**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Resident #41) reviewed for incontinent care. The facility failed to ensure Resident #41's foley bag was not place on the bed during wound care. This failure could place residents at risk for pain, infection, injury, and hospitalization. Findings included: Record review of Resident #41's face sheet dated 05/30/24 revealed a [AGE] year-old male was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #41 had diagnoses included: hypertension (blood pressure in the blood vessels is too high), cerebral infraction (damage to tissues in the brain due to loss of oxygen to the area), diabetes mellitus (a disease of inadequate control of blood levels of glucose), and atherosclerotic heart disease( thickening or hardening of the arteries). Record review of Resident#41's admission MDS assessment dated [DATE] revealed: Resident #41 had BIMS of 12 out of 15 indicated moderate impaired cognition. Further review revealed Resident #41 had an indwelling foley catheter. Record review of Resident #41's care plan dated 03/2724 revealed Resident #41 has foley catheter. Interventions: Monitor/record/report to MD for s/sx UTI: pain, burning, blood-tinged urine, Record review of Resident #41's physician order dated May 2024 read in part . Indwelling catheter DX: urine retention, Monitor for S/S of Infection, initiated on 03/08/24 . During an observation on 05/29/24 at 2:17 p.m., the wound care nurse placed Resident #41's Foley bag on the bed from 2:18 p.m. to 2:28 p.m. during wound care, and the urine backed up into the Foley tube. During an interview on 05/29/24 at 2:42 p.m., the Wound care nurse said she placed Resident #41's Foley bag on the bed, and it was at the same leave as the bladder. The wound care nurse said the Foley bag should be placed below the bladder for the urine to drain by gravity. The wound care nurse said Resident #41 could have a UTI if the urine flowed back into his bladder. The wound care nurse said she had in service on Foley care, and the DON and ADON monitored the nurses to ensure they were providing care appropriately when they made random checks. During an interview on 05/30/24 at 1:52 p.m., the DON said placing Resident #41's Foley bag on the bed could have caused pressure, urine flow backward, and infection. The DON said the Foley bag should always be below the Resident's bladder. The DON said she and the ADON monitored the nurses when they make random rounds and talk to the residents about care. Record review of the facility policy on catheter care urinary dated 2001 MED - PASS, Inc. read in part . The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections . Maintaining Unobstructed Urine Flow .#3 Position the drainage bag lower than the bladder at all times to prevent urine from flowing back into the urinary bladder .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care and services, including oxygen administration was provided such care, consistent with professional standards of practice for 2 of 4 residents (Resident #10 and #11) reviewed for respiratory therapy in that: The facility failed to ensure Resident #10 and Resident 11's oxygen was set according to physician orders. This failure could place residents at risk of respiratory distress. The findings were: 1. Record review of Resident #10's face sheet dated 05/30/24 revealed an [AGE] year-old female was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #10 had diagnoses included: respiratory failure (a serious condition that makes it difficult to breathe on your own) and chronic obstructive pulmonary disease (a long - term lung disease that makes it hard to breath. Record review of Resident #10's quarterly MDS assessment dated [DATE] revealed: Resident #10 had BIMS 12 indicated moderately impaired cognition. Further review revealed it was not indicated Resident #10 was on oxygen. Record review of Resident #10's care plan dated 01/29/24 revealed the resident was on oxygen. Intervention: monitor and report signs of hypoxia (cyanosis, tachypnea, dyspnea, confusion, restlessness, nasal flaring, elevated blood pressure, increased respirations, increased pulse) to physician Record review of Resident #10 physician order dated May 2024 read in part . O2 @2-3LPM via nasal cannula continuous per concentrator every shift ordered date 5/29/2024 . During an observation on 05/29/24 at 9:20 a.m., it was revealed that Resident #10's oxygen concentrator was set on 4L. Resident #10 did not respond when asked if she knew where the oxygen should be set on the concentrator. During an interview on 05/29/24 at 11:28 a.m., LVN M said he had not checked Resident #10's oxygen setting since he came to work today and needed to know how many liters of oxygen Resident #10 should be on. LVN M said he would guess 2 to 3 Liters because that was what most residents ordered for oxygen. LVN M stated that you must get an order from the physician to increase or decrease the oxygen setting. LVN M said if Resident #10 was having any crisis, the nurse could increase or decrease the oxygen, notify the doctor, and follow the doctor's order. LVN M said the night nurse did not tell him Resident #10 had any crisis or emergency with regrade to respiration. During an interview on 05/30/24 at 1:31 p.m., the DON said LVN M should have checked Resident #10's order to make sure the O2 was set as ordered, and it was the same negative outcome for the resident as the previous resident. The DON said the ADON, ADON, NP, or the doctors monitor the nurses. The DON said they monitor the nurses by checking the EMAR and ETAR to see if the nurses have signed off, and each department head checks on the residents. During an interview on 05/31/24 at 3:40 p.m., the ADON said her expectation was for LVN M was to check Resident #10 oxygen setting upon coming to the shift and check on the setting sparingly through his shift. The ADON said that for Resident #10 to be on oxygen, the resident should have a physician's order and that the setting on the concentrator should match the order. The ADON said it depended on what Resident #10 diagnoses were, and if Resident #10 got more oxygen than required, Resident #10 could have a negative outcome. The ADON did not respond on what type of outcomes. The ADON said the nurse must have a physician order to increase or decrease the oxygen setting. The ADON said the facility had a respiratory therapist who came and educated the nurses, and the DON, ADON, monitored the nurses. 2. Record review of Resident 11's face sheet dated on 05/31/24 revealed a [AGE] year old male was administered to the facility on [DATE]. Resident #11 Resident #11 had diagnoses included: dyspnea(shortness of breath), and chronic obstructive pulmonary disease(a long - term lung disease that makes it hard to breath). Record review of Resident #11's admission MDS dated [DATE] revealed: Resident #11 had a BIMS of 15 which indicated intact cognition. Further review revealed Resident #11 was on oxygen therapy. Record review of Resident 11s care plan dated 03/28/24 read Oxygen: Resident requires the use of oxygen related to chronic obstructive pulmonary disease. Intervention: educate the resident on the importance of keeping oxygen on and at the prescribed setting. O2 @_3_LPM via nasal cannula continuous per concentrator. Record review of Resident 11's physician's order dated May 2024 read in part . O2 @3-4LPM via nasal cannula continuous per concentrator every shift ordered date 5/31/2024 . During an observation on 05/29/24 at 9:46 a.m., Resident #11's oxygen was set at 6 liters on the concentrator. Resident #11 could not verbalize where the oxygen was supposed to be set. During an interview on 05/29/24 at 11:16 a.m., LVN M said the oxygen was set at 6 Liters on the concentrator, but Resident #11's 02 should be set between 3 and 4. LVN M said Resident #11 should have an order if the oxygen would be higher than the previous order. LVN M said Resident #11's friend usually changes the