Every finding on record at Ignite Medical Resort St Marys LLC

Based on observation, interview, and record review, the facility failed to establish and maintain a comprehensive infection prevention and control program designed to help prevent the development and transmission of Legionella (A [NAME] of pathogenic Gram-negative bacteria that includes the species L. pneumophila, causing legionellosis, all illnesses caused by Legionella, including a pneumonia-type illness called Legionnaires' disease and a mild flu-like illness called Pontiac fever) and/or other water-borne pathogens (a bacterium, virus, or other microorganism that can cause disease) that included specific assessments, in accordance with State of Missouri rules and Centers for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS) standards and guidelines; the facility failed to follow Infection Control policies by not ensuring distilled water (water in which the minerals have been removed) used in oxygen concentrators (a medical device that filters air to deliver concentrated medical grade oxygen 85 to 95% purity to patients with breathing issues) was kept off of the floor and dated with the date it was opened for two sampled residents, (Resident #13 and #36), failed to ensure indwelling catheters (drainage device for those who could not empty their bladder), were not touching the floor for three sampled residents, (Resident #13, #79, and #80) out of 18 sampled residents. This deficient practice had the potential to affect all residents, visitors, volunteers, and staff who resided, visited, used, or worked in the facility. The facility census was 86 residents with a licensed capacity for 130 residents at the time of the survey. Review of the facility's policy, Catheterization of Urinary Bladder (a medical procedure when a flexible tube was inserted through the urethra (a tube that transports urine from the bladder (a hollow organ that stores and empties urine out of the body) into the bladder to drain urine), dated April 2023 showed:-Staff was to hang the collection bag (bag that held urine) appropriately to the side of the bed, keeping it below the bladder and off of the floor. Review of the facility's policy, Respiratory Supplies, dated 5/2023 did not address respiratory equipment supplies. 1.Review of the facility's 44-page water-borne pathogen prevention program binder titled Water Management Plan, created 7/2/21 and provided by the Administrator, showed:-A completed CDC toolkit assessment including control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens was not included.-No CDC Legionella Environmental Assessment Form had been done.-Page #8 had a previous Environmental Services Director's (EVSD) name listed as part of the Program Team.-At the bottom of all pages except the front cover-page it read, This Water Management Plan Expires on 06/15/2022. Observation on 4/27/26 between 9:39 A.M. and 9:53 A.M. during the Life Safety Code (LSC) kitchen walk-through inspection with the Certified Dietary Manager (CDM) showed the following:-The kitchen proper had a portable steam table, 2-sink food preparation table, and a hand washing sink.-The adjacent kitchen galley had an ice-machine and a sink.-An attached dishwashing room had a chemical, low-heat dishwasher and a 3-sink sanitizing area. Observation on 4/28/26 between 10:29 A.M. and 1:45 P.M. during the LSC walk-through with the Environmental Services Director (EVSD) showed the following on the first floor of a two-story building:-The public water supply entered through the west side of the building.-The building was equipped with a complete fire sprinkler system with sidewall and ceiling mounted sprinkler heads located throughout the facility.-The fire sprinkler riser room (a dedicated space for fire protection equipment) was accessed through an outside garage door at the west parking lot.-There were at least 60 resident rooms with toilet and sink access.-Two public restrooms were next to the central nurse station.-A medication room with a sink was located behind each of the separate nurse stations.-There were housekeeping closets with floor mop sinks or ceramic service sinks (mop/service sinks are used in janitorial and maintenance areas to fill and empty mop buckets, clean mops, and dispose of dirty water) and hot/cold water piping throughout the facility.-There were three commercial clothes washers in the laundry area.-There were four Bathhouses with showers and/or baths in the facility. -There was a Beauty Shop with a sink. During an interview on 4/28/26 at 1:47 P.M. the EVSD said:-They should have a Legionella plan somewhere.-He/She knew they had logs of running faucets and eyewash stations.-They do not do toilet flushings though because rooms were mostly all occupied. During an interview on 5/1/26 between 8:32 A.M. and 8:51 A.M. the EVSD said:-The facility's ownership had a contracted company create their water management plan.-Besides doing sink/eyewash checks, he/she just made sure all water outlets were checked throughout the year. During an interview on 5/1/26 between 9:11 A.M. and 9:33 A.M. the Administrator said he/she was educated on the water pathogen prevention program through an instructional email from their corporate office. 2. Review of Resident #13's face sheet showed he/she was admitted to the facility with the following diagnoses:-Chronic Obstructive Pulmonary Disease (COPD – an ongoing lung condition caused by damage to the lungs).-Retention of Urine (the inability to fully or partially empty the bladder, causing pain and pressure).-He/She had a guardian.-He/She was cognitively intact. Review of the resident's Care Plan dated 1/27/26 showed:-Staff were to administer oxygen per physician's orders.-Oxygen setting was to have been set at two liters per nasal cannula (plastic tube that delivers oxygen via a resident's nose).-He/She had a urinary catheter.-Staff was to check placement of tubing each shift, dated 4/27/26. Review of the resident's Physician's Order Sheet (POS) dated April 2026 showed:-Monitor oxygen saturation (a measurement of oxygen in the blood), every shift, dated 1/27/26.-Albuterol Sulfate Nebulization Solution (a fast acting medication used to treat COPD) 2.5 milligrams (mg)/3 milliliter (ml), to inhale three ml via nebulizer (a medical device that turns liquid medication into a fine mist for inhalation) ever six hours as needed for wheezing or shortness of breath.-There was no order for the urinary catheter. Observation on 4/24/26 at 10:00 A.M. showed:-The resident was sitting in his/her wheelchair, the catheter was attached to the bottom of the wheelchair touching the floor.-The resident had an oxygen concentrator that had a humidifier with a water reservoir.-There was an opened jug of distilled water for the humidifier sitting on the floor. -The distilled water did not have a date written on it which showed when it had been opened. Observation on 4/27/26 at 11:46 A.M., and 4/28/26 at 10:50 A.M., showed:-There was an opened jug of distilled water for the humidifier sitting on the floor. -The distilled water did not have a date written on it which showed when it had been opened. Observation and interview on 4/28/26 at 2:00 P.M. showed:-There was an opened jug of distilled water for the humidifier sitting on the floor. -The resident was sitting in his/her wheelchair with the catheter attached to the bottom of the wheelchair touching the floor. -The resident said he/she used oxygen at night.-The distilled water usually sat on the floor where the staff put it. Observation on 4/28/26 at 2:30 P.M. of the resident's catheter care with Licensed Practical Nurse (LPN) C, Certified Medication Technician (CMT) B, and Certified Nursing Assistant (CNA) C showed:-The resident was sitting in his/her wheelchair with the catheter attached to the bottom of the wheelchair touching the floor. -CMT B and CNA C used a mechanical lift to move the resident from his/her wheelchair into his/her bed to do catheter cares.-While in the bed the catheter was attached to the bed frame, hanging down touching the floor. -CNA C and CMT B stepped on and kicked the catheter bag out of the way while doing cares.-CMT B and CNA C used a mechanical lift to move the resident back into his/her wheelchair. -The catheter was attached to the bottom of the wheelchair by LPN C.-The catheter was dragging on the floor as LPN C started to wheel the resident out of the room. During an interview on 4/28/26 at 3:00 P.M. CNA C said:-The catheter should not have been touching the floor.-He/She had education provided by the facility during orientation and annually regarding catheter care and placement.-Hanging down from the bottom of the wheelchair was where they always placed the catheter. -He/She did not know what to do about the distilled water, the night nurse took care of the respiratory equipment.-Maybe should have put the jug of distilled water on the counter. During an interview on 4/28/26 at 3:10 P.M. CMT B said:-The catheter should not have touched the floor but he/she did not know where to put it.-The night nurse took care of the respiratory equipment.-The distilled water should not have been on the floor.-They had received education during orientation from the facility regarding catheter care and placement. During an interview on 4/28/26 at 3:20 P.M. LPN C said:-The night nurse took care of the respiratory equipment.-The jug of distilled water should not have been on the floor.-If the distilled water was opened it should have had the date it was opened written on it.-Any nursing staff should not have allowed the distilled water to have been sitting on the floor, he/she had not noticed it. -The catheter should not have touched the floor as it was an infection control issue.-Any nursing staff should have changed the position of the catheter so it did not touch the floor.-There should have been some kind of barrier between the catheter and the floor but he/she did not know what to do. -The facility had provided a skills fair and went over the respiratory equipment and catheter care and placement. Observation on 5/1/26 at 9:30 A.M. showed the resident's distilled water jug was sitting on the floor with no date on it. 3. Review of Resident #36's face sheet showed he/she was admitted to the facility with the following diagnoses:-COPD.-Respiratory Failure (a life threatening condition where the lungs cannot adequately oxygenate the blood).-He/She had a guardian.-He/She was cognitively intact. Review of the resident's POS dated April 2026 showed a physican order for continuous oxygen at two liters per minute every shift for COPD. Review of the resident's Care Plan dated 4/28/26 did not show the resident was on oxygen therapy. Observation on 4/27/26 at 12:33 P.M. showed:-The resident was sitting in his/her room wearing oxygen.-There was an opened jug of distilled water with no date written on it, sitting on the floor. Observation and interview on 4/28/26 at 10:30 A.M. showed:-The resident was sitting in his/her room wearing oxygen.-There was an opened jug of distilled water with no date written on it, sitting on the floor.-The resident said he/she used oxygen more often now, always at night.-The night staff took care of the oxygen equipment. -The jug of distilled water sat on the floor after staff opened it. 4. Review of Resident #79's Care Plan dated 6/5/25 showed:-The resident had a suprapubic catheter (S/P) catheter (a urinary bladder catheter inserted through the skin about one inch above the symphysis pubis) related neuromuscular dysfunction of bladder secondary to Parkinson's disease (brain disorder causing unintended or uncontrolled movements) and dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses). -The resident would have shown no signs or symptoms of urinary tract infection through review date. Review of the resident's Order Summary Report dated 6/6/25 showed:-Change Urinary Catheter Drainage bag as needed.-Cleansed area to urinary catheter site, patted dry, applied split gauze every shift. Review of the resident's Quarterly Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) dated 3/24/26 showed the resident had an indwelling urinary catheter. Observation on 4/28/26 at 10:38 A.M. showed:-The resident was sitting in his/her wheelchair propelling down the hall headed towards the dining area with his/her urinary catheter bag dragging on the floor. -The resident traveled approximately 10 feet with the urinary catheter bag touching the floor and being dragged. Observation on 4/30/26 at 10:46 A.M. showed the resident sitting in wheelchair by therapy with urinary catheter bag touching the floor not in a privacy bag or on a barrier. 5. Review of Resident #80's admission Record showed the resident admitted to the facility with a diagnosis of acute kidney failure. Review of the resident's care plan dated 4/14/26 showed:-The resident had a urinary catheter related to urinary retention. -Nothing in the care plan about urinary catheter bag placement noncompliance. Review of the resident's Order Summary Report showed:-Urinary catheter care was to include anchoring tubing.-Checking skin integrity every shift and as needed. Review of the resident's admission MDS dated [DATE] showed the resident had an indwelling urinary catheter. Observation on 4/27/26 at 1:00 P.M. showed the resident's urinary catheter was lying on the floor not in a privacy bag or on a barrier. 6. During an interview on 4/30/2026 at 9:01 A.M., CNA B said:-Urinary catheter bags were not supposed to be lying on the floor or dragged on the floor. -The urinary catheter bag should not touch the floor because that would be an infection control issue. -To prevent the urinary catheter bag from touching the floor it should have been in a privacy bag or on a barrier placed under the bag.-The urinary catheter bag would have been hung on the wheelchair, so the bag and the tubing was not touching the floor. During an interview on 4/30/26 at 9:07 A.M., LPN B said:-It was inappropriate for the urinary catheter bag to touch the floor or be dragging on the floor while pushing the resident in a wheelchair.-It would have been an infection control issue for the urinary catheter bag to be touching the floor. -The urinary catheter bag should be placed in a privacy bag or have a barrier so the catheter bag would not touch the floor. -A urinary catheter bag should have never just been laid on the floor. -If a resident was noncompliant with keeping the urinary catheter bag off the floor it should have been care planned.-When a resident was noncompliant with urinary catheter bag placement the resident should have been educated about urinary catheter bag placement and checked frequently for proper urinary bag placement. During an interview on 5/1/26 at 9:00 A.M. the Assistant Chief Nursing Officer (ACNO)/Infection Preventionist (IP) said:-All nursing staff were responsible for ensuring that respiratory equipment was kept clean.-If a resident was on oxygen and the concentrator had a humidifier the resident would have distilled water.-The jug of distilled water should not have been sitting on the floor.-The jug of distilled water should have had the date that it was opened written on it. -He/She did spot checks to ensure it was not on the floor and if it was opened that there was a date written on it.-He/She was ultimately responsible for ensuring staff did not place the distilled water on the floor and had written the date that it was opened. -The resident's catheter should never touch the floor.-The catheter bag needed to be at or below the level of the resident's bladder.-If a resident was in bed and the catheter would have touched the floor then the catheter bag should have been in a wash basin or had some type of barrier so it did not touch the floor such as a chux (a disposable paper pad). -All nursing staff had been educated on infection control practices such as the respiratory equipment and catheter placement during orientation, annually during the skills fair, and as needed.-He/She was ultimately responsible for ensuring staff followed infection control practices. During an interview on 5/1/26 at 10:30 A.M. the Chief Nursing Officer (CNO) said:-Oxygen therapy should be kept clean by direct nursing staff.-Distilled water should not be on the floor.-If opened, the distilled water should have had the date written on it that it had been opened.-Direct nursing staff should look to ensure the distilled water was not on the floor and was dated.-Night shift nurses, then the Unit Manager were ultimately responsible for ensuring respiratory equipment was kept in a sanitary condition. -Catheter bags were not to be laid on the floor, touching the floor, or dragging on the floor while the resident was pushed in a wheelchair. -The direct staff should have ensured that the catheter did not touch the floor when the resident was in the wheelchair and in the bed.-If the bed was in the low position, the catheter should have been kept in a wash basin or had a chux between the catheter and the floor so there was a barrier.-If a resident was noncompliant with catheter bag placement, the care plan should have been updated to reflect this.-If a resident was noncompliant that the staff should check catheter bag placement frequently, educate the resident on the importance of catheter bag placement, and document the education. -The unit manager was ultimately responsible for ensuring that the catheter did not touch the floor.-Staff had education on catheters and respiratory equipment during orientation, annually, during the annual skills fair, and monthly.

Based on interview and record review, the facility failed to provide, in advance, the risks and benefits of the medications Divalproex (a mood-stabilizing to treat bipolar disorder [a mental health condition characterized by intense, alternating mood swings]), Trazodone (an antidepressant that treats major depressive disorder) and Duloxetine (a medication used to treat depression and anxiety [a persistent, excessive, and uncontrollable fear or worry that interfered with daily life]) for one sampled resident (Resident #38) out of 18 sampled residents. The facility census was 86 residents. Review of the facility's Psychotropic Medications policy, dated May 2025, showed:-The Chief Nursing Officer (CNO) was the party responsible for ensuing all state and federal regulations were followed regarding the administration and monitoring of psychotropic medications.-Psychotropic medications included drugs from the following classes: hypnotics,antipsychotics, long and short-acting benzodiazepines, sedatives/anxiolytics andantidepressants.-Psychotropic medication regimen was reviewed quarterly and upon changes indrug classification with resident/responsible party during care planmeetings to ensure ongoing informed consent.1. Review of Resident #38's Antidepressant Consent Form, dated 5/1/25, showed:-The resident was taking Mirtazapine (a prescription medication used to treat major depressive disorder), 15 milligrams (mg) at bedtime.-The Consent was marked with electronic initials of the resident.Review of the resident's Antianxiety Medication Consent Form, dated 5/25/25, showed:-The resident was taking Hydroxyzine (a prescription medication used to treat anxiety) every four hours as needed.-The resident was taking Lorazepam (a prescription medication used to treat anxiety disorders) 0.5 mg every eight hours as needed.Review of the resident's Electronic Health Record (EHR) showed:-There was no consent that indicated the resident was taking Divalproex.-There was no consent that indicated the resident was taking Trazadone.-There was no consent that indicated the resident was taking Duloxetine.Review of the resident's Quarterly Minimum Data Set (MDS- a standardized, federally mandated assessment tool used in nursing homes to evaluate a resident's functional, medical, psychosocial, and cognitive status) dated 3/12/26, showed the resident was severely cognitively impaired.Review of the resident's physician orders, dated April 2026, showed:-The resident was diagnosed with dementia (a decline in mental abilities such as memory, reasoning, and communication) and anxiety disorder (a mental health condition characterized by excessive, persistent, and uncontrollable worry or fear).-The resident's medication orders included:--Divalproex Sodium 125 milligrams (mg), two capsules by mouth three times a day for a mood stabilizer.--Duloxetine HCl Capsule 20 mg, one capsule by mouth one time a day fordepression, anxiety--Trazodone HCl Tablet 50 mg by mouth at bedtime.During an interview on 4/29/26 at 1:14 P.M., Certified Medication Technician (CMT) A said:-The resident was taking Duloxetine and Divalproex.-The families were informed of what medications the residents were taking.-The nurses were the ones responsible for consent to treat.During an interview on 4/29/2026 at 1:19 P.M., the Assistant Chief Nursing Officer (ACNO) said:-The resident was on several medications that were psychotropics.-Families were given medication information and it was documented in the EHR.During an interview on 4/29/2026 at 1:51 P.M., Licensed Practical Nurse (LPN) A said:-Resident's received risks and benefits for each medication.-Physicians were responsible for getting the consents completed.-They should be in the resident's EHR. -The resident had consent for the antipsychotics he/she was taking. During an interview on 5/1/26 at 10:30 A.M., the Chief Nursing Officer (CNO) said:-Residents and representatives were notified when they were taking antipsychotics or psychotropics and the risks and benefits were also explained.-It should have been documented in the consents.-The ACNO was responsible for reviewing and documenting the risks and benefits.-Risks and benefits were also reviewed during care plan meetings.-The risks and benefits were reviewed quarterly by the ACNO. -It was his/her expectation to have progress notes stating it was reviewed with the resident or family member. -Each medication had a Consent to Treat and Risks and Benefits completed and documented. -Each medication was addressed individually.-The Consent to Treat and Risks and Benefits was audited during survey and periodically.-If Consent to Treat and Risks and Benefits were not documented then they were not completed.

