Inspection·June 9, 2022

F 000 INITIAL COMMENTS

F 000 An unannounced recertification survey and complaint survey for complaint number 2022007186 was conducted on through at Oak Hammock at the University of Florida Inc. The allegations contained in the complaint were not substantiated. The facility was in noncompliance with 42 CFR 483. Requirements for Long Term Care Facilities.

F 658 Services Provided Meet Professional Standards SS=D CFR(s): 483.21(b)(3)(i) $483.21(b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (i) Meet professional standards of quality. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure the services provided for tube care met professional standards of quality to 5 residents with tube, Resident #26, in a total sample of 25 residents. Findings include: During an observation on beginning at 9:50 AM, Staff A, Licensed Practical Nurse (LPN), entered Resident #26's room. Staff A explained that she would be giving his morning medications through his tube, (G tube). Staff A sanitized her the resident's medications from the medication cart. Staff A placed the medications in the individual cup. Staff A crushed all the

F000 Preparation and execution of this plan of correction does not constitute admission or agreement by the provider of the terms or conclusions set forth in the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required by provisions of the Federal and State laws.

F658 IMMEDIATE CORRECTIVE ACTION 1. (Staff A, LPN, was immediately in-serviced and counseled on the facility's practice guidelines for verifying the placement prior to giving flushes or administering medications. Resident #26 was assessed by DON to PLAN OF CORRECTION AND PLAN OF DEFICIENCIES C OAK HAMMOCK AT THE UNIVERSITY OF FLORIDA INC 2660 SW 53RD LN GAINESVILLE, FL 32608 PREFIX ID PREFIX DEFICIENCY) COMPLETION DATE

F 658 Continued From page 1 pills individually. Staff A entered the resident's room and placed all medications on a bedside table. Staff A donned a pair of gloves and opened a new feeding syringe. Staff A checked the resident's identification. Staff A exposed the resident's abdomen to visualize his GJ tube. Staff A immediately flushed the GJ tube with 15 milliliter (ml) water. Staff A did not check for tube placement, did not do visual check for tube placement, and did not check for residual prior to flushing the GJ tube with 15 ml water. Staff A proceeded to administer all the medications separately with 10 ml of water. Staff A flushed the GJ tube after each medication administration. Staff A made a final flush with 60 ml of water. Staff A cleaned the bedside table, washed her . . . in the bathroom sink, then exited the resident's room at 10:12 AM. During an interview with Staff A, LPN, on at 10:13 AM, when asked why she did not check for tube placement, Staff A stated, "Our DON (Director of Nursing) told us that we no longer need to check for tube placement. We only check for residuals. DON stated that we are injecting too much air into the tube. Sorry, I forgot to check for residual." During an interview with the DON on . . . at 3:10 PM, when asked what the policy on medication administration via GJ tube is, the DON stated, "The latest best practice in literature is that we do not put air any longer, but nurse is supposed to check for residual, do visual check of the tube for placement, and if suspicious, we get an order for x-ray." Review of the facility policy and procedure titled "Medication Administration via . . . Tube" with

F 658 verify placement of . . . and assessed for any injury. Resident #26 was free of injury and . . . was verified to be in place. IDENTIFICATION OF RESIDENTS 1. The facility has determined that all residents with . . . have the potential of being affected. 2. All residents with . . . were audited to ensure process for verifying placement of . . . were in place. Those identified that are at risk were reviewed, and modifications have been made to physician orders and care plan. SYSTEMATIC CHANGES 3. The policy for verifying placement of . . . was revised and shared with the QAPI committee on 4. All licensed nursing staff will be updated on changes of policy and retrained on the . . . policies for verifying placement according to the facility .s practice guidelines. 5. In-service training includes observation of each nurse performing the procedure. A validation checklist will be completed for each nurse to determine if the nurse is performing the procedure correctly. Findings will be reviewed with each nurse. Corrective action/education will be provided as needed. Staff who have not received in-serviced by required to complete prior to returning to C 106066 06/09/2022 OAK HAMMOCK AT THE UNIVERSITY OF FLORIDA INC 2660 SW 53RD LN GAINESVILLE, FL 32608 PREFIX ID PREFIX DEFICIENCY) COMPLETION DATE

F 658 Continued From page 2 a revision date of ... reads, "Policy: It is the policy of this facility to ensure the safe and effective administration of medications via ... by utilizing best practice guidelines ... 9. Procedure: ... h. Check that tube is in place. ... h. Check external tube and if suspected of dislodgement, notify doctor to get x-ray. 1. Check residual per physicians' order."

