Schleicher County Medical Center

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure all residents had the right to formulate an advance directive for 3 of 9 residents (Residents #1, #8, and #33) reviewed for advance directives. The facility failed to ensure Resident's #1, #8, and #33 Out-of-Hospital Do-Not-Resuscitate (OOH-DNR) forms were completed correctly. This failure could place residents at risk of having their end of life wishes dishonored, and of having CPR performed against their wishes. Findings included: Resident #1Review of Resident #1's admission Record, dated [DATE], revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease (a neurological condition causing memory problems), closed fracture of the left and right leg, diabetes (a condition where the body cannot process insulin correctly), chronic obstructive pulmonary disease (lung disease making it difficult to breathe), seizures, heart problems, and urinary tract infections. Review of Resident #1's Significant Change MDS Assessment, dated [DATE], revealed:Resident #1's BIMS score was 8 of 15, indicating moderate cognitive impairment. Review of Resident #1's Care Plan, initiated [DATE], revealed Resident #1 was a DNR status. Review of Resident #1's Order Summary, dated [DATE], revealed orders that Resident #1 was a DNR dated [DATE]. Review of Resident #1's DNR form completed [DATE] revealed:Section A: Resident #1 signed the DNR on [DATE].Section B: Resident #1's legal agent signed the DNR on [DATE].Section Two Witnesses: The Public Notary Signed the DNR on [DATE] but no witnesses were present. Physician's Statement: Resident #1's NP signed the DNR (not a physician licensed by the Texas Medical Board) and did not include the date, his printed name, or his license number. Resident #8Record review of Resident #8's admission record dated [DATE] reflected an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Dementia (A loss of brain function that worsens over time and affects memory, thinking, behavior, and language), and Congestive Heart Failure (A chronic condition in which the heart does not pump blood as well as it should). Record review of Resident #8's quarterly MDS assessment dated [DATE] reflected a BIMS score of 3, indicating cognition was severely impaired. Record review of Resident #8's quarterly care plan dated [DATE] revealed Resident #8 was a DNR status. Record review of Resident #8's medical orders reflected an OOH-DNR order dated [DATE]. Record review of Resident #8's OOH-DNR dated [DATE] revealed: Physician's Statement - Signed by Staff #D, a NP, not a physician licensed by the Texas Medical Board and did not include the date or his license number. There was no physician signature in the bottom section stating, All persons who have signed above must sign below, acknowledging that this document has been properly completed. Resident #33 Review of Resident #33's admission Record, dated [DATE], revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, high cholesterol, and heart problems. Resident #33 discharged on [DATE]. Review of Resident #33's Significant Change MDS, dated [DATE] revealed: He had long and short-term memory problems with severely impaired decision-making abilities. This was an acute onset of mental status change. Resident #33 had a life expectancy of less than 6 months. Review of Resident #33's Care Plan initiated [DATE], revealed the resident was a DNR status. Review of Resident #33's Physician Order Summary as of [DATE] revealed:Resident #33 was admitted to hospice diagnosis Alzheimer's disease dated [DATE].Resident #33 was a DNR dated [DATE]. Review of Resident #33's Facility DNR form documented.Section B: Resident #33's authorized representative signed the form, but did not date it. Physician's Statement: The NP signed the form and dated it [DATE], but did not include his license number.There were not two qualified witnesses witnessing the form as signed and valid. Review of Nurse's Notes dated [DATE] at 4:16 PM revealed: Received a call from Hospice asking if we had a copy of the DNR for the resident. Nurse informed Hospice that Nurse sent her a copy [DATE] and gave a copy to Hospice Nurse this morning when she came to get consents from the family member]. Hospice went on to explain that the DNR we had was not witnessed for the [family member] signature, therefore not valid and that resident needed to be placed on a full code status until they could get a DNR signed from the [family member] and hospice physician tomorrow. Discontinued DNR order, full code order implemented, notified ADON, charge nurse to put on 24 hour report and administration. Review of the Hospice OOH-DNR signed [DATE] revealed:Section C: Resident #33's [family member] signed and dated the OOH-DNR on [DATE].Physician's statement: The Hospice physician signed and dated the OOH-DNR on [DATE].The notary signed the form on [DATE].There were no witnesses to the signing of the form. In an interview on [DATE] at 2:53 PM the ADON said the blank OOH-DNR forms go with the resident to the clinic visit with the provider, the form was completed at the clinic visit and sent back to the facility to be scanned into the electronic medical record. The ADON said that the staff person scanning in the OOH-DNR's does not review them for accuracy/completion. Review of the Instructions for Issuing an OOH-DNR Order (included in the OOH-DNR Order) used by the facility and published by the Texas Department of State Health Services, revised [DATE], revealed:Purpose: The Out-of-Hospital Do-Not-Resuscitate (OOH-DNR) Order was for use by qualified persons or their representatives to direct health professionals to forgo resuscitation attempts and to permit the person to have a natural death with peace and dignity. Section A - If an adult person is competent and at least [AGE] years of age he/she will sign and date the Order in Section A.Section B - If and adult person is incompetent or otherwise mentally or physically incapable of communication and has a legal guardian, agent in a medical power of attorney, or proxy in a directive to physician, the guardian, agent, or proxy may execute the OOH-DNR Order by signing and dating it in section B.Section C - If the adult person is incompetent or otherwise mentally or physically incapable of communication and does not have a guardian, agent, or proxy, then a qualified relative may execute the OOH-DNR by signing and dating it in Section C.Section D - If the person is incompetent and his/her attending physician has seen evidence of the person's previously issued proper directive to physicians or observed the person competently issue an OOH-DNR in a nonwritten manner, the physician may execute the Order on behalf of the person by signing and dating it in Section D-In addition, the OOH-DNR must be signed and dated by two competent adult witnesses, who have witnessed either the competent adult person making his/her signature in section A, or authorized declarant making his/her signature in either sections B, C or E and if applicable., have witnessed a competent adult person making an OOH-DNR Order by non-written communication to the attending physician, who must sign in section D, and also the physician's statement section. Optionally, a competent adult person or authorized declarant may sign the OOH-DNR in the presence of a notary-public. However, a notary cannot acknowledge witnessing the issuance of an OOH-DNR in a nonwritten manner, which must be observed and only can be acknowledged by two qualified witnesses.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to maintain an infection control program designed to prevent the development and transmission of infections for 1 of 4 (Resident #21) reviewed for infection control. The facility failed to ensure Resident #21's oxygen nasal cannula tube was bagged when not in use and CNA A touched the nasal cannula with her bare hands to place it on the resident's nose. This failure could place the residents at risk of infection. Findings included:Record review of Resident #21's admission record, dated 09/24/2025, indicated she was admitted to the facility on [DATE] with diagnoses of dementia and COPD chronic obstructive pulmonary disease (COPD is an ongoing lung condition caused by damage to the lungs). She was [AGE] years of age. Record review of Resident #21's physician order report dated 09/24/2025 indicated in part: Oxygen via at 1-2 LPM via nasal cannula continuously every shift. (LPM=liters per minute). Record review of Resident #21's care plan dated 04/22/2025 indicated in part: The resident is at risk for impaired gas exchange r/t COPD, hypoxemia and cough. Resident will maintain an oxygenation saturation within personal goal range. Administer oxygen as prescribed or per standing order. (r/t = related to). Record review of Resident #21's MDS dated [DATE] indicated in part: BIMS of 3 indicating the resident had severe impairment. Functional Limitation in Range of Motion - Upper extremity (shoulder, elbow, wrist, hand) is dependent - A helper completed all the activities for the resident. Respiratory treatments - Oxygen