Every finding on record at Christian Extended Care & Rehabilitation

Based on interview and record review, the facility failed to ensure employee two-step tuberculin skin tests were completed in accordance with guidelines from the Centers for Disease Control and Prevention (CDC) and State health department, as per the facility policy, for four out of nine employees reviewed. The census was 47. Review of the facility's Employee Health policy, last reviewed July 2022, showed: -Purpose: To provide specific directions for consistent processing of all employee health-related concerns within the corporation's residences; -Policy: -Employment History and Physical Examinations: --All newly hired employees must be medically certified to be free from communicable disease before there is contact with any resident; -Tuberculosis Control Program: --The first step of the two-step Mantoux tuberculin test (TST) will be administered with negative results confirmed pre-resident contact and on an annual basis thereafter; --A Tuberculosis (TB) control program based upon guidelines from the CDC, American Lung Society, and the Public Health Department will be in effect in all resident care facilities of the corporation. Review of the CDC guidance for Clinical Testing Guidance for TB: TST, dated 1/31/25, showed: -Background: The TB skin test is a test used to determine if a person is infected with TB bacteria. In this test, a standardized solution made with purified protein derivative (PPD), which is derived from tuberculin, is injected under the skin; -Determining an approach: -Two-step testing is a strategy used to reduce the likelihood that a boosted reaction will be misinterpreted as a recent infection if the person has to be tested again. Two-step testing should be used for the initial (baseline) skin testing of persons who will be retested periodically. If the TB skin test is used for baseline testing of U.S. health care personnel, use two-step testing; -If the first TB skin test result is negative, a second TB skin test should be done one to three weeks later. Review of the Department of Health and Senior Services (DHSS) TB Screening for Long Term Care Employees flowchart, updated 3/11/14, showed: -Employee accepts position (the hire date); -If no documentation of prior two-step TST, administer TST first step prior to employment. Can coincide reading the results with the employee start date by administering TST two to three days prior to the employee start date; -Read results of first step TST within 48 to 72 hours of administration. Results must be read and documented in millimeters (mm) prior to or on the employee start date; -If negative, administer second step within one to three weeks; -Read results within 48 to 72 hours of administration. 1. Review of Employee D's personnel file, showed: -Hire date 3/18/24; -A first step TB test administered on 3/15/24 and read on 3/18/24 with a negative result; -A second step TB test administered on 10/28/24 and read on 10/31/24 with a negative result; -The second step TB test administered late, not within three weeks of the first step TB test. 2. Review of Employee A's personnel file, showed: -Hire date 12/26/24; -A first step TB test administered on 12/23/24 and read on 12/26/24 with a negative result; -A second step TB test administered on 2/5/25 and read on 2/7/25 with a negative result; -The second step TB test administered late, not within three weeks of the first step TB test. 3. Review of Employee C's personnel file, showed: -Hire date 1/21/25; -A first step TB test administered 1/17/25 and read 1/20/25 with a negative result; -A second step TB test administered 3/19/25 and read 3/21/25 with a negative result; -The second step TB test administered late, not within three weeks of the first step TB test. 4. Review of Employee B's personnel file, showed: -Hire date 9/16/24; -A first step TB test administered 9/13/24 and read 9/16/24 with a negative result; -A second step TB test administered 10/15/24 and read 10/18/54 with a negative result; -The second step TB test administered late, not within three weeks of the first step TB test. 5. During an interview on 3/26/25 at 10:16 A.M., the Human Resources (HR) Manager said employee TB test documentation should be located in their personnel files. Employees come in for their first TB test on the Friday before they start orientation. They bring a form with them to orientation, where the TB test is reviewed by the nurse. Afterward, the form goes to the Infection Preventionist (IP). The HR Manager does not see the form after it goes to the IP. There is a lack of communication regarding TB test tracking and he sees where they need to strengthen the process for this. 6. During an interview on 3/27/25 at 10:46 A.M., the IP said she started in her role with the facility in September 2024 and she is responsible for ensuring employee TB tests are completed. HR provides the IP with a list of new hires. On the Friday before they start orientation, new hires present to the facility for their first TB test, which is administered by the IP or the nurse on duty. The employee is given a TB test form, and the carbon copy of the form remains with the IP. The employee's first step TB test is read by the instructor at orientation on Monday. The instructor signs off on the TB test form and sends it back to the IP. Sometimes the IP has issues getting the form back from the orientation instructor. For example, a new hire that just started on 3/7/25 had orientation on 3/10/25, and the IP still has not received that employee's TB test form from orientation. After the first step TB test is read, the IP tells the employee they have to come back to see her for the second step TB test in seven to 21 days after their first step TB test is administered. She does not schedule a time for the employee to come in for their second step TB test and she leaves it open to the employee to come back and see her. She checks her file periodically and when she sees the employee's window closing for the second step TB test, she will put a note by the time clock for the employee to come see her. Sometimes the new hires do not come back to see her for their second step TB test within the timeframe. 7. During an interview on 3/26/25 at 12:34 P.M., the Executive Director said after the employee's first step TB test is read at orientation, the form to track their TB testing gets scanned to HR and should be placed in the employee's file. The second step TB test should be completed within 21 days of the first step TB test. The IP oversees completion of the second step TB test. There is a miscommunication with the steps in between the first and second TB tests, which is why some second step TB tests are late.

Based on observation, interview and record review, the facility staff failed to provide the required assistance with activities of daily living (ADLs, bathing, dressing, hygiene, grooming, and toileting) for three residents to maintain adequate personal hygiene (Resident #270, Resident #169, and Resident #19). The sample was 12. The census was 47. Review of the facility's Skin Integrity policy, revised, September, 2022, showed: -Policy: All residents will be assessed for the risk of skin breakdown; Risk factors identified will be evaluated; Interventions will be developed and implemented to minimize or stabilize the risk; Interventions will be care planned; -Prevention: Excessively dry skin should be treated with a moisturizing lotion. Review of the facility's A.M. and P.M. Care policy, revised October, 2022, showed: -Purpose: To provide grooming and hygiene to each resident, assisting with bathing, dressing, elimination as needed; -Responsibility: All nursing staff shall be responsible for ADLs; -Policy: It shall be the policy of the facility, that each resident receives assistance with ADLs as needed throughout each day; -A.M. care procedure: Give nail care as needed; Care for the residents feet and toenails as necessary. Review of the facility's Foot and Nail Care policy, revised, February, 2024, showed: -Policy: To provide proper foot and nail care; -Responsibility: It is the responsibility of nursing staff to follow this policy; -Policy: Fingernail and toenail care will be provided by staff or a podiatrist (foot doctor); Only a licensed nurse or a podiatrist should cut toenails of diabetic residents; -Practice: -Fingernail and toenail care should be provided after a bath or shower when cuticles are soft; -Basic foot care: -Good nursing care includes routine care, early recognition of problems and referrals to the podiatrist when necessary; -The elderly are especially susceptible as circulation becomes poorer as one ages; -Bathe and examine feet regularly; -Observe feet for cracks, redness, blisters, corns, cuts, sores or discoloration of the skin; -Moisturize feet with lotion; -Keep the skin clean, dry and well lubricated; -Shoes and socks must be always clean and dry; -Document any changes in the resident's medical record. 1. Review of the Resident #270's face sheet, undated, showed: -An admitted : 3/4/25; -Diagnoses that included: Lymphedema (swelling that creates excess fluid of upper and lower extremities), spinal stenosis (narrowing of the spinal canal that can cause pain and immobility), heart failure, obesity, and leukemia (cancer that develops in the bloodstream). Review of the resident's care plan, in use at the time of survey, showed: -ADLs: The resident requires minimum to moderate assistance with dressing, grooming, hygiene, and bathing; -Skin: Check the resident's skin daily; The resident has a history of lymphedema and chronic (long term) skin issues with his/her legs and feet; Please let the nurse know of any concerns. Review of the resident's skin assessments showed: -On 3/27/25 at 3:07 P.M., skin abnormalities: Flaking and scales; Preventive skin care: barrier cream; -The skin assessment did not address the location of skin abnormality. Review of the resident's Bathing Detailed Report showed: -On 3/19/25 at 12:25 A.M. and 10:40 P.M., the resident declined bathing activity. Review of the resident's shower sheets showed: -On 3/22/25, the resident's lower extremities were circled and labeled psoriasis (a skin condition that causes a scaly rash) on the body graph; Does the resident need his/her toenails cut?: Blank; Signed by Certified Nursing Assistant (CNA); Charge Nurse signature: Blank. -On 3/26/25, the resident's lower extremities were circled and labeled abnormal skin on the body graph; Does the resident need his/her toenails cut?: Blank; Signed by the CNA; Charge Nurse signature: Blank; -No other shower sheets were available for review. Observation on 3/26/25 at 8:28 A.M., showed the resident lay in bed. Certified Medication Technician (CMT) A gave the resident his/her morning medication. The resident's feet and lower legs were exposed. The resident's feet were extremely dry with large flakes of skin. Both feet had approximately one half of an inch nails, which were jagged. The resident's fifth toenail on his/her right foot was long and curled under. On both hands, the resident's fingernails were long, at approximately one fourth of an inch. Observation and interview on 3/27/25 at 7:40 A.M., showed the resident lay in bed and his/ her feet were exposed. The resident's feet were extremely dry with large flakes of skin. Both feet had approximately one half of an inch nails, which were jagged. The resident's fifth toenail on his/her right foot was long and curled under. On both hands, the resident's fingernails were long, at approximately one fourth of an inch. The resident said he has only received two showers since he/she was admitted . He/She did not know when his/her shower days were and just gets in the shower when the staff come in and offer him/her one. The resident said he/she is unable to care for his/her feet and requires assistance. He/She has never been seen by a podiatrist and no staff member has trimmed his/her toenails, and his/her feet looked rough. The resident also said his/her fingernails have never been trimmed by staff and they are longer than he/she would like. During an interview on 3/27/25 at 10:30 A.M., CNA H said the resident's toenails and feet looked pretty bad. The resident's toe nails were really long and his/her feet were dry. The resident did not refuse care. CNA H didn't think that nursing would be able to trim the resident's toenails, and that the podiatrist would have to do it. During an interview on 3/27/25 at approximately 12:00 P.M., Registered Nurse (RN) J said he/she was aware of the resident's long toenails but didn't think that the nail clippers they use would work on the resident because the nail clippers are flimsy. 2. Review of Resident #169's face sheet, undated, showed: -An admitted , 3/8/25; -Diagnoses that include: polyneuropathy (a condition that affects multiple nerve endings), hemiplegia (paralysis of one side of the body), hemiparesis (numbness to one side of the body), and stroke. Review of the resident's baseline care plan, dated, 3/8/25, showed: -Plan of care: Functions at optimal level with ADLs; -Interventions: Provide assistance to support level of need. Review of the resident's skin assessments showed: -On 3/26/25 at 9:49 A.M., skin abnormalities: Flaking and scars; Preventive skin care: Lotion; -On 3/26 25 at 9:00 P.M.: skin abnormalities: None; -The skin assessment did not address the location of the skin abnormality. Review of the resident's Bathing Detail Report showed: -On 3/18/25 at 5:19 P.M., the resident received a sponge bath and no skin issues were observed. Review of the resident's shower sheets showed: -On 3/14/25, there were no identified skin issues listed on the body graph; Does the resident need his/her toenails cut?: No; Signed by CNA; Charge Nurse signature: Blank. -No other shower sheets were available for review. Observation and interview on 3/26/25 at 9:05 A.M. showed the resident lay in bed. The Nurse Manager removed the resident's socks and large flakes of dry skin came out of the sock. The resident's feet were extremely dry with small cracks on the bottom of both of his/her feet. The resident's toenails on both feet were thick, jagged and approximately one fourth of an inch long. On the resident's right heel, there was a thick-skinned area, which the Nurse Manager said looked like a callus. Both of the resident's hands had long fingernails, approximately one fourth of an inch long, with dark matter underneath. Observation and interview 3/27/25 at 9:40 A.M., showed the resident lay in bed. CNA G removed the resident's socks. The resident's feet were extremely dry with small cracks on the bottom of both of his/her feet. The resident's toenails on both feet were thick, jagged and approximately one fourth of an inch long. On the resident's right heel, there was a thick-skinned area. Both of the resident's hands had long fingernails, approximately one fourth of an inch long, with dark matter underneath. CNA G said that the resident should have lotion applied to his/her feet. 3. Review of Resident #19's admission minimum data set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/5/25, showed: -Diagnoses included spinal stenosis and trigeminal neuralgia (chronic pain condition affecting nerve in face); -Cognitively intact; -Partial/moderate assistance with taking shoes on and off. Review of the resident's care plan, in use at the time of the survey, showed: -Focus: Resident is currently dependent and needs assistance with all transfers and ADLs; -Goal: Increasing resident's independence; -Interventions: Resident has skin breakdown and a goal of healing. Please follow physician instructions on daily wound care to help resident heal prior to discharge. Review of the facility's podiatry list, dated, 2/27/25 at 11:05 A.M., showed: -The resident is not on the list to be seen by the podiatrist. Review of the resident's most recent skin assessment, dated 3/26/25, showed: -Skin temperature: Warm; -Skin moisture: Dry; -Skin abnormalities: Flaking; -The skin assessment did not address the location of the skin abnormality. Observation and interview on 3/26/25 at 11:25 A.M., showed the resident's left foot had thick dry skin with flakes. The resident's right foot had dry, thick, flaky skin. Dry skin flakes were observed on the resident's white bedding near his/her feet. The resident's toenails were various lengths and jagged. The resident said staff had not trimmed his/her toenails since he/she admitted to the facility. He/She said staff put lotion on his/her wounds but not on his/her feet. Observation and interview on 3/27/25 at 10:28 A.M., showed CNA F took the resident's socks off to perform a skin assessment of the resident's feet. When CNA F pulled the resident's right sock off, dry skin flakes flew through the air. CNA F said Sorry if any skin got on you. The resident's left foot had thick dry skin with flakes. The resident's right foot had dry, thick, flaky skin. Dry skin flakes were observed on the resident's bedding near his/her feet. The resident's toe nails were various lengths and jagged. During an interview on 3/27/25 at 12:05 P.M., Licensed Piratical Nurse (LPN) E said he/she was aware of the dry skin on the resident's feet. He/She would expect any skin concerns to be documented on the resident's skin assessments. He/She would expect staff to inform the resident's nurse of any skin concerns. Staff wash the resident's feet with soap and water and apply lotion to them. 4. During an interview on 3/27/25 at 10:30 A.M., CNA H said that the CNAs are expected to address any skin issues or nail issues on the shower sheets. Showers are to be provided to the residents twice a week. Shower sheets are filled out even when the resident refuses. The CNA and the Charge Nurse are to sign the shower sheets. The CNAs can provide fingernail grooming and foot care but cannot trim toenails. The nurses or the foot doctor can only trim resident toenails. 5. During an interview on 3/27/25 at approximately 12:00 P.M., RN J said that the CNAs can address any skin or nail issues on the shower sheets. The CNA and the Charge Nurse should sign the shower sheets. CNAs can provide fingernail care and trimming on bathing days and as needed. The nurses are allowed to trim the resident's toenails if the resident is not diabetic. RN J did not think that the rehabilitation residents can be seen by the podiatrist due to the payer source. Those residents would have to go to a podiatrist in the community. The podiatrist only sees long term care residents. The facility has a thick moisturizing cream that is used facility wide for any dry skin and can be applied to the resident's feet when needed. Skin assessments are completed weekly or more frequently as needed. Dry skin and nail issues can be documented by the nurses on the resident's skin assessment. There is a box on the skin assessment that will let the nurse describe the skin abnormality, where it is located on the resident and if there are any interventions in place. 6. During an interview on 3/28/25 at 9:34 A.M., the Administrator and the Corporate Director of Clinical Services said skin assessments should be completed in accordance with the facility's policy. Skin assessments for rehabilitation residents are completed weekly by the nurse. When nursing staff provide care, they should follow the policy and report any skin areas of concern to the nurse. If they notice any change with the resident's skin, they should report it to the nurse. If they notice dry skin, the CNAs should provide lotion. Nursing staff should provide ADL care in accordance with the policy. The shower schedule is posted at the nurses' station. It is expected that staff follow the shower schedule. Nursing staff are expected to provide showers, bed baths, and personal care in accordance with the resident's needs and preferences. Staff are expected to document showers and bed baths on shower sheets and in the electronic charting record. The staff are expected to follow the policy for reporting toenail and fingernail issues. Areas of concern are expected to be addressed on the shower sheet by circling the area. The shower sheets are expected to be signed by the nurse and the CNA. Refusal of showers are expected to be documented on the shower sheets and in the electronic charting record. CNAs can provide basic nail fingernail care. If they feel as though it is beyond their scope, they are expected to report to the nurse. The nurse should follow the nail care policy and if they feel it is warranted make a podiatry referral for the resident. MO00249504 MO00248446 MO00246253 46888

