Every finding on record at Hancock Manor Nursing Home

Based on facility policy review, Centers for Disease Control (CDC) Hand Hygiene documentation review, observation, and interview, the facility failed to maintain infection control practices while delivering meal trays to 4 residents (Resident #1, Resident #6, Resident #9, and Resident #24) of 35 residents reviewed on 2 units of 4 units observed for meal tray delivery and the facility failed to follow hand hygiene during wound care for 1 resident (Resident #24) of 2 residents reviewed.The findings include:Review of the facility policy titled, Handwashing/Hand Hygiene, revised 8/2019, revealed .This facility considers hand hygiene the primary means to prevent the spread of infections .All personal [personnel] shall follow the handwashing/hand hygiene procedures . wash hands .contact with resident . Before .handling food . assisting a resident with meals .Review of the CDC document titled, Hand Hygiene for Healthcare, dated 2/7/2024, revealed .Patients in healthcare settings .should clean their hands .Before .eating food . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including Cellulitis (Inflammation or Infection of Tissue) of Right and Left Lower Limb, Muscle Weakness, Diabetes Mellitus, and Need for Assistance with Personal Care. Review of the comprehensive care plan for Resident #1 revised 4/22/2026, revealed .requires staff assistance with ADLs [Activities of Daily Living] .Assist with meals set up and clean up PRN [as needed] .independent with eating . Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Further review revealed the resident needed supervision or touching assistance with eating, and the resident needed partial assistance with self-care. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] with readmission 7/3/2026 with diagnoses including Diabetes, Adult Failure to Thrive, and Dementia. Review of the quarterly MDS assessment dated [DATE], revealed Resident #6 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Further review revealed Resident #6 required supervision assistance with eating and partial to moderate assistance with personal hygiene. Review of the comprehensive care plan for Resident #6 revised on 5/4/2026, revealed .ADLs: Resident has a self-care deficit, requires assistance with ADLs to maintain .DX [Diagnoses]: Decreased mobility, Dementia Special Note for ADL care: Resident may occasionally receive 2 person assist with ADLs due to fluctuations in ADL care .staff support needs . Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses including Dementia, Muscle Weakness, and Pain. Review of the quarterly MDS assessment dated [DATE], revealed Resident #9 scored a 5 on the BIMS assessment which indicated the resident had severe cognitive impairment. Further review revealed Resident #9 required supervision with eating and partial to maximal assistance with personal hygiene. Review of the comprehensive care plan for Resident #9 revised on 4/22/2026, revealed .ADL self-care deficit .Eating .supervision .assistance with meal set up . Review of the medical record revealed Resident #24 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Malignant Neoplasm of Skin, Delirium, Visual Loss, and Muscle Weakness. Review of the comprehensive care plan for Resident #24 revised 8/4/2025, revealed .requires staff assistance with ADLs .Assist with meals set up and clean up PRN .independent with eating . Continued review revealed .Skin cancer lesions left forehead .Tx [treatment] per orders . Review of a quarterly MDS assessment dated [DATE], revealed Resident #24 scored a 12 on the BIMS assessment which indicated the resident had moderate cognitive impairment. Further review revealed Resident #24 required set-up assistance with eating and partial moderate assistance with personal hygiene. Continued review revealed the resident had an open cancer lesion. Review of physician's orders dated 9/9/2026, revealed .Cleanse skin ulcer to forehead with wound cleanser, pat dry. Apply skin prep, air dry then apply band-aid . During an observation of meal delivery on 9/8/2026 at 11:42 AM, on Unit 2 Hallway revealed Certified Nursing Assistant (CNA) B retrieved a lunch tray from the meal cart, entered Resident #24's room, placed the tray on the overbed table, opened the food containers, and exited the room without offering hand hygiene to Resident #24. Continued observation revealed CNA B retrieved another tray from the food cart, entered Resident #1's room, placed the tray on the overbed table, opened the food containers, and exited the room without offering hand hygiene to Resident #1.During an observation of meal delivery on 9/8/2026 at 11:45 AM, on the unit 4 meal tray cart revealed CNA A retrieved a meal tray from the meal tray cart, entered Resident #6's room, placed the tray on the overbed table, positioned the overbed table, opened the food containers, and exited the room without offering hand hygiene to Resident #6. Continued observation revealed CNA A retrieved another tray from the unit 4 meal tray cart, entered Resident #9's room, placed the tray on the overbed table, positioned the overbed table, opened the food containers, and exited the room without offering hand hygiene to Resident #9. During an interview on 9/8/2026 at 11:50 AM, CNA A confirmed she failed to offer hand hygiene to Resident #6 and Resident #9 with meal tray delivery. CNA A stated, .I did not offer hand hygiene and I should have . During an interview on 9/8/2026 at 11:55 AM, CNA B confirmed she failed to offer hand hygiene to Resident #24 and Resident #1 with meal tray delivery. CNA B stated, .I did not assist the residents [Resident #24 and Resident #1] to sanitize their hands before they started eating and I should have .During an interview on 9/8/2026 at 1:05 PM, the Director of Nursing (DON) stated it was her expectation for staff to offer hand hygiene during meal tray delivery. The DON confirmed CNA A failed to follow the facility's infection control policy.During an observation on 9/10/2026 at 9:20 AM, revealed the Wound Care Nurse prepared supplies for Resident #24. Further observation revealed the Wound Care Nurse sanitized the hands, applied gloves, and cleansed Resident #24's left forehead wound with wound cleanser/gauze. Continued observation revealed the Wound Care Nurse used the same gloved hands she used to cleanse the wound to open a sterile bandage and place it on the residents left forehead wound. During an interview on 9/10/2026 at 9:35 AM, the Wound Care Nurse confirmed she failed to follow proper infection control practices when she did not remove her gloves, did not perform hand hygiene, and applied a sterile bandage after cleansing the open wound for Resident #24. During an interview on 9/10/2026 at 9:47 AM, the Assistant Director of Nursing (ADON) confirmed the Wound Care Nurse did not follow infection control practices when she provided wound care to Resident #24.