therapy. During an observation and interview on 09/24/2025 at 10:42 AM CNA A assisted Resident #21 to her wheelchair. The resident's oxygen nasal cannula tube was seen wrapped around the oxygen tank which was attached to the back of the resident's wheelchair. CNA A took the nasal cannula with her bare hands, touched the part that goes into the resident's nasal area and then placed it on the resident's nose. CNA A said Resident #21 was not able to remove the oxygen nasal cannula and tube by herself and that some other staff member must have removed it and placed it on the oxygen tank. The CNA said they normally placed the oxygen nasal cannula tube on the oxygen tank and had never noticed a storage bag on the tank to store the oxygen nasal cannula tube. During an observation and interview on 09/24/2025 at 1:40 PM Resident #21 was awake and alert in her bed resting. The resident said she did not remove the nasal canula from her nose as she was unable to. Resident #21 said the staff were the ones that would do that and store it in the storage bag as she was unable to do that. During an interview on 09/24/2025 at 1:46 PM CNA A said that she had not noticed that Resident #21 did not have a bag on the oxygen tank to store the oxygen nasal cannula tube. CNA A said not having a bag to store the oxygen nasal cannula tube could lead to the nasal cannula becoming contaminated and possibly introduce bacteria into the resident's nose. CNA A said she had reported it to a nurse and the nurse had already placed a bag on the resident's wheelchair to store the oxygen nasal cannula tube. During an interview on 09/24/2025 at 1:52 PM RN B said when the oxygen nasal cannula tube was not in use, the staff were supposed to store it in the plastic bag. RN B said it was supposed to be stored to prevent contamination of the nasal cannula. RN B said she had recently placed a bag on Resident #21's oxygen tank so the staff could store the oxygen nasal cannula tube in it. During an interview on 09/25/2025 at 12:15 PM the ADON said it was expected for the oxygen nasal cannula tube to be stored in a bag when not in use. The ADON said the purpose of that was to prevent infections. The ADON was made aware of the observation of CNA A touching the nasal cannula with her hands and placing it on Resident #21's nose. The ADON said the aide should not have touched the nasal cannula with her hands as that could lead to contamination. The ADON said they would conduct training on making sure staff knew not to touch the nasal cannula and to store it in a bag when not in use. During an interview on 09/25/2025 at 2:44 PM the Administrator said it was expected for staff to store the oxygen nasal cannula tube in a bag when not in use. The Administrator was made aware of the observation of the oxygen tube and nasal cannula not bagged and then touched by the CNA. The Administrator said they would make sure there were enough bags to store the oxygen nasal cannula tube. The Administrator said not storing the oxygen nasal cannula tube in a bag could have an outcome of infections. Record review of the facility's policy titled Oxygen Administration and dated 05/12/2025 indicated in part: Policy - Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Staff shall perform hand hygiene and don gloves when administering oxygen or when in contact with oxygen equipment. Other infection control measures include. Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. Keep delivery devices covered in plastic bag when not in use. Record review of the facility's policy titled Infection prevention and control program dated 01/15/25 indicated in part: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. Standard precautions- All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure in accordance with professional standards of practices, the medical records on each resident were accurately documented for 2 of 3 residents (Residents #33 and #34) reviewed for accurate medical records.The facility failed to accurately document the type of discharge for Residents #33 and #34.This failure could affect residents whose records are maintained by the facility and could place them at risk for errors in care and treatment. The findings included:Resident #33 Review of Resident #33's admission Record, dated [DATE], revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, high cholesterol, and heart problems. Resident #33 discharged on [DATE].Review of Resident #33's Exit MDS, dated [DATE] documented a Death in Facility. Review of Resident #33's Nurse's Note, dated [DATE] at 8:31 AM, revealed, Nurse went in around 0818 to resident was found unresponsive, no respirations noted, no pulse, pupils were dilated and fixed, skin was cold to the touch, and there was generalized cyanosis noted. Charge nurse, RN, listened for any heart sounds and respirations for a full 2 minutes and none were noted. Resident #33 was pronounced dead at 0818 AM.Review of Resident #33's Physician's Discharge summary, dated [DATE], documented resident died in the facility.Review of Resident #33's Transfer/Discharge Report, printed [DATE], revealed he was transferred/ discharged on [DATE] to a nursing home: nursing home unknown/ TBD Resident #34Review of Resident #34's admission Record, dated [DATE], revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Cerebral Infarction (a condition where blood flow to the brain is interrupted leading to brain cell damage or death), Chronic Kidney Disease (a chronic disease of the kidneys leading to kidney failure) and Vascular Dementia (a group of thinking and social symptoms that interferes with daily functioning). Resident #34 was discharged on [DATE].Review of Resident #34's Exit MDS, dated [DATE] documented a Death in Facility. Review of Resident #34's Record of Death, dated [DATE] revealed the time of Resident #34's death was 10:32 AM on [DATE].Review of Resident #34's Physician's Discharge summary, dated [DATE], documented the resident died in the facility on [DATE]. The medical provider signed the report.Review of Resident #34's Transfer/Discharge Report, completed [DATE], revealed Resident #34 was transferred/discharged on [DATE] to a nursing home: nursing home unknown/ TBD. An RN signed the report.Interview on [DATE] at 2:31 PM, the administrator said Residents #33 and #34 did pass away and the NC struggles with the electronic medical record and computers in general. The administrator confirmed NC had received training.Interview on [DATE] at 2:53 PM with the ADON and NC, the ADON said Residents #33 and #34 did die at the facility. The ADON said the charge nurse on duty at the time of a death or discharge/transfer completes the Transfer/Discharge Report, prints it, signs it, and adds it to a file for things to be scanned into the electronic medical record. The NC said she does not double-check the accuracy of records when she scans them in. Interview on [DATE] at 3:08 PM, the ADON stated the discharge summary had to be checked for the wrong box if the documentation program was checked as a drop-down screen. The ADON said whoever scanned in the discharge summary looked at it but we have a lot of paper to scan. The ADON stated any nurse could do the transfer/ discharge summary. The ADON looked at Resident #33 and #34's discharge summary and said the same nurse did each discharge summary. The ADON said it was probably on the 2p.m. - 10 p.m. shift when things always went wrong. The ADON stated the Nurse printed the discharge summary, signed it, and the summary went in the accordion file to be scanned.Review of the facility's policy Documentation in Medical Record revised [DATE], revealed in part: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen.
The facility failed to ensure food items in the facility's only dry storage was sealed appropriately.
These failures could place residents at risk for food-borne illness, and food contamination.
Findings include:
Observations of the kitchen's dry storage area on 08/13/24 at 09:37 AM, revealed
One bag of southern yellow cornbread was opened.
Observations of the kitchen's dry storage area on 08/14/24 at 11:27 AM, revealed the following items were not sealed:
- one bag of southern yellow cornbread,
-one bag of Tostitos original tortilla chips,
-one bag of cereal, and
-one bag of spaghetti pasta.
Interview with the Dietary Manager (DM) on 08/14/24 at 11:38 AM, revealed he was not aware there was food in the dry storage that was. The DM stated that these items was recently used but was unaware how long they had been opened. The DM stated all food and items that was opened was to be dated with an opened date and if the package could not be sealed the item should be placed in a resealable bag/container and labeled if not visible through the container or bag. The DM stated the bags not being appropriately sealed could cause cross contamination. The DM stated he will take this as a chance to teach his staff.
Review of the undated policy titled Food Safety Requirements stated in part, Storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents (Resident #16) reviewed for care plans.
