TEAGUE NURSING AND REHABILITATION

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 1 of 1 residents reviewed for medication administration (Residents #23). <BR/>Licensed Vocational Nurse (LVN) failed to properly wash or sanitize her hands when moving from Resident to Resident when administering medications to resident # 23.<BR/>This deficient practice placed all residents identified at risk for cross contamination and the spread of infection.<BR/>Findings include:<BR/>Review of Resident #23's face sheet reflected Resident #23 was a [AGE] year-old female with an admission date of 10/01/21. Resident #23's diagnoses included anemia (blood disorder in which the blood has a reduced ability to carry oxygen due to a lower than normal number of red blood cells), diabetes type 2 (high blood sugar, insulin resistance, and relative lack of insulin), hypertension (high blood pressure - long term condition in which blood pressure in arteries is persistently elevated), muscle wasting and atrophy (when muscles waste away), and hypokalemia (a low level of potassium in the blood serum). <BR/>Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] reflected Resident #23 had a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #23 was cognitively intact and able to complete an interview. <BR/>During an observation on 08/15/2022 at 11:37 AM, LVN was observed passing medication to Residents #10 and #23 without sanitizing hands in between. LVN prepared and administered medications to Resident #10 and then without washing or sanitizing hands, prepared and administered Resident #23's medications. <BR/>During an interview on 08/15/2022 at 11:41 AM, LVN stated no, she did not sanitize her hands in between passing medication to the 2 residents. She stated she just forgot to sanitize her hands in between the 2 residents. She stated she normally sanitized her hands in between residents, and it was their policy to do so. She stated she was in-serviced regularly on handwashing and sanitizing hands when passing medication or doing anything in between residents. She stated she was aware that not sanitizing her hands in between residents could spread germs and increase the risk of infection which could possibly cause harm to residents. <BR/>During an interview on 08/16/2022 at 11:22 AM, MA stated she either washed or sanitized her hands in between every resident when passing medications. She stated she was in-serviced regularly on handwashing and sanitizing hands when passing medication or doing anything in between residents. She stated she believed that not sanitizing hands in between residents could spread germs and increase the risk of infection which could possibly cause harm to residents. She stated no matter what department or title someone was, whether they are in management or working on the floor, everyone should wash or at least sanitize their hands when going from one resident to the next. <BR/>During an interview on 08/16/2022 at 12:52 PM, ADON stated she washed or sanitized her hands in between every resident no matter what task she was performing and always in between administering medications. She stated she had been in-serviced on handwashing/sanitizing hands when going from one resident to another and performing any task. She stated she believed that not sanitizing or not washing hands in between residents could cause an increased risk of spreading infection and could potentially cause harm to a resident. <BR/>During an interview on 08/16/2022 at 1:00 PM, the DON stated it was her expectation that all staff washed or sanitized their hands when going from resident to resident when passing medications or performing any task. She stated she in-serviced staff on handwashing or sanitizing hands when going from resident to resident when performing any task including administering medications. She stated she believed that not sanitizing or not washing hands in between residents could cause an increased risk of spreading infection and could potentially cause harm to a resident.<BR/>During an interview on 08/16/2022 at 1:12 PM, the ADM stated it was his expectation that all staff washed or sanitized their hands in between every resident when passing medication or performing any task. He stated he is in-serviced staff regularly on handwashing or sanitizing hands when going from resident to resident during any task including medication administration. He stated he believed that not sanitizing or not washing hands in between residents could cause an increased risk of spreading infection and could potentially cause harm to a resident.<BR/>Review of the Handwashing/Hand Hygiene policy (revised August 2019), provided by the ADM, titled revealed the following: policy statement: This facility considers hand hygiene the primary means to prevent the spread of infections; # 2. stated all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. #7 stated use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: c. Before preparing or handling medications.