Based on observation and interview the facility failed to properly store medical supplies in 1 of 2 medication rooms observed for proper storage. The findings include: During an observation on [DATE] at 1:25 PM, in the main nurse's station medication storage room revealed approximately 80 of the 1 milliliter (ml) needleless syringes (a medical device designed to measure and deliver or withdraw liquids) with an expiration date of [DATE]. During an interview on [DATE] at 1:29 PM, the Director of Nursing (DON) confirmed the 1 mL syringes were expired and available for resident use.

Based on facility policy review, observations, and interview, the facility failed to ensure food items were sealed properly, and failed to ensure expired foods were not available for resident use which had the potential to affect 29 of 30 residents. The findings include:Review of the facility's policy titled, Food Storage, dated 7/11/2024, revealed .All products should be inspected for safety .Use Use-By dates on all food .Review of the facility's policy titled, Food Receiving and Storage, dated 11/2017, revealed .Dry foods that are stored in bins will be .labeled and dated ( use by date) .All foods stored in the .freezer will be covered .labeled and dated ( use by date) .During an observation of the food preparation area on 8/11/2025 at 10:04 AM with the Certified Dietary Manager (CDM), revealed the following:Two undated/unlabeled 8-quart plastic containers of dry cereal with 2 quarts remaining in one, and 4-quarts remaining in the other. One undated/unlabeled 12-quart plastic container of dry cereal with 1-quart remaining.During an interview on 8/11/2025 at 10:07 AM, the CDM confirmed the dry food items had not been stored properly. During an observation of the dry storage area on 8/11/2025 at 10:13 AM, with the CDM, revealed the following: 1. One undated 18-quart plastic container of bow tie pasta with 6 quarts remaining.2. Two 55-ounce cans of ripe olives with a use by date of 7/1/2025.During an interview on 8/11/2025 at 10:17 AM, the CDM confirmed the bow tie pasta had not been stored properly and the two cans of ripe olives had a use by date of 7/1/2025, had not been discarded, and was available for resident use. During an observation of the walk-in freezer on 8/11/2025 at 10:23 AM, with the CDM, revealed the following: 1. One unsealed, unlabeled, and undated bag of hash browns.2. One unsealed, unlabeled, and undated bag of french fries. During an interview on 8/11/2025 at 10:30 AM, the CDM confirmed frozen foods were open to air, unlabeled, undated, were not stored properly, and was available for resident use.