The facility failed to have a care plan in place to accurately address Resident #16's oxygen use.
This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs.
The findings included:
Record review of admission record indicated Resident #16 was an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #16 had medical diagnoses that included palliative care, Cerebral infarction, unspecified severe protein-calorie malnutrition, and pain.
Record review of Resident #16's admission MDS assessment dated [DATE] revealed his Cognitive Skills for Daily Decision Making to be severely impaired - never/rarely made decisions. He required maximum assistance and was dependent on staff for all ADL's except for eating. He relied on staff for mobility. Under section O for Respiratory treatments C1. Oxygen therapy was selected while a resident at the facility.
Record review of Resident #16's order summary dated August 14th, 2024 included, Oxygen @2-5 LPM via nasal cannula and may titrate for patient comfort at night at bedtime, and, While resident is up and awake, no oxygen required as long as SPO2 remains above 92%. every shift.
Record review of Resident #16's care plan dated 07/24/2024 revealed no care plan for oxygen use.
Interview on 08/15/24 at 01:35 PM, the DON stated she would check orders and medical diagnosis for items that should be care planned. The DON stated she had been working on care plans she took over in June since her MDS nurse did not want to do them anymore. the DON stated Resident #16s care plan addressed the under terminal illness. The DON stated she had worked on it today. The care plan was updated after surveyor intervention.
Review of facility policy titled Comprehensive Care Plans dated 06-01-2024 revealed, in part:
A comprehensive person-centered care plan is developed and implemented for each resident, consistent with the resident's rights, that include measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted professional principles for 1 of 1 medication rooms inspected for medication storage.
The medication room had opened and undated vial of Tuberculin (TB) medication in the refrigerator.
This failure could place residents at risk of receiving medications that were expired and not produce the therapeutic effect.
The findings were:
During an observation and interview on [DATE] at 02:12 PM the medication room was inspected with RN A present. There was a small refrigerator which contained one 0.1 ml vial of Tuberculin formula which had been opened but no open date was found. The Tuberculin container indicated Once entered, vial should be discarded after 30 days. RN A said it was each nurse's responsibility to date the vials when they are opened. RN A said she was not aware the vial was undated.
During an interview on [DATE] at 12:20 PM, the DON was made aware of the opened and undated TB vial located in the medication room. The DON said she was not sure as to why the vial was undated since it had been opened. The DON said it was everybody's job to monitor the refrigerator or any other medications that required an open date when opened and discarded when expired. The DON said if the staff used an expired or undated TB vial it could lead to a false TB test result.
Record review of policy titled Medication storage and dated [DATE] indicated in part:
It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturers recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation and security. All OTC, insulins, multi dose vials (needle puncture) should be labeled with an open date and discarded within 28 days unless the manufacturer specifies different date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #9) of 2 residents reviewed for infection control.
CNA B failed to change her gloves when going from dirty to clean during peri-care for Resident #9.
CNA C failed to wash her hands prior to putting gloves on and assisting Resident #9 with personal care.
This failure could place residents at risk for cross contamination and the spread of infection.
Finding include:
Record review of Resident #9's admission record dated 08/15/24 indicated she was admitted to the facility on [DATE] with diagnoses of stroke and chronic respiratory failure. She was [AGE] years of age.
Record review of Resident #9's care plan dated 08/2024 indicated in part: Focus: The resident has bladder incontinence. Goal: The resident will remain free from skin breakdown due to incontinence and brief use through the review date. Interventions: Check resident every 2 hours and PRN as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN after incontinence episodes.
Record review of Resident #9's MDS dated [DATE] indicated in part: BIMS = 10 indicating the resident was moderately impaired Urinary continence = Frequently incontinent. Bowel continence = Always incontinent .
During an observation on 08/14/24 at 02:02 PM, CNA B and CNA C performed incontinent care for Resident #9. CNA C entered the resident's room and put on a pair of gloves without first washing her hands. Both CNAs opened Resident #9's brief and rolled her to her right side. CNA B took a wet wipe and wiped the resident's rectal area which contained a smear of bowel movement on the wipe. CNA B took some skin protectant ointment and applied it to the resident's buttocks while still wearing the same soiled gloves. While still wearing the same soiled gloves CNA B took a new brief and placed it under the resident's bottom and rolled the resident back onto the brief. CNA B took some wet wipes and wiped Resident #9's vaginal area. Both CNAs then removed their gloves and washed their hands. CNA C turned the faucet on and washed her hands with water only and for approximately five seconds then turned the faucet off with her bare hands.
During an interview on 08/14/24 at 02:12 PM, CNA B said she had been trained to change her gloves once they became contaminated to prevent cross contamination. CNA B said she should have changed gloves after she cleansed Resident #9's rectal area since she then touched the new brief and cleansed the resident's vaginal area. CNA B said she had forgotten to change her gloves at the appropriate time. CNA B said if she did not change her gloves then that could lead to cross contamination and the spread of germs. CNA B said they had received training on infection control to include glove changing and handwashing but again she had forgotten to change her gloves after they became contaminated.
During an interview on 08/14/24 at 02:14 PM, CNA C said she had been trained on glove changes and handwashing. CNA C said she had to wash her hands for around 20 seconds with soap and water and turn off the faucet with a paper towel to prevent re-contamination of her hands. CNA C acknowledged she had washed her hands quickly and had not used soap nor closed the faucet with a paper towel after assisting Resident #9 with personal care. CNA C said she had gotten nervous and messed up. CNA C said if she did not wash her hands correctly that could lead to the spread of infections.
During an interview on 08/15/24 at 12:16 PM, the DON was made aware of the incontinent care observation performed on Resident #9 by CNAs B and C. The DON said it was expected for the CNAs to wash their hands prior to and after performing personal care. The DON said staff were supposed to wash their hands for 15 to 20 seconds with soap and water. The DON said the CNAs were supposed to change their gloves and wash their hands when going from dirty to clean. The DON said the failure probably occurred because the CNAs got nervous and forgot their steps. The DON said that LVN D conducted training with the CNAs in regard to infection control and incontinent care. The DON said if the CNAs did not wash their hands or changed their gloves that could lead to the spread of infections.
During an interview on 08/15/24 at 01:24 PM, LVN D said she conducted training with the staff regarding infection control such as personal care of the residents. The LVN D was made aware of the observation of incontinent care performed by CNAs B and C. LVN D said the CNAs were expected to wash their hands prior to performing resident care. LVN D said the CNAs were supposed to wash their hands for at least 20 seconds with water, soap and turn the faucet off with a paper towel to prevent recontamination of their hands. LVN D said the CNAs were expected to change their gloves and wash their hands when going from dirty to clean. LVN D said CNA B should have changed her gloves before touching the new brief and wiping Resident #9's vagina. LVN D said she believed the failure occurred because the CNAs got nervous and forgot their steps. LVN D said if the CNAs did not wash their hands or changed their gloves at the required time that could lead to cross contamination.
Record review of the facility policy titled Hand hygiene dated 04/11/2023 indicated in part: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents and visitors. This applies to all staff working in all locations within the facility. Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of antiseptic hand rub also known as alcohol-based-hand-rub. Hand hygiene technique when using soap and water: a. Wet hands with water, avoid using hot water to prevent drying of skin. b. apply to hands the amount of soap recommended by the manufacturer. C. rub hands together vigorously for at least 20 seconds covering all surfaces of the hands and fingers. D. rinse hands with water. E. dry thoroughly with a single use towel. F use clean towel to turn off the faucet. Additional considerations: The use of gloves does not replace hand hygiene. If your task requires gloves perform hand hygiene prior to donning gloves and immediately after removing gloves.
