Every finding on record at Candler Skilled Nursing Unit

Based on observations, staff interviews, record reviews, and review of facility policies Isolation Categories, Central Venous Catheters, and Hand Hygiene), the facility did not ensure that nurses consistently followed infection control practices during peripheral venous catheter infusions for two residents(R) (R12, R50), peripheral catheter care for one (R) (R12), wound care for one (R) (R39), and bed linen handling for two (R) (R9, R12). These practices created the potential risk for infection due to contamination. Findings Include:Review of the facility's policy titled, Isolation Categories, dated 8/8/2023, section I. Standard Precautions revealed that A. Purpose: To prevent the transmission of infections which are spread by direct or indirect contact with infective blood or body fluids.3. Requirements: b. Handwashing with an antimicrobial soap or hand sanitizing with an alcohol based handrub must be performed before and after glove use, before and after touching the patient and or potentially contaminated articles, before leaving the room, and before taking care of another patient.c. A cover gown is required if contamination of clothing with blood or body fluid is likely/can be anticipated. Review of the facility's policy titled, Central Venous Catheters, dated 5/28/2025, the Policy Statement revealed that It shall be the policy of [Facility Name] to care for patients needing central venous access including single, multi-lumen, or large bore catheters and maintain the catheters for patients who have them. D. Dressing Change: Note: A second caregiver (nurse or PCT) must be present to assist with maintaining a sterile field. Review of facility's policy titled, Hand Hygiene, dated 9/26/2025, the Policy Statement revealed that It shall be the be the policy of [Facility Name] to reduce the risk fo spread of infection among co-workers and patient populations. [Facility Name] recognizes that proper hand hygiene is the single most effective means of preenting and controlling the spread of infection. Section Procedures revealed that B. Indications for use of Alochol-Based Hand Rub:.1.Upon entering room, 2. Before having direct contact with patients, 3. Before inserting devices, 4. After contact with patient's intact skin, 5. After contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings, only if hands are not visibly soiled, 6. When moving from a contaminated body site to a clean body site during patient care, 8. Gloves are not a replacement for hand hygiene. Hands will be washed or alcohol-based hand rub used immediately before and immediately after wearing gloves.Review of the Face Sheet revealed that R12 was admitted on [DATE] for a diagnosis of acute kidney injury on chronic kidney injury.Review of Five Day Scheduled Minimum Data Set (MDS) for R12, dated 03/18/2026, revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 6 (indicating severe cognitive impairment). Section GG (Functional Abilities and Goals) documented that the resident required partial to moderate assistance for activities of daily living (ADL) Section I (Active Diagnosis) revealed diagnosis of but not all-inclusive non-Alzheimer's dementia, acute kidney failure (AKF), Hypertension (HTN), chronic kidney disease (CKD), and atrial fibrillation. Section O (Special Treatments, Procedures, and Programs) revealed that residents were receiving intravenous (IV) medications and antibiotics.Review of the care plan for R12, dated 03/14/2026, revealed a focus are that resident has an infection of sepsis. Interventions included administering medications as per physician's order, monitor for signs and symptom's adverse reactions to medications, reporting signs and symptoms of worsening infection to resident's physician and hospice, and determine resident/family wishes regarding antibiotic interventions.Review of the physician orders revealed that R12 had an order for meropenem [IV antibiotic] 500 mg {milligrams} administered intravenously every 12 hours. Sodium chloride 0.9 percent flush ten mg intravenously three times a day at 4:00AM, 12:00 PM, 8:00 PM. Observation on 03/25/2026 at 10:12 AM revealed that Licensed Practical Nurse (LPN) FF revealed that her hands were clean upon entering room and applied gloves. She was not wearing a gown. She prepared the Meropenem (IV antibiotic) by priming the IV line. She cleaned hand and changed gloves. She cleaned the line, flushed the line, and drew back blood. She connected the IV antibiotic to the resident's peripheral inserted central catheter (PICC) in the right arm. She then started the IV pump.Interview with LPN FF on 03/25/2026 at 2:53 PM revealed that she was not wearing a gown during the IV infusion. She states that R12 was not under enhanced barrier precautions. She states she is under standard precautions. She states a gown was not necessary only if pulling out the line.Observation on 03/25/2026 at 4:44 PM with the Director of Nursing (DON) and LPN FF revealed that supplies were prepared. The DON and LPN FF were not wearing gowns. The DON performed hand hygiene and applied gloves. She used an alcohol wipe along the edge of the dressing. She then applied sterile gloves from the central dressing kit. She removed the dressing and the Biopatch with the sterile gloves. The same gloves used to remove the dressing and Biopatch were then used to remove gray gloves from the box on the wall, and she applied the new gloves. She cleaned the area with an alcohol swab, followed by a chlorhexidine swab using a back and forth motion. She removed her gloves and sanitized her hands. She applied a new pair of gray gloves from the box on the wall, placed the Biopatch around the line, applied a stabilizer to the arm, connected the PICC line to the stabilizer, and applied the sterile dressing on top.Interview on 03/25/2026 at 5:04 PM with the DON confirmed that she used the sterile gloves to remove the dressing. She admits that she should have had the other nurse obtain another pair of sterile gloves. She admits that she used up and down motion to clean the site. She confirmed that cleaning a PICC line site after removing the dressing was a sterile procedure. She admits that she was not wearing a gown during the procedure. Record Review revealed that R50 was admitted on [DATE] with a diagnosis of obstructive uropathy, leiomyosarcoma, chronic malnutrition on TPN (Total Parental Nutrition) with PEG (percutaneous endoscopic gastrostomy) feeding tube, urine foley catheter in place, and peripheral venous catheter to the left arm. Review of physician orders dated 03/25/2026 revealed an order Fluconazole (antifungal) 400 mg (milligrams) intravenously every 24 hours.Observation on 03/25/2026 at 10:30 AM revealed Registered Nurse (RN) DD revealed that she did not wear a gown during the care provided to residents. RDDD connected the IV line after cleaning the site and started the infusion.Interview on 03/25/2026 at 1:51 PM with RN DD revealed that she had not been wearing a gown during the administration of R50's antifungal infusion. She stated that she had never been instructed to wear a gown for this task. RN DD reported that residents were placed under standard precautions, which, according to her understanding, required the use of gloves.Observation on 03/25/2026 at 11:17 AM of RN DD complete wound care of R 39. She had supplies set up in room on bedside table. She was not wearing a gown. She had medication cart in room. RN DD sanitized hand and applied gloves. She then removed dressing to the right calf, left ankle and left calf. She did not sanitize or change gloves. She cleaned wound with half strength Dakin's (wound cleaner). She then applied Santyl gel to the wound straight from the tube. She laid the tube down on the pad under resident between the two wounds. She then removed gloves. She touched the silver alginate with bear hands to cut out a piece for the wound. RN DD did not sanitize hands prior to applying gloves then applied foam dressing to the right calf. She proceeded to address the left ankle by removing her gloves but did not sanitize hands. She cleaned wound with half strength Dakin's (wound cleaner). She removed gloves and did not sanitize. She then cut with bear hands a silver alginate then donned a new pair of gloves without sanitizing hands. She then applied outer foam dressing. Finally, RN DD cleaned hands and applied new gloves. She cleaned the small wounds to the left calf with 0.9 percent sodium chloride. She changed gloves but did not sanitize before the application of the xeroform and foam dressing.Interview on 03/25/2026 at 2:42 PM, RN DD stated that she had not been wearing a gown because the resident was under standard precautions. She acknowledged that, when removing a dressing, hand hygiene should be performed and gloves should be changed. She reported, I knew what I was supposed to do, but I knew I did not do everything correctly. RD DD confirmed that the Santyl gel and scissors had been placed on the field during the dressing change. She also admitted that she placed the tube back into the bag without cleaning it.Observation on 03/25/2026 at 2:04 PM of Wound Care Nurse (WCN) EE revealed that she was not wearing a gown while providing colostomy care to R9. WCN EE was observed using scissors taken from her pocket to cut off the resident's brief. She then placed the scissors back into her left scrub pocket without cleaning them. WCN EE exited the room while still wearing gloves to obtain additional colostomy supplies. After completing the ostomy care, she proceeded to change R9 because the colostomy had leaked onto the bed and the resident's gown. She was observed leaning against the bed in her scrubs while removing the top sheet and R9's gown. She placed the top sheet, gown, and the towel used to clean around the colostomy on the floor. Further observation revealed RN DD entered the room without a gown. She sanitized her hands and applied gloves. RN DD rolled the feces soiled linen under R9 and then tucked clean linens underneath the soiled linens. She placed the feces soiled fitted sheet into the trash can located in the room. WCN EE then exited the room.Interview on 3/25/2026 at 2:34 PM with WCN EE confirmed that she did not disinfect scissors and admits that they need to be cleaned. She admits that she was not wearing a gown because the resident was under standard precautions. She admitted she should not wear used gloves outside of the room. She confirmed that linens were placed on the floor. She reports that the process is to put the linen in the linen bag in the nursing pod. She was told she could not bring bags into the room. She states that each pod has a linen cart. The nurse must come out of the room with the dirty linen.A concurrent observation and interview on 03/26/2026 at 11:15 AM revealed Certified Nursing Assistant (CNA) GG existing the room of R12 carrying dirty linens. A meal tray was observed placed on top of the soiled linen hamper, and CNA GG asked the nurse to move the tray. The dirty linens were observed in direct contact with the CNA's scrubs. She lifted the hamper lid and placed the linens inside. CNA GG acknowledged that linens should not come into contact with her clothing. She also stated that there had not been a linen bag in the resident's room. She reported that she had placed the dirty linens on the bedside commode in the room until she completed the bed change.Interview on 3/25/2026 at 3:40 PM with DON revealed that the facility uses the health system policy of universal precautions. The enhanced barrier precautions were standard precautions, which were gloves and good handwashing. The nurse would glove and sanitize when changing the dressing to adding a new dressing, but gown was not needed. Good hand washing when entering and exiting a room. Gowns are not needed during wound care, IV infusion, bath or changing a colostomy. A concurrent interview with Infection Preventionist (IP) HH and IP II revealed that the facility followed the Five Moments for Hand Hygiene, which included removing gloves and performing hand hygiene when transitioning from dirty to clean tasks. IP II stated that a nurse should sanitize hands-unless visibly soiled-and apply a new pair of gloves after removing a dressing or when moving to another body part. IP HH stated that the facility used standard precautions. IP II confirmed that the facility did not use enhanced barrier precautions and that the unit was treated the same as any other unit within the health system. They reported that if linens were soiled with bodily fluids, staff were expected to wear appropriate PPE, including a gown. They further stated that dirty linens, even when not visibly soiled, should not be held against CNA's or nurse's scrubs. Both IPs confirmed that soiled linens should not be placed on the floor. The expectation was that staff would take the linens outside the resident's room to the linen cart and place them in the cart before completing the bed change. They also stated that a central line dressing change was a sterile procedure, but wearing a gown was not required.