Based on facility policy review, medical record review, observations, and interview, the facility failed to revise the comprehensive care plan for 1 resident (Resident #6) of 12 residents reviewed for care plans.The findings include:Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised 12/2016, revealed .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident .Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change .The interdisciplinary Team must review and update the care plan .when the resident has been readmitted to the facility from a hospital stay .Medical record review revealed Resident #6 was admitted to the facility on [DATE] with diagnoses including Hypertensive Heart Disease, Atrial Fibrillation, Diabetes, Dysphagia (difficulty swallowing), and Percutaneous Endoscopic Gastrostomy (PEG) Tube (a feeding tube inserted through the abdominal wall into the stomach, allowing for direct delivery of liquid nutrition or medication when someone cannot eat or drink normally).Review of a significant change Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #6 scored a 99 on the Brief Interview for Mental Status (BIMS) assessment, which indicated the resident was unable to participate in the interview. Further review revealed the resident required a feeding tube.Medical record review revealed Resident #6 was transferred to the emergency room (ER) for dislodgement of the PEG tube on 2/28/2025, 3/9/2025, 5/24/2025, and 7/25/2025.Review of a comprehensive care plan for Resident #6 dated 7/9/2025, revealed .has a PEG Tube for nutrition .resident will not have injury related to aspiration [inhaling food or liquid into the airways] .will maintain weight and nutritional balance .out to ER on [DATE] for resident pulling out his peg tube .out to ER [DATE]-pulled tube out .05/24/2025 out to ER for peg tube replacement due to dislodging . Further review revealed no documentation the care plan had been revised to include the resident manipulated the PEG tube.During an observation on 8/11/2025 at 10:05 AM, Resident #6 was sitting in his wheelchair, pleasantly confused, well-groomed, with no restlessness, and was not observed manipulating the PEG tube.During an observation on 8/12/2025 at 2:00 PM, Resident #6 was sitting in a chair at the bedside. Resident #6 was pleasantly confused, well-groomed, with no restlessness, and was not observed manipulating the PEG tube.During an interview on 8/13/2025 at 10:05 AM, Certified Nursing Assistant (CNA) A stated, .we sometimes use a velcro covering on his [Resident #6's] stomach .to try and keep him from pulling at his feeding tube, but he [Resident #6] pulls at the covering, it [velcro covering] gets pulled up higher toward his chest .so it [velcro covering] doesn't always keep the feeding tube covered . During an interview on 8/13/2025 at 11:30 AM, the Director of Nursing (DON) confirmed a velcro abdominal binder was used as indicated when Resident #6 was restless to help maintain the PEG tube position due to past inadvertent dislodging. The DON stated the resident pulled at the velcro abdominal binder at times, which kept the binder from covering the PEG tube.During an interview on 8/13/2025 at 11:35 AM, the Minimum Data Set (MDS) Nurse confirmed the comprehensive care plan for Resident #6 had not been revised to include the resident's manipulation of the PEG tube or interventions.

Based on facility policy review, medical record review, observation and interviews, the facility failed to ensure contracted staff followed Enhanced Barrier Precautions (EBPs - an infection control strategy using personal protective equipment (PPE) such as isolation gowns during high-contact care to reduce the risk of spreading multidrug-resistant organisms) for 1 resident (Resident #6) of 7 residents reviewed for EBPs.The findings include:Review of the facility's policy titled, Enhanced Barrier Precautions, dated 8/2022, revealed .Enhanced barrier precautions .are used as an infection prevention and control intervention .EBPs employ targeted gown and glove use during high contact resident care activities .Examples of high-contact activities requiring the use of gown and gloves for EBPs include .dressing .bathing/showering .providing hygiene .changing briefs .device care or use .urinary catheter, feeding tube .Medical record review revealed Resident #6 was admitted to the facility on [DATE] with diagnoses including Heart Disease, Diabetes, and Tube Feeding Placement.Review of the Physician's orders for Resident #6 dated 3/24/2025, revealed an order for Enhanced Barrier Precautions due to Chronic Wounds, Percutaneous Endoscopic Gastrostomy (PEG) (a tube surgically inserted into the abdominal wall to provide nutrition, hydration, and medication) and a urinary catheter.Review of a facility document titled Facility Notification of Hospice Admission, for Resident #6 dated 6/28/2025, revealed the resident was admitted to Hospice services.Review of the comprehensive care plan for Resident #6 dated 3/29/2025, revealed .enhanced barrier precautions will be maintained .follow enhanced barrier precaution guidelines when providing care .direct care activities include dressing, bathing/showering, transferring, providing hygiene, changing linens, assisting with toileting and incontinent care .Review of a significant change Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #6 scored a 99 on the Brief Interview for Mental Status (BIMS) assessment, which indicated he was unable to participate in the interview. Further review revealed the resident required a feeding tube, a urinary catheter, and had a wound.During an observation and interviews on 8/12/2025 at 9:03 AM, revealed Resident #6 had a red rectangular sign attached to the left side of the door trim which stated .isolation .PPE gown and gloves required . Further review revealed a storage bin located near Resident #6's room with appropriate PPE. Further observation revealed two contracted hospice personnel at the bedside, providing Activities of Daily Living (ADL) care for Resident #6. Hospice Licensed Practical Nurse (LPN) B and Hospice Certified Nursing Assistant (CNA) C were not wearing isolation gowns. Hospice LPN B and Hospice CNA C stated they provided care for Resident #6 routinely, and were unaware the resident was on EBPs and confirmed they failed to wear an isolation gown when they provided care for Resident #6.During an interview on 8/13/2025 at 11:20 AM, the Director of Nursing confirmed Hospice LPN B and Hospice CNA C had not followed the facility's infection control policy for EBP's.

Based on the facility policy review, medical record review and interviews, the facility failed to prevent the use of a [CONDITION(S)] medication without a related diagnosis for 1 resident (Resident #32) of 5 residents reviewed for unnecessary medications. The findings include: Review of the facility policy titled Antipsychotic Medication Use dated 12/2016, showed .Antipsychotic medications may be considered for residents with dementia but only after medical, physical .psychological, emotional psychiatric, social .environmental causes of behavioral symptoms have been identified and addressed .Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective .will identify .symptoms that may warrant the use of antipsychotic medications .Residents who are admitted from the community .transferred from a hospital .who are already receiving antipsychotic medications will be evaluated for the appropriateness and indications for use . Resident #32 was admitted to the facility on [DATE] with diagnoses including Depressive Disorder, Anxiety Disorder, Alzheimer's Disease, Dementia, Long Term use of Anticoagulants and Cognitive Communication Deficit. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #32 had severe cognitive impairment. Further review revealed active diagnoses of .Alzheimer's .Anxiety .Depression . (a Psychotic disorder was not indicated) and the resident had received antipsychotic, antianxiety, antidepressant medications on all 7 days of the 7 day look back period. Review of the current Comprehensive Care Plan showed Resident #32 received anti-psychotics, anti-depressants, and anti-anxieties with interventions including pharmacy review of the drug regimen (by the pharmacist) for identification and drug interactions. Review of the Medication Administration Record (MAR) dated 8/2022 showed .[MEDICATION(S)] [an antipsychotic medication used to treat mental and mood disorders] 25 mg [milligrams-unit of measure] .by mouth at HS [hour of sleep] . Resident # 32 was admitted to the facility from the hospital on [MEDICATION(S)] ([MEDICATION(S)]). The medication was increased 2 times on 8/19/2022 and again 8/26/2022. Review of the monthly pharmacy review dated 8/17/2022 showed no recommendations and did not indicate Resident #32 was receiving [MEDICATION(S)] with no [CONDITION(S)] diagnosis. Review of the MAR dated 9/2022 showed Resident #32 continued to receive [MEDICATION(S)] ([MEDICATION(S)]) with an increase in dosage on 9/2/2022. The MAR for 9/2022 showed no indications for the usage of [MEDICATION(S)]. Review of the initial Psychiatric Evaluation dated 8/16/2022, showed Resident #32 had a history of anxiety and depression. The evaluation showed staff reported episodes of crying spells with pacing the hallways. The evaluation showed no psychotic symptoms assessed or reported. During a telephone interview on 9/8/2022 at 10:22 AM, the Pharmacist stated Resident #32 had been admitted from the hospital on the [MEDICATION(S)] and she completed Resident #32's medication review on 8/17/2022. The Pharmacist confirmed there was no supporting [CONDITION(S)] diagnosis for the use of [MEDICATION(S)] and had not consulted with the medical doctor regarding the prescribed medication. During an interview on 9/8/2022 at 11:22 AM, the Director of Nursing (DON) confirmed Resident #32 had received [MEDICATION(S)] without a diagnosis of [CONDITION(S)] since admission to the facility on [DATE].

Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure the call light was kept within reach for 2 Residents (# 20 & #131) of 22 residents sampled. The findings include: Review of the facility policy, Answering Call Lights revised 6/1/16 revealed .When the resident is in the bed or confined to a chair be sure the call light is within easy reach of the resident . Medical record review revealed Resident #20 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 8 indicating the resident had moderate cognitive impairment. Further review revealed the resident required extensive assistance of 1 staff member for bed mobility and transfers, assistance of 1 staff member for walking in the room, and extensive assistance of 2 staff members for toileting. Medical record review of the Care Plan dated 8/1/18 revealed .At risk for falls related to generalized weakness .Call light in reach . Observation and interview with Certified Nursing Assistant (CNA) #1 on 8/27/18 at 11:27 AM, in the resident's room, confirmed the call light was lying in the floor at the bedside. Further interview confirmed the resident was able to use the call light to ask for assist with CNA stating .sometimes he does . Observation of Resident #20 on 8/27/18 at 1:19 PM, in the resident's room, revealed the resident lying in the bed with the call light lying on the floor at the bedside. Observation of Resident #20 on 8/27/18 at 2:12 PM, in the resident's room, revealed the resident lying in the bed with the call light lying on the floor at the bedside. Observation and interview with Licensed Practical Nurse (LPN) #1 on 8/27/18 at 2:17 PM, in the resident's room, confirmed the call light was lying on the floor at the bedside. Medical record review revealed Resident #131 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Care Plan dated 8/11/18, revealed the resident was at risk for falls related to Generalized Weakness, Dementia, Balance Issues and a History of Falls with Interventions including call bell in reach. Medical record review of an Admission MDS dated [DATE], revealed the resident had a BIMS score of 4, indicating the resident had severe cognitive impairment. Continued review revealed the resident required extensive assistance of 2 for bed mobility, transfers, and toileting and required assistance of 1 staff member for walking in the room. Observation and interview with LPN #2 on 8/27/18 at 8:55 AM, in the resident's room revealed the resident lying in bed with his gown pulled up and the call bell lying on the floor at bedside. Interview with LPN #2 on 8/27/18 at 9:00 AM, outside the resident's room confirmed the residents call light was not within reach of the resident. Observation and interview with CNA #2 on 8/28/18 at 3:15 PM, in the resident's room revealed the resident lying in bed with his gown pulled up and the call light was lying on the floor at bedside. Interview with CNA #2 on 8/28/18 at 3:20 PM, outside the resident's room confirmed the call bell was not within the residents reach. Interview with the Assistant Director of Nursing (ADON) on 8/28/18 at 2:40 PM, in the ADON's office, confirmed the facility failed to ensure call light was kept within reach for Resident #20.

Based on facility policy review, observation, and interview, the facility failed to ensure expired medications were not available for resident use for 1 of 2 medication carts. The findings include: Review of the facility policy Medication Management revealed .Medications are stored, dispensed, and destroyed in a manner to ensure safety and conformance with State and Federal laws . Observation of the 2 & 4 medication cart with Licensed Practical Nurse (LPN) #1 on 8/29/18 at 8:54 AM, at the nurse's station, revealed 12 [MEDICATION NAME] (a narcotic pain medication) 5 milligram (mg) tablets in the narcotic box with an expiration date of .5/18 . Interview with LPN #1 on 8/29/18 at 9:28 AM, in the conference room, confirmed the 12 [MEDICATION NAME] 5mg tablets observed in the 2 & 4 medication cart were expired in (MONTH) of (YEAR) and the facility failed to ensure expired medications were not available for resident use.

Based on review of facility policy, medical record review, observation, and interview, the facility failed to sanitize or wash the hands during a medication pass for 1 resident (#29) of 8 residents who were observed during the medication pass. The findings included: Review of facility policy Infection Control, Standard Precautions, with no date, revealed .Standard precautions will be used in the care of all residents regardless to their [DIAGNOSES REDACTED]. Further review revealed .Hand hygiene .wash hands after touching blood, body fluids, secretions, excretions, and contaminated items whether or not gloves are worn .follow hand hygiene policy . Medical record review revealed Resident #29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation on 10/12/15 at 8:59 AM, on the 200 Hallway, during a medication pass, revealed Licensed Practical Nurse (LPN) #1 prepared the medications for Resident #29. Further observation revealed the nurse placed the medications in a cup, covered the medication cup with another cup, and crushed the medications. Continued observation revealed the LPN placed the unused medication cup in the trash container located on the side of the medication cart, touched the dirty trash container lid with the hands, and did not sanitize or wash the hands after touching the trash container lid. Further observation revealed the nurse entered the room and without washing or santizing the hands, administered the oral medications and then administered eye drops to the resident with ungloved and unsantizied hands. Interview with LPN #1 on 10/12/15 at 9:01 AM, in the 200 Wing Hallway, confirmed the nurse failed to sanitize or wash the hands after touching the dirty contaminated trash container lid and prior to administering the oral medications and eye dops to the resident. Interview with the Director of Nursing (DON), who is the facility's Infection Control Preventionist, on 10/12/15 at 9:10 AM, in the DON's office, confirmed the nurse failed to follow the facility's policy regarding hand hygiene.

Based on observation and interview, the facility failed to ensure a homelike environment related to odors for one of four hallways observed. The findings included: Observation on July 30, 2013, at 9:45 a.m., on the 100 wing hallway revealed a foul smelling odor on the wing just past the fire doors. Continued observation revealed the odor worsened in one room of four rooms observed. Observation on July 30, 2013, at 2:00 p.m., on the 100 wing hallway, revealed a foul smelling odor in the hallway just past the fire doors. Continued observation revealed the odor was worse in one of the four rooms observed. Observation on July 31, 2013, at 10:00 a.m., on the 100 wing hallway, just past the fire doors revealed a continued foul smelling odor in the hallway and worse in one of the four rooms observed. Interview with Licensed Practical Nurse #1 on July 30, 2013, at 2:00 p.m., on the 100 wing hallway confirmed the odor had been present for years. Continued interview revealed "...thought it was coming from the bathroom or the sink of (named room) but it was not..." Interview on July 30, 2013, at 2:30 p.m., on the 100 wing hallway with Certified Nurse Assistant #1 confirmed the odor was present and had been noticed for years. Interview with the facility maintenance worker on July 30, 2013, at 3:25 p.m., on the 100 wing hallway, confirmed the foul odor smell on the 100 wing hallway just past the fire doors. Continued interview revealed "...have never noticed it...not sure what it is..." Interview with the Director of Nursing on July 30, 2013, at 3:45 p.m., on the 100 wing hallway confirmed the fowl odor smell. Continued interview revealed "...I think it is the sewer line..." Interview with the Administrator on July 31, 2013, at 10:30 a.m., on the 100 wing hallway confirmed the foul smelling odor on the 100 wing hallway and the smell was worse in one of the four rooms observed. Continued interview revealed "...will notify our maintenance and have them look at it..."

Based on medical record review and interview, the facility failed to ensure the accuracy of completed assessments for range of motion for one (#11) and for a contracture for one (#31) of thirty residents reviewed. The findings included: Resident #11 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had no cognitive impairment, required assistance with all activities of daily living, and had no limitations with range of motion. Observation on July 31, 2013, at 10:15 a.m., revealed the resident sitting up in bed. Continued observation revealed both hands contracted. Interview with the resident during the observation confirmed the resident had limited range of motion in both hands. Interview with the Assistant Director of Nursing (ADON)/Minimum Data Set Coordinator, in the ADON's office on July 31, 2013, at 10:30 a.m., confirmed the resident had limited range of motion in both hands related to contractures and confirmed the Minimum Data Set, dated dated dated [DATE], was inaccurate. Resident #31 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident had no impairment of the lower extremity. Medical record review of a Physical Therapy Evaluation dated April 10, 2013, revealed the resident had plantar flexion contractures of the right lower extremity (Right knee/LE (lower extremity). Observation on July 29, 2013, at 2:09 p.m., revealed the resident seated in a geri-chair in the resident's room. Further observation revealed the right foot was contracted inward to the left. Interview with the resident during the observation revealed the resident was unable to walk. Interview with the ADON in the ADON's office on July 31, 2013, at 11:40 a.m., confirmed the facility had failed to code the functional limitations in range of motion to reflect the plantar flexion contractures of the right lower extremity.

Based on medical record review, observation, and interview, the facility failed to develop a comprehensive care plan to address contracture for one resident (#31) of thirty sampled residents. The findings included: Resident #31 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Physical Therapy Evaluation dated April 10, 2013, revealed the resident had plantar flexion contractures of the right lower extremity (Right knee/LE (lower extremity). Medical record review of the Care Plan dated July 14, 2013, revealed no interventions to address the resident's plantar flexion contractures of the right lower extremity. Observation on July 29, 2013, at 2:09 p.m., revealed the resident seated in a geri-chair in the resident's room. Further observation revealed the right foot was contracted inward to the left. Interview with the resident during teh observation revealed the resident was unable to walk. Interview with the ADON (Assistant Director of Nursing) in the ADON's office on July 31, 2013, at 10:55 a.m., confirmed the facility had failed to develop a care plan to address the plantar flexion contractures of the right lower extremity.

Based on medical record review, observation, facility policy review, and interview, the facility failed to ensure that consistent infection control principles where maintained to prevent cross contamination during medication administration for one resident (#3) of thirty residents reviewed and failed to maintain standard infection practices during ice pass. The findings included: Medical record review of the Physician's Recapitulation Orders for July 2013 revealed "[MEDICATION NAME] .05 % (eye drops to increase tear production) instill 1 drop into each eye 2 times daily..." Observation in the resident's room on July 30, 2013, at 8:27 a.m., revealed the Charge Nurse administered eye drops to resident #3. Continued observation revealed the Charge Nurse applied the gloves, failed to wash the hands, administered the eye drops to both eyes touching both eye lids, and failed to change the gloves between each eye drop administration. Review of facility policy, Administration of Eye Drops and Ointments, revealed "...wash hands, put on gloves...If eye drops are to be administered in both eyes...wash hands, glove, administer eye drops to one eye. D/C (discontinue) gloves, wash hands. Put on clean gloves, administer eye drops to other eye..." Interview with the Charge Nurse on July 30, 2013, at 8:34 a.m., outside the resident room confirmed the Charge Nurse did not wash the hands prior to gloving and failed to wash the hands, change gloves in between administration of eye drops. Interview with the Director of Nursing in the facility conference room, on July 31, 2013, at 10:33 a.m., confirmed the facility had failed to follow the policy for the administration of eye drops. Observation on July 31, 2013, at 9:30 a.m., on the 100 wing hallway revealed Certified Nursing Assistant (CNA) #1 passing ice for four rooms on the hallway. Continued observation revealed CNA #1 brought the ice pitcher outside of the resident's room, placed the individual ice pitcher over the clean ice chest, used a scoop and placed ice in the pitcher while holding the pitcher directly over the clean ice chest. Continued observation revealed CNA #1 returned the scoop to the holder, closed the ice chest lid and then returned the dirty ice pitcher back into the resident's room. Review of facility policy, Ice Chest and Ice Machine, with no date revealed "...(b) hold scoop used with ice chest by handle; do not touch bowl surface with hands...(g) remove all extraneous equipment and items from around or on the ice chest and machines; if possible, limit access to ice chest..." Interview on July 31, 2013, at 9:45 a.m., at the nurse's station, confirmed CNA #1 filled the dirty ice pitcher with ice directly over the clean ice chest and returned the ice pitcher to the resident's room. Interview with the Assistant Director of Nursing (ADON) on July 31, 2013, at 9:50 a.m., at the nurse's station, confirmed CNA #1 did not follow standard infection control practice by filling the dirty ice pitcher with ice over the clean ice chest.

Based on observation, medical record review, and interview, the facility failed to follow standard practice for infection control during a dressing change for one resident (#1) for thirteen residents reviewed. The findings included: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]. Observation on January 23, 2012, at 1:15 p.m., in the resident's room, revealed Licensed Practical Nurse (LPN) #2 cleaning and applying [MEDICATION NAME] dressing to the resident's coccyx. Continued observation revealed LPN #2 applied wound cleanser to one gauze pad (4x4), wiped one side of the wound, wiped the other side of the wound, wiped the center of the wound and dried the wound using the same dirty gauze pad and proceeded with the dressing change. Interview with LPN #2 on January 23, 2012, at 1:30 p.m., outside of the resident's room, confirmed the LPN used the same dirty gauze pad three times to clean and dry the wound. According to the European Pressure Ulcer Advisory Panel (EPUAP) and the National Pressure Ulcer Advisory Panel (NPUAP), 2009 "...bacteria is present on all skin surfaces...when the primary defense provided by intact skin is lost, bacteria reside on the wound surface also...infection may spread beyond the pressure ulcer, resulting in systemic inflammatory response syndrome (SIRS) or sepsis...to avoid these serious consequences the professional should focus on identification of high risk individuals, prevention, early detection and prompt and effective treatment..." Interview with the Assistant Director of Nursing (ADON) on January 23, 2012, at 2:00 p.m., at the nurses' station, confirmed the use of the same dirty gauze pad to clean and dry the wound does not follow standard practice.

Based on observation, review of facility policy and interview, the facility failed to maintain accurate narcotic records for one resident (#7) of thirteen residents reviewed. The findings included: Resident #7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review revealed physician's orders [REDACTED]. Observation on January 24, 2012, at 10:40 a.m., in the 200 hallway, revealed during narcotic count verification check with Licensed Practical Nurse (LPN) #1, Hydrocodone /APAP 5/500mg twenty six (26) tablets were present in the drawer and the narcotic record for resident #7 revealed twenty five (25) tablets. Interview with LPN #1 on January 24, 2012, at 10:41 a.m., in the hallway confirmed twenty six Hydrocodone tablets were present and the resident's narcotic record revealed twenty five tablets. LPN #1 confirmed the medication was signed out on January 24, 2012 at 9 a.m. for resident #7 and during the 9 a.m. medication pass, was not sure if the Hydrocodone tablet was administered to resident #7. Review of the facilities Verification of Controlled Substance Count Sheet revealed the narcotic count was correct at the previous shift change. Review of the facilities Narcotic Count Policy and Procedure, dated September 12, 2003, revealed"...the number of entries on the narcotic delivery log should match up with the number of cassettes listed on your narcotic cassette sheet..." Interview with LPN #1 and the Director of Nursing (DON), on January 24, 2012, at 10:45 a.m., in the DON office, confirmed twenty six Hydrocodone tablets were present, the narcotic count sheet revealed twenty five tablets and the narcotic count was not correct.

Based on medical record review and interview, the facility failed to obtain laboratory services for one (#2) of thirteen sampled residents. The findings included: Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review revealed a physician's orders [REDACTED]." Further review revealed a physician's orders [REDACTED]. Interview with the Director of Nursing (DON), in the DON's office on January 24, 2012, at 12:15 p.m., confirmed the lab had not been obtained as ordered by the physician.