Record review of the facility's policy titled Helping a resident with toileting needs and dated 06/01/2024 indicated in part: It is the practice of this facility to assist residents with toileting needs in order to maintain the resident's dignity as well as proper hygiene. Put on gloves-if you contaminate your gloves in any way during the procedure you must change into a new pair. Help with wiping and throw the paper into the trash bag or toilet. Remove your gloves and dispose of them in the trash bag. Help the resident with their clothing and assist them back into their bed or chair. Put on new gloves - help the resident wash, rinse, and dry their hands. Remove your gloves and place in the trash bag. Properly dispose of trash bag and wash your hands.
Record review of the facility's document titled Standard precautions infection control dated 04/01/2023 indicated in part: All staff are to assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. Therefore, all staff shall adhere to standard precautions to prevent the spread of infections to residents, staff and visitor. Standard precautions refer to the infection prevention practices that apply to all residents, regardless of suspected or confirmed diagnosis or presumed infection status. This includes hand hygiene, selection and use of PPE (e.g., gloves, gowns, facemasks, respirators, eye protection), respiratory hygiene and cough etiquette, safe injection practices, environmental cleaning and disinfection and reprocessing of reusable resident medical equipment.
Record review of the facility's policy titled Infection prevention and control program and dated 03/01/2024 indicated in part: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure the resident environment remained as free from accident hazards was possible and each resident received adequate supervision and assistive devices to prevent accidents for 1 of 4 residents (Resident #1) reviewed for accidents and supervision .
1. HA A failed to ensure Resident #1 was properly transferred by two persons using a Hoyer lift.
2. The facility failed to ensure HA A was properly trained before transferring Resident #1 by Hoyer lift .
The noncompliance was identified as PNC. The noncompliance began on 8/29/23 and ended on 9/4/23. The facility had corrected the noncompliance before the investigation began.
This failure could place residents at risk of severe injury.
Findings included:
Record review of Resident #1's electronic health record revealed a [AGE] year-old female with an admission date of 01/17/2013. Resident #1 had diagnoses which included: Alzheimer's Disease with late onset (progressive memory impairment), anemia (lack of red blood cells), dementia in other diseases classified elsewhere (impairment of brain functions), hyperlipidemia (high levels of fat in blood), chronic pain, rhinitis (stuffy nose), constipation (difficult bowel movements), hypokalemia (below normal potassium), sclerosing mesenteritis (tissue that holds the small intestines in place becomes inflamed), Cushing's syndrome (over production of cortisol), Vitamin B12 deficiency (deficient in Vitamin B12), anxiety disorder (anxiety that interferes with daily life), insomnia (sleep disorder), intermittent explosive disorder (sudden episodes of unwarranted anger), restless leg syndrome (irresistible urge to move the legs), type 2 diabetes with diabetic polyneuropathy (adult onset of the way the body processes blood sugar with damage to the small blood vessels that supply the nerves in the body), mixed obsessional acts (pervasive and invasive thoughts that cause anxious and distress), atherosclerotic heart disease of native coronary artery without angina (substances collect on inner walls of the heart arteries), localized edema (swelling due to excessive accumulation of fluid at specific site), GERD (acid reflux), hemiplegia hemiparesis (loss of strength in arm, leg and sometimes face on one side of body), unspecified hearing loss, psychotic disorder (disconnection from reality).
Record review of Resident #1's electronic health record revealed the most recent Care Plan, dated 6/9/2023, revised on 9/2/23, reflected Transfer: I am an extensive assist x2 staff for transferring. I use a Hoyer lift x2 staff at all times.
Record review of incident/accident report, dated 10/1/23, revealed Resident #1 had a witnessed fall, dated 9/2/23 at 1:15 PM.
Record review of Resident #1's physician orders, dated 7/11/23, revealed Hoyer Lift x2 CNA for all transfers.
Record review of Resident #1's progress note, dated 9/2/23 at 4:36 pm, revealed Resident returned from the ER at 1630 [4:30 pm] with no new medication changes. RSD was given a tetanus shot at the ER per RSD hitting her head on a medal piece of equipment for safety and prevention of other precautions. RSD was also given 5 staples to laceration that occurred on the back of the head from the fall
Interview on 10/1/23 at 11:20 AM with RN A revealed staff were trained on Hoyer lifts. The facility had someone come in and do a whole staff meeting on it. They were also trained upon hire. There should be two people providing support to do a Hoyer lift. The facility has hospitality aides, and they could only do certain tasks when on the floor until tested. The tasks they could do was pass water and answer call lights and hand residents things. They could not do hands on anything. Hospitality aides could assist with Hoyer lifts, but they could not actually do the Hoyer lift.
Interview on 10/1/23 at 12:19 PM with HA A revealed she was not trained on Hoyer Lifts prior to the incident. HA A stated CNA B supported the back of the resident and HA A pulled the Hoyer Lift backwards, operating the lift, during the incident with Resident #1 that resulted in her fall and injury. HA A stated she thought the failure was the sling was too big or not on properly resulting in the resident slipping out of the sling and hitting her head on the leg of the Hoyer.
Interview on 10/1/23 at 12:59 PM with CNA B revealed CNA B had section 1 and HA A had hall 3. CNA B stated she did not put Resident #1 in the sling. CNA B had been asking HA A several times if she needed help and she would not answer or say she needed help, but CNA B kept checking on her. CNA B stated, I knocked on the door to Resident #1's room and HA A was in there with Resident #1 and Resident #1 was already in the sling in the Hoyer. So, I assisted. HA A operated the Hoyer lift. CNA B stated HA A was a HA, and she should have known not to do a one-person transfer. HA A was already in there and had not asked for help; CNA B walked in on her. The HA should be the assist and the CNA should operate the Hoyer, but she already was. CNA B stated she had not seen HA A do any Hoyer Lifts since and HA A was only allowed to observe. CNA B stated the resident went to the ER and received 5 staples in her head. CNA B stated, It is not allowed for HA to work their own floor, so I don't know why she was working her own floor. They scheduled her on her own hall because I remember I thought that was weird that she was scheduled that way. I voiced that concern to [LVN A ].
Interview on 10/1/23 at 2:42 PM with LVN A revealed, Hospitality Aide (HA) could provide water and answer lights but couldn't provide any care. LVN A stated, They can stock and let us know if someone needs something. They can pass a tray, but they can't feed until certified or if they have had feeding training. I have not ever had a CNA voice any concerns with an HA having their own hall. They are never assigned to their own area. LVN stated the expectation for Hoyer lifts were there always had to be two people and preferred them both to be certified unless they had Hoyer lift training and were checked off on the training. Hoyer lift training should be provided upon hire unless they had something provided of previous training. LVN A stated HA A was not to do Hoyer Lifts because LVN A was not aware that HA A was checked off.
Interview on 10/1/23 at 2:59 PM with ADON revealed she never had a report HA worked their own floor. The ADON stated, HA can pass ice water and answer a light but if it has anything to do with transfers or care, they have to go call the CNA on the floor. If they are doing the training and they have been checked off on, they can assist with transfers, as long as it is with a certified aide or nurse. The ADON revealed, the training was eye opening on how many didn't understand the sling colors. We just believe the failure was just the sling, it was ill fitting. The ADON revealed the facility had new training and equipment to prevent it from happening again. The ADON stated CNA B was spotting and HA A was on the Hoyer. HA A should have been spotting and CNA B should have been on the remote. The ADON revealed she did not know who was supposed to be training HA A that day and the facility would start adding who it was on the schedule . ADON stated, We located this failure that day since we don't know who was supposed to be training her [HA A].