F 658 work. MONITORING 1. Director of Nursing Services (DON), or designee, will complete audits with two nurses performing verification procedures on two residents, 3 times weekly x 4 weeks, then monthly x 2 months to ensure nurses are performing the procedure in accordance with our facility's practice guidelines. 2. Director of Nursing Services (DON), or designee, will report and discuss findings of audits at the QAPI committee monthly x 90 days for input on the need to increase, decrease or discontinue the auditing.

F 880 ... Prevention & Control SS=D CFR(s): 483.80(a)(1)(2)(4)(e)(f)

F 880 $483.80 Control The facility must establish and maintain an prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable and $483.80(a) prevention and control program. The facility must establish an prevention and control program (IPCP) that must include, at a minimum, the following elements: $483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling and communicable for all residents, staff, volunteers, and other individuals. C 06/09/2022 OAK HAMMOCK AT THE UNIVERSITY OF FLORIDA INC 2660 SW 53RD LN GAINESVILLE, FL 32608 PREFIX DATE DEFICIENCY)

F 880 Continued From page 3 F 880 providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards: §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable or before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable or should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of ( ) When and how isolation should be used for a resident, including but not limited to: (A) The type and duration of the isolation, depending upon the agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable or skin from direct contact with residents or their food, if direct contact will transmit the ; and (vii)The hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. LIST OF DEFICIENCIES C 06/09/2022 OAK HAMMOCK AT THE UNIVERSITY OF FLORIDA INC 2660 SW 53RD LN GAINESVILLE, FL 32608 PREFIX (EACH UPDATE MUST BE PRECEDED BY FULL PREFIX DEFICIENCY) (X8) COMPLETION DATE

F 880 Continued From page 4 F 880 Personnel must handle, store, process, and transport linens so as to prevent the spread of $483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to maintain an infection and control program to help prevent the possible development and transmission of communicable and The facility failed to ensure staff performed hygiene during change for Resident #33, and during medication administration for Resident #31, in a total sample of 25 residents. Findings include: 1. During an observation on at 8:42 AM, Staff B, Licensed Practical Nurse (LPN), was preparing to administer the morning medications for Resident #31. Staff B entered Resident #31's room with his medications and a portable/ ( ) apparatus that was on top of her medication cart. Staff B did not sanitize the apparatus before she entered the resident's room. Staff B immediately applied the apparatus on Resident #31's right and obtained a reading of Staff B administered the scheduled medications, then exited the room at 8:51 AM. Staff B did not sanitize or the apparatus after use and placed the apparatus on to the medication cart.

F880 IMMEDIATE CORRECTIVE ACTION 1. Staff B, LPN, was immediately in-serviced and counseled on the proper procedures for cleaning and of resident care equipment. Staff B was retrained with return demonstration/competency on the cleaning and of equipment. 2. Staff C, LPN, was immediately in-serviced and was retrained with return demonstration/competency on the handwashing, gloving and care policies. Resident #33 was assessed by Care RN for signs and symptoms of No issues or concerns were identified. has been assessed daily with treatment to monitor for any signs and symptoms of IDENTIFICATION OF RESIDENTS 1. The facility has determined that all residents that require the use of resident care equipment have the potential of being affected. Preventionist immediately ensured all resident care equipment was cleaned and All resident: s vital signs in Staff B: s STATE SURVEY AGENCY LIST OF DEFICIENCIES C 06/09/2022 OAK HAMMOCK AT THE UNIVERSITY OF FLORIDA INC 2660 SW 53RD LN GAINESVILLE, FL 32608 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETION DATE