Based on observation, staff interviews, record review, and the facility's policy titled Documentation of Patient Care, the facility did not fully develop or carry out a complete person centered care plan for three of 21 sampled residents (R12, R40, and R41). This practice may have contributed to the potential for unmet needs, possible medical issues, or a reduced quality of life for these residents.Findings Include: Review of the facility's policy titled, Documentation of Patient Care, dated 10/17/2025, that the Policy Statement, revealed that It shall be the policy of the [Facility Name] to provide a process for recording patient information in a systematized, clear and concise record. Section Definition of Terms revealed .Care Plan-Addresses primary reason(s) for admission and provides estimated length of stay. Contains outcomes and interventions.1.Review of the Face Sheet revealed that R12 was admitted on [DATE] for a diagnosis of acute kidney injury on chronic kidney injury.Review of Five Day Scheduled Minimum Data Set (MDS) for R12, dated 03/18/2026, revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 06 (indicating severe cognitive impairment). Section GG (Functional Abilities and Goals) documented that he resident required partial to moderate assistance to roll left and right, sit to lying, lying to sitting on side of bed and transfers. Section I (Active Diagnosis) revealed diagnosis of but not all-inclusive non-Alzheimer's dementia, acute kidney failure (AKF), Hypertension (HTN), chronic kidney disease (CKD), chronic combined systolic and diastolic heart failure, and atrial fibrillation. Section P (Physical Restraints) documented restraints were not used.Review of care plan for R12, dated 03/14/2026, revealed that bed rails were not addressed as part of the care plan.Review of the physician orders for R12 revealed no order for bilateral upper and lower bed rails.Review of record for R12 revealed no bed rail assessment.Review of Consent Form for Protective Devices dated 03/12/2026 for R12 reflected she was unable to sign documented that side rail use was recommended equipment to be used for positioning and mobility device.Observation on 03/24/2026 at 9:57 AM revealed that R12 in bed with bilateral upper and lower bed rails were in the up position on the bed.Observation on 03/25/2026 at 08:11 AM revealed that R12 in bed bilateral upper and lower bed rails were in the up position on the bed.Observation and Interview on 03/26/2026 at 9:15 AM revealed that R12 had bilateral upper and lower bed rails were in the up position on the bed. R12 states she wants to get up and was yelling out.Observation and Interview on 03/26/2026 at 11:10 AM with Licensed Practical Nurse (LPN) CC confirmed that the resident's bed had bilateral upper and lower bed rails in the up position. She states that resident was confused.Interview on 3/26/2026 at 1:24 PM with LPN BB confirmed that side rails are used for R12 because she was confused and for her safety. The use of four rails is used when no one was at bedside. 2.Review of Face Sheet revealed that R40 was admitted on [DATE] for a diagnosis tension pneumothorax.Review of the Five-Day Minimum Data Set (MDS) for R40, dated 03/24/2026, revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 12 (indication moderate cognitive impairment). Section GG (Functional Abilities and Goals) documented that the resident required supervision or touch assistance for sit to lying, sit to stand, and chair to bed transfer. The documentation revealed that rolling left to right and lying to sitting was not attempted due to medical condition or safety.Review of care plan for R40, dated 03/18/2026, revealed focus are of restraints use type was side rails times two.Review of the physician orders for R40 revealed no order for bilateral upper and lower bed rails.Review of record for R40 revealed no bed rail assessment.Review of Consent Form for Protective Devices dated 03/18/2026 for R40 documented the use of two side rails was recommended equipment.Observation on 3/25/2026 at 8:05AM revealed that R40 had two upper rails and left lower bed rail in the up position on the bed.Observation on 03/25/2026 at 3:55 PM revealed that R40 had two upper rails and left lower bed rail in the up position on the bed.Observation on 03/26/2026 at 8:25 AM revealed that R40 had bilateral upper and lower bed rails in the up position on the bed. He states he tries to move around in the bed. He states they usually have all the bedrails up.Observation and Interview on 03/26/2026 at 11:03AM with LPN BB revealed that R40 had four bed rails up. She states that the residents sign paperwork for bedrails. She reports that anyone that comes in signs the bed rail form. She states that four bed rails are not considered a restraint. Anytime the resident wants the rail down they can have the rail down. 3.Review of Face Sheet revealed that R41 was admitted on [DATE] status post a closed femur fracture repair.Review of the Five-Day Minimum Data Set (MDS) for R41, dated 03/19/2026, revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 11 (indication moderate cognitive impairment). Section GG (Functional Abilities and Goals) documented that the resident required partial to moderate assistance for lying to sitting, sitting to stand, and toilet transfers. The documentation revealed that rolling left to right and sitting to lying was not attempted due to medical condition or safety.Review of care plan for R41, dated 03/19/2026, revealed that bed rails were not addressed as part of the care plan.Review of the physician orders for R41 revealed no order for bilateral upper and lower bed rails.Review of record for R41 revealed no bed rail assessment.Review of Consent Form for Protective Devices dated 03/19/2026 for R40 documented the use of side rail use was equipment recommendation for positioning and mobility device.Observation on 03/25/2026 at 8:20 AM revealed that R41 had bilateral upper and lower bed rails were in the up position on the bed.Observation on 03/25/2026 at 4:05 PM revealed that bilateral upper and lower bed rails were in the up position on the bed.Observation on 03/26/2026 at 10:52 AM revealed that bilateral upper and lower bed rails were in the up position on the bed.Observation and Interview on 03/26/2026 at 11:10 AM with LPN CC confirmed that R41 had bilateral upper and lower bedrails in the up position. She reported that R41 was at risk for falls. She states that the rails are used to prevent falls. LPN CC confirmed that bed rails should be a part of the care plan.Interview with MDS Coordinator on 03/25/2026 at 12:50 PM revealed that baseline care plan was completed by nursing on admission.Interview with Director of Nursing (DON) on 03/26/2026 at 11:25 AM confirmed that R40 care plan was for the use of two side rails. His plan of care did not include more than two bedside rails. She confirmed that R12 and R40 that residents plan of care did not include bed rails. She admits that bed rails are not part of the plan of care because they use the consent forms. She admits that bilateral upper and lower bedside rails are considered restraints.