Interview on 10/1/23 at 3:39 PM with the DON revealed the DON did not know who was training on the day of the incident. The DON stated she was informed CNA B had offered to help and that was how CNA B and HA A ended up together. The DON stated, I don't want to say she was working the floor alone , but I think that is how it was. I have seen the video of what happened. I did not see what happened inside the room. [HA A] was not in the room with Hoyer alone very long before [CNA B] came and helped. HA A should have been trained upon hire on Hoyer lift transfers. The DON revealed HA A could not use a Hoyer lift and could only be there to spot and for this incident CNA B was spotting. The DON stated, I know now that HA A was working the floor on her own but did not know that before .
Interview on 10/1/23 at 3:39 PM with the DON revealed the facility did a large Hoyer lift training and now require a specific aide to do the training who had a lot of experience . The facility replaced slings and put (resident's) name in them to make sure they were appropriate. The DON revealed, the facility made some administrative changes, and the aide with experience will take over the scheduling and making sure the trainings were done. CNA C was that before , but the facility was making that change .
Interview on 10/1/23 at 5:13 PM with the ADM revealed the ADM interviewed HA A and asked her if she knew she couldn't transfer alone, and HA A told her she knew that . When asked why she did it, she began crying. The ADM stated she asked HA A was she comfortable with Hoyer Lift transfers and HA A informed the ADM she thought she could do it. The ADM stated when she asked HA A why she did it she just started crying. The ADM revealed HA A admitted to her she was not familiar with Hoyer's but didn't tell anyone. The ADM stated, [HA A] had her own section (hall) and that was why the facility was changing things to prevent this from happening again. Maintenance came in and checked every Hoyer and one had a loose leg and so it was replaced. The lift that was replaced was not the lift that was used for Resident #1 .
Interview on 10/1/23 at 5:13 PM with the ADM revealed, We are switching up who does the schedule and so we have the ADON, and DON sign off on it now. We had training done and all direct care staff got the training; it was mandatory. Then, we made every single one of them demonstrate [how to operate a Hoyer lift] and we had them get in the sling so they could see how that felt.
Record review of New Hire Orientation checklist, dated 8/28/23, for HA A reflected Skills Review and Body Mechanics: Safe Lifting/Transfer/Gait Belts and Mechanical Lifts had no documentation and were not checked off ; indicating training was not completed
Record review of Safe Resident Handling/Transfers policy, dated 9/4/23, revealed, .6. The staff will inspect the equipment prior to use to ensure functionality and will alert maintenance or other designee if the equipment is not functioning properly . 8. The facility will ensure that there are appropriate amounts of varying sizes of slings to accommodate residents and that residents will be measured correctly as per the manufacturer's instructions on proper sling sizing . 10. Two staff members must be utilized when transferring residents with a mechanical lift. 11. Staff will be educated on the use of safe handling/transfer practices to include use of mechanical lift devices upon hire, annually and as the need arises or changes in equipment occur. 12. Staff must demonstrate competency in the use of mechanical lifts prior to use and annually with documentation of that competency placed in their education file.
Record review of the No Lift Policy, dated 6/04, revealed, .4. Nursing staff will receive training in the use of mechanical lifts during the orientation period.
The facility took the following actions to correct the noncompliance:
Record review of Staff Meeting dated 9/4/23 revealed all 16 direct care staff were in- serviced on Proper use of Hoyer lift and sit to stand.
Record review of Electronic Total Lift Competency dated 9/4/23 9/6/23 revealed 16 direct care staff were checked off on; HA A checked off on 9/4/23.
Record review of invoice dated 9/4/23 for one Electric Patient Lift.
Record review of invoice dated 9/7/23 for 12 slings of 7 different sizes.
Interview on 10/1/23 at 2:59 pm with ADON revealed The audits for the Hoyer's are being done more often and had more intense training: Two people and an employee in the Hoyer. Audits will be every three months and it was annually and at hire before. We have a designated aide will do the training who has 15 years of experience. We purchased new slings specifically for each patient and we have a new Hoyer and we have removed the Hoyer [Resident #1] was in because the wheels got stuck sometimes and we are ironing the names [of residents] in the slings. We have also increased monitoring and audits of Hoyer lifts. ADON revealed she does not know who was supposed to be training HA-A that day and the facility will start adding who it is on the schedule.
Throughout the course of the investigation from 10/1/23-10/2/23 staff were interviewed and confirmed their understanding of the in-service training provided by the facility. Staff interviewed included two CNAs (one night shift), one HA, one LVN, one RN.
Interview on 10/1/23 at 2:11 pm with family member revealed staff use 2-3 staff to transfer their resident with Hoyer Lift.
Two observations were conducted of staff conducting a safe, competent Hoyer Lift transfer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure staff had the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 4 residents (Resident #1) reviewed for accidents and supervision .
1. HA A failed to ensure Resident #1 was properly transferred by two persons using a Hoyer lift.
2. The facility failed to ensure HA A was properly trained and able to demonstrate compentency in skills and techniques before transferring Resident #1 by Hoyer lift .
The noncompliance was identified as PNC. The noncompliance began on 8/29/23 and ended on 9/4/23. The facility had corrected the noncompliance before the investigation began.
This failure could place residents at risk of severe injury.
Findings included:
Record review of Resident #1's electronic health record revealed a [AGE] year-old female with an admission date of 01/17/2013. Resident #1 had diagnoses which included: Alzheimer's Disease with late onset (progressive memory impairment), anemia (lack of red blood cells), dementia in other diseases classified elsewhere (impairment of brain functions), hyperlipidemia (high levels of fat in blood), chronic pain, rhinitis (stuffy nose), constipation (difficult bowel movements), hypokalemia (below normal potassium), sclerosing mesenteritis (tissue that holds the small intestines in place becomes inflamed), Cushing's syndrome (over production of cortisol), Vitamin B12 deficiency (deficient in Vitamin B12), anxiety disorder (anxiety that interferes with daily life), insomnia (sleep disorder), intermittent explosive disorder (sudden episodes of unwarranted anger), restless leg syndrome (irresistible urge to move the legs), type 2 diabetes with diabetic polyneuropathy (adult onset of the way the body processes blood sugar with damage to the small blood vessels that supply the nerves in the body), mixed obsessional acts (pervasive and invasive thoughts that cause anxious and distress), atherosclerotic heart disease of native coronary artery without angina (substances collect on inner walls of the heart arteries), localized edema (swelling due to excessive accumulation of fluid at specific site), GERD (acid reflux), hemiplegia hemiparesis (loss of strength in arm, leg and sometimes face on one side of body), unspecified hearing loss, psychotic disorder (disconnection from reality).
Record review of Resident #1's electronic health record revealed the most recent Care Plan, dated 6/9/2023, revised on 9/2/23, reflected Transfer: I am an extensive assist x2 staff for transferring. I use a Hoyer lift x2 staff at all times.
Record review of incident/accident report, dated 10/1/23, revealed Resident #1 had a witnessed fall, dated 9/2/23 at 1:15 PM.
Record review of Resident #1's physician orders, dated 7/11/23, revealed Hoyer Lift x2 CNA for all transfers.