<BR/>Review of the Administering Medications policy (revised April 2006) provided by the DON revealed the following: Policy Interpretation and Implementation; # 2. Established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) must be followed during the administration of medications. <BR/>Review of the Policies and Practices - Infection Control policy (revised September 2005) provided by the DON, revealed the following: Policy Statement: The facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. Policy Interpretation and Implementation; # 4. All personnel will be informed of our infection control policies and practices, including where and how to find and use pertinent procedures. <BR/>Review of documents dated 07/11/2022, 07/20/2022, and 08/03/2022 revealed staff was in-serviced frequently on handwashing and policies and practices of infection control. <BR/>Review of documents 07/11/2022 on handwashing and policies and procedures - infection control, revealed LVN attended these in-services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure assessments accurately reflected the status for 1 of 7 residents (Resident #1) reviewed for assessments.<BR/>The facility failed to ensure Resident #1's weekly skin assessments were performed timely, accurately, and appropriately.<BR/>This failure could place residents at risk of missing treatment needs.<BR/>Findings included:<BR/>Record review or Resident #1's AR, dated 4/2/2024, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. He was diagnosed with a urinary tract infection (which was the result of bacteria, that caused an infection of the urinary system,) chronic kidney disease, stage 3 (which was a disease of the kidney that disrupted the body's ability to filter impurities,) and diabetes mellitus type 2 (which was a condition of the body that disrupted how the body used sugar for fuel.)<BR/>Record review of Resident #1's admission MDS, dated [DATE], reflected Section C., Cognitive Patterns; Resident #1 had a BIMS Score of 15. (A BIMS Score of 15 indicated no cognitive impairment). Section M., Skin Conditions reflected Resident #1 he was not a risk for pressure ulcers; had no unhealed pressure ulcers; had no venous or arterial ulcers; had no infections of the feet; had no diabetic foot ulcers; had no open lesions of the feet; and he had no moisture associated skin damage. The resident did not reflect any skin/ulcer or injury treatments. Section GG., Functional Abilities and (Range of Motion;) Resident #1 had no impairment on either side of his upper extremities (shoulder, elbow, wrist, and hand) and no impairment in either lower extremities (hip, knee, ankle, and foot.) Resident #1 utilized a wheelchair for mobility. Resident #1 was dependent upon staff for toileting hygiene, shower/bathe self, lower body dressing, and putting on/talking off shoes, sitting to standing, chair/bed to chair transfer, and tub/shower transfer. Being dependent upon staff meant the helper did all of the effort, or the assistance of 2 or more helpers was required for the resident, to complete the activity.<BR/>Record review of discharge paperwork for hospitalization from a 1/28/2024 to 2/2/2024. On 2/2/2024, the resident returned to the nursing facility.<BR/>Record review of a complaint, made on 2/2/2024, reflected Resident #1 was hospitalized on [DATE] through 2/2/2024 for low blood pressure and low urine output. He released from the local hospital on 2/2/2024 to return to the nursing facility. The complainant made allegations that Resident #1 was not receiving appropriate skin care.<BR/>Record review of Resident #1's CP, initiated on 2/2/2024, reflected a focus area for skin conditions, evidenced by Resident #1 having returned from the hospital on 2/2/2024 with a stage II pressure injury to his coccyx, tailbone, and a scabbed area on top of his bi-lateral feet. The goal, initiated on 2/5/2024, reflected Resident #1 would have intact skin, free from redness, blisters, or discoloration. Resident #1's pressure injury would show signs of healing and remain free from infection. The intervention, initiated 2/2/2024, reflected nursing staff would administer medications as ordered. Monitor/document for side effects and effectiveness. Administer treatments as ordered and monitor for effectiveness. Assess/record/monitor wound healing at least weekly. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed, and healing progress. Report declines to the MD. Avoid positioning the resident on (coccyx). Do not massage over bony prominences and use mild cleansers for peri care/washing. Educate the resident/family/caregivers as to causes of skin breakdown; including transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition, and frequent repositioning.<BR/>Record review of Resident #1's WSA performed on WSA 2/15/2024 reflected other skin finding reflected redness r/t friction on inner thigh area- barrier cream applied. Signed 2/28/2024 by the DON. <BR/>(The WSA was not completed timely as the document was dated to have occurred on 2/15/2024 but was not signed until 13 days later on 2/28/2024.)<BR/>Record review of discharge paperwork for hospitalization from a 2/18/2024 to 3/3/2024. On 3/3/2024, the resident returned to the nursing facility <BR/>Record review of Resident #1's WSA performed on 2/22/2024 reflected other skin finding reflected redness r/t friction on inner thigh area-barrier cream applied. Signed 3/04/2024 by the DON. <BR/>(The WSA was not accurate because Resident #1 was not at the facility on 2/22/2024.)