Alameda County Medical Center D/P Snf

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure safe practices on storage and handling of the hazardous medications (or HD, Drugs that pose short- or long-term harm upon exposure to human via skin or inhalation) in three out of six medication carts with resident census of 106 based on CDC's (Centers for Disease Control and Prevention, a federal agency leading the science-based, data-driven, service organization that protects the public's health) National Institute for Occupational Safety and Health (NIOSH a federal agency that is part of the CDC; NIOSH conducts research and makes recommendations for the prevention of work-related hazards, injury and illness) guidelines.
The unsafe storage and handling of hazardous medications could pose health risk to staff and residents.
Findings:
1. During a concurrent observation and interview with Licensed Nurse 2 (LN 2), on 8/19/24, at 10:40 AM, in the facility's B2 unit, the Medication Cart 2 stored multiple medications labeled by pharmacy as Hazardous Material with a black and white strip as part of prescription label. Further observation indicated a bottle of drug called megestrol tablet (or Megace, a type of hormone used to treat cancer or stimulate appetite) was stored inside an individual zip lock plastic bag with a large yellow [NAME] to handle safely Observe safety precautions for handling and administration. The medication cart additionally stored other labeled hazardous material drugs including finasteride (a hormone used to treat enlarged prostate) and tofacitinib (a drug belong to class of drugs called tumor necrosis factor blockers, suppressed immune system, and used to treat sever arthritis) that were not contained inside a zip lock bag to prevent the accidental exposure during medication storage and handling. LN 2 stated she was not sure why some bottles were in a hazard bag, and some were not.
2. During a concurrent observation and interview with Licensed Nurse 3 (LN 3), on 8/19/24, at 11 AM, in facility's B2 unit, the Medication Cart 1 stored multiple medications labeled by pharmacy as Hazardous Material on the body of the prescription label. Further observation indicated a bottle of drug called methotrexate in tablet form (a drug used to treat cancer and severe arthritis) was stored inside an individual zip lock plastic bag with a large yellow warning to handle safely Observe safety precautions for handling and administration. The medication cart additionally stored other labeled hazardous material drugs including colchicine tablet (drug used to treat pain associated with [NAME] arthritis), Dilantin (or Phenytoin, used to treat or prevent seizure in the brain; Seizure a disease that caused temporary burst of uncontrolled electrical activity in the brain leading to loss of conscious and body movement) in capsule form, and Liquid bottles of megestrol. LN 3 stated the yellow hazard bag alerted the nurse to use gloves when handling the drug.
3. During an inspection of the facility's Medication Cart 2, at Unit B3, on 8/19/23, at 2:54 PM, accompanied by Licensed Nurse 7 (LN 7), the cart stored a bottle of drug called megestrol tablet stored inside an individual zip lock plastic bag with a large yellow warning to handle safely Observe safety precautions for handling and administration. Further observation indicated storage of hazardous drugs without protective covering including oxcarbazepine bottle of pills (drug used to treat Seizure), Divalproex bottle of pills (or Depakote, a seizure drug also used for treating mood swings) which was not labeled as Hazardous in the body of the label, and Dilantin (or phenytoin drug used to treat seizure) liquid bottles with yellow color spills on the outer surface of the bottle.
In an interview with Director of Nursing (DON), on 8/22/24, at 12:49PM, the DON stated the inconsistent storage of hazardous drugs for safe handling could be pose safety to staff who used the medication cart every day. The DON stated the facility relied on pharmacy to provide consistent method of highlighting the risks and safe containment. The DON stated pharmacy should put all of the hazardous drugs in a protective bag for safe use and handling. The DON stated the nurses should use gloves and whatever needed per policy. The DON stated having hazardous med in the hazard bag helped the nurses to recognize them for safer handling in addition to use of protective gloves.
Review of facility's undated policy, titled Policies and Procedures for Safe handling of Hazardous Drugs, the policy under purpose indicated The policies and procedures within this document are designed to establish safe handling of hazardous drugs (HD's) for the healthcare worker at this facility and to provide guidance to create a safe, consistent method for receipt, storage, preparation, administration and disposal of hazardous drug. The policy on objective section indicated To ensure that the staff at this LTC (Long Term Care) nursing facility handle all hazardous drug according to procedures in this document or to state or federal regulation, whichever is stricter. The policy on receiving section indicated Yellow HD Caution: Hazardous Drug auxiliary labels should be affixed by pharmacy personnel receiving medication to manufacturers packaging prior to transportation to storage. The policy on storage section indicated HDs shall be stored in a manner that prevents spillage .
Review of the Center for Disease Control's National Institute for Occupational Safety and Health (CDC, and NIOSH, a federal agency sets standard of safety in health care) document, titled Managing Hazardous Drug Exposures: Information for Healthcare Settings, dated 4/2023, last accessed on 8/27/24 via https://www.cdc.gov/niosh/docs/2023-130/default.html, the document indicated Workplace exposure to hazardous drugs can result in negative acute and chronic health effects in healthcare workers including adverse reproductive outcomes. Efforts should be made to reduce all worker exposures to hazardous drugs. Occupational exposure to hazardous drugs merits serious consideration, as workers may be exposed daily to multiple hazardous drugs over many years.
Review of the clinical guidelines from American Society of Health-System Pharmacists (ASHP serves as a collective voice on issues related to medication use and public health), titled ASHP Guidelines on Handling Hazardous Drugs, last accessed on 8/24/24 via https://www.ashp.org/-/media/assets/policy-guidelines/docs/guidelines/handling-hazardous-drugs.ashx , the guideline indicated Drugs that have been identified as requiring safe handling precautions should be clearly labeled at all times during their transport, storage, and use . The document indicated NIOSH categorized hazard level to three groups: Group 1 hazard level included antineoplastic drugs (cancer drugs) and Group 2, and Group 3 were non-antineoplastic hazardous drugs including reproductive risks (ability to have healthy children).
Review of the facility provided NIOSH list of hazardous drug, and comparative review of the drug information website called UpToDate Lexidrug, last accessed on 8/27/24, the documents indicated Megace (or megestrol) was on Group 1 of hazardous drugs while tofacitinib, Dilantin, and oxcarbazepine were listed in the Group 2 of hazardous drugs and finasteride and colchicine were listed in the Table 3 of the NIOSH hazardous drug with recommendation Use appropriate precautions for receiving, handling, storage, preparation, dispensing, transporting, administration, and disposal.

Based on interview and record review the facility failed to ensure safe use of antibiotic eye medication called erythromycin ophthalmic (eye) ointment (ointment a smooth oily preparation mixed with antibiotic to treat eye infection) for ongoing long-term use in one out of five residents reviewed for unnecessary medication (Resident 36).
This unsafe practice could contribute to ineffective use of antibiotic for an unapproved indication and risk of antibiotic becoming ineffective with long term use.
Findings:
During a record review of Resident 36's electronic medical record, titled MAR Report (MAR stands for Medication Administration Record; a document used by nursing staff to document orders carried out based on doctor's order), dated 8/21/24, the record indicated an order for eye medication called erythromycin as follow:
erythromycin (Romycin, another name for antibiotic) 5 mg/gm (0.5%) [mg stands for milligram and gm stands for gram as measure of weight, and % stand for percent as measure of potency] ophthalmic ointment: Freq (Frequency of use) 2 times daily; Route: Both eyes; Start 4/8/24 . End: 4/8/25.
