Preserve at Mentor Ridge The

Based on interview, observation, record review, review of Teriparatide injection: Package Insert- Drugs. Com, and policy review the facility failed to ensure multi-use pen and/ or vials for injections were dated when opened. This affected one resident (#47) out of one resident observed receiving an injection. This had the potential to affect two residents (#24 and #47) that had orders for receiving an injection.

Findings include:

Review of medical record for Resident #47 revealed an admission date of 11/12/21 with diagnoses including history of falling, cardiac arrhythmia, and hypertension.

Review of September 2023 physician order revealed Resident #47 had an order that included: Teriparatide subcutaneous solution pen injector 600 microgram per 2.4 milliliter (ml) inject .08 ml subcutaneously (SQ) one time per day for osteoporosis.

Observation on 09/11/23 at 9:17 A.M. revealed Licensed Practical Nurse (LPN) #600 administered Resident #47 her Teriparatide as ordered. Observation revealed the pen injector was already opened and undated as to when it had been opened.

Interview on 09/11/23 at 9:25 A.M. with LPN #600 verified the Teriparatide pen injector was undated when it had been opened, and she did not know when it had been opened.

Review of facility policy labeled Medication Administration

Based on interview, observation, record review, and policy review the facility failed to maintain proper infection control measures during mealtime including proper hand hygiene and/ or not placing dirty dishes/ utensils on a cart that was serving meals. This affected 23 residents (#27, #28, #29, #30, #31, #32, #33, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47, #48, #49 and #50) who resided on the second floor and had the potential to affect all 48 residents residing at the facility.

Findings include:

Observation on 09/11/23 at 12:13 P.M. revealed Caregiver #601 placed gloves on and pushed a metal cart containing multiple lunch trays from the second floor servery down the hallway. Caregiver #601 entered Resident #38's room with his lunch tray. She proceeded to set up Resident #38's lunch tray by moving his bedside tray table and opening containers. She then proceeded to continue to wear the same gloves and pick up his breakfast tray that contained dirty dishes and utensils that were sitting on his counter. Caregiver #601 then placed the dirty breakfast tray onto the lunch cart that contained other lunch trays to be delivered. Caregiver #601 proceeded to push the cart down the hallway to pass more trays wearing the same gloves and did not perform hand hygiene. Observation revealed while pushing the cart, silverware from the cart fell to the floor, Caregiver #601 bent down with her gloved hands and picked up the silverware off the ground and placed onto Resident #38's breakfast tray on the cart. Observation revealed Caregiver #601 did not remove the gloves and/ or wash her hands after picking up the silverware from the floor. Caregiver #601 proceeded to Resident #43's room to deliver her tray. She set the tray on her over the bed table, opened her containers and placed a clothing protector in Resident #43's lap. Caregiver #601 then proceeded to leave Resident #43's room wearing the same gloves and did not perform hand hygiene and proceeded to pass the other trays on the cart.

Interview on 09/11/23 at 12:24 P.M. with Caregiver #601 verified that she did not perform hand hygiene after passing Resident #38 and #43's lunch tray. She also verified that she had removed Resident #38's breakfast tray from his room that contained dirty dishes and utensils and placed it on the lunch cart that contained lunch trays that needed to be served. She verified while passing trays, silverware had dropped to the floor, and she picked up the silverware from the floor without performing hand hygiene and proceeded to pass a tray.

Interview on 09/11/23 at 1:18 P.M. with the Director of Nursing revealed between each tray passed staff were to perform hand hygiene and was unsure why Caregiver #601 had placed gloves on to pass the trays. She also verified anytime staff picked something off the floor, staff was to perform hand hygiene and that they should not place dirty utensils and/ or dishes on a cart with meals that needed to be served. She revealed she did not have a policy regarding hand hygiene during mealtime and/ or not placing dirty dishes on meal cart that was serving meals.