Based on observations, resident interview, staff interview, and facility policy, Restraints, the facility failed to ensure that residents (R) (R12, R40, and R41) of 21 residents was free from bedrail restraint. This deficient practice had the potential risk of psychosocial and limited physical activity.Findings Include:Review of the facility's policy titled, Restraints, dated 7/19/2024 revealed that the Policy Statement, stated that It shall be the policy of [Facility Name] to create a physical, social, and cultural environment limiting use of restraint to clinically appropriate and adequately justified situations. [Facility Name] supports all patients' rights to: be free from physical or mental abuse, and corporal punishment; be free from restraint of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff; have restraints imposed to protect themselves, a staff member, or others; and, have the restraint discontinued at the earlies possible times. The Definition of Terms section included that, Items which are protective devices and ar not considered restraints.Bed rails-as long as less than 4 are raised or if the patient can lower the rails when he or she desires. Section titled Procedures, included .C. The use of restraint must be in accordance with order of an LIP (Licensed Independent Practitioner) who is responsible for the care of the patient or authorized to order restraint by [facility Name].1.Review of the Face Sheet revealed that R12 was admitted on [DATE] for a diagnosis of acute kidney injury on chronic kidney injury. Review of Five Day Scheduled Minimum Data Set (MDS) for R12, dated 03/18/2026, revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 06 (indicating severe cognitive impairment). Section GG (Functional Abilities and Goals) documented that he resident required partial to moderate assistance to roll left and right, sit to lying, lying to sitting on side of bed and transfers. Section I (Active Diagnosis) revealed diagnosis of but not all-inclusive non-Alzheimer's dementia, acute kidney failure (AKF), Hypertension (HTN), chronic kidney disease (CKD), chronic combined systolic and diastolic heart failure, and atrial fibrillation. Section P (Physical Restraints) documented restraints were not used. Review of the physician orders for R12 revealed no order for bilateral upper or lower bed rails. Review of record for R12 revealed no bed rail assessment. Review of Consent Form for Protective Devices dated 03/12/2026 for R12 reflected she was unable to sign documented that side rail use was recommended equipment to be used for positioning and mobility device. Observation on 03/24/2026 at 9:57 AM revealed that R12 had bilateral upper and lower bed rails were in the up position on the bed. Observation on 03/25/2026 at 08:11 AM revealed that R12 had bilateral upper and lower bed rails were in the up position on the bed. Observation and Interview on 03/26/2026 at 9:15 AM revealed that R12 had bilateral upper and lower bed rails were in the up position on the bed. R12 states she wants to get up and was yelling out. In an observation and Interview on 3/26/2026 at 11:10 AM with Licensed Practical Nurse (LPN) CC confirmed that the resident's bed had bilateral upper and lower bed rails in the up position. She states that resident was confused, but that was not her patient. In an interview with LPN BB on 03/26/2026 at 1:24 PM admits that side rails are used for R12 because she has confusing and for her safety. The use of four rails are used when no one is at bedside. 2.Review of Face Sheet revealed that R40 was admitted on [DATE] for a diagnosis tension pneumothorax. Review of the Five-Day Minimum Data Set (MDS) for R40, dated 03/24/2026, revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 12 (indication moderate cognitive impairment). Section GG (Functional Abilities and Goals) documented that the resident required supervision or touch assistance for sit to lying, sit to stand, and chair to bed transfer. The documentation revealed that rolling left to right and lying to sitting was not attempted due to medical condition or safety. Review of the physician orders for R40 revealed no order for bilateral upper and lower bed rails. Review of record for R40 revealed no bed rail assessment. Review of Consent Form for Protective Devices dated 03/18/2026 for R40 documented the use of two side rails was recommended equipment. Observation on 03/25/2026 at 8:05AM revealed that R40 had two upper rails and left lower bed rail in the up position on the bed. Observation on 03/25/2026 at 3:55 PM revealed that R40 had two upper rails and left lower bed rail in the up position on the bed. Observation on 03/26/2026 at 8:25 AM revealed that R40 had bilateral upper and lower bed rails in the up position on the bed. He states he tries to move around in the bed. He states they usually have all the bedrails up. Observation and Interview with LPN BB on 03/26/2026 at 11:03 AM revealed that resident had four bed rails up. She states that the residents sign paperwork for bedrails. She reports that anyone that comes in signs the bed rail form. She states that four bed rails are not considered a restraint. Anytime the resident wants the rail down they can have the rail down. 3.Review of Face Sheet revealed that R41 was admitted on [DATE] status post a closed femur fracture repair. Review of the Five-Day Minimum Data Set (MDS) for R41, dated 03/19/2026, revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 11 (indication moderate cognitive impairment). Section GG (Functional Abilities and Goals) documented that the resident required partial to moderate assistance for lying to sitting, sitting to stand, and toilet transfers. The documentation revealed that rolling left to right and sitting to lying was not attempted due to medical condition or safety. Review of the physician orders for R41 revealed no order for bilateral upper and lower bed rails. Review of record for R41 revealed no bed rail assessment. Review of Consent Form for Protective Devices dated 03/19/2026 for R40 documented the use of side rail use was equipment recommendation for positioning and mobility device. Observation on 03/25/2026 at 8:20 AM revealed that R41 had bilateral upper and lower bed rails were in the up position on the bed. Observation on 03/25/2026 at 4:05 PM revealed that R41 had bilateral upper and lower bed rails were in the up position on the bed. Observation on 03/26/2026 at 10:52 AM revealed that R41 had bilateral upper and lower bed rails were in the up position on the bed. Observation and Interview on 03/26/2026 at 11:10 AM with LPN CC confirmed that R41 had bilateral upper and lower bedrails in the up position. She reported that R41 was at risk for falls. She states that the rails are used to prevent falls. LPN CC was unsure if the resident had consent in place. Interview with Director of Nursing (DON) on 03/26/2026 at 11:25 AM revealed that consent forms are obtained for the use of bed rails. She confirmed that there are no orders for bed rails or bed rail assessments for R12, R40, and R41. The only assessments that are completed by the facility is skin assessment and fall risk assessment. This is what is used throughout the healthcare system. She confirmed that R40 was consented for two bed rails. The more of two rails can be verbally consented by the resident or residents' family. She confirmed that bilateral upper and lower bed rails in up position on the bed is considered a restraint.