setting, and everybody was aware of it. LVN M said Resident #11 could have a negative out when given more oxygen than ordered. LVN M said he did not report to the DON; he just told the hospice nurse that Resident #11's friend increased the setting on the concentrator. LVN M said the nurse he took over from today did not give him any report that Resident #11 had any issue that would warrant the oxygen to be increased. LVN M said he had not checked Resident #11's oxygen setting since he came to work today and would check the oxygen setting whenever he got to the resident's room because he was the only nurse for 35 residents. During an interview on 05/30/24 at 1:16 p.m., the DON said for Resident #11 to be on oxygen, Resident 11 must have a doctor's order, and when the setting was increased or decreased, the doctor must give an order. The DON said LVN M should know, and the nurse should fix the setting on the concentrator according to the order. The DON said LVN M should make rounds every two hours to check on residents with oxygen and ensure oxygen was in the correct setting. The DON said if Resident #11 had an emergency, the nurse could change the setting to stabilize the resident, and the doctor would be notified as soon as the resident was stabilized and followed the physician's order. The DON said that depending on Resident #11's diagnosis, the resident's health could worsen if the oxygen was set above or below the resident's order. The DON said Resident #11's physician knew the family's increasing O2. The DON said he had to check the physician's statement and get back to the surveyor. Record review of the facility policy on oxygen administration dated 2001 MED - PASS, Inc. revision date October 2010 read in part . The purpose of this procedure is to provide guidelines for safe oxygen administration . Preparation . 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate administering of all drugs to meet the needs for 1 of 9 Residents (#36) reviewed for pharmacy services in that: Register Nurse (RN) A failed to follow medication administration policies resulting in Licensed Vocational Nurse (LVN) A attempting to give Resident #36 a double dose of resident's 8:00 a.m. prescribed medications. RN A failed to document the start date for Resident #36's medications. Failures could place all residents at risk of drug diversion, health decline, and/or death. Findings included: Record review of the Face Sheet for Resident #36 reflected a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included: end stage renal disease, dependence on renal dialysis, atrial fibrillation, atherosclerotic heart disease of native coronary artery without angina pectoris, with a primary diagnosis of hypertension. Record review of Resident #36 Minimum Data Set (MDS) assessment, dated 03/08/2024, reflected a Brief Interview for Mental Status (BIMS) of 15 which indicated the resident was cognitively intake. Record review of Resident #36's Care Plan with a printed date of 05/31/2024, reflected the following: Focus: Cardiac: Resident is at risk for cardiac issues related to atrial fibrillation, coronary artery disease, hypertension Date Initiated: 12/10/2022 Revision on: 3/29/2023. Goals: Resident will be compliant with medication regimen for cardiac health issues through next review Date Initiated: 12/10/2022 Revision on: 01/29/2024 Target Date: 06/26/2024. Resident will not have any symptoms of cardiac distress through next review Date Initiated: 12/10/2022 Revision on: 01/29/2024 Target Date: 06/26/2024. Resident will have blood pressures within the following parameters through next review Date Initiated: 12/10/2022 Revision on: 01/29/2024 Target Date: 06/26/2024. Interventions/Tasks: Monitor vital signs as indicated and Notify Medical Doctor (MD) as needed Date Initiated: 12/10/2022. Notify MD of symptoms of cardiac distress such as chest pain; irregular heart rate; fainting; numbness; pain or tingling in extremities, neck, or upper back; cold sweats; dizziness; increased or decreased blood pressure Date Initiated: 12/10/2022. Observe for edema, weight gain, and adventitious lungs sounds and report to MD when needed date Initiated: 12/10/2022. Observe for side effects or cardiac medications Date Initiated: 12/10/2022. Record review of Resident #36's electronic medication administration record (EMAR) dated 05/31/2024 reflected LVN A administered the following 8:00 a.m. medications: Amlodipine Besylate Oral Tablet 5 MG for high blood pressure. Do not give if systolic is < 120 diastolic <60. Blood Pressure (bp, ): Finasteride Tablet 5 MG for benign prostatic hypertrophy (BPH). Lidoderm External Patch 5 % to relieve the pain. Sertraline HCL tablet 50 mg for depression. Amiodarone HCL tablet 200 mg for arrythmia. Apixaban tablet 5 mg for blood clot prevention. Record review of Resident #36's EMAR creation date 05/31/2024 at 02:11 p.m. reflected Captopril Tablet 25 MG Give 12.5 mg by mouth every 24 hours as needed for elevated bp greater than 170 PRN Administration was: Ineffective. Author RN A. Interview on 05/31/2024 at 10:39 AM Resident #36 stated he had a dialysis chair time of just 6 a.m. on 05/31/2024. He stated just before going to dialysis, RN A gave him his morning meds. He stated around 8:00 a.m., while still in dialysis LVN A attempted to pass him his morning meds again. He stated he denied the meds informing LVN A he had already received them. He stated he feared had he not been alert; he would have received a double dose of medications. Interview on 05/31/2024 at 11:46 a.m. LVN A stated she had been a nurse with the facility for 3-years. She stated that on 05/31/2024 her shift began at 6:00 a.m. but she arrived at 6:30 a.m. and began passing meds. She stated at about 7:00 a.m. she entered the dialysis room and recorded Resident #36's bp from the dialysis machine he was hooked up to and asked resident had he gotten his morning meds. She stated Resident #36 told her he had received his meds from RN A. She stated that the eMAR reflected that Resident #36 had not received his meds. She then signed off on Resident #36's meds. She stated that had not happened before. She stated because she late, RN A covered for her morning med passes until she arrived. Interview on 05/31/2024 at 11:58 a.m. the DON stated that he was not aware that LVN A had signed off on meds administered by RN A. The DON stated the staff that administers medication should be the staff who signed off on medications, to ensure it was giving and to follow the 6th rights of the medication. The DON stated the medication policy stated that meds were to be given 45 minutes before dialysis begins unless it was a bp medication. He stated the EMAR would not allow staff to sign-off on medications passes without adding a resident's bp. He stated Resident #36's bp fluctuates and was often very high and that was the reason resident received his medication prior to dialysis. He stated medication can be passed to dialysis residents before, during or after dialysis and could be nursing judgement. He stated he would check the actual time Resident #36 received dialysis and provide documentation. Interview on 05/31/2024 at 01:35 p.m. the MD stated that because Resident #36's bp runs high it was fine to administer his bp medication prior to dialysis. He stated that enough of the medication would be absorbed to benefit the resident. He stated the resident's medication doses were adjusted to compensate for the dialysis treatments. Interview on 05/31/2024 at 03:17 p.m. Resident #36 stated that most often he takes his morning meds before dialysis. He stated if his bp was below 125, he would hold all meds until after dialysis and if it was higher than 125, he would take all meds. He stated his chair time was at 6am. He stated that the staff get him up in the morning sometime around 5:00 a.m. and to dialysis at 5:30 a.m. Interview on 05/31/2024 at 3:37 p.m. the DON stated that Resident #36 was given his bp meds around 5:00 a.m. on 05/31/2024 