F 880 Continued From page 5

F 880 During an interview with Staff B, LPN, on at 10:05 AM in the presence of the Director of Nursing (DON), when asked what the process was to care for equipment for multiple resident use, Staff B stated, "Like a cuff, we sanitize them before and after use with a sanitizer wipe, leave for 2 minutes to dry. I have sanitizer wipes in my medication cart." When asked why she failed to sanitize the cuff, Staff B replied, "I was so nervous." Review of the facility policy and procedures titled "Cleaning and Equipment" reviewed on of Residents-Care Policy: Resident-Care equipment can be a source of indirect transmission of. Reusable resident-care equipment will be cleaned in accordance with current CDC (Centers for Prevention) recommendations in order to break the chain of Control and Compliance Guidelines: 1. Staff shall follow established control principles for cleaning and reusable equipment. General guidelines include: ... d. Multiple-resident use equipment shall be cleaned and after each use. e. Most equipment may be cleaned/ in the areas in which the equipment is used." 2. During an observation on at 11:25 AM, Staff C, LPN, accompanied Staff #, Registered Nurse (RN), entered Resident #33's room to change. All supplies were on a paper barrier over bedside table. Staff C washed her and donned a pair of gloves. Staff C exposed the resident's left used a sanitized scissors to cut old dated . The left heel had assigned area were monitored for signs and symptoms of spread of with no issues found. Audits have been performed and no additional issues have been found. 2. The facility has determined that all residents with care orders in place have the potential of being affected. Care RN audited all residents with treatments and no issues were found. SYSTEMATIC CHANGES 1. The policy for cleaning and of resident care equipment was reviewed and remains current. 2. All licensed nursing staff will be in-serviced on the facility's Cleaning and of Resident Care Equipment policy and Practice Guideline. In-service training includes observation of all nursing staff performing the procedure. A validation checklist will be completed for each nurse to determine if the nurse is performing the procedure correctly. Findings will be reviewed with each nurse. Corrective action will be provided as needed. 3. The policies for care, which include handwashing and gloving, were reviewed and remain current. 4. All licensed nursing staff will be retrained on the facility's care policies and perform a handwashing/glove use return demonstration/competency. Staff who C 06/09/2022 106066 OAK HAMMOCK AT THE UNIVERSITY OF FLORIDA INC 2660 SW 53RD LN GAINESVILLE, FL 32608 PREFIX PREFIX COMPLETION DATE

F 880 Continued From page 6 F 880 an open ... approximately 10 centimeter in diameter. The ... was macerated, no drainage, surrounding tissue is pink. Staff C replaced gloves and washed ... in sink. Staff C cleansed the ... with normal ... Staff C did not replace the gloves after cleansing the ... Staff C immediately applied a dime size on the ... then applied in a 4 x 4 gauze, used a Kerlix roll and wrapped the left heel. Staff C dated the ... During an interview with Staff D, RN, on at 10:40 AM, confirmed that Staff C failed to wash her ... and change gloves before applying the ( ... ). Staff D stated, "She was very nervous." Review of the facility policy and procedures titled Treatment" with a revision date of reads, "Policy: The facility completes accurate documentation of ... assessments and treatments, including response to treatment, change in condition, and changes in treatment." Review of the facility's Hygiene Table showed ... hygiene with either soap and water or ... rub before applying and after removing personal protective equipment (PPE), including gloves; before and after handling clean or soiled ... linen, etc.; and after handling items potentially contaminated with ... or ... have not received in-service by ... will be required to complete prior to returning to work. 1. All licensed staff will be in-serviced on proper ... hygiene procedures and complete Online Nursing Home Covid-19 Training modules 1 and 6 provided by CMS. Staff who have not received in-service by ... will be required to complete prior to returning to work. Preventionist completed CDC Online Prevention training coursework including module 1 on ... module 6A on ... and module 6B on ... MONITORING 1. Director of Nursing Services (DON), or designee, will perform visual audits of two licensed staff cleaning and resident care equipment being used on five residents, 3 times weekly x 4 weeks, then monthly x 2 months to ensure procedure is performed correctly. 2. Director of Nursing Services (DON), or designee, will perform audits of two licensed staff performing handwashing/gloving during ... care with five residents, 3 times weekly x 4 weeks, then monthly x 2 months to ensure procedure is performed correctly. 3. Preventionist will perform competency of all licensed staff performing proper ... hygiene per facility protocol that aligns with CDC ... C 06/09/2022 106066 OAK HAMMOCK AT THE UNIVERSITY OF FLORIDA INC 2660 SW 53RD LN GAINESVILLE, FL 32608 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETION DATE