Based on observations, interviews, record review, and review of the facility's policies titled Sanitation Inspection and Checklist, Area and Equipment Cleaning, and Cutting Boards, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, the facility failed to clean the hand washing sinks, kitchen floors, preparation tables, shelves and drawers, stove, the grill, grill area, ovens, sides and front of the deep fat fryer, refrigerators, the steamer/convection ovens, [NAME], three food warmers, blast chiller, four double ovens, tilt kettle to include the pipes and six carts and replace cutting boards when scarred and discolored. The deficient practice had the potential to place residents receiving an oral diet from the kitchen at risk for foodborne illness. The facility census was 14 residents. Findings include: Review of the facility's policy, titled Sanitation Inspection and Checklist, dated 1/2025, read in part: Policy: A basic sanitation inspection is conducted at least once per month to ensure that established procedures are being followed and that sanitation standards are maintained. The Compass Safety Assessment-Dining is conducted quarterly . Review of the facility's policy, titled Area and Equipment Cleaning, dated 1/2025, read in part: Policies: Written procedures are available, detailing daily, weekly (as needed) cleaning for all areas and equipment in the department. Procedures: Director - Develops a reference manual on cleaning areas and equipment in the Food and Nutrition Services. Includes the Master Cleaning Schedule -Cleaning Frequency form. Trains associates on cleaning procedures and use of reference manual; training is documented. Manual is kept where it is accessible by all associates .which includes cleaning procedures for most equipment, chemicals to use, and PPE to wear. File and retain records for 3 months (Equipment Cleaning Log). Management/Supervisory Personnel - Assigns weekly and special cleaning to be completed each day. Review of the facility's policy, titled Cutting Boards, dated 1/2024, read in part: Policies: .Replace all cutting boards with grooves and pits 1/8-inch or deeper that cannot be cleaned and sanitized using routine cleaning and sanitizing procedures. Review of the cleaning schedules from September 2024 to February 2025 revealed the kitchen tasks were completed (marked with a checkmark), supervisors daily verification was checked, and managers weekly verification was initialed. Review of the contracted company invoices revealed the most recent quarterly cleaning dates of service were 1/27/2025, 1/29/2025,1/30/2025, 2/5/2025, and 2/6/2025, which included cleaning the char broilers, fryers, ovens, tilt skillet, steamers, hotbox warmers, serving equipment, dish machine, floor cleaning, gas, and electric lines. On 3/4/2025 at 11:56 am, the initial tour was conducted with the Nursing Home Administrator (NHA), the Chef, the Dietary Manager (DM) employed in the position as of 3/4/2025, and the Nutritional Clinical Manager (NCM) present. Observations revealed the hand-washing sinks were grey in color; the original color was white. There were three green cutting boards in use by dietary staff that were discolored, greyish/white, and had deep scars. There was a red cutting board in use by dietary staff that was discolored, greyish/white with deep cut scars. The kitchen equipment had food debris, food dripped in front and sides, doors, handles, and crevices, and the inside had built up burnt food on the bottom and was greasy to the touch. The ice machine's front and bottom sections had splatter and debris. The shelves under the prep tables had dried liquids and food crumbs. The coffee station prep table had dried liquid (coffee) stains. The carts were stained, grey in color, and had food debris. The clean dish racks had food debris and were discolored. The floors throughout the kitchen had food debris/grease and black/grey discoloration up to the baseboards and under all the equipment. The equipment observed was, preparation tables, shelves and drawers, stove, the grill, grill area, ovens, sides and front of the deep fat fryer, refrigerators, the steamer/convection ovens, [NAME], three (food warmers, blast chiller, four double ovens, tilt kettle to include the pipes, six carts), and kitchen floors. On 3/06/2025 at 10:21 am, a second observation and tour was made of the kitchen with the DM, Chef, and NCM. The DM had to serve meals and was unavailable to complete the observation and tour. The Chef and NCM completed the tour. Interviews were conducted with the Chef and NCM during the second tour. The NCM stated that she did not enter the kitchen often, only when she needed something for a resident, such as a special cup or utensils. The Chef stated he/ had been employed at the facility for three months, had not replaced cutting boards, and did not know the last time they were replaced. He stated they should be replaced every six months or quarterly. The Chef stated the floors were swept and mopped two times a day, and the carts were supposed to be wiped down daily. He said a company was contracted to clean all of the equipment quarterly. The Chef stated he was not aware of daily cleaning logs. A request was made by the surveyor to review the daily cleaning logs. The NCM stated that she would try to locate them, if they had them, as well as the invoices for the contracted cleaning company. She stated the previous DM had left a month ago, and she did not know how to locate the logs or invoices. The Chef and the NCM acknowledged the food debris and grease on the equipment and the floors. The Chef stated the DM, himself, and the Sous Chef were responsible for ensuring the kitchen was kept clean. The Chef stated that it was his expectation to have a clean kitchen at all times. He said it was important to keep the kitchen clean for safety and sanitation.

