Adamsplace, Llc

Based on Infection Control Manual review, employee list review and interview, the facility failed to offer COVID-19 vaccinations to employees hired after 2/2025 which had the potential to affect 37 of 37 residents that were residing in the facility. The findings include: Review of the Infection Control Manual Volume 1, dated 10/2025, revealed .This Infection Prevention and Control program is designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections.Immunizations/vaccinations are offered, as appropriate, to patients and partners to decrease the incidence of preventable infectious diseases. Review of the current employee list revealed 29 employees were hired after 2/2025. During an interview on 12/17/2025 at 10:00 AM, the Infection Control Preventionist (ICP)/Director of Nursing (DON) was asked to explain the process for COVID-19 vaccinations for staff. The ICP/DON stated, We did not offer the COVID vaccination this year.several of the local clinics had it. During an interview on 12/17/2025 at 12:58 PM, the Administrator stated, Covid is a thing of the past, it will be here until we die . During an interview on 12/17/2025 at 2:21 PM, the ICP/DON was asked when the facility last offered the COVID-19 vaccination to staff. The ICP/DON responded the last time it was offered to be given to staff inside the facility was February 2025.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review and interview, the facility failed to ensure residents were accurately assessed for antipsychotic medication use for 2 of 5 (Resident #6 and #45) sampled residents reviewed for unnecessary medication use. The findings include: 1. Review of the facility's policy titled, RAI (Resident Assessment Instrument) -MDS [Minimum Data Set] 3.0 Completion, dated October 2025, revealed .Residents are assessed using a comprehensive assessment process.antipsychotic medication use and management has important associations with the quality of life and quality of care of residents receiving these medications. 2. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE], with diagnoses including Depression, Anxiety, and Agitation. Review of the Physician's Order dated 11/21/2025, revealed quetiapine (an antipsychotic medication) was ordered at 8:00 PM daily. Review of the November 2025 Medication Administration Record (MAR) revealed Resident #6 received quetiapine 200 mg daily at 8:00 PM from 11/22/2025 to 11/30/2025. Review of the admission MDS assessment dated [DATE], revealed Resident #6 scored a 13 on the Brief Interview for Mental Status (BIMS) assessment, which indicated she was cognitively intact. Further review revealed the use of an antipsychotic medication was not captured. The MDS assessment failed to document Resident #45 received an antipsychotic medication during the assessment period. 3. Review of the medical record revealed Resident #45 was admitted to the facility on [DATE], with diagnoses including Depression and Anxiety. Review of the Physician's Order dated 11/21/2025, revealed quetiapine was ordered at 8:00 PM daily. Review of the Physician Orders dated 12/3/2025, revealed quetiapine tablet was ordered at 9:00 PM daily. Review of the December MAR dated revealed Resident #45 received quetiapine 100 mg at 9:00 PM 12/3/2025 to 12/16/2025. Review of the admission MDS dated [DATE], revealed Resident #45 scored a 15 on the BIMS assessment, indicated she was cognitively intact. Further review revealed her use of an antipsychotic medication was not captured. The MDS assessment failed to document Resident #45 received an antipsychotic medication during the assessment period. During an interview on 12/17/2025 at 8:38 AM, the MDS Coordinator was asked does the admission MDS for Resident #6 and Resident #45 have the Antipsychotic quetiapine documented. The MDS Coordinator stated, It is not and definitely should have been .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure medications were properly stored when medications were found unattended and unsecured at the bedside for 1 of 37 (Resident # 24) residents.The findings include: 1. Review of the facility policy titled, Medication Storage In The Facility, dated 2/25/2025, revealed .The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. 2. Review of the medical record revealed Resident #24 was admitted to the facility on [DATE], with diagnoses including Glaucoma, Cataract Extraction, and Macular Degeneration. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #24 scored a 12 on the Brief Interview for Mental Status (BIMS) assessment, which indicated she was moderately cognitively impaired. Review of the Physician Orders dated 11/18/2025, revealed .latanoprost drops [used to treat glaucoma] .0.005% [percent] .Administer: 1drop .ophthalmic (eye).At Bedtime into affected eye(s). Observation in Resident #24's room on 12/15/2025 at 10:41 AM, revealed 1 bottle of latanoprost eye drops laying on Resident #24's bedside table. Review of the medical record revealed Resident #24 did not have a medication self-administration assessment completed. During an interview on 12/15/2025 at 10:47 AM, Licensed Practical Nurse (LPN) I was asked should prescription eye drops be left at the bedside unsecured and unattended in the resident's room. LPN I stated, They should not. During an interview on 12/16/2025 at 2:25 PM, the Director of Nursing (DON) was asked if medications should be left unattended in a resident's room. The DON stated, .If the Resident does not have a self-administration evaluation / assessment, then no there should not be any left at bedside.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the Centers for Disease Control and Prevention (CDC) guidelines, policy review, Infection Control Manual review, Infection Tracker review, Infection Control Monthly/Quarterly Report review, observation, and interview, the facility failed to ensure proper infection control practices were followed during medication administration when 1 of 1 nurses (Registered Nurse (RN) C) failed to allow the glucometer machine (a device used to check blood sugar levels with the use of a blood sample) to dry for the manufacturer's suggested time frame after use and when the facility failed to establish and implement an effective infection control program to identify, report, investigate, and control infections and communicable diseases when the facility failed to track and monitor organisms for outbreaks and cross contamination. This had the potential to affect 37 of 37 residents who resided in the facility. The findings include: 1. Review of the CDC Guidelines, Considerations for Blood Glucose Monitoring and Insulin Administration, dated 8/7/2024, revealed .Blood glucose meters are portable devices that measure blood glucose levels and aid in diabetes self-management.Blood glucose meters can easily become contaminated during use. When used in healthcare or other group settings, germs and infections can spread if preventative measures are not in place. 2. Review of the undated facility policy titled, [Named Glucometer] Blood Glucose Monitor Cleaning and Disinfecting, revealed The meter should be cleaned and disinfected after use on each patient.To clean: Wipe surface of the meter to clean blood and other body fluids.To Disinfect: Wipe entire surface of the meter to remove bloodborne pathogens. Treated surface must remain wet for recommended contact time.[Named Germicidal Disposable Wipe] [Purple Top] .Contact Times.2 minutes. 3. Review of the Infection Control Manual Volume 1, dated 10/2025, revealed .This Infection Prevention and Control program is designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections.The goal of the Infection Preventive and Control Program is to provide a system of preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for patients, partners, volunteers, visitors, and others who provide contracted services.There is ongoing surveillance among patients and partners to identify possible infection or communicable diseases; to report as required by state or federal law; to investigate and control spread.Infection Control Committee.The committee will evaluate the effectiveness of the Infection Control program through review, trending, and reporting the following.Outbreak tracking and trending. 4. Review of the medical record revealed Resident #16 was admitted to the facility on [DATE], with diagnoses including Diabetes, Hyperglycemia, and Long-Term use of Insulin. Review of the Physician's Order dated 12/8/2025, revealed .FSBS [Finger Stick Blood Sugar] AC [before meals] and at HS [at bedtime] . During an observation and interview in Resident #16's room on 12/16/2025 at 11:25 AM, RN C entered the Resident's room to obtain Resident #16's blood glucose level. RN C took the glucometer off the dresser and removed the germicidal wipes from a cup and began to cleanse the glucometer machine. RN C wiped the glucometer machine up and down 1 time on the front side and the bottom and immediately placed a test strip in the machine and took the resident's blood glucose level, without allowing the glucometer machine to dry. RN C exited Resident #16's room and returned to the medication cart. RN C stated, I know I didn't clean my machine for 2 