F 880 Continued From page 7

F 880 hygiene. Audits will continue for 3 times weekly observing 2 licensed staff, x 4 weeks, then monthly x 2 months to ensure procedure is performed correctly. Licensed staff will demonstrate competent washing techniques with corrective education provided as needed by Preventist, or Director of Nursing, to ensure procedure is performed correctly. 4. Director of Nursing Services (DON), or designee, will report and discuss audit findings of cleaning and resident care equipment at the QAPI committee monthly x 90 days for input on the need to increase, decrease or discontinue the auditing. 5. Director of Nursing Services (DON), or designee, will report and discuss findings of handwashing/gloving during care at the QAPI committee monthly x 90 days for input on the need to increase, decrease or discontinue the auditing. 6. Preventist, or designee, will report and discuss findings of proper hygiene competencies and visual audits at the QAPI committee monthly x 90 days to ensure direct care staff is performing the procedure in accordance with our facility :s practice guidelines. ROOT CAUSE ANALYSIS COMPLETED 6/20/22 1. Staff B, LPN, and Staff C, LPN, exhibited deficiencies in control as a result of internal factors, such as C 06/09/2022 OAK HAMMOCK AT THE UNIVERSITY OF FLORIDA INC 2660 SW 53RD LN GAINESVILLE, FL 32608 PREFIX PREFIX COMPLETION DATE

F 880 Continued From page 8 F 880 nervousness during review by surveyors. Upon interviews with both key staff members, nurses were able to verbally explain control processes in correct form, and subsequently demonstrate proper techniques. Incorrect actions occurred due to inconsistency in routine observations of staff performing control procedures. 35961003 C 06/09/2022 OAK HAMMOCK AT THE UNIVERSITY OF FLORIDA IN 2660 SW 53RD LN GAINESVILLE, FL 32608 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE

N 000 INITIAL COMMENTS

N 000 An unannounced re-licensure survey and complaint investigation (complaint number 2022007186) was conducted at Oak Hammock at the University of Florida Inc on through . The allegations contained in the complaint were not substantiated. Deficient practice was identified at the time of the survey.

N 201 400.022(1)(f), FS Right to Adequate and SS=D Appropriate Health Care

N 201 (f) The right to receive adequate and appropriate health care and protective and support services, including social services; mental health services, if available; planned recreational activities; and therapeutic and rehabilitative services consistent with the resident care plan, with established and recognized practice standards within the community, and with rules as adopted by the agency. This Statute or Rule is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure residents received appropriate health care services consistent with established and recognized practice standards with the community. The facility failed to ensure staff performed hygiene during change for Resident #33, and during medication administration for Resident #31, and the facility failed to ensure the services provided to tube care met professional standards of quality to 1 of 5 residents with tube, Resident #2, in a total sample of 25 residents. Findings include:

N000 Preparation and execution of this plan of correction does not constitute admission or agreement by the provider of the terms or conclusions set forth in the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required by provisions of the Federal and State laws.

N201 IMMEDIATE CORRECTIVE ACTION 1. Staff B, LPN, was immediately in-serviced and counseled on the proper procedures for cleaning and resident care equipment. Staff B was retrained with return /22 STATE FORM 6809 C8KN11 C 35961003 06/09/2022 OAK HAMMOCK AT THE UNIVERSITY OF FLORIDA IN 2660 SW 53RD LN GAINESVILLE, FL 32608 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE

N 201 Continued From page 1

N 201 1. During an observation on at 8:42 AM, Staff B, Licensed Practical Nurse (LPN), was preparing to administer the morning medications for Resident #31. Staff B entered Resident #31's room with his medications and a portable/ apparatus that was on top of her medication cart. Staff B did not sanitize the apparatus before she entered the resident's room. Staff B immediately applied the apparatus on Resident #31's right and obtained a reading of Staff B administered the scheduled medications, then exited the room at 8:51 AM. Staff B did not sanitize or the apparatus after use and placed the apparatus on to the medication cart. During an interview with Staff B, LPN, on at 10:05 AM in the presence of the Director of Nursing (DON), when asked what the process was to care for equipment for multiple resident use, Staff B stated, "Like a cuff, we sanitize them before and after use with a sanitizer wipe, leave for 2 minutes to dry. I have sanitizer wipes on my medication cart." When asked why she failed to sanitize the cuff, Staff B replied, "I was so nervous." Review of the facility policy and procedures titled "Cleaning and of Residents-Care Equipment" reviewed on reads, Policy: Resident Care equipment can be a source of indirect transmission of Reusable resident-care equipment will be cleaned and in accordance with current CDC (Centers for Prevention) recommendations in order to break the chain of Policy Explanation and Compliance Guidelines: 1. Staff shall follow established control principles for demonstration/competency on the cleaning and of equipment. 2. Staff C, LPN, was immediately in-serviced and was retrained with return demonstration/competency on the handwashing, gloving and care policies. Resident #33 was assessed by Care RN for signs and symptoms of . No issues or concerns were identified. has been assessed daily with treatment to monitor for any signs and symptoms of 3. Staff A, LPN, was immediately in-serviced and counseled on the facility's practice guidelines for verifying the placement prior to giving flushes or administering medications. Resident #26 was assessed by DON to verify placement of and assessed for any injury. Resident #26 was free of injury and was verified to be in place. IDENTIFICATION OF RESIDENTS 1. The facility has determined that all residents that require the use of resident care equipment have the potential of being affected. Preventioist equipment was ensured all resident care equipment was cleaned and All resident is vital signs in Staff B's assigned area were monitored for signs and symptoms of spread of with no issues found. Audits have been performed and no additional issues have been found. STATE FORM notes C8KN11 35961003 C 06/09/2022 OAK HAMMOCK AT THE UNIVERSITY OF FLORIDA IN 2660 SW 53RD LN GAINESVILLE, FL 32608 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE

N 201 Continued From page 2

N 201 cleaning and ... reusable equipment. General guidelines include: ... d. Multiple-resident use equipment shall be cleaned and equipment may be cleaned/ e. Most after each use. in the areas in which the equipment is used* 2. During an observation on at 11:25 AM, Staff C, LPN, accompanied by Staff D, Registered Nurse (RN), entered Resident #33's room to change ... change. All supplies were on a paper barrier over bedside table. Staff C washed her and donned a pair of gloves. Staff C exposed the resident's left ... used a sanitized scissors to cut old ... dated. The left heel had an open ... approximately 10 centimeter in diameter. The ... was macerated, no drainage, surrounding tissue was pink. Staff C replaced gloves and washed in sink. Staff C cleansed the ... with normal ... Staff C did not replace the gloves after cleansing the ... Staff C immediately applied a dime size on the ... then applied in a 4 x 4 gauze, used a Kenrix roll and wrapped the left heel. Staff C dated the ... During an interview with Staff D, RN, on at 10:40 AM, confirmed that Staff C failed to wash her ... and change gloves before applying the ... ( ... ). Staff D stated, "She was very nervous." Review of the facility policy and procedures titled "Treatment" with a revision date of reads, "Policy: The facility completes accurate documentation of ... assessments and treatments, including response to treatment, change in condition, and changes in treatment." Review of the facility's Hygiene Table 2. The facility has determined that all residents with ... care orders in place have the potential of being affected. Care RN audited all residents with ... treatments and no issues were found. 3. The facility has determined that all residents with ... have the potential of being affected. 4. All residents with ... were audited to ensure process for verifying placement of ... were in place. Those identified that are at risk were reviewed, and modifications have been made to physician orders and care plan. SYSTEMATIC CHANGES 1. The policy for cleaning and of resident care equipment was reviewed and remains current. 2. All licensed nursing staff will be in-serviced on the facility's Cleaning and of Resident Care Equipment policy and Practice Guideline. In-service training includes observation of all nursing staff performing the procedure. A validation checklist will be completed for each nurse to determine if the nurse is performing the procedure correctly. Findings will be reviewed with each nurse. Corrective action will be provided as needed. 3. The policies for ... care, which include handwashing and gloving, were reviewed and remain current. STATE FORM notes C8KN11 STATE FORM notes C8KN11 35961003 C 06/09/2022 OAK HAMMOCK AT THE UNIVERSITY OF FLORIDA IN 2660 SW 53RD LN GAINESVILLE, FL 32608 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE

N 201 Continued From page 3 showed hygiene with either soap and water or based rub before applying and after removing personal protective equipment (PPE), including gloves; before and after handling clean or soiled linen, linen, etc.; and after handling items potentially contaminated with or or 3. During an observation on beginning at 9:50 AM, Staff A, Licensed Practical Nurse (LPN), entered Resident #26's room. Staff A explained that she would be giving his morning medications through his, tube (GJ tube). Staff A sanitized her and prepared to pull the resident's medications from the medication cart. Staff A placed the medications into the individual medication cup. Staff A crushed all the pills individually. Staff A entered the resident's room and placed all medications on a bedside table. Staff A donned a pair of gloves and opened a new feeding syringe. Staff A checked the resident's identification. Staff A exposed the resident's abdomen to visualize his GJ tube. Staff A immediately flushed the GJ tube with 15 milliliter (ml) water. Staff A did not check for tube placement, did not do visual check for tube placement, and did not check for residual prior to flushing the GJ tube with 15 ml water. Staff A proceeded to administer all the medications separately with 10 ml of water. Staff A flushed the GJ tube after each medication administration. Staff A made a final flush with 60 ml of water. Staff A cleaned the bedside sink, washed her in the bathroom sink, then exited the resident's room at 10:12 AM. During an interview with Staff A, LPN, on at 10:13 AM, when asked why she did not check for tube placement, Staff A stated, "Our DON (Director of Nursing) told us that we no

