at 11:25 AM, during an observation of R #59's room revealed R #59's catheter bag and oxygen tube were on the floor. PPP. Record review of R #59's Face Sheet revealed the diagnosis of Neuromuscular dysfunction of bladder (Patient lacks bladder control due to brain or nerve problem). QQQ. Record review of R #59's Care Plan revision date 05/17/22 revealed .make sure catheter has privacy bag and tubing is not dragging on the floor . RRR. On 06/15/22 at 11:26 AM, during an interview, RN #24 confirmed that R #59's catheter bag and tubing was on the floor. SSS. On 06/15/22 at 12:58 PM, during an interview the DON confirmed that catheter bag and tubing should be off the floor. TTT. Record review of Catheter Care, Urinary policy revision date 10/01/10 revealed the following: . Infection Control 2. b. Be sure the catheter tubing and drainage bag are kept off the floor . Process surveillance UUU. On 06/14/22 at 2:30 PM, during an interview with the Infection Preventionist when asked about the facility process surveillance (auditing and review of infection control practices) of the facility staff's infection control practices, she stated, I have not completed process surveillance since I started working here (April 2022). VVV. Record review of Infection Prevention policy revision date 06/09/17 revealed the following: Policy . It is the policy of the [name of the facility] that surveillance of infections will be done on a regular and ongoing basis for both the residents and employees of the facility . 1.Procedure .4. The infection Preventionist Nurse will present the monthly summaries, organisms identified, and graphs to infection prevention committee members at a monthly meeting or as often as practicable. C. Infection rates will be calculated monthly by the infection control coordinator, using percentages based on the average daily census for the month, and by using resident days. 1.Incidence rates reflect new cases if infection in the resident population in a month . WWW. Record review of Infection Prevention Assessment and Plan policy revision date 06/09/17 revealed the following: 1.Procedure .10. Infection prevention for [name of the facility] will include a Risk Assessment for our residents and Plan to address identified infection risks . XXX. Record review of Quality Improvement Plan for Infection Prevention policy revision date 04/11/17 revealed the following: Procedure .3. Monitor of resident and employee infections and communicable disease, and calculation of Nosocomial infection (acquired during the process of receiving health care that was not present during the time of admission) rates on a monthly basis and by using resident days. B. Information that is collected will be used for reports and will be filed in the Infection Prevention office. 1.Monthly reports will include Nosocomial Infection report, organism found, tally sheets, updated monthly chronic UTI reports, graphs, Agendas, and minutes of infection prevention quarterly meetings. A running list of all resident UTI's and cultures will be updated monthly and distributed to staff to follow organisms, symptoms, procedures, criteria met for infection, and evaluation of outcomes of treatment for UTI's on all residents affected . These deficienct practices resulted in an Immediate Jeopardy that was identified on 06/08/22 at 4:46 pm. A final Plan of Removal was submitted and approved on 06/10/22 at 1:22 pm. Plan of Removal The new Infection Control Nurse located a tracking and trending form for Infection Control and Antibiotic Stewardship. The IC nurse began backfilling information form July 1, 2021, to present to begin the tracking and trending on 06/10/22 and should be completed by 06/11/22. Related to ABX (antibiotic) use: Administrator received permission from Power of Attorney [POA] on 06/10/22 to perform a straight catheterization (process of inserting a catheter into a body cavity) on resident for CNS (culture and sensitivity). Administrator and physician will discuss referral to Urologist with POA after results return form CNS, but POA resistant due to resident age, gave permission to give her telephone number to surveyors. Resident placed on Contact and Isolation Precautions, until results from CNS come back negative from lab. If results are positive will consult physician for further instruction. Resident provided her own lift with immediate training on cleaning and disinfection. New lift provided for all other residents on unit. Immediately Education for Contact Precaution PPE, Hand Hygiene for staff and residents, as well as proper cleaning and disinfection of equipment and surfaces on 06/09/22 with NOC (night shift) shift for this unit. Training will continue at start of each shift (prior to starting on floor) to ensure all staff trained properly. Training will be completed by 06/17/22 for all rotations and to ensure training completed for any staff out on vacation or leave. Training for all new hire will be completed on orientation.