minutes . RN C was asked should you have cleaned your machine for at least 2 minutes. RN C stated, Yes. RN C pulled out another germicidal wipe and cleansed the glucometer machine up and down 1 time on the front side and bottom again. RN C failed to disinfect the glucose monitor before or after the blood glucose check for at least 2 full minutes according to the facility's policy. During an interview on 12/16/2025 at 2:36 PM, the Director of Nursing (DON) was asked when staff are cleansing a glucometer machine and use a Sani-cloth how long should the cleansing and drying time be. The DON stated. At least 2 - 3 minutes. The DON was asked should a nurse use the glucometer machine before the full 2 minutes for drying time is completed. The DON stated, No, we need to wait that time.I have already put an in-service in place. 4. Review of the Infection Tracker, dated 9/2025, 10/2025, and 11/2025, revealed no documentation that infections were tracked by organism. Review of the Infection Control Monthly/Quarterly Report, dated 9/2025, 10/2025, and 11/2025, revealed no documentation that infections were tracked by organism. The facility was unable to provide documentation of tracking and trending of infections by organism and location in the facility to monitor for outbreaks, cross contamination, and the need for staff education or reeducation related to Infection Control. During an interview on 12/17/2025 at 12:58 PM, the Infection Control Preventionist (ICP)/DON was asked how the tracking and trending was discussed during the Infection Control meetings. The ICP/DON provided the Infection Control Monthly/Quarterly Report. The ICP/DON was asked to show where the report included what organisms were being monitored. The ICP/DON responded, I can't. The ICP/DON was asked to show where the report included exact room location of infections. The ICP/DON replied, I can't. The ICP/DON was asked to show where the report included if residents with a UTI had the same staff providing care for them. The ICP/DON stated, I can't. The ICP/DON was asked if infections should be monitored by tracking and trending to prevent cross contamination. The ICP/DON stated, Yes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Mayo Clinic website article, medical record review, observation, and interview, the facility failed to provide appropriate diagnoses for the use of antipsychotic medications for 2 of 5 (Resident #6 and #45) reviewed for unnecessary medications. The findings include: 1. Review of the Mayo Clinic.org website article titled, Drugs-Supplements and Quetiapine, Side Effects and Dosages, dated December 1, 2025, revealed Quetiapine [an antipsychotic medication used to treat diagnoses such as bipolar disorder and schizophrenia] is used alone or together with other medicines to treat bipolar disorder (depressive and manic episodes) and schizophrenia. Quetiapine extended-release tablet is also used together with other antidepressants to treat major depressive disorder. This medicine should not be used to treat behavioral problems in older adult patients who have dementia or Alzheimer disease. Quetiapine is an antipsychotic medicine that works in the brain . 2. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE], with diagnoses including Parkinson's Disease, Depression, Diabetes, and Agitation. Review of the Physician's Order dated 11/21/2025, revealed .quetiapine [Seroquel an antipsychotic medication] tablet: 200 mg [milligrams]; amt [amount]; 1 tab [tablet]; oral [by mouth] At Bedtime 8:00 PM. Review of the November 2025 Medication Administration Record (MAR) revealed Resident #6 received quetiapine 200 mg daily at 8:00 PM from 11/22/2025 to 11/30/2025. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #6 scored a 13 on the Brief Interview for Mental Status (BIMS) assessment, indicating she was cognitively intact. Medications received included Antidepressant, Antianxiety, and Opioid medications. The MDS was not coded to show that Resident #6 received an antipsychotic medication. Review of the Pharmacy Recommendations dated November 2025, revealed the Pharmacist requested a diagnosis for Quetiapine. The Physician entered diagnoses which included Agitation, Insomnia, and Anxiety. Review of the Physician Progress notes revealed no diagnosis for the use of quetiapine. During an interview on 12/16/2025 at 3:00 PM, Resident #6 was asked if she knew why she takes quetiapine 200mg at bedtime. Resident #6 replied, Yes, I take that for anxiety and to help me sleep . During an interview on 12/16/2025 at 4:15 PM, the Director of Nursing (DON) was asked if the physician responded to the pharmacy recommendation from November 2025 regarding a diagnosis for quetiapine. The DON looked Resident #6 up on the computer and stated, The physician replied that it is given for agitation, anxiety, and insomnia. 