Review of facility policy labeled Infection Control- Infection Surveillance

Based on record review, interview, and policy review the facility failed to ensure residents who were capable of self-evacuating be evacuated in at least two fire drills a year on each shift and failed to conduct fire drills on each shift at least every three months. This had the potential to affect seven residents (#28, #31, #33, #37, #39, #46 and #47) who were able to self-evacuate and had the potential to affect all 48 residents residing in the facility. Findings include: 1. Review of the fire drills from September 2022 to August 2023 revealed residents who were capable of self-evacuating were only evacuated twice, 01/26/23 at 6:25 A.M. (night shift) and 06/24/23 at 9:36 A.M. (dayshift). Interview with Maintenance Director #602 on 09/11/23 at 11:45 A.M. verified residents capable of self-evacuation were only evacuated twice in the past year. Interview with the Director of Nursing on 09/11/23 at 1:18 P.M. revealed there were seven residents (#28, #31, #33, #37, #39, #46 and #47) who were able to self-evacuate. Review of the Fire ProcedureBased on record review, interview, and policy review the facility failed to ensure residents who were capable of self-evacuating be evacuated in at least two fire drills a year on each shift and failed to conduct fire drills on each shift at least every three months. This had the potential to affect seven residents (#28, #31, #33, #37, #39, #46 and #47) who were able to self-evacuate and had the potential to affect all 48 residents residing in the facility.

Findings include:

1. Review of the fire drills from September 2022 to August 2023 revealed residents who were capable of self-evacuating were only evacuated twice, 01/26/23 at 6:25 A.M. (night shift) and 06/24/23 at 9:36 A.M. (dayshift).

Interview with Maintenance Director #602 on 09/11/23 at 11:45 A.M. verified residents capable of self-evacuation were only evacuated twice in the past year.

Interview with the Director of Nursing on 09/11/23 at 1:18 P.M. revealed there were seven residents (#28, #31, #33, #37, #39, #46 and #47) who were able to self-evacuate.

Review of the Fire Procedure

Based on observation, interview, record review, and policy review the facility failed to ensure Resident #48, who used oxygen, had a No Smoking sign posted on the doorway of his room. This affected one resident (#48) out of four residents (#15, #23, #38, and #48) who are on oxygen. The facility census was 48. Findings include: Review of the medical record revealed Resident #48 was admitted on 09/08/23 with diagnoses including chronic obstructive disease, clostridium difficile, pulmonary disease, pleural effusion, acute respiratory failure with hypoxia, anxiety, heart failure, and emphysema. Review of the September 2023 physician's orders revealed Resident #48 had an order for three liters of oxygen continuous per nasal cannula. Observation on 09/11/23 at 10:45 A.M. with Maintenance Director #602 revealed Resident #48 was using oxygen via a nasal cannula and had an E tank (an approximate three-foot aluminum tank that holds oxygen) in his room. The doorway did not have a No Smoking sign. Interview on 09/11/23 at 10:50 A.M. Maintenance Director #602 verified Resident #48 did not have a No Smoking sign on his doorway. Review of the facility policy labeled Oxygen AdministrationBased on observation, interview, record review, and policy review the facility failed to ensure Resident #48, who used oxygen, had a No Smoking sign posted on the doorway of his room. This affected one resident (#48) out of four residents (#15, #23, #38, and #48) who are on oxygen. The facility census was 48.

Findings include:

Review of the medical record revealed Resident #48 was admitted on 09/08/23 with diagnoses including chronic obstructive disease, clostridium difficile, pulmonary disease, pleural effusion, acute respiratory failure with hypoxia, anxiety, heart failure, and emphysema.

Review of the September 2023 physician's orders revealed Resident #48 had an order for three liters of oxygen continuous per nasal cannula.

Observation on 09/11/23 at 10:45 A.M. with Maintenance Director #602 revealed Resident #48 was using oxygen via a nasal cannula and had an E tank (an approximate three-foot aluminum tank that holds oxygen) in his room. The doorway did not have a No Smoking sign.

Interview on 09/11/23 at 10:50 A.M. Maintenance Director #602 verified Resident #48 did not have a No Smoking sign on his doorway.

Review of the facility policy labeled Oxygen Administration