Based on observation and interview, the facility failed to label and cover opened food packages, keep the kitchen floor and ceiling clean, and failed to ensure staff followed the facility hairnet/beard net policy. This had the potential to affect all residents who consumed food prepared by the facility. The census was 48. 1. Observation on 10/10/23 at 9:35 A.M. of the bulk storage room, showed the following: -An opened, undated jug of syrup on the shelf with dry pasta; -An undated, opened package of sandwich cookie pieces, with no covering on the far back storage rack. Observation on 10/11/23 at 7:56 A.M. of the dry storage room, showed the following: -An opened, undated jug of syrup on the shelf with dry pasta; -An undated, an opened package of sandwich cookie pieces, with no covering on the far back storage rack; -An opened, undated bag of chocolate chips, half full on the top shelf of the rack in the middle of the room. Observation on 10/12/23 at 6:41 A.M., showed an opened, undated package of chocolate chips in the dry storage room. During an interview on 10/12/23 at 1:42 P.M., the Dietary Manager said he expected open food to be stored properly and dated. 2. Review of the facility's undated kitchen weekly cleaning responsibilities showed no instructions regarding the upkeep/cleaning of floors or the ceiling. Observation on 10/10/23 at 8:31 A.M., showed the floor in front and behind the fryer and stove had a brownish black liquid substance spill with food debris mixed in. Observation on 10/11/23 at 7:41 A.M., of the kitchen, showed the following: -The floor in between the stove and oven appliances had a dark liquid, grease build up; -The floor under the stove and fryer had a brown liquid spill. Observation on 10/11/23 at 8:05 A.M., showed an accumulation of dust hanging from the ceiling above the dishwashing sink. Observation on 10/11/23 at 10:06 A.M., showed an accumulation of dust above the dish machine room, with a large fan blowing on clean dishes. Observation on 10/11/23 at 10:06 A.M., showed a dust build up on the ceiling light above the recipe screen station. Observation on 10/11/23 at 10:07 A.M., showed a dust build up on the ceiling above the prep station next to the ice machine. Observation on 10/11/23 at 10:08 A.M., showed an accumulation of dust on the ceiling above the steam table and the prep area. Observation on 10/12/23 at 6:45 A.M. of the kitchen, showed the following: -Accumulation of dust on the ceiling above the steam table; -Accumulation of dust hanging on the ceiling above the dishwashing sink area; -Accumulation of dust on the ceiling in the dishwashing room. During an interview on 10/12/23 at 1:42 P.M., the Dietary Manager said he expected ceilings to be free of dust and the floors to be clean. 3. Review of the facility's uniform policy, dated January 2016, showed the following: -Mandatory uniform standards for every scheduled shift with no exceptions: -All long hair will be pulled into a pony tail and covered by a hairnet; -Approved hair restraints must be worn; -Beards/mustaches must be kept neat, trimmed and may not be grown at work. All team members with a beard/mustache working in production areas must wear a beard guard required by local health department code. Observations on the following dates and times, showed: -10/10/23 at 12:54 P.M., Dietary Staff L in the kitchen walking around with no hairnet. His/Her hair was approximately six inches long; -10/10/23 at 6:24 P.M., a male staff member in the kitchen working at the steam cart. The staff member did not have a beard net on. The staff member's beard length was approximately an inch; -10/11/23 at 7:44 A.M., Dietary Staff L walked through the kitchen in a food preparation area with no hairnet. His/Her hair was approximately six inches long; -10/11/23 at 8:05 A.M., Dietary Staff H walking through the kitchen with clean dishes with a hairnet on, with hair sticking out the sides of the hairnet. The hair sticking out was approximately three inches long; -10/11/23 at 8:07 A.M., Dietary Staff K wearing his/her hairnet improperly while at the steam cart, preparing breakfast plates. He/She was plating food for room trays. His/Her hair stuck out of the hairnet. His/Her hair sticking out of the hairnet was approximately three inches long; -10/11/23 at 8:13 A.M., a contracted employee walked through the kitchen in the food preparation area where pizza was being prepped. He/She did not wear a hairnet. His/Her hair was approximately four inches long; -10/11/23 at 8:36 A.M., Dietary Staff H scooping ice from the machine. His/Her hairnet was falling off. One inch long hair was coming out of his/her hairnet; -10/11/23 at 9:07 A.M., Dietary Staff L walking around the kitchen with his/her beard net hanging down. His/Her beard was approximately one inch long. His/Her hair was in a locked hair style approximately six inches long; -10/11/23 at 9:26 A.M., Dietary Staff J walked into the kitchen and up to the steam cart where salad toppings were located, He/She did not wear a hairnet. His/Her hair was approximately eight inches long; -10/11/23 at 9:28 A.M., Dietary Staff H walked into the main part of the kitchen with no beard net on. His/Her beard was approximately an inch long; -10/11/23 at 10:13 A.M., Dietary Staff H in the dishwashing area with his/her beard net not on properly, and his/her beard was exposed. The beard was approximately one inch long; -10/12/23 at 6:43 A.M., Dietary Staff I in the kitchen at the steam table which held breakfast food. He/She did not wear a hair net. His/Her hair was approximately seven inches long. During an interview on 10/12/23 at 1:34 P.M., Dietary Staff K said beard nets and hairnets are required any time staff are in the kitchen. He/She expected staff to wear their hairnets and beard nets properly. During an interview on 10/12/23 at 1:42 P.M., Dietary Staff J said hairnets should be worn every time staff go into the kitchen to prevent hair from getting in the residents' food. During an interview on 10/12/23 at 1:42 P.M., the Dietary Manager said he expected staff to wear a hair net or beard net any time they are in the kitchen in order to keep the kitchen and food sanitary to ensure residents' health. 4. During an interview on 10/12/23 at 1:50 P.M., the Administrator said he expected kitchen staff to follow facility policies on hairnets and beard nets. He expected for the kitchen to be clean and free from dust build up on the ceiling and spills/grease build up on the floors. He expected staff to follow the cleaning schedule and procedures.