Based on observation, interviews, and review of the facility policy titled Uniform Dress Code the facility failed to ensure that dietary staff wore covering for facial hair and failed to ensure items in the dry storage area was labeled with expiration dates. This deficient practice had the potential to affect 21 of 21 residents receiving an oral diet. Findings: Review of policy revealed the following: Section: Orientation and Education Subject: Uniform Dress Code Date Issued: 5/1995 Date Revised: 1/2023 Procedures: Associates Working with Food - Restrain all facial hair with a beard net/restraint. During an initial kitchen tour on 12/1/2023 at 8:21 am with the Nurse Manager, Patient Services Nutritional Manager, Director of Food Services, and the Executive Chief revealed the following: 1. Patient Services Nutritional Manager is noted to have a beard but is not wearing a beard guard. 2. Director of Food Services is noted to have a beard but not wearing a beard guard. During a kitchen visit and interview on 12/1/2023 at 12:40 pm the Patient Services Nutritional Manager facilitated obtaining food temperatures for food on the steam table. He was noted to not be wearing a beard guard. During an interview with Patient Services Manager regarding his beard he reported that as long as his beard is less than 1/4 inch in length, he did not have to wear a beard guard. He denied that his beard was longer than 1/4 inch and if it was his supervisor would make him wear a beard guard. The final tour of kitchen and interview began at 11:43 am and ended at 12:03 pm on 12/3/2023. Present for the tour were the Administrator, Nurse Manager, Director of Food Services, and Patient Services Nutritional Manager. At 11:47 am tour of dry storage revealed the following: 1. There was a six pound can of carrots that did not have an in date or expiration date. 2. There was a can of spaghetti sauce with no expiration date. 3. There was a can of marinara sauce with no expiration date. 4. There were two 25# (pound) bags of corn meal without an expiration date. 5. There were 3 boxes of unopened and 1 partially used box of graham crackers without an expiration date. Interview with the Director of Food Services while in the dry storage area revealed that canned items have a long shelf life. He reported that any item that gets opened gets an orange label that details the name of the item, date opened, and the expiration date. He reported that inventory is turned over every 7 days so nothing should expire. He acknowledged that there was no way to identify the expiration date of the identified items. It is noted that supplies in the dry food storage had items for both the hospital and nursing home residents, but this tour focused on the items specific for the nursing home residents. Interview on 12/3/2023 at 12:02 pm with the Director of Food Services regarding use of the beard guard today but not on previous days. The Director of Food Services reported that they were wearing beard guards today because the surveyor had previously questioned the Patient Services Manager about the beard guard usage. It was reported that they typically did not wear them because management is not typically in the kitchen around the food. He was informed that the Patient Services Manager facilitated food temps on the food at the steam table. The Director of Food Services reviewed the facility policy and acknowledged that he was not aware that the policy said to restrain all facial hair.

Based on observations, interviews, and review of the facility policy titled Oxygen Therapy the facility failed to provide posting of cautionary and safety signs indicating the use of oxygen for three of seven rooms (530, 538, and 548) with residents utilizing oxygen. Review of policy titled Oxygen Therapy, dated 10/20/2020, did not indicate that signage was needed on doors for residents receiving oxygen therapy. During an interview with (Director of Nursing) DON on 12/2/2023 at 8:35 am who reported that R119 receives trach care BID PRN (twice a day/as needed) however he covers his trach to talk and only requires suctioning as need. It was further reported that R119 receives oxygen as needed but was breathing on room air. Observations on 12/2/2023 at 10:39 and 12/3/2023 at 10:12 am revealed no signage noted on door or surrounding area to indicate oxygen by resident in room [ROOM NUMBER]. Observation of room [ROOM NUMBER] on 12/3/2023 at 10:14 am the door partially opened and the resident in the room wearing oxygen but there was no signage posted indicating the use of oxygen. During a tour with Nurse Manager and Administrator on 12/3/2023 at 10:50 am rooms [ROOM NUMBER] observed to not have signage on door indicating oxygen use by the residents in each room. It was confirmed that the residents in each room were utilizing oxygen, but it was reported that they did not typically put any signage on the room doors. During a subsequent interview on 12/3/2023 at 11:08 am with the Nurse Manager and the Administrator it was reported that oxygen usage signage is located in each room where the oxygen is received for the resident. During a tour of the unit on 12/3/2023 at 12:47 pm there was no signage noted on any room doors or entry/exit doors of the unit to indicate oxygen usage. Each room is noted to have a notch indicating where oxygen can be received from in each room. There was no signage posted on the door prior to entry into the rooms or on the walls in the room indicating oxygen usage.

Based on observations, interviews, and review of policy titled Infection Control Guidelines the facility failed to ensure infection control practices to prevent cross contamination related to entering/exiting a resident room without use of proper personal protection equipment (PPE) and failing to discard trash in a trash receptacle. This deficient practice affected one room (room [ROOM NUMBER]) of 21 rooms with residents. Findings: Review of policy titled Infection Control Guidelines, dated 9/6/2022, revealed the following: III. Control Measures - The maintenance of uniform transmission-based precautions within the hospital is essential to protect patients and those responsible for their care from cross-infection. Signage on door to room [ROOM NUMBER] revealed the following: STOP: Airborne Contact EYE AC E Process: Clean hands when entering and leaving patient room Wear a mask while in patient room N95 for any Aerosolizing Procedures Wear eye protection while in patient room (face shield/goggles) Wear a gown while in patient room (remove when visibly soiled or when leaving the unit) When going in room to room - When leaving the room remove gloves and sanitize hands and gown Put on fresh gloves while going to next room Review of an unnamed document with the breakdown of all precautions and how staff should dress and the daily cleaning schedule revealed that for airborne precautions staff should wear gown, gloves, N95 mask, and eye protection. The daily cleaning included clean room daily with disinfectant. Keep room door closed. 1.During an observation on 12/2/2023 at 9:12 am Physician BB entered into room [ROOM NUMBER] (Airborne Contact signage on door) with a face mask on. Physician BB is noted to have left the room door open while visiting with the resident in the room. Physician BB exited the room at 9:15 am. 2. During an observation on 12/2/2023 at 9:19 am Physician BB was observed to enter room [ROOM NUMBER] again and wearing only his face mask upon entry into the room and the door remained open while in the room with the resident. Physician BB was in the process of rounding but agreed to speak with surveyor before leaving for the day. However, Physician BB did not return for interview. 3. During an observation on 12/2/2023 at 1:32 pm Environmental Tech CC was observed with housekeeping cart outside of room [ROOM NUMBER]. Environmental Tech CC applied PPE which included N95 mask, gloves, and gown prior to entering room [ROOM NUMBER]. Environmental Tech CC entered the room at 1:35 p.m. and closed the door behind her. At 1:38 pm Environmental Tech CC opened the room door and tossed a bag of trash containing gloves and gowns on the floor in the hallway. The bag of trash was not closed, and gloves were hanging out of the bag. She also put used green rags in a container on the housekeeping car and then went back into the room. At 1:43 pm Environmental Tech CC exited the room in full PPE, put the trash in a trash can, and then removed her PPE in the hallway. The area where the trash had been tossed on the floor was not cleaned prior to Environmental Tech CC leaving the area. During an interview on 12/2/2023 at 1:45 p.m. with Environmental Tech CC she acknowledged that she did drop the trash from isolation room [ROOM NUMBER] on the floor prior to placing it in the trashcan but stated it should have been placed directly in the trash can. During interview and observation with the Nurse Manager and Administrator on 12/3/2023 at 10:53 am the Nurse Manager reported that anyone entering room [ROOM NUMBER] should wear PPE per the guidance on the door. This included gloves, gowns, face shield/goggles, and an N95 mask. Interview on 12/3/2023 at 11:14 am with the Coordinator for Environmental Services DD who reported that prior to Environmental Techs entering an isolation room they should put on face shield, N95 mask, gown, and gloves. It was further reported that everything should be carried in to the room to start the cleaning process so that there is no back and forth from the room to the cart with supplies. It was reported that PPE would be taken off once out of the room. Coordinator for Environmental Services DD reported it is not proper protocol to drop the trash bag outside of the isolation room and then go back into the isolation room. Upon review of the picture of trash in hallway, Environmental Services DD reported that this was not the appropriate protocol.