Record review of Resident #1's progress note, dated 9/2/23 at 4:36 pm, revealed Resident returned from the ER at 1630 [4:30 pm] with no new medication changes. RSD was given a tetanus shot at the ER per RSD hitting her head on a medal piece of equipment for safety and prevention of other precautions. RSD was also given 5 staples to laceration that occurred on the back of the head from the fall
Interview on 10/1/23 at 11:20 AM with RN A revealed staff were trained on Hoyer lifts. The facility had someone come in and do a whole staff meeting on it. They were also trained upon hire. There should be two people providing support to do a Hoyer lift. The facility has hospitality aides, and they could only do certain tasks when on the floor until tested. The tasks they could do was pass water and answer call lights and hand residents things. They could not do hands on anything. Hospitality aides could assist with Hoyer lifts, but they could not actually do the Hoyer lift.
Interview on 10/1/23 at 12:19 PM with HA A revealed she was not trained on Hoyer Lifts prior to the incident. HA A stated CNA B supported the back of the resident and HA A pulled the Hoyer Lift backwards, operating the lift, during the incident with Resident #1 that resulted in her fall and injury. HA A stated she thought the failure was the sling was too big or not on properly resulting in the resident slipping out of the sling and hitting her head on the leg of the Hoyer.
Interview on 10/1/23 at 12:59 PM with CNA B revealed CNA B had section 1 and HA A had hall 3. CNA B stated she did not put Resident #1 in the sling. CNA B had been asking HA A several times if she needed help and she would not answer or say she needed help, but CNA B kept checking on her. CNA B stated, I knocked on the door to Resident #1's room and HA A was in there with Resident #1 and Resident #1 was already in the sling in the Hoyer. So, I assisted. HA A operated the Hoyer lift. CNA B stated HA A was a HA, and she should have known not to do a one-person transfer. HA A was already in there and had not asked for help; CNA B walked in on her. The HA should be the assist and the CNA should operate the Hoyer, but she already was. CNA B stated she had not seen HA A do any Hoyer Lifts since and HA A was only allowed to observe. CNA B stated the resident went to the ER and received 5 staples in her head. CNA B stated, It is not allowed for HA to work their own floor, so I don't know why she was working her own floor. They scheduled her on her own hall because I remember I thought that was weird that she was scheduled that way. I voiced that concern to [LVN A].
Interview on 10/1/23 at 2:42 PM with LVN A revealed, Hospitality Aide (HA) could provide water and answer lights but couldn't provide any care. LVN A stated, They can stock and let us know if someone needs something. They can pass a tray, but they can't feed until certified or if they have had feeding training. I have not ever had a CNA voice any concerns with an HA having their own hall. They are never assigned to their own area. LVN stated the expectation for Hoyer lifts were there always had to be two people and preferred them both to be certified unless they had Hoyer lift training and were checked off on the training. Hoyer lift training should be provided upon hire unless they had something provided of previous training. LVN A stated HA A was not to do Hoyer Lifts because LVN A was not aware that HA A was checked off for that training.
Interview on 10/1/23 at 2:59 PM with ADON revealed she never had a report HA worked their own floor. The ADON stated, HA can pass ice water and answer a light but if it has anything to do with transfers or care, they have to go call the CNA on the floor. If they are doing the training and they have been checked off on, they can assist with transfers, as long as it is with a certified aide or nurse. The ADON revealed, the training was eye opening on how many didn't understand the sling colors. We just believe the failure was just the sling, it was ill fitting. The ADON revealed the facility had new training and equipment to prevent it from happening again. The ADON stated CNA B was spotting and HA A was on the Hoyer. HA A should have been spotting and CNA B should have been on the remote. The ADON revealed she did not know who was supposed to be training HA A that day and the facility would start adding who it was on the schedule . ADON stated, We located this failure that day since we don't know who was supposed to be training her [HA A].
Interview on 10/1/23 at 3:39 PM with the DON revealed the DON did not know who was training on the day of the incident. The DON stated she was informed CNA B had offered to help and that was how CNA B and HA A ended up together. The DON stated, I don't want to say she was working the floor alone , but I think that is how it was. I have seen the video of what happened. I did not see what happened inside the room. [HA A] was not in the room with Hoyer alone very long before [CNA B] came and helped. HA A should have been trained upon hire on Hoyer lift transfers. The DON revealed HA A could not use a Hoyer lift and could only be there to spot and for this incident CNA B was spotting. The DON stated, I know now that HA A was working the floor on her own but did not know that before .
Interview on 10/1/23 at 3:39 PM with the DON revealed the facility did a large Hoyer lift training and now require a different aide to do the training who had a lot of experience . The facility replaced slings and put (resident's) name in them to make sure they were appropriate. The DON revealed, the facility made some administrative changes, and the aide with experience will take over the scheduling and making sure the trainings were done. CNA C was that before , but the facility was making that change.
Interview on 10/1/23 at 5:13 PM with the ADM revealed the ADM interviewed HA A and asked her if she knew she couldn't transfer alone, and HA A told her she knew that . When asked why she did it, she began crying. The ADM stated she asked HA A was she comfortable with Hoyer Lift transfers and HA A informed the ADM she thought she could do it. The ADM stated when she asked HA A why she did it she just started crying. The ADM revealed HA A admitted to her she was not familiar with Hoyer's but didn't tell anyone. The ADM stated, [HA A] had her own section (hall) and that was why the facility was changing things to prevent this from happening again. Maintenance came in and checked every Hoyer and one had a loose leg and so it was replaced. The lift that was replaced was not the lift that was used for Resident #1 .
Interview on 10/1/23 at 5:13 PM with the ADM revealed, We are switching up who does the schedule and so we have the ADON, and DON sign off on the schedule now. We had training done and all direct care staff got the training; it was mandatory. Then, we made every single one of them demonstrate [how to operate a Hoyer lift] and we had them get in the sling so they could see how that felt.
Record review of New Hire Orientation checklist, dated 8/28/23, for HA A reflected Skills Review and Body Mechanics: Safe Lifting/Transfer/Gait Belts and Mechanical Lifts had no documentation and were not checked off; indicating training was not completed.
Record review of Safe Resident Handling/Transfers policy, dated 9/4/23, revealed, .6. The staff will inspect the equipment prior to use to ensure functionality and will alert maintenance or other designee if the equipment is not functioning properly . 8. The facility will ensure that there are appropriate amounts of varying sizes of slings to accommodate residents and that residents will be measured correctly as per the manufacturer's instructions on proper sling sizing . 10. Two staff members must be utilized when transferring residents with a mechanical lift. 11. Staff will be educated on the use of safe handling/transfer practices to include use of mechanical lift devices upon hire, annually and as the need arises or changes in equipment occur. 12. Staff must demonstrate competency in the use of mechanical lifts prior to use and annually with documentation of that competency placed in their education file.
Record review of the No Lift Policy, dated 6/04, revealed, .4. Nursing staff will receive training in the use of mechanical lifts during the orientation period.
The facility took the following actions to correct the noncompliance:
Record review of Staff Meeting dated 9/4/23 revealed all 16 direct care staff were in-serviced on Proper use of Hoyer lift and sit to stand.
Record review of Electronic Total Lift Competency dated 9/4/23 9/6/23 revealed 16 direct care staff were checked off on; HA A checked off on 9/4/23.
Record review of invoice dated 9/4/23 for one Electric Patient Lift.
Record review of invoice dated 9/7/23 for 12 slings of 7 different sizes.
Interview on 10/1/23 at 2:59 pm with ADON revealed The audits for the Hoyer's are being done more often and had more intense training: Two people and an employee in the Hoyer. Audits will be every three months and it was annually and at hire before. We have a designated aide to do the training who has 15 years of experience. We purchased new slings specifically for each patient and we have a new Hoyer and we have removed the Hoyer [Resident #1] was in because the wheels got stuck sometimes and we are ironing the names [of residents] in the slings. We have also increased monitoring and audits of Hoyer lifts. ADON revealed she does not know who was supposed to be training HA-A that day and the facility will start adding who it is on the schedule.