Based on interview and record review, the facility failed to electronically transmit resident Minimum Data Sets (MDS), a federally mandated assessment instrument completed by facility staff, in a timely manner for four of four months reviewed. The census was 48. Review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) manual, version 1.18.11 dated October 2023, showed: -All Medicare and/or Medicaid-certified nursing homes and swing beds, or agents of those facilities, must transmit required MDS data records to CMS' Internet Quality Improvement and Evaluation System; -Transmitting Data: Providers must transmit all sections of the MDS 3.0 required for their State-specific instrument and all tracking or correction information; -Comprehensive assessments must be transmitted electronically within 14 days of the care plan completion date. All other MDS assessments must be submitted within 14 days of the MDS completion date; -For entry and death in facility tracking records, information must be transmitted within 14 days of the event date; -The manual includes a submission timeframe table for MDS record types. Review of the facility's CMS submission, MDS final validation report, dated 7/3/23 at 3:30 P.M., showed: -20 records processed; -Two records submitted late. Review of the facility's CMS submission, MDS final validation report, dated 7/3/23 at 3:40 P.M., showed: -48 records processed; -Five records submitted late. Review of the facility's CMS submission, MDS final validation report, dated 8/14/23 at 5:30 P.M., showed: -19 records processed; -Two records submitted late. Review of the facility's CMS submission, MDS final validation report, dated 8/20/23 at 6:33 P.M., showed: -20 records processed; -Three records submitted late. Review of the facility's CMS submission, MDS final validation report, dated 9/4/23 at 1:23 P.M., showed: -20 records processed; -Three records submitted late. Review of the facility's CMS submission, MDS final validation report, dated 9/4/23 at 1:24 P.M., showed: -20 records processed; -Four records submitted late. Review of the facility's CMS submission, MDS final validation report, dated 9/12/23 at 10:38 P.M., showed: -21 records processed; -One record submitted late. Review of the facility's CMS submission, MDS final validation report, dated 9/18/23 at 11:43 A.M., showed: -27 records processed; -Three records submitted late. Review of the facility's CMS submission, MDS final validation report, dated 10/10/23 at 11:09 A.M., showed: -20 records processed; -20 records submitted late. Review of the facility's CMS submission, MDS final validation report, dated 10/10/23 at 11:11 A.M., showed: -Seven records processed; -Seven records submitted late. Review of the facility's CMS submission, MDS final validation report, dated 10/10/23 at 11:16 A.M., showed: -20 records processed; -Seven records submitted late. During an interview on 10/12/23 at 2:16 P.M., the MDS Coordinator said she is the only MDS Coordinator for the facility and she is responsible for completing and submitting all resident MDS. MDS data should be submitted within 14 days in accordance with the timeframes outlined in the RAI and the facility's policy. There have been issues submitting MDS information due to the facility's name changing. Review of the facility's history, showed the facility's name last changed in 2019. During an interview on 10/13/23 at 8:34 A.M., the Administrator said the facility has one MDS coordinator, who is responsible for completing and transmitting the MDS for all residents. He would expect the MDS to be completed within the timeframes outlined in the RAI manual. He would expect MDS information be transmitted within 14 days, in accordance with the timeframes for each MDS type, as outlined in the RAI manual.

Based on observation, interview and record review, the facility failed to ensure medications kept in the facility medication room were within the date of expiration and to ensure a medication in the medication cart was labeled when it was opened and with the expiration date from opening. These practices affected one out of one medication room and one out two medication/treatment carts reviewed. The census was 48. Review of the facility's Storage and Expiration Dating of Medications, Biologicals policy, last revision on 8/7/23, showed: -Facility should ensure that medications and biologicals that have an expired date on the label, have been retained longer than recommended by the manufacturer or supplier guidelines, are stored separate from other medications until destroyed or returned to the pharmacy or supplier; -Once any medication or biological package is opened, facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened. 1. Observation of the facility medication room on 10/11/23 at 8:53 A.M., showed: -One bag of Vancomycin (used to treat and prevent various bacterial infections), 750 milligrams (mg)/150 milliliter (ml) intravenous (IV) solution, expired 10/7/23; -Three bags of Vancomycin, 750 mg/150 ml IV solution, expired 10/9/23. During an interview on 10/11/23 at approximately 9:00 A.M., Licensed Practical Nurse (LPN) G said the four observed IV medications were expired and should be returned to the pharmacy. 2. Observation of the South hall medication cart on 10/11/23 at 9:30 A.M., showed a bottle of Lactulose (used to treat constipation) 10 grams/15 ml, opened and undated. 3. During an interview on 10/12/23 at 2:18 P.M., the Interim Director of Nursing (DON) said the nurses in charge of administering the medications were responsible for checking expiration dates and expired medications should be discarded immediately. She expected staff to label multiple-dose medications when opened. She expected staff to follow the facility policy in medication storage, including how to discard expired medications.

Based on observation and interview, the facility failed to post, in a form and manner accessible and understandable to residents and resident representatives, the name, address, and telephone number for the State Survey Agency, and a statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulation, including but not limited to resident abuse, neglect, exploitation, and misappropriation of resident property. The census was 48. Observations throughout the survey from 10/10/23 through 10/13/23, showed no contact information for the State Survey Agency posted. During a group interview on 10/11/23 at 11:00 A.M., six out of six residents, whom the facility identified as alert and oriented, said they did not know where contact information for the State Survey Agency was posted in the facility. During an interview on 10/13/23 at 9:02 A.M., the Administrator said the State Survey Agency contact information should be prominently displayed in a manner that is accessible and understandable for all residents. A statement that residents may file a complaint with the State Survey Agency should be also be posted.

Based on interview and record review, the facility failed to notify a representative of the State Long-Term Care (LTC) Ombudsman of resident transfers and discharges. The census was 48. Review of the facility's Discharge/Transfer of a Resident, Including Against Medical Advice policy, revised December 2022, showed: -Purpose: To provide guidelines when discharging or transferring a resident to another health care residence, another bed within the residence, or when leaving against medical advice (AMA); -Non-emergency transfers of discharges - initiated by the community, return not anticipated; --A copy of the discharge notice shall be provided to a representative of the Office of the State LTC Ombudsman. This copy must be sent at the same time notice is provided to the resident and resident representative; --In these exceptional cases, the notice must be provided to the resident, resident's representative if appropriate, and LTC Ombudsman as soon as practicable before the transfer or discharge; --The community will maintain evidence that the notice was sent to the Ombudsman; -Emergency transfers/discharges - for medical reasons, or for the immediate safety and welfare of a resident, initiated by the community; --Social Services personnel/designee shall provide notice of transfer to a representative of the State LTC Ombudsman via a monthly list that is submitted; --**NOTE** In situations where the community has decided to discharge the resident while the resident is still hospitalized , the community must send a notice of discharge to the resident and resident representative before the discharge, AND must also send a copy of the discharge notice to a representative of the Office of the State LTC Ombudsman. Notice to the Office of the State LTC Ombudsman must occur at the same time the notice of discharge is provided to the resident and resident representative, even though, at the time of initial emergency transfer, sending a copy of the transfer notice to the Ombudsman only needed to occur as soon as practicable as described above under Emergency Transfers. Contents of the notice must contain all the elements described previously in Non-emergency Transfers initiated by the community. During an interview on 10/4/23 at 3:13 P.M., the Ombudsman said he/she did not receive monthly notices of transfers and discharges from the facility. Review of the facility's Ombudsman notification documentation from June 2023 through October 2023, provided 10/12/23, showed: -On 10/12/23, the Social Services Coordinator (SSC) emailed the Ombudsman's office a list of transfers and discharges from March 2023 through September 2023; -No documentation the facility notified the Ombudsman's office of transfers and discharges prior to 10/12/23. During an interview on 10/12/23 at 1:56 P.M., the SSC said she had been employed with the facility for less than three months. She had not notified the Ombudsman's office of resident transfers and discharges until today, 10/12/23, as she was unaware that was her role. The Ombudsman's office should be notified of all resident transfers and discharges from the facility. The facility should provide this notification to the Ombudsman on a monthly basis, on the first business day of the month. During an interview on 10/13/23 at 8:34 A.M., the Administrator said he expected the Ombudsman's office to receive notification of resident transfers and discharges on a monthly basis. The SSC was responsible for notifying the Ombudsman's office of resident transfers and discharges. The current SSC was new to the facility and was trained by the previous SSC. The previous SSC went on leave earlier this year and while on leave, their designee might not have been tasked with notifying the Ombudsman's office.

