GOWER CONVALESCENT CENTER, INC

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure staff
maintained all areas in the facility in a clean, comfortable, and home like manner. The
facility census was 64.
1. Observation on 07/24/18 at 2:25 PM showed the following:
– Smoke barrier doors to 200 hall black scuff marks wood chipped on bottom and sides;
-Room door 202 wood chipped and scuffed marks;
-room [ROOM NUMBER] no light fixture cover on ceiling light bulbs exposed part hanging
down;
-room [ROOM NUMBER] door wood chipped on sides and scuff marks on bottom;
-Shower door on 200 hall wood chipped throughout and black scuff marks along the bottom;
-room [ROOM NUMBER] door wood chopped along edges;
-Dust all around air intake on ceiling in hallway by room [ROOM NUMBER];
-Dust all around air intake in hallway by room [ROOM NUMBER];
-room [ROOM NUMBER] door wood chipped black scuff marks on door;
-Mechanical room door by exit on 400 hall chunks of wood missing and chipped;
-Cracking across length of tile flooring between smoke doors by social service office
cracked tiles and small pieces missing.
Observation on 07/25/18 at 8:25 AM showed the following:
– room [ROOM NUMBER] ceiling cracking and flaking around light fixture;
-room [ROOM NUMBER] door wood chipped and cracked;
-room [ROOM NUMBER] black scuff marks on bottom of door;
-Utility room door wood cracked and chipped throughout;
-Bath door on 100 hall door black scuff marks on bottom and wood chipped;
-room [ROOM NUMBER] corner of wall by sink cracked and chipped and exposed metal;
-3 foot long and 2 foot wide of black gorilla tape on the floor in front of exit door on
the 200 hall.
During an interview on 7/27/18 at 10:00 A.M., Maintenance Director said someone put the
gorilla tape on the floor a long time ago to keep a resident from going out the door. He
does environmental rounds on a quarterly basis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, interviews and record review, the facility failed to ensure staff
followed professional standards of care when staff failed to administer eye drops,
inhalers, medications and oxygen correctly which affected three of 27 sampled residents
(Resident # 19, #15, and #17. The facility census was 64.
1. Review of the facility’s ophthalmic medication administration procedures, revised
1/1/09, showed, in part:
– Instillation of medication: steady your hand with the dripper by resting it lightly
against the resident’s forehead. With your other hand, gently pull down the lower lid of
the affected eye and instill the drop into the conjunctival sac along the margin of the
eyelid;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, interviews, and record review, the facility failed to ensure staff
provided proper and complete perineal care for three of 27 sampled residents, (Residents
#12, #40 and #42). The facility census was 64.
1. Review of the facility’s undated competency sheet for perineal care to female resident,
showed, in part:
– Gently wash the inner legs and outer peri area along the outside of the perineal folds.
NOTE: Use a clean area of he wash cloth for each wipe of peri are per care plan;
– Wash the outer skin folds from front to back;
– Wash the inner perineal folds from front to back;
– Gently open all skin folds and wash the inner area from the front to back;
– Wash and dry the anal area.
Review of the facility’s undated competency sheet for perineal care to male resident,
showed, in part:

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, interviews and record review, the facility failed to ensure staff
used proper techniques to reduce the possibility of accidents or injuries during the use
of a mechanical lift, which affected two out of 27 sampled residents, (Residents #34 and
#50), and during the use a gait belt (a safety device and mobility aide used to provide
assistance during transfers, ambulation or repositioning), which affected three residents
(Residents #21, #40 and #41). The facility census was 64.
1. Review of the undated facility policy on the use of mechanical lifts showed:
– Prior to lifting the resident staff should lock the casters.
– Staff should never close the left legs while transporting a resident.
Review of the facility’s, undated Invacare Lift manufacture’s manual, for use of the
mechanical lift showed:
– Staff must always be kept in the open position during lifting and transfers.
– Staff should not lock the rear casters during lifting and transporting.