The order in the MAR did not have a specific duration of use or an indication for use of antibiotic in the eyes.
Review of Resident 36's electronic medical record, signed by Medical Doctor 2 (MD 2), dated 7/29/24, the record by eye specialist indicated resident had previous eye surgeries and was treated with multiple eyes drops for glaucoma (a chronic eye disease that damages the nerves, which connects the eye to the brain) and its complications. The record further indicated Resident 36 had an eye condition called Dry Eye Syndrome (an eye condition that occurs when the eyes didn't produce enough tears, or the tears didn't work properly to provide lubrication for the eyes) and treated by artificial tears (a type of eye drop that mimicked the lubrication of natural tears) and erythromycin eye ointment.
Efforts to get a hold of MD 2 via phone was unsuccessful during the Department's survey.
During a concurrent record review and interview with Medical Doctor 1 (MD 1), the primary physician caring for Resident 36, on 8/21/24, at 1:21 PM, at facility's nursing station for B1 unit, MD 1 stated the eye specialist ordered resident's eye medicines. MD 1 reviewed the most recent progress note by MD 2 on 7/29/24 and confirmed the antibiotic ointment was used as lubricant. MD 1 could not find an active order for artificial tears as noted in the eye specialists' note. MD 1 stated long term use of eye antibiotic could contribute to resistance (means antibiotic no longer worked on the bugs) not to the extent of an antibiotic given by mouth. MD 1 was not sure why the artificial tears eye lubricant was not listed as an order to be administered to Resident 36.
During an interview with facility's Consultant Pharmacist (CP), on 8/22/24, at 11:26 AM, the CP stated she tracked antibiotic use in the facility part of Antibiotic Stewardship Program (or ASP, a set of coordinated approaches to improve how antibiotics were prescribed for the right diagnosis, dose, and duration, and only when needed. This helped minimize the spread of antibiotic resistant). The CP stated she didn't realize how long the eye antibiotics was used when she last reviewed the Resident 36's record. The CP stated the eye specialist and infection disease doctor should have consulted to assess continuation of long-term use of eye antibiotic. The CP stated she could not find a standard of practice or publication that supported long term use of the eye antibiotic as a lubricant.
Review of the facility's policy, titled Medication Therapy, dated 4/2007, the policy indicated Each resident's medication regimen shall include only those medications necessary to treat existing conditions and address significant risks. The policy further indicated . the staff and practitioner (assisted by consultant pharmacist) will review an individual's current medication regimen, to identify whether: a. there is a clear indication for treating that individual with medication; . c. the frequency of administration and duration of use are appropriate .
Review of erythromycin ophthalmic ointment via online drug information site called UpToDate LexiDrug, last accessed on 8/27/24, the drug monograph (a scientific document that provides factual information about a drug product) indicated the labeled indication for use was Ocular infections (ocular the eye; infection on the surface of the eye). The drug monograph under Warning/Precautions: Concerns related to adverse Effects indicated Prolonged use may result in fungal or bacterial superinfection (new infection occurring after or on top of an earlier infection with continued use of antibiotic).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure safe storage practices for medications and medical supplies stored in medication carts, treatment cart and refrigerators with census of 106 when:
1. Medication Cart 2 in Unit B2 stored undated inhalation medication called Ipratropium/Albuterol (or DuoNeb, an inhalation solution used to treat breathing problems) and opened packets of a skin patch called lidocaine topical system (or Ztlido, a numbing agent used to treat pain).
2. Medication refrigerator in Unit B2 medication room stored unlabeled prescription medication called CathFlo (or alteplase, medication used to unclog Intravenous (IV, into the Vein) line by dissolving the blood clots) and two boxes of suppositories (drug inserted in rectum) called bisacodyl (a bowel laxative) and acetaminophen (pain drug) that did not require refrigeration based on manufacturer recommendation.
3. Treatment Cart in Unit B4 stored unlabeled prescription drugs called Santyl (a topical product used to remove dead tissue from wounds so they can start to heal), tubes of Triamcinolone 0.1% cream (%, or percent and measure of potency), opened wound care supplies and expired bleach product in active storage areas.
4. Medication refrigerator in Unit B3 was unlocked and stored outdated medications including Flu vaccine, an antibiotic liquid medication called vancomycin (used to treat stomach infection) and undated antibiotic liquid bottle called Cephalexin (or Keflex- used to treat infection).
These failed practices could contribute to unsafe and spoiled medication use in the facility.
Findings:
1. During a concurrent observation and interview with Licensed Nurse 2 (LN 2), on [DATE], at 10:40 AM, in the facility's B2 unit, the Medication Cart 2 stored an inhalation medication called DuoNeb out of its foiled wrap. The product label on the foil box indicated Protect from light. Unit-dose vials should remain stored in the protective foil pouch at all times. Once removed from the foil pouch, the individual vials should be used within one week. The Medication Cart 2 contained two opened packets of a topical drug called lidocaine in the active storage areas. The packets did not have resident name, date, and time it was opened. LN 2 acknowledged the findings and stated the patch was refused by resident.
2. During a concurrent observation and interview with Registered Nurse 1 (RN 1), on [DATE], at 12:18 PM, in facility's medication room at unit B2, the refrigerator inside the medication room stored one vial of CathFlo with no label or resident's name on it. Further inspection indicated bisacodyl and acetaminophen suppository boxes were stored in the refrigerator door. The label on bisacodyl product box indicated to Store at 20 to 25 degrees Celsius (68-77-degree Fahrenheit) (Celsius and Fahrenheit are temperature scales) and the label on acetaminophen indicated store at 20-25 degree Celsius (68-77 degrees Fahrenheit) or in a cool place. RN 1 acknowledged the findings.
3. During a concurrent observation and interview with Licensed Nurse 5 (LN 5), on [DATE], at 2:48 PM, in facility's B4 unit, the Treatment Cart stored unlabeled and used prescription medications and expired supply for wound care in the active storage areas as follow:
a. One Santyl ointment 30 gm tube (gm is gram, a measure of weight) with no resident label and partially used.
b. Two Triamcinolone 0.1% cream 80 gm tubes marked Rx Only (means prescription drug), with no resident label and partially used.
c. Opened and unwrapped packet of a wound care supply called Hydrogel colloidal Sheet with Leptospermum Honey; MEDIHONEY; the packet was marked Do not re-use and indicated a sterile product.
d. An opened bottle of a liquid product called Sodium Hypochorite (same as bleach) had manufacturer expiration date on the bottle for 2/2024.
LN 5 acknowledged the findings.
4. During a concurrent observation and interview with Licensed Nurse 6 (LN 6), in the facility's B3 medication room, the medication refrigerator was placed on the ground floor and unlocked. Further observation indicated storage of outdated flu vaccine and undated antibiotic as follow:
a. One box of influenza Vaccine (or Flu vaccine) had expiration date of [DATE].
b. One amber color bottle of vancomycin oral solution (antibiotic to treat gut infection) marked as expired on [DATE].
c. Two bottles of liquid antibiotic called cephalexin 250mg/5mL (antibiotic used to treat various infections; the powder product mixed with water prior to dispensing; mg is milligram and mL is milliliter, a measure of dosage and volume) did not have date of reconstitution (date that powder mixed with water). The label on the bottle indicated discard after 14 days.
LN 6 acknowledged the findings.
In an interview with Pharmacy Supervisor (RX-S), on [DATE], at 11:15 AM, in the B3 hallway, the RX-S stated the pharmacy conducted floor inspection (checking medication storage areas in the facility) on monthly basis and report given to nursing leadership for review.