Throughout the course of the investigation from 10/1/23-10/2/23 staff were interviewed and confirmed their understanding of the in-service training provided by the facility. Staff interviewed included two CNAs (one night shift), one HA, one LVN, one RN.
Interview on 10/1/23 at 2:11 pm with a family member revealed staff use 2-3 staff to transfer their resident with Hoyer Lift.
Two observations were conducted of staff conducting a safe, competent Hoyer Lift transfer.

Based on observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that ensure the accurate administering of all drugs to meet the needs of the residents, for 1 of 1 medication room and 1 of 1 treatment cart inspected for medication storage.
The medication room had opened, undated and an expired vials of tuberculin in the medication refrigerator.
The treatment cart contained insulin pens without open dates.
This failure could place residents at risk of receiving medications that were expired and not produce the desired effect, and at risk of not receiving the therapeutic benefit of medications or adverse reactions to medications.
Findings include:
During an observation and interview on 06/27/23 at 05:54 PM, the medication room was inspected with LVN A present. The door was locked and LVN A unlocked the door. Inside a small refrigerator were two opened 1ml vials of Tuberculin solution. One of the vials had an open date of 05/18/23 and the other opened vial did not have an open date. The Tuberculin solution box indicated Once entered, vial should be discarded after 30 days. LVN A said she did not know if someone was assigned to inspect the refrigerator for expired and undated medications. LVN A said it was probably everyone's job to date the vials when they were opened.
During an observation and interview on 06/28/23 at 11:10 AM, the nurse treatment cart was inspected with LVN B. The treatment cart was locked and the nurse unlocked it. Inside one of the drawers there were 2 opened insulin pens that had no open date on them. LVN B said she was not sure who opened the pens and they should be dated when opened. LVN B said if they administered insulins that were expired they might not be as effective.
During an interview on 06/29/23 at 10:46 AM, the DON said it was her expectation for the TB vial and insulin pens to be dated when opened and disposed when expired. The DON said she was not sure if there was someone designated to inspect the medication room for expired medications or the treatment carts but that they were working on fixing that as she had just started as DON on 06/12/23. The DON said the vials and pens not being dated occurred because it was probably overlooked by the staff that opened it and did not discard the expired TB vial. The DON said if staff used an expired test solution it could give an inaccurate reading and an expired insulin could lead to the medication to being as effective.
During an interview on 06/29/23 at 11:54 AM, the Administrator said it was her expectation for staff to date insulin pens and TB vials when opened. The Administrator said it was her expectation for the DON and ADON to monitor that staff were dating them. The Administrator said if staff used an expired medication it could lead to false reading and the resident not receiving the correct medication dose.
Record review of the facility policy titled Labeling of medications and biologicals dated 06/28/23 indicated in part: All medications and biologicals used in the facility will be labeled in accordance with current state and federal regulations to facilitate consideration of precautions and safe administration of medications. Labels for multi-use vials must include: The date the vial was initially opened or accessed (needle-punctured). All opened or accessed vials should be discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial.
Record review of the facility policy titled Insulin Pen dated 06/28/23 indicated in part: It is the policy of this facility to use insulin pens in order to improve the accuracy of insulin dosing. Insulin pens must be clearly labeled with the resident name, physician name, date dispensed, type of insulin, amount to be given, frequency and expiration date. Insulin pens must be dated upon opening. Insulin pens should be disposed of after 28 days or according to manufactures recommendations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for one (Resident #4) of one resident reviewed for infection control.
LVN C failed to sanitize the bedside table and put down a barrier to prevent cross contamination.
LVN C failed to sanitize scissors after they became contaminated prior to ostomy care for Resident #4.
LVN C failed to wash her hands prior to donning gloves for resident care.
This failure could place resident's risk for cross contamination and the spread of infection.
Findings Included:
Record review of Resident #4's face sheet indicated she was [AGE] years old admitted to the facility on [DATE] with diagnoses including dementia, diabetes mellitus, colostomy status, localized infection of the skin and subcutaneous tissue, major depressive disorder.
Record review of the MDS assessment dated [DATE] indicated Resident #4 was understood and understood others. The MDS indicated she had minimal impaired cognition based on her BIMS score of 14. The MDS indicated Resident #4 had a pressure ulcer/injury. Resident receives applications of ointments/medications for pressure ulcer/injury. Resident has indwelling catheter and colostomy. Resident requires extensive assistance for transfers, uses wheelchair for mobility.
Record review of the comprehensive care plan dated 5/23/23 indicated Resident #4 has potential/actual impairment to skin integrity due to open area to ostomy stoma. Goal is that the resident will have no complications related to open skin. Interventions are to follow facility protocols for treatment of injury. Monitor/document location and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infection and maceration to physician.
Record review of Resident #4's physician orders dated 3/09/23 Cleanse and clean ostomy as needed. Apply thin duoderm around ostomy site for skin protection prior to applying wafer, may also use hydrocolloid gel around site for protection, change every 3 days and as needed. Perform skin assessment everyday shift on Thursdays.
During an observation on 6/27/23 at 1:50 PM, LVN C entered Resident #4's room. LVN C placed supplies for colostomy bag and dressing change on the residents bedside table. It was noted by surveyor that residents abdomen was swollen, red and excoriated. LVN C stated that resident had developed a little ulcer next to the stoma and surrounding skin was irritated. LVN C then pulled scissors out of her pocket, placed the scissors in her mouth, washed her hands and donned gloves while holding the scissors in her mouth. LVN C then walked to residents bedside table and removed the moldable convex skin barrier with flange from the package. LVN C took the scissors from her mouth and cut the hole to size for placement over the stoma. LVN C then opened the skin protectant wipe package and applied to residents skin, then LVN C attached the moldable convex skin barrier to residents skin. LVN C then took the drainable pouch and attached it to the flange of the moldable convex skin barrier. LVN C doffed gloves and left the residents room to get tape, stating that wafer did not stick to skin. LVN C returned to residents room, donned new gloves, failing to wash her hands. LVN C then, applied Hypafix tape all around wafer. LVN C covered resident with blanket, then doffed gloves and washed her hands prior to leaving the room.
During interview on 06/29/23 at 11:45 AM with ADON, she stated that she is responsible for nurse training regarding resident care procedures. ADON stated that her expectations for colostomy care are as follows:
1.Walk into the residents room and wash hands.
2. Clean bedside table with sanitizing wipes and lay down barrier paper.
3. Remove supplies from package and set up on barrier paper.
4. Wash hands and don clean gloves.
5. Remove soiled moldable convex skin barrier with flange and bag.
6. Wash hands and don clean gloves.
7. Pre- cut moldable convex skin barrier with flange and attach new bag.
8. Assess pain level and pre- medicate if necessary.
9. Apply skin barrier, attach moldable convex skin barrier with flange and new bag.
10. Doff gloves and wash hands. Position resident for comfort.
During an interview on 06/29/23 at 12:30 PM, the Administrator stated that all staff is expected to perform proper hand hygiene prior to resident care. Administrator stated that infection control is important to the safety of the residents.
Record review of the facility's policy titled Hand hygiene and revised 02/01/23 indicated in part:
Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. The use of gloves does not replace hand hygiene. Perform hand hygiene prior to donning gloves and immediately after offing gloves. Perform hand hygiene after handling contaminated objects, before performing resident care procedures.