<BR/>Record review of Resident #1's WSA performed on 2/29/2024 reflected other skin finding reflected redness r/t friction on inner thigh area-barrier cream applied. Signed 3/04/2024 by the DON. <BR/>(This WSA was not accurate because Resident #1 was not at the facility on 2/29/2024.)<BR/>Record review of a WSA performed on 3/14/2024 reflected other skin finding reflected redness r/t friction on inner thigh area-barrier cream applied. Signed 3/20/2024 by the DON. <BR/>(The WSA was not completed timely as the document was dated to have occurred on 3/14/2024 but was not signed until 6 days later on 3/20/2024.)<BR/>A telephone interview on 4/01/2024 at 12:57 PM with the complainant revealed Resident #1 admitted to the local hospital for low urine output and low blood pressure on 1/28/2024. While in the care of the facility, the complainant learned that Resident #1 had skin integrity issues and thought the facility could do more to protect his skin. The hospital treated Resident #1's skin concerns and he discharged back to the nursing facility on 2/2/2024.<BR/>Interview and observation on 4/02/2024 at 9:40 AM with Resident #1 revealed he had been at the facility since the end of November 2023. He was observed was lying on his back. His feet and ankles were in PU relieving boots with a pillow in between; There was a visible bandage on the resident's right foot/ankle dated 4/01/2024. The visible portions of his feet were observed clean with recently trimmed nails. He denied pain with his wounds. Resident #1 revealed he did not have any pressure ulcers on his body when he came to the facility, but he had developed pressure ulcers and sores on his feet, ankles, and back side since his arrival. Since his return to the facility on 2/2/2024, Resident #1 was receiving skin assessments, ulcer assessments, and VOHRA. He has been provided with pressure relieving boots and staff have been placing a pillow between his legs to provide comfort. He denied physical pain associated with his wounds. <BR/>Interview on 4/04/2024 at 2:15 PM with LVN B revealed she had been an LVN for 37 years and had been working at the facility for the last 3.5 years. She stated that she had been trained to complete accurately and to sign the treatment note once completed. She described timely documentation to be done as soon as possible. She remembered a time when she was 2 days late with accurate and timely documentation and she received a one-on-one counseling. She stated that staff was not allowed to enter documentation for other staff members. She stated late and inaccurate documentation placed residents at [NAME] of meeting treatments, the need for follow up assessments, and worsening health condition.<BR/>Interview on 4/04/2024 at 2:25 PM with LVN D revealed she had been an LVN for the last 8 years and had been working at the facility for the last 10 months. She stated she had been trained to perform accurate assessments and to make sure they were completed at the time. She explained she had been late one time with an assessment and was counseled by the DON the next day. Timely and accurate documentation helps the team provide care to the resident and inaccurate, or missing information, placed the resident at risk of missing important aspects of care.<BR/>Interview and record review on 4/4/2024 at 4:40 PM with the DON revealed WSA were supposed to be performed weekly. The WSAs were supposed to be filled out by the nursing staff and the assessments were supposed to be passed along to the DON and the ADON with any issues or concerns. The DON stated WSA performed on 2/15/2024 was completed by her but was not signed until 2/28/2024, 13 days later. She stated she did not perform the WSA but got the assessment on a piece of paper from a nurse and entered the information for a nurse after the fact. The WSA performed on 2/22/24 was completed by the DON on 2/22/24 but was not signed until 3/04/2024, 13 days later. The DON stated that she had been having trouble with staff not completing their notes on time. She knew she was not supposed to be entering other staff's documentation, but she did it anyway to help them out. If the resident's skin condition did not get identified through assessments, the failure was the first line of defense, who were the CNAs, who did not report skin conditions to the charge nurse. The second line of defense, who were the charge nurses, were supposed to document skin conditions and refer those issues with the ADON and the DON. The third line of defense, who were the ADON and the DON, were at fault for inaccurate assessments because they were not checking behind the nursing staff. There were no safeguards in place to identify documentation errors. If there were, she stated we would have caught them. The DON stated that untimely and inaccurate documentation placed residents at risk of missing treatments, worsening of wounds, missing follow up care, and having their needs go unmet. The DON was the facility's Assessment Coordinator.