Based on interview and record review, the facility failed to confirm physician's orders and administer insulin for one resident with a diagnosis of diabetes (Resident #1) for six days until the resident was discharged from the facility. After the resident was discharged , he/she returned to the hospital after showing a blood sugar of 376 (normal pre meal blood sugar range is 80-130, or less than 180 after eating). The sample size was five. The census was 40. Review of Resident #1's medical record, showed: -Diagnoses included chronic kidney disease, type 2 diabetes with hyperglycemia (high blood sugar) and hypertension (high blood pressure); -discharged on [DATE]. Review of the resident's baseline care plan, updated 10/10/22, showed -admitted : 10/7/22; -Clinical diagnoses: Type 2 diabetes mellitus with other specified complication; -Type 2 diabetes mellitus with hyperglycemia; -Type 2 diabetes mellitus with diabetic neuropathy (weakness, numbness, and pain from nerve damage); -Confirmation: confirmed; -Type: admitting; -Status date: 10/9/22; -Clinical diagnosis: Type 2 diabetes mellitus with ketoacidosis (occurs when there is not enough insulin in the body) without coma; -Confirmation: confirmed: -Type: admitting; -Status date: 10/11/22. Review of the resident's Nurse Practitioner's progress notes, dated 10/10/22, showed: -Diagnoses and all orders for this visit: Type 2 diabetes with stage III chronic kidney disease, with long term current use of insulin; -Assessment and plan: Continue glargine (long-acting insulin); -History of present illness (HPI): This is a patient with a past medical history of Alzheimer's disease, coronary artery disease (CAD, heart disease), high blood pressure, peripheral artery disease (circulatory condition), thyroid disease, dementia, and coronary stent who had been admitted to the hospital from 10/4/22 through 10/7/22, where he/she had presented with complaint of lethargy (lack of energy), was sent to the hospital by family due to lethargy. Patient was found to have and was treated for diabetic ketoacidosis (DKA) with hyperkalemia (high potassium) with acute kidney injury (AKI). Insulin drip with improvement. I reviewed his/her medications and will continue these per hospital discharge orders. Patient to take part in physical therapy and occupational therapy. Will monitor blood glucose reading and adjust insulin for optimal glycemic control; -Medication list: Insulin glargine 100 unit/milliliter (mL) vial for injection. Inject 35 units under the skin nightly, subcutaneous. Review of the resident's history and physical, dated 10/11/22, showed: -Assessment/plan: Diabetic ketoacidosis without coma associated with type 2 diabetes mellitus; -HPI: Patient was admitted to the hospital on October 4th with a presentation of lethargy. He/She was sent to the hospital by his/her family. At that time was found to have elevated blood sugars and was treated with DKA and hyperkalemia and acute kidney injury. Patient was placed on insulin drip as well as intravenous (IV) fluids with improvement; -Medication list at end of visit: insulin glargine 100 unit/mL. Inject 35 units under the skin nightly; -Visit diagnoses: Diabetic ketoacidosis without coma associated with type 2 diabetes mellitus. Review of the resident's Nurse Practitioner's progress notes, dated 10/13/22, showed: -Diagnoses and all orders for this visit: Diabetic ketoacidosis without coma associated with type 2 diabetes mellitus; -Assessment and plan: Glargine 35 units daily; -HPI: On 10/13/22, patient has been doing well on insulin glargine and I reviewed recent glucose readings which have been optimal, but he/she did have a blood sugar of 379 last night. Will continue to reinforce dietary adherence to low concentrated sweets/carb consistent diet; -Medication list: Insulin glargine 100 unit/mL vial for injection. Inject 35 units under the skin nightly, subcutaneous. Review of the resident's Physician's Orders Sheet (POS), dated 10/7/22 through 10/16/22, showed: -An order, dated 10/7/22, for blood glucose monitoring as needed (PRN). When signs and symptoms of hypo/hyperglycemia (low/high blood sugar) are present; -An order, dated 10/7/22, for insulin glargine 100 units/mL 35 units, subcutaneous injection. Once a day at bedtime. High Risk. Review of the resident's medication administration record (MAR), dated October 2022, showed an order, dated 10/7/22, for insulin glargine 100 units/mL, 35 units, injection, subcutaneous. Once a day at bedtime was administered on 10/7 through 10/15/22. Review of the resident's blood glucose results, showed: -On 10/8/22, his/her blood glucose was 89; -On 10/9/22, his/her blood glucose was 142; -On 10/10/22, his/her blood glucose was 167; -On 10/11/22, his/her blood glucose was 189; -On 10/12/22, his/her blood glucose was 379; -On 10/13/22, his/her blood glucose was 211; -On 10/14/22, his/her blood glucose was 198; -On 10/15/22, his/her blood glucose was 272. Review of the resident's medical record, showed the resident discharged to the hospital on 10/16/22 for aggressive behaviors. Review of the resident's hospital discharge record, dated 10/16/22, showed: -Reason for visit: Aggressive behavior; -Diagnosis: Aggressive behavior; -Take these medications: blood glucose meter, use to check blood sugar daily; -Ask your doctor about these medications: Glucose blood strip, use to check blood sugar daily; -Insulin glargine 100 unit/mL vial for injection. Inject 35 units under the skin nightly. Review of the resident's Nurse Practitioner's progress notes, dated 10/17/22, showed: -Diagnoses and all orders for this visit: Late onset Alzheimer's dementia with behavior disturbance; -Diabetic ketoacidosis without coma associated with type 2 diabetes mellitus; -HPI: Patient was sent out to the emergency department yesterday reportedly for aggressive behavior towards staff during care, and refusing care. Unsure etiology patient was sent back with no new orders. He/She does have cognitive decline related to his/her dementia, but had not had any behavior disturbances until now. I saw and examined patient today and he/she was at his/her baseline without any issues and was pleasant; -Medication list: Insulin glargine 100 unit/mL vial for injection. Inject 35 units under the skin nightly, subcutaneous. Review of the resident's Nurse Practitioner's progress notes, dated 10/19/22, showed: -Diagnoses and all orders for this visit: Late onset Alzheimer's dementia with behavior disturbance; -HPI: Patient has not had any aggressive behaviors reported. I did review his/her urinalysis and did not show any infection and had no culture indicated. Will monitor for changes; -Medication list: Insulin glargine 100 unit/mL vial for injection. Inject 35 units under the skin nightly, subcutaneous. Review of the resident's medical record, showed no documentation to discontinue insulin glargine or blood glucose monitoring. Review of the resident's POS, dated 10/17/22 through 10/24/22, showed: -An order, dated 10/22/22, to discharge resident home; -No orders for insulin glargine or blood glucose monitoring. Review of the resident's MAR, dated 10/17/22 through 10/24/22, showed insulin glargine 100 unit/mL. Inject 35 units was not administered. During an interview on 10/28/22 at 8:30 A.M., the resident's family member said the resident was extremely weak when he/she discharged from the facility. Last night, the resident's blood sugar was 376 and he/she was sent to the emergency room . During an interview on 4/20/23 at 3:14 P.M., the Administrator said the nurse is responsible for re-capping after a resident is readmitted from the hospital. The Assistant Director of Nursing (ADON) or Nurse Manager completes the audit to ensure orders are entered correctly. She expected staff to follow physician's orders. She expected the resident's insulin to be on the POS unless it was not included in the hospital discharge orders upon re-admission. MO00209081

Based on interview and record review, the facility failed to follow their policy regarding catheters (a thin tube inserted through the urethra into the bladder to drain urine) when they failed to obtain orders for placement of an indwelling urinary catheter and catheter care. In addition, the facility failed to follow the policy and the resident's care plan by not documenting urinary output for one resident (Resident #6). The sample size was six. The census was 43. Review of the facility's Care of Indwelling Catheter, Drainage bag/Leg bag Policy, dated September 1998, and revised July 2020, showed: -Procedure: -To provide guidelines for proper care for the indwelling catheter, drainage bag, and/or leg bag to prevent complications; -Responsibility: -It is the responsibility of all nursing staff to know this procedure; -Policy: -Catheter care is performed each shift and as needed to keep the catheter and perineal area (including and between the anus and the genitals) clean; -Catheter care practice: -Check catheter drainage and tubing at the beginning of the shift, and periodically throughout the shift, and at the end of the shift. Check to be sure there are no kinks or obstructions, and that the bag is below the level of the bladder. Also check to see if bag needs to be emptied. Report presence of blood, highly concentrated urine, and low or no urine output; -Empty drainage bags at the end of each shift and as needed. Measure the amount of urine using a separate measuring device, as previously stated. Document output in the designated area on the medical record. Review of the resident's medical record showed: -admitted to the facility from an acute care hospital on 6/3/22; -discharged to an acute care hospital on 6/17/22. Review of Resident #6's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/10/22, showed the following: -Cognitively intact: -Understood/understands; -Adequate hearing and vision; -Clear speech - distinct intelligible words; -One person physical assist for bed mobility, dressing, toilet use, personal hygiene and bathing; -Bladder and bowel: Indwelling catheter and intermittent catheterization; -Diagnoses of cancer, obstructive uropathy (any pathologic condition, anatomic or functional, of the urinary tract caused by obstruction), end stage renal disease (ESRD, chronic irreversible kidney failure), high blood pressure, stroke and malnutrition. Review of the resident's care plan, dated June 2022, showed: The resident has an indwelling catheter related to urinary obstruction and retention. Please monitor his/her output and characteristics of his/her urine. Report to his/her physician if either change. Review of the resident's June 2022 physician's order sheet (POS), showed: -No orders for a catheter; -No orders for size; -No diagnoses for a catheter; -No orders for catheter care; -No orders for urinary output documentation. Review of the resident's admission note dated 6/4/22 at 2:14 A.M., showed the resident admitted to the facility for acute kidney injury (AKI, is an abrupt loss of kidney function) and urinary retention. He/she was incontinent of bowel and had a 12 french (size) catheter in place. Review of the resident's bowel and bladder chart detail report (activities of daily living (ADL) documentation) showed: -On 6/4/22 on shift three: -Used indwelling catheter, voided 500 milliliters (ml); -No documentation of catheter use and/or output on shifts one or two; -On 6/5/22 on shift two: -Used indwelling catheter, voided 400 ml; -No documentation of catheter use and/or output on shifts one or three; -On 6/12/22 on shift one: -Used indwelling catheter, voided 550 ml; -No documentation of catheter use and/or output on shifts two or three; -On 6/13/22 on shift one: -Used indwelling catheter, voided 1100 ml; -No documentation of catheter use and/or output on shifts two or three; -On 6/14/22 on shift three: -ADLs performed; -No documentation of catheter use and/or output on shifts one, two or three; -On 6/16/22 on shift one: -Used indwelling catheter, voided 750 ml; -On 6/16/22 on shift two: -Used indwelling catheter, voided 500 ml; -No documentation of catheter use and/or output on shift three. Further review of the resident's bowel and bladder chart detail report (ADL documentation) showed no documentation of catheter use and/or output on the following days: 6/2/22 to 6/11/22 and 6/15/22. During an interview on 8/18/22 at 11:43 A.M., the Director of Nursing (DON) initially said she did not remember seeing the resident with a catheter. She would check the notes. The resident's discharge notes showed he/she had a catheter at the time of discharge. She did not see anything related to the catheter, which was unusual. There were nurse's notes on 6/8/22, basically for catheter care. He/she had complained of pressure. The catheter was repositioned and flushed. She did not see the order for when the catheter was actually placed. The POS should reflect a catheter, the need for a catheter as well as catheter care. She would expect for everything affiliated with the catheter to be documented on the POS. The nurse who gets the order is responsible for ensuring those orders are in place on the POS. The only way she can tell if catheter care is being done is by the documentation, the nurse's notes, and by what the certified nurse aides (CNAs) document in the ADL documentation. Within the ADL documentation, the questions are already built in to document urinary output for the catheter. During an interview with the administrator and the DON on 8/22/22 at 3:46 P.M., the DON said she would expect for the urinary output for the catheter to be documented every shift per their policy.