2. Review of Resident #50’s quarterly Minimum Data Set, a federally mandated assessment
instrument completed by facility staff, dated, 6/6/18, showed:
– Cognitively intact;
– Required extensive assistance of two staff for bed mobility and toilet use;
– Dependent on two staff for transfers;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, interview, and record review, the facility failed to ensure staff
provided proper catheter (sterile tube inserted into the bladder to drain urine) care in a
manner to prevent a urinary tract infection (UTI, an infection of the urinary system), or
the possibility of a UTI, which affected two of 27 sampled residents, ( Resident #48 and
#50). The facility census was 64.
1. Review of the facility’s indwelling catheter drainage bag/leg bag policy, revised
1/19/15, showed, in part:
– The catheter drainage bags will be emptied at the end of the each shift and the output
documented; – – Gloves should be worn, changed and hands washed between each resident;
– The catheter bag and/or tubing must not touch the floor at any time to prevent
contamination and decrease the possibility of a UTI.
Review of the facility’s undated competency sheet for giving peri care with catheter,
showed, in part:
– Separate the perineal folds, and gently wash around the opening of the urethra with soap
and warm water;
– Wash the catheter tubing from the opening of the urethra outward four inches or farther
if needed. Do not pull on the catheter;
– Using a fresh wash cloth, continue washing and rinsing the peri area. Dry the perineal
area.
2. Review of Resident #50’s quarterly Minimum Data Set, (MDS), a federally mandated
assessment instrument completed by facility staff, dated, 6/6/18, showed:
– Cognitively intact;
– Lower extremities impaired on both sides;
– Had a Foley catheter;
– [DIAGNOSES REDACTED].
Review of the resident’s care plan, revised 7/18/18, showed:
– The resident had an indwelling Foley catheter and it put the resident at a greater risk
for UTI’s;
– Give good peri/catheter care each shift and as needed;
– When in bed drainage bag to be in pink tub under bed with dignity cover on it.
Observation on 7/26/18, at 7:01 A.M., showed:
– The resident laid in bed with the drainage bag hanging on the side of the bed and did
not have a cover over it.
– Certified Nurse Aide (CNA) A wiped down each side of the groin with a different wipe
each time;
– CNA A wiped down the middle of the perineal folds;
– CNA A wiped down the catheter tubing toward the insertion site;
– CNA A did not provide peri care to the buttocks.
During an interview on 7/26/18, at 1:26 P.M., NA A said:
– He/she should have wiped away from the insertion site;
– He/she should have provided peri care to the buttocks.
3. Review of Resident #48’s care plan, revised 5/9/18, showed:
– The resident had a history of [REDACTED].
– Provide proper peri care with incontinent episodes and as needed.
Review of the resident’s quarterly MDS, dated , 6/27/18, showed:
– Cognition severely impaired;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and interview the facility failed to ensure that as needed (PRN)
[MEDICAL CONDITION] drugs were limited to 14 days without physician document rationale for
extending any PRN [MEDICAL CONDITION] drugs past 14 days. This affected three out of 27
residents (Resident #9, #19, #52). The facility census was 64.
1. Review of Resident #19’s face sheet showed:
– admitted : 1/27/17;
– [DIAGNOSES REDACTED].
Review of the resident’s quarterly Minimum Data Set, (MDS), a federally mandated
assessment instrument completed by facility staff, dated, 5/16/18, showed:
– Cognitively intact;
– Had four anti-anxiety medication in the last seven days.
Review of the resident’s care plan, revised, 7/19/18, showed:
– The resident used [MEDICAL CONDITION] drugs and was anxious at times;
– Approaches included pharmacy consultant review, review for continued need at least
quarterly, try gradual dose reduction yearly after first year unless contraindicated.
Review of the resident’s physician’s orders [REDACTED].
– an order for [REDACTED].
Review of the resident’s electronic chart (Echart) showed:
– No documentation or rationale from the physician to continue the use of PRN anti-anxiety
medication after 14 days.
2. Record review of resident #9’s quarterly MDS, dated [DATE] showed:
-admission date of [DATE];
-[DIAGNOSES REDACTED].
Review of residents POS dated (MONTH) (YEAR) showed:
-[MEDICATION NAME] .25 mg (for anxiety) every 8 hours as needed, start date of 2/4/18.
Review of residents medical record showed no documentation of rationale from the physician
to continue use of PRN anti-anxiety medication after 14 days.
3. Review of Resident #52’s quarterly MDS, dated ,[DATE], showed:
– Cognitively intact;
– Received antidepressant medications;
– [DIAGNOSES REDACTED].