just before dialysis because the resident's bp was high. He stated that the resident has a PRN of captopril every shift and as needed. He stated RN A should have informed MD that the resident's bp was high and if the medication did not work, and a progress note was made by RN A 05/31/2024. Interview on 05/31/2024 at 11:06 p.m. RN A stated he had worked at the facility nearly 2-years. He stated that Resident #36 had a 6:00 a.m. dialysis chair time on 05/31/2024. He stated took resident's vitals at 5/5:06 a.m. and resident's bp was 172/80. He stated that resident had a prescription for captopril 12 mgs to be administered prn. He stated that he took the vitals again and after 6am and it was 159/75 and since it was still high, he called the MD who told him to administer all the resident's morning meds. He stated he administered the meds that were normally assigned for the LVN A to administer: He stated he was rushing off shift and forgot to sign off on administering Resident #36' meds or complete the progress note regarding the MD's order to administer the prn medication. He stated the importance of checking off on administering resident's medications was to ensure that the residents do not receive double doses He stated it was all on him that the meds were not signed off and notes not entered regarding the MD's instructions. He stated had an in-service on med administration about 2-weeks ago. Record review of policy Medication Administration Schedule with a revised date of November 2020 reflected: Scheduled medications are administered within one (1) hour of their prescribed time, unless otherwise specified. Record review of policy Medication and Treatment Orders with a revised date of July 2016 reflected: Policy Statement Orders for medications and treatments will be consistent with principles of safe and effective order writing. Policy Interpretation and Implementation 7. Verbal orders must be recorded immediately in the resident's chart by the person receiving the order and must include prescriber's last name, credentials, the date, and the time of the order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 4 of 5 staff (CNA K, Wound care nurse, CMA N, and Laundry aide A ) and one(linen closet W) out of two clean linen closet observed for infection control. 1. The facility failed to ensure CNA K followed proper infection control and hand washing procedure during incontinent care for Resident #24. wound care. 2. CMA N did not sanitize the plastic medication container after using to administer medication for Resident #20 3. CMA N did not wash her hands prior to administering eye drops for Resident #24. 4. The facility failed to ensure to ensure clean item was not stored on the floor in the west clean linen closet. 5. The facility failed to ensure laundry aide A followed proper hand washing technique and infection control procedure when she demonstrated hand washing after loading dirty linen in the washing machine. These failures could place the residents at risk for infection. Findings included: 1.Record review of Resident #24 face sheet dated 05/30/24 revealed a [AGE] year-old male was admitted to the facility on [DATE]. Resident [NAME] had diagnoses included: hypertensive heart disease (a group of heart problems that occur when high blood pressure is present over a long period of time), peripheral vascular disease (is a circulatory condition that occur when blood vessels outside of the heart and brain narrow, block blood flow to other parts of the body), diabetes mellitus (a disease of inadequate control of blood levels of glucose), and hemiplegia(paralysis that affects only one side of the body). Record review of Resident 24's quarterly MDS assessment dated [DATE] revealed: Resident [NAME] had BIMS of 14 out of 15 indicated intact cognition. Further review revealed Resident [NAME] was extensive to depended on staff for ADL care. Record review of Resident #24's Physician orders reflected the following order: -Dated 12/29/2022 Dorzolamide-timolol instill 1 (one) drop in both eyes two times a day for glaucoma. Record review of Resident #24's care plan initiated 08/11/21 revealed Resident [NAME] has ADL self-care performance deficit related to disease process CVA with right sided Hemiplegia. Intervention: Toilet use: The resident is not toileted, requiring incontinent episode care with each incontinent episode. Further review of the care plan revealed dated 00/13/23 that resident was being care planned for impaired vision related to glaucoma with intervention to administer eye drop dorzolamide-timolol 1 drop in both eyes two times a day for glaucoma. During an observation on 05/29/24 at 10:30 a.m., CNA K provided incontinent care for Resident #24. CNA K changed her gloves but did not wash or sanitize her hands before she donned other gloves after cleaning the Resident #24 peri area. CNA K used the same gloves she cleaned Resident#24's buttocks and rectum, applied a clean incontinent brief, and repositioned and covered Resident #24. CNA K washed her hands after she provided care for Resident #24, and she used the wet paper towel which was wet and turned off the water faucet. During an interview on 05/29/24 at 10:56 a.m., CNA K said there was no reason for not sanitizing her hand when she changed her gloves after she cleaned Resident #24 peri area. She said she did not have sanitizer with the incontinent care supply on the table. CNA K said hands are sanitized to prevent the spread of germs. CNA K said she forgot to change the gloves after she cleaned Resident #24 buttocks and rectum before she took the clean brief with the dirty gloves and applied the brief on Resident #24. CNA K said she could have transferred the germs from the dirty gloves to the clean brief. CNA K said she was in service on infection control, including PPE and hand washing. CNA K said she used the same paper towel, dried her hands, and turned off the water tap. CNA K said she could have reinfected her hands with the germs. CNA K said if the germs get to the residents, they could get an infection. CNA K said the nurse monitors the aide during care, and she had skills check-off and in-service in providing incontinent care for the residents. During an interview on 05/30/24 at 1:48 p.m., the DON said CNA K should have sanitized her hands when she changed her gloves after she cleaned Resident #24's peri area. The DON said CNA K should have changed her gloves before she took a clean incontinent brief and applied it to Resident #24 before dressing him. The DON said CNA K could have put Resident #24 at risk of infection when she dressed him with dirty gloves. During an interview on 05/31/24 at 9:34 p.m., the DON said he expected CNA K to follow the infection control procedures they were in serviced on monthly, which included hand washing. The DON said he expected CNA K to use a dry paper towel to turn off the water faucet to prevent cross-contamination. 2.Observation on 05/30/2024 at 9:00AM CMA N walked in Resident #24's room with a pair of gloves in hand to administer the medication eye drop dorzolamide-timolol. Resident #24 asked for a soda out of his personal fridge. CMA N got the soda out of the fridge and gave to Resident #24. CMA N proceeded to place the pair of gloves on without washing her hands and proceeded to administer the eye drop 1 drop in each eye. After administering the eye drops, CMA removed her gloves and washed her hands. Interview on 05/30/2024 at 9:08AM CMA N said the reason she had not washed her hands prior to administering eyedrops to both of Resident #24 eyes was because she had already washed her hands earlier in another resident room after administering medications and therefore did not feel she needed to wash her hands again. CMA N said she became nervous and forgot to wash her hands again prior to administering eye drops to Resident #24. Interview on 05/30/24 at 9:35AM the DON said he was the NF Infection Control Nurse and the Infection Control Preventionist. The DON said the staff received in-services monthly on infection control. The DON said when administering eyedrops, one should wash hands prior to administering eyedrops and afterwards for infection control. Record review of the facility policy on Instillation of Eye Drops dated 2001 revealed in part: .The purpose of this procedure is to provide guidelines for installation of eye drops to treat medical conditions, eye infections and dry eyes .wash and dry your hands thoroughly .put on gloves . 