Based on observation, interview, and record review, the facility failed to ensure staff used acceptable infection control procedures by wearing the appropriate Personal Protective Equipment (PPE) while providing personal care on the COVID-19 quarantine unit for one resident (Resident #183) and not ensuring staff washed their hands and changed gloves appropriately during wound care for one resident (Resident #232). In addition, staff failed to follow infection control practices regarding mask usage while preparing food and failed to ensure an ice scoop remained covered to prevent contamination. The census was 45. Review of the facility's policy on Infection Control Novel Coronavirus Prevention and Response, updated 7/30/20, showed: -Purpose: To provide direction for the prevention of the novel Coronavirus disease and guidelines should Coronavirus (COVID-19) affect any facility resident or employee; -Policy: The facility will respond promptly upon suspicion of illness associated with a novel Coronavirus in efforts to identify, treat and prevent the spread of [MEDICAL CONDITION]; -Definitions: Coronavirus is [MEDICAL CONDITION] that causes mild to severe respiratory illness; -Resident Care: When COVID-19 status is unknown: Options include placement in a single room or in a separate observation area so the resident can be monitored for evidence of COVID-19. All recommended COVID-19 PPE should be worn during care of residents under observation, which includes use of an N95 (a particle filtering facepiece respirator) or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e. goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown (if anticipating droplet exposure during resident care task). 1. Review of Resident #183's entry tracking Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/10/20, showed an admission date of [DATE]. Observation on 9/18/20 at 5:32 A.M., showed the resident lay in bed on the quarantine hall. Certified Nursing Assistant (CNA) B entered the room wearing goggles and an N95 mask. After washing his/her hands and applying gloves, he/she provided personal care. He/She failed to apply a disposable isolation gown prior to providing care. During an interview on 9/18/20 at 6:10 A.M., CNA B said he/she should have had a isolation gown on while providing care. During an interview on 9/22/20 at 1:00 P.M., the Director of Nurses (DON) said she would expect the staff to don (apply) an isolation gown prior to providing personal care. 2. Review of the facility's policy on Standard and Transmission Based Precautions, updated 6/2018, showed the following: -Standard Precautions are based on the principle that all blood and body on the principle that all blood and fluids, secretions, excretions, (except) non-intact skin and mucus membrane may contain transmissible infection agents; -Hand hygiene: Remains the single most effective means preventing infections and controlling disease transmission. Wash hands whenever they are soiled with body substance, before starting starting work, before food preparations, before eating, after using the toilet, before and after removing gloves or other protective equipment, before passing medications or performing treatments and when each resident's care is completed. When in doubt, wash your hands; -Gloves: Wear gloves when it can be reasonable to be anticipated that hands will be in contact with mucous membranes, non-intact skin, any moist body substances, blood, urine, feces, wound drainage, oral secretions, sputum, vomit or items/surfaces soiled with these substances and or persons with a rash. Review of Resident #232's entry tracking MD'S, dated 9/10/20, showed an admission date of [DATE]. Observation on 9/22/20 at 7:00 A.M., showed the resident lay in bed. After washing hands and applying gloves, Nurse C and the DON turned the resident to his/her left side and removed the wet and soiled brief, revealing a dressing to the coccyx. Nurse C cleaned the wound twice with wound cleaner and without changing his/her gloves, or washing his/her hands applied [MEDICATION NAME] (a honey impregnated gel used to remove dead tissue) and a foam dressing. During an interview on 9/22/20 at 7:15 A.M., Nurse C said he/she should have washed his/her hands and changed his/her gloves after cleaning the wound and before applying the treatment. During an interview on 9/22/20 at 7:20 A.M., the DON said she would expect the nurse to remove gloves, clean hands, and reapply clean gloves prior to applying treatment and dressing. 3. Review of the CDC Using PPE, updated August 19, 2020, showed the following: -Facemasks Do's and Don'ts for HCP (Health Care Provider): -When putting on your facemask, clean your hands and put on your facemask so it fully covers your mouth and nose; -Don't wear your facemask under your nose or mouth. Observation on 9/18/20 at 11:33 A.M., showed, Cook G prepared food in the kitchen with a mask on his/her mouth. The mask did not cover his/her nose. Observation on 9/22/20 at 10:50 A.M., showed Cook G prepared food in the kitchen with a mask on his/her mouth. The mask did not cover his/her nose. During an interview on 9/22/20 at 7:18 A.M., the Dietary Manager said kitchen staff should have on masks at all times. The mask should be worn properly, covering the mouth and nose. During an interview on 9/22/20 at 1:10 P.M., the Administrator and DON said masks should be worn properly, covering the mouth and the nose. 4. Observations of the dining room on 9/16/20 through 9/18/20 from 6:30 A.M. to 3:00 P.M. and 9/21/20 from 6:30 A.M. to 3:00 P.M. and 9/22/20 at 7:18 A.M., showed an uncovered ice scoop in a tray next to the sink. During an interview on 9/22/20 at 7:18 A.M., the Dietary Manager said the ice scoop should not be next to the sink, uncovered. Staff could wash their hands and water could splatter onto the ice tray, spreading germs.

Based on observation, interview and record review, the facility failed to ensure one of one resident sampled with a hand brace received assistance to wear the left hand brace per skilled therapy instructions (Resident #5). The total sample was 12. The census was 45. Review of Resident #5's significant change in status Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/25/20, showed: -admission date of [DATE]; -[DIAGNOSES REDACTED]. Review of a restorative care program form, dated 6/30/20 with an effective date of 7/1/20, showed: -Patient will tolerate application of left hand splint following meals; -Place splint on after meals, leaving thumb out. Allow resident to wear as tolerated. He/she may remove the splint or ask staff to remove the splint; -Notify therapy of any redness or skin breakdown if it occurs. Review of the resident's quarterly MDS, dated [DATE], showed: -Makes self understood: Usually understood; -Ability to understand others: Sometimes understood; -Does not reject care; -Extensive assistance of one required for dressing; -Functional limitations in range of motion: Impairment of one upper extremity (shoulder, elbow, wrist or hand); -Occupation Therapy end date: 7/1/20. Observations on the following dates and times, showed: -9/16/20 at 10:40 A.M., the resident sat in a wheelchair in his/her room. His/her left had appeared contracted. He/she had no splint on; -9/17/20 at 10:27 A.M., the resident sat in a wheelchair in his/her room without a left hand splint on; -9/18/20 at 10:54 A.M., the resident sat in a wheelchair in his/her room without a left hand splint on. Observation on 9/22/20 at 8:33 A.M., after breakfast, showed the resident sat in his/her room in a wheelchair without a left hand splint on. Certified Nursing Assistant (CNA) H, assigned to care for the resident, said he/she had taken care of the resident several times before today. The CNA said the resident will usually not leave the hand splint on. The CNA found the hand splint in a drawer in the resident's room and placed it on upside down on the resident's right hand. He/she had just secured the last Velcro strap on the splint when CNA I came to the door. CNA I told CNA H the splint was on upside down. CNA H unstrapped the splint, turned it around and placed it back on the right hand and left the room. At 8:40 A.M., the surveyor asked the CNA to check the splint order on the restorative care program sheet. The CNA then checked the care tracker (electronic system CNAs access that shows what type of care a resident requires). The same order from the restorative care program sheet was in the the care tracker system. The CNA said he/she had not noticed it before and he/she did not know the splint was for the left hand, but is finding out now. The CNA went to the resident and moved the splint from the resident's right hand to the left hand. During an interview on 9/22/20 at 8:58 A.M., the therapy program director said the splint is to address the resident's contracture. The resident does take the splint off at times, but will usually wear it 40 to 60 minutes before he/she removes it, which is why she wrote the order for after meals. If the resident wears it about an hour each time then that's about three hours a day which would still be beneficial. She did not know why CNA H did not know how to apply the splint or which hand to wear it on because she recalls in-servicing CNA H about the splint. Observation on 9/22/20 at 11:10 A.M., showed the resident sat in the dining room with the left hand splint on. The resident did appear as if he/she was attempting to remove it at that time. During an interview on 9/22/20 at 1:00 P.M., the Director of Nurses said she expects staff to follow skilled therapy instructions for splints. If a resident refuses their splint, it should be documented.

Based on observation, interview and record review, the facility failed to have systems in place to ensure one resident received proper care and staff assistance while turning and positioning during incontinence care. The resident rolled from the bed, landed on the floor and sustained a left arm fracture (Resident #182). The sample was 12. The census was 45. Review of Resident #182's admission face sheet, showed an admission date of [DATE]. Review of a document titled CORP-One-Click (MDS 3.0, (Minimum Data Set, a federally mandated assessment instrument completed by facility staff)) Report (a seven day look back assessment completed by direct care staff showing the level of care a resident required during the assessment period and used by the facility MDS Coordinator to complete the residents MDS assessment. The assessment period for this report was 9/2/20 through 9/8/20. The report showed 17 entries, each entry represented a different date and shift. For bed mobility, the resident required: No setup or physical help from staff one time, set-up help only one time, one person physical assistance 13 times and two (+) person physical assistance two times. Review of the resident's admission MDS, dated [DATE], showed: -Makes self understood: Understood; -Understands others: Understands; -Brief Interview for Mental Status score of 03 out of 15 (a score of 00-07 indicates severe impairment); -Extensive assistance of two (+) persons required for bed mobility and transfers; -One person physical assistance required for bathing; -Impairment of one upper extremity; -Mobility device: Wheelchair; -[DIAGNOSES REDACTED]. -Receiving skilled physical therapy (PT), occupational therapy (OT), speech therapy and respiratory therapy; -Height of 4'10; -Weight of 238 pounds. During an interview on 9/22/20 at 12:06 P.M., the MDS Coordinator said the seven day look back assessment is completed by the certified nursing assistants (CNA)s. She is required to code the level of assistance on the MDS based on the highest amount of assistance the resident received during that look back period. Review of the resident's last PT progress note, completed by Physical Therapy Assistant (PTA) D and dated 9/14/20, showed: -Prior level of function 9/13/20: Patient is able to roll and supine (on back) to sit with maximum assist (75%); -Current level of function: The patient is able to roll and transition sit to supine with near total dependence (90% to 95% assist) and with initiation cue and with 90%. The patient is able to roll and transition sit to supine with visual and tactile instruction/cues; -Skilled services provided since last report: Instructed patient in proper technique with bed mobility to reduce caregiver burden and improve patient independence; -Patient training: Patient education and training provided for bed mobility and the patient was able to follow with 10% accuracy; -Precautions: Falls. Review of a facility investigation for fall with injury report, dated 9/20/20, showed: -The resident requires assistance of one or two persons for bed mobility, depending upon her level of self-performance at the time care is rendered. He/she requires a mechanical lift (device that transfers a resident not capable of bearing weight) and two staff for transfers. On 9/20/20 at 6:00 A.M., resident was being assisted with incontinence care when he/she rolled from the bed onto the floor. Pain noted with range of motion to the left upper extremity. Physician was contacted and an order was obtained for an x-ray of the left arm. X-ray showed a left humeral (upper arm) fracture. Resident sent to hospital for evaluation and treatment. Resident returned from hospital with a sling in place, new orders for pain medication and an orthopedic evaluation; -Resident interview on 9/21/20: The resident stated he/she remembered falling, but not how he/she fell ; -Interview with CNA E said during care of the resident (9/20/20 at 6:00 A.M.), he/she reached for an incontinence brief to put on the resident. The resident moved his/her leg forward and it went off the bed. The resident then rolled forward and off the bed landing on his/her left arm complaining of pain. The CNA said the resident could be handled by one staff member as other instances of assistance of one have been successful to maintain the highest level of independence. He/she did turn the resident while providing care. On 9/21/20 at 9345 A.M., the Director of Nurses (DON) and administrator reported to the survey team the resident's accident from 9/20/20. The DON said the resident required one to two persons for bed mobility and sustained a left humerus fracture. During an interview on 9/21/20 at 10:10 A.M., CNA E said he/she was providing care to the resident the morning of 9/20/20, when the resident rolled off the bed. That was the first day he/she provided care for the resident. Prior to providing care, he/she checked the care tracker system (an electronic system used by CNAs that shows what type of care a resident requires) which showed one or two staff for bed mobility. He/she asked the resident before beginning care if he/she could assist with turning and repositioning, the resident said yes. He/she raised the bed to about the height of his/her hips. The resident was on a bath sheet, which he/she pulled on to turn the resident onto his/her right side. The resident was positioned in the middle of the bed. He/she kept his/her left hand on the resident and reached for an incontinence brief with his/her right hand. It was at that time he/she thinks the resident's left leg shifted or he/she swung his/her leg out causing him/her to roll forward and off the bed. He/she was unable to stop the resident from falling. Review of the resident's care tracker system, showed the facility changed the resident's bed mobility and toileting assistance to two persons on 9/21/20. During observation and interview on 9/22/20 at 10:58 A.M., the resident lay in bed with a sling on his/her left arm/shoulder. The resident said he/she really could not recall what happened the day he/she fell out of bed. One minute he/she was on the bed and the next he/she ended up on the floor. During an interview on 9/22/20 at 11:40 A.M., the therapy program manager said the resident had been discharged from skilled therapy services on 9/17/20. Nursing staff should be constantly assessing residents to determine if more care is required and let them know. She reviewed the last skilled therapy progress note, dated 9/14/20, and said PTA D completed the note. During an interview on 9/22/20 at 11:45 A.M., Occupational Therapist F said he/she had worked with the resident and felt for nursing staff, the resident definitely needed two staff for bed mobility due to the resident's weight. During an interview on 9/22/20 at 11:50 A.M., PTA D said for him/her, the resident was a maximum assistance of one for bed mobility and transfers. He/she felt it was ok for one nursing staff to provide bed mobility. During an interview on 9/22/20 at 12:00 P.M., the DON said the resident's care plan showed he/she needed bed mobility assistance of one or two staff when the resident fell out of bed and sustained the fracture. A resident may need one assist at times and two assist at other times depending on the resident's ability at the time of care. It is up to the CNA to make that determination. MO 745