Based on observations, record review, review of policy titled Medication Administration, and staff interviews, the facility failed to provide an environment that was free from potential accidents and hazards for one of 22 residents (R) (R#20). Specifically, the facility failed to properly store medications and a needle syringe left in R#20's room. Findings include: An observation conducted on 9/23/22 at 10:35 a.m. revealed medications (bottle of antacids, nasal spray, and an inhaler) on the counter and needle syringe on bi-pap machine at bedside. An observation on 9/24/22 at 11:19 a.m. revealed (bottle of antacids, nasal spray, an inhaler) on the counter and needle syringe on bi-pap machine at bedside. Further observation on 9/24/22 at 12:40 p.m. revealed the same medications as previously mentioned in addition to [MEDICATION(S)]-Hydrocortisone/[MEDICATION(S)] cream, [MEDICATION(S)] Flex pen which were all on the counter and needle syringe on bi-pap machine bedside. An interview with R#20 was conducted during this time. She revealed her daughter brought the nasal spray and Antacids from home last week. Review of Records revealed R#20 admitted on [DATE] with diagnoses but not limited to [CONDITION(S)] ([CONDITION(S)]), and Chronic [CONDITION(S)]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident had a Brief Interview for Mental Status (BIMS)score of 13, indicating that the resident is cognitively intact. Review of Physician Orders dated September 2022 revealed, active orders for [CONDITION(S)], Nasal Spray, inhaler, [MEDICATION(S)], [MEDICATION(S)]-Hydrocortisone/[MEDICATION(S)] Cream and an inactive order for [MEDICATION(S)] flex pen. No records of order indicating may use home medication were noted. Review of the undated facility policy titled Medication Administration Policy Statement revealed General Procedures for all Medication Administration: 5(d) Do not leave drugs unattended or unlabeled. 7(b) Use of patient supplied home medications requires order form the Licensed Independent Practitioner (LIP)indication may use home medication in addition to medication name, does, route, and frequency. During an interview on 9/24/22 at 12:45 p.m. with Licensed Practical Nurse (LPN) AA, she verified medications and needle syringe were in room and confirmed that they should not have been left in room or at bedside. LPN AA revealed needle syringe was an Arterial Blood sampling kit that was left on the bi-pap machine at bedside. She revealed the facility did not carry the brands for Antacids or Nasal spray, but the other medications were dispensed by the facility. During an interview on 9/24/22 at 1:07 p.m. with the Nurse Manager, she confirmed that it is her expectations for staff to properly store medications and needle syringes in a secure location under nurse's supervision and they should not be openly available.

Based on observation, review of the facility policy titled Solid Municipal Waste Disposal (Non -Regulated Medical Waste), and staff interview, the facility failed to ensure the surrounding area of one of two dumpsters was free from trash and debris. Finding include: Review of the facility policy titled Solid Municipal Waste Disposal (Non-Regulated Medical Waste) dated 7/9/08 revealed: Purpose: To establish procedures for the proper disposal of solid municipal waste. 1. Solid Municipal Waste Disposal (Non - Regulated Medical Waste) b. Never handle loose trash. All trash should be placed in appropriate liners and tied shut. Observation of the dumpster area that included the dock area on 6/5/19 at 12:32 p.m. with Dietary Director (DD) revealed trash and debris around the area including soiled blue and white gloves, cups, masks, and a garbage bag with items. During interview and observation on 6/6/19 at 12:32 p.m., DD confirmed that the dumpster area was surrounded with trash and debris. DD stated this is the dumpster used by dietary staff to remove trash from the kitchen and that the Maintenance Department is responsible for the cleanliness of the dumpster area. Further observation with the Administrator on 6/6/19 at 8:35 a.m. revealed an accumulation of additional trash and debris around the dumpster area. On 6/6/19 at 8:38 a.m., Dietary Aide (DA) CC was observed transporting trash to the dumpster. During interview at this time, DA CC revealed that he had not received instructions to monitor the dumpster cite for debris and trash. During an interview on 6/6/19 at 10:49 a.m., the Manager of Plant Operations (MPO) revealed that his job duties are maintenance and repair monitoring for the dumpster. Maintenance covers submitting work orders for leakage, line maintenance, and other repairs. This job does not consist of monitoring for trash and debris. He stated that the Environmental Department is responsible for monitoring cleanliness of the dumpster area. During an interview on 6/6/19 at 8:41 a.m., the Department Manager of Environment (DME) revealed the policy of the facility is that all trash and debris is removed from the dumpster daily. She stated that she was not aware of the debris and trash in the area until this morning when she saw boxes that were on the ground, masks, gloves, food containers, and debris around the dumpster. DME explained that some of the trash may have come from the clinical area. DME stated that she usually conducts monitoring rounds twice daily at the dumpster site. DME verified that this is the main dumpster used by the facility, and further stated that the manager on duty is to contact the environmental technician to clean up the site if trash or debris is noted in the dumpster area.

Based on record review, review of the facility policy titled Discharge to Nursing Home, Rehab, Subacute, or TCU, and staff interviews, the facility failed to provide information related to the bed-hold policy for one of one resident (R) (#8) reviewed for hospital discharge in the last 30 days. Findings include: Review of the clinical record for R#8 revealed no documentation related to the discharge/transfer and bed-hold information being provided to the resident or their responsible party for his discharge to the hospital on [DATE]. During an interview on 6/6/19 at 3:55 p.m., the Administrator stated they do not provide a copy of the bed-hold policy to the residents transferring to the hospital. He stated that they just discharge them and re-admit them if they want to return and that they do not do bed holds for the residents. During an interview with the Rehabilitation Manger/Program Director CC on 6/6/19 at 4:00 p.m., she confirmed that bed hold information was not being provided to the resident or their responsible party. During an interview with the Case Manager/Social Worker FF on 6/06/19 at 4:08 p.m. she stated that she does not provide any bed hold information to any resident and that she never has. She stated she was not aware that she should be providing this information to the resident or their responsible party upon discharge or transfer. Review of the facility policy titled Discharge to Nursing Home, Rehab, Subacute or TCU dated 5/30/17 revealed: Procedure - Section II, External SNF Transfer to Acute Care: A) CCC (Clinical Care Coordinator) will be notified by nursing, in order to evaluate the bed-hold status at the skilled nursing facility and to assess the ongoing needs of the resident.