In an interview with Director of Nursing (DON), on [DATE], at 9 AM, the DON stated the medication storage areas were regularly checked for outdates by pharmacy.
Review of facility's policy, titled Labeling of Medication Container, dated 4/2007, the policy indicated all medications maintained in the facility shall be properly labeled in accordance with current state and federal regulations . Labels for individual containers shall include all necessary information, such as the resident's name, . The expiration date when applicable . The facility did not provide medication storage policy.

Based on observation, interview and record review, the facility failed to ensure 106 of 106 residents had food prepared and stored in a safe and sanitary manner when:
1. frozen raw tilapia and frozen raw shrimp was stored above ready to eat chicken enchiladas and bean and cheese pupusas.
2. a dispensing scoop was stored in panko breadcrumbs.
3. staff did not perform hand hygiene when their hands were contaminated by picking up a clipboard which fell on the floor.
These failures placed the facility's 106 residents who received food from the kitchen at risk of foodborne illness.
Findings:
1. During a concurrent observation and interview on 8/19/24, at 10:27 a.m., with Director of Food and Nutrition Services (DFNS) and Registered Dietitian 1 (RD 1), the freezer containing protein products was inspected. One opened box of frozen raw tilapia, one opened box of frozen raw shrimp and one closed box of frozen raw shrimp was found on the shelving above an open box of ready-to-eat chicken enchiladas, two unopened boxes of ready-to-eat chicken enchiladas and three closed boxes of ready-to-eat bean and cheese pupusas. RD 1 stated the raw seafood products needed to be stored below the heat to serve food products.
During a concurrent observation and interview on 8/19/24, at 10:30 a.m., with DFNS, a chart titled, proper refrigerator and freezer storage, dated 1/2024, was reviewed. DFNS stated the chart indicated the frozen seafood is stored below frozen cooked and ready-to-eat food.
A review of the Food and Drug Administration Food Code, dated 2022, indicated food be protected from cross contamination by separating raw animal foods from ready-to-eat foods.
2. During an observation on 8/19/24, at 10:41 a.m., a bin with a removable lid of panko breadcrumbs was inspected. Inside the container was a metal scoop resting in the panko breadcrumbs.
During a concurrent observation and interview on 8/19/24, at 10:42 a.m., with DFNS and RD 1, RD 1 stated the scoop resting in bin needed to be stored outside of the bin to prevent food contamination.
A review of the FDA Food Code, dated 2022, indicated dispensing utensils used for dry food items are stored with their handles above the top of the food within containers or equipment that can be closed, such as bins of sugar, flour, or cinnamon.
3. During an observation on 8/21/24, at 12:10 p.m., food service worker 1 (FSW 1) was wearing gloves and taking food temperatures at the lunch tray line. While moving from a movable cart to the tray line, a clipboard containing the temperature logs fell on the floor, and FSW 1 picked up the clipboard and placed it back on the cart. Without performing hand hygiene or changing gloves, FSW 1 continued to take food temperatures, such as mashed potatoes, pureed food and food held in a hot holding cart, until completion of the task.
During an interview on 8/21/24, at 12:45 p.m., with RD 1, RD 1 stated kitchen staff were expected to change gloves and wash hands with soap and water after contamination by dirty surfaces such as the floor.
During a record review of facility Policy and Procedure (P&P) titled, Sanitation and Infection Prevention/Control Hand Hygiene, dated 1/24, the P&P indicated in the food & nutrition services department: all associates associated with the handling of food shall wash hands. Hands are washed with soap and water at the following times: after any other activity that may contaminate the hands.
A review of the FDA Food Code, dated 2022, indicated staff wash hands after activity that may contaminate the hands.

Based on observation, interview, and record review, the facility failed to ensure staff followed policies and procedures designed to prevent infection in two out of 12 residents observed for medication administration observation and blood sugar testing (Resident 81 and Resident 407) when:
1. For one of 12 residents (Resident 81), Licensed Nurse 1 (LN 1) failed to clean the pill cutter (an instrument used to cut pills to provide an accurate dose) before and after use or practice hand hygiene.
2. For two of 12 residents (Resident 81 and Resident 407), Licensed Nurse 1 (LN 1) failed to clean the blood glucometer (instrument to check the level of sugar in the blood: blood glucose) in between resident use based on standards of practice and facility's policy.
These failures had the potential to cause infection or spread infection in the facility.
Findings:
1. During an observation on 8/20/24, at 11:30 AM, Resident 81 required a pain medication called hydromorphone (or Dilaudid, an opioid pain medication) in 2mg dosage in pill form (mg is milligram, a unit of measure). LN 1 retrieved a 4 mg pill from narcotic storage in the med medication room. LN 1 removed the pill from the packaging without hand hygiene and placed the pill in the pill cutter. The pill cutter was observed to have residue/powder present before the current med medication administration. LN 1 placed one half pill in a medication cup and the other half pill in another cup inside the medication cart drawer. LN 1 did not clean the pill cutter after use.
2. During an observation on 8/20/24, at 11:40 AM, Resident 81 required blood sugar testing by finger stick before lunch. After retrieving the glucometer from the medication cart drawer, LN 1 scanned the blood sugar test strip package. LN 1, without hand hygiene, took the pain medication, test strip, and blood sugar monitor (glucometer) to the room marked as Enhanced Barrier Precaution (means it required special prevention means before performing certain type of physical bodily care). LN 1 did not clean the blood sugar machine (glucometer) before entering Resident 81's room. LN 1 placed the glucometer on Resident 81's bedside table and administered the pain medication. LN 1 then performed finger stick with poking the Resident 81's index finger with a lancet (a thick and long needle used to puncture the fingertip to get blood drop) to get blood drop for the test. LN 1 completed the blood sugar check and left the room. LN 1 using the same glove wiped the glucometer's outer surface quickly for less than 10 seconds with one Sani-Cloth wipe (facility's sanitization choice for killing germs on the resident care devices). LN 1 then walked to the nursing station to put the glucometer in its docking station to transmit the information into the computer.
LN 1 then proceeded to next Resident 407 for blood sugar measurement using the same glucometer. LN 1 with gloved hand added the test strip to the glucometer and went into the room with lancet (a sharp point or needle that used to poke finger to get drops of blood), alcohol wipes and Sani-Cloth wipe. LN 1 poked the left middle finger and squeezed it to get blood to soaking the test strip. LN 1 placed the glucometer on top of bedside table while poking the finger for blood drop. LN 1 soaked the test strip with blood to get the blood sugar number. LN 1 used the same glove to quickly clean the outer surface of the glucometer with one Sani-Cloth wipe for less than 10 seconds.
In an interview with Director of Nursing (DON), on 8/20/24, at 2:31 PM, the DON stated she expected nursing staff to clean the shared glucometer before and after each resident use. The DON stated the nursing staff should wipe all external surfaces of glucometer for one minute to keep the surface wet according to required contact time of the 2 minutes.
Review of the facility's preferred sanitization wipe called Sani-Cloth (a germicidal disposable wipe), reviewed on 8/20/24, the product information on its packet indicated Cleaning Procedure: All blood and other body fluids must be thoroughly cleaned from surfaces and objects before disinfection by germicidal wipe. Open, unfold and use first germicidal wipe to remove visible soil . The second germicidal wipe to thoroughly wet surfaces. Allow surface to remain wet for two (2) minutes. Let air dry.