Based on observation, interview and record review, the facility failed to ensure insulin pens were dated when opened for one of four medication carts. The census was 45. Review of the facility's Insulin Administration and Storage policy, updated 10/2018, showed: -Purpose: To provide guidelines for proper administration of insulin and establish safe practices for storage of insulin agents; -Policy: Insulin will be stored and administered according to pharmacy and manufacturer's guidelines; -Practice: Safety Storage Guidelines for insulin: A) All [MEDICATION NAME]agents should be stored in the refrigerator until opened and are good until the expiration date if the temperature is maintained at 36-46 Fahrenheit. B) After opening, insulin vials should be stored on the medication cart as long as the temperature does not exceed the recommended temperatures for the particular insulin. Insulin pens must be stored at room temperature after opening. D) The nurse who opens the vial of insulin/pen will be responsible for checking the manufacturer's expiration date and will date the bottle indicating the expiration date once opened. This will be 14-42 days after opening for most products or the manufacturer's date, whichever comes first. Observation on 9/17/20 at 7:28 A.M., of medication cart #2 on the quarantine hall, showed seven of eight opened insulin pens without expiration/discard dates. During an interview on 9/17/20 at 7:32 A.M., Nurse C said it is the facility's policy to date insulin pens when opened. During an interview on 9/17/20 at 7:34 A.M., the Director of Nurses said insulin pens should be dated when opened.

Based on interview and record review, the facility failed to issue written emergency transfer/discharge notices to residents and/or residents' representatives when the residents were transferred to a hospital for various medical reasons, and failed to send a copy of the notice to a representative of the State Long-Term Care (LTC) Ombudsman, for three residents (Residents #7, #60, and #58). The sample was 12. The census was 45. 1. Review of Resident #7's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, admission and discharge assessments, showed: -admission date of [DATE]; -discharged to the hospital 4/25/20; -Readmission to the facility 6/2/20. Review of the resident's medical record, showed no documentation the resident and/or their representative were provided a written notice of the resident's transfer to the hospital. 2. Review of Resident #60's MDS admission and discharge assessments, showed: -admission date of [DATE]; -discharged to the hospital 8/25/20; -Readmission to the facility 8/28/20. Review of the resident's medical record, showed no documentation the resident and/or their representative were provided a written notice of the resident's transfer to the hospital. 3. Review of Resident #58's medical record, showed: -admission date of [DATE]; -discharged to the hospital 9/6/20; -Readmission to the facility 9/7/20; -No documentation the resident and/or their representative were provided a written notice of the resident's transfer to the hospital. 4. During an interview on 9/21/20 at 9:47 A.M., Nurse A said when a resident goes out to the hospital for a medical issue, the nurse is responsible for sending the red folder with the resident. The red folder has a checklist of documentation to send for the resident's transfer, such as physician orders, code status, and history and physical. To his/her knowledge, the red folder does not include a written notice regarding the resident's right to appeal the transfer or discharge. 5. Review of the facility's Acute Care transfer Checklist, revised 8/30/13, showed: -No statement of the resident's appeal rights, including the name, address, and telephone number of the entity which receives such requests; -No information on how to obtain an appeal form and assistance in completing the form and submitting the hearing request; -No name, address, and telephone number of the state LTC Ombudsman. 6. During an interview on 9/22/20 at 10:09 A.M., the administrator said residents are provided with a packet upon admission which includes the facility's bed hold policy and contact information for the Ombudsman and local state survey agency. When a resident goes out to the hospital, the nurse sends a red transfer checklist folder with the resident. The red folder does not contain a written notice of transfer/discharge including a statement of the resident's right to appeal, or the contact information for the Ombudsman and local state survey agency since this information was provided to the resident upon admission. To his/her knowledge, the facility was not sending a copy of transfer/discharge notices to the Ombudsman. 7. During an interview on 9/22/20 at 1:10 P.M., the administrator confirmed she could not locate documentation to show Residents #7, #60, and #58 and/or their representatives were provided with written notice of transfer/discharge, including the resident's rights to appeal. The facility is expected to follow the regulatory requirements for providing written notices of transfer/discharge.

Based on interview and record review, the facility failed to ensure staff appropriately assisted a resident who required the assistance of two staff for bed mobility. While being assisted by one staff member, the resident rolled off the bed, fell and was hospitalized with a subdural hematoma (severe head injury in which there is a pool of blood between the brain and its outermost covering) (Resident #355). The census was 47. Review of Resident #355's medical record, showed an admission date of [DATE]. Review of the resident's baseline care plan, dated 4/11/19, showed: -Roll left and right; -Dependent; -Helper does all of the effort; -Resident does none of the effort to complete the activity; -Assistance of two or more helpers is required for the resident to complete the activity. Review of the resident's progress note, dated 4/13/19 at 7:17 A.M., showed at 6:15 A.M., the aide stated he/she was doing rounds and while rolling the resident over to change him/her, the resident rolled off the left side of the bed. The resident stated he/she had no pain other than the injury to his/her top lip. Vital signs: Temperature 98.5 (normal, 98.6 degrees Fahrenheit (F)), heart rate 82 (normal range, 70-90 beats per minute), respiratory rate 18 (normal range, 16-20 breaths per minute), blood pressure 142/64 (normal range, 100-120 systolic (top reading) and normal range, 60-80 diastolic (bottom reading)), oxygen saturation (percent of oxygen in the blood) 94% (normal, above 92%) on 2 liters oxygen via nasal cannula. While assessing resident, his/her family member walked in, incident was explained in detail, call made to physician. During an interview on 5/10/19 at 4:30 P.M., Certified Nurse Aide (CNA) [NAME] said he/she was familiar with the resident from a previous stay at the facility, and had also been assigned to the resident during his/her readmission to the facility in April, 2019. The resident was a one person assist for bed mobility. The only time staff needed two people was to assist the resident with his/her Hoyer lift (mechanical) transfer. CNA [NAME] didn't have access to the resident's care plan, but got report from the nurse. The resident fell on night shift while CNA [NAME] provided incontinence care and rolled the resident back and forth. The resident went too far. The resident was a heavy man/woman, and CNA [NAME] tried to break the resident's fall. The resident hit the floor and his/her body landed before his/her head. CNA [NAME] didn't see the resident's head hit anything. Review of the facility's post fall evaluation, dated 4/13/19, showed: -Occurrence: 6:15 A.M.; -Findings: Oriented times four (aware of person, place, time, and situation); -Injury: Bruise; -Neurological evaluation: Pupils equal and reactive to light, no change in level of consciousness, no change in speech, -Post fall analysis: -Environmental safety planning for fall prevention: Resident specific safety measures, wheels locked; -Interventions in place to prevent falls: Adequate lighting; -Team meeting notes: Resident rolled out of bed while being changed during rounds. Further review of the progress notes, showed the following: -4/13/19: -At 5:19 P.M., the resident was on the floor on his/her right side in front of recliner chair. The recliner was raised up into a standup position. Range of motion performed without difficulty. The resident denied pain and no injuries were noted. The resident was assisted by two nurses and two CNAs with the Hoyer lift into bed. Director of Nursing (DON) and supervisor notified. Physician and family notified; -At 5:21 P.M., the resident's family member was at the facility and requested the resident be up in the recliner chair and requested staff not give the resident the remote to the chair, -At 5:27 P.M., the resident was alert and oriented times four and able to make his/her needs known. Up in recliner chair with assist of two and Hoyer lift for transfers. Incontinent of bowel and bladder with assist of one for activities of daily living (ADL) care. No distress noted. Upper left lip remains swollen from earlier fall with ice pack applied throughout the day; -4/14/19: -At 3:16 A.M., the resident was alert and oriented times four, able to make needs known, incontinent of bowel and bladder, with assist of 2 staff with transfers and care per family request. Upper lip remains swollen, ice pack applied throughout the night. Will continue to monitor; -At 3:49 P.M., the resident was alert and oriented times four, able to make needs known, up in recliner with assist of two and Hoyer lift for transfers, incontinent of bowel and bladder with assist of one for ADL care, feeds self meals in room; -4/15/19 at 7:21 A.M., resident is alert and oriented times three (aware of person, place and time) and able to make needs known. Resident was an assist of two with the Hoyer lift for ADLs and transfers. Family came in with concerns, call to physician and resident sent to the hospital per family's request. Assistant Director of Nurses (ADON) notified. Two Emergency Medical Technicians (EMTs) arrived to transport resident to the hospital, also per family's request. Vital signs within normal limits. Review of the resident's hospital records, dated 4/15/19, showed the following: -Weight, 312 pounds; -Resident presents after a fall and was found to have a right [MEDICATION NAME]/subdural hematoma; -Neurology is consulted for transient speech difficulty. Resident was brought to the emergency room after family noticed he/she slurred his/her words and had occasional speech difficulty, described as worsening stuttering from baseline and mumbled speech. During an interview on 4/24/19 at 2:35 P.M., the administrator said the facility investigated the resident's fall. Staff reported providing assistance of one and assistance of two during the resident's care in bed about 50/50. The administrator wasn't sure what the facility's assessment/recommendation showed regarding what kind of staff assistance the resident required. During an interview on 4/24/19 at 3:40 P.M., the resident's physician said he/she knew the resident was a sick man/woman. The physician didn't know how many staff were needed to provide the resident's care, and said it was a nursing decision. The resident was dependent on staff, did not ambulate and was chair-bound. The physician said facility protocol should be followed. During interviews on 5/13/19 at 9:55 A.M. and 2:40 P.M., the DON said there was a communication issue with the CNAs. Some thought they could manage the resident by themselves. In a previous admission, they could provide care to him/her with one staff member. With the April, 2019 admission, the resident came back much weaker. The resident was dependent on staff for mobility. The resident's initial readmission assessment showed he/she required two staff/maximum assistance. The resident was a large man/woman. MO 038