Review of the resident’s POS, dated (MONTH) (YEAR), showed an order dated 7/27/18 with an
end date open ended for [MEDICATION NAME] (used to treat anxiety), 0.25 milligrams every
eight hours as needed.
Review of the resident’s progress notes, showed the resident’s physician did not provide a
rationale for use of the medication beyond 14 days.
Review of the resident’s consultant pharmacist monthly drug regimen review for 8/1/17
though 7/12/18 showed the consultant pharmacist did not address the resident’s as needed
[MEDICATION NAME].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, interviews, and record reviews the facility failed to ensure staff
administered medications (med) with a less than 5% medication error rate. Facility staff
made three medication errors out of 32 opportunities for error resulting in a medication
error rate of 9.38%. This affected three of 27 sampled residents (Resident #41, #26, #58)
The facility census was 64.
1. The facility policy on med administration, dated 1/9/2009, showed:
– Staff must follow manufacture’s recommendations for mixing medications.
– Staff must always administer the right dose of a medication.
– Staff must always administer medications at the right time.
2 Review of the [MEDICATION NAME] package insert, date 7/2/18, showed:
– The medication was used to treat constipation.
– The medication must be mixed with four to eight ounces of fluid.
Review of Resident #58’s physician order [REDACTED].
Observation on 7/25/18 at 10:00 A.M. of Certified Medication Technician (CMT) B showed
he/she mixed the medication with an unmeasured amount of water and gave the medication to
the resident.
Observation on 7/25/18 at 10:05 of CMT B showed he/she measured the water and found the
glass held three ounces.
During an interview on 7/25/18 at 10:05 A.M. CMT B said he/she should have placed the
[MEDICATION NAME] in at least four ounces of water.
3. Review of the package insert for Humalog insulin, dated 2012, showed:
– The medication was a fast acting insulin.
– The medication should be administered no more than 15 minutes before or immediately
after a meal.
– The most common side effect of the medication was low blood sugar which could be
life-threatening.
Review of Resident #26’s POS, dated (MONTH) 2019, showed an order for [REDACTED].
Observation on 7/25/18 of Licensed Practical Nurse (LPN) C showed:
– At 11:52 A.M. he/she administered to the resident Humalog 10 u sq.
– The resident then went to the dining room but did not receive any food or caloric
fluids.
– At 12:17 staff served the resident a glass of lemonade.
During an interview on 7/25/18 at 12:30 P.M. LPN C said he/she should have ensured the
resident ate within 15 minutes of administering Humalog.
4. Review of the package insert from Novalog flex pen, dated (YEAR), showed after applying
the needle to the Novalog Flex pen and before administering the medication to the
resident, staff must prime the needle with 2 u of insulin to clear the air from the
needle.
Review of Resident #41’s POS, dated (MONTH) (YEAR), showed an order for [REDACTED].
Observation on 7/25/18 at 12:09 P.M. of LPN administering medication to the resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, interviews, and record review, the facility failed to ensure staff
properly stored controlled substances (substances with a high probability abuse) which
affected two of 27 sampled residents, (Resident #6 and #48). The facility was 64.
1. Review of the facility’s stability and storage of medications policy, revised, 1/1/09,
showed:
– It did not address how staff should handle narcotic pain medication when the bubble pack
(a package enclosing medications in transparent dome-shaped plastic on a flat cardboard
backing), had been punctured.
2. Observation and interview on 7/24/18 at 2:34 P.M., of the north hall medication cart,
showed:
– Resident #48 had a bubble pack of [MEDICATION NAME] 5-325 milligrams (mg.), one every
four hours as needed during the night for pain;
– The bubble pack had four tablets which had been taped on the back with puncture holes
noted;
– The Quality Assurance (QA) Nurse said some of the staff have long fingernails and they
puncture the bubble pack, so the staff tape the back of the bubble pack.
3. Observation on 7/24/18 at 2:14 P.M. of Certified Medication Technician (CMT) B and CMT
C counting controlled substances showed Resident #6’s bubble pack of [MEDICATION NAME] (a
narcotic pain reliever) 5 milligrams (mg) / 325 mg with blister #19 torn the with of the
tablet inside.