During a review of the facility policy and procedure titled, Cleaning and Disinfecting Non-Critical Resident Care Items, dated June 2011, the policy indicated Reusable items are cleaned and disinfected or sterilized between residents.
During a review of the facility policy and procedure titled, Point of Care Blood Glucose (sugar) Testing, dated April 2023, the policy indicated glucometers were to be cleaned after every patient use, when soiled and at least once per day routinely.
A review of the facility policy and procedure titled, Handwashing/Hand Hygiene, dated August 2015, indicated that hand hygiene should be performed before and after direct contact with residents, before preparing or handling medications, after contact with resident intact skin or blood, and after contact with medical equipment.
During an interview on 8/22/24, at 12:30 PM, with Registered Nurse/Clinical Instructor (RN/CI), the RN/CI stated annual skills competency evaluation had to be completed every year on the same month of original hire date. RN/CI stated the annual skills competency evaluation for infection control practices had not started for this year yet.
During a review of the facility's RN/LVN Annual Skills Competency Checklist, the following skills were indicated as being included in the annual competency checklist: B. Safety/Infection Control: Universal Precaution, Enhanced Standard Precautions, Transmission-based Precautions, Hand Hygiene guidelines, Donning & Doffing of PPE .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure the facility had a medication error rate of less than 5 percent when nursing staff failed to follow physician orders for administration of medication for two of eight sampled residents (Resident 89 and Resident 231) during medication pass: Resident 89 did not receive an ordered blood test before meals and Resident 231 did not receive the correct dosage of medication during medication pass.
The failure to follow medication administration instructions during two of 28 opportunities of medication administration resulted in an error rate of 7.1 percent.
Findings:
1. During a review of Resident 89's Minimum Data Set (MDS-an assessment tool to direct care), dated 7/24/23, the MDS indicated Resident 89 had a diagnosis of diabetes mellitus (the body's inadequate production of the hormone insulin results in high blood sugar levels causing excessive urination and damage to body organs). The MDS also indicated Resident 89 received an injection of insulin on seven of seven days in the assessment look-back period.
During a review of Resident 89's July physician orders, the physician order start date 5/15/23, indicated the following sliding scale (dosage to vary by level of blood glucose) dosage of seven units of insulin for a blood glucose reading of 201-250 was to be administered by injection before the meal. The physician order indicated Resident 89 was to have a blood glucose test before each meal.
During an observation on 7/26/23 at 12:51 p.m., Licensed Vocational Nurse 1 (LVN 1) took a blood glucose sample for Resident 89 as he began to eat his lunch. LVN 1 stated Resident 89's blood glucose reading was 201. LVN 1 stated Resident 89 was on a sliding scale for insulin administration. LVN 1 stated she did not want to bother the resident with an injection in the middle of his meal and would give his insulin later.
2. During a review of Resident 231's MDS dated [DATE], the MDS indicated Resident 231 had a diagnosis of seizure disorder. (Seizures are the result of abnormal electrical impulses in the brain, and can result in sudden, violent, irregular movements of a limb or the body.)
During a review of Resident 231's July physician orders, start date 7/21/23, indicated an order for 1000 milligrams (mg) of oral Keppra (an anti-seizure medication) twice a day.
During a medication pass observation and concurrent interview on 7/26/23 at 8:51 a.m., LVN 1 poured five milliliters (mLs) of liquid Keppra into a medication cup for Resident 231 and Resident 89 drank the medication. LVN 1 stated the label on the Keppra bottle indicated a concentration of 500 mg of Keppra for each 5 mLs of liquid. LVN 1 stated the Keppra was to prevent seizures.
During a follow-up interview on 7/26/23 at 1:00 p.m., LVN 1 stated she had administered 5 ml of Keppra to Resident 231, which was only a 500 mg dose. LVN 1 stated Resident 231 should have received a 1000 mg dose.
During a concurrent interview and observation of Resident 231's physician orders and Keppra bottle label on 7/26/23 at 1:04 p.m., with the Infection Preventionist (IP), the IP stated Resident 231's Keppra medication label indicated a concentration of 500 mg per 5 mLs of liquid. The IP stated Resident 231's order was for 1000 mg of Keppra, which would be 10 mLs of liquid.

2. A review of Resident 83's Minimum Data Set (MDS, an assessment tool used to guide care), dated 6/15/23, indicated Resident 83 had a diagnosis of dementia (memory loss).
A review of Resident 83's Physician Order, dated 7/13/23, indicated, Cleanse Sacral (the spinal area between the lower back and tailbone) wound with normal saline (NS, used to clean wounds), pat dry .Pack loosely with plain packing strip (thin strips of material used to fill deep pockets in wounds), adding wound gel (ointment for the wound). Cover with Mepilex (bordered foam dressing that is moisture-proof and bacteria-proof) dressing .
During a concurrent observation and interview on 7/27/23, at 11:15 a.m., with Licensed Vocational Nurse 1 (LVN 1), in Resident 83's room, LVN 1 completed Resident 83's wound care. LVN 1 opened Resident 83's bedside nightstand bottom drawer and placed the newly sanitized scissors inside the drawer. The bottom drawer also contained a box with several sealed gauze dressings, an opened bottle of plain packing strips, and a roll of paper tape. LVN 1 stated she stored Resident 83's wound care supplies, including the sanitized scissors, dated opened bottles of NS, bottle of plain packing strip, and paper tape inside Resident 83's nightstand bottom drawer between treatments.
During an interview on 7/28/23, at 9:20 a.m., with the Infection Preventionist (IP), the IP stated wound care treatment supplies were stored in the treatment cart and clean supply room. The IP stated Licensed nurses (LN) were expected to gather sufficient supplies for each individual resident treatment to the resident bedside, and not store supplies inside the resident room due to safety and infection control concerns. The IP stated open bottles of NS brought into a resident's room should be discarded after opening due to risk of infection.
A review of the facility's policy and procedure (P&P) titled, Wound Care, revised October 2020, the P&P indicated, .Assemble the equipment and supplies as needed. Date and initial all bottles and jars upon opening .Wipe reusable supplies with alcohol as indicated .Return reusable supplies to resident's drawer in treatment cart. Take only the disposable supplies that are necessary for the treatment into the room. Disposable supplies cannot be returned to the cart .
A review of the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents, revised July 2017, the P&P indicated, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities .Implementing interventions to reduce accident risks and hazards shall include the following .safety items and approaches for sharp items .
Based on observations, interviews, and document reviews, the facility failed to ensure staff followed policies and procedures designed to prevent infection and spread of infection when:
1. For two of five unsampled residents (Resident 105, Resident 229), a Licensed Vocational Nurse (LVN 1) failed to clean the blood glucometer (instrument to check the level of sugar in the blood: blood glucose) in between resident use.
2. For one of four sampled residents (Resident 83) with wound care issues, LVN 1 stored clean wound care supplies in a resident room and failed to discard a bottle of normal saline (NS, salt-water solution) used for wound irrigation opened inside the resident room.
These failures had the potential to cause infection or spread infection for Residents 105, 229, and 83.