<BR/>Interview on 4/4/2024 at 4:40 PM with the ADM revealed he expected his staff to follow facility policy and make sure assessments were accurate, appropriate, and timely. He stated a daily assessment should be completed that day and a weekly assessment should be completed that week. Late documentation, inaccurate, or inappropriate documentation placed the residents at risk of facing barriers to receiving good care. A fail safe in place to catch errors in documentation was the standard of care meeting held each week. Also, the DON and the ADON were supposed to be following up on staff to make sure documentation was being completed correctly. If there were documentation errors committed by the DON, the ADM felt the regional nurse was at fault for not checking up and making sure the DONs documentation was being done correctly. The DON was the facility's assessment coordinator.<BR/>Record review of the facility's Resident Assessment Policy, dated October 2023, reflected the assessment coordinator was responsible for ensuring timely and appropriate resident assessments. Assessments were completed by staff members who had skills and qualifications to assess relevant care areas and who were knowledgeable about the resident's strengths and areas of decline.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure assessments accurately reflected the status for 1 of 7 residents (Resident #1) reviewed for assessments.<BR/>The facility failed to ensure Resident #1's weekly skin assessments were performed timely, accurately, and appropriately.<BR/>This failure could place residents at risk of missing treatment needs.<BR/>Findings included:<BR/>Record review or Resident #1's AR, dated 4/2/2024, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. He was diagnosed with a urinary tract infection (which was the result of bacteria, that caused an infection of the urinary system,) chronic kidney disease, stage 3 (which was a disease of the kidney that disrupted the body's ability to filter impurities,) and diabetes mellitus type 2 (which was a condition of the body that disrupted how the body used sugar for fuel.)<BR/>Record review of Resident #1's admission MDS, dated [DATE], reflected Section C., Cognitive Patterns; Resident #1 had a BIMS Score of 15. (A BIMS Score of 15 indicated no cognitive impairment). Section M., Skin Conditions reflected Resident #1 he was not a risk for pressure ulcers; had no unhealed pressure ulcers; had no venous or arterial ulcers; had no infections of the feet; had no diabetic foot ulcers; had no open lesions of the feet; and he had no moisture associated skin damage. The resident did not reflect any skin/ulcer or injury treatments. Section GG., Functional Abilities and (Range of Motion;) Resident #1 had no impairment on either side of his upper extremities (shoulder, elbow, wrist, and hand) and no impairment in either lower extremities (hip, knee, ankle, and foot.) Resident #1 utilized a wheelchair for mobility. Resident #1 was dependent upon staff for toileting hygiene, shower/bathe self, lower body dressing, and putting on/talking off shoes, sitting to standing, chair/bed to chair transfer, and tub/shower transfer. Being dependent upon staff meant the helper did all of the effort, or the assistance of 2 or more helpers was required for the resident, to complete the activity.<BR/>Record review of discharge paperwork for hospitalization from a 1/28/2024 to 2/2/2024. On 2/2/2024, the resident returned to the nursing facility.<BR/>Record review of a complaint, made on 2/2/2024, reflected Resident #1 was hospitalized on [DATE] through 2/2/2024 for low blood pressure and low urine output. He released from the local hospital on 2/2/2024 to return to the nursing facility. The complainant made allegations that Resident #1 was not receiving appropriate skin care.<BR/>Record review of Resident #1's CP, initiated on 2/2/2024, reflected a focus area for skin conditions, evidenced by Resident #1 having returned from the hospital on 2/2/2024 with a stage II pressure injury to his coccyx, tailbone, and a scabbed area on top of his bi-lateral feet. The goal, initiated on 2/5/2024, reflected Resident #1 would have intact skin, free from redness, blisters, or discoloration. Resident #1's pressure injury would show signs of healing and remain free from infection. The intervention, initiated 2/2/2024, reflected nursing staff would administer medications as ordered. Monitor/document for side effects and effectiveness. Administer treatments as ordered and monitor for effectiveness. Assess/record/monitor wound healing at least weekly. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed, and healing progress. Report declines to the MD. Avoid positioning the resident on (coccyx). Do not massage over bony prominences and use mild cleansers for peri care/washing. Educate the resident/family/caregivers as to causes of skin breakdown; including transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition, and frequent repositioning.<BR/>Record review of Resident #1's WSA performed on WSA 2/15/2024 reflected other skin finding reflected redness r/t friction on inner thigh area- barrier cream applied. Signed 2/28/2024 by the DON. <BR/>(The WSA was not completed timely as the document was dated to have occurred on 2/15/2024 but was not signed until 13 days later on 2/28/2024.)