Based on observation, interview and record review, the facility failed to monitor symptoms and side-effects of psychotropic medications (a medication that affects brain activities associated with mental processes and behavior) for two sampled residents (Residents #12 and #38) out of five residents sampled for medication review. The facility census was 86 residents. Review of the facility's policy Psychotropic Medications dated December 2019 showed:-The resident's need for the psychotropic medication will be monitored, as well as when the resident has received optional benefits from the medication and when the medication dose can be lowered or discontinued.-The physician's order for a psychotropic medication will include both a qualifying diagnosis for the drug and a list of behaviors which the staff will monitor during the drug administration. 1. Review of Resident #12's admission record showed the resident:-Some of his/her diagnoses included Alzheimer's Disease (a progressive loss of brain cells that leads to memory loss and the decline of other thinking skills), dementia (a progressive mental disorder characterized by memory problems, impaired reasoning and personality changes), visual hallucinations (a vivid visual experience involving the perception of an object or an event occurring without corresponding external stimuli in an awake state), major depressive disorder (depressed mood most of the day and a loss of interest in normal activities and relationships), and anxiety disorder (psychiatric disorder that involve extreme fear, worry and nervousness). Review of the resident's care plan dated with multiple dates showed:-On 4/29/24 the resident had the potential for alterations in psychosocial well-being due to visual hallucinations, dementia, Alzheimer's Disease, major depressive disorder, and anxiety.-On 4/29/24 the resident was receiving antipsychotic medication as part of the regimen to treat agitation related to dementia and Alzheimer's disease, major depressive disorder, and anxiety and interventions included monitor, document, and report any adverse reactions to the psychotropic medications such as unsteady gait, tardive dyskinesia (a neurological disorder characterized by involuntary uncontrollable movements occurring as a side effect of prolonged use of antipsychotic drugs), Extrapyramidal symptoms (EPS-shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations (thinking about suicide or wanting to take your own life), social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person. -On 4/29/24 the resident was receiving antianxiety medication and interventions included monitoring the resident for safety, confusion, amnesia (memory loss), loss of balance, and cognitive impairment. Monitor, document, and report any adverse reactions to antianxiety medications such as drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgment, memory loss, forgetfulness, nausea, stomach upset, blurred or doublevision, mania, hostility, rage, aggressive or impulsive behavior, and hallucinations (a sensory perception (sight, sound, smell, taste, or touch) that feels real but is created by the mind in the absence of external stimuli).-On 5/17/24 depression and anxiety interventions included monitor, document, and report any signs or symptoms of depression including hopelessness, anxiety, sadness, insomnia (inability to fall or stay asleep), anorexia (eating disorder characterized by an intense fear of gaining weight, leading to extreme food restriction, severe weight loss, and a distorted body image), verbalizing negative statements, repetitive anxious or health-related complaints, and/or tearfulness.-On 6/12/24 the resident had impaired cognitive function and/or impaired thought processes related to visual hallucinations, dementia and Alzheimer's Disease. -On 12/12/24 the resident was resistive to Gradual Dose Reduction (GDR-tapering of medication dosage—particularly psychotropics—to determine if symptoms can be managed on a lower dose or if the medication can be discontinued) attempts and alternative medications other than antipsychotic therapy because he/she has been on this regimen for years and did not want to change it despite education and recommendations. Review of the resident's physician's progress note dated 2/8/26 showed:-The resident was seen for hallucinations and not taking pills for medical management.-The resident was followed by the Psychiatrist for depression and anxiety management. Review of the resident's PHQ-9 (validated assessment to determine diagnosis and monitor depression severity) assessment dated [DATE] showed the resident had a moderate severity of depression. Review of the resident's nurse's note dated 2/16/26 at 10:47 A.M. showed:-The Nurse Practitioner (NP) attempted a GDR of Seroquel (an antipsychotic medication). -Following the GDR, the resident became tearful and exhibited increased agitation and anxiety. -Based on the resident's response, the NP determined that the current medication regimen was effective in maintaining baseline functioning. -The plan was to continue the present dose and monitor for ongoing stability. Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 2/25/26 showed the resident:-Was cognitively intact.-Received antipsychotic (class of medicines used to treat psychosis and other mental and emotional conditions), antianxiety (medication to treat anxiety), and antidepressant (medication used to treat clinical depression) medications. Review of the resident's physician's note dated 3/20/26 showed:-The resident noted worsening depression. -The resident said he/she had a couple of things going on that he/she felt were contributing to his/her depression.-The resident was also concerned that his/her Seroquel was previously decreased which caused him/her worsening psychosis depression. During an interview on 4/27/26 at 12:33 P.M., the resident said:-One of his/her previous roommates died and he/she had a hard time dealing with that. -He/She had a counselor that he/she talked to about his/her former roommate. Review of the resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated April 2026 showed:-A physician's order dated 9/25/25 for Seroquel, give 100 milligrams (mg), give one tablet one time a day for agitation. --There was no monitoring of antipsychotic medication for side effects or symptoms of agitation.-A physician's order dated 9/25/25 for Buspirone (an antianxiety medication) 5 mg, give one tablet two times a day for anxiety.--There was no monitoring of antidepressant medication for side effects or symptoms of anxiety.-A physician's order dated 11/3/25 for Alprazolam (an antianxiety medication) 1 mg, give one tablet two times a day for anxiety.--There was no monitoring of antianxiety medication for side effects or symptoms of anxiety.-A physician's order dated 4/27/26 for Lorazepam (an antianxiety medication) tablet 0.5 mg, give one tablet every three hours as needed for anxiety for 14 Days.--There was no monitoring of antianxiety medication for side effects or symptoms of anxiety. During an interview on 4/29/26 at 2:33 P.M., Licensed Practical Nurse (LPN) A said:-Monitoring of psychoactive medications was usually documented on the TAR.-Currently, the medication monitoring orders came in as a batch order when the medications were ordered and the monitoring orders automatically populated.-The resident had been at the facility a long time and when his/her orders were entered, they might not have included the monitoring orders.-The resident had no current symptoms of anxiety, depression, or agitation.-The resident told them when he/she was anxious or hallucinating. 2. Review of Resident #38's TAR, dated January 2026 showed no monitoring of side effects of antianxiety or antidepressant medications. Review of the resident's TAR, dated February 2026, showed no monitoring of side effects of antianxiety or antidepressant medications. Review of the resident's care plan dated 2/11/26, showed:-The resident was taking antianxiety medications which were associated with an increased risk of confusion, amnesia, loss of balance, and cognitive impairment that looked like dementia and increased risk of falls, broken hips and legs.-The resident was free from discomfort or adverse reactions related to antianxiety therapy. -Administer antianxiety medications as ordered by the facility physician. -Monitor for side effects and effectiveness every shift. -Monitor the resident for safety. -Monitor/document/report any adverse reactions to antianxiety therapy: --Drowsiness.--Lack of energy.--Clumsiness.--Slow reflexes.--Slurred speech.--Confusion and disorientation.--Depression.--Dizziness.--Lightheadedness.--Impaired thinking and judgment.--Memory loss or forgetfulness.--Nausea or stomach upset.--Blurred or double vision. --Unexpected side effects: Mania, hostility, rage, aggressive or impulsive behavior, hallucinations.-The resident received antidepressant medication. -The resident was free from discomfort or adverse reactions related to antidepressant therapy.-Monitor/document/report adverse reactions to antidepressant therapy: --Change in behavior/mood/cognition.--Hallucinations/delusions.--Social isolation.--Suicidal thoughts.--Withdrawal.--Decline in activities of daily living (ADL routine self-care tasks, such as bathing, dressing, eating, and mobility, essential for daily functioning).--Continence, no voiding.--Constipation, fecal impaction, diarrhea.--Gait changes.--Rigid muscles, balance probs, movement problems.--Tremors, muscle cramps.--Falls, dizziness/vertigo.--Fatigue, insomnia.--Appetite loss, weight loss.--Dry mouth and eyes. Review of the resident's TAR, dated March 2026 showed no monitoring of side effects of antianxiety or antidepressant medications. Review of the resident's Quarterly MDS dated [DATE], showed the resident was severely cognitively impaired. Review of the resident's POS dated April 2026, showed:-The resident was diagnosed with dementia (a decline in mental abilities such as memory, reasoning, and communication) and anxiety disorder (a mental health condition characterized by excessive, persistent, and uncontrollable worry or fear).-The resident's medication orders included:--Divalproex Sodium (medication used to treat and manage manic episodes associated with bipolar disorder), 125 mg, two capsules by mouth three times a day for a food stabilizer.--Duloxetine HCl Capsule (medication used to treat major depressive disorder, generalized anxiety disorder), 20 mg, one capsule by mouth one time a day for depression and anxiety.--Trazodone HCl Tablet (medication used to treat major depressive disorder and anxiety), 50 mg by mouth at bedtime.-NOTE: There was no monitoring ordered for Divalproex, Duloxetine or Trazodone. Review of the resident's TAR, dated April 2026 showed no monitoring of side effects of antianxiety or antidepressant medications. During an interview on 4/29/2026 at 1:15 P.M., Certified Medication Technician (CMT) A said:-The resident was on Divalproex. -Staff watched for lethargy (a state of extreme tiredness, sluggishness, or lack of energy and motivation) and other changes in behavior.-He/She understood the medications the resident was taking.-Behaviors were typically recorded in the TAR.-Behaviors were monitored specifically to the medication class. -The behavior monitoring on the TAR was for behaviors in general, not specific to the side effects of the medication. During an interview on 4/29/2026 at 1:19 P.M., the Assistant Chief Nursing Officer (ACNO), said:-The resident's Physician Orders showed several medications that were psychotropics.-Behavior monitoring documented in the TAR was for the side effects that could happen. During an interview on 4/29/2026 at 1:51 P.M., LPN A said:-Nursing staff monitored for behaviors. -The CMT would let him/her know if the resident had any side effect behaviors and he/she would chart the information on the TAR. -Nursing staff were doing behavior monitoring that was specific to the medications.-The resident had an order to monitor behaviors related to his/her antipsychotics. During an interview on 4/30/2026 at 10:31 A.M., the MDS Director said nurses monitored and documented behaviors in the progress notes or on the TAR. During an interview on 5/01/2026 at 10:01 A.M., CMT/Restorative Aide (RA) said: -The TAR had blank spaces to chart that staff had monitored behaviors. -There were different sections for medication side effect related behaviors. 3. During an interview on 5/1/26 at 10:33 A.M., the Director of Nursing (DON) said:-Psychotropic medications such as antipsychotic, antidepressant, hypnotic (medications that induce sleep) and antianxiety medications needed monitoring for side effects.-Direct nursing staff was supposed to document monitoring through a behavior monitoring order.-The behavior monitoring should include all side effects.-The nurses usually wrote a nurse's note if there was anything different going on for that resident.-They were supposed to document in the electronic health record where it asks if the behavior presented itself and they select yes or no.-The nurses could populate a progress note from the TAR.-If there were no side effects listed in the order, then they are not monitored.

Based on observation, interview and record review, the facility failed to ensure adequate oral care for one sampled resident (Resident #7) out of 18 sampled residents. The facility census was 86 residents. Review of the facility's Activities of Daily Living (ADL - dressing, grooming, bathing, eating, and toileting) policy, revised April 2023, showed:-The facility will provide each resident with care, treatment, and services according to the resident's individual care plan, based on the individual resident's comprehensive assessment.-Cares and services included grooming.1. Review of Resident #7's admission Record showed the resident was admitted with the following diagnoses:-Monoplegia (paralysis on one side) of upper limb following stroke affecting the dominant right side.-Monoplegia of upper limb following stroke affecting left non-dominant side.-Contracture (fixed tightening of muscles, tendons, and ligaments, preventing normal movement) of muscle, right upper arm.-Contracture of right and left elbows.-Dysphasia (difficulty swallowing).-Need for assistance with personal cares.-Dementia (a progressive organic mental disorder characterized by chronic confusion, deterioration of intellectual capacity and function, and impairment of memory, judgment, and impulses).Review of the resident's Oral/Dental Health care plan, initiated 7/19/21 showed:-Staff were to perform mouth inspections with oral care. Report any changes to the nurse.-Interventions included oral swabbing with a glycerin swab three times daily due to being on nothing by mouth (NPO) status to assist with keeping mouth clean.Review of the resident's dental hygienist records, dated 3/3/26 showed:-Oral hygiene instructions: Resident was unable to perform self-oral care and needed to have his/her mouth swabbed clean to include the surface of his/her tongue to remove mucus that stayed on all surfaces of his/her oral cavity. If not removed the mucus would become dried out and hard on surfaces and tend to be extremely hard to remove. Using damp gauze could help with removal. All this was happening because the resident was NPO. Brush teeth with water only to remove plaque that formed on the surfaces of the teeth. Assist resident to brush twice daily, focusing on gumline and remove mucus throughout with swabs or gauze.-Prophylaxis (professional teeth cleaning): --Teeth were brushed with toothbrush dipped in Chlorohexidine (a powerful antiseptic and antimicrobial agent) to remove plaque and aid in removing dried and very hardened mucus on all surfaces. Topical fluoride varnish provided. Oral hygiene instruction given. --Gingivitis (gum disease characterized by red, swollen, and bleeding gums) severe inflammation from dried mucus on gums, lips, tongue, and palate. --Heavy plaque (sticky biofilm of bacteria that forms on teeth causing tooth decay and gingivitis).--Moderate to heavy calculus (hardened dental plaque (mineralized biofilm) that adheres to teeth and cannot be removed by brushing alone).--Oral Hygiene: Very poor. Resident was in much need of staff help and was unable to perform self-oral care.Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 4/10/26 showed the resident:-Was severely cognitively impaired.-Had upper body impairments on both sides.-Was dependent on others for oral hygiene.-Had inflamed or bleeding gums or loose natural teeth.Review of the resident's oral hygiene task documentation showed on 4/14/26, 4/17/26, 4/19/26, and 4/20/26 the resident's teeth were cleaned only once daily.Review of the resident's dental record, dated 4/22/26 showed:-Caries (decay) present.-Silver Diamine Fluoride (SDF - a liquid applied to teeth to immediately arrest decay and prevent further damage, often used as an alternative to fillings or sedation) on decay to prevent further decay. -Tissue red and irritated.-Oral hygiene poor.-Routine hygiene services recommended. SDF after cleaning to prevent further decay.-Recommend brushing twice daily, focusing on the gumline.-Resident had broken teeth the Doctor of Dental Surgery (DDS) would monitor. Review of the resident's oral hygiene task documentation showed on 4/22/26, 4/24/26, and 4/25/26 the resident's teeth were cleaned only once daily.Observation on 4/27/26 at 9:54 A.M. showed:-The resident was lying in bed with mouth slightly open.-The resident's lips were very dry.-A crusty film coated the resident's tongue.During an interview on 4/27/26 at 3:11 P.M. the resident's legal representative said:-The resident's gums were always dry.-The resident couldn't brush or swab his/her own mouth.-He/She often cleaned the resident's mouth when he/she visited because the oral cavity was dry and the oral surfaces needed cleaning.Observation on 4/28/26 at 10:40 A.M. showed:-The resident was lying in bed with his/her mouth open.-The resident's lips were very dry.-A dry, crusty, and pealing coating covered the resident's tongue.Observation on 4/29/26 at 2:53 P.M. showed:-The resident was lying in bed with his/her mouth open.-The resident's lips were dry.-A band of saliva had dried between the upper and lower lips on the left side of the resident's mouth.Observation on 4/30/26 at 9:19 A.M. showed:-The resident was lying in bed with his/her mouth open.-The resident's lips were dry.-A band of dried saliva stretched between the upper and lower lips on the left side of the resident's mouth.During an interview on 4/30/26 at 3:06 P.M. Nursing Assistant (NA) A said:-The resident's lips got chapped a lot.-He/She used a sponge on the resident's mouth and tried to swab the resident's tongue which had a coating on it.-Staff needed to clean the resident's mouth at least a few times a day and moisturize the resident's lips. During an interview on 5/1/26 at 8:42 A.M. Certified Nursing Assistant (CNA) D said:-Staff had to swab the resident's mouth to clean it.-Sometimes the resident's family member cleaned the resident's mouth, but staff should still swab his/her mouth at least once during their shift because the resident's lips and tongue were dried very frequently.During an interview on 5/1/26 at 10:10 A.M. the Infection Preventionist said:-The dentist put a protective coating on the resident's teeth to help slow the decay of his/her teeth.-Staff should swab the resident's mouth every morning and, on the day, and night shift whenever needed.-The resident's mouth should be swabbed any time it looked dry. Staff should dip the swab into mouthwash and swab the resident's mouth with a moistened, but not wet, swab.-The resident had moisturizer for his/her lips which should be in his/her toilet room or nightstand.During an interview on 5/1/26 at 10:30 A.M. the Chief Nursing Officer (CNO) said:-The resident was a mouth breather, so his/her oral care needed to be done more frequently than most residents. -Staff could use a flavored moistened swab or a swab that was moistened with half water and half mouthwash for the resident's oral care.-Staff should check the resident's mouth and lips whenever they were in the resident's room to try to keep the resident's mouth clean and moistened.

Based on observation, interview, and record review, the facility failed to provide daily activities to one sampled resident (Resident #7) who required 1:1, small group, and bedside activities out of 18 sampled residents. The facility census was 86 residents. Review of the facility's Activities policy, dated May 2023, showed:-The facility shall provide a comprehensive, ongoing activity program designed to meet the interests, needs, and abilities of each resident, promoting their physical, cognitive, social, emotional, and psychosocial well-being.-The purpose of the Activity program is to ensure residents have access to meaningful activities that reflect individual preferences, enhance quality of life, support their physical, emotional, spiritual, and social well-being and respect their cultural and personal choices.-The policy applied to all residents including short-term and long-term care, memory care, and residents with disabilities.1. Review of Resident #7's admission Record showed the resident was admitted to the facility with the following diagnoses:-Monoplegia (paralysis on one side) of upper limb following stroke affecting right, dominant side.-Monoplegia of upper limb following stroke affecting left, non-dominant side.-Contracture (fixed tightening of muscles, tendons, and ligaments, preventing normal movement) of muscle, right upper arm.-Contracture of right and left elbows.-Dementia (a progressive organic mental disorder characterized by chronic confusion, deterioration of intellectual capacity and function, and impairment of memory, judgment, and impulses).Review of the resident's Dependence for Activities care plan, initiated 11/13/20, showed:-Invite the resident to scheduled activities and escort him/her to activity functions.-Provide assistance as required during the activity.Review of the resident's Little Interest in Activities care plan, initiated 1/12/21 showed:-Establish the resident's prior level of activity and interests by talking with the resident, caregivers, and family.-Modify activities to accommodate participation.-Provide 1:1 and small group activities.Review of the resident's Leisure Preference care plan, initiated 4/2/21, showed the resident was interested in the following:-Having visitors.-Music (it didn't specify the type he/she enjoyed).-Outdoor activities.-Sensory program activities.-Spiritual activities.Review of the Activity calendars for January 2026 to April 2026 showed:-Group activities were scheduled daily at 10:00 A.M. and 2:00 P.M. -Sunday activities also included church at 1:00 P.M. -Monday activities included group exercise at 11:00 A.M.Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 4/10/26 showed the resident:-Was severely cognitively impaired.-Had impaired vision.-Was on a nothing by mouth (nil per os -NPO) status.-Felt down and depressed 12 to 14 days out of 14 days.-Had difficulty concentrating.-Found it somewhat important to listen to music, be around animals, do things with groups of people, and get outside when the weather permitted.-Found it very important to have family involvement and to participate in religious services.-Had upper and lower impairments on both sides of the body.Observation on 4/27/26 at 9:54 showed:-The resident was lying on his/her back in bed. His/Her arms and hands were contracted with his/her arms drawn upwards and fists in a closed position. The resident opened his/her eyes when spoken to and responded to yes/no questions and appeared to comprehend simple conversation.-The resident's roommate's television (TV) was on, but the roommate was not in the room.-The resident was not watching the TV program, wasn't positioned to look out the window, was not engaged in a 1:1 interaction or a bedside activity and wasn't listening to music or otherwise engaged.During an interview on 4/27/26 at 2:38 P.M. the resident's legal representative said:-He/She visited the resident almost daily and had never noticed bedside activities for any resident and didn't think the facility offered that.-As far as he/she knew the resident had only been offered music activities when he/she was out of bed. Observation on 4/28/26 at 10:40 A.M., 2:03 P.M., and 3:12 P.M. showed:-The resident was in bed lying on his/her back. The resident's roommate's TV was on, but the roommate was not in the room. The resident was not looking at the TV. The resident was not engaged in any activities that would stimulate his/her mind or senses such as listening to music, being read to, looking out the window at something colorful or interesting, or being provided 1:1 or bedside activities.-A dry erase board on the resident's unit showed the daily group activities were BINGO at 10:00 A.M. and Nail Spa at 2:30 P.M., with both activities located in the main resident dining room.Observation on 4/29/26 at 8:55 A.M., 10:54 A.M., 12:11 P.M., and 2:48 P.M. showed:-The resident was in bed lying on his/her back. The resident's roommate's TV was on, but the resident was not looking at it. The resident was not engaged in any activities that would stimulate his/her mind or senses such as listening to music or being provided 1:1 or bedside activities. The curtain was closed on each observation.-A dry erase board on the resident's unit showed the daily group activities were Spring Watercolors at 10:00 A.M. and Happy Hour at 2:30 P.M., with both activities located in the main resident dining room.Observation on 4/30/26 at 9:18 A.M. showed:-The resident was lying in bed on his/her back. The curtain was closed. The resident's roommate's TV was on, but the resident wasn't watching it. -The resident was not engaged in any sensory or other activity.During an interview on 4/30/26 at 9:36 A.M. the Entertainment Assistant said:-A typical day started with getting residents for the 10:00 A.M. group activity. There was also a 2:30 P.M. group activity. -The scheduled 10:00 A.M. activity for the day was bible study and the Minister gathered residents for that. -One to one activities weren't reflected on the calendar, so he/she brought snacks or chatted with some of the residents who didn't really focus when he/she wasn't busy with the group activities.-He/She started in the position a couple of weeks ago and hadn't yet done any bedside activities.-The resident stayed in bed. There were three other residents who usually were in bed on the resident's hall. So far, he/she had only taken snacks to the residents who were in bed.-For residents who spend most of their time in bed he/she could probably file or paint their nails, do hand massages with lotion, read to them, or take music to them. The Activities department had a CD player and a variety of CDs. Some residents might like a birdfeeder to look at.-All residents could be taken to group activities where there was music if they were up and in their wheelchairs.During an interview on 4/30/25 at 10:13 A.M. the Director of Entertainment said:-He/She had just started in the position in mid-April.-So far, he/she had focused mostly on the 10:00 A.M. and 2:30 P.M. group activities like BINGO and crafts which were reflected on the calendar. A few of the residents on the locked unit sometimes came to the main activities. -On Sundays they had coffee and hymns which were played on his/her phone while residents drank their coffee and did coloring sheets.-In between the two main scheduled activities, Activity staff went on the locked unit for 1:1 activity like card games or nail spa.-The resident and five other residents on his/her hall couldn't get out of bed on their own and could benefit from bedside activities when they weren't up. -Activity staff had to go to them if they were in bed and would bring them ice cream and donuts weekly. -The resident was on a G (gastronomy) feeding tube (liquid nutrition delivered through a tube directly into the stomach or small intestines) so he/she didn't get anything by mouth. -The resident could respond to yes/no questions. He/She loved music and especially used to like church music. Activity staff could bring him/her to Happy Hour where they played music or take him/her outside if he/she was out of bed.-The 1:1 activity were currently not reflected on the monthly Activities calendar.During an interview on 5/1/26 at 9:02 A.M. Certified Nursing Assistant (CNA) D said:-The resident liked looking out his/her window.-Some days he/she wanted out of bed and some days he/she didn't.During an interview on 5/1/26 at 10:10 A.M. the Assistant Director of Nursing (ADON) said:-The resident liked short spurts of conversation about five or 10 minutes in length.-A good activity for the resident would be music.-The resident might like looking out the window or having lotion applied to his/her hands.-The resident seemed to enjoy attending holiday parties for Christmas, Valentine's Day, Mother's Day, and other holidays with his/her family member.During an interview on 5/1/26 at 10:30 A.M. the Director of Nursing (DON) said:-Examples of 1:1 and bedside activities were bringing a CD player and CD to a resident's room, reading a poem or book, and showing pictures to the resident and discussing what was in the pictures. -The resident could also listen to music with other residents when out of bed.-The best activities for the resident were 1:1, bedside, and small group activities.-Each resident should be offered activities every day, including residents needing 1:1 and bedside activities.