Based on observation, interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice by failing to ensure active wound treatment orders had been obtained and treatments documented for a resident who used a [DEVICE] (wound vac, device used to provide negative pressure to a wound to manage wound drainage). In addition, the facility failed to ensure ordered wound treatments remained intact and in place, and failed to follow the facility policy to ensure and provide accurate skin assessments and documentation for two of four residents investigated for skin conditions (Resident #247 and #146). The census was 47. 1. Review of the facility's negative pressure wound therapy policy, revised (MONTH) (YEAR), showed: -Purpose: To provide guidance for proper use of negative pressure wound closure therapy; -General information: Therapy must not be turned off for more than two hours per day; -Machine settings for continuous versus intermittent and pressure in millimeters of Mercury (mm/hg) must be obtained from the physician; -Dressings are generally changed two to three times per week or as ordered by the physician; -Replace canister weekly (preferably with dressing change) or sooner, if canister is full or it has a foul odor. System will contain body fluids. Follow standard precautions; -Procedure: Obtain physician's orders [REDACTED]. Review of the Resident #247's medical record, showed: -admitted on [DATE]; -[DIAGNOSES REDACTED]. Review of the resident's electronic physician orders [REDACTED]. -An order, dated 5/18/19 for meropenem (antibiotic) 1,000 microgram (mcg) intravenous (IV) every 8 hours. Stop date 5/25/19 for a [DIAGNOSES REDACTED]. -No orders for the wound vac or wound vac settings; -No treatment orders to the right thigh/groin wound. Review of the resident's care plan, dated 5/20/19, showed: -Skin: The resident has a wound to the right groin and he/she has a goal of healing. Has a wound vac in place and nurse changes the dressing three times a week. Staff ensure that the dressing is intact and he/she is free of pain/signs of infection; -General: admitted on [DATE] with a [DIAGNOSES REDACTED]. He/she is currently taking IV antibiotics for an infection to the right groin. The stop date for IV antibiotics is 5/25/19. Resident has a peripherally inserted central catheter (PICC, IV access) line to the right upper extremity. Review of the resident's progress notes, showed on 5/20/19: Surgical wound to the right groin caused by a hematoma (bleed under the skin). Measured 5.8 cubic centimeters (cm) x 26 cm x 6.1 cm. Faint odor noted. Wound bed is beef pink in greater than 75% of the wound area and an area of darker red tissue noted. Maceration (skin damage cause by prolonged moisture exposure) noted to less than 25 % of surrounding tissue. Complaints of pain to the groin at times. An as needed (PRN) pain pill was administered prior to wound vac administration. At this time the wound vac is functioning. Review of the resident's hospital wound care progress notes, dated 5/24/19, showed: -Dressing change frequent to right groin wound: Monday, Wednesday, and Friday; -Wound cleansing: (MONTH) shower and/or cleanse wound with mild soap and water. Remove old dressing, discard into plastic bag and place into trash. While in the shower, cleanse the wound with a mild soap and rinse thoroughly. Do not scrub or use excessive force. Pat wound area dry using gauze sponges. Do not dry with bath towel used on rest of body; -Primary wound dressing: Santyl (wound cleaning ointment used to break up and remove dead skin and tissue), apply nickel thick amount to wound bed only. Apply nickel thick with wound vac; -Negative pressure wound therapy: Wound vac to wound continuously at 125 mm/hg pressure; -Use black foam when replacing dressing. During observations and interviews on 5/29/19 at 9:13 A.M. and 12:57 P.M., the resident lay in bed. The resident said he/she had the wound since April. He/she currently uses a wound vac on the wound and confirmed that staff completes the treatment. The treatments are done on Monday, Wednesday and Friday. Observation showed the wound vac measured 125 mm/hg of pressure. Approximately 3 feet of the wound vac tubing lay directly on the floor. The wound vac hung on the resident's foot board. Further review of the resident's progress notes, showed on 5/30/19: Wound to right groin is a surgical wound. Measurements are 8 cm x 25 cm x 5.8 cm. Wound vac is not maintaining a seal. Wound vac has been changed three times in the last two days. Call placed to the physician twice to receive new orders. At this time, new orders received to apply wet to dry dressing as needed for wound vac leaking. Resident scheduled to be seen by physician tomorrow. Observations and interview on 5/30/19, showed: -At 8:30 A.M., during a care observation, the wound vac tubing lay directly on the floor; -At 4:41 P.M., the resident lay in bed with the wound vac not on. The resident said the wound vac was not able to seal on the part of his/her thigh and now the staff are using wet to dry dressings. Further review of the resident's ePOS, dated 5/30/19, showed to apply wet to dry dressing PRN to the right groin wound if wound vac seal is leaking. During an interview on 5/31/19 at 9:24 A.M., the Director of Nursing (DON) said she would expect the resident to have treatment orders in the ePOS for the wound vac. The charge nurse is responsible for ensuring there are orders. She would expect staff to obtain an order for [REDACTED]. Staff incorrectly put a stop date on the order. The wound vac tubing should not be on the floor due to infection control. The nurse is responsible for ensuring the tubing was not on the floor. During an interview on 5/31/19 at 9:30 A.M., Licensed Practical Nurse (LPN) G confirmed that the wound vac was on the right groin. The nurses changed the wound vac almost daily and when it could not hold a seal, they applied wet to dry dressings. 2. Review of the facility's skin integrity and assessment policy, dated 7/2017, showed: -Purpose: To provide guidelines for the treatment of [REDACTED]. -Responsibility: It is the responsibility of all involved caregivers to know and assist in the implementation of the policy and applicable procedures; -Policy: On admission or readmission and routine assessments thereafter, all residents will be assessed for the risk of skin breakdown; -Assessment: Upon admission the nurse will complete a head to toe baseline assessment to determine any existing skin impairment and document the results. If existing impairments are found, the nurse will implement appropriate interventions, notify the physician and obtain treatment orders. -Prevention: Residents at risk should have a visual skin inspection daily. Aides will report any abnormal findings to a nurse. Review of Resident #146's medical record, showed: -admitted to the facility on [DATE]; -Moderate cognitive impairment; -[DIAGNOSES REDACTED]. Review of the resident's baseline care plan, dated 5/20/19, showed: -General information: The resident admitted with several wounds. The facility staff to follow practices for assessment and treatment of [REDACTED].>-The care plan did not specify wound location or ordered wound treatments. Review of the resident's ePOS, showed the following admission orders [REDACTED] -Admit to long-term care; -Clean area to left heel with wound cleanser, apply skin prep (protective barrier) to periwound (wound edges), apply nickel thick [MEDICATION NAME] (medical grade honey used to treat wounds) to the wound bed and cover with a foam dressing. Change daily and PRN; -Clean mid back with wound cleanser, apply skin prep to the periwound and apply [MEDICATION NAME] (transparent waterproof dressing) absorbent pad. Change every 21 days and PRN. Review of the nurse wound assessment report, showed: -An admission wound note dated 5/17/19 at 4:00 P.M., showed a wound to the right buttocks stage II (partial thickness skin loss) pressure ulcer noted, measured 1.0 cm x 1.0 cm x 0.1 cm. Wound bed is pink. Surrounding tissue is pink and blanchable (blood flow easily returns after pressure applied). The resident denies pain. A light amount of serosanguineous (thin, clear fluid) drainage present. Continue to apply the foam dressing and change every seven days. The mid back skin tear measured 1.2 cm x 1.6 cm. Continue to apply the [MEDICATION NAME] dressing and change every 21 days. No complaint of pain to the area. Scant (small amount) amount of serosanguineous drainage noted. Left ankle noted to have an unstageable wound (the wound depth not visible due to coverage of the wound bed with dead tissue). Measurements are 4.5 cm X 3.6 cm and 25 % slough (thick, stringy yellow dead tissue attached to the wound bed) tissue noted. No foul odor. No complaint of pain. [MEDICATION NAME] applied with a dry dressing. Family and physician aware of all wounds. Offered wound services but at this time family declines but will discuss it; -On 5/26/19 at 10:20 A.M., a wound to the left posterior (back) heel present on admission. The wound measured 4.2 cm x 2.2 cm x 0.1 cm. The wound noted as light pink and light drainage. Slough noted to wound. [MEDICATION NAME] applied and covered with a dry dressing. Review of the resident's skin assessment notes, showed: -On 5/26/19 at 10:12 A.M., the back of the resident's left ankle had excoriation (red irritated skin). Staff applied [MEDICATION NAME]. The wound had light drainage and measured 2.2 cm. (The assessment did not address the skin tear to the resident's mid back, or the treatment applied); -On 5/28/19 at 4:00 P.M., an unstageable pressure ulcer to the back of the left ankle. A small amount of drainage noted. [MEDICATION NAME] and gauze applied, no odor noted to the wound. (The assessment did not note ankle wound measurements or the skin tear to the resident's mid back); During an interview on 5/29/19 at 11:42 A.M., the residents spouse said the resident had a wound to the back of his/her left heel and also had a wound in between his/her shoulder blades. The wounds had been received when the resident fell at home. The staff had applied treatment to the heel wound and the wound seemed to be getting better, slowly. He/she had not seen the wound between the resident's shoulder blades. During a skin assessment observation and interview on 5/30/19 at 9:35 A.M., LPN F used gloved hands and removed the resident's sock from the left foot. The left heel noted to be wrapped with undated gauze wrap. LPN F disposed of the saturated dressing. The wound appeared red with a small amount of yellow drainage noted to the dressing and the wound bed. LPN F measured the left heel wound as 3 cm x 2 cm. LPN F applied the ordered treatment to the back of the resident's left heel. He/she assisted to reposition the resident onto his/her side and exposed the back. Noted to the resident's mid upper back was a dried, rolled up [MEDICATION NAME]. A circular wound noted as open and exposed. The wound base noted as red and a small amount of clear drainage noted from the wound and presented to the inside of the resident's shirt. The wound measured 0.8 cm x 0.8 cm. LPN F said he/she did not know the resident had any other wounds except for the left heel wound. The old [MEDICATION NAME] appeared to be dried and the wound appeared uncovered for several days. The resident required assistance to get dressed and the aides should have reported the wound to the resident's back as uncovered. The skin tear to the resident's back had a treatment order to be changed every 21 days and PRN. Since the order is done every 21 days, the skin tear treatment had not been scheduled to be completed. The nurses perform weekly skin assessments and the skin tear wound should have been noted on the weekly skin assessments the nurses completed. The resident's spouse said it looks like that has been uncovered for several days, that dressing looks old. LPN F applied the ordered treatment to the mid back skin tear. Further review of the resident's skin assessment notes, showed: -On 5/30/19 at 9:41 A.M., an unstageable pressure ulcer noted to the back of the left heel. The wound is dry and [MEDICATION NAME] applied; -On 5/30/19 at 9:47 A.M., pressure ulcer noted to the back of the left heel. Area pale pink, drainage present and dressing applied; -The assessment did not include the measurements or treatment applied to the mid back skin tear. During an interview on 5/30/19 at 10:00 A.M., the Assistant Director of Nursing said she expected CNAs to notify the charge nurse immediately of any wounds that are uncovered or exposed. The charge nurse could then perform an assessment and apply a treatment. The resident was admitted with the wound to the upper back and the back of the heel. The weekly skin assessments should be accurate and completed in a full head to toe fashion. There had been no measurements or noted documentation of the skin tear wound to the upper back since the resident had been admitted . During an interview on 5/30/19 at 10:55 A.M., the DON said she expected a full head to toe skin assessment to be done upon admission and then at least weekly. Weekly skin assessments should be documented correctly and accurate. Wound measurements should be included as part of the weekly skin documentation. Weekly measurements allow for wound tracking if the wound had changed. If a dressing comes off a wound, the aides should tell the nurse immediately. The nurse would assess the wound and apply the ordered treatment and document.