<BR/>Record review of discharge paperwork for hospitalization from a 2/18/2024 to 3/3/2024. On 3/3/2024, the resident returned to the nursing facility <BR/>Record review of Resident #1's WSA performed on 2/22/2024 reflected other skin finding reflected redness r/t friction on inner thigh area-barrier cream applied. Signed 3/04/2024 by the DON. <BR/>(The WSA was not accurate because Resident #1 was not at the facility on 2/22/2024.)<BR/>Record review of Resident #1's WSA performed on 2/29/2024 reflected other skin finding reflected redness r/t friction on inner thigh area-barrier cream applied. Signed 3/04/2024 by the DON. <BR/>(This WSA was not accurate because Resident #1 was not at the facility on 2/29/2024.)<BR/>Record review of a WSA performed on 3/14/2024 reflected other skin finding reflected redness r/t friction on inner thigh area-barrier cream applied. Signed 3/20/2024 by the DON. <BR/>(The WSA was not completed timely as the document was dated to have occurred on 3/14/2024 but was not signed until 6 days later on 3/20/2024.)<BR/>A telephone interview on 4/01/2024 at 12:57 PM with the complainant revealed Resident #1 admitted to the local hospital for low urine output and low blood pressure on 1/28/2024. While in the care of the facility, the complainant learned that Resident #1 had skin integrity issues and thought the facility could do more to protect his skin. The hospital treated Resident #1's skin concerns and he discharged back to the nursing facility on 2/2/2024.<BR/>Interview and observation on 4/02/2024 at 9:40 AM with Resident #1 revealed he had been at the facility since the end of November 2023. He was observed was lying on his back. His feet and ankles were in PU relieving boots with a pillow in between; There was a visible bandage on the resident's right foot/ankle dated 4/01/2024. The visible portions of his feet were observed clean with recently trimmed nails. He denied pain with his wounds. Resident #1 revealed he did not have any pressure ulcers on his body when he came to the facility, but he had developed pressure ulcers and sores on his feet, ankles, and back side since his arrival. Since his return to the facility on 2/2/2024, Resident #1 was receiving skin assessments, ulcer assessments, and VOHRA. He has been provided with pressure relieving boots and staff have been placing a pillow between his legs to provide comfort. He denied physical pain associated with his wounds. <BR/>Interview on 4/04/2024 at 2:15 PM with LVN B revealed she had been an LVN for 37 years and had been working at the facility for the last 3.5 years. She stated that she had been trained to complete accurately and to sign the treatment note once completed. She described timely documentation to be done as soon as possible. She remembered a time when she was 2 days late with accurate and timely documentation and she received a one-on-one counseling. She stated that staff was not allowed to enter documentation for other staff members. She stated late and inaccurate documentation placed residents at [NAME] of meeting treatments, the need for follow up assessments, and worsening health condition.<BR/>Interview on 4/04/2024 at 2:25 PM with LVN D revealed she had been an LVN for the last 8 years and had been working at the facility for the last 10 months. She stated she had been trained to perform accurate assessments and to make sure they were completed at the time. She explained she had been late one time with an assessment and was counseled by the DON the next day. Timely and accurate documentation helps the team provide care to the resident and inaccurate, or missing information, placed the resident at risk of missing important aspects of care.<BR/>Interview and record review on 4/4/2024 at 4:40 PM with the DON revealed WSA were supposed to be performed weekly. The WSAs were supposed to be filled out by the nursing staff and the assessments were supposed to be passed along to the DON and the ADON with any issues or concerns. The DON stated WSA performed on 2/15/2024 was completed by her but was not signed until 2/28/2024, 13 days later. She stated she did not perform the WSA but got the assessment on a piece of paper from a nurse and entered the information for a nurse after the fact. The WSA performed on 2/22/24 was completed by the DON on 2/22/24 but was not signed until 3/04/2024, 13 days later. The DON stated that she had been having trouble with staff not completing their notes on time. She knew she was not supposed to be entering other staff's documentation, but she did it anyway to help them out. If the resident's skin condition did not get identified through assessments, the failure was the first line of defense, who were the CNAs, who did not report skin conditions to the charge nurse. The second line of defense, who were the charge nurses, were supposed to document skin conditions and refer those issues with the ADON and the DON. The third line of defense, who were the ADON and the DON, were at fault for inaccurate assessments because they were not checking behind the nursing staff. There were no safeguards in place to identify documentation errors. If there were, she stated we would have caught them. The DON stated that untimely and inaccurate documentation placed residents at risk of missing treatments, worsening of wounds, missing follow up care, and having their needs go unmet. The DON was the facility's Assessment Coordinator.