4. Record review of Resident #20's face sheet dated 05/01/2024 revealed an 83year old male admitted to the NF on 04/12/2024. Resident diagnoses included the following: type two diabetes mellitus (when the body has difficulty controlling blood sugar and using for energy), dementia (memory loss and judgement), peripheral vascular disease (narrowing of blood vessels causing a decrease in blood flow to the limbs), dysphagia (difficulty swallowing), and muscle weakness. Record review of Resident #20's MDS dated [DATE] revealed that resident had a BIMS score of 10 indicating that resident cognition was moderately impaired. Record review of Resident #20's Physician Orders for the month of May 2024 reflected the following orders: -Aspirin 81mg give 1 (one)tablet by mouth once a day -Plavix 75mg give 1 tablet by mouth once a day -Miralax 17 gm by mouth once a day (mix in 8 ounces of water) -Senna 8.6mg give 1 tablet by mouth once a day -Acetaminophen 500mg give 1 tablet by mouth three time a day -Lidocaine Patch 4% apply to right leg, left leg, and back topically one time a day for pain, remove after 12 hours and remove per schedule Observation on 05/30/24 at 8:12AM CMA N placed Resident #20's medications inside of a clear plastic container and carried into Resident #20's room to administer. CMA N placed the clear plastic container on top of Resident #20's bedside table. When CMA N finished administering the medications, she washed her hands and took the medication container out of the room and placed on top of another medication cart and proceeded to go down the hallway. Interview on 05/30/24 at 8:48AM CMA N said she sanitized the plastic medication bend once a day on her shift but guessed she could have sanitized the plastic container after removing from Resident #20's room. CMA N said the last in-service she received on infection Control was about a year ago regarding CNA as it related to resident care. CMA N said she done this in-service/training online. Interview on 05/30/24 at 9:35AM the DON said when medication containers are taken in a resident room, the container must be sanitized after each use because of infection control. Record review of the facility policy on Instillation of Eye Drops dated 2001 revealed in part: .The purpose of this procedure is to provide guidelines for installation of eye drops to treat medical conditions, eye infections and dry eyes .wash and dry your hands thoroughly .put on gloves . 5. During an observation and interview with the maintenance director on 05/30/24 at 11:27 a.m., it was revealed that a deflated air mattress was in a clear trash bag and on the floor under the rack in the west clean linen room. The Maintenance director said the bag with the air mattress should not be placed on the floor because of infection control. The maintenance director said he did not know who placed it on the floor, and it should not be stored in the clean linen room. 6. During an observation and interview on 05/30/24 at 11:37 a.m., Laundry aide A demonstrated how she would wash her hands after she loaded the washer with dirty linen before she went over to the clean linen. Laundry aide A turned the water faucet off with her wet hand and then dried her. The maintenance director interpreted for laundry aide A, and she said she forgot to dry her hands first before she turned off the water faucet with dry paper. Laundry aide A said she should have turned off the water faucet with a dry paper towel to prevent infection control. Record review of the facility Policy on Handwashing/Hand Hygiene revised October 2023 revealed in part . This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections .Indications of hand hygiene .immediately before touching a resident and after touching a resident .Indications for Hand Hygiene . #1Hand hygiene is indicated #1f . before moving from work on a soiled body site to a clean body site on the same resident .#1g .immediately after glove removal . Washing Hand #4 . Use towel to turn off the faucet .

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (LVN C) of 1 staff members reviewed for pharmacy services in that: LVN C stored Resident #44's Dorzolamide-Timolol 2-0.5% eye drops in the 2 [NAME] Medication cart uncapped. Resident #44s Dorzolamide-Timolol 2-0.5% eye drops was stored in the 2 [NAME] Medication cart without a cap while not in use. These failures could place residents receiving medications at risk for eye infections. Findings Include: Observation and interview on 5/10/2023 at 11:00 am revealed LVN C administering Dorzolamide-Timolol 2-0.5% eye drops to Resident #44's left and right eye. LVN C did not recap the eyedrop bottle. LVN C placed the opened eyedrop bottle in a pill bottle to store it in the 2 [NAME] medication cart. After Surveyor intervention, LVN C said if eye drops were not recapped, residents were at risk of getting bacteria leading to eye infections. She said the nursing staff were expected to recap eyedrops properly, using the cap to avoid cross-contamination when eyedrops were not in use. She said if eyedrop bottles were not recapped, the process was to order new eyedrops from the pharmacy. She said the inside of the pill bottle was contaminated so she should have recapped the eye drops to prevent contamination. She could not recall the last time she was in-serviced for infection control. In an interview on 5/10/2023 at 11:28 am with the DON, he said the expectation for storage of eye drops was to seal the eye drops properly by recapping the bottles. He said nursing staff should never administer eye drops to a resident if they discovered the eye drop bottle was not sealed properly with the cap being on because residents could get eye infections. He said the nursing staff were expected to seal eye drops properly, using the cap to avoid cross-contamination when eye drops were not in use. He said the expectation for storing eye drops was to date and recap the bottles. He said if there was no cap on eye drop bottles, the nursing staff were supposed to order new eye drops from the pharmacy. The DON said the nursing staff had been in-serviced for infection control in the month of May 2023. This Surveyor asked the DON why the failure occurred; he looked down. The DON had no response. Record review of facilities policy titled; Instillation of Eye Drops read in part . Recap the medication bottle .

Based on observation, interview, and records reviewed, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 facility kitchen, reviewed for proper ice scoop storage in that: -The ice machine scoop was not stored in a covered container. This failure could place residents at risk for cross contamination and food-borne illness. Observation on 05/09/2023 at 3:45 p.m. revealed the ice machine scoop was being stored, uncovered, on the side of the ice machine. During an interview with the Dietary Manager on 05/09/2023 at 3:46 p.m., he said the ice scoop should be stored in an enclosed container. He said the container fell and broke last month. Record review of the facility's Ice Machines and Ice Storage revised date January 2012, read in part: Policy Statement: Ice machines and ice storage distribution containers will be used and maintained to assure a safe and sanitary supply of ice. Policy interpretation and implementation 2. To help prevent contamination of ice machines, ice storage chests/containers or ice, staff shall follow these precautions: e. Keep the ice scoop/bin in a container when not in use.