Based on observation, interview, and record review, the facility failed to provide frequent repositioning for one sampled resident, (Resident #7) who was unable to reposition himself/herself and to ensure proper settings for the Low Air Loss (LAL) mattress (a specialized surface designed for prevention and treatment of pressure ulcers/injuries (injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure or friction) according to standards of practice and facility policy for two sampled residents (Residents #7 and #22) who were at risk for pressure ulcers out of 18 sampled residents. The facility census was 86 residents. Review of the facility's Wound Policy and Procedure, dated May 2023, showed:-The facility was committed to providing a comprehensive wound management program to promote the resident's highest level of functioning and well-being and to minimize the development of in-house acquired pressure ulcer/injuries.-The wound management program incorporated currently accepted standards of practice and guidelines. The following resources provided the framework and guiding principles for pressure ulcer prevention and management:--Agency for Healthcare Research and Quality (AHRQ).--National Pressure Injury Advisory Panel (NPIAP).--Centers for Medicare/Medicaid: Guidance for Long Term Care.Review of the NPIAP website showed:-Repositioning and mobilizing individuals was an important component in the prevention of pressure injuries. Extended periods of lying or sitting on a particular part of the body and failure to redistribute the pressure on the body surface could result in sustained deformation of the soft tissues and ultimately to ischemia (tissue death) and inevitable tissue damage.-Reposition all residents at risk of pressure injuries unless contra-indicated.-One study investigated the association between repositioning frequency and pressure injury incidence. In the study frequently repositioned amounted to at least 12 repositions per day over the study period of 21 days. For participants with a high pressure injury risk based on Braden Scale score (used to predict a patient's risk of developing pressure injuries) there was a lower incidence of pressure injuries among those who were frequently turned. -Support surfaces are devices for pressure redistribution. Continue to reposition individuals placed on a pressure redistribution support surface.-Low Air Loss (LAL - mattress systems, commonly used for preventing and treating pressure injuries are active support surfaces that provide pressure redistribution using constant airflow to manage heat and humidity of the skin. Many combine alternating pressure using cyclic inflation and deflation to change load distribution.)-Pressure and firmness settings included:--Weight-based settings to adjust firmness according to the patient's weight. Set as close to the patient's weight as possible.--Comfort adjustments: If a patient complains that the mattress was too firm or too soft comfort adjust the weight setting up or down by one increment from the resident's weight.--Some systems had a firm or max inflate button that inflated all LAL mattress cells to maximum pressure. This was designed for nursing procedures only and this setting should not be left on permanently.1. Review of Resident #7's admission Record showed the resident was admitted to the facility with the following diagnoses:-Monoplegia (paralysis on one side) of upper limb following stroke affecting right dominant side.-Monoplegia of upper limb following stroke affecting left non-dominant side.-Contracture (fixed tightening of muscles, tendons, and ligaments, preventing normal movement) of muscle, right upper arm.-Contracture of right and left elbows.-Need for assistance with personal cares.-Dementia (a progressive organic mental disorder characterized by chronic confusion, deterioration of intellectual capacity and function, and impairment of memory, judgment, and impulses).Review of the resident's Limited Physical Mobility Related to Stroke care plan, dated 11/13/20 showed the resident was dependent upon staff for rolling from side to side, repositioning from sitting to lying and lying to sitting, and required a two-person mechanical lift for all transfers. Review of the resident's Increased Potential for Impairment to Skin Integrity care plan, dated 11/13/25 showed:-The resident was diagnosed with the following, increasing his/her risk for skin impairments: Malnutrition, Type II Diabetes Meletus (DM - a metabolic disease), contractures, vascular insufficiency, decreased mobility, chronic incontinence, and a personal history of vascular wounds and pressure injuries.-Assist with turning and repositioning at routine intervals.-LAL mattress for pressure reduction. Ensure inflation set for the resident's comfort.-Wheelchair pressure reduction cushion.-Monitor skin when providing cares and notify the nurse of any changes in skin appearance.Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 4/10/26 showed the resident:-Was severely cognitively impaired.-Had upper body impairments on both sides.-Had lower body impairments on both sides.-Was dependent upon staff for toileting needs, personal hygiene, and rolling from side to side.-Weighed 130 pounds.-Was at risk for developing pressure injuries.-Had pressure-reducing devices for his/her chair and bed.Review of the resident's Pressure Ulcer Risk Unavoidability assessment, dated 4/27/26 showed the resident:-Was at high risk for developing pressure injuries.-Had moisture-associated skin damage (MASD - a painful and normally preventable condition in which there is inflammation and erosion of the skin caused by prolonged exposure to moisture such as urine, sweat, stool, or wound discharge often managed with barrier creams) on the right and left buttocks identified 4/27/26. Suspected fungal rash as well.-Had a vascular wound on the right heel (chronic, slow-healing open sore caused by poor blood circulation, typically occurring on the lower legs and feet) identified 4/27/26.-Was contracted and unable to move on his/her own due to significant medical history and comorbidities. Pressure prevention interventions in place for LAL mattress, offloading heals, turning and repositioning.Review of the resident's orders dated April 2026 showed to set LAL mattress to comfort.Observation on 4/27/26 at 9:54 A.M. showed:-The resident was lying on his/her back with arms drawn up and both hands contracted shut.-His/Her LAL mattress was set close to the 287-pound setting, at approximately 280 pounds. The next lower setting read 176 pounds, and the lowest setting showed 88 pounds.-The mattress could be set by dial at any point between these main setting numbers.Observation on 4/28/26 at 10:40 A.M., 2:03 P.M., and 3:12 P.M. showed:-The resident was lying on his/her back.-His/Her LAL mattress was set close to the 287-pound setting, at approximately 280 pounds.Observation on 4/29/26 at 8:53 A.M., 10:54 A.M., 12:11 P.M., 2:48 P.M., and 3:20 P.M. showed:-The resident was lying on his/her back.-His/Her LAL mattress was set close to the 287-pound setting, at approximately 280 pounds at 8:53 A.M., 10:54 A.M. and 12:11 P.M. -At 2:48 P.M. and 3:20 P.M. his/her LAL mattress was set half-way between 88 and 176 pounds, at approximately his/her actual weight.Observation on 4/30/26 at 9:18 A.M. and 10:48 A.M. showed the resident was lying on his/her back.Observation on 4/30/26 at 12:14 P.M. and 2:53 P.M. showed the resident was sitting in a high-backed wheelchair near the nurses' station.During an interview on 4/30/26 at 3:06 P.M. Nurse Assistant (NA) A said:-Staff try to get the resident up for three or four hours a day.-The resident was supposed to be repositioned every two hours whether he/she was out of bed or not. He/She should be positioned on his/her right and left sides as well as his/her back to prevent pressure ulcers.-The resident had a LAL mattress that was set by the nurse, a cushion in his/her wheelchair, and wore padded boots when he/she was up in his/her wheelchair to prevent pressure ulcers.-The resident had a wedge under his/her calves when in bed to help keep his/her heels up to prevent pressure ulcers on his/her heels.Observation on 4/30/26 at 3:25 P.M. showed the resident was sitting on a cushion in a high-backed wheelchair near the nurses' station with his/her padded boots.Observation on 5/1/26 at 8:32 A.M. and 9:35 A.M. showed the resident was in bed lying on his/her back.During an interview on 5/1/26 at 8:42 A.M. Certified Nursing Assistant (CNA) D said:-Staff were supposed to use a wedge under the resident's legs to keep his/her heels elevated for pressure relief. When positioned on either the right or left the wedge could still be used to raise his/her heels.-The resident was unable to reposition himself/herself.-Staff were supposed to reposition the resident every two hours. Sometimes staff got the resident out of bed which helped reposition him/her. If the resident didn't get out of bed, he/she still needed to be repositioned.During an interview on 5/1/26 at 9:53 A.M. the Assistant Director of Nursing (ADON) said:-The resident needed to be repositioned every two hours by turning the resident when in bed or putting the resident in his/her wheelchair when he/she wanted up. -He/She had a pressure reducing cushion and pillow boots to be worn when up in his/her wheelchair to help prevent pressure injuries.2. Review of Resident #22's admission record showed the resident was admitted to the facility with the following diagnoses:-Stroke, affecting left non-dominant side.-Malignant neoplasm (cancer) of lung.-Secondary malignant neoplasm of the brain.-Morbid obesity.Review of the resident's Alteration in Skin Integrity care plan, initiated 12/27/23 showed:-The resident was at risk of alteration in skin integrity due to stroke affecting one side, morbid obesity, incontinence, and need for assistance with personal cares.-Encourage/assist with turning and repositioning.-LAL mattress for pressure reduction. Review of the resident's Pressure Ulcer Unavoidability Risk assessment, dated 1/12/26, showed the resident:-Was at high risk for developing a pressure injury.-Had a LAL mattress.Review of the resident's quarterly MDS, dated [DATE] showed the resident:-Was moderately cognitively impaired.-Required substantial/maximal assistance for rolling from side to side, going from a sitting to a lying position and from a lying to sitting position.-Was dependent upon staff for transfers.-Was at risk for pressure injuries.-Had a pressure-reducing device for his/her chair and bed.Review of the resident's weight showed he/she weighed 258.9 pounds on 4/2/26.Review of the resident's physician orders on 4/28/26 showed LAL mattress. Check functionality every shift and set to the resident's weight every shift.Observation on 4/28/26 at 10:08 A.M. showed the resident 's LAL mattress was set to 660 to 750 pounds.Observation on 4/29/26 at 8:36 A.M. and 10:52 A.M. showed the resident 's LAL mattress was set to 660 to 750 pounds.Observation on 4/29/26 at 2:45 P.M. showed the LAL mattress was set at 250 pounds, close to the resident's actual weight.Observation on 4/29/26 at 9:13 A.M. showed the LAL mattress was still set close to the resident's weight.During an interview on 4/29/26 at 9:13 A.M. the resident said he/she slept well the night before and his/her bed felt more comfortable.3. During an interview on 5/1/26 at 9:53 A.M. the Assistant Director of Nursing (ADON) said:-Residents with a LAL mattress needed the mattress set according to physician's orders. The orders would say to set by weight or comfort.-The charge nurse was responsible for setting the LAL mattresses.-If the order said to set for comfort, staff could set the mattress a little higher or a little lower than the resident's exact weight.During an interview on 5/1/26 at 10:30 A.M. the Director of Nursing (DON) said:-Pressure reducing devices such as pressure-reducing boots, cushions and mattresses should be encouraged as recommended by therapy or as ordered by the physician.-LAL mattresses should be set by the charge nurse according to the resident's weight or they could be set based on the resident's comfort if the orders allowed that.-For anyone who was unable to reposition themselves staff should assist with repositioning every two hours.