<BR/>Interview on 4/4/2024 at 4:40 PM with the ADM revealed he expected his staff to follow facility policy and make sure assessments were accurate, appropriate, and timely. He stated a daily assessment should be completed that day and a weekly assessment should be completed that week. Late documentation, inaccurate, or inappropriate documentation placed the residents at risk of facing barriers to receiving good care. A fail safe in place to catch errors in documentation was the standard of care meeting held each week. Also, the DON and the ADON were supposed to be following up on staff to make sure documentation was being completed correctly. If there were documentation errors committed by the DON, the ADM felt the regional nurse was at fault for not checking up and making sure the DONs documentation was being done correctly. The DON was the facility's assessment coordinator.<BR/>Record review of the facility's Resident Assessment Policy, dated October 2023, reflected the assessment coordinator was responsible for ensuring timely and appropriate resident assessments. Assessments were completed by staff members who had skills and qualifications to assess relevant care areas and who were knowledgeable about the resident's strengths and areas of decline.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 1 of 1 residents reviewed for medication administration (Residents #23). <BR/>Licensed Vocational Nurse (LVN) failed to properly wash or sanitize her hands when moving from Resident to Resident when administering medications to resident # 23.<BR/>This deficient practice placed all residents identified at risk for cross contamination and the spread of infection.<BR/>Findings include:<BR/>Review of Resident #23's face sheet reflected Resident #23 was a [AGE] year-old female with an admission date of 10/01/21. Resident #23's diagnoses included anemia (blood disorder in which the blood has a reduced ability to carry oxygen due to a lower than normal number of red blood cells), diabetes type 2 (high blood sugar, insulin resistance, and relative lack of insulin), hypertension (high blood pressure - long term condition in which blood pressure in arteries is persistently elevated), muscle wasting and atrophy (when muscles waste away), and hypokalemia (a low level of potassium in the blood serum). <BR/>Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] reflected Resident #23 had a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #23 was cognitively intact and able to complete an interview. <BR/>During an observation on 08/15/2022 at 11:37 AM, LVN was observed passing medication to Residents #10 and #23 without sanitizing hands in between. LVN prepared and administered medications to Resident #10 and then without washing or sanitizing hands, prepared and administered Resident #23's medications. <BR/>During an interview on 08/15/2022 at 11:41 AM, LVN stated no, she did not sanitize her hands in between passing medication to the 2 residents. She stated she just forgot to sanitize her hands in between the 2 residents. She stated she normally sanitized her hands in between residents, and it was their policy to do so. She stated she was in-serviced regularly on handwashing and sanitizing hands when passing medication or doing anything in between residents. She stated she was aware that not sanitizing her hands in between residents could spread germs and increase the risk of infection which could possibly cause harm to residents. <BR/>During an interview on 08/16/2022 at 11:22 AM, MA stated she either washed or sanitized her hands in between every resident when passing medications. She stated she was in-serviced regularly on handwashing and sanitizing hands when passing medication or doing anything in between residents. She stated she believed that not sanitizing hands in between residents could spread germs and increase the risk of infection which could possibly cause harm to residents. She stated no matter what department or title someone was, whether they are in management or working on the floor, everyone should wash or at least sanitize their hands when going from one resident to the next. <BR/>During an interview on 08/16/2022 at 12:52 PM, ADON stated she washed or sanitized her hands in between every resident no matter what task she was performing and always in between administering medications. She stated she had been in-serviced on handwashing/sanitizing hands when going from one resident to another and performing any task. She stated she believed that not sanitizing or not washing hands in between residents could cause an increased risk of spreading infection and could potentially cause harm to a resident. <BR/>During an interview on 08/16/2022 at 1:00 PM, the DON stated it was her expectation that all staff washed or sanitized their hands when going from resident to resident when passing medications or performing any task. She stated she in-serviced staff on handwashing or sanitizing hands when going from resident to resident when performing any task including administering medications. She stated she believed that not sanitizing or not washing hands in between residents could cause an increased risk of spreading infection and could potentially cause harm to a resident.