3. Review of the medical record revealed Resident #45 was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction, Pulmonary Embolism, Acute Respiratory Failure, and Atrial Fibrillation. Review of the Physician's Order dated 11/21/2025, revealed .quetiapine tablet: 100 mg; amt; 1 tab; oral At Bedtime 8:00 PM. Review of the Physician's Order dated 12/3/2025, revealed .quetiapine tablet: 100 mg; amt; 1 tab; oral At Bedtime 9:00 PM. Review of the December MAR dated revealed Resident #45 received quetiapine 100 mg at 9:00 PM at bedtime from 12/3/2025 to 12/16/2025. Review of the admission MDS assessment dated [DATE], revealed Resident #45 scored a 15 on the BIMS assessment, which indicated she was cognitively intact. Medications received during the assessment period were Insulin, Anticoagulant, Antibiotic, and Antiplatelet medications. The MDS was not coded to show that Resident #45 received an antipsychotic medication. During an interview on 12/16/2025 at 3:25 PM, Resident #45 was asked why she takes Quetiapine. Resident #45 stated, .I take it to sleep . During an interview on 12/17/2025 at 8:42 AM, the Family Nurse Practitioner (FNP) was asked what diagnosis was for the use of quetiapine (Seroquel) for Resident #45. The FNP stated, It is for insomnia. FNP was asked if that was an appropriate for antipsychotic medication. The FNP stated, We interview the resident and asked how long they been on the medication and why are they taking the medication. She had been on the Seroquel for years and at the high 100 mg dose for sleep. The FNP stated, We have borrowed residents for a short time, and we do not want to mess with the long-term medications the residents have been on long term. She had lot of anxiety on her arrival, and she complained she did not sleep at all the first few times. She also has major depression wanting to go home and get out the chest tube. She does not see psych .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the Ombudsman Emergency Transfers log, medical record review, and interview, the facility failed to notify the Ombudsman of emergency transfers for 3 of 3 (Resident #41, #42 and #43) sampled residents reviewed for discharges. The findings include: 1. Review of the .Ombudsman Emergency Transfers from Facility form dated August, September, October, and November 2025, revealed .send this form to the Office of the State Ombudsman .each month . 2. Review of the medical record revealed Resident #41 was admitted to the facility on [DATE], with diagnoses including Displaced Bimalleolar (serious break to both the inner and outer parts of the ankle) Fracture of Right Lower Leg, Disruption of External Operation (surgical) Wound, and Osteomyelitis (serious bone infection). Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #41 scored a 2 on the Brief Interview for Mental Status (BIMS) assessment, which indicated she was severely cognitively impaired. Review of Progress Notes dated 11/6/2025 at 9:15 AM, revealed .daughter informed of clinical status, as well as MD [Medical Doctor] recommendations for ED [Emergency Department] evaluation .daughter states understanding and verbalized she will meet pt [patient] in ER [Emergency Room] . Review of the .Ombudsman .Emergency Transfers from Facility document, dated 11/2025, revealed there was no documentation Resident #41 was transferred to the hospital. 3. Review of medical record revealed Resident #42 was admitted to the facility on [DATE], with diagnoses including Encounter for Surgical Aftercare Following Surgery on the Digestive System, Neutropenia (abnormally low neutrophil or key infection fighting white blood cell count) due to Infection, Immunodeficiency (the immune system cannot fight infections), and Multiple Myeloma (rare blood cancer of plasma cells in the bone marrow). Review of the admission MDS assessment dated [DATE], revealed Resident #42 scored a 15 on the BIMS assessment, which indicated he was cognitively intact. Review of the Progress Notes dated 9/20/2025 at 2:26 PM, revealed .NURSE FOUND PATIENT TACHYPNEIC [fast heart rate] AND DIAPHORETIC [sweaty] THIS AM [morning] DURING MED PASS .PATIENT WAS HYPOTENSIVE WITH BP [blood pressure] -70/42, LOW O2 [oxygen] SATS [saturations]-81% [percent] WITH O2 AT 8 LITERS VIA [by way of] NASAL CANNULA .GAVE PRN [as needed] NEB [nebulizer] TREATMENT .COUGHED UP A SMALL AMOUNT OF SPUTUM [thick secretions], O2 SATS WENT UP TO 93% .PHYSICIANS NOTIFIED D/T [due to] LOW BP AND RESPIRATORY DISTRESS NEW ORDERS RECEIVED TO SEND PATIENT TO HOSPITAL FOR FURTHER EVAL [evaluation] .EMS [emergency medical service] NOTIFIED .CONTINUED TO DECLINE . Review of the . Ombudsman .Emergency Transfers from Facility document, dated 9/2025, revealed there was no documentation Resident #42 was transferred to the hospital. 