Based on record review, review of the facility policy titled Standing Orders for Influenza Vaccine Protocol, and staff interview, the facility failed to provide documented evidence that education/information was provided to residents prior to being offered the flu or pneumonia vaccine for five residents (R) (#800, #801, #112, #113, and #114) of 13 sampled residents. Findings include: Review of the clinical record revealed R#800 was admitted to the facility on [DATE]. It was documented in the clinical record that the patient/caregiver refused the flu vaccine. Further review of the clinical record revealed no documented evidence that the resident received education/information prior to being offered the flu vaccine. Review of the clinical record revealed R#801 was admitted to the facility on [DATE]. It was documented in the clinical record that the patient/caregiver refused the flu vaccine. Further review of the clinical record revealed no documented evidence that the resident received education/information prior to being offered the flu vaccine. Review of the clinical record revealed R#112 was admitted to the facility on [DATE]. It was documented in the clinical record that the patient/caregiver refused the pneumonia vaccine. Further review of the clinical record revealed no documented evidence that the resident received education/information prior to being offered the pneumonia vaccine. Review of the clinical record revealed R#113 was admitted to the facility on [DATE]. It was documented in the clinical record that the patient/caregiver refused the pneumonia vaccine. Further review of the clinical record revealed no documented evidence that the resident received education/information prior to being offered the pneumonia vaccine. Review of the clinical record revealed R#114 was admitted to the facility on [DATE]. It was documented in the clinical record that the patient/caregiver refused the pneumonia vaccine. Further review of the clinical record revealed no documented evidence that the resident received education/information prior to being offered the pneumonia vaccine. During an interview on 6/4/19 at 3:43 p.m., the Administrator and the Clinical Unit Manager AA both indicated that the influenza vaccine is only offered during the flu season and that information/education was only provided at that time. They confirmed that there was no documentation to indicate information/education was provided to the residents or their representatives for either vaccine at the time of the influenza or pneumococcal vaccine offering. During an interview on 6/5/19 at 11:35 a.m., the Director of Nursing (DON) and the Infection Control Registered Nurse (RN) BB both stated that there are no procedures/protocols for the pneumonia vaccine for this unit. If the resident asks for information they will provide it to them. The DON also stated that she could not provide information about the influenza vaccines for the residents already discharged because the computer locks them out of that section unless it is within the flu season. Review of the facility policy titled Standing Orders for Influenza Vaccine Protocol dated 10/19/18 revealed: The standing order protocol will be in effect during the CDC's recommended time-frame (usually (MONTH) 1 through (MONTH) 31). D. Provide Vaccine Information Statements: Provide all patients with a copy of the most current Vaccination Information Statement. The facility policy did not include information pertaining to the pneumonia vaccine.

Based on staff interview and record review, it was determined the facility failed to develop a care plan and routinely and thoroughly assess pressure ulcers for one resident (#59) from a total sample of 19 residents. Findings include: Resident (R) #59 was admitted to the facility on [DATE]. An Admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 2/28/17, documented that the resident was admitted with an unstageable pressure ulcer. The MDS assessment also documented that the resident had a stage one pressure ulcer, and that the pressure ulcers would be addressed in the care plan. However, there was no evidence that a care plan had been developed to address the presence of the pressure ulcers. During an interview on 5/11/17 at 1:36 p.m., the Director of Nursing (DON) confirmed there was no care plan for the pressure ulcers. The facility had a policy for Pressure Ulcers and the Prevention of Skin breakdown. The policy defined a stage one pressure ulcer as being intact skin with non-blanchable redness of a localized area, usually over a bony prominence. The policy also included that the nurse would document the type of wound, location, measurement, and description of how the wound looked on the Admission Assessment and with every Shift Assessment. During an interview on 5/10/17 at 3 p.m., the DON stated that physical assessments of residents are completed every shift by the charge nurse on duty. If a pressure ulcer is identified, then usually a wound consultation is requested and they evaluate the pressure ulcer and obtain orders. After the wound consultation is completed, it would be the charge nurse's responsibility to reassess the pressure ulcer every shift and provide treatment. Although there was evidence in the clinical record of preventive measures, physical assessments and treatments being completed on R#59, the assessments of the pressure ulcers were not consistent and thoroughly descriptive. A 2/22/17 Wound Registered Nurse (RN) Assessment/Treatment Note documented that the resident had an unstageable,eshcar covered pressure ulcer to the left heel that measured 1 cm by 0.5 cm. The pressure ulcer was assessed again on 3/5/17 but was only described as being beefy red. There were no further thorough assessments to including staging or measurements of the pressure ulcer. A 2/26/17 wound note documented that R#59 had a nonblanchable reddened area to the right heel. On 3/2/17 the pressure ulcer was again described as being a nonblanchable redded area. On 3/5/17 it was described as being dusky red. However, there were were no thorough, descriptive assessments of this pressure ulcer to including staging and measurements. On 3/3/17 a nurse's note documented that sacral skin breakdown was assessed with [REDACTED]. There was no initial thorough assessment of this pressure ulcer to include a description of the ulcer, staging or measurements. On 3/5/17 the sacral pressure ulcer was described as being dusky red and measuring 1 cm x 0.5 cm. No staging was included with this assessment. The resident discharged from the facility on 3/7/17. The discharge assessment documented that the resident's skin was within normal limits.

Based on staff interview and record review, it was determined the facility failed to develop a care plan for pressure ulcers for one resident (#59) from a total sample of 19 residents. Findings include: Resident #59 was admitted to the facility on [DATE]. An Admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 2/28/17, documented that the resident was admitted with a 1 centimeter (cm) by 0.5 cm, unstageable pressure ulcer. The MDS assessment also documented that the resident had a stage one pressure ulcer, and that the pressure ulcers would be addressed in the care plan. A 2/22/17 Wound Registered Nurse (RN) Assessment/Treatment Note documented that the resident had an unstageable,eshcar covered pressure ulcer to the left heel that measured 1 cm by 0.5 cm. A further review of the clinical record revealed a 2/26/17 wound note that documented a nonblanchable reddened area to the right heel. However, there was no evidence that a care plan had been developed to address the presence of the pressure ulcers. During an interview on 5/11/17 at 1:36 p.m., the Director of Nursing (DON) confirmed there was no care plan for the pressure ulcers. Cross reference to F314

Based on record review and staff interview, the facility failed to accurately code the Minimum Data Set (MDS) assessment for pressure ulcers for three residents (#25, #59, and #12) from a total sample of 19 residents. Findings include: 1. Resident (R) #25 was admitted to the facility on [DATE]. A review of the clinical record revealed that a pressure ulcer was identified on 12/29/16. The pressure ulcer was described as being a suspected Deep Tissue Injury (DTI) and measuring 1 centimeter (cm) by 1 cm. The pressure ulcer was reassessed on 1/5/17 and documented as being a DTI and measuring 0.8 cm by 0.8 cm. However, licensed nursing staff failed to include the pressure ulcer on the 14 day MDS assessment with an Assessment Reference Date (ARD) of 1/5/17. 2. R#59 was documented in the clinical record as having an unstageable pressure ulcer the left heel since 2/22/16, a nonblanchable area to the right heel (Stage I) since 2/26/17, and a pressure ulcer to the sacrum since 3/3/17. A review of the 14 day MDS assessment, with an ARD of 3/7/17, revealed that licensed nursing staff documented the presence of the unstageable pressure ulcer to the right heel. However, licensed nursing staff failed to include the stage one pressure ulcer on the right heel or the pressure ulcer on the sacrum on the MDS assessment. 3. Review of the clinical panel for R#12 revealed admission to the facility on [DATE]. On admission a sacral stage 3 pressure ulcer measuring 0.3 cm X 0.3 cm was noted on the clinical panel. Review of the 14 day MDS assessment did not include an existing pressure ulcer. Interview 5/11/17 at 1:03 p.m. with the Administrator revealed there is no policy that includes development of MDS assessments. Interview 5/11/17 at 1:40 p.m. with the MDS nurse revealed the process to complete an accurate MDS assessment includes review of the clinical panel, all orders, and nurse and physician notes. The MDS nurse indicated she had been employed by the facility since 5/8/17. She revealed the 14 day MDS assessments for R#12, R#59 and R#25 were not accurate because the presence of pressure ulcers were not included.