Based on observation, interview, and record review, the facility failed to ensure residents received care consistent with professional standards of practice to prevent the development of pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) which resulted in the development of a pressure ulcer; failed to implement ordered interventions to promote healing of developed ulcers for one sampled resident (Resident #74) which resulted in the worsening of the pressure ulcer; and failed to accurately assess resident's skin for the monitoring of pressure ulcer development and progression for three sampled residents, (Residents #74, #1 and #62) out of 18 sampled residents. The facility census was 84 residents. Review of the facility policy titled Skin Integrity, dated 11/2019, showed: -Staff would ensure a resident who entered the facility without a pressure sore [pressure ulcer] would not develop one unless unavoidable (hospice, end of life skin failure). -A nurse would perform a full body skin assessment within two to six hours after admission and weekly thereafter. -Preventative measures would be put into place for residents at risk of developing a pressure ulcer. -A resident who had or developed a pressure ulcer would receive treatment to promote healing and prevent further development. -Staff would ensure pressure relieving devices were placed on the resident's bed. 1. Review of Resident #74's after visit summary (discharge orders) from the resident's hospital stay, dated 7/19/24, showed instruction to facility staff to monitor an ulcer to his/her left heel and change the wound dressing daily as needed. Review of the resident's Care Plan, dated 7/20/24, showed: -He/She was at risk for alteration in skin integrity. -An addendum on 8/1/24 showed he/she had an actual impairment to skin integrity related to a suspected deep tissue injury to the left heel with a goal of showing signs of healing. Review of the resident's Admission Minimum Data Set (MDS-a federally mandated comprehensive assessment completed by facility staff for care planning), dated 7/26/24, showed: -Diagnoses of high blood pressure, renal failure (inability of the kidneys to adequately filter blood), chronic lung disease and pneumonia (an infection in the lungs) and malnutrition (lack of proper nutrition, caused by not having enough to eat, not eating enough of the right things, or being unable to use the food that one does eat). -The resident had a Stage I pressure ulcer (intact skin with non-blanchable redness of a localized area usually over a bony prominence) but lacked indication of the location. -The resident was cognitively intact. -The resident did not reject cares within the seven-day look-back period (a period in which staff observe a resident to document MDS data). -The resident needed substantial assistance with lower body dressing including putting on and taking off footwear. Review of the resident's pressure ulcer Care Area Assessment (CAA, a focused worksheet in the MDS assessment), dated 7/26/24, showed: -The resident admitted with a Stage I pressure ulcer to the coccyx (area just above the buttock). -The resident had a pressure relieving mattress on his/her bed. -The resident was a high risk for pressure ulcer development. -No other documented pressure ulcers. Review of the resident's Physician Order Summary, dated 8/19/24, showed orders for: -Weekly skin assessments dated 7/19/24. -A low air loss mattress (a pressure relieving air mattress that reduces the risk of pressure injury development) dated 7/22/24. -Prevalon boots (a pressure reducing boot) when in bed every shift for skin injury prevention dated 7/22/24. -Encouragement of turning and repositioning, beginning 8/8/24. -Wound care to the left heel, cleansing with normal saline, pat dry, apply skin prep and cover with a dry dressing, beginning 8/14/24. --A discontinued order for cleansing bilateral heels with normal saline, pat dry, apply skin prep and leave open to air twice daily, valid from 7/22/24 to 8/14/24. Review of the resident's Treatment Administration Record (TAR) dated July 2024 showed: -Administration of an order for cleansing bilateral heels with normal saline, pat dry, apply skin prep and leave open to air twice daily with missing documentation on 7/23/24's day shift. -Administration of a low air loss mattress with no documentation of resident refusal. -Administration of Prevalon boots with missing documentation on 7/23/24 and no documentation of resident refusal. Review of the resident's TAR dated August 2024 showed: -Administration of an order for cleansing bilateral heels with normal saline, pat dry, apply skin prep and leave open to air twice daily with missing documentation on 8/7/24 and 8/8/24 day shift. -Encouragement of turning and repositioning, beginning 8/8/24, with missing documentation on day shift 8/18/24. -Administration of a low air loss mattress with no documentation of resident refusal. -Administration of Prevalon boots with missing documentation on day shifts for 8/8/24 and 8/18/24, and no documentation of resident refusal. -Administration of wound care to the left heel, cleansing with normal saline, pat dry, apply skin prep and cover with a dry dressing, beginning 8/14/24, with missing documentation on day shift 8/18/24, night shift 8/21/24 and omission of the administration on night shift of 8/17/24 due to resident sleeping. Review of the resident's weekly skin assessments showed: -An admission skin assessment on 7/19/24 showed non-blanchable redness to the coccyx and genital area as well as blanchable redness to the left heel. -A skin assessment on 7/27/24 showed swelling to both legs but no other skin issues. -A skin assessment on 8/4/24 showed swelling and no other skin issues. -A skin assessment on 8/10/24 showed a blister with drainage on the left heel. --No further nursing skin assessments were documented as of 8/19/24. Review of the resident's wound rounds documentation (documentation from weekly Nurse Practitioner (NP) wound rounds with the facility wound nurse) showed: -The first visit on 8/1/24 showed a wound to the left heel measuring 3.2 centimeters (cm) long, 5.1cm wide, and an unknown depth. The wound was 80% deep maroon and 20% blanchable redness and marked present on admission. A low air loss mattress was part of the treatment plan. No staging was provided by the NP during this visit and no progress note was provided by the facility on this date. All documentation was performed by the facility wound nurse. -No provider notes or assessments provided by the facility documented an assessment of the wound to the resident's left heel until 8/14/24. -On 8/14/24 a visit showed the pressure ulcer to the left heel measuring 3.2cm long, 4.2cm wide and an unknown depth. The wound was 100% hard necrotic tissue and marked present on admission. Review of an attached progress note by NP A showed the wound was an unstageable pressure ulcer (a wound that is covered in necrotic tissue that prevents the assessment of the wound depth, but if the tissue was removed would reveal a Stage III pressure ulcer (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) or IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) Observation on 8/19/24 at 9:34 A.M., showed the resident was lying in bed without a low air loss mattress in place and with no Prevalon boots. Observation on 8/21/24 at 9:52 A.M., of wound rounds with NP A and Assistant Director of Nursing (ADON) A showed: -NP A and ADON A assessed the resident's wound. At this time, the wound measured 4.3cm long (an increase of 0.9cm), 6.5cm wide (an increase of 2.3cm) and an unknown depth. The wound was 85% hard necrotic tissue, but now had a surrounding border of broken-down skin appearing red (10%) and with 5% slough (a yellow material made up of dead cells). The resident did not have a low air loss mattress at this time. During an interview on 8/21/24 at 9:53 A.M., NP A said the resident's wound was worsening. During an interview on 8/21/24 at 10:30 A.M., NP A said: -Wound rounds were a focused assessment, not all skin was evaluated. -He/She and other NPs make progress notes each time they see a resident for wounds. -Skin assessments should have been completed at least once per week. -All wound assessments should have measurements and a full description of the wound. -He/She believed Resident #74's wound was present on admission. -He/She would expect documentation of the wound with a full assessment as soon as the wound was noted. -He/She would expect orders for prevention and treatment to be implemented immediately after the identification of a skin integrity impairment. -He/She would expect all physician orders to be carried out by staff including the implementation of a low air loss mattress. During an interview on 8/22/24 at 8:22 A.M., the Director of Nursing (DON) said Resident #74: -Did not have a low air loss mattress in place. -Should have had one on the bed. During an interview on 8/23/24 at 8:54 A.M., Certified Nursing Aide (CNA) F said: -He/She was aware the resident had a pressure ulcer. -Nurses did wound treatments to the resident's foot daily. -CNA's and other staff tried to ensure the resident's heels were elevated off the bed. -He/She was unaware of a low air loss mattress for the resident. During an interview on 8/23/24 at 11:38 A.M., ADON A said: -He/She was responsible for the wound care in the facility. -Skin assessments populated weekly, and the floor nurses were responsible for doing them. -Weekly skin assessments should have listed every skin condition the resident had along with a full assessment including wound measurements. -Stage I pressure ulcers and other identified redness were not monitored by the facility because they could heal within a few weeks and would take too long to document on. -He/She was not wound care certified. -If a wound was identified by nursing staff, orders for prevention and treatment would have been put in up to 72 hours after identification when he/she had a chance to evaluate the wound. -No skin or pressure ulcer treatments should lack documentation. -A lack of documentation on an order in the medical record indicated the treatment was not done. -There should have been a low air loss mattress in place for Resident #74, and any refusals of interventions should have been documented. -Since redness was documented on Resident #74 on admission, the unstageable pressure ulcer to the left heel would be either recurring or worsening, not a facility acquired ulcer. 33409 2. Review of Resident #1's face sheet showed the resident admitted with the following diagnoses: -Quadriplegia (paralysis of all four extremities and usually the trunk). -Osteomyelitis (an infection in a bone) of right upper arm. -Pressure injury/ulcer right elbow. Review of the resident's Hospital Discharge Summary dated 8/1/24 at 4:24 P.M., showed: -The resident had documentation that he/she had wounds noted on 6/14/24 while in the community and was admitted to the hospital with worsening wounds on 7/18/24. -The resident was discharged from the hospital on 8/1/24 and admitted to the facility with pressure wounds. -Wound #1, was unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) on the left buttocks. The wound measurements at that time were length (L) of 3.5 cm by width (W) of 2.0 cm by depth (D) of 0.5 cm. The wound bed was moist, yellow, slough and pale pink in color. -Wound #2 was a Stage IV pressure injury (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) on the left hip. The wound bed was moist with yellow slough and was the shape of an oval. The wound measurements were L of 1.5 cm by W of 2 cm by D of 0.8 cm. -Wound #3, was a Stage IV pressure injury on the right buttocks, The wound bed was moist, with yellow slough, and pale pink in color. The wound measurements were L of 4.0 cm by W of 2.5 cm by D of 2 cm. -Wound #4 on the right elbow presented as a pressure injury. The resident had surgery on the elbow area which made it a new surgical wound. Review of the resident's nursing evaluation for admitted d 8/2/24 at 12:29 A.M. showed: -The resident admitted to the facility on [DATE] at 4:30 P.M. -Staff should document the impairment site and the initial wound measurements. -Documentation of a large wound to right buttocks, left buttocks, and left hip, a surgical wound to the right elbow wound where he/she underwent debridement (the removal of dead tissue) and was closed with sutures. -There were no initial wound measurements transcribed to the initial skin assessment form or in the comments note. Review of the resident's Physician Order Sheet (POS) dated 8/2/24 at 3:12 P.M. showed: -Wound care to the resident's right and left buttocks and left hip: cleanse with normal saline, pat dry, apply Dakin's solution (used to kill germs and prevent germ growth in wounds) soaked gauze, cover with an Abdominal (ABD, is a gauze dressing that absorbs fluid from large or heavily draining wounds) dressing pad and secure with tape, every shift for wound care and as needed for missing or soiled dressing. Review of the resident's wound care plan initiated on 8/2/24 showed: -The resident was at risk for alteration in skin integrity. --Provide skin/wound treatments as ordered. Review of the resident's TAR dated 8/1/24 to 8/23/24 showed: -Order dated 8/2/24 at 3:12 P.M., for wound care treatment to the resident's right buttocks, left buttocks and left hip: nursing staff were to cleanse wounds with normal saline, pat dry, apply Dakin's-soaked gauze, cover with ABD and secure with tape, every shift for wound care and as needed for missing or soiled dressing. --No documentation of wound care treatment completed on admission and 8/2/24. Review of the resident's medical record dated 8/1/24 to 8/7/24 showed there was no documentation of a comprehensive wound assessment that included wound measurements and detailed descriptions of the wounds upon admission to the facility. Review of the resident's wound care plan initiated on 8/7/24 showed the resident had an actual impairment to skin integrity related to pressure injury to the left buttock, left hip, right buttock, and right elbow. Review of the resident's POS dated 8/8/24 showed the resident was to have weekly skin checks on Thursday during the day shift. Must open and document the skin evaluation for each resident assessment (including no new areas found). Review of the resident's TAR dated 8/8/24 showed the resident's weekly skin observation/assessment to be completed on 8/8/24 had no nursing initial or check mark documented to indicate the assessment was completed. Review of the resident's weekly skin observation/assessment dated [DATE] showed: -Nursing documented the resident had pressure wounds to bilateral buttocks, left hip, and a surgical wound on his/her right elbow. -Did not have a comprehensive wound assessment of the resident's wound to include wound measurements and detail description of the wounds. Review of the resident's NP wound encounter note dated 8/14/24 at 3:37 P.M., showed: -The resident had a diagnosis that included infection, irrigation debridement of right upper extremity. -Was seen for wound rounds. --The resident who was recently admitted to Hospital on 7/16/24 for worsening wound infections from community. He/she did have a medical history of quadriplegia secondary to driving accident many years ago and was wheelchair-bound with muscle spasms. He/she also presented with complaints of chills and not feeling well and drainage from his/her right elbow. Patient was found to have a wound of his/her right elbow as well as three separate wounds on his/her buttocks and coccyx. His/her elbow wound did require surgical debridement by an orthopedist while at the hospital. Patient was initially started on antibiotic for elbow wound. No surgical interventions were necessitated on resident's buttock and coccyx wounds. Patient was ultimately started on Intravenous (IV) antibiotic daily and would continue this through 9/7/24. The resident was ultimately stabilized and deemed appropriate for discharge to a skilled nursing care facility on 8/1/24. -The resident had three pressure injuries on his/her left and right buttocks and coccyx region. Furthermore, he/she had a new surgical wound to his/her right elbow. The pressure injury of his/her left and right buttocks and coccyx regions were deep with undermining (the destruction of tissue or ulceration extending under the skin edges so that the pressure is larger at its base than at the skin surface. Undermining often develops from shearing forces and is differentiated from tunneling by the larger extent of the wound edge involved in undermining and the absence of a channel or tract extending from the pressure ulcer under the adjacent intact skin). They did not have heavy exudate however the current treatment included Dakin's solution they are considered to be wet. There was slough within the wound beds however there did not appear to be a concern for infection at that time. The resident did not endorse significant pain to any of the sites. -The resident's skin included three pressure injury/wounds to his/her left and right buttocks and coccyx regions, with a new surgical wound to the right elbow. -Wound #1 Stage IV pressure injury on his/her left buttock, measured Length of 5.30 cm by Width of 4.00 cm By Depth of 0.50 cm. --Base: Epithelial (Pale Pink or Red) at 70% and Slough Loosely Adherent at 30%. Had clear serous drainage. -Wound #2 Stage IV pressure injury on left hip measured L of 2.50 cm by W of 4.00 cm and D of 0.90 cm. --Had Undermining at 9 o'clock to 1 o'clock with a depth of 3.90 cm. --Base epithelial (pale pink or red) at 20%, Bright Pink or Red at 30% and Slough Loosely Adherent at 50%. Had clear serous drainage. -Wound #3 right buttock stage IV pressure injury. Measurement of L of 3.00 cm by W of 2.60 cm and D of 2.10 cm. Had undermining at 9 o'clock to 1 o'clock and d of 6.60 cm. --Base of wound had epithelial at 10%, bright pink or red at 5% and slough loosely adherent at 85%. Had clear serous drainage. -Cleanse the wounds with normal saline and primary dressing: Cleanse with normal saline, pat dry, skin prep peri wound, pack with Dakin's soaked gauze, cover with ABD and secure with tape. -Wound #4 now a surgical wound on right elbow. --Closed well-approximated at 100%. --Measurement of size L at 7.00 cm by W of 0.20 cm and D of 0.00 cm --Intact Skin: 100% --Cleanse with normal saline, pat dry, apply Xeroform ( sterile, non-adherent gauze dressing that's used to cover and protect wounds, abrasions, and burns), cover with ABD Kerlix, and secure with Ace wrap. -Plan: Surgical wound right elbow: Cleanse with normal saline, pat dry, apply xeroform, cover with ABD Kerlix, and secure with Ace. Three pressure ulcers of left and right buttocks and coccyx region: Cleanse with normal saline, pat dry, skin prep peri wound, pack with Dakin's soaked gauze, cover with ABD and secure with tape. Continue Intravenous (IV) Daptomycin (antibiotic) 500 milligram (mg) per IV daily. Review of the resident's wound round documentation written by the wound nurse dated 8/21/2024 at 7:32 A.M., showed: -Wound #1 Stage IV pressure injury on left buttock, measured Length of 5.30 cm by Width of 4.00 cm By Depth of 0.50 cm --Base: Epithelial (Pale Pink or Red) at 70% and Slough Loosely Adherent at 30%. Had clear serous drainage. -Wound #2 Stage IV pressure injury on left hip measured Length of 2.50 cm by Width of 4.00 cm and Depth of 0.90 cm --Had Undermining at 9 o'clock to 1 o'clock /with depth of 3.90 cm --Base Epithelial (Pale Pink or Red) at 20%, Bright Pink or Red at 30% and Slough Loosely Adherent at 50%. Had clear serous drainage. -Wound #3 stage IV pressure injury on right buttock, Measure Length of 3.00 cm by Width of 2.60 cm and Depth of 2.10 cm. Had undermining at 9 o'clock to 1 o'clock and depth of 6.60 cm --Base of wound had Epithelial (Pale Pink or Red) at 10%, Bright Pink or Red at 5% and Slough Loosely Adherent at 85%. Had clear serous drainage. -NOTE: the documentation had the same measurements and descriptions the resident's NP wound note dated 8/14/24. During an interview on 8/21/24 at 11:47 A.M., the resident said: -He/she did not have wound care treatment completed on the morning of 8/21/24. -He/she was informed the wound nurses would complete treatment after lunch time that day. -He/she thought nursing reported his/her wounds were improving. -Nursing staff were completing wound care twice a day or as needed. Observation on 8/21/24 at 1:45 P.M., of the resident's wound care showed: -Wound nurse and NP provided assessment and care of the resident wounds. -Had barrier for supplies, staff washed hands and applied gown and gloves for wound care. -NP removed old dressing dated 8/20/24 and measured each wound area. -The resident's right buttock wound was size of a golf ball and measured L 2.5 cm by W of 3.7 cm by D of 1.3 cm. Had undermining from 11 o'clock to 1 o'clock with tunneling of 4.4 cm at deepest area. -The left hip wound was about golf ball size, and measured L of 2.5 by W of 3.7 by D of 0.8, had undermining from 9 o'clock to 12 o'clock with tunneling of 2.2 cm at the deepest area. -The left buttock wound was about [NAME] size, and measured L of 5.3 by W of 4.0 by D of 0.6, had undermining from 12 o'clock to 3 o'clock, with tunneling of 0.9 at deepest area. The wound had white outer edges, inner edges pink, cream color inner wound and was healing muscle base. -NP said all wounds appeared to be improving and had no excessive drainage noted. -The resident's right elbow was a healed surgical wound. Preventive treatment with padding noted. -Wound Nurse took pictures of each of the wounds and recorded measurements to be uploaded into the resident's electronic record under wound rounds. -Wound nurse cleansed each wound with normal saline, pat dry, then applied Dakin's soaked gauze pad in wounds, covered with ABD and secured with dressing. Review of resident's wound documentation showed: - On 8/22/24 at 9:04 A.M., the facility provided wound care documentation and pictures of the resident's wounds dated 8/7/24, 8/14/24 and 8/21/24 that were not accessible to surveyor. -The resident did not have documentation upon admission of a comprehensive initial wound assessment that included measurements and descriptions of all the wounds by facility nursing staff or wound nurse. During an interview on 8/21/24 at 10:31 A.M., NP A said: -The facility had a dedicated wound round documentation section. The NP and physician were able to review wound rounds for monitoring active wounds or reoccurring wounds. -He/she would do wound rounds only for open active wounds. -The facility had just completed a facility wide wound and skin assessment for all residents at the facility. -The NP and physician wound round templates flowed into the NP/physician progress notes. -Wound rounds included measurements of the wound by the NP and the wound nurse transcribed the wound measurements and descriptions of the wounds in the wound rounds report. -Weekly skin assessments were to be completed by nursing staff for those residents who were at high risk for skin issues. -The charge nurse would be responsible for completing the resident's weekly skin observations and documenting them in the electronic record. -He/she had not seen Resident #1 related to his/her wounds. His/her partner had seen the resident on 8/14/24. -He/she would expect to have detailed descriptions and measurements by nursing staffing for new wounds or wounds upon admission. -The wound nurse would be responsible for completing the resident's initial wound evaluation/assessment. -The resident would only be seen by the wound NP when there was a referral due to a new or worsening wound, and they had open active wounds. -The facility wound nurse did the initial nursing staging of the wound then it was verified by the NP. -The wound NP or physician would be responsible for final staging of all wounds at the facility. During an interview on 8/22/24 at 9:22 A.M., the wound nurse said: -Admission skin evaluations should be documented in the section under general skin areas for all residents. -He/she would not expect the admitting nurse to have a detailed comprehensive description of each wound and would not expect the admission nurse to measure the wounds upon admission. -He/she would expect to have a general review of the placement of the wounds. -the admitting nurse would be expected to notify the wound nurse and physician when a resident was admitted to the facility with something big or with severe wounds. He/she would review the resident's hospital orders, observe the skin and obtain a physician's order for wound care and treatments at that time. -Resident #1 was admitted with wounds and had wound orders from the hospital and had a detailed initial assessment from the hospital wound clinic. -He/she could not recall if Resident #1 had a wound assessment documented by the facility between 8/1/24 and 8/6/24, that included a comprehensive wound assessment that included initial measurements upon admission. -The wound rounds documentation in Resident #1's electronic record did not show the past wound assessments only the most recent wound assessment that had been entered. -The wound documentation that was entered the morning of 8/21/24 at 7:33 A.M., by him/her was the wound round assessment from 8/14/24. During an interview on 8/23/24 at 9:21 A.M., Licensed Practical Nurse (LPN) A said: -admitted ask about hospital about any skin/wound concern and document and then compare hospital and facility nursing skin assessment. -He/she would call the wound nurse either the day of admission or the following day to notify him/her of a new admission with wounds. -The wound nurse would assess the wounds and obtain wound orders if needed. -Resident#1 had a non-removable dressing on his/her elbow, he/she would look at the dressing under the ace wrap and document findings. -He/she would not measure wounds. -He/she would document a general description of the wound. -The first wound assessment would be completed by the facility wound nurse and would be comprehensive and detailed with a description and measurements of the wound. -The wound nurse would assess wounds normally within 24 for 48 hours after notification of a wound or upon admission. -He/she would transcribe the hospital wound care orders to the resident's admission POS. -Resident #1 received wound care every day and evening shift by nursing staff. -He/she was not aware if the resident refused care or treatment. -Nursing staff assigned to the resident would be responsible for completing the resident's weekly skin observation form. -Weekly skin observations would be populated under the treatment area in the resident's electronic record. -The resident's weekly wound rounds and treatments were to be completed by the facility wound nurse. -The wound nurse would document in the wound rounds tab. -Licensed nursing staff would document any wound/skin changes and should notify the wound nurse and physician of any changes. -His/her wound documentation would include complete wound care with a general description of the wound. During an interview on 8/22/24 at 1:56 P.M., CNA C said: -He/she would notify the charge nurse of any resident skin changes. -CNA's were responsible for charting under the tasks area and should make note of any skin issues. -The bath sheets were to be completed by the CNA's and should include documentation of any new skin issues or changes in the residents skin. 51150 3. Review of Resident #62's POS dated 11/27/23 showed the following physician's orders: -Skin checks weekly. Every day shift, every Friday. Must open and document skin evaluations for each assessment (including no new areas found). Review of the resident's care plan dated 11/28/23 showed: -The resident was at risk for alteration in skin integrity. -The resident would remain free of new skin impairment through the review date of 8/2/2024. -The resident would receive skin/wound treatments as ordered. Review of the resident's quarterly MDS dated [DATE] showed: -The resident was at risk for developing pressure ulcers. -The resident did not have one or more unhealed pressure ulcer(s) at stage I or higher. -The resident did not have any other ulcers, wounds, or skin problems. Review of the resident's POS dated 6/11/24 showed the following physician's orders: -Wound Care: Right Ankle: Cleanse with normal saline (NS), pat dry, Skin Prep (A topical barrier between skin and adhesives) to the peri wound, apply Silver Alginate (Silver Alginate contains silver ions. It is typically used on infected wounds or wounds that are at a high risk of infection. Silver has antimicrobial properties that can help to prevent and treat wound infections) to the wound bed, cover with dry dressing. Every day shift for wound care. Review of the resident's TAR dated June 2024 showed the resident's daily wound care to be completed on 6/27/24 had no nursing initial or check mark. Review of the resident's care plan revision dated 7/8/24 showed: -The resident had actual impairment to skin integrity related to a Stage III pressure ulcer on the right ankle. -The resident's pressure ulcer will show signs of healing and remain free from infection through review date. -Facility protocols would be followed for treatment of injury. Review of the resident's POS dated 7/9/24 showed the following physician's orders: -Wound Care: Right Outer Ankle: Cleanse with wound cleanser, pat dry, Skin Prep to the peri wound, apply Hydrafera Blue (Hydrofera Blue's capillary action continuously pulls harmful bacteria- laden slough, exudate, and debris away from the wound bed) to the wound bed, cover with dry dressing. Every day shift for wound care. Review of the resident's POS dated 7/17/24 showed the following physician's orders: -Wound Care: Right Outer Ankle: Cleanse with wound cleanser or NS, pat dry, Skin Prep to the peri wound, apply Hydrogel (Hydrophilic starch polymers (predominately composed of water). These are available in sheets, amorphous gels, or gauze) to the wound bed, cover with dry dressing. Every day shift for wound care. Review of the resident's POS dated 7/24/24 showed physician's orders for skin checks weekly. Every day shift, every Wednesday. Must open and document skin evaluations for each assessment (including no new areas found). Review of the resident's significant change MDS dated [DATE] showed: -The resident was at risk for developing pressure ulcers. -The resident did have one or more unhealed pressure ulcer(s) at stage 1 or greater. -The resident did have one Stage III pressure ulcer. -The resident did have pressure ulcer care. Review of the resident's TAR dated July 2024 showed: -The resident's daily wound care

Based on observation and interview, the facility failed to maintain the floor under the deep fat fryer and the six burner stove free from a buildup of food debris; failed to maintain the floor under the shelves in the dry good storage room free from dried food debris; failed to maintain the utensil rack free from dust; failed to maintain the sprinkler heads over the back side of the kitchen free from a dust buildup; failed to maintain the temperature of milk in a serving container the dining room at or close to 41 F (degrees Fahrenheit) and failed to maintain the area around the door of the North entrance to the kitchen free from a buildup of dust. This practice potentially affected all residents who ate food from the kitchen. The facility census was 84 residents. 1. Observation on 8/19/24 from 9:49 A.M. to 10:13 A.M., during the initial kitchen review showed: -A buildup of food debris under the shelves the dry goods storage room -A buildup of food debris and one whisk under the six-burner stove, the deep fat fryer and the convection oven, and -A buildup of dust on the sprinkler heads over the side of the kitchen that baking preparation was conducted in. During an interview on 8/19/24 at 10:13 A.M., Dietary [NAME] (DC) A said they have not pulled out the appliances in a few days and collectively, they have been short on dietary staff. Observation on 8/21/24 at 9:48 A.M., showed a buildup of dust on the sprinkler heads located over the baking area of the kitchen. During an interview on 8/21/24 at 9:50 A.M., the Dietary Manager (DM) said he/she did not remember the last time he/she notified the Maintenance Department about cleaning those sprinkler heads. Observation on 8/22/24 from 5:57 A.M. to 8:58 A.M., during the breakfast meal preparation showed: -A buildup of dust on the sprinkler heads over the side of the kitchen that baking preparation was conducted in. -A buildup of dust on the utensil rack over the table. -Milk in a container in the dining room with a temperature of 63 F. -A buildup of dust on the self-closing fixture and the top of the door between the main kitchen and the galley (a long area adjacent to a main kitchen). During interview on 8/22/24 at 9:04 A.M., the DM said the following: -He/she would ask the maintenance department to clean the top of the door between the kitchen and the galley. -He/she had not requested the dietary staff to check the temperature of the milk in the drink cart during the meals.

Based on observation and interview, the facility failed to maintain commode risers (assistive devices to improve the accessibility of toilets to older people or those with disabilities. They can aid in transfer from wheelchairs and may help prevent falls) in resident rooms A110, A105, A102, B104, C106, C104, C102, E107, E108, G104, D107 free from areas that were not easily cleanable; failed to maintain the fan in resident rooms B105, free from a buildup of dust; failed to maintain the ceiling vent in in resident room A101; failed to ensure the floor was maintained clean in resident rooms A105 and C109; failed to ensure the countertop in the A Hall shower room was in good repair; failed to ensure the grab bar was firmly attached to the wall in the restroom of B105; and failed to ensure the shower chair in D105 was in good repair. This practice potentially affected at least 30 residents who resided in or used those areas. The facility census was 84 residents. 1. Observation on 8/21/24 with the Environmental Services Director (EVS) Director showed the areas that were not easily cleanable on commode risers in the following rooms: -At 10:23 A.M., the commode riser in resident room A110 was not easily cleanable. -At 10:25 A.M., the commode riser in resident room A105 was not easily cleanable. -At 10:59 A.M., the commode riser in Resident room A102 was not easily cleanable. -At 11:28 A.M., the commode riser in Resident room B112 was not easily cleanable. -At 11:36 A.M., the commode riser in Resident room B107 was not easily cleanable. -At 11:50 A.M., the commode riser in Resident room B103 was not easily cleanable. During an interview on 8/21/24 at 11:51 A.M., the EVS Director said there were many commode risers which needed to be replaced and he/she would order the replacements. Observation on 8/21/24 with the EVS Director showed the areas that were not easily cleanable on commode risers in the following rooms: -At 12:17 P.M., the commode riser in Resident room C104 was not easily cleanable. -At 12:19 P.M., the commode riser in resident room C105, was not easily cleanable. -At 1:44 P.M., the commode riser in resident room E107 was not easily cleanable. -At 2:25 P.M., the commode riser in Resident room G104 was not easily cleanable. -At 2:44 P.M., the commode riser in Resident room D107 was not easily cleanable. 2. Observation on 8/21/24 at 11:40 with the EVS Director showed a buildup of dust on the fan blades of the fan in resident room B105. During an interview on 8/26/24 at 9:43 A.M. Housekeeper B said the following observing the fan in resident room B105: -They were told not to clean the fans and he/she did not know how the fans got cleaned. 3. Observation on 8/21/24 at 10:46 A.M., showed a heavy buildup of dust inside the ceiling vent in resident room A101. During an interview on 8/21/24 at 10:48 A.M., the EVS Director said: -He/she noticed the heavy dust buildup in that ceiling vent and he/she would identify other ceiling vents with a heavy dust buildup. 4. Observation on 8/21/24 at 10:30 A.M., showed an old spill on the floor behind the door in resident room A105. During an interview on 8/21/24 at 10:32 A.M., the EVS Director said he/she was unaware of that spill. Further observation showed he/she notified a Housekeeper to go to that room and clean that spill. 5. Observation on 8/21/24 at 12:09 A.M., showed a buildup of dust and powder on the floor in resident room C109. During an interview on 8/26/24 at 9:44 A.M., Housekeeper B said the housekeepers needed to use the swivel tool to get under the beds and get the powder and dust up and off the floor. 6. Observation on 8/21/24 at 10:51 A.M., showed two areas of missing tile pieces from the countertop in the A Hall shower room which caused an area that could potentially cause skin damage. One area was 12 inches (in.) long. The other area was eight in. long. During an interview on 8/21/24 at 10:52 A.M., the EVS director said: -Those areas needed to be repaired. -He/she was not sure how long those pieces of tile were missing. 7. Observation on 8/21/24 at 11:44 A.M., showed the grab bar was not securely affixed to the wall in the restroom of resident room B106. During an interview on 8/21/24 at 11:46 A.M. the EVS director said: -He/she needed to repair that grab bar. -He/she was unaware that grab bar was not secured to the wall. During an interview on 8/26/24 at 9:39 A.M., Housekeeper B said he/she reported the loose grab bar in B106 to the EVS Director less than a month ago. 8. Observation on 8/21/24 at 2:45 P.M., showed the shower chair in the restroom of D105 was broken. During an interview on 8/21/24 at 2:46 P.M., the EVS director said: -The shower chair in D105 needed to be discarded. -He/she found out that day that the shower chair was broken.