<BR/>During an interview on 08/16/2022 at 1:12 PM, the ADM stated it was his expectation that all staff washed or sanitized their hands in between every resident when passing medication or performing any task. He stated he is in-serviced staff regularly on handwashing or sanitizing hands when going from resident to resident during any task including medication administration. He stated he believed that not sanitizing or not washing hands in between residents could cause an increased risk of spreading infection and could potentially cause harm to a resident.<BR/>Review of the Handwashing/Hand Hygiene policy (revised August 2019), provided by the ADM, titled revealed the following: policy statement: This facility considers hand hygiene the primary means to prevent the spread of infections; # 2. stated all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. #7 stated use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: c. Before preparing or handling medications.<BR/>Review of the Administering Medications policy (revised April 2006) provided by the DON revealed the following: Policy Interpretation and Implementation; # 2. Established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) must be followed during the administration of medications. <BR/>Review of the Policies and Practices - Infection Control policy (revised September 2005) provided by the DON, revealed the following: Policy Statement: The facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. Policy Interpretation and Implementation; # 4. All personnel will be informed of our infection control policies and practices, including where and how to find and use pertinent procedures. <BR/>Review of documents dated 07/11/2022, 07/20/2022, and 08/03/2022 revealed staff was in-serviced frequently on handwashing and policies and practices of infection control. <BR/>Review of documents 07/11/2022 on handwashing and policies and procedures - infection control, revealed LVN attended these in-services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 1 of 1 residents reviewed for medication administration (Residents #23). <BR/>Licensed Vocational Nurse (LVN) failed to properly wash or sanitize her hands when moving from Resident to Resident when administering medications to resident # 23.<BR/>This deficient practice placed all residents identified at risk for cross contamination and the spread of infection.<BR/>Findings include:<BR/>Review of Resident #23's face sheet reflected Resident #23 was a [AGE] year-old female with an admission date of 10/01/21. Resident #23's diagnoses included anemia (blood disorder in which the blood has a reduced ability to carry oxygen due to a lower than normal number of red blood cells), diabetes type 2 (high blood sugar, insulin resistance, and relative lack of insulin), hypertension (high blood pressure - long term condition in which blood pressure in arteries is persistently elevated), muscle wasting and atrophy (when muscles waste away), and hypokalemia (a low level of potassium in the blood serum). <BR/>Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] reflected Resident #23 had a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #23 was cognitively intact and able to complete an interview. <BR/>During an observation on 08/15/2022 at 11:37 AM, LVN was observed passing medication to Residents #10 and #23 without sanitizing hands in between. LVN prepared and administered medications to Resident #10 and then without washing or sanitizing hands, prepared and administered Resident #23's medications. <BR/>During an interview on 08/15/2022 at 11:41 AM, LVN stated no, she did not sanitize her hands in between passing medication to the 2 residents. She stated she just forgot to sanitize her hands in between the 2 residents. She stated she normally sanitized her hands in between residents, and it was their policy to do so. She stated she was in-serviced regularly on handwashing and sanitizing hands when passing medication or doing anything in between residents. She stated she was aware that not sanitizing her hands in between residents could spread germs and increase the risk of infection which could possibly cause harm to residents. <BR/>During an interview on 08/16/2022 at 11:22 AM, MA stated she either washed or sanitized her hands in between every resident when passing medications. She stated she was in-serviced regularly on handwashing and sanitizing hands when passing medication or doing anything in between residents. She stated she believed that not sanitizing hands in between residents could spread germs and increase the risk of infection which could possibly cause harm to residents. She stated no matter what department or title someone was, whether they are in management or working on the floor, everyone should wash or at least sanitize their hands when going from one resident to the next. <BR/>During an interview on 08/16/2022 at 12:52 PM, ADON stated she washed or sanitized her hands in between every resident no matter what task she was performing and always in between administering medications. She stated she had been in-serviced on