Based on observation and interview, the facility failed to dispose of garbage and refuse properly for 1 of 1 waste receptacle reviewed for garbage disposal. -The one dumpster contained waste and its two side doors were left open. This failure could place residents at risk for exposure to germs and diseases carried by vermin and rodents. Findings included: Observation on 05/09/2023 at 6:45 a.m. with the [NAME] revealed the dumpster's two side doors were open. Observation on 05/09/2023 at 3:40 p.m. with the Dietary Manager revealed the dumpster's side door was open. During an interview on 05/09/2023 at 6:46 a.m. the Cook, stated both side doors were left opened. She said the doors should always be closed. During an interview on 05/09/2023 at 3:41 p.m., the Dietary Manager stated one of two side doors was left opened. He said it should have been closed. Record review of the facility's Food-Related Garbage and Refuse Disposal revised date October 2017, read in part: Policy Statement: Food-related garbage and refuse are disposed of in accordance with current state laws. Policy interpretation and implementation 2. All garbage and refuse containers are provided with tight fitting lids or covers and must be kept covered when stored or not in continuous use. 5. Garbage and refuse containing food waste will be stored in a manner that is inaccessible to pests.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records reviewed, the facility failed to develop and implement a baseline care plan that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 4 (Residents #92, #210, #212 and CR #93), of 8 residents reviewed for baseline care plans. -The facility failed to complete a baseline care plan within the required 48-hour timeframe for Residents #92, #210, #212, and CR #93. This failure could place residents at risk for not receiving necessary care and services or not having important care needs identified. The findings included: Resident #92 Record review of Resident #92's face sheet dated 05/11/23, revealed an [AGE] year-old female with an admit date of 04/21/23. Diagnoses included urinary tract infection, site not specified, enterococcus as the cause of disease classified elsewhere (infection usually present around vagina, rectum), hemoglobinuria due to hemolysis from other external causes (presence of hemoglobin in the urine), type 2 diabetes mellitus with hyperglycemia (elevated blood glucose level), moderate protein calorie malnutrition (imbalance of nutrients), and major depressive disorder. Record review of Resident #92's Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 6 indicating cognitive impairment. Functional status revealed resident required one-person physical assist with bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. Record review of Resident #92's baseline care plan, dated 04/24/2023, revealed Section II. Social Services was incomplete. Resident #210 Record review of Resident #210's face sheet dated 05/11/23, revealed a [AGE] year-old male with an admit date of 05/02/2023. Diagnoses included non-pressure chronic ulcer of other part of right foot with unspecified severity (localized injury to the skin or underlying tissue), syphilis unspecified (sexually transmitted infection), chronic viral hepatitis C (viral infection that causes inflammation to the liver), type 2 diabetes mellitus with hyperglycemia (elevated blood glucose level), hypertensive heart disease with heart failure (heart condition caused by high blood pressure), and chronic ischemic heart disease unspecified (heart problems caused by narrowing heart arteries). Record review of Resident #210's baseline care plan, dated 05/02/2023, revealed Section II. Social Services was incomplete. Resident #212 Record review of Resident #212's face sheet dated 05/11/2023, revealed a [AGE] year-old male with an admit date of 05/02/2023. Diagnoses included encounter for orthopedic aftercare following surgical amputation (removal of limb), acquired absence of left foot, type 2 diabetes mellitus with hyperglycemia (elevated blood glucose level), hypertensive heart disease without heart failure (heart condition caused by high blood pressure), and unspecified atrial fibrillation (irregular heart rhythm). Record review of Resident #212's baseline care plan, dated 05/02/2023 revealed Section II. Social Services was incomplete. CR #93 Record review of CR #93's face sheet dated 05/11/2023, revealed a [AGE] year-old male with an admit date of 03/10/2023 and discharge date of 03/29/2023. Diagnoses included posterior reversible encephalopathy syndrome (condition in which parts of the brain are affected by swelling), muscle weakness generalized, type 2 diabetes mellitus without complications (high blood sugar), alcohol use unspecified with withdrawal unspecified, hypertensive emergency (severe elevation in blood pressure), acute respiratory failure with hypoxia (respiratory failure where the level of oxygen becomes dangerously low), and unspecified abnormalities of gait (walking) and mobility. Record review of CR #93's baseline care plan, dated 03/13/2023, revealed Section II. Social Services was incomplete. During an interview on 05/10/2023 at 10:45 a.m., the Director of Nursing (DON) said the timeframe to have the baseline care plan completed was 24 to 48 hours after the resident was admitted to the facility. He said if it was not completed within the required timeframe, the resident and/or family would not be aware of their baseline care and the evaluations from all the departments at the facility. He said they had a full-time social services assistant who was responsible for completing the social services portion of the baseline care plan. He said the social services portion was usually delayed because she had to see what the resident's discharge plan was. During an interview on 05/10/2023 at 11:30 a.m., the Social Services Assistant said she had been working at the facility for over 2 years. She said she was responsible for completing the social services portion on the baseline care plan. She said the timeframe to have the baseline care plan completed was 24 to 48 hours after the resident was admitted to the facility. Record review of the facility's Care Plans - Baseline undated, read in part: Statement A baseline plan of care should be developed for each resident within forty-eight (48) hours of admission Interpretation and Implementation 1. The baseline care plan should include instructions needed to provide effective person-centered care of the resident which may include the following: a. Initial goals based on admission orders and discussion with the resident representative. b. Physician orders; c. Dietary orders; d. Therapy services; e. Social services; and f. PASARR recommendation, if applicable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the implementation of services that are to be furnished to maintain the resident's highest practicable physical well-being based on the comprehensive care plan for 1 of 14 residents reviewed for care plans, in that: The facility failed to ensure Resident #62 was provided wound care treatment everyday as called for by the resident's plan of care. This failure could affect all residents and place them at risk of receiving inadequate care. Findings included: Record review of Resident #62's face sheet revealed a [AGE] year-old male admitted into the facility on [DATE] and was diagnosed with acute osteomyelitis of the right ankle and foot, type 2 diabetes and acquired absence of right great toe. Record review of Resident #62's MDS, dated [DATE], revealed the resident had a surgical wound and a BIMS score of 15 indicating the resident's cognition was intact. In an interview with and observations of Resident #62 on 03/08/2022 at 10:50AM, the resident was found to have a dressing on his right foot. The resident stated he had his right big toe amputated recently but does not get his wound care everyday as ordered. He stated often his wound care is missed on the weekends. Record review of Resident #62's TAR of February 2022, revealed the resident was ordered to receive wound care on his right toe amputation as follows: - Clean with NS, pat dry, betadine periwound, pack wound with CA alginate and cover with dry dressing QD and PRN until resolved. Start date 2/19/2022, end date 02/23/2022 - Clean with NS, pat dry, betadine periwound, pack wound with wound dressing gel, CA alginate and cover with dry dressing QD and PRN until resolved. Start date 2/23/2022, end date 03/02/2022. - Clean with NS, pat dry, betadine periwound, pack tunnel with idoform w/ medihoney on it, collagen, CA alginate and cover with dry dressing QD and PRN until resolved. Start date 03/02/2022, until present. On dates 02/26/2022, 02/27/2022, and 03/05/2022, the opportunities for provision of wound care were missed. In an interview with LVN G on 03/09/22 at 02:23 PM, she stated the Wound Care Nurse is the main nurse that provides wound care service in the facility but all other LVNs were responsible to provide wound care on their residents on the day the Wound Care Nurse was not on duty. She stated the risks for the resident skipping their wound care was the risk of infections and discomfort due to bandaging not being changed. In an interview with the Wound Care Nurse on 03/09/22 at 02:34 PM she stated Resident #62 received care for his right toe amputation and the wound care doctor saw him weekly as well. She said his wound care was ordered daily and PRN and she only works Monday through Friday. She stated, on the weekends, any nurse or charge nurse was qualified to do wound care and there was no excuse for the wound care not to be done on weekends. She stated she was not sure who worked on the weekend but sees some of the weekend days were missed. She stated there was little risk to the resident if his wound care was missed every two or three days because his wound currently had no odor, swelling, and because of the types of treatment ointments with dressing he was getting. She stated the facility's standard of care and frequency of care was higher than the average facility because they work with residents with the goal to get them physically well enough sooner to return to lesser care settings at home. In an interview with the DON on 03/09/22 at 03:20 PM, she stated she noticed Resident #62's wound care was not documented. She stated assigned LVN W, usually work worked night shifts to come in and do wound care on those weekends but she is not sure why she did not document the wound care. She said monitoring was being done and the issue likely occurred due to staffing issues, but they try their best to meet the mark. She stated the use of agency nurses also makes it necessary for her usual nursing staff to follow up on the resident's care to ensure the agency nurses are actually providing wound care. In a phone interview with LVN W on 03/09/22 at 03:35 PM she said she did not do any wound care on any of the assigned residents on 03/05/2022 because she was scheduled to start late and she was trying to figure out which residents needed wound care, on which part of their body and what tools were needed. She stated Saturday, 03/05/2022, was her trial day. Record review of the facility's policy on wound care, October 2010, revealed, the purpose of this procedure is to provide guidelines for the care of wounds to promote healing . Verify that there is a physician's order for this procedure . Review the resident's care plan to assess for any special needs of the resident . Record review of the facility's policy on care planning, dated September 2013, did not address implementation of resident care plans.