Based on observation, interview and record the review, the facility failed to ensure [MEDICATION NAME] fluids are administered consistent with professional standards of practice and in accordance with physician orders [REDACTED].#247) out of one resident investigated for [MEDICATION NAME]/intravenous (IV) fluids. The sample was 12. The census was 47. Review of the facility's central vascular access device ([MEDICAL CONDITION]) flushing and locking policy, dated 1/15/04, showed: -To be performed by: Licensed nurses according to state law and facility policy. The nurse is responsible and accountable for obtaining and maintaining competence with infusion therapy within his/her scope of practice; -Considerations: Central vascular access devices include PICC lines; -Specific flush/locking orders must be documented; -Guidance: A physician/licensed independent practitioner is required to flush/lock a catheter. The order must include: -Flushing/locking agents; -Strength/concentration; -Volume; -Frequency; -Only 10 milliliter (ml) barrel diameter syringes or larger will be used to flush/lock catheter. Review of the Resident #247's medical record, showed [DIAGNOSES REDACTED]. Review of the resident's physician orders [REDACTED]. -An order, dated 5/18/19, for meropenem (antibiotic) 1,000 microgram (mcg) IV every 8 hours. Stop date 5/25/19 for a [DIAGNOSES REDACTED]. -An order, dated 5/20/19, for PICC catheter care every week. Change dressing on admission, weekly, and as needed using transparent dressing; -No order for PICC line flush. Review of the resident's care plan, dated 5/20/19, showed him/her admitted on [DATE] with a [DIAGNOSES REDACTED]. He/she was currently taking IV antibiotics for an infection to the right groin. The stop date for IV antibiotics was 5/25/19. Resident had a PICC line to the right upper extremity. Review of the resident's progress notes, dated 5/28/19, showed resident completed the IV antibiotics and had a PICC line in place. Resident requested staff to leave the PICC line in until he/she goes to his/her follow up appointment with the physician. Review of the resident's POS, dated 5/30/19, showed to discontinue the PICC line. Observations and interview on 5/29/19 and 5/30/19, showed: -On 5/29/19 at 9:13 A.M. and 12:57 P.M., the PICC line on the resident's right arm. The dressing dated 5/26/19. Resident confirmed that staff flushes the PICC line every day, and he/she had completed the antibiotics at this time; -On 5/30/19 at 4:41 P.M., the resident confirmed that the PICC line was removed today. During an interview on 5/31/19 at 9:24 A.M., the Director of Nursing said she would expect the PICC line orders to include the dressing change and flush. The charge nurse is responsible for ensuring the physician orders [REDACTED].

Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 25 opportunities observed, three errors occurred resulting in a 12% medication error rate (Residents #352, #38 and #15). The census was 47. 1. Review of the facility Policy and Procedure for Insulin Administration, dated (MONTH) (YEAR), showed: -Using a pre-filled syringe ([MEDICATION NAME]), a safety test using 2 units of insulin must be released prior to each injection. Some insulin pens require 3 units to prime the needle. This action also expels any air that may be in the syringe. Review of Resident #352's medical record, showed [DIAGNOSES REDACTED]. Review of the resident's electronic physician order sheet (ePOS), dated 5/6/19 through 5/31/19, showed an order dated 5/7/19, to administer [MEDICATION NAME] (fast acting) insulin 20 units subcutaneously (SQ, under the skin) three times a day before meals. Observation on 5/30/19 at 7:19 A.M., showed Nurse C removed the [MEDICATION NAME][MEDICATION NAME] from a drawer in the medication administration cart. He/she removed the cap, dialed in 20 units of insulin and without cleaning the top of the [MEDICATION NAME], placed a sterile needle on the [MEDICATION NAME]. Without priming the insulin [MEDICATION NAME], he/she administered the insulin to the resident. During an interview on 5/30/19 at 12:00 P.M., the Director of Nursing (DON) said she would expect staff to clean the tip of the insulin [MEDICATION NAME] with an alcohol swab prior to placing a sterile needle on it and would expect staff to follow the facility policy for priming the [MEDICATION NAME] with 2 to 3 units of insulin prior to administering the insulin to ensure the resident receives the correct amount of insulin. 2. Review of Resident #38's ePOS, date 5/1/19 through 5/31/19, showed: -[DIAGNOSES REDACTED].>-An order dated 3/13/19, to administer [MEDICATION NAME] sulfate (iron) 325 milligrams (mg) one tablet once a day. Observation on 5/30/19 at 8:15 A.M., showed Nurse C obtained the [MEDICATION NAME] sulfate 325 mg one tablet, crushed the tablet, mixed with water and administered the [MEDICATION NAME] sulfate by gastric tube (feeding tube) to the resident. At 8:29 A.M., Nurse C said he/she knew the [MEDICATION NAME] sulfate should not be crushed and verified he/she did crush the tablet and administered the crushed [MEDICATION NAME] sulfate. The order should have been clarified when resident was first admitted with the order and he/she would now call the physician and get the order changed to liquid [MEDICATION NAME] sulfate. During an interview on 5/30/19 at 12:00 P.M., the DON said it would never be appropriate to crush [MEDICATION NAME] sulfate due to stomach irritation and she would expect staff to obtain an order for [REDACTED].>3. Review Resident #15's medical record, showed [DIAGNOSES REDACTED]. Review of the resident's ePOS, showed an order dated 3/12/19, for [MEDICATION NAME] (Vitamin B-12) 500 micrograms (mcg), take one tablet daily for vitamin deficiency. During an observation and interview on 5/29/19 at 9:38 A.M., Certified Medication Technician (CMT) H administered the resident two tablets of Vitamin B-12 to equal a 1000 milligram (mg) dose. CMT H said the medication cart did not have a stock bottle of B-12 and he/she administered two tablets of the 500 mg to replace the ordered 500 mcg dose. He/she did not realize the administered B-12 had been an incorrect dose. He/she did not consider checking the medication room for the stock bottle of B-12. Review of the medication administration notes, showed on 5/29/19 at 9:50 A.M., CMT H wrote a note of medium importance: Had to administer the resident B-12 1000 mg because the facility does not have the B-12 500 in stock. The resident's nurse notified. Further review of the resident's ePOS on 5/30/19 at 11:43 A.M., showed: -A discontinued order for [MEDICATION NAME] 500 mcg once daily; -A new order to start [MEDICATION NAME] 500 mcg, take 1000 mcg daily for vitamin deficiency, start first dose on 5/29/19 at 9:55 A.M. During an interview on 5/30/19 at 12:00 P.M., the DON said that she expected staff to administer medications as ordered. If the medication cart is out of a stock medication, the staff should either go obtain the medication from the medication room or ask the charge nurse to obtain the medication from the medication room. Vitamin B-12 is carried as a stock medication in the facility. Staff should not substitute medications for what is ordered and a physician order needs to be obtained before changing a medication.

Based on observation, interview and record review, the facility failed to ensure safe infection control measures were maintained by not changing gloves or washing hands during wound care treatment and not cleaning the end of an insulin [MEDICATION NAME] (prefilled injectable insulin) prior to placing a sterile needle on the end for two residents (Residents #146 and #352). The sample was 12. The census was 47. 1. Review of Resident #146's medical record, showed: -admitted to the facility with a wound to the back of the left heel. -[DIAGNOSES REDACTED]. Review of the resident's electronic physician order [REDACTED]. During an observation and interview on 5/30/19 at 9:15 A.M., Licensed Practical Nurse (LPN) F entered the resident's room, washed his/her hands and applied gloves. The resident lay in his/her bed. LPN F placed wound care supplies on the barrier that lay on the over bed table. LPN F used his/her gloved hands and removed a soiled dressing from the back of the resident's left heel. He/she disposed of the soiled dressing and obtained the wound cleanser spray. He/she used the same gloved hands and applied the cleanser to clean 4 x 4 gauze and wiped off the heel wound and disposed of the used gauze pads. LPN F used the same gloved hands and applied skin prep to the wound edges. He/she used the same gloved hands and opened two sterile 4 x 4 gauze packages, applied [MEDICATION NAME] ointment to the gauze and applied the gauze to the wound. He/she opened a sterile package of [MEDICATION NAME] (foam padded bordered dressing) and applied the dressing over the 4 x 4 gauze. He/she used the same gloved hands, removed a pen from his/her pocket, labeled and dated the outside of the [MEDICATION NAME] dressing and placed the pen back into his/her pocket. He/she removed his/her gloves and washed his/her hands. LPN F said he/she had forgotten to remove his/her gloves or wash his/her hands after removing the soiled dressing before he/she handled the clean or sterile wound treatment supplies. Gloves should be changed and hands washed after removing or handling dirty dressings or cleaning the wounds. Wound infection could occur if the nurse does not wash his/her hands or change the gloves. During an interview on 5/30/19 at 9:44 A.M., the Director of Nursing (DON) said the nurses should always remove gloves and wash hands after handling soiled dressings, before wound cleansing and before handling clean wound supplies. If staff do not wash hands and change gloves when performing wound treatments, an infection may develop in the wound as a result of cross contamination. 2. Review of Resident #352's medical record, showed [DIAGNOSES REDACTED]. Review of the resident's ePOS, dated 5/6/19 through 5/31/19, showed an order dated 5/7/19, to administer [MEDICATION NAME] (fast acting) insulin 20 units subcutaneously (SQ, under the skin) three times a day before meals. Observation on 5/30/19 at 7:19 A.M., showed Nurse C removed the [MEDICATION NAME][MEDICATION NAME] from a drawer in the medication administration cart. He/she removed the cap, dialed in 20 units of insulin and without cleaning the top of the [MEDICATION NAME], placed a sterile needle on the [MEDICATION NAME]. He/she took the insulin [MEDICATION NAME] to the resident's room, put on gloves, administered the insulin to the resident, removed the needle from the [MEDICATION NAME], removed his/her soiled gloves and placed the uncapped [MEDICATION NAME] directly on the resident's sink without any type of clean barrier under the [MEDICATION NAME]. He/she washed his/her hands, took the insulin [MEDICATION NAME] to the medication cart, placed the cap back on the [MEDICATION NAME], placed the [MEDICATION NAME] in a plastic bag and then into the drawer of the medication cart. Nurse C did not clean the top of the insulin [MEDICATION NAME] prior to placing a sterile needle and administering the insulin, did not cap the insulin [MEDICATION NAME] prior to laying it directly on the sink and did not clean the [MEDICATION NAME] prior to capping it and placing it in the plastic bag in the drawer of the medication cart. During an interview on 5/30/19 at 12:00 P.M., the DON said she would expect staff to clean the tip of the insulin [MEDICATION NAME] with an alcohol swab prior to placing a sterile needle on it and it would never be appropriate to lay the insulin [MEDICATION NAME] directly on the sink without any type of covering over the tip or clean barrier under it due to infection control issues.

Based on interview and record review, the facility failed to have a system in place to ensure certified nurse assistants (CNAs) received the required 12 hours of in-service training based on performance reviews, for two of eight employee files reviewed of the CNAs who worked in the facility more than one year. The facility showed they currently had eight CNAs, who worked in the facility more than one year. The census was 47. 1. Review of CNA A's training record, showed: -Date of hire, 7/5/16; -Total hours of training completed for the last full year of employment, 8 hours and 45 minutes. 2. Review of CNA B's training record, showed: -Date of hire, 8/6/12; -Total hours of training completed for the last full year of employment, 10 hours and 45 minutes. 3. During an interview on 5/31/19 at 7:10 A.M., Human Resource (HR) D said she is responsible for keeping track of the CNA 12 hours of in-services, verified both CNA A and CNA B did not have the 12 hours of in-services as required and could not find any further in-service training.