Findings:
1. During an observation and concurrent interview on 7/26/23 at 12:37 P.M., with LVN 1, LVN 1 brought the blood glucometer to Resident 105's bedside. LVN 1 placed the blood glucometer on Resident 105's bed sheet as she collected a blood sample onto a test strip, placed the test strip sample in the blood glucometer, and discarded the test strip sample after obtaining the blood glucose value. LVN 1 picked up the blood glucometer using gloved hands, walked to the exit door, removed her gloves, placed the glucometer in her armpit, sanitized her hands, then carried the glucometer out of the room and placed it on top of the nursing medication cart. After collecting supplies, LVN 1 donned gloves, carried the glucometer, without intervening cleaning of the glucometer, toward Resident 229's room. When asked when the glucometer needed to be cleaned, LVN 1 stated the glucometer needed to be cleaned when it had visible blood on it. LVN 1 stated she did not see visible blood on the blood glucometer now. LVN 1 entered Resident 229's room and placed the glucometer on Resident 229's overbed table, collected a blood sample on the test strip, placed the sample test strip in the glucometer, read the result, picked up and carried the glucometer to a counter by the exit, and directly placed the glucometer on the counter. LVN 1 doffed her gloves, sanitized her hands, donned gloves, and cleaned the glucometer without sanitizing the counter or Resident 229's overbed table.
During an interview on 7/26/23 at 1:04 P.M., the Infection Prevention (IP) nurse stated the blood glucose machine should be cleaned before and after each resident's use.
During a review of the facility's policy and procedure (PNP) titled, Obtaining a Fingerstick Glucose Level, revised date October 2011, the PNP indicated always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses.

Based on observation, interview, and record review, the facility failed to ensure one of 22 sampled residents (Resident 72) was treated with dignity and respect when a Certified Nursing Assistant 1 (CNA 1) failed to provide visual privacy during provision of care for ADLs (activities of daily living such as personal hygiene, bathing, dressing, toileting).
The failure to fully enclose Resident 72's bed by use of the privacy curtain had the potential to result in public exposure of Resident 72's body during provision of care and cause emotional distress.
Findings:
A review of Resident 72's Minimum Data Set (MDS, an assessment tool used to guide care), dated 6/9/23, the MDS indicated Resident 72 was totally dependent on the assistance of one staff person for ADLs. The MDS indicated Resident 72's vision was severely impaired (no vision or sees only light, colors or shapes; eyes do not appear to follow objects), was sometimes able to make himself understood, and sometimes able to understand others.
During a concurrent observation and interview on 7/24/23, at 10:50 a.m., with Certified Nursing Assistant 1 (CNA 1), in the doorway outside Resident 72's room, Resident 72's bed was in a fully occupied four-bed room with Resident 72's bed on the side of the room nearer to the hallway and door. Resident 72's left side was visible from the hallway through a two-foot gap created when the privacy curtain was not pulled to the wall for complete enclosure at the foot of the bed. Resident 72 lay flat in bed with no clothing on above the hips while CNA 1 assisted Resident 72 with a bed bath. When asked about the privacy curtain gap, CNA 1 stated the privacy curtain should enclose the bedside to provide visual privacy.
During an interview on 7/26/23, at 1:01 p.m., with the Director of Nursing (DON), the DON stated
nursing staff should provide resident's privacy during ADL care, either by pulling the cubicle curtain completely around the resident bed or by closing the door in a room occupied by one resident.
A review of the facility's policy and procedure (P&P) titled, Quality of Life - Dignity, revised August 2021, the P&P indicated, Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality .Resident shall be treated with dignity and respect at all times. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth .Staff shall promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures .
A review of the facility's policy and procedure (P&P) titled, Activities of Daily Living (ADLs), Supporting, revised May 2022, the P&P indicated, Privacy will be provided using items such as cubicle curtains and closing room doors if needed .

Based on interview and record review, for one of 24 (Resident 65) sampled residents, the facility failed to consistently monitor Resident 65's behaviors and side effects related to the use of psychotropic (capable of affecting the mind, emotions, and behaviors) medications during the months of July 2019, August 2019, and September 2019.
For Resident 65, this deficient practice had the potential to result in the physician receiving and using inaccurate information to make decisions regarding the need to continue, increase, or decrease of the use of psychotropic medications.
Findings:
Review of Resident 65's Face Sheet indicated Resident 65 was admitted to the facility with diagnoses that included Traumatic Brain Injury Assault (an injury to the brain caused by an impact such as a road traffic incident, assault, or fall).
Review of Resident 65's Minimum Data Set (MDS - an assessment tool used to direct care), dated 7/16/19, indicated Resident 65 had diagnoses that included a severe chronic mental disorder and depression.
Review of Resident 65's Physician Orders (PO) indicated Resident 65 was to receive the following:
a. Haldol, order dated 5/30/19, for a severe chronic mental disorder manifested (m/b) by auditory hallucination and talking to self;
b. Trazadone (Desyrel), order dated 5/27/19, for insomnia associated with depression m/b sleeplessness, and;
c. Sertraline (Zoloft), order dated 5/30/19, for depression.
Review of Resident 65's Medication Administration Records (MARs), dated July 2019, August 2019, and September 2019, indicated that there was inconsistent monitoring of Resident 65's behaviors for the use of Haldol and Sertraline, and inconsistent monitoring of Resident 65's time spent sleeping related to the use of Trazadone on multiple days and across multiple shifts (days, afternoon, and night shifts). The MARs also indicated there was inconsistent monitoring of side effects related to Resident 65's use of Sertraline on multiple days and across multiple shifts (days, afternoon, and night shifts).
During an interview and concurrent record on 9/26/19, at 8 a.m., Registered Nurse (RN) 4 stated Resident 65's behavior and side effect monitoring was not consistent for multiple days and across multiple shifts from July to September 2019. RN 4 stated it was important to monitor the (Resident 65's) behaviors and presence of side effects during psychotropic drug use in order (for the physician) to know the need for continued use, increase, or decrease of the psychotropic medications.
In an interview with the Director of Nursing (DON) on 9/26/19 at 12:20 p.m., and concurrent record review of Resident 65's MAR from July to September 2019, DON stated some of the licensed nurses were noncompliant with the behavior and side effects monitoring documentation for resident's psychotropic drug use from July to September 2019. DON stated the Interdisciplinary Team's (IDT's) recommendations for the psychotropic drugs' Gradual Dose Reduction (GDR) were based on the identified number of incidents of behavior manifestations and medication side effects monitored.
Review of the facility's policy and procedure titled, Antipsychotic Medication Use, with revised date December 2018, indicated .Antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional, psychiatric, social and environmental cause of behavioral symptoms have been identified and addressed. Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review

Based on observation, interview and record review, for two of 27 sampled residents (Residents 49 and 76 and 94), the facility failed to ensure Residents 49 and 76 were free of significant medication errors when:
1. Resident 49 did not receive Renvela (a phosphate binder medication that prevents the absorption of phosphorus in the blood) as ordered by the physician, and;
2. Resident 76 did not receive Renagel (a type of phosphate binder) and Lomotil (medication to treat diarrhea) as ordered by the physician.
For Residents 49 and 76, this failure had the potential to result in increased phosphorus levels adverse effects (e.g. body changes that pull calcium out of your bones, making them weak).
For Resident 76, this failure had the potential to result in dehydration.
Findings:
1. Review of Resident 49's nutrition care plan, last reviewed 9/12/19, indicated the goal was for Resident 49 to have blood phosphorus (a mineral) level between 3 - 5.5 milligrams/deciliter (mg/dL). One of the approaches was for licensed nurses to give medications as ordered.