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide appropriate treatment and services to prevent complications for 1 of 3 resident (Resident #33) reviewed for gastrostomy tube. -CNA P placed Resident # 33's bed in a flat position to provide incontinent care and adjusted Resident #33's feeding pump. This failure could affect residents with a gastrostomy tube by placing them at risk for aspiration. Findings include: Record review of the admission sheet for Resident # 33 revealed an [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE]. Her diagnoses included gastrostomy status, pneumonia, dysphagia, oropharyngeal phase and aphasia. Record Review of Resident #33's quarterly MDS assessment dated [DATE] revealed the BIMS score was blank indicating severely impaired cognitive skills. Staff assessment for mental status was conducted resident was unable to complete interview. Resident # 33 has short term memory problem, long term memory problem, and cognitive skills for daily decision making is severely impaired never/rarely made decision. Further review of the MDS revealed that she required total dependence from one-person physical assist for dressing, toilet use and personal hygiene. Resident was always incontinent of bowel and bladder. The resident was marked as having a feeding tube. Record review of Resident # 33's care plan initiated on 6/28/2020 revised on 11/18/2020 revealed the following care plan: Focus-Enteral feeding: Resident#33 has Inability to maintain adequate nutrition/ Potential for aspiration Related to Dx: Requires enteral feeding via PEG/GT Goal-Resident #33 will tolerate tube feeding without N/V, diarrhea, s/sx of aspiration, abdominal distention, dehydration daily x 90days. Interventions/Tasks: Check Resident#33 prior to each feeding. Enteral tube feeding as ordered per MD. Enteral Feed every shift Diabetisource ac 70 cc/20 hrs via continuous pump. Flush enteral tube with 30 ml water before and after medication administration and/or as ordered. Monitor enteral tube placement every shift. Monitor for abdominal distention, regurgitation, nausea, cramps, diarrhea. Record review of Resident #33's Physician orders dated 01/11/2022 revealed an order for enteral feeding every shift Diabetisource ac 70 cc/20 hrs via continuous pump. Record review of Resident #33's Physician orders dated 01/11/2022 revealed an order for enteral feeding every shift H20 flushes 45 cc/q 1 hrs via continuous pump. Observation and attempted interview on 03/09/2022 at 9:16a.m., with Resident #33, revealed Resident was resting on her bed. Resident was alert and well groomed. The resident mumbled for 5 minutes while being interviewed and could not make self-understood and did not respond appropriately to asked questions about her stay at the facility. Observation of Resident # 33 on 03/09/2022 at 9:21a.m., revealed CNA P entered the room and informed Resident #33 of incontinent care to be performed. CNA P set Resident # 33's enteral feeding pump from run to hold then lowered Resident # 33's head of bed down to a flat position. CNA P provided incontinent care, laying resident in a flat position. After care was completed, CNA P changed the setting of Resident #33's enteral feeding pump to run to resume Resident #33's feeding. In an interview on 03/09/2022 at 9:38a.m., with CNA P, she said she was not trained to set enteral feeding pumps. CNA P said she saw how the nurses did it, so she learned from them. She said, I probably should have asked a nurse to hold the feeding as it's not in my scope of practice. She said the feeding was supposed to be on hold while providing incontinent care to prevent the resident's risk of choking. In an interview on 03/09/2022 at 9:51a.m., LVN I, said she administered Resident #33's morning meds at 9:00 a.m., and did not put the feeding pump on hold. She said she was not aware CNAs were providing care to the resident. She said CNA's were not allowed to touch the enteral feeding pumps because they were not licensed, and they were supposed to get a nurse to put the feeding pump on hold and let the nurse know when they were finished providing care so the nurse could re-start the feeding. She said if CNA's put the pump on hold residents could possibly not get their feedings and it was risk for aspiration. In an interview on 03/09/2022 at 10:47a.m., the DON, said only nurses were allowed to manipulate the enteral feeding pumps. The DON said CNA's were not trained or competent to manipulate enteral feeding pumps. The DON said it was not in CNAs scope of practice. The DON said the CNA should have asked the nurse to place Resident # 33's enteral feeding on hold or off as it placed the resident at risk for aspiration. Record review of facility's Administration Medications through an Enteral Tube policy (revised November 2018) read in part: .Purpose: The purpose of this procedure is to provide guidelines for the safe administration of medication through an enteral tube . Record review of facility's Enteral Nutrition policy (Revised November 2018) read in part: .Policy Statement: Adequate nutritional support through enteral nutrition is provided to residents as ordered. 16. Risk of aspiration is assessed by the nurse and provider and addressed in the individual care plan . Record review of facility's Job Description: Certified Nursing Assistant prepared by/Date: Human Resources (2-2019) read in part: .General Purpose: The primary purpose of your job position is to provide each of your assigned residents with routine daily nursing care and services in accordance with the resident's assessment and care plan, and as may be directed by your supervisor. Essential Duties: Perform only those nursing care procedures that you have been trained to do .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 1 of 4 residents (39) reviewed for pharmacy services. - LVN O failed to administer medication to Resident #39 correctly by crushing Protonix DR granules, a medication for acid reflux/heart burn that should not be crushed. This failure could place residents receiving medications via feeding tube at risk for inadequate therapeutic outcomes. Findings Include: Record review of Resident #39's face sheet dated 03/09/22 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included: pressure ulcers, dysphagia (difficulty swallowing), cognitive communication deficit, muscle weakness, anemia, depression, epilepsy, GERD and an esophageal obstruction . Record review of Resident #39 's care plan revised 03/08/22 revealed, Focus- feeding tube, resident has a feeding tube to meet my nutrition needs and is at risk for complications. Goals- resident will have nutritional need met through feeding tube and will not have any complications with feeding tube through next review. Interventions- tube feeding and flushes as ordered. Record review of Resident #39's admission MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 03 out of 15, total dependence on all ADLs and always incontinent of both bladder and bowel. Record review of Resident #39's Physician's Order dated 02/22/22 revealed, Protonix Tablet Delayed Release 40 mg give 1 tablet via g-tube one time a day for GERD. Record review of Resident #39's Physician's Order dated 02/23/22 revealed, enteral feed order- flush tube with 30 mL before and after medication administration and 5-10 mL between each medication every shift. An observation and interview on 03/09/22 at 08:17 AM revealed, LVN O preparing medication for administration via G-tube for Resident #39. She retrieved a packet of Protonix 40 mg DR for suspension, a medication that should not be crushed, and 14 other solid and liquid medications and poured them into individual medication cups. At 08:23 AM she placed each solid form (tablets and granules) in individual pill crush bags and crushed the medications and returned them to their individual medication cups. LVN O said she crushed the Protonix Granules because it sometimes clogs the G-tube during medication administration. At 08:37 AM she entered into the resident's room, suspended the medications in 5-10 mL of water and administered them to Resident #39 after checking for placement and completing a 30 mL flush. LVN O flushed with 10 mL of water between each of the medications and then performed a 30 mL flush after medication administration. In an interview on 03/09/21 at 10:35 AM, the DON said that Protonix DR for suspension granules should not be crushed because it alters the rate of release into the body. She said crushing medication that should not be crushed impacts the efficacy of the medication and places residents at risk of insufficient therapy. In an observation and interview on 03/09/1 at 10:42 AM, LVN O said she did not realize that she could not crush Resident #39's Protonix 40 mg DR granules for suspension. She said DR/ER and enteric coated medications should not be crushed because their formulation is supposed to release the medication into the body over a prolonged period and crushing the medication would change this periodic release. She looked at the packet of the Protonix and said since it said DR (delayed release) she should not have crushed the medication and she would contact Resident #39's doctor to inform them of the medication error and awaiting further instructions. She said that by crushing the Protonix she changed the release pattern which placed Resident #39 at risk of insufficient therapy. Record review of the facility policy titled Crushing Medications revised 04/18 revealed, 2- The nursing staff and/or consultant pharmacist shall notify any attending physician who gives and order to crush a drug that the manufacturer states should not be crushed (for example, long-acting or enteric coated medication).