N 201 4. All licensed nursing staff will be retrained on the care policies and perform a handwashing/glove use return demonstration/competency. All licensed staff will be in-serviced on proper hygiene procedures and complete Online Nursing Home Covid-19 Training modules 1 and 6 provided by CMS. Staff who have not received in-service by will be required to complete prior to returning to work. Online Prevention completed CDC Prevention training coursework including module 1 on and module 6A on and module 6B on 5. The policy for verifying placement of was revised and shared with the QAPI committee on 6. All licensed nursing staff will be updated on changes of policy and retrained on the policies for verifying placement according to the facility's practice guidelines. 7. In-service training includes observation of each nurse performing the procedure. A validation checklist will be completed for each nurse to determine if the nurse is performing the procedure correctly. Findings will be reviewed with each nurse. Corrective action/education will be provided as needed. Staff who have not received in-serviced by will be required to complete prior to returning to work. 35961003 C 06/09/2022 OAK HAMMOCK AT THE UNIVERSITY OF FLORIDA IN 2660 SW 53RD LN GAINESVILLE, FL 32608 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE

N 201 Continued From page 4

N 201 longer need to check for tube placement. We only check for residuals. DON stated that we are injecting too much air in the tube. Sorry, I forgot to check for residual." During an interview with the DON on 3:10 PM, when asked what the policy on medication administration via GJ tube is, the DON stated, "The latest best practice in literature is that we do not put in air any longer, but nurse is supposed to check for residual, do visual check of the tube for placement, and if suspicious, we get an order for x/ray." Review of the facility policy and procedure titled "Medication Administration via Tube" with a revision date of ___ reads, "Policy: It is the policy of this facility to ensure the safe and effective administration of medications via ___ by utilizing best practice guidelines ... 9. Procedure: ... h. Check that tube is in place. Check external tube and if suspected of dislodgement, notify doctor to get x/ray. 1. Check residual per physicians' order." Class III MONITORING 1. Director of Nursing Services (DON), or designee, will perform visual audits of two licensed staff cleaning and resident care equipment being used on five residents, 3 times weekly x 4 weeks, then monthly x 2 months to ensure procedure is performed correctly. 2. Director of Nursing Services (DON), or designee, will perform audits of two licensed staff performing handwashing/gloving during care with five residents, 3 times weekly x 4 weeks, then monthly x 2 months to ensure procedure is performed correctly. 3. ... Preventist will perform competency of all licensed staff performing proper ___ hygiene per facility protocol that aligns with CDC hygiene. Audits will continue for 3 times weekly observing 2 licensed staff, x 4 weeks, then monthly x 2 months to ensure procedure is performed correctly. Licensed staff will demonstrate competent washing techniques with corrective education provided as needed by Preventist, or Director of Nursing, to ensure procedure is performed correctly. 4. Director of Nursing Services (DON), or designee, will report and discuss audit findings of cleaning and ___ resident care equipment at the QAPI committee monthly x 90 days for input on the need to increase, decrease or discontinue the auditing. STATE FORM notes C8KN11

N 201 Continued From page 5 N 201 5. Director of Nursing Services (DON), or designee, will report and discuss audit findings of handwashing/gloving during care at the QAPI committee monthly x 90 days for input on the need to increase, decrease or discontinue the auditing. 6. ... Preventionist, or designee, will report and discuss findings of proper hygiene competencies and visual audits at the QAPI committee monthly x 90 days to ensure direct care staff is performing the procedure in accordance with our facility's practice guidelines. 7. Director of Nursing Services (DON), or designee, will complete audits with two nurses performing verification procedures on two residents, 3 times weekly x 4 weeks, then monthly x 2 months to ensure nurses are performing the procedure in accordance with our facility's practice guidelines. 8. Director of Nursing Services (DON), or designee, will report and discuss findings of audits at the QAPI committee monthly x 90 days for input on the need to increase, decrease or discontinue the auditing.