handwashing/sanitizing hands when going from one resident to another and performing any task. She stated she believed that not sanitizing or not washing hands in between residents could cause an increased risk of spreading infection and could potentially cause harm to a resident. <BR/>During an interview on 08/16/2022 at 1:00 PM, the DON stated it was her expectation that all staff washed or sanitized their hands when going from resident to resident when passing medications or performing any task. She stated she in-serviced staff on handwashing or sanitizing hands when going from resident to resident when performing any task including administering medications. She stated she believed that not sanitizing or not washing hands in between residents could cause an increased risk of spreading infection and could potentially cause harm to a resident.<BR/>During an interview on 08/16/2022 at 1:12 PM, the ADM stated it was his expectation that all staff washed or sanitized their hands in between every resident when passing medication or performing any task. He stated he is in-serviced staff regularly on handwashing or sanitizing hands when going from resident to resident during any task including medication administration. He stated he believed that not sanitizing or not washing hands in between residents could cause an increased risk of spreading infection and could potentially cause harm to a resident.<BR/>Review of the Handwashing/Hand Hygiene policy (revised August 2019), provided by the ADM, titled revealed the following: policy statement: This facility considers hand hygiene the primary means to prevent the spread of infections; # 2. stated all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. #7 stated use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: c. Before preparing or handling medications.<BR/>Review of the Administering Medications policy (revised April 2006) provided by the DON revealed the following: Policy Interpretation and Implementation; # 2. Established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) must be followed during the administration of medications. <BR/>Review of the Policies and Practices - Infection Control policy (revised September 2005) provided by the DON, revealed the following: Policy Statement: The facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. Policy Interpretation and Implementation; # 4. All personnel will be informed of our infection control policies and practices, including where and how to find and use pertinent procedures. <BR/>Review of documents dated 07/11/2022, 07/20/2022, and 08/03/2022 revealed staff was in-serviced frequently on handwashing and policies and practices of infection control. <BR/>Review of documents 07/11/2022 on handwashing and policies and procedures - infection control, revealed LVN attended these in-services.

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 reviewed for dietary services.<BR/>1. The facility failed to ensure food items in the refrigerator were dated and labeled appropriately.<BR/>2. The facility failed to ensure expired items were discarded. <BR/>These failures could place residents in the facility at risk for food-borne illness, and food contamination. <BR/>Findings included:<BR/>Observations of the walk in Refrigerator in the kitchen on 08/15/22 at 9:15 AM revealed the following items were either expired and/or not dated and labelled appropriately:<BR/>Three packets of honey ham with 'used by 08/10/22' written on the box. <BR/>3 packets of honey ham in a box with 7/9/22 written on it. There was no used by date.<BR/>1/4 unsealed packet of sausage with no date on it.<BR/>Observation and interview on 08/15/22 at 9:30 am with the DS revealed the above-mentioned items and deficiencies. He immediately removed those items from the shelves of the refrigerator. He said he never knew that the used by date was a mandatory requirement. He also stated that the expired items should not be there. He took full responsibility of the mistakes and stated he was determined to eliminate these issues in the future. <BR/>During the interview with the Diet over the phone on 8/16/22 at 1:00 PM, she stated the 'used by date' should be written on opened packets, leftovers and items removed from freezer to the refrigerator. She stated the shelf life of ham is five days when it is in the refrigerator. She would be providing a list of items and their allowed shelf lives to the kitchen at the facility for future reference. <BR/>During an interview with the ADM on 8/17/22 at 10:00 AM, he stated that labelling (that includes 'used by date') on every product that are stored was mandatory and expired items should be discarded immediately. He said a deficiency in food handling was evident in the kitchen and he would be organizing an in-service with the support of the Diet to address this issue. <BR/>Record review of the Dietary Services- Departmental Operations policy revised on August, 2010, revealed . 6. Dry foods that are stored in bins will be removed from original packaging, labelled and dated ('used by' date). Such food will be rotated using a 'first in- first out system'.<BR/> 7. All foods stored in the refrigerator or freezer will be covered, labeled, dated ('use by' date) .