Based on observation, interview and record review, the facility's physician failed to visit one sampled resident (Resident #8) at least once every 30 days for the first 90 days after admission and the facility failed to ensure the physician visited the resident every 60 days for five sampled residents (Resident's #25, #38, #41, #62, and #15) out of 18 sampled residents. The facility census was 84 residents. Review of the facility Physician's Visits Frequency, Timeliness and Alternates policy and procedure updated 5/2024, showed: -The Physician or Nurse Practitioner must make actual face to face contact with the resident and at the same physical location, not via a telehealth arrangement. -Residents must be seen by a physician at least once every 30 days for the first 90 days after admission and at least once every 60 days thereafter. -Physician visits are considered timely if it occurs no later than 10 days after the date the visit was required. -All required physician visits must be made by the physician personally. -At the option of the physician, required visits after the initial visit may alternate between personal visits by the physician and visits by a physician's assistant, nurse practitioner and clinical nurse specialist. 1. Review of Resident #25's Face Sheet showed the resident was admitted on [DATE], with diagnoses including dementia (a chronic condition that causes a loss of cognitive functioning, such as thinking, remembering, and reasoning, to the point that it interferes with daily life), psychosis (a mental disorder that causes people to lose touch with reality and have difficulty relating to others), anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome), depression (a common mental health condition that can affect anyone, and is characterized by a persistent low mood or loss of interest in activities for long periods of time), repeated falls, diabetes, high cholesterol, protein calorie malnutrition (lack of proper nutrition, caused by not having enough to eat, not eating enough of the right things, or being unable to use the food that one does eat), muscle weakness, anemia (low iron), kidney disease, high blood pressure, heart disease, and history of urinary tract infection (UTI). Review of the resident's quarterly Minimum date Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 6/24/24, showed the resident: -Was alert with significant cognitive impairment and memory loss. -Needed set up assistance and supervision with eating. -Needed moderate to maximum staff assistance with transfers, bathing, dressing, toileting and hygiene. -Used a wheelchair for mobility. Review of the resident's Physician's Order Sheet (POS) dated August 2024, showed physician's orders for: -Bupropion (an antidepressant) extended release 300 milligrams (mg) daily for depression. -Cholecalciferol (Vitamin D3) 1000 units daily for supplement. -Duloxetine (used to treat depression) 60 mg daily for depression. -Famotidine 20 mg daily for indigestion. -Hydrocodone -Acetaminophen 5-325 mg every four hours as needed for pain. -Hydroxyzine Pamoate (an anti-anxiety) 25 mg twice daily for anxiety. -Metformin 500 mg twice daily for diabetes. -Rosuvastatin Calcium 20 mg daily for lipid control. -Sertraline (an antidepressant) 100 mg every evening for depression. -Aspirin 81 mg daily for heart health. Review of the resident's Medical Record from 9/8/2023 to 8/9/2024 showed: -From 9/8/23 to 12/31/23 the resident was seen by the Nurse Practitioner (NP) every month. -The physician documented he/she visited on 10/30/23. This was the most recent physician's note that was documented in the resident's medical record. -The physician had not visited the resident in 10 months. 46519 2. Review of Resident #8's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Unspecified Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgement, and impulses). -Coronary Artery Disease (CAD- plaque build-up in the wall of the arteries that supply blood to the heart). -Major Depressive Disorder (MDD- a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life. -Post-Traumatic Stress Disorder (PTSD-a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). -Chronic Kidney Disease (CKD- a long standing kidney disease based on kidney damage or decreased kidney function for three or more months). Review of the resident's undated care plan showed: -The resident had impaired cognitive function and/or thought processes related to dementia. -The resident had impaired visual function. -The resident had an Activities of Daily Living (ADL) self-care performance deficits and limitations in physical mobility. -The resident had the potential for alterations in psychosocial well-being. Review of the resident's NP encounter note dated 6/26/24 showed the resident was seen by NP A and not by the facility's physician. Review of the resident's NP encounter note dated 6/27/24 showed the resident was seen by NP A and not the facility's physician. NOTE: This indicated the resident had not been seen by the facility's physician since admission. Review of the resident's admission MDS dated [DATE] showed the resident had moderately impaired cognition. 3. Review of Resident #41's face sheet showed he/she admitted to the facility with the following diagnoses: -Personal History of Transient Ischemic Attack (TIA- a stroke like attack which may be a warning sign of a future stroke) and Cerebral Infarction (ischemic stroke- occurs as a result of disrupted blood flow and restricted oxygen to the brain). -Congenital (a condition or trait that exists at birth) Hydrocephalus (a condition in which fluid accumulates in the brain and can cause brain damage). -Seizures (a sudden, uncontrolled burst of electrical activity in the brain causing changes in behavior, movements, feelings, and level of consciousness). -Hemiplegia (paralysis of one side of the body) following Cerebral Infarction Affecting the Left Dominant Side. -MDD. Review of the resident's NP encounter note dated 9/11/23 showed the resident was seen by NP B and not the facility's physician. Review of the resident's NP encounter note dated 11/1/23 showed the resident was seen by NP B and not the facility's physician. Review of the resident's NP encounter note dated 1/5/24 showed the resident was seen by the facility's physician. Review of the resident's NP encounter note dated 4/16/24 showed the resident was seen by NP C and not the facility's physician. Review of the resident's NP encounter note dated 5/31/24 showed the resident was seen by NP A and not the facility's physician. Review of the resident's NP encounter note dated 6/17/24 showed the resident was seen by NP C and not the facility's physician. Review of the resident's Quarterly MDS dated [DATE] showed the resident was cognitively intact. Review of the resident's NP encounter note dated 8/13/24 showed the resident was seen by NP A and not the facility's physician. NOTE: This indicated the resident was only seen by the facility's physician once in 11 months. Review of the resident's care plan dated 8/18/24 showed: -The resident had impaired cognitive function or impaired thought processes. -The resident had an ADL self-care performance deficit. -The resident had depression. -The resident had the potential for nutritional deficit. -The resident had a seizure disorder. 4. During an interview on 8/23/24 at 9:48 A.M. Licensed Practical Nurse (LPN) B said he/she had not normally worked on the Long-Term Care (LTC) side of the facility and was unsure of the physician visit schedule. 26996 5. Review of Resident #62's quarterly MDS dated [DATE] showed the resident: -Was cognitively intact. -Had the following diagnoses: --High blood pressure. --Stroke. --Diabetes Mellitus (DM-a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin). --Seizure disorder (a hyperexcitation of neurons in the brain leading to a sudden, violent involuntary series of contractions of a group of muscles). Review of the resident's physician/nurse practitioner notes showed: -On 4/17/24 the resident was seen by the nurse practitioner. -On 4/19/24 the resident was seen by the nurse practitioner. -On 5/15/24 the resident was seen by the nurse practitioner. -On 6/6/24 the resident was seen by the nurse practitioner. -On 7/10/24 the resident was seen by the nurse practitioner. -On 7/17/24 the resident was seen by the nurse practitioner. -On 7/24/24 the resident was seen by the nurse practitioner. -On 8/1/24 the resident was seen by the nurse practitioner. -On 8/7/24 the resident was seen by the nurse practitioner. -On 8/14/24 the resident was seen by the nurse practitioner. -On 8/21/24 the resident was seen by the nurse practitioner. -There was no documentation that showed the residents physician saw the resident face to face alternating with the nurse practitioner every 60 days. During an interview on 8/23/24 at 9:00 A.M. LPN B said he/she was not aware how often the nurse practitioner and/or physician were required to see the resident. 33409 6. Review of Resident #38's Admission Face Sheet showed he/she was readmitted on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease (COPD, difficulty breathing) and Atrial fibrillation (A-Fib irregular heart beat). Review of the resident's Electronic Medical Record dated 8/25/23 to 8/23/24 showed: -He/She had one Physician visit documented on 4/17/24, as the resident's Initial History and Physical and was electronically signed by the physician on 4/19/24. -That was the most recent physician's note documented in the resident's medical record. -There was no other documentation to show the physician had visited the resident in four months. -The facility could not provide documentation of physician visit every 60 days for the resident. Review of the resident's Annual MDS dated [DATE], showed the resident: -Was alert and cognitively intact. -Needed moderate to maximum staff assistance with transfers, bathing, dressing, toileting and hygiene. -Used a wheelchair and walker for mobility. Review of the resident's POS dated August 2024, showed physician's orders to include not limited to: -admitted to skilled nursing on 7/22/24 for rehabilitation. -Welbutrin XL extended release 24 hours 300 mg one tablet daily for depression. -Lovenox Injection 150 mg/ml subcutaneously one time a day for preventive for Deep Vein Thrombosis (DVT). -Oxycodone hydrochloride (HCI) 15 mg one tablet by mouth every four hours as needed for pain. -Tramadol HCI 50 mg give two tablets every four hours as needed for pain. 50579 7. Review of Resident #15's Quarterly MDS dated [DATE] showed the resident: -Was moderately cognitively impaired. -Had high blood pressure, A urinary tract infection within the previous 30 days, high cholesterol, Diabetes Mellitus type II, stroke, and Dementia. Review of the resident's physician/nurse practitioner notes dated 1/3/24 to 8/19/24 showed: -The resident was seen by a nurse practitioner every month. -The physician documented he/she saw the resident on 2/22/24. -The physician had not seen the resident in six months. 8. During an interview on 8/23/24 at 11:36 A.M. Assistant Director of Nursing (ADON) A and ADON B, both said: -The Nurse Practitioner would visit the residents daily if needed, but they usually visited each resident at least weekly. -They saw the physician in the building at least monthly, but they don't round with him/her so they don't know who he/she visited with when he/she was in the building. -They did not know how frequently the residents physicians were supposed to visit the resident between Nurse Practitioner visits. -The physician had a set patient list upon each visit and he/she determined who he/she needed to see according to that list. -They did not know how frequently the physician was supposed to visit Resident #8, #25, #41, #62, #38, and #15 between Nurse Practitioner visits. During an interview on 8/23/24 at 1:08 P.M., the DON said: -He/she would expect to have physician visit progress notes in the resident's medical record. -The Physicians should visit each resident every 60 days. -They could alternate every 60 days with the Nurse Practitioner visits. -He/she did not know who monitored to ensure the Physician saw each resident every 60 days. -He/she was unsure when Resident #8, #25, #41, #62, #38, and #15 were last seen by the facility's physician.

Based on interview and record review, the facility failed to ensure the physician responded to the pharmacist's recommendation for Gradual Dose Reduction (GDR) for psychotropic (relating to or denoting drugs that affect a person's mental state) medication in a timely manner for two sampled residents (Resident #25 and #62), failed to follow up on a physicians response to the pharmacist's Medication Regimen Review (MRR), failed to follow a physician dose recommendation, and failed to ensure appropriate indication for antipsychotic medication dose increases for one sampled resident (Resident #50) out of 18 residents. The facility census was 84 residents. Review of the facility's Pharmacy Services policy and procedure updated 5/2024, showed: -Medication Regimen Review-Reviews will be conducted in accordance with all state and federal requirements. Pharmacist medication reviews to the physician and nursing will be completed in a timely manner, but not later than five days from receiving. Review of the facility's Psychotropic Medications policy and procedure updated 5/2024, showed: -The physician's order for a psychotropic medication will include both a qualifying diagnosis for the drug and a list of behaviors which the staff will monitor during the drug administration. -The attending physician must certify that a psychotropic medication is necessary to treat a specific condition/behavior. -The drug dosage must be periodically reduced with a goal of discontinuing it, or replacing it with another less potent prescription. -All antipsychotic's will be tapered as a gradual dose reduction unless clinically contraindicated. -The continued use is in accordance with current standards of practice and they physician has documented rationale for why any attempted dose reduction would be likely to impair the resident's function or cause psychiatric instability by exacerbating and underlying medical or psychiatric disorder. 1. Review of Resident #25's Face Sheet showed the resident was admitted on [DATE], with diagnoses including dementia (a chronic condition that causes a loss of cognitive functioning, such as thinking, remembering, and reasoning, to the point that it interferes with daily life), psychosis (a mental disorder that causes people to lose touch with reality and have difficulty relating to others), anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome), depression (a common mental health condition that can affect anyone, and is characterized by a persistent low mood or loss of interest in activities for long periods of time), repeated falls, diabetes, high cholesterol, protein calorie malnutrition (lack of proper nutrition, caused by not having enough to eat, not eating enough of the right things, or being unable to use the food that one does eat), muscle weakness, anemia (low iron), kidney disease, high blood pressure, heart disease, and history of urinary tract infection (UTI). Review of the resident's Drug Regimen Review dated 5/15/24, showed the pharmacist review listed three medications for GDR: -Bupropion (an antidepressant) 300 milligram (mg) daily since 8/19/22 -the pharmacist's recommendation was to review for GDR. -Duloxetine (used to treat depression) 60 mg daily since 8/19/22 - they recommendation was to review for GDR. -Quetiapine (Seroquel an antipsychotic) 25 mg take a half tablet twice daily since 11/27/22 -the pharmacist's recommendation was to review for GDR. -The physician's response showed Quetiapine was discontinued, but there was no documented response to the recommendation for a gradual dose reduction for Bupropion or Duloxetine to show if the physician agreed or disagreed with the pharmacist's recommendation and there was no rationale for why the physician disagreed with the recommendation. Review of the resident's Physician's Psychiatric Note dated 6/10/24, showed: -The Psychiatrist was seeing the resident for a psych follow-up and GDR medication management. -Seroquel was discontinued. Continue to monitor the resident's response. Resident appeared to be in a good mood. Nursing staff reported no behaviors today. No other acute psychiatry concerns noted today. -The Psychiatrist documented he/she reviewed the resident's Medication Administration Records (MARS) for compliance with medications. -The Psychiatrist documented he/she reviewed the resident's current psychiatric medication regimen and that a GDR was completed on Seroquel. He/She documented that the resident was currently taking Bupropion 300mg daily and Duloxetine 60mg once daily. -They Psychiatrist did not address the Pharmacist's recommendation for trying a GDR with Bupropion or Duloxetine. Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 6/24/24, showed the resident: -Was alert with significant cognitive impairment and memory loss. -Needed set up assistance and supervision with eating. -Needed moderate to maximum staff assistance with transfers, bathing, dressing, toileting and hygiene. -Used a wheelchair for mobility. -Had symptoms of depression but did not have behaviors (hallucinations or psychosis) during the lookback period. Review of the resident's Medical Record showed there was no documentation showing a GDR was completed on Bupropion 300 mg once daily and Duloxetine 60 mg once daily or that the Physician/Psychiatrist did not agree with the Pharmacist's recommendation. There was no documentation showing any rationale for why a GDR was not appropriate for the resident in the resident's medical record. Review of the resident's Physician's Order Sheet (POS) dated 6/2024, 7/2024 and 8/2024 showed physician's orders for: -Bupropion 300mg daily for depression (ordered 3/18/22). -Duloxetine 60mg daily for depression (ordered 11/29/22). Review of the resident's Drug Regimen Reviews dated 6/14/24 and 7/13/24, did not show documentation that the Pharmacist continued to address the recommendation for GDR of Bupropion 300mg once daily and Duloxetine 60mg once daily. Review of the resident's Physician's Psychiatric Note dated 8/9/24, showed: -The Psychiatrist visited the resident for follow up for mental/psychiatric management and documented the staff was reporting the resident had tearfulness, agitation and was combative toward staff since the reduction of Seroquel. He/She documented he/she was performing a mental/psychiatric medication check and follow up. -The Psychiatrist documented the resident reported feelings of anxiety and agitation. -The Psychiatrist reviewed the resident's Medication Administration Record (MAR) and complete list of medications. To include his/her current psychiatric medication regimen. -The Psychiatrist documented the plan was to continue psychotropic medication(s) as presently prescribed. Patient currently benefited psychiatrically and behaviorally at current dose(s). Dose reduction attempt at this time would risk decompensation of patient. During an interview on 8/22/24 at 1:59 P.M., Assistant Director of Nursing (ADON) A said: -Regarding the Drug Regimen Reviews, when they received pharmacy recommendations, they provided the recommendation to the physician or Nurse Practitioner within 48 hours of receiving it. -If there was a recommended change in dosage or other medications, they would get a verbal order from the physician and then they could change the order to reflect the new physician's order. -The GDR had to be responded to by the prescribing physician or Nurse Practitioner (NP) and if the physician was not in agreement with the recommendation they should document why they were not going to try a gradual dose reduction. -The former NP used to document why they did not agree with the recommendations on the drug Regimen Review form or in the notes, and then the nurse would send the documentation back to the pharmacist. -He/She did not know why the physician or NP would not have responded for each of the resident's medications but maybe they thought that discontinuing Seroquel was what was needed at the time. -He/She was not sure if the current NP was aware that he/she was supposed to document rationale for not following the recommendation of the pharmacist and may need additional education. -The expectation was that the physician would respond to the recommendation and document why they were not agreeing with the recommendation. During an interview on 8/23/24 at 1:31 P.M. the Director of Nursing (DON) said: -When the pharmacist had a recommendation, he/she would put it in the physician's box and the NP or physician would get the information. -if the physician recommended a gradual dose reduction of psychotropic medications and the physician did not agree with the recommendation, the physician should document a rationale for why they did not agree. -They usually tried to get the Drug Regimen Review recommendations to the physician and returned from the physician within a week. 50579 2. Review of Resident 50's behavior progress notes dated 1/1/24 to 8/23/24 showed no documented behaviors exhibited by the resident. Behavior monitoring documentation dated 1/1/24 to 8/23/24 was requested on 8/23/24 but none was received prior to exit on 8/26/23. Review of the resident's fall progress notes dated 1/1/24 to 8/23/24 showed: -Two falls on 3/7/24 where the resident was attempting to ambulate by himself/herself. A description of immediate action taken that included taking a urine sample and a hospice (end of life care) visit to change around a few of the patient's meds. --An increase in Quetiapine occurred within 24 hours. -Three falls on 3/12/24 in which the resident slid out of his/her wheelchair onto the floor and was discovered twice on the floor of his/her room. --An increase in Quetiapine occurred within 24 hours. -A fall on 6/13/24 in which the resident attempted to get out of the wheelchair by himself/herself. --An increase in Quetiapine occurred within 24 hours. -Falls on 2/12/24, 3/17/24, 5/30/24, 6/8/24, and 7/15/24. Review of the resident's quarterly MDS assessment, dated 5/18/24, showed: -Diagnoses including cognitive communication deficit (difficulty with communication related to cognitive decline), depression, dementia (cognitive decline) without behavioral disturbance, psychotic disturbance, mood disturbance or anxiety. -The resident was moderately cognitively impaired. -The resident exhibited no behaviors or delusions. -The resident had two or more falls within the previous quarter. -The resident received antipsychotics on a routine basis. -A GDR was not attempted and a physician documented a GDR was clinically contraindicated on 5/15/24. Review of a Consultant Pharmacist conducted monthly pharmacy Medication Regimen Review (MRR), dated 6/12/24, showed: -No appropriate diagnosis for the order of Quetiapine. -A recommendation to discontinue the Quetiapine order or add appropriate diagnoses. -A signature on the physician/prescriber response section, dated 6/17/24, with a box checked with Agree and no comments noted. Review of the resident's NP Provider Progress Note dated 7/9/24 showed NP C recommended Quetiapine 50mg twice daily instead of 75mg twice daily. During an interview on 8/13/24 at 11:38 A.M., ADON B said: -He/She had not noticed a change in the resident's behaviors over the previous six months. -The resident could be tearful and irritated then a couple hours later be happy, but he/she was unaware of any other behaviors. -Recommendations from MRR's should be completed by the review the following month. -He/She was unaware of what the physician wanted to do for the MRR on 6/17/24. -He/She would have sought clarification for the physician response to the MRR on 6/17/24. -He/She did not know why Quetiapine was increased for the resident. Review of the resident's NP Provider Progress Note dated 8/14/24 showed: NP C recommended Quetiapine 50mg twice daily instead of 75mg twice daily. Review of the resident's POS, dated 8/18/24, showed orders for: -Quetiapine 75mg twice daily for delusions beginning 6/14/24. -Behavior monitoring for targeted behaviors (agitation, aggression, crying, withdrawal). -Discontinued orders for Quetiapine as follows: --25mg once at bedtime from 1/18/23 to 3/7/24. --50mg once at bedtime from 3/7/24 to 3/12/24. --50mg twice daily from 3/12/24 to 6/14/24. During an interview on 8/22/24 at 3:10 P.M., Social Services Designee (SSD) A said: -He/She was unaware of any aggressive behaviors by the resident. -He/She did not notice a change in behaviors over the past several months. During an interview on 8/23/24 at 1:09 P.M., the DON said: -ADON A and ADON B were responsible for ensuring MRR's were completed and followed up on. -He/She would expect physician responses to be followed up on by staff. -He/She had not been aware of an increase in behaviors for Resident #50. -He/She would not expect an increase in an antipsychotic medication without an increase in behaviors or another indication. -He/She would not expect an antipsychotic be increased within 24 hours of a resident fall, but would instead have considered a decrease in the medication. 51150 3. Review of Resident #62's Care Plan dated 11/28/23 showed: -The resident had the potential for alterations in psychosocial well-being. -The resident had risk for falls. -The resident was receiving antianxiety medication. -The resident was receiving antidepressant medication. Review of the resident's MRR dated 2/20/24 showed: -A recommended GDR for Lorazepam (anti-anxiety) 0.25 mg twice per day (BID). -The physician response was Lorazepam 0.5 mg BID. -No indication/rationale was given for physician's response. Review of the resident's Face Sheet showed the resident was readmitted on [DATE] with the following diagnoses: -Syncope (temporary loss of consciousness caused by a fall in blood pressure), collapse. -Major depressive disorder (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living) single episode, unspecified. -History of falling. -NOTE: Anxiety (anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus) was not listed. Review of the resident's quarterly MDS dated [DATE] showed: -The resident had a diagnosis of depression. -The resident had no other psychiatric or mood disorders. -The resident was not receiving Antipsychotic Medication (a group of psychoactive drugs (pertaining to a drug or other agent that affects such normal mental functioning as mood, behavior, or thinking processes) commonly but not exclusively used to treat psychosis). -The resident was receiving Antianxiety medication. -The resident was receiving Antidepression medication. Review of the resident's Care Plan dated 6/5/24 showed the resident had depression. Review of the resident's POS dated 7/20/24 showed the following physician's orders: -Lorazepam oral tablet 0.5 mg give 0.25 mg by mouth two times a day for anxiety. Review of the resident's POS dated 8/20/24 showed the following physician's orders: -Lorazepam oral tablet 0.5 mg give 1 tablet by mouth two times a day for anxiety. During an interview on 8/23/24 at 11:35 A.M. Assistant Director of Nursing (ADON) A said: -GDR recommendations were given to the physician and then given back to the clinical team (ADON's and DON). -There should be a rationale from the physician on all GDR recommendations. -He/She was not sure why the physician would not write a rationale on a recommended GDR on Lorazepam. -He/She would expect that the physician would have written a rationale for not initiating a GDR recommendation on Lorazepam. During an interview on 8/23/24 at 1:31 P.M. the DON said: -If a resident was being treated by a medication for anxiety, the resident should have a diagnosis of anxiety. -ADON A and ADON B were responsible for GDR follow-ups. -If a GDR was recommended by the pharmacist of a psychotropic medication and the physician did not agree with the recommendation, the physician should document a rationale for why they did not agree. -GDR recommendations should be taken care of within a week of receiving them from the pharmacist.