Based on observation, record review and staff interview the facility failed to follow infection control protocol for contact isolation of (1) resident (F) with a [DIAGNOSES REDACTED]. Findings include: Review of the clinical record for resident F revealed a [DIAGNOSES REDACTED]. Observation on 8/27/15 at 10:05 am revealed Patient Care Technician (PCT) AA entering the room of resident F who was on contact isolation due to[DIAGNOSES REDACTED] and MRSA of the nares. She put on gloves and a mask while inside the resident's room but did not wear an isolation gown. Personal Protective Equipment ( PPE) equipment was observed outside the door. When leaving the residents room AA informed Surveyor that she had just placed the resident on a bed pan. Continued observation revealed that AA re-entered the residents room to remove the bed pan. She carried the gloves and mask in her hand and spoke with the resident while she put them on. AA then removed the bed pan which contained a copious amount of brown diarrhea like substance and held it close to her body. She then performed personal hygiene for the resident. Interview on 8/27/15 at 10:25 a.m. with PCT AA, when asked why she didn't have a gown on when giving care to resident F she revealed that she did not want to make the resident feel bad by wearing a gown. AA further revealed that during morning meeting she learned that resident F did have a [DIAGNOSES REDACTED]. However, AA further stated his stool did looked suspicious. AA acknowledged that when a resident is on isolation for[DIAGNOSES REDACTED] you should wear a disposable gown when dealing with fecal matter and other bodily fluids. She further revealed that she was the only PCT performing care with all of the residents on the unit that day. Interview on 8/27/15 at 11:05 a.m. with the Director of Nursing (DON) revealed that she expected staff entering a contact isolation room to always wear gowns and gloves and if there is a chance of splatter they should always wear a mask according to the contact isolation protocol. Continued interview revealed that all staff is trained in infection control starting with new hires training, as well as annual computer based training. Interview on 8/27/15 at 1:24 p.m. with Registered Nurse (RN) BB who was certified in Infection control (CIC) prevention revealed that every employee is given orientation on the transmission of infection control. The clinical staff receives two days during orientation and then annually and all staff are educated on the proper PPE for residents on Contact isolation. BB further revealed that staff should always wear gloves and a gown, if there is a cough a mask. Continued interview revealed that the current policy states that all staff should always wear gowns when entering a room where the resident is on contact isolation.

Based on record review, staff and family interview the facility failed to ensure notification to family regarding a positive laboratory result for [MEDICAL CONDITIONS] for one (1) resident (F) from a census sample of six (6) residents. Findings Include: Review of the clinical records revealed that resident F a [AGE] year old male was admitted on [DATE] with a [DIAGNOSES REDACTED]. During a family interview on 8/26/15 at 11:05 a.m. with his spouse and daughter they revealed that they were both upset that neither of them were notified that resident F was positive for ([MEDICAL CONDITION] however, they were aware that he had [MEDICAL CONDITION] (MRSA) of the nares. They continued to reveal that they were not informed about a concern in his current condition and they did not know about his [DIAGNOSES REDACTED]. Review of the Data Information sheet for resident F revealed that the #1 emergency contact was his spouse and #2 contact was his daughter. Review of the Lab results for resident F revealed a positive [MEDICAL CONDITION] result dated 8/25/15. Further review of the clinical record for resident F revealed no evidence of notification to the responsible party documented in the nurse's note or social worker notes. Interview on 8/27/15 at 9:15 a.m. with the Administrator revealed that he expects his staff to notify family of any immediate emergency or change in condition. He further revealed that they should be notified no later than 8:00 a.m. Interview on 8/27/15 at 1:34 p.m. with Registered Nurse (RN) EE revealed that resident F was placed on [MEDICAL CONDITION] isolation on 8/25/15 but entered the unit on 8/12/15 with contact isolation [MEDICAL CONDITION] of the nares. EE acknowledged that the family should have been notified as soon as his [MEDICAL CONDITION] status was positive and there was a change in his condition. Interview on 8/27/15 at 1:41 p.m. with the Director of Nursing (DON) revealed that according to the facility policy an emergency contact should be notified within the hour of any critical results. She continued to reveal that as per nursing protocol the facility should inform family as soon as they are aware and that it was the responsibility of the nurse to inform the family whenever they learn of a critical result. Review of the notification policy revealed that the facility should ensure all physicians and emergency contacts are notified of any change in condition.

Based on record review and staff interview the facility failed to ensure that electronic records, specifically, the resident Minimum Data Set Assessment (MDS) on which all plans of care are based, were transmitted accurately and timely to the State agency. The current census was eleven (11) residents. Findings include: Prior to entrance to the facility a Monthly Report of Missing or Late MDS submission form revealed the facility has forty-two (42) missing and/or late Minimum Data Set (MDS) Assessments. An interview with the Administrator on 1/22/13 at 10:00 a.m. revealed he was not aware of the missing or late MDS Assessment reported to the State agency. An interview with the MDS Coordinator "AA" on 1/22/13 at 10:15 a.m. revealed that she was not aware there were missing or late MDS assessments from the facility to the State agency.

Based on observation, staff interviews and record review the facility failed to ensure that physician orders [REDACTED]. Findings include: Interview with Licensed Practical Nurse (LPN) "BB" on 1/23/13 at 8:30 a.m. revealed resident #126 was NPO (nothing by mouth) due to a scheduled procedure ([MEDICATION NAME]) scheduled for 1/23/13. Staff interview revealed they anticipated the resident going for the procedure at midday . Observation on 1/23/13 at 9:35 a.m. of resident #126 revealed the resident in his room, drinking water from a large water pitcher. Signage or other indication was not visible to indicate the resident was NPO. An interview on 1/23/13 at 9:45 a.m. with Registered Nurse (RN) "CC" and Licensed Practical Nurse (LPN) "BB" revealed that both were aware the resident was to be NPO but neither had checked the resident's water pitcher to ensure that it is empty. The water pitcher was emptied by staff and the Endoscopy lab was notified that the resident had not remained NPO as ordered. Interview at 9:51 a.m. on 1/23/13 with Certified Nursing Assistant (CNA) "DD" revealed it was the night shift staff's responsibility to remove and/or empty water pitchers if the resident was NPO for a procedure the following day.. An interview on 1/23/13 at 10:01 a.m. with RN "CC" revealed the night shift should have emptied the water pitcher and removed any liquids from the resident's room, the resident should have been made aware to not have anything to eat or drink, plus a sign should have been put on the resident's door.

Based on record review and staff interview the facility failed to have quarterly Quality Assurance meetings. Findings include: On 1/24/13 at 12:40 p.m. an interview with the Administrator revealed that a QA meetings was conducted on 4/05/12, 11/15/12 and 1/24/13 but there was not meeting for August 2012. The Administrator was aware of the requirement for quarterly QA meetings, but did not know why a meeting was not held during that calendar quarter.

Based on observation, record review and staff interviews the facility failed to maintain the staffing posting as a permanent record for a minimum of eighteen (18) months. Findings include: Initial tour on 1/22/13 at 8:15 a.m. revealed that staffing was posted on a dry eraser board. An interview on 1/22/13 at 11:30 a.m. with the Charge Nurse, revealed that staffing was only maintained on the dry eraser board and that no permanent record was kept by the facility. An interview with the Administrator on 1/22/13 at 3:30 p.m. revealed that the staffing posting was not maintained by the facility.