During an interview on 7/24/18 at 2:15 P.M. both CMTs said they should discard any
medications behind torn blisters.
4. During an interview on 7/27/18, at 9:04 A.M., the Director of Nursing (DON) said:
– If the bubble pack had been punctured, staff should write it up to be destroyed;
– If it was a small hole, staff should get a second person to verify the medication and
put a colored sticker on it;

Based on observation and interview the facility failed to ensure they stored and prepared
food under sanitary conditions when staff stored food on the floor, failed to keep food
sealed, labeled, dated. Additionally, staff did not wash hands during meal service and
failed to wear beard nets when preparing and serving food. The facility census was 64.
1. Review of facility food storage policy, dated 11/2/2016 showed:
-All food will be stored on shelves;
– No food will be stored directly on any floor surface;
-All opened or prepared foods will be stored in air tight/sealable containers;
-All containers will be labeled and dated.
Observation on 07/24/18 at 9:06 AM in the kitchen showed the following:
-Walk in freezer had open bags of chicken strips and hash brown patties not dated;
– 3 bags of french fries, 2 bags of hash browns, and garlic bread used and not dated;
-Two large cans of applesauce on floor in pantry;
-Large fan covered in dust turned on and pointed in direction where clean dishes come out
of dishwasher.
Observation on 07/25/18 at 12:08 PM showed Dietary Aide A;
– Brought a food cart to north dining room;
– Without washing hands, applied gloves and picked up a grilled cheese and cut in halves;
-Handled plates, bread, and meal cards;
-Gave four crackers to resident and touched resident hands;
-Used tongs in one hand and other hand to scoop salad in individual bowls for residents;
-Grabbed buttered bread and put on plate;
– Continued to handle food throughout the meal service with the same pair of gloves and
without washing hands.
Observation on 7/25/18 at 9:45 A.M. showed the following:
-Dietary cook with a beard and goatee preparing lunch with no beard net;
-Fan still covered in dust blowing on clean dishes;
-Food still undated, not sealed, not labeled and used bag of chicken breast not dated in
walk in freezer;
-Back wall over three compartment dink and dishwashing area covered in various rust stains
and dust;
-Cook dishing plates for main dining room with beard and goatee and no beard net.
Observation on 7/26/18 at 7:08 AM showed Dietary manager dishing breakfast plates behind
steam table had a beard and no beard net on.
During an interview on 7/27/18 at 9:35 A.M., Dietary Supervisor said food should be off
the floor, sealed, dated. They have a weekly cleaning schedule, and maintenance is
responsible for cleaning the fan. They do have beard nets, but the cook since the cooks
beard was trimmed, did not need beard net.
During an interview on 7/27/18 at 10:16 A.M., Dietary Manager said food should be sealed,
labeled, and dated, and nothing stored on the floor. They have beard nets, but was told by
someone as long as their beard is not longer than eyebrow length, they do not need to wear
them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to establish an antibiotic
stewardship program that includes antibiotic use protocols and a system to monitor
antibiotic use. This deficient practice had the potential to affect all residents in the
facility. The facility census was 64.
1. Record review showed the facility had not developed or implemented an Antibiotic
Stewardship Program that should include:
– Protocols to optimize the treatment of [REDACTED].
– Procedure to reduce the risk of adverse events, including the development of
antibiotic-resistant organisms, from unnecessary or inappropriate antibiotic use;
– Procedure to promote and implement a facility-wide system to monitor the use of
antibiotics including a system of reports related to monitoring antibiotic usage and
resistance data;
– Designated appropriate facility staff accountable for promoting and overseeing
antibiotic stewardship;
– Accessing pharmacists and others with experience or training in antibiotic stewardship;
– Implementation of a policy or practice to improve antibiotic use;
– Regular reporting on antibiotic use and resistance to relevant staff such as prescribing
clinicians and nursing staff;
– Educate staff and residents about antibiotic stewardship.
During a joint interview on 7/25/18 at 8:25 A.M., the Director of Nurses said she had a
thick stack of forms from Antibiotic Stewardship webinars, but had not yet gone through
and pulled out what she wanted to use for the facility. The Administrator said there was
no formal Antibiotic Stewardship policy in place for the facility, it is a work in
progress.