Based on observation, interview and record review, the facility failed to maintain hot foods on room trays for C and E Hall, at or close to a temperature of 120 F (degrees Fahrenheit) at the time of service; failed to maintain the temperature of milk in glasses on room trays at or close to a temperature of 41 F at the time of service; and failed to evaluate the room tray delivery procedure. This practice potentially affected at least 12 residents who resided on those halls who received room trays towards the end of the room tray delivery time for those halls. The facility census was 84 residents. Review of the Facility's policy entitled Food Temperatures, the Correct Use of the thermometer, dated 2021, showed: -To ensure food safety, food temperatures are taken and recorded. -Food temperatures are taken and recorded on the temperature monitoring log which indicates the correct temperature for each item. -Hot food holding temperature are taken and recorded for food on the steam tables Cold food temperatures are taken and recorded prior to the cold food leaving the kitchen and again in the dining rooms. -A calibrated stem type thermometer is inserted into the thickest part of the food. The sending area of the thermometer (the part of the probe that is below the indentation or dimple) is checked to determine if the indentation or dimple is all the way in the food. and -Corrective action is taken for foods not meeting the temperature standard. 1. Observation on 8/22/24 from 7:03 A.M. to 7:42 A.M. showed the following for C hall: -From 7:03 A.M. to 7:15 A.M., Dietary staff placed trays for C Hall on the cart. -At 7:15 A.M., the room tray cart for C hall, left the kitchen. -At 7:17 A.M. the room tray cart for C Hall arrived at C hall. -At 7:22 A.M., Certified Nursing Assistant (CNA) A and CNA G started to serve trays from the cart. -At 7:24 A. M, CNA A had to stop passing trays to help a resident set up. -At 7:27 A.M. CNA G had to stop passing trays to provide cueing to a resident who kept walking away from the table to sit and eat. -At 7:31 A.M., the temperature of the milk in one of the glasses was measured at 63.9 F. Observation on 8/22/24 at 7:35 A.M., showed the temperatures of foods on the test tray on C Hall, were the following: -Eggs were 108.1 F. -Bacon was 102.2 F. -The milk was 53.2 F During an interview on 8/22/24 at 7:40 A.M., the Chief Nursing Officer (CNO) said: -He/she had not had a chance to look at the room tray delivery service. -At times, some residents who needed more assistance or more cueing should be served last so that other residents could be served earlier and trays would not sit on the cart and get cold if staff had to help those residents. During an interview on 8/22/24 at 7:42 A.M., CNA G said someone from the dietary department did come down to C Hall and check room trays, but he/she could not remember the last time was that happened. Observation on 8/22/24 at 8:39 A.M., with CNA H showed the temperature of the hot cereal on a test tray for E Hall was 107.4 F. During an interview on 8/22/24 at 9:02 A.M., the Dietary Manager (DM) said he/she checked the temperatures of the room trays randomly, not regularly.

Based on observation, interview and record review, the facility failed to ensure the audible portion of the call system was operational at the Nurse's area on C Hall (a unit with residents who had some level of dementia),. This practice affected 14 residents who resided on C Hall. The facility census was 84 residents. Review of the description page of the Nurse Call system for the Touchscreen Nurse Console showed: -The Touchscreen Nurse Console is used on the nurse call system as the primary interface among users of the system. -Consoles are typically located in areas where staff congregate and need to communicate with patients, residents and fell ow staff members. -The Console displays incoming calls, including calling station, room number, the bed ( A or B), call priority, elapsed time of the call, and other relevant patient information. -The Console has adjustable talk/listen volume settings for each individual patient/staff intercom station. 1. Observation on 8/20/24 at 2:00 PM., showed a call light flashing and alarming on the outside of C Hall but the call light was not audible within C Hall. During an interview on 8/20/24 at 2:03 P.M., the Chief Nursing Officer (CNO) said the alarm did not sound on that unit and then he/she went to answer that call light. Observation on 8/21/24 from 11:21 A.M. through 11:24 A.M., during a call light test showed the following: -The call light in resident room C105 was activated and the sound was heard at the North Unit Nurse's Station which was located outside of the C Hall. -Certified Nursing Assistant (CNA) A had his/her back turned to the hallway while he/she served a resident at the nurse's area. During an interview on 8/21/24 at 11:23 A.M., CNA A said he/she could not hear the call system from where he/she was located at the nurse's area. During an interview on 8/22/24 at 8:16 A.M., the North Unit Manager said he/she told staff on C hall to make regular rounds and the installers of the call light system did not think about placing a Touch Screen Nurse Console at the nurse's area on C hall. Observation on 8/22/24 at 11:37 A.M., showed the call light for resident room C104 was flashing, but there was not an audible sound while the call light from resident room C104 was activated. During an interview on 8/26/24 at 12:13 P. M, the Administrator acknowledged that placing a Touchscreen Console on C Hall would make the call system more audible on that hall.

Based on observation and interview, the facility failed to maintain the covers of cleanouts (an access point which provides access to the sewer or other plumbing line so that blockages could be removed) in a tight fitting manner so the covers would not be a hazard to facility residents or staff located on C Hall and at the area between D Hall and the Rehabilitation Unit Nurse's station. This practice potentially affected 14 residents on C Hall and 19 residents who resided on D Hall and E Hall who would pass through that area. The facility census was 84 residents. 1. Observation on 8/22/24 at 11:01 A.M., showed the cleanout cover on C Hall moved around when the cover was stepped on and the blue tape which once held it to the floor, was broken. During an interview on 8/22/24 at 11:03 A.M., the Environmental Services (EVS) Director said the cap that the screw of the cover, screws into was broken and that caused the cover to be loose. 2. Observation on 8/26/24 at 9:50 A.M., showed the cleanout cover in the area between D Hall and the Rehabilitation Nurse's station moved when it was stepped on. During an interview on 8/26/24 at 9:52 A.M., the Rehabilitation Unit Manager said he/she did not know how long that cleanout cover had been loose. During an interview on 8/26/24 at 10:02 A.M., the EVS Director said when the carpet was removed, the carpet removers accidentally broke the cap that the screw goes into for the cleanout covers.

Based on observation, interview and record review, the facility failed to provide dignity and privacy while completing Activities of Daily Living (ADL-A collective term for all basic skills you need in regular daily life) and performing perineal care (care to the area between the anus and the exterior genitalia) for one sampled resident (Resident #62) out of 18 sampled residents. The facility census was 84 residents. Review of the facility's Dignity policy and procedure updated in July 2024, showed: -The facility will promote care for residents of the facility in a manner and in an environment that maintains and enhances each resident ' s dignity and respect. -All staff will provide dignity to each resident by maintaining the resident ' s privacy of body. -All staff will refrain from any practice which could be considered demeaning to an elder. 1. Review of Resident #62's Face Sheet showed the resident was admitted to the facility with the following diagnoses: -Difficulty in walking. -Muscle weakness. -Need for assistance with personal cares. -Cerebral Infarction (ischemic stroke, a cerebral infarction occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). -Major Depressive Disorder (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living). Review of the resident's Care Plan dated 11/28/23 showed the resident: -Had a communication problem. -Had ADL self-care performance deficits and limitations in physical mobility. -Had incontinence (having no or insufficient control over urination or defecation). -Had the potential for alterations in psychosocial well-being. -Had depression. Review of the resident's annual Minimum Data Set (MDS-A federally mandated assessment tool required to be completed by facility staff for care planning) dated 6/3/24 showed the resident: -Had cognitive impairment. -Had functional limitation in Range Of Motion (ROM the extent or limit to which a part of the body can be moved around a joint or a fixed point; the totality of movement a joint was capable of doing). -Needed partial/moderate assistance with ADL's. -Had an indwelling urinary catheter (a tube passed through the urethra into the bladder to drain urine) -Had frequent incontinence. -Had a history of stroke. -Had depression. Observation on 8/21/24 at 12:24 P.M., showed: -The resident received wound care on his/her right ankle by Nurse Practitioner (NP) A and Assistant Director of Nursing (ADON) A. -The window curtains were open during wound care. -A bystander was outside of resident's window during cares. Observation on 8/22/24 at 10:44 A.M., showed: -ADON A and Certified Nurse Assistant (CNA) J performed perineal care on the resident. -The window curtains were left open during perineal care. -Several bystanders (approximately seven) were observed and seen outside of the resident ' s window during resident care. -The resident was fully exposed to outside bystanders during resident cares. During an interview on 8/22/24 at 1:22 P.M., CNA B said: -He/She would promote dignity and privacy by knocking on the resident's door before entering, introduce self, and pulling the resident's curtain for privacy. -He/She would close window blinds/curtains if a resident was next to a window during resident cares. During an interview on 8/22/24 at 1:40 P.M., CNA J said: -He/She would shut a resident door and pull their curtains to promote dignity and privacy during cares. -He/She forgot to pull resident's window curtains during cares, but he/she normally would have. During an interview on 8/23/24 at 8:59 A.M., Licensed Practical Nurse (LPN) B said: -All residents should be given privacy and dignity during personal cares. -He/She would expect window curtains/blinds to be shut if a resident was receiving cares next to a window. -He/She would expect curtains between two residents in the same room would also be closed during resident cares. During an interview on 8/23/24 at 11:35 A.M., ADON A said: -He/She would expect privacy and dignity to be given to each resident in the facility during resident cares. -He/She would expect all curtains in a resident room to be closed during resident cares, including window curtains. -He/She should have made sure the window curtain was closed while providing Resident #62 personal care. During an interview on 8/23/24 at 1:09 P.M., the Director of Nursing (DON) said: -He/She would expect privacy and dignity to be given to each resident in the facility. -He/She would expect staff to close all doors, blinds, and curtains in a resident room, while a resident was receiving personal cares.

Based on observation, interview and record review, the facility failed to obtain a physician order for self administration of medication at bedside and failed to evaluate and document the ability to self-administer medication for two sampled residents (Resident #343 and #345) out 18 sampled residents. Facility's resident census of 84 residents. The facility did not provided a policy for Resident Self-administration of medication at time of exit. 1. Review of Resident #343's Admission Face Sheet showed the resident admitted to the facility on [DATE], had a diagnosis of Chronic Obstructive Pulmonary Disease (COPD - a disease process that decreases the ability of the lungs to perform ventilation). Review of the resident's Electronic Medical Record from 8/7/24 to 8/18/24 showed the resident did not have physician order for self administration of medication at bedside and did not have Self Administration of Medication Evaluation completed prior to 8/18/24. Review of the resident's Physician Order Sheet (POS) dated 8/7/24 to 8/18/24 showed: -ProAir HFA (Ventolin) Inhalation Aerosol Solution 108 (90 Base) microgram (mcg)/ACT (Albuterol Sulfate) 2 puff inhale orally every four hours as needed for shortness of breath. -Breo Ellipta Inhalation Aerosol Powder Breath Activated 200-25 mcg/ACT (Fluticasone Furoate-Vilanterol) one puff inhale orally one time a day for shortness of breath. -The resident did not have a physician's order to keep medication at bedside. -The resident did not have a physician's order to self administer the medication by himself/herself. -The resident did not have a physician's order for evaluation by nursing staff to assess the residents ability to be able to provide his/her own breathing treatment. Review of the resident's Medication Administration Record (MAR) dated 8/1/24 to 8/18/24 showed: -A physician's order for ProAir HFA (Ventolin) Inhalation Aerosol Solution 108 (90 Base) mcg/ACT (Albuterol Sulfate) two puff inhale orally every four hours as needed for shortness of breath dated 8/8/24. -There was no documentation the resident had administered the inhaler by himself/herself. -There was no monitoring of the use of the inhaler medication by the Certified Medication Technician (CMT) or nursing staff. Observation on 8/19/24 at 11:09 A.M. and 11:47 A.M., of the resident's room showed: -He/She was in private room. -He/She had Ventolin inhaler on his/her bedside table, unattended. Observation and interview on 8/19/24 at 3:03 P.M., of the resident showed: -He/She had a left arm amputation. -He/She administered the Ventolin inhaler medication as needed for shortness of breath. -The resident took the inhaler medication in his/her right hand. He/she shook the Ventolin inhaler then removed the cap with his/her teeth. -Placed his/her lips around the mouth piece, pushed the vial, while he/she inhaled. -He/She held his/her breath for a few seconds and then exhaled. -He/She then placed the cap back on the medication and laid it on the bedside table. -He/She was not aware if staff monitored when he/she took the inhaler medication or if nursing staff documented on the resident's MAR the medication was given. -He/She could not remember if nursing staff evaluated his/her ability to administer the inhaled medication. Review of the resident's Health Status Note dated 8/19/24 at 4:41 P. M. showed: -The resident had complaints of shortness of breath. -The resident provided breathing treatment by the nurse with some relief. -The resident's heart rate elevated to 133 beats per minute. -The resident again said he/she was having difficulty breathing at 3:30 P.M. The resident's oxygen level was at 99% and heart rate was 127 beats per minute. -The resident said he/she may be anxious (experiencing worry, unease, or nervousness, typically about an imminent event or something with an uncertain outcome). Anxiety medication was given for possible anxiety episode. -The resident again said he/she was having shortness of breath at 4:00 P.M. and the medication did not help. -Breathing treatment administered with no relief and heart rate was 142 beats per minute. -Attempted to call the resident's emergency contact with no answer. -Nurse Practitioner (NP) on unit and ordered to send the resident to hospital for evaluation and treatment. Nurse called second contact listed and notified of condition. Emergency Medical Services arrived and transported to hospital. During an interview on 8/20/24 at 1:55 P.M., CMT D said: -Self administration of medication for Resident #343, should be on the resident MAR, and pop up on the MAR when needed to be given. -He/she would observe the resident while the medication was being taken and document on the MAR. -He/she did not see a physician order at that time for self administration of any medication. -The resident's Ventolin inhaler would require a physician's order to be kept at bedside and to be self administered. -The resident would be assessed by the charge nurse, respiratory staff to assess for the resident's ability and knowledge to self administer the inhaler medication. 2. Review of Resident #345's Admission Face sheet showed the resident admitted to the facility on [DATE] with diagnoses of Pneumonia (an infection in your lungs caused by bacteria, viruses or fungi) and COPD. Review of the resident's POS dated 8/8/24 to 8/19/24 showed the resident: -Was admitted to skilled nursing on 8/8/24 for rehabilitation. -Had an order for Trelegy Ellipta (works to lower inflammation in your lungs and open up and relax your airways over time, while Albuterol works over a short period of time) inhaler one puff, one time a day for COPD. Review of the resident's Care Plan dated 8/8/24 to 8/19/24 showed: -No care plan for self administration of medication or evaluation to self administer medication. Observation 8/20/24 at 12:29 P.M., of the resident showed: -He/She had a Tregely inhaler at his/her bedside. During an interview on 8/20/24 at 12:29 P.M. the resident said: -He/She used the inhaler on his/her own once a day. Observation on 8/21/24 at 7:15 A.M., of medication administration with CMT C showed: -CMT C looked for Resident #345's Trelegy Ellipta inhaler in the medication cart. -CMT C did not find the resident's inhaler in the medication cart. -The inhaler was on the resident's bedside table and was labeled with the resident's name. During an interview on 8/21/24 at 7:25 A.M., the resident said: -He/she had already taken the inhaler medication that morning. During an interview on 8/21/24 at 7:27 A.M., CMT C said: -He/she did not see a physician's order for the inhaler medication to be left at bedside for Resident #345. -He/she normally would not leave an inhaler at bedside and would setup medications for the resident to administer and observe the use. Observation on 8/21/24 at 7:30 A.M. showed CMT C placed the resident's inhaler back into the CMT medication cart. 3. During an interview on 8/23/24 at 9:21 A.M., Licensed Practical Nurse (LPN) A said: -He/she would expect to have a physician's order for self administration and have a self administration assessment completed for residents that had medications at bedside. -He/she was not aware that Resident #343 and #345 had inhalers left at bedside. -The CMT or nursing should verify the resident had an order and if an assessment for self-medication had been done. -The CMT or nursing would still be required to document and monitor medications self administered by the resident. -On the MAR the medication /inhaler would still pop up to be self administered and monitored. -Nursing staff would document if reviewed or given. During an interview on 8/23/24 at 11:36 A.M., Assistant Director of Nursing (ADON) A and ADON B said: -Nursing staff would be expected to complete a resident self-administration medication evaluation and obtain a physician's order to keep medication at bedside and self-administer medication. -ADON A was not aware Resident #343 and Resident #345 had medications left at bedside until it was brought to their attention. During an interview on 8/23/24 at 1:31 P.M., the Director of Nursing (DON) said: -He/She would expect there to be a phsycian's order and nursing evaluation for self-administration of medication completed to keep medication at bedside. -Nursing should verify the resident had an order and if an assessment for self-medication was completed. -The CMT or nursing staff would be required to monitor resident self-administration of medication and document the medication as being monitored by nursing and taken by the resident.