4. Review of the medical record revealed Resident #43 was admitted to the facility on [DATE], with diagnoses including Encounter for Orthopedic Aftercare Following Surgical Amputation, Peripheral Vascular Disease, Sepsis due to Methicillin Resistant Staphylococcus Aureus (a type of bacteria resistant to many antibiotics), Pseudomonas (infection caused by bacteria found in soil and water), Hypertension, and Anxiety. Review of the admission MDS dated [DATE], revealed Resident #43 scored a 12 on the BIMS assessment, which indicated he was moderately cognitively impaired. Review of Progress Notes dated 10/31/2025 at 5:19 PM, revealed .Wife came and let us know that [Named Hospital] had a bed for him and that he would be leaving to go there .NP [Nurse Practitioner] was notified and unit mgr [manager] also notified. Review of the . Ombudsman .Emergency Transfers from Facility document, dated 10/2025, revealed there was no documentation Resident #43 was transferred to the hospital. During an interview on 12/17/2025 at 9:50 AM, the Health Information Manager (HIM) was asked if she was the person responsible for getting the Ombudsman list generated and sent to the Ombudsman. The HIM stated, Yes. The HIM was asked if Residents #41, #42 and #43 should have been on the list. The HIM stated, Yes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview the facility failed to develop a comprehensive care plan for 2 of 4 residents (Resident #14 and #251) who required indwelling urinary catheters.
The findings include:
Review of the undated facility policy titled, Updating and revising Care Plans, .New problems are added to the current care plan even if the change is not considered significant enough for a complete revision .
Review of the medical record, revealed Resident #14 was admitted to the facility on [DATE] with diagnoses which included Malignant Neoplasm of Gallbladder, Urinary Retention, and Type 2 Diabetes.
Review of the 5-day Minimum Data Set (MDS) dated [DATE], revealed Resident #14 had a Brief Interview for Mental Status (BIMS) score of 11 indicating moderate cognitive impairment.
Review of the Physician Orders for Resident #14 dated 5/16/2021, revealed Indwelling urinary catheter; catheter care every shift; document output; 16 F [French] three times a day.
Review of the care plan dated 5/19/2021, revealed Resident #14 was care planned for Urinary Retention and Urinary Tract Infection. Continued review revealed the resident was not care planned for an indwelling urinary catheter.
Observation on 6/14/2021 at 10:53 AM, in Resident #14's room revealed the resident's catheter bag attached to the left side of the footstool.
During an interview conducted on 6/15/2021 at 3:37 PM, Licensed Practical Nurse (LPN) #2 confirmed Resident #14 was not care planned for an indwelling urinary catheter.
During an interview conducted on 6/15/2021 at 4:03 PM, the Quality Assurance (QA) Nurse confirmed she did not see a care plan for an indwelling catheter for Resident #14. She stated, when a resident has an indwelling catheter, it should be on the comprehensive care plan.
During an interview conducted on 6/16/2021 at 3:38 PM, the Assistant Director of Nursing (ADON) confirmed Resident #14 should've had the indwelling urinary catheter care planned when the catheter was placed.
Review of the medical record, revealed Resident #251 was admitted to the facility on [DATE] with diagnoses which included Nontraumatic Chronic Subdural Hemorrhage, Dementia Without Behavioral Disturbance, and Personal History of Transient Ischemic Attack (TIA), and Cerebral Infarction Without Residual Deficits.
Review of the admission MDS dated [DATE], revealed Resident #251 had a BIMS score of 7 indicating severe cognitive impairment.
Review of Physican Orders for Resident #251 dated 6/12/2021, revealed .indwelling urinary catheter; catheter care every shift, document output 18Fr [French] 15ml [milliliters] bulb for promotion of wound healing .
Review of the Care Plan on 6/15/2021 at 3:30 PM, revealed Resident #251 was not care planned for indwelling urinary catheter.
Observation on 6/14/2021 at 11:45 AM, in Resident #251's room revealed a catheter bag attached to the bottom of the wheel chair.