Review of Resident 49's physician's orders indicated Resident 49 went to dialysis every Monday, Wednesday, and Friday around lunch time. The physician's orders indicated for Resident 49 to receive one 0.8-gram packet of Renvela by mouth three times daily with meals.
During an interview and concurrent review on 9/25/19, at 10:08 a.m., Director of Nursing (DON) stated Resident 49's MAR Medication Administration Record (MAR) for September 2019 did not indicate that Resident 49 receive Renvela as an as needed (PRN) medication. The MAR indicated from 9/3/19 until 9/9/19, there was no information whether Resident 49 received Renvela. The MAR also indicated there were seven out of 48 possible doses that Resident 49 did not receive in September 2019.
2. Review of Resident 76's facesheet, printed 9/24/19, indicated Resident 76 was admitted to the facility with diagnoses that included kidney failure.
Review of Resident 76's Minimum Data Set (MDS - an assessment tool used to guide care), dated 5/24/19, indicated Resident 76 had the ability to clearly think, reason, and remember.
Review of Resident 76's physician's orders indicated Resident 76 was to receive 1600 milligrams (mg) of Renagel three times daily with meals.
Review of Resident 76's chronic kidney disease care plan last reviewed 7/30/19 indicated for licensed staff to administer phosphate binder per physician's order.
During an interview and concurrent review on 9/25/19, at 12:06 p.m., Infection Preventionist (IP) stated there was no documentation in Resident 76's MAR that a breakfast dose of Renagel was administered to Resident 76. Resident 76's MAR indicated on days that Resident 76 went to dialysis, the breakfast dose for Renagel indicated not administered, patient off the floor. The MAR indicated Resident 76 did not receive 11 out of 76 possible doses of Renagel.
During an interview on 9/23/19, at 11:12 a.m., Resident 76 stated she had not been able to eat well because of diarrhea.
During an interview on 9/23/19 at 11:12 a.m., Certified Nursing Assistant (CNA) 5 stated Resident 76 had been having diarrhea, which was known by licensed staff. CNA 5 stated when Resident 76 had two episodes of loose stools in one shift, the licensed nurses were notified so they could give Resident 76 anti-diarrhea medication.
Review of Resident 76's Medication Administration Record (MAR), printed 9/24/19, indication Resident 76 was to receive 2.5 milligrams (mg) of Lomotil two times per day as needed for diarrhea. The MAR
In an interview and concurrent record review on 9/24/19, at 1:23 p.m., Resident 76's bowel movement record indicated she had large, thin bowel movements on 9/2/19, 9/16/19, 9/17/19, 9/19/19, 9/20/19 and 9/22/19. Registered Nurse (RN) 3 stated Resident 76's bowel movement record indicated Resident 76 had (multiple) episodes of diarrhea. RN 3 stated large, thin bowel movement meant large, watery or loose bowel movement.
Review of Resident 76's MAR, printed 9/24/19, indicated that Resident 76 did not receive Lomotil when she had large, thin bowel movements (diarrhea) on 9/2/19, 9/16/19, 9/17/19, 9/19/19, 9/20/19, and 9/22/19.
(Refer to F726 for additional information regarding dialysis dependent residents)

Based on observation, interview, and record review, for two of four sampled residents (Residents 104 and 107) the facility failed to implement their infection prevention and control policy and procedures when:
1. Resident 104's indwelling catheter uncovered drainage bag was touching the floor, and;
2. Registered Nurse (RN) 3 did not perform hand hygiene (general term that applies to hand washing, antiseptic hand wash, and alcohol-based hand rub)
hands between glove changes and touched clean gauze with bloody gloves.
For Residents 104 and 107, these deficient practices had the potential to result in the spread of infection.
Findings:
1. Review of Resident 104's Physician Orders, dated 5/24/19, indicated Resident 104 had a condom catheter related to his diagnoses of Benign Prostatic Hyperplasia (enlarged prostate) and urine retention.
During an observation on 9/24/19, at 8:22 a.m., Resident 104's uncovered urinary catheter drainage bag was touching the floor.
In an interview on 9/24/19, at 8:22 a.m., Certified Nursing Assistant (CNA) 1 stated urinary catheter drainage bag should not be touching the floor to prevent cross-contamination.
Review of the facility's policy and procedure titled, Catheter Associated Urinary Tract Infection (CAUTI) Prevention Policy, revised 8/2015, indicated .Patients with indwelling catheters will receive care compliant with recommended strategies to prevent Catheter Associated Urinary Tract Infection (CAUTI) under the professional medical judgement of the provider .Proper techniques for Urinary Catheter Maintenance .Do not rest the bag on the floor
2. Review of Resident 107's Minimum Data Set (MDS - an assessment tool used to guide care), dated 8/28/19, indicated Resident 107 had multiple diagnoses that included left and right hip pressure ulcers (opening over the bony area caused by pressured) at Stage 4 (an advance level).
Review of Resident 107's physician's orders, not dated, indicated directions to cleanse the left and right ischial tuberosity (hip) wounds daily with Theraworx (a cleaning solution), place Theraworx to moisten Drawtex (gauze), apply on wound bed and cover with Optifoam (foam) dressing until healed.
During an observation of Resident 107's left and right hip pressure ulcers wound treatment with RN 3 on 9/25/19 at 10:44 a.m., RN 3 cleaned Resident 107's bloody wound beds with Theraworx. After RN 3 cleaned the bloody wound beds, without changing gloves, she pat the wounds dry with clean gauze. Then RN 3, with bloody gloves, applied clean gauze and foam dressing over the wounds. After applying the clean dressings, RN 3 removed her gloves and sanitized her hands.
During an interview with RN 3 on 9/25/19, at 11:13 a.m., RN 3 stated she should have changed her soiled gloves before touching clean gauze during wound care.
During an interview with the Infection Prevention and Control Nurse (IPCN) on 9/25/19, at 11:04 a.m., she stated during wound care after cleaning a wound and gloves are soiled, the gloves should be changed before touching clean supplies. IPCN stated hands should be sanitized after removing gloves.

2. Review of Resident 104's Minimum Data Set (MDS - an assessment tool used to guide care, dated 8/20/19, indicated Resident 104 was totally dependent on the assistance of one or two staff persons for Activities of Daily Living (ADLs - e.g. turning in bed, dressing, eating, personal hygiene).
Review of Resident 104's Physician Orders, dated 5/24/1,9 indicated an order for condom catheter for related to his diagnoses of Benign Prostatic Hyperplasia (enlarged prostate) and urine retention.
During an observation in Resident 104's room on 9/24/19, at 8:22 a.m., Resident 104's urinary catheter drainage bag was hanging on the right side of his bed frame, facing the door, and the contents were visible without a privacy bag to cover it.
In an interview immediately following the observation, Certified Nursing Assistant (CNA) 1 stated Resident 104's urinary catheter drainage bag should be placed in a privacy bag due to dignity issues.
Review of the facility's policy Quality of Life - Dignity, with revised date August 2009, indicated .Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality .1. Residents shall be treated with dignity and respect at all times .2. 'Treated with dignity' means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth .11. Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by .a. Helping the resident to keep urinary catheter bags covered
Based on observation, interview, and record review, the facility failed to ensure two of four sampled residents (Residents 36 and Resident 104) were treated with dignity and respect when:
1. Certified Nursing Assistant (CNA) 7 entered Resident 36's room without knocking and/or without permission. This failure resulted in Resident 36 feeling mad that his privacy was not respected.