Deficiency Text Not Available

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure food was stored in accordance to professional standards for foodservice safety for 3 of 3 main storage areas (dry storage, walk-in cooler and the walk-in freezer), in that: - Boxes of food items were observed on the floor in the walk-in cooler, freezer and dry good storage. This failure could affect all residents who eat meals served by the dietary department and place them at risk for potential food-borne illness. Findings included: During observations of the kitchen and an interview with the Dietary Manager on 03/08/2022 at 8:50AM, an opened box of kosher salt was observed sitting in an opened resealable bag. The Dietary Manager stated that the bag should have been resealed; in the walk-in cooler, a box of potatoes and a box of chicken was observed sitting on the floor; in the walk-in freezer, a box of [NAME] tots, a box of lemon merengue and 4 boxes of frozen vegetables were observed resting on the floor; in dry good storage, a box of rolled oats and a box of canned cheddar sauces. The Dietary Manager stated that he received a delivery of food around 8AM this morning and they were wheeled in and dropped off by the delivery men. He said he usually tried to put them away as soon as possible or at least by the end of the day but he knew they were supposed to rest at least 6 inches off the ground and or on the shelfs before storing them away. He stated the consequences of having food on the floor was attraction of rodents and pests. Record review of the facility's policy on Food Receiving and Storage, dated October 2017, stated, .food in designated dry storage areas shall be kept off the floor (at least 18 inches) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections involving 2 of 2 staff (Wound Care Nurse and CNA P) and 2 of 4 residents (Resident #31and #33) reviewed for infection control. -The facility failed to ensure the Wound Care Nurse followed infection control techniques while performing wound care for Resident #31 by crossing from a dirty part of the procedure to the clean part. -CNA P failed to perform hand hygiene and contaminated clean items while providing care for Resident #33. These failures could place residents at risk of cross contamination, infection and hospitalization. Findings include: Resident #31 Record review of the admission sheet for Resident # 31 revealed an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included pressure ulcer of right heal, unstageable, non-pressure chronic ulcer of other part of right lower leg with other specified severity, bipolar disorder, and displaced fracture of greater trochanter of right femur, subsequent encounter for closed fracture with routine healing. Record Review of Resident #31's quarterly MDS assessment dated [DATE] revealed the BIMS score was 07 out of 15 indicating severely impaired cognitively. Further review of Section M1040. Other Ulcers, Wounds and Skin Problems was coded Resident having Diabetic foot ulcer. Record review of Resident #31's Physician orders dated 3/8/22 revealed an order for L-heel/dm: clean with ns, pat dry, paint with betadine, apply collagen and cover with dry dressing qd and prn until resolved. Everyday shift and as needed. Record review of Resident # 31's care plan initiated on 10/08/2021 and revised on 01/20/2022 revealed the following care plan: Focus- Resident #31 has diabetic ulcer of the l heel r/t Diabetes Goal-The resident will have no complications related to ulcer through review date. Interventions/Tasks- Monitor pressure areas for color, sensation, temperature. Monitor/document wound: Size, Depth, Margins: periwound skin, sinuses, undermining, exudates, edema, granulation, infection, necrosis, eschar, gangrene, Document progress in wound healing on an ongoing basis. Notify MD as indicated. Redness and swelling, Red lines coming from the wound, Excessive pain, Fever. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Observation and interview on 03/09/2022 at 9:52a.m., revealed Resident #31 was resting on her bed. She was alert and well groomed. Observation of wound care for Resident #31 on 03/09/2022 at 9:55a.m., revealed the Wound Care Nurse performed hand hygiene, applied clean gloves to remove the soiled dressing from the left heel pressure injury, dated 03/08/22. The Wound Care Nurse threw the soiled dressing into the biohazard bag taped to the resident's foot of the bed. Observed an open area of approximately 0.9 centimeters in diameter on the left heel. Without removing the soiled gloves and sanitizing her hands, the Wound Care Nurse cleansed the wounds with normal saline x2, patted dry with a clean dry gauze, applied the betadine, collagen and covered it with clean dry dressing on the left heel. The Wound Care Nurse without changing gloves, placed a clean pair of socks on the resident and covered the resident. In an interview on 03/09/2022 at 10:09a.m., with the Wound Care Nurse, she said she should have changed her gloves after removing the soiled dressing as it posed a risk for infection control. She said the DON periodically checked on her. She said she received training on infection control this week either Monday (3/7/22) or Tuesday (3/8/22). In an interview on 03/09/2022 at 10:47a.m., with the DON, this state surveyor shared her wound care observation from earlier. The DON said she would correct the Wound Care Nurse as her actions create a risk for infection control and cross contamination. She said the Wound Care Nurse should have changed her gloves prior to moving from a dirty to a clean site. She said staff were in serviced weekly on infection control/hand hygiene. She said she spot checked the wound care nurse monthly and wound care doctor made rounds with wound care nurse weekly. Resident #33 Record review of the admission sheet for Resident # 33 revealed an [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE]. Her diagnoses included gastrostomy status, pneumonia, dysphagia, oropharyngeal phase and aphasia. Record Review of Resident #33's quarterly MDS assessment dated [DATE] revealed the BIMS score was blank indicating severely impaired cognitive skills. Staff assessment for mental status was conducted resident was unable to complete interview. Resident # 33 has short term memory problem, long term memory problem, and cognitive skills for daily decision making is severely impaired never/rarely made decision. Further review of the MDS revealed that she required total dependence from two persons physical assist for dressing, toilet use and personal hygiene. Resident was always incontinent of bowel and bladder. The resident was marked as having a feeding tube. Record review of Resident # 33's care plan initiated on 6/28/2020 revised on 11/18/2020 revealed the following care plan: Focus- Resident # 33 has an ADL self-care performance deficit r/t generalized weakness and impaired mobility Goal: Resident # 33 will improve current level of function through the review date. Interventions: Bathing/Showering: Assist x 2, INCONTINENT CARE Assist X 2 Observation on 03/09/2022 at 9:21a.m., revealed CNA P and CNA L provided incontinent care to Resident #33. CNA P removed Resident #33's brief and tucked it under the resident's buttocks. CNA L assisted Resident #33 turn onto her right side to clean her buttocks. Resident had a bowel movement. CNA P cleaned the resident and removed the soiled brief, draw sheet and the fitted sheet. CNA P then searched the resident's dresser for a fitted sheet with the same dirty gloves. CNA P said she was unable to find the fitted sheet but found a draw sheet. With the same soiled gloves she placed the clean draw sheet on the resident's bed. In an interview on 03/09/2022 at 9:38a.m., with CNA P, she said she should have changed her gloves, washed her hands or used hand sanitize since the resident had a bowel movement. She said the resident's sheets were soiled so they hurried up and stiped her bed. She said they did not have a fitted sheet, so she searched for the fitted sheet in the resident's dresser. She said the failure placed the resident at risk for infections and cross contamination. She said she was in-serviced on infection control/hand hygiene 2 months ago. In an interview on 03/09/2022 at 10:47a.m., with the DON, she said the CNA should have either washed or sanitized her hands after touching a dirty area prior to moving to a clean area when performing incontinent care. She said CNA P brought to her attention and shared her observation. She said she told CNA P to remove all the clothing from the resident's dresser as all were contaminated. She said these failures were risk for infection control. Record review of facility's Wound Care policy (Revised October 2010) read in part: .Purpose: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Steps in the Procedure: 4. Put on exam glove. Loosen tape and remove dressing. 5. Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly. 6. Put on gloves . Record review of Wound Care Competency Checklist-Direct Care provider (not dated) read in part: .Diabetic Foot Ulcers (DFU) Ulcer treatment: Cleanses DFU as per hospital/facility policy. Applies/changes dressings as ordered per hospital/facility policy . Record review of facility's Handwashing/Hand Hygiene policy (Revised August 2019) read in part: .7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for following situations: g. Before handling clean or soiled dressing, gauze pads, etc.; h. Before moving from a contaminated body site to a clean body site during resident care; 9. The use of gloves does not replace hand washing/hand hygiene. Integration of gloves use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections . Record review of facility's Infection Control policy (Revised October 2018) read in part: .This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infection .

Based on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, included the appropriate accessory and cautionary instructions, the expiration date when applicable and stored all drugs and biologicals in locked compartments and under proper temperature controls, and permitted only authorized personnel to have access to the keys for 4 out of 4 medication carts (West Back Nursing Cart, [NAME] Medication Aide Cart, East Nursing Cart and East Medication Aide Cart) and 1 out of 1 Medication Rooms (West Medication Room) reviewed for medication storage. - The facility failed to ensure that the [NAME] Back Nursing Cart and East Medication Aide Cart did not contain medication stored outside of specified manufacturer temperature ranges. - The facility failed to ensure that the [NAME] Medication Aide Cart and the East Nursing Cart did not contain open multi-dose containers without open dates. - The facility failed to ensure that the [NAME] Medication Room did not contain expired IV medication. Findings Include West Medication Aide Cart. In an observation and interview on 03/09/22 at 10:00 AM, inventory of the [NAME] Medication Aide Cart with the Medaide revealed: - An open bottle of liquid protein with manufacturer instructions of 3-month shelf life from date opened with no open date. The Medaide said when a multidose container of liquid protein was opened it should be labeled with the open date. She said that the opened date was used to track the expiration date since the opened bottle should not be used more than 3 months after opening. She said that nursing staff are expected to check their nursing carts every shift as used for inappropriately labeled and expired medications. The Medaide said since the liquid protein did not have an open date its expiration date could not be established. She said when medication expires it loses efficacy so the liquid protein could not be used and it must discarded in the drug disposal bin located in the medication room. West Back Nursing Cart In an observation and interview on 03/09/22 at 10:05 AM, inventory of the [NAME] Back Nursing Cart with LVN I revealed: - An open bottle of Acidophilus, a probiotic, at room temperature in the drawer with manufacturer instructions of Refrigerate After Opening. LVN I said she did not know the probiotic had to be refrigerated. She said nursing staff are expected to check their nursing carts every shift as the medications are used and since the probiotic was at room temperature it should be discarded in the drug disposal bin located in the medication room. LVN I said that when medications that should be stored in the refrigerator were left at room temperature it can deteriorate and loose efficacy so it should not be used. West Medication Room In an observation and interview on 03/09/22 at 10:10 AM, inventory of the [NAME] Medication Room with LVN I revealed: - 2 50 ml IV bags of Furosemide, a diuretic, 80mg prepared on 02/22/22 at 05:15 PM with pharmacy instructions of expires 24 hours from preparation in the refrigerator. - 2 100 ml IV bags of Levofloxacin 750mg, an antibiotic, with expiration dates of 03/08/22 in the refrigerator. LVN I said all nursing staff should check the medication rooms for expired medications daily, she said the residents had discharged or moved to the other unit so there was no risk of administering the expired IVs. She said since the IVs were expired, they could not be used and must be placed in the drug disposal bin for destruction . LVN I said that expired IVs can have a loss in efficacy placing residents at risk for decreased therapeutic effects. East Nursing Cart In an observation on 03/09/22 at 10:15 AM, inventory of the East Nursing Cart with LVN O revealed: - An open bottle of liquid protein with manufacturer instructions of 3-month shelf life from date opened with no open date. East Medication Aide Cart In an observation on 03/09/22 at 10:25 AM, inventory of the East Medication Aide Cart with LVN O revealed: - 2 open bottles of Acidophilus, a probiotic, at room temperature in the drawer with manufacturer instructions of Refrigerate After Opening. In an interview on 03/09/22 at 10:25 AM, LVN O said that nursing staff should check their carts for inappropriately labeled, expired and medications stored outside of their specified temperatures on every shift as the cart is used. She said that all multidose containers should be labeled when open in other to track their expiration date and since the bottle of liquid protein had no expiration date it must be discarded in the drug disposable bin. LVN O said she did not know the bottles of acidophilus required refrigeration and when medication expires or is stored at the wrong temperature they can lose its efficacy resulting in a loss of therapeutic effect if given to residents. In an interview on 03/09/22 at 10:35 AM, the DON said that nursing staff are expected to check their carts for expired, inappropriately labeled and medication stored at the wrong temperature on each shift, while the ADON is responsible for checking the medication room daily. She said that all medications should be stored at manufacturer specified temperature ranges and by leaving the acidophilus at room temperature the medication can deteriorate. The DON said all multidose containers should be labeled with a date when opened in order to track the expiration date and once expired the medication should be discarded promptly. She said medication stored outside of specified manufacturer temperatures, inappropriately labeled and expired medications should be discarded in the drug disposal bin located in the medication room since they can deteriorate and/or lose efficacy placing residents at risk for uncertain therapeutic outcomes if used. Record review of the facility policy titled Storage of Medications revised 11/20 revealed, 1- drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light, and humidity controls. 4 . Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. 7- medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses' station or other secured location.