Record review of the facility's policy titled Infection Prevention and revised 02/01/23 indicated in part: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

Based on interview and record review, the facility failed to follow guidelines for mandatory submission of staffing information based on payroll data in a uniform format. Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS.
The facility failed to submit PBJ staffing information to CMS for the 2nd quarter of the fiscal year 2023.
The facility's failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment.
The findings included:
Record review of the CMS PBJ Staffing Data Report, CASPER Report 1705D FY Quarter 2 2023 (January 1 - March 31), dated 06/22/2023, revealed the following entry: Failed to Submit Data for the Quarter .Triggered .Triggered=No Data Submitted for the Quarter.
Review of the facility's Employee List dated 6/27/23 indicated the following:
1 Administrator
5 RNs (included DON)
6 LVNs.
17 CNAs
3 Maintenance Personnel
6 Housekeeping Personnel
1 Human Resources
8 Dietary Personnel
4 Hospitality Aides
2 Medication Aides.
1 Activity Director.
Record review of the facility CMS form 672 (Resident Census and Conditions of Residents) dated 06/28/23 provided by the DON indicated a total of 28 residents in the facility.
During an interview on 06/29/23 at 09:14 AM, the Administrator said that a Payroll Based Journal had not been submitted by the previous DON and was one of the reasons they had terminated her. The Administrator said they were unable to tell if the previous DON had even attempted to submit the Payroll Based Journal so at this time they had no evidence to show this had been done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents with bed rails were assessed for the risk of entrapment from bed rails, failed to provide ongoing monitoring and supervision for the use of bed rails, and failed to have a care plan in place for bed rails for 1 of 1 resident (Resident #7) reviewed for the use of full (4) bed rails.
1.
Resident # 7 had full side rails at her request without a developed care plan with measurable goals benefits and risks related to side rail use.
2.
The facility failed to routinely assess Resident #7 for ongoing need for and risks of side rail use (including entrapment).
3.
The facility failed to conduct and document routine monitoring of Resident #7 while full side rails were in use.
This failure could affect residents by putting them at an increased and unnecessary risk of harm, entrapment, and injury.
Findings included:
Review of Resident #7's admission Record dated 6/29/23 revealed she was a [AGE] year-old female originally admitted to the facility on [DATE] with a most recent admission date of 6/16/23. She had diagnoses which included dementia, repeated falls, macular degeneration (a degenerative condition affecting the central part of the retina resulting in distortion or loss of central vision), psychotic disorder with hallucinations, psychotic disorder with delusions, major depressive disorder, chronic pain, and Alzheimer's disease.
Review of Resident #7's quarterly MDS assessment, dated 5/20/23, revealed: She had moderate difficulty hearing and used hearing aids, she had unclear speech, was usually understood and was usually able to understand others, and she had impaired vision. Her mental status exam score was 11, indicating she had moderately impaired cognition. She required extensive or 2 plus person assistance with all ADLs and required a wheelchair for mobility. She was frequently incontinent of bowel and bladder. She received a scheduled pain medication regimen and had a history of falls. She received an antidepressant daily and an opioid daily. She had documented bed rail use daily.
Review of Resident #7's Bed Rail Assessment, dated 6/16/23, revealed she was non-ambulatory, her level of consciousness fluctuated, she had an alteration in safety awareness due to cognitive decline, and had a history of falls. The assessment also revealed she had poor bed mobility, difficulty with balance and trunk control, she had difficulty with postural hypotension (decreased blood pressure with a change in position), and she was visually impaired. Further review of Resident #7's chart revealed only one other bed rail assessment dated [DATE].
Review of Resident #7's Fall Risk Evaluation, dated 6/16/23, revealed a score of 19, indicating she was a high risk for falls.
Review of Resident #7's Comprehensive Care Plan, revised 6/27/23, revealed no care plan for the use of full bed rails.
Observation on 6/27/23 at 1:52 PM revealed Resident #7 resting quietly in bed with full bed rails up and the bed at a normal height. Resident #7's call light button was within reach.
Review of Resident #7's Order Summary, dated 6/28/23, revealed the following orders:
Bed in low position while resident in bed every shift (order date 4/11/23)
Full rails when in bed as personal safety per resident request every shift (order date 4/11/23)
Fall precautions PRN (order date 5/1/23)
Donepezil HCl tablet 10mg - give 1 tablet by mouth at bedtime for dementia related to Alzheimer's (order date 2/13/23)
Memantine HCl tablet 10mg - give 1 tablet by mouth two times a day related to Alzheimer's (order date 11/30/22)
Sertraline HCl tablet 50mg - give 1 tablet by mouth one time a day for depression related to major depressive disorder (order date 11/30/22)
Sertraline HCl tablet 100mg - give 1 tablet by mouth one time a day for depression related to major depressive disorder (order date 11/30/23)
Tramadol HCl tablet 50mg - give 2 tablets by mouth at bedtime for pain (order date 2/13/23)
Tramadol HCl tablet 5mg - give 2 tablets by mouth every 6 hours as needed for moderate and sever pain (order date 2/13/23)
Review of Resident #7's Consent section of her electronic chart on 6/29/23 revealed a Physical Restraint Informed Consent dated 11/7/14 for full bed rails signed by the resident's spouse, a consent for full bed rail use dated 5/2/16 signed by Resident #7, and a Shared Risk Agreement - Side Rails dated 6/29/16 signed by Resident #7.
In an interview on 6/29/23 at 12:37 PM, the ADON stated that Resident #7 liked to lay in bed on her side with a pillow between her knees and very rarely moved once she was comfortable, but the aides did frequent checks while she was in bed. She stated that rounds were every 2 hours and if call light went off during the night. There was no set schedule for checking the residents during the day. The ADON stated there was no official monitoring system in place for Resident #7's bed rails. She stated the nursing staff had not readdressed Resident #7's desire to have the side rails in a long time. She stated that she believed the side rails were care planned in the old EMR system but was not aware that they were not in the new EMR system that had been in use since December 2022.
In an interview on 6/29/23 at 1:26 PM, the Administrator stated she was not aware of the need for routine monitoring for bed rails. She stated she was aware that some care plans were missing information but did not specifically know that Resident #7 did not have a care plan for full bed rails. She stated the former DON was responsible for creating care plans and after she was terminated in February 2023, she discovered that the care plans were not being done correctly.
Review of facility policy Proper Use of Side Rails dated 2/01/23 revealed, in part:
As part of the resident's comprehensive assessment, the following components will be considered when determining the resident's need, and whether or not the use of side/bed rails meets those needs:
a.
Medical diagnosis, conditions, symptoms, and/or behavioral symptoms
b.
Size and weight
c.
Sleep habits
d.
Medications
e.
Acute medical or surgical interventions
f.
Underlying medical conditions
g.
Existence of delirium
h.
Ability to toilet self safely
i.
Cognition
j.
Communication
k.
Mobility (in and out of bed)
l.
Risk of falling
The use of side rails will be specified in the resident's plan of care.
The facility will provide ongoing monitoring and supervision of side/bed rail use for effectiveness, assessment of need and determination when the side/bed rail will be discontinued. Responsibilities are specified as follows:
a.
direct care staff will be responsible for care ad treatment in accordance with the plan of care.
b.
a nurse assigned to the resident will complete reassessments in accordance with the facility's assessment schedule, but not less than quarterly, upon a significant change in status, or a change in the type of bed/mattress/rail.
c.
the interdisciplinary team will make decisions regarding when the side/bed rail will be used or discontinued, or when to revise the care plan to address any residual effects of the rail.