2. Resident 104's urinary catheter (small flexible tube inserted through the urethra and into the bladder to drain urine) drainage bag was not covered by a urinary catheter drainage bag cover. For Resident 104, this failure had the potential to result in the loss of dignity.
Findings:
1. Review of Resident 36's Minimum Data Set (MDS - an assessment tool used to guide care), dated 3/6/19, indicated Resident 36 was totally dependent on the assistance of one or two staff persons for Activities of Daily Living (ADLs - e.g. turning in bed, dressing, eating, personal hygiene). The MDS also indicated Resident 36's Brief Interview for mental status was 15 (indicated he was able to recall words, repeat words and knew the correct year, date and month).
During an observation and joint interview on 9/23/19, at 10:21 a.m., CNA 7 entered Resident 36's room without knocking and without asking for permission. CNA 7 stated she thought it was okay to enter Resident 36's room without knocking and asking permission because Resident 36's curtain was open, and he could see her standing in the doorway.
During an interview with Resident 36 on 9/23/19, at 10:25 a.m., Resident 36 stated he was mad and felt his privacy was not respected when CNA 7 entered his room with knocking and asking permission.
During an interview with the Clinical Instructor (CI) on 9/26/19, at 11:34 a.m., CI stated the staff should treat residents with dignity and respect.
Review of the facility's policy and procedure titled Quality of Life - Dignity, revised 8/2009, indicated .6. Residents' private space and property shall be respected at all times. a. Staff will knock and request permission before entering resident's room

Based on interview and record review, the facility did not provide competency training to provide services for dialysis-dependent (dialysis - a process where a machine filters the blood of wastes when the kidneys are not healthy enough to do it) residents in accordance with the facility assessment.
This failure had the potential to result in dialysis-dependent residents receiving inappropriate care and services.
Findings:
Review of the Facility Assessment last reviewed 7/12/19 indicated the average number of residents on special treatments and conditions included 6-10 residents who were on hemodialysis (also known as dialysis). Staff training/education and competencies needed to provide level of requirements were also included in the facility assessment. The nursing staff skill sets that were evaluated annually included specialized care such as dialysis.
During an interview and concurrent review of competency trainings with Clinical Instructor (CI) on 9/26/19 at 10:36 a.m., CI stated she had just started work in June 2019 and has not given competency training on dialysis care and management to licensed nurses.
During an interview with Director of Nursing (DON) on 9/26/19 at 11:57 a.m., DON stated there was no competency training provided to licensed nurses recently. DON stated the last training provided was in 2017. DON stated training should be provided every year because of the resident population and characteristics that the facility had.
(Refer to F760 for additional information regarding Residents 49 and 76)

Based on interview and record review, for one of 27 (Resident 51) sampled residents, the facility failed to inquire about Advance Directive (a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity) from Resident 51 and/or their representative.
This failure had the potential to result in Resident 51 not receiving care in accordance with his wishes.
Findings:
Review of the annual Minimum Data Set (MDS - an assessment tool used to guide care), dated 6/21/19, indicated Resident 51's Brief Interview for mental status was 15 (indicated he was able to recall words, repeat words and knew the correct year, date and month).
During a review of the medical record for Resident 51, the Physician Orders for Life-Sustaining Treatment (POLST) form, signed 7/29/19, indicated Section D - Information and Signatures regarding Advance Directives was left unanswered.
Review of Resident 51's quarterly Minimum Data Set (MDS - an assessment tool used to direct care), dated 6/21/19, indicated the advance directive section was not completed. Further review of the MDS indicated resident 51 had the ability to clearly think, reason, and remember.
During an interview with Resident 51 on 9/26/19 at 11:36 a.m., he stated that no one from the facility had talked to him about an advance directive prior to 9/25/19. He stated he was interested in receiving information about one.
Review of Resident 51's Resident Care Conference, dated 7/22/19, indicated the advance directive question had not been answered for Resident 51.
During a concurrent interview and record review with the Assistant Director of Nursing (ADON) on 9/24/19 at 9:54 a.m., ADON stated that the advance directive was addressed with residents and their representatives during the initial resident care conferences and when needed. ADON stated Resident 51's advance directive should have been addressed during his initial resident care conference.
Review of facility's policy and procedure titled Advance Directives, revised 5/2019, indicated .2. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so .2. If the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident's legal representative .5. Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. 6. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Review of Resident 9's Face Sheet indicated resident was admitted to the facility on [DATE].
Review of the Minimum Data Set (MDS - an assessment tool used to direct care) indicated the last Annual MDS was done on 7/18/18 and the next Annual MDS was due on 7/18/19. Resident 9's Annual Assessment was still open, was not completed, and was more than 120 days overdue.
During a concurrent interview and record review on 9/25/19, at 8:38 a.m., MDSC stated Residnet 9's Annual MDS Assessment was still open and has not been completed.
Review of the facility's policy Resident Assessment Instrument, with revised date September 2010 indicated, .1. The Assessment Coordinator is responsible for ensuring that the Interdisciplinary Assessment Team conduct timely resident assessment and reviews according to the following schedule .d. Once every twelve months
Based on interview and record review, the facility failed to complete comprehensive Minimum Data Set assessments (MDS - an assessment tool used to guide care) for five of 27 sampled residents (Residents 259, 260, 25, 17, and 9) within the regulatory specified timeframes when:
1. the Minimum Data Set Coordinator (MDSC) did not complete the admission MDS assessment for Resident 259 and 260 within 14 calendar days of their respective admission to the facility.
2. the MDSC did not complete the annual MDS for Resident 25, 17, 21, and 9 within 12 months of their respective previous annual MDSs.
This deficient practice had the potential to delay care planning for Residents 259, 260, 25, 17, and 9.
Findings:
1. Review of the Resident 259's Face Sheet, printed 9/24/19, indicated Resident 259 was admitted to the facility on [DATE].
Review of Resident 259's MDS record, indicated Resident 259's admission MDS had a reference date of 7/22/19, and the MDS was not completed within 14 calendar days of Resident 259's admission to the facility.
2. Review of the Resident 260's Face Sheet, printed 9/24/19, indicated Resident 260 was admitted to the facility on [DATE].
Review of Resident 260's MDS record, indicated Resident 260's admission MDS had a reference date of 7/30/19, and the MDS was not completed within 14 calendar days of Resident 260's admission to the facility.
During an interview on 9/24/19, at 9:55 a.m., MDSC stated Resident 259's and Resident 260's admission MDSs were not completed due to her workload. MDSC stated the work flow process at the facility was meant for two MDSCs, and she could not keep up with the work flow. MDSC stated the admission MDSs should have been completed by day fourteen of Resident 259's and Resident 260's stay.
The facility's policy and procedure titled Resident Assessment Instrument, revised 9/2010, indicated .1. The Assessment Coordinator is responsible for ensuring that the Interdisciplinary Assessment Team conduct timely resident assessments and reviews according to the following schedule: a. Within fourteen (14) days of the resident's admission to the facility; d. once every twelve (12) months
3. Review of Resident 25's Facesheet, printed 9/26/19, indicated Resident 25 was admitted to the facility in 2016.
During an interview and concurrent record review on 9/25/19, at 1:35 p.m., Minimum Data Set Coordinator (MDSC) stated she performed the MDS assessments for the facility. MDSC stated Resident 25's MDS annual comprehensive assessment was due on 8/12/19. MDSC stated she completed Resident 25's MDS annual assessment on 8/26/19, which was (14 days) late.