During an interview conducted on 6/16/2021 at 9:00 AM, the Director of Nursing (DON) confirmed Resident #251 was not care planned for an indwelling urinary catheter according to the Physician Order dated 6/12/2021.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview the facility failed to ensure 1 of 23 residents (Resident #1) had clean and groomed fingernails.
The findings include:
Review of the facility's undated policy titled, Fingernails, Cleaning, and Trimming, revealed .Designated partner will care for patients nails with bathing and PRN [as needed] .
Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses which included Unspecified Dementia without behavioral disturbance, Seborrheic Dermatitis, and Candidiasis of skin and nail.
Review of the Quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #1 required extensive assistance of staff for personal hygiene.
Review of the comprehensive care plan dated 1/14/2021, revealed Resident #1 was care planned for .keep nails trimmed as pt [patient] tolerates .
Review of the Physician Orders dated June 2021 for Resident #1 revealed .Ensure fingernails are kept short and filed due to pt scratching .order began on 3/5/2021 .
During an Observation and interview on 6/15/2021 at 10:04 AM revealed Resident #1 sitting in his reclining chair in the spa room. Continued observation revealed the resident's nails were long with brown dried debris under his fingernails on both hands. Continued interview the resident stated he had already taken a shower this morning [6/15/2021]. Continued interview when asked if staff cleaned his nails during his bath he stated no.
During an Observation and interview on 6/15/2021 at 10:50 AM revealed Resident #1 sitting in his reclining chair in the dining room. Continued observation revealed the resident's nails remained long with brown dried debris under his fingernails on both hands. Continued interview when asked if he liked his nails that long he looked at his nails and said, you can cut them if you want.
During an Observation and interview on 6/15/2021 at 10:55 AM in the presence of Certified Nurse Aide (CNA) #1 revealed Resident #1 sitting in his reclining chair in the dining room. Continued interview with CNA #1 confirmed the resident had brown dried debris underneath his fingernails on both of his hands; CNA #1 looked at the resident's hands and said, they are not clean at the moment.
During an Observation and interview on 6/15/2021 at 10:56 AM in the presence of the 2nd floor Unit Manager and CNA #1 revealed Resident #1 sitting in his reclining chair in the dining room. Continued interview with the Unit Manager she stated residents' nails are to be cleaned before meals and with baths. Continued interview the Unit Manager confirmed Resident #1's nails were long and had brown dried debris underneath his fingernails on both hands. The Unit Manager looked Resident #1's hands and stated no, they are not clean, we will get them clean and clipped for him.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation and interview the facility failed to provide a sanitary environment for 1 (Resident #16) of 2 residents reviewed for enteral feeding per feeding pumps.
The findings include:
Review of the facility policy titled, 304 Nursing, dated May 2021, revealed, .Reusable items are used for an individual patient if the product remains intact and sanitary. Items which become broken, chipped or unsanitary are replaced as needed .
Review of the medical record revealed Resident #16 was admitted to the facility on [DATE] with diagnoses which included Anorexia, Protein-Calorie Malnutrition, Adult Failure to Thrive, Aphasia, and Encounter for Attention to Gastrostomy.
Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #16 had a Brief Interview for Mental Status score of 1 which indicated the resident had severe cognitive impairment. During further review revealed the resident required a feeding tube.
Review of Physician Order dated 6/8/2021, for Resident #16 revealed, .Osmolite 1.2 Cal [Calorie] (nutritional supplements) liquid; 0.06 gram-1.2 kcal/mL [kilocalorie/milliliter]; amt [amount]: 60ml/hour; gastric tube Every Shift .
Observations conducted on 6/14/2021 at 10:45 AM, 11:30 AM, 1:22 PM, 3:18 PM, 4:08 PM, and at 4:25 PM, revealed Resident #16's enteral tube feeding pump pole had a moderate amount of dried tan debris on the pole and the base of the pole.
During an interview conducted on 6/14/2021 at 4:25 PM, in Resident #16's room, Licensed Practical Nurse (LPN) #1 confirmed the enteral tube feeding pole had a moderate amount of dried tan debris on the pole and the base of the pole.