Based on observation, interview and record review, the facility failed to ensure the skin issues that were identified in the initial skin assessment were acted upon timely for one sampled resident (Resident #47); failed to obtain treatment orders timely for one sampled resident (Resident #47); and failed to ensure documentation of the weekly skin assessments were completed for one sampled resident (Resident #47) who was admitted with skin issues and was at risk for developing pressure wounds (areas of damaged skin and tissue caused by sustained pressure that reduces blood flow to vulnerable areas of the body) and failed to complete and document weekly skin assessment orders and failed to follow up on a change in condition in skin for one sampled resident (Resident #62) out of 18 sampled residents. The facility census was 84 residents. Review of the facility policy titled Skin Integrity, updated 5/2024, showed: -Staff would ensure a resident who entered the facility without a pressure sore/ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) would not develop one unless unavoidable (hospice, end of life skin failure). -A nurse would perform a full body skin assessment within two to six hours after admission and weekly thereafter (identification on admission of the presence of a pressure ulcer or the presence of a deep tissue injury or skin areas at risk for breakdown). -The nurse will conduct a full body skin assessment for each resident weekly to ensure no risks have developed. -If the resident is determined to be at risk or has developed any skin integrity abnormalities, the nurse will implement action according to the specific skin issue identified per protocol. -The nurse and interdisciplinary team will plan and implement preventive care to avoid complications resulting from a resident's inactivity. 1. Review of Resident #47's face sheet showed the resident was admitted to the facility on [DATE], with diagnoses including obesity, difficulty walking, need for assistance with personal care, kidney disease (damage to or disease of a kidney with gradual loss of kidney function), and lymphedema (swelling that generally occurs in an arm or leg, but can also occur in the chest wall, abdomen, neck and genitals. The condition is caused by a blockage in the lymphatic system). Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 7/22/24 showed the resident: -Was alert and oriented without confusion. -Had incontinence and needed some assistance with toileting. -Had moisture associated skin damage (MASD areas of damaged skin and tissue caused by sustained pressure that reduces blood flow to vulnerable areas of the body). -Did not have any pressure ulcers. -Had ointments/treatments and devices to reduce pressure. Review of the resident's initial Nursing Evaluation Note dated 7/17/24 showed: -The resident had skin integrity concerns. -The resident had redness under both breasts, abdominal folds, genital area, lower extremities were red and inflamed, there was an open area (undefined) on his/her coccyx (a small triangular bone at the base of the spinal column) and shearing (shearing wound damages the skin on a deeper level-shearing occurs when tissue layers laterally shift in relation to each other; as when bone and deep tissue layers move in opposite directions) on bilateral (both) gluteal folds (the horizontal skin crease that forms below the buttocks, separating the upper thigh from the buttocks). -There were no physician's orders for treatment to the resident's skin documented. Review of the resident's admission Skin Observation assessment dated [DATE] showed: -The resident's skin color to his/her left and right upper extremities were normal. The resident's skin temperature on his/her upper extremities was warm and dry. -The resident's skin color to his/her left and right lower extremities were normal. The resident's skin temperature was warm and equal on bilateral sides. Lower extremity skin was moist. -The resident had skin integrity concerns. -The resident had redness under both breasts, abdominal fold, genital area, bilateral lower extremities area was red and inflamed, there was an open area (undefined) on his/her coccyx and shearing on bilateral gluteal folds. -There were no physician's orders for treatment to the resident's skin documented. Review of the resident's Medical Record showed there were no physician's orders for treatment to the resident's left and right lower extremities (shearing). Review of the resident's Skilled Nursing Note dated 7/18/24 showed: -The resident was receiving skilled services for physical therapy, occupational therapy, respiratory therapy and wound care. -The resident's existing skin alterations included skin tear, and pressure wound with no concerns noted related to his/her skin alteration evaluation. Review of the resident's Nurse Practitioner (NP) Note dated 7/19/24 showed: -He/She visited the resident and examined him/her for initial consultation. He/She reviewed the resident's transfer notes and physician's orders. -He/She discussed the purpose of the consultation and encouraged participation in therapy. -The resident had impairment with his/her mobility, balance, transfers, self-care and safety awareness. -The resident's skin color was appropriate for his/her race, warm, visible skin was intact, discoloration was noted to his/her bilateral lower extremities and had dry skin. -Recommendations addressed the resident's medication, comorbidities (diagnoses), rehabilitation and pain management, but did not address the resident's skin issues or treatment for the skin on both the resident's bilateral lower extremities. Review of the resident's Physician's Note dated 7/21/24 showed the resident was admitted to the facility for skilled rehabilitation services and pain management. It showed: -The resident was admitted to the facility from the hospital after having increased shortness of air and worsening back pain. His/Her pain had limited him/her to the point of immobility and inability to care for himself/herself despite using routine pain medications. -The resident was stabilized and was admitted to the facility for rehabilitation. -The physician reviewed the resident's symptoms and conducted a physical examination. -The physician reported the resident had no skin rash or lesions. There was no documentation showing the resident had any skin issues. Review of the resident's Wound assessment dated [DATE] showed a score of 17 (a score of 17 meant the resident was at risk for developing pressure ulcers). Review of the resident's Physician's Telephone Orders showed: -Wound Care left thigh back: cleanse with normal saline, pat dry, apply skin prep (a moisture barrier cream) to the skin around the wound, apply hydrafera blue (an antibacterial wound dressing) to the wound bed (the tissues at the base of the wound) and cover with a dry dressing every day shift for wound care. The order was dated 7/24/24. -Wound care right thigh back: cleanse with normal saline, pat dry, apply skin prep to the skin around the wound, apply hydrafera blue to the wound bed and cover with a dry dressing every day shift for wound care. The order was dated 7/24/24. -Low air loss mattress to bed for pressure reduction every shift for skin prevention low air loss mattress to bed for pressure reduction was dated 7/25/2024. Review of the resident's Medication Administration Record (MAR) dated July 2024, showed wound care treatment to the resident's bilateral thighs started on 7/24/24. Review of the resident's Skin Observation Assessments showed: -7/26/24, showed the resident's left gluteal fold had shearing to fold, the resident's right gluteal fold had shearing to fold, there was redness to the resident's sacrum (a shield-shaped bony structure that is located at the base of the lumbar vertebrae and that is connected to the pelvis). -There were no additional skin assessments documented fin the resident's electronic medical record for two weeks from 7/26/24 to 8/14/24. Review of the resident's Wound Report dated 7/29/24 showed: -The resident's coccyx was healed. -The area to the resident's left thigh was MASD due to incontinence. The measurement was 1.0 centimeters (cm) length (L) by 1.5 cm width (W) by 0.0 cm depth (D). The documentation showed the area was closed and the tissue had partial thickness and intact skin was 40 percent, epithelial (pale, pink, red skin) skin was 10 percent, non-granulating skin (the wound surface appeared smooth and red as opposed to berry-like) was 50 percent, without exudate (fluid that leaks out of blood vessels into nearby tissues). -The area to the resident's right thigh was MASD due to incontinence. The measurement was 1.5cm (L) by 2.0 cm (W) by .10 cm (D). The documentation showed the area was closed, and the tissue had partial thickness, intact skin was 40 percent, epithelial tissue was 10 percent, non granulating tissue was 50 percent, without exudate. Review of the resident's Skin Observation Assessments showed: - 8/14/24, showed there was redness to the resident's coccyx, the resident's left gluteal fold showed redness and open area, that resembled shearing, the resident's right gluteal fold showed redness and an open area, that resembled shearing. The nurse notified the resident's family and the wound team of the new area on 8/14/24. Review of the resident's Physician's Order Sheet (POS) dated August 2024, showed physician's orders for: -Wound care right thigh back: cleanse with ns, pat dry, skin prep to the peri wound, apply silver sulfadiazine cream to wound bed, cover with dry dressing every shift for wound care and as needed for missing or soiled dressing. The order was dated 8/7/2024. -Wound care left thigh back: cleanse with ns, pat dry, skin prep peri wound, apply silver sulfadiazine cream to wound bed, cover with dry dressing every shift for wound care and as needed for missing or soiled dressing. The order was dated 8/7/2024. -Low air loss mattress to bed for pressure reduction every shift for skin prevention low air loss mattress to bed for pressure reduction was dated 7/25/2024. Review of the resident's comprehensive undated care plan showed the resident was at risk for alteration in skin integrity and had MASD to his/her bilateral posterior thighs. Interventions showed staff would: -Apply barrier cream per facility protocol to help protect skin from excess moisture. -Encourage/assist with turning and repositioning every 2-3 hours. -Provide skin/wound treatments as ordered. -Encourage the resident to avoid scratching and keep hands and body parts from excessive moisture and keep his/her fingernails short. -Educate resident/family/caregivers of causative factors and measures to prevent skin injury. -Encourage good nutrition and hydration in order to promote healthier skin. -Evaluate and treat per physician's orders. -Evaluate resident for signs and symptoms of possible infections. -Keep the resident's skin clean and dry. Use lotion on dry skin. -Obtain blood work, labs and laboratory cultures of any open wounds as ordered by the physician. -Complete weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations, by the wound nurse or provider. -Documentation showed the resident declined treatments to wounds at times. Observation and interview on 8/20/24 at 9:13 A.M., showed the resident was sitting in his/her recliner, fully dressed for the weather with glasses on watching television (tv). He/She was alert and oriented and said: -He/She was in the facility for rehabilitation and treatment of pain and had been in the facility about three weeks. -He/She stayed in his/her room for most of the day by choice. -Nursing staff needed to assist him/her with all of his/her cares and he/she did have some incontinence. -He/She was admitted to the facility with wounds to his/her bottom and legs, but the nurses treated them daily and the wound care team also came in to assess and treat them. -They recently changed the medications they were using to treat the wounds and since then they had been healing well and he/she was pleased with that. During an interview on 8/20/24 at 4:00 P.M., the Administrator said: -The former NP completed their wound assessments, treatments and monitoring of all wounds. After he/she left the facility, the NP that was working with him/her at the time wanted to continue providing this service in house. -The current NP was taking classes for wound certification but had not completed the classes yet. -They began to notice that the wounds were not being followed as they should have been and the documentation was not being completed as it should and so they decided to hire a wound care consultant which would start on September 1, 2024 (the contract with the wound consultant was signed July 2024). During an interview on 8/22/24 at 1:50 P.M., Certified Nursing Assistant (CNA) C said: -When they completed any cares they looked at the resident's skin to see if there were any issues, red areas and any bruises. -They also gave resident baths and document any skin issues they saw on the resident's bath sheets that they provided to the charge nurse. -If they saw any skin issues, they notified the charge nurse and the nurse would assess the resident's skin. -He/She was familiar with the resident and noticed the areas on the back of his/her upper thighs. -The resident's thighs looked like really irritated, macerated skin. -He/She had not seen an open area or torn skin on the resident's thighs or bottom, but the nurse completed treatments on the areas daily. During an interview on 8/23/24 at 11:36 A.M., with Assistant Director of Nursing (ADON) A and ADON B, ADON A said: -Skin assessments populate weekly. -The floor nurse was responsible for completing the skin assessments. They documented what they saw and if they saw a skin issue, they were responsible for contacting him/her or the Nurse Practitioner. -Any nurse could assess the resident's skin, they don't typically document measurements, any skin issue that could heal within two weeks he/she did not necessarily track, but he/she would assess it and implement preventive measures. -All skin assessments should be documented on the skin assessment document in the electronic record. -He/She would expect the charge nurse, once notified that there was a skin issue, to notify him/her or the NP of the skin issue and they completed a full assessment of the wound and would obtain the order for treatment. -The charge nurse documented the initial assessment of skin upon admission. If there were orders from the hospital, they should document those and they should document what the skin looked like. Treatment for the resident's skin/wound should begin immediately. -If there was already an identified area then there should be preventative measures, treatment in place and he/she would expect the nurses to implement the treatments upon seeing them. -The nurses should document skin assessment weekly and follow up on the skin areas weekly. If the resident refused to allow them to assess there should be documentation showing that. -Wound assessments were completed weekly on Wednesdays. If the bath aide noticed anything abnormal, they should notify the charge nurse -He/She completed the wound risk assessments upon admission, and they automatically populate during the wound rounds weekly. -For non pressure wounds he/she could put a treatment order in place but the nurses were responsible for providing the treatments and monitoring. He/She would also ask the Nurse Practitioner if they wanted him/her to track the wound and would follow whatever they advised him/her to do. -He/She was tracking and monitoring the resident's wound weekly and completed rounds with the NP. During an interview on 8/23/24 at 1:31 P.M., the Director of Nursing (DON) said: -Upon admission the charge nurse was expected to complete a full skin assessment on the resident. -The nurse's documentation should be a detailed description of the skin/wound to include shearing. -If the resident had skin issues/wounds, the nurse should make an initial description of the wound/skin and would start an initial treatment or would get an order from the physician for treatment orders and implement them immediately or within the first 48 hours. -The charge nurse should then notify the Wound Nurse and he/she would start the resident on wound rounds and would complete a skin assessment on the resident. -If the Wound Nurse assessed the skin and determined it was not something he/she needed to follow, the nursing staff would continue the treatments and monitoring. -If the Wound Nurse assessed the skin and determined that the treatment orders were not adequate, he/she would change the treatment with the notification of the NP. -If the Wound Nurse assessed the skin and determined he/she would start wound rounds, he/she would also start treatment orders on the wound with notification of the NP. -Wound rounds were weekly and should be completed and documented every seven days. The NP staged the wounds during wound rounds. -Skin assessments were completed weekly by the nurses and they should be documented in the evaluations section of the resident's medical record. -He/She expected the skin assessment to be completed and documented at the time the form was opened in the electronic record system. -Staff should report any observed skin areas to the nurse. If there were missing skin assessments, wound assessments or other wound documentation then it was not completed. During an interview on 8/21/24 at 10:31 A.M., NP A said: -When he/she came in to complete dedicated rounds they completed a full assessment for all wounds. -The facility nursing staff were supposed to complete the initial skin assessment (upon admission) and then skin assessments weekly thereafter. -If the nurses saw a skin issue, they would notify the Wound Nurse and he/she would put the resident on the list to be seen if he/she felt it was necessary. -He/She would then come and complete a full wound assessment on the resident, measure and identify the wound and order treatment for the wound. -He/She would see the resident weekly and monitor the resident's wound (he/she has wound round documentation that was provided to the facility every week). -He/She would expect the nurse or wound nurse to notify him/her immediately if a resident came in with wounds or skin issues to include MASD. -Treatment for wounds should be implemented immediately or as soon as the order was obtained. -Resident #47 had an open area prior to admission that was more of a friction wound from wiping. It looked like scraping from excessive wiping. -The resident's primary care physician was monitoring the resident's skin prior to him/her admitting to the facility, but he/she was now reviewing and assessing it weekly. -He/She was referred for wound assessment and he/she observed and documented the assessment of the resident's wounds on his/her initial rounds (on 7/24/24) and he/she had seen and updated the resident's progress weekly during weekly wound rounds. -The resident's wounds may have been staged as a Stage I injury (observable, pressure-related alteration of intact skin with non-blanchable redness of a localized area usually over a bony prominence), but there was no blister just blood from friction. -He/She determined the resident had MASD (documented on the wound report). -The resident should have had a treatment order for his/her wound upon admission and if not, the nurse should have obtained it upon admission and began implementing treatments. -They were currently putting silver silvadene (a topical antibiotic used in partial thickness and full thickness burns to prevent infection) on the areas. -Now the injury was just friction from incontinence and excessive wiping. 51150 2. Review of Resident #62's POS dated 11/27/23 showed the following physician's orders: -Skin checks weekly. Every day shift, every Friday. Must open and document skin evaluations for each assessment (including no new areas found). Review of the resident's Care Plan dated 11/28/23 showed: -The resident was at risk for alteration in skin integrity. -The resident would remain free of new skin impairment through the review date of 8/2/24. -The resident would receive skin/wound treatments as ordered. Review of the resident's quarterly MDS dated [DATE] showed: -The resident was at risk for developing pressure ulcers. -The resident did not have any other ulcers, wounds, or skin problems. Review of the resident's POS dated 7/24/24 showed the following physician's orders: -Skin checks weekly. Every day shift, every Wednesday. Must open and document skin evaluations for each assessment (including no new areas found). Review of the resident's Treatment Administration Record (TAR) dated July 2024 showed the resident's weekly skin check to be completed on 7/5/24 had no nursing initial or check mark. Review of the resident's communication log with hospice (end of life care) dated 8/14/24 showed the resident was getting an open wound on his/her left buttock cheek. Review of the resident's bath sheet dated 8/14/24 showed the resident had an abnormal color on an area on his/her bottom. Review of the resident's skin observation documentation dated 8/14/24 showed: -The resident had skin issues observed. -There was a small open area, no bleeding, on the left gluteal fold. Review of the resident's bath sheet dated 8/17/24 showed: -The resident had an excoriated area. -A staff member wrote, butt red. -No explanation of excoriated area on body diagram. -No explanation of butt red on body diagram. -No staff signature. Review of the resident's Electronic Medical Record (EMR) on 8/20/24 showed: -No skin observations were documented from 3/27/24 to 5/9/24. -No skin observations were documented from 5/10/24 to 6/6/24. Observation on 8/20/24 at 11:43 A.M. of the resident's perineal care showed: -An open wound was noted on the residents left buttock. -During cares, the open wound was not treated. Review of the facility wound report dated 8/21/24 showed: -The resident had a pressure wound on his/her right outer ankle. -The resident had no other skin wounds listed. Observation on 8/21/24 at 10:06 A.M. of wound rounds showed: -NP A and ADON A assessed the residents ankle wound. -NP A and ADON A both said that the ankle wound was the only wound that the resident had. During an interview on 8/21/24 at 10:31 A.M. NP A said: -Skin assessments should be completed and documented weekly by the nurses. -Once a wound was found during weekly assessments, the resident was added to the NP's weekly wound round schedule. -He/She was unaware of a wound on residents buttocks. -He/She would expect to be notified by nursing staff if an area of concern was found on a residents skin. Observation and interview on 8/21/24 at 12:24 P.M. of perineal care showed: -ADON A said that he/she did not see any wounds on the buttocks before barrier cream was applied. -ADON A wiped some of the barrier cream off the buttocks and looked again. -ADON A then said that he/she saw an open wound after assessing the area a second time. Review of the resident's wound assessment details report dated 8/22/24 at 7:15 A.M. showed: -MASD wound on resident buttocks. -The wound was facility acquired. -The wound was 0.30 cm (L) x 0.40 cm (W) x 0.10 cm (D). During an interview on 8/23/24 at 8:59 A.M. LPN B said: -Charge nurses were responsible for weekly skin assessment and documentation of those assessments. -He/She was not aware that the resident had a wound on his/her buttocks. During an interview on 8/23/24 at 12:47 P.M. ADON A said: -Floor nurses were responsible for weekly skin assessment and documentation of assessments. -Floor nurses reported to the facility wound nurse when a wound was noted in an assessment. -He/She was the current facility wound nurse. -He/She was not aware of the resident having a wound on the buttocks. During an interview on 8/23/24 at 1:09 P.M. the DON said: -Floor nurses should be completing and documenting skin assessments weekly. -Weekly skin assessments should reflect all skin conditions. -He/She would expect nursing staff to read and follow up on all hospice notes.

Based on observation, interview and record review, the facility failed to ensure indwelling Foley catheter (a urinary bladder catheter inserted through urethra, is a external opening of the urinary tract, into the bladder to drain urine) care was preformed to include cleaning of insertion site and surrounding skin area for one sampled resident (Resident #1) who was at risk for Urinary Tack Infections (UTI - an infection of one or more structures in the urinary system), and failed to transcribe and implement hospital discharge orders to attempt a voiding trial to remove the urinary catheter in one week (7/26/24) for one sampled resident (Resident #74) out of 18 sampled residents. The facility census was 84 residents. Review of the facility's Foley Catheter Care Policy revised on 4/2024 showed: -Foley Catheter care will be provided to all resident with indwelling catheter as least every shift and more often as needed. -The purpose of catheter care was to prevent possible urinary tract infections from bacteria spreading from perineal area (Peri-care, to the area between the anus and the exterior genitalia) and external catheter into the bladder. -Physician order for catechization should include the reason /indication for catheterization. -Begin catheter cleaning starting at the urethra meatus and wiping away from the body. -Drainage bag is to be emptied at the end of each shift (or more often as needed) by emptying into a labeled, measured graduate with the total documented in the clinical record. 1. Review Resident #1's Admission Face sheet showed the resident admitted with following diagnosis include: -Quadriplegia (paralysis of all four extremities and usually the trunk) -Neurogenic bladder (a disorder of urinary bladder control due to damage to the spinal cord or to the nerves supplying the bladder). -Pressure injury/ulcer (is localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction) on the right and left buttocks. Review of the resident's Physician Order Sheet (POS) dated 8/2/24 showed: -Foley Catheter care was to include anchoring tubing and checking skin integrity every shift and as needed every shift. -Record urine output for every shift. -Change Foley Drainage Bag as needed. Review of the resident's Care Plan dated 8/2/24 showed: -The resident had a Foley catheter. -Check placement of catheter tubing every shift. -No intervention related to the process of the care of a Foley catheter. Review of the resident's admission Minimum Data Set (MDS, a federally mandated comprehensive assessment conducted by facility staff) dated 8/3/24, showed: -Diagnoses of Neurogenic Bladder, Pressure injuries. -The resident was cognitively intact. -The resident had an indwelling urinary catheter. -The resident required total assistance from staff for toileting. Observation on 8/20/24 at 10:21 A.M., of the resident's catheter care showed: -Certified Nursing Assistant (CNA) D and CNA E provided care for the resident. -The resident was on enhanced barrier precaution due to a risk for infection related to catheter and wounds. -The resident had an indwelling Foley catheter with drainage bag. -CNA D provided catheter care for the resident. -CNA D cleaned the Foley catheter tubing by holding the top of the tubing with one hand and wiped downward toward the drainage bag tubing. -CNA D, did not clean around opening of the catheter insertion site and the surrounding area as part of perineal area care and catheter care. -CNA D used a bleach wipe and cleaned the outside of the drainage bag. -The resident's drainage bag tubing had white/yellowish thick substance and the drainage bag had about a 100 cubic centimeters (cc) of dark tea color urine. -CNA D and CNA E removed gloves and washed hands between the dirty to clean process. During an interview on 8/20/24 at 10:25 A.M. CNA D and CNA E said: -They did not empty the resident's drainage bag at that time since it did not have much urine output. During an interview on 8/22/24 at 1:56 P.M., CNA C said: -Part of resident catheter care would be to clean around the catheter insertion site and surrounding skin. -The drainage bag was to be emptied every shift and the amount of urine output recorded. During an interview on 8/23/24 at 9:13 A.M., CNA D said: -Catheter care use one wipe at a time down catheter tubing and clean the bag with bleach wipes. -He/she did not clean the resident's catheter insertion site and surrounding skin area as part of the catheter care and peri care provided. -He/she should have cleaned the catheter insertion site around the urethra first and then completed full peri care as part of the catheter care process. -He/She had facility in-service related to catheter care and peri care in the past. During an interview on 8/23/24 at 9:21 A.M., Licensed Practical Nurse (LPN) A said: -He/she would expect CNA's to complete full catheter care to include cleaning of the insertion site and surrounding skin area. During an interview on 8/23/24 at 11:36 A.M., Assistant Director of Nursing (ADON) B said: -He/she would expect CNA's to perform catheter and peri-care to include cleaning the insertion site and surrounding skin. During an interview on 8/23/24 at 1:08 P.M., the Director of Nursing (DON) said: -He/she would expect care staff to ensure to clean catheter insertion site and peri area as part of the residents catheter care process. 50579 2. Review of Resident #74's After Visit Summary (discharge orders) from the resident's hospital stay, dated 7/19/24, showed an instruction to facility staff to attempt a voiding trial to remove the urinary catheter in one week (7/26/24) and, if unsuccessful, consult with a urologist. Review of the resident's Care Plan, dated 7/20/24, showed he/she had a urinary catheter in place. Review of the resident's admission MDS dated [DATE], showed: -Diagnoses of high blood pressure, renal failure (inability of the kidneys to adequately filter blood), benign prostatic hyperplasia (BPH, an enlarged prostate). -The resident had an indwelling urinary catheter. -The resident was not evaluated for urinary continence. -The resident was cognitively intact. -The resident required moderate assistance from staff for toileting. An admission progress note, dated 7/22/24, showed Nurse Practitioner (NP) A instructed facility staff to Continue Foley catheter, consider trial for DC. Review of the resident's medical record showed a lack of assessment for foley catheter removal and a lack of attempted voiding trials. Observation on 8/19/24 at 9:34 A.M., showed the resident had an intact foley catheter in place. During an interview on 8/23/24 at 11:12 A.M., LPN B said: -He/She had been responsible for admission order entry in the past. -He/She would have expected a nurse to enter orders for the foley catheter voiding trial based on the hospital discharge orders on 7/19/24. -He/She would have expected a nurse to obtain clarification on the NP progress note on when to start the voiding trial, but stated the note implied the NP agreed to the voiding trial per the discharge orders. During an interview on 8/23/24 at 11:38 A.M., ADON A said: -The hospital gave admission orders to attempt a foley catheter voiding trial to remove the catheter in seven days of discharge from the hospital. -NP A's progress note indicated that he/she was ordering the foley catheter trial be done upon the patients discharge home. - DC referred to discharge home, not discontinue. -The facility did not assess the resident's current urinary continence status or the status prior to insertion of the urinary catheter. -The facility had not consulted with a urologist for the resident. -The reason the catheter was still in place was the diagnosis of BPH. -He/She was unsure of the facilities role in assessing the resident for removal of the catheter. During an interview on 8/23/24 at 1:09 P.M., the DON said: -The hospital gave admission orders to attempt a foley catheter voiding trial to remove the catheter in seven days of discharge from the hospital. -NP A's progress note indicated that he/she was ordering the foley catheter trial be done upon the patients discharge home. - DC referred to discharge home, not discontinue. -The facility did not assess the resident's current urinary continence status or the status prior to insertion of the urinary catheter. -The reason the catheter was still in place was the diagnosis of BPH. -The facility only assessed removal of catheters based on physician orders. -It was up to the provider to determine if a foley catheter should remain and he/she did not expect staff to assess the resident for removal of the foley catheter if a provider had ordered the catheter. -It was the responsibility of the physician or nurse practitioner to assess the resident for foley catheter removal, not facility staff.

Based on observation, interview and record review, the facility failed to ensure oxygen equipment was stored using the proper infection control practices when not in use for one sampled resident (Resident #37) out of 18 sampled residents. The facility census was 84 residents. Review of the facility's policy titled Oxygen Handling and Transport dated January 2024 showed oxygen concentrators, cylinders, and equipment would be kept and maintained in such a way as to be compliant with all relevant health and safety guidelines. 1. Review of Resident #37's face sheet showed he/she admitted to the facility with the following diagnoses: -Chronic Obstructive Pulmonary Disease (COPD- a disease process that decreases the ability of the lungs to perform ventilation). -Unspecified Chronic (persisting for a long time) Bronchitis (inflammation of the lining of bronchial tubes, which carry air to and from the lungs. -Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgement, and impulses). Review of the resident's undated care plan showed the resident had the potential for altered respiratory status/difficulty breathing related to non-compliance with oxygen history of COPD, and chronic bronchitis with the goal of the resident's oxygen saturation level would remain above 90% but did not indicate the route or amount of oxygen used. Review of the resident's Quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 5/28/24 showed: -The resident had moderately impaired cognition. -It did not indicate the resident was on oxygen. Review of the resident's Physician Order Sheet (POS) dated August 2024 showed an order for oxygen Pro Re Nata (PRN- as needed) via nasal cannula (a device that delivers extra oxygen through a tube into your nose) flow at 2 Liters (L) per minute to keep saturation (measures how much oxygen is in the blood) greater than 90%. Observation on 8/19/24 at 9:51 A.M. showed: -The resident was asleep in his/her bed. -He/She had an oxygen concentrator next to his/her bed, on, and the oxygen tubing was on the floor. Observation on 8/21/24 at 8:59 A.M. showed: -The resident was asleep in his/her bed. -He/She had an oxygen concentrator next to his/her bed, on, and the oxygen tubing was on the floor. Observation on 8/21/24 at 11:36 A.M. showed: -The resident was not in his/her room. -He/She had an oxygen concentrator next to his/her bed, on, and the oxygen tubing was on the floor. Observation on 8/22/24 at 12:54 P.M. showed the oxygen tubing remained on the ground in the same spot as the day before, 8/21/24. During an interview on 8/22/24 at 1:07 P.M. Certified Nursing Assistant (CNA) A said: -Oxygen tubing should be stored in a bag and labeled with the resident's name, room number, and date. -If he/she were to see oxygen tubing laying on the floor, then he/she would get new tubing for the resident. -He/She thought the resident only used his/her oxygen during the night. -The resident was mostly independent with his/her care, so the nursing staff weren't usually on his/her side of the room. -He/she was unaware that the oxygen tubing in the resident's room was on the floor. During an interview on 8/22/24 at 1:56 P.M. Assistant Director of Nursing (ADON) B and the Director of Nursing (DON) said: -Oxygen tubing needed to be stored in a bag. -The bag should be labeled with a date and the initials of the resident. -If either of them were to see oxygen tubing on the floor then they would dispose of it. -The resident very rarely used oxygen. -They expected the CNA's to have noticed that the oxygen tubing was on the floor in the resident's room and get the resident new oxygen tubing. During an interview on 8/22/24 at 2:43 P.M. the MDS Coordinator said: -Oxygen tubing needed to be stored in a bag. -The bag should be labeled with the resident's name and date. -Oxygen tubing should not be stored on the floor. During an interview on 8/23/24 at 9:49 A.M. Licensed Practical Nurse (LPN) B said: -There should be a bag in the resident's room for staff to store the oxygen tubing. -The bag should be labeled with the resident's name and date. -Oxygen tubing was not ever to be stored on the floor. -He/She would have expected the CNA's to have noticed the oxygen tubing on the resident's floor. -He/She expected for the CNAs to tell him/her if the oxygen tubing needed to be replaced, so he/she could provide the resident with new tubing.

Based on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident #8) who had a diagnoses of Post-Traumatic Stress Disorder (PTSD- a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event) received trauma based interventions or developed a care plan that showed interventions for the staff to provide care to protect the resident and prevent trauma from recurring out of 18 sampled residents. The facility census was 84 residents. Review of the facility's policy titled Trauma Informed Care dated May 2024 showed: -The facility ensured that residents who were trauma survivors received culturally competent, trauma-informed care (a framework for relating to and helping people who have experienced negative consequences after exposure to dangerous experiences) in accordance with professional standards of practice and accounting for each resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. -The facility would assist the resident in locating and arranging to attend support groups. -The facility would offer to host support meetings as appropriate. -All facility staff, in all departments involved in resident care would partner with resident/representative to develop a comprehensive, individualized, person-centered care plan related to recognition that healing happens in relationships and meaningful sharing of power and decision-making. -Trauma informed care was an important component of integration to person-centered care through which the staff offer individualized support and services that were responsive to the resident's wishes and goals. -The facility would involve residents and family members as well as staff members and community partners related to trauma informed care through education and opportunities to provide input. -The symptoms of trauma varied greatly. -Upon admission, an initial screening for history of trauma would be completed and would determine if residents had trauma-related symptoms. 1. Review of Resident #8's face sheet showed he/she admitted to the facility with the following diagnoses: -Unspecified Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgement, and impulses). -Major Depressive Disorder (MDD- a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life. -PTSD. -Insomnia (persistent problems falling and staying asleep). -Anxiety Disorder (any group of mental conditions characterized by excessive fear of or apprehension about real or perceived threats. -Borderline Personality Disorder (a personality disorder characterized by severe mood swings, impulsive behavior, and difficulty forming stable personal relationships). Review of a Psychiatric Evaluation dated 6/27/24 completed by Nurse Practitioner (NP) D showed the nursing staff had reported impulsiveness and anxiousness behaviors to NP D. Review of the resident's Admission Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 6/29/24 showed: -The resident had moderately impaired cognition. -The resident had an active diagnosis of PTSD. -The resident had felt down, depressed, or hopeless 12-14 days (nearly every day) during the look back period. -The resident had trouble falling or staying asleep or slept too much 12-14 days during the look back period. -The resident felt tired or had little energy 12-14 days during the look back period. -The resident exhibited no behaviors during the look back period. Review of the resident's care plan dated 7/8/24 showed the resident had no focus or interventions related to his/her diagnosis of PTSD or trauma informed care. Observation on 8/20/24 at 11:15 A.M. showed the resident sitting in the dining room and verbalized he/she was not feeling well that day. Observation on 8/20/24 at 11:47 A.M. of the resident showed: -He/She seemed to be upset by something. -He/She was taking sharp, quick, heavy breaths at the dining table and then left the dining room. Review of the resident's Electronic Medical Record (EMR) on 8/22/24 showed no trauma assessment could be found. Observation on 8/22/24 at 8:23 A.M. showed the resident was angry and worried about not receiving his/her medications yet. During an interview on 8/22/24 at 8:37 A.M. the resident said: -He/She had been upset that morning. -He/She was upset because the staff around him/her were moving too fast. -He/She was also worried because he/she had not received his/her morning medication yet. -He/She had not seen a therapist since admitting to the facility. -He/She did not think the facility had offered him/her therapy. -He/She thought therapy would be beneficial because it would help him/her with fast-talking and worry. -He/She was unsure of anything else that would help him/her with his/her diagnosis of PTSD. During an interview on 8/22/24 at 10:05 A.M. Social Services Designee (SSD) A said: -He/She was unaware of the resident's PTSD diagnosis. -He/She had not completed an initial screening for history of trauma with the resident or the resident's representative. -He/She knew the resident had been seen by NP D and was not sure if NP D had offered or recommended any services. -He/She was unsure of any triggers to the resident's behaviors. -He/She thought he/she would be the staff person most likely to complete the trauma informed care assessments. -The resident should have been offered services related to his/her diagnosis of PTSD. During an interview on 8/22/24 at 10:17 A.M. Family Member A said: -He/She was the resident's health care Durable Power of Attorney (DPOA- a legal document that gives another person the authority to make a medical decision for an individual). -The resident had grown-up in an abusive household. -The resident had been mentally ill for a long time. -The resident was frequently anxious and that was his/her main behavior. -The facility had not discussed any psychiatric services to him/her or the resident. -He/She thought the resident would benefit from seeing a therapist. -He/She was willing to do anything that would bring any peace and happiness to the resident. During an interview on 8/22/24 at 1:03 P.M. Certified Nursing Assistant (CNA) A said: -He/She was unaware of the resident's diagnosis of PTSD. -He/She was unsure if the resident had any triggers related to his/her psychiatric disorders. -He/She was unsure if the resident received any psychiatric services. -He/She was unsure if CNAs had access to residents' care plans. -The CNAs would go over resident behaviors during report. -Services should have been offered to the resident. -He/She was unsure of who would be responsible for setting up the services. During an interview on 8/22/24 at 1:51 P.M. Assistant Director of Nursing (ADON) B and the Director of Nursing (DON) said: -They were both aware of the resident's diagnosis of PTSD. -The DON would not expect the CNAs to know that the resident had PTSD. -The resident only had behaviors related to his/her diagnosis of Dementia and not PTSD. -The resident did not receive any psychiatric services at that point in time. -The resident's family declined therapy services. -The resident's family just dumped the resident at the facility. -Social Services would be the one to offer any services that might be beneficial to the resident. -Social Services would also be responsible for the trauma informed care assessment and any related documentation to the services that were offered. -Per the DON, No one wants to talk about it, it was in her childhood or something. During an interview on 8/22/24 at 2:33 P.M. the MDS Coordinator said: -He/She was aware of the resident's diagnosis of PTSD. -He/She was unsure if the resident had received any services related to his/her diagnosis of PTSD. -The staff would only know about the resident's PTSD diagnosis if they had access to the resident's diagnosis list. -He/She thought the nurses would be responsible for informing care staff about any pertinent diagnoses including PTSD. -A focus on PTSD should be on the resident's care plan. -He/She was unsure of any triggers that the resident had related to his/her PTSD. -He/She was unsure if there was a designated staff person to perform a trauma assessment and assess for any triggers. During an interview on 8/23/24 at 9:45 A.M. Licensed Practical Nurse (LPN) B said: -Any CNAs that cared for the resident should know about his/her diagnosis of PTSD. -He/She thought therapy services should be offered to resident/resident's representative regardless of the resident's dementia diagnosis. -He/She was unsure of who was responsible for completing the trauma assessments. -He/She thought that any services offered to a resident should be documented somewhere in the resident's chart. During an interview on 8/23/24 at 1:09 P.M. the DON said: -The MDS Coordinators and the nurses could update care plans. -Nurses were responsible for initiating care plans upon admission and then the MDS Coordinators were responsible for the care plans afterwards. -He/She expected care plans to be individualized and reflect the residents' current status. -The resident's diagnosis should be on the resident's care plan.

Based on observation, interview and record review, the facility failed to assess residents prior to the use of side rails for three sampled residents (Resident #1, #2 and #3), failed to obtain a physician's order for the use of [REDACTED]#4 and #5) of five sampled residents. Resident #1 was cognitively impaired, assessed to be at risk for falls and required full assistance for bed mobility. The resident was found deceased , with his/her head between the side rail and the low air loss mattress. The facility census was 81 residents. The administrator was notified on [DATE] at 1:27 P.M. of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE], as confirmed by surveyor onsite verification. Record review of the facility document titled Restraints: Bed Rail Safety Check, undated, showed: -The seven areas in the bed system that have a potential for entrapment are: --Within rail; --Under rail, between rail supports or next single rail support; --Between rail and mattress; --Under rail, at ends of rail; --Between split bed rails; --Between end of rail and side edge of head or foot board; and --Between head or foot board and mattress end; -Preventing entrapment: --The bars within the bed rails should be closely spaced to prevent a resident's head from passing through the openings and becoming entrapped; --The mattress to bed rail interface should prevent an individual from falling between the mattress and bed rails and possibly smothering; --Mattresses may shrink over time or after cleaning causing space between the rails and the mattress; --Check for compression of the mattress' outside perimeter. Easily compressed perimeters can increase the gaps between the mattress and the bed rail; --Ensure that the mattress is appropriately sized for the bed frame. Not all beds and mattresses are interchangeable; --The space between the bed rails and the mattress and the headboard and the mattress should be filled by the mattress or by an added firm inlay. This creates an interface with the bed rail that prevents an individual from falling between the mattress and bed rails; --Latches securing bed rails should be stable so that the bed rails will not fall when shaken; --Older bed rails with tapered or winged ends should not be used for residents at risk of entrapment; --Maintenance and monitoring of the bed, mattress, and accessories should be ongoing; --Bed rail safety check determination includes: Within rail - recommendation of less than four and three quarters inch space, under rail, between rail supports or next single rail support - less than four and three quarters space, between rail and mattress - less than four and three quarters space and under rail, at ends of rail less than two and three eights inch and more than a 60 degree angle. Record review of the facility's Bed Safety policy, dated ,[DATE], showed: -To promote a safe and restraint free environment, while acknowledging individual resident needs, the facility allowed the use of approved bedside mobility aides for residents after an evaluation was completed and a health care provider order was obtained. Bedside assist devices should not be used to restrict resident mobility; -The following bedside assist devices may be utilized after a resident evaluation and review by the Interdisciplinary team: Halo safety device, transfer pole, overhead trapeze and assist handle; -Residents utilizing an assist device should have a consent or other state required form completed to confirm risks are fully disclosed; -A health care provider order shall be obtained prior to the implementation of a bed assist device; -Beds and assist devices provided by third party must comply with this policy. 1. Record review of Resident #1's face sheet showed he/she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].>-[MEDICAL CONDITION] (a brain disease that alters brain function or structure); -Muscle weakness; -[MEDICAL CONDITION] and [MEDICAL CONDITION] (muscle weakness or [DIAGNOSES REDACTED] on one side of the body that can affect the arms, legs and facial muscles); -Ataxia (impaired balance or coordination, can be due to damage to brain, nerves, or muscles); -Cerebral infarction (stroke); -Dementia (a group of thinking and social symptoms that interferes with daily functioning, including memory loss and judgment); and -[MEDICAL CONDITION] (longstanding disease of the kidneys leading to [MEDICAL CONDITION]). Record review of the resident's significant change in status Minimum Data Set (MDS- a federally mandated assessment form for use in care planning), dated [DATE], showed: -He/She was severely cognitively impaired; -He/She required extensive assistance of two persons for bed mobility and transfer; and -The bed rail was not used. Record review of the resident's medical record showed the resident did not have physician order or a consent for the use of side rails. Record review of the resident's care plan, dated [DATE], showed: -He/She had memory problems, impaired decision making skills and impaired ability to comprehend; -He/She had impaired communication related to not always able to state needs and he/she did not always understand information; -He/She required extensive assist from staff for activities of daily living (eating, bathing, dressing, toileting and transferring); -He/She required a Hoyer lift (an assistive device that allows resident to be transferred between a bed and a chair by use of hydraulic power) for transfer; -He/She required a broda chair (a chair that provides tilt-in-space positioning and mobility) for mobility and extensive assistance for mobility of the chair; -He/She had potential for falls related to limited mobility, cognitive limitations, the need for assistance, weakness, incontinence, [MEDICAL CONDITION]/[MEDICAL CONDITION] to the right side, and history of falls; -He/She required a fall mat beside bed and the bed in the lowest position; -Place assist device, frequently used items, and call light within easy reach; -The care plan did not contain any information or interventions for the use of side rails for the resident. Record review of the resident's Device Evaluation, dated [DATE], showed: -He/She was evaluated for the use of a unspecified device; -Bed rails were not checked for evaluation. Record review of the resident's Device Evaluation, dated [DATE], showed: -He/She had re-evaluation for continued use of a wheelchair; -Bed rails were not checked for evaluation. Record review of the resident's medical record showed the resident did not have any device evaluations for the use of side rails. During an interview on [DATE] at 3:20 P.M., the DON said the resident did not have a side rail (device) assessment, and he/she was unable to find a physician's order or consent for the device. Observation on [DATE] at 12:25 P.M., of the resident's room showed: -The resident had a Low Air Loss Mattress (LALM - mattress that floats the patient on air-filled cells while circulating air across the skin to reduce moisture and help maintain a constant skin interface pressure); -Bolsters were attached to the left side of bed at the top and the bottom with about a ,[DATE] inch opening in the center for getting in and out of the bed; -The quarter side rail was on the left side of the bed, when looking at the rail from in the bed; -There was about a 6- inch gap on the left side of the bed and about a 4 inch gap between the mattress and the bed rail on the right side. Observation of the resident's bed on [DATE] at 3:15 P.M., showed he/she had a side hoop rail on his/her bed. During an interview on [DATE] at 12:28 P.M., Certified Nurse Assistant (CNA) A said: -He/She was not working on [DATE], the day the resident expired; -The resident's bed normally had bolsters on both sides of his/her bed; -The resident used bolsters on the right side of the bed that were the same as on the left; -The bolsters on the right side must have been removed to make it easier to get the resident out of the bed; -The space between the bed rail and the mattress appeared to be 6 inches on the left side and 4 inches on the right side. During an interview on [DATE] at 1:06 P.M., Licensed Practical Nurse (LPN) A said: -The resident had a gradual decline from his/her medical issues; -He/She was more active before going on hospice (end of life care); -He/She was unable to pull up or reposition himself/herself; -The resident would use the assist device (bed rail) for support when being changed; -It was more reassuring to him/her to have something to hold on to when being rolled over during changes. During an interview on [DATE] at 11:20 [NAME]M., the Director of Nursing (DON) said: -There were no restraints used in the facility; -The facility was 100% free of physical and chemical restraints. During an interview on [DATE] at 11:50 [NAME]M., CNA B said: -He/She was the CNA for the resident; -The resident was pretty immobile; -He/She observed the resident in bed on his/her back on [DATE] about 2:00 P.M.; -He/She had not observed the resident move around in the bed; -He/She would help the resident with bed positioning and sometimes the resident would hold onto the rail; -The resident transferred with a Hoyer lift; -He/She found the resident on the left side of the resident's bed in the resident's room on [DATE] around 3:30 P.M.; -He/She observed the resident's neck between between the mattress and the bed rail; -He/She was real surprised when the resident was found and had not thought the resident could move independently in that way. During an interview on [DATE] at 12:05 P.M., CNA C said: -He/She would have the resident ready in the morning about 6:30 [NAME]M. or 7:00 [NAME]M. each day, brush teeth, brush hair, put in teeth and place glasses on; -He/She would put the resident in bed after breakfast; -The resident was an extensive assist of two persons for transfers; -The resident would kick his/her feet a little, but was unable to move his/her body; -The resident required assistance to move in bed; -The resident was unable to do anything on the left side of his/her body, the resident was able to move only a little on the right; -He/She did not know how the resident had ended up like that; -The resident had been having hallucinations and might have wanted to see his/her husband. During an interview on [DATE] at 12:20 P.M., LPN D said: -CNA B called him/her to the resident room; -The resident was found on the floor on the left side of the bed on [DATE]; -The bed was in the low position, low to the floor because the resident was a fall risk; -He/She said the resident had not fallen since he/she had worked at the facility; -The resident's body was on the floor, the resident's head was between the side rail and the mattress; -The resident had been able to move his/her right hand at the dinner table; -He/She said the resident had been seen moving the right leg; -The resident was not actively dying; -The facility staff assisted the resident up and out of bed for meals; -The resident required a Hoyer lift transfer with extensive assist of two facility staff persons; -He/She thought the resident was having hallucinations. During an interview on [DATE] at 2:00 P.M., the Clinical Director with the hospice agency said the resident was delivered a LALM with perimeter mattress overlay on [DATE] at 8:27 [NAME]M. During an interview on [DATE] at 10:05 [NAME]M., the Director of Facilities said: -He/She did monthly checks for the safety of all facility resident beds; -The form titled, Restraints: Bed Rail Safety Check is used to complete safety checks. The form contains instructions on measurement of spaces between the bed and side rails; -The beds with side rails were to have no more than a four and three quarter-inch gap between the mattress and the side rail; -All of the side rails cannot be more than two and three eighths inch gap between the mattress and the lower portion of the side rail; -The same bed assessment for entrapment was used for residents who are provided a Low Air Loss Mattress; -He/She used an automated tracking calendar that notified him/her when assessments and tasks were due like bed checks since (MONTH) 2019; -The automated tracking calendar that notified him/her is called TELS (Technology Enabled Lifelong Solutions), an electronic building management system, managed by a supply company, that is intended to stream line building management; -He/She could not think of any beds that were an issue for the past three months; -The facility staff was responsible for notification of delivery of a new bed or mattress for facility residents upon arrival. The system did not provide notification; -The resident's bed equipment was not checked. There was no notification of delivery when the durable medical equipment dropped off the mattress and bed. During an interview on [DATE] at 10:30 [NAME]M., LPN D said: -He/She has not had a situation where the durable medical equipment company would bring in a bed or a mattress; -He/She would talk to the manager unless the resident is on hospice and then hospice was responsible to follow the process for durable medical equipment being brought into the facility and inform the manager of the delivery of durable medical equipment. During an interview on [DATE] at 10:45 [NAME]M., LPN F said: -The unit had two LALMs provided by hospice; -If he/she needed a mattress or a bed for a resident, he/she would tell the Assistant Director of Nursing (ADON) or the DON and Central Supply; -He/She did not know if there was any resident required screening to be completed to ensure the bed, mattress and side rails were safe. During an interview on [DATE] at 10:15 [NAME]M., LPN G said: -If a bed or LALM comes into the building, he/she would notify the family and the Durable Power of Attorney; -He/She had not had that happen since he/she has been here; -Central Supply or Maintenance should be notified of the new bed and mattress and the bed would be assessed to ensure the bed, mattress and side rails were safe. During an interview on [DATE] at 11:20 [NAME]M., the DON said: -He/She would not know when a resident was going on a LALM until the durable medical equipment company delivered the mattress; -The staff would notify maintenance and as part of the bed/mattress check side rails would be assessed as well, according to the policy; -It would probably be charted in the notes on the chart; -The Director of Facilities would not necessarily know when a bed or mattress was delivered and if he/she was not notified of the mattress delivery, it would get missed on the TELS check for safety; -He/She said staff were not notified of the resident's side rail, therefore there was no assessment of the rails. During an interview on [DATE] at 11:55 [NAME]M., the Administrator said: -The Director of Facilities had thrown the receipts away for the LALM; -The process to notify the Director of Facilities when durable medical equipment, such as beds and mattresses came into the facility, so that the item can be checked for safety had failed; -The Director of Facilities had no record of the mattress or bed being delivered to the facility; -Staff put the receipt for the new bed in the maintenance mail box, but the maintenance person threw the receipt away; -The resident's bed was not added to the checklist for safety. During an interview on [DATE] at 2:50 P.M., the resident's Physician (Physician A) said: -The physicians' group answering service had sent notification the resident had expired; -He/