4. Review of Resident 17's Facesheet, printed 9/26/19, indicate Resident 17 was admitted to the facility in 2015.
During an interview and concurrent record review on 9/25/19, at 1:35 p.m., MDSC stated Resident 17's MDS annual comprehensive assessment was due on 7/29/19. MDSC stated she completed Resident 17's MDS annual assessment on 9/26/19, which was (59 days) late.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, for one (Residents 27) of 27 sampled residents the facility failed to ensure a Minimum Data Set (MDS - a resident assessment tool used to guide care) Significant Change in Status Assessment (SCSA - major decline or improvement in a resident's status) was done within 14 days after it was determined. Minimum Data Set Coordinator (MDSC) completed Resident 27's SCSA 64 days after it was due.
This deficient practice had the potential to result in Resident 27 not receiving care based on their current health status.
Findings:
Review of Resident 27's Face Sheet, printed 9/20/19, indicated Resident 27 was admitted to the facility on [DATE].
During an interview on 9/26/19, at 8:30 a.m., MDSC stated Resident 27's SCSA was completed late because she had to facilitate care conferences and review charts before care conferences occurred. MDSC stated Resident 27's SCSA could not be completed until after the care conference had occurred. MDSC stated it was too much work, not enough time and help to complete the assessment on time.
Review of Resident 27's Minimum Data Set (MDS - an assessment tool to direct resident care) records, indicated Resident 27 had a SCSA comprehensive assessment reference date of 7/22/19 and was completed on 9/24/19 (64 days late).
The facility's policy and procedure titled Change in a Resident's Condition or Status, revised 5/2017, indicated .9. If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted as required by current OBRA regulations governing resident assessments and as outlined in the MDS RAI Instruction Manual
The facility's policy and procedure titled Resident Assessment Instrument, revised 9/2010, indicated .1. The Assessment Coordinator is responsible for ensuring that the Interdisciplinary Assessment Team conduct timely resident assessments and reviews according to the following schedule: b. When there has been a significant change in the resident's condition

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 9. Review of Residents 1, 12, 15, 18 and 77's record on 9/26/19, at 12 p.m., indicated the following:
a. Resident 1's quarterly MDS dated [DATE] was completed 9/24/19 (85 days late);
b. Resident 12's quarterly MDS dated [DATE] was completed 9/24/19 (82 days late);
c. Resident 15's quarterly MDS dated [DATE] was completed 9/25/19, (83 days late);
d. Resident 18's quarterly MDS dated [DATE] was completed 8/15/19, (17 days late), and;
e. Resident 77's quarterly MDS dated [DATE] was completed 9/26/19, (67 days late).
Review of the facility's policy and procedure titled Resident Assessment Instrument, revised 9/2010, indicated .1. The Assessment Coordinator is responsible for ensuring that the Interdisciplinary Assessment Team conduct timely resident assessments and reviews according to the following schedule: c. At least quarterly
Based on interview and record review, for 13 of 27 (Resident 2, 4, 7, 10, 8, 14, 6, 22, 1, 12, 18, 15, and 77) sampled residents, the facility failed to complete Quarterly Minimum Data Set (MDS, an assessment too used to direct care) Assessments in the regulatory specified manner.
This failure had the potential for Residents 2, 4, 7, 10, 8, 14, 6, 22, 1, 12, 18, 15, and 77 to not receive care and services needed based on their current health status.
Findings:
1. Review of Resident 2's the Face Sheet, printed 9/26/19, indicated Resident 2 was admitted to the facility on [DATE].
Review of Resident 2's Quarterly MDS assessment indicated it was due on 7/2/19 and completed on 9/24/19 (84 days late).
2. Review of Resident 4's the Face Sheet, printed 9/26/19, indicated Resident 4 was admitted to the facility on [DATE].
Review of Resident 4's Quarterly MDS assessment indicated it was due on 7/10/19 and completed on 9/24/19 (76 days late).
3. Review of Resident 7's Face Sheet, printed 9/26/19, indicated Resident 7 was admitted to the facility on [DATE].
Review of Resident 7's MDS Quarterly MDS Assessment indicated it was due on 7/3/19 and completed on 9/24/19 (84 days late).
4. Review of Resident 10's Face Sheet, printed 9/26/19, indicated Resident 10 was admitted to the facility on [DATE].
Review of Resident 10's Quarterly MDS assessment indicated it was due on 7/11/19 and completed on 9/24/19 (76 days late).
During an interview and concurrent record review of Residents 2, 4, 7, 10's last MDS Assessments on 9/25/19 at 8:38 a.m., the MDSC was unable to show completed MDS quarterly reviews, based on each of the residents' assessment reference dates. MDSC stated all MDSs for the (Quarterly) MDS assessments for Residents 2, 4, 7, 10's were either still open, completed late, and/or transmitted late.
7. Review of Resident 6's Face Sheet, printed 9/20/19, indicated Resident 6 was admitted to the facility on [DATE].
Review of Resident 6's Quarterly MDS assessment indicated it was due on 7/2/19 and completed on 9/24/19 (85 days late).
8. Review of the Resident 22's Face Sheet, printed 9/20/19, indicated Resident 22 was admitted to the facility on [DATE].
Review of Resident 22's Quarterly MDS assessment indicated it was due on 7/31/19 and completed on 9/24/19 (56 days late).
During an interview on 9/26/19 at 8:30 a.m., MDSC stated Resident 6's and Resident 22's
Quarterly MDSs were completed late.
5. Review of Resident 8's Facesheet, printed 9/26/19, indicated Resident 8 was admitted to the facility in 2015.
During an interview and concurrent record review on 9/26/19, at 1:35 p.m., Resident 8's Quarterly MDS indicated it was due on 7/9/19 and completed on 9/26/19. MDSC stated she completed the Quarterly MDS assessment on 9/26/19, which was (80 days) late.
6. Review of Resident 14's Facesheet, printed 9/26/19, indicated Resident 14 was admitted to the facility in 2018.
During an interview and concurrent record review on 9/26/19, at 1:35 p.m., Resident 8's Quarterly MDS indicated it was due on 7/16/19 and completed on 9/26/19. MDSC stated she completed the Quarterly MDS assessment on 9/26/19, which was (73 days) late.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, for one (Resident 94) of 27 sampled residents, the facility failed to develop and implement comprehensive care plans to address medical and nursing needs of the residents when there was no comprehensive care plan to address indwelling catheter.
This failure had the potential to result in delayed or unrecognized catheter related adverse affects.
Findings:
Review of the Resident Face Sheet, not dated, indicated Resident 94 was admitted to the facility on [DATE].
Review of the annual Minimum Data Set (MDS-an assessment tool used to guide care), dated 5/18/19, indicated Resident 94 had an indwelling urinary catheter (a flexible tube that is inserted into the bladder to drain urine).
Review of Resident 94's physician's orders, dated 9/26/19, indicated Resident 94 had an order for a suprapubic catheter.
During a concurrent interview and record review with the Assistant Director of Nursing (ADON) on 9/25/19 at 12:08 p.m., ADON stated she could not find in Resident 94's medical record a care plan that addressed his indwelling urinary catheter. ADON stated Resident 94 needed a care plan that addressed the indwelling urinary catheter.
Review of the facility's policy and procedure titled Care Plans, Comprehensive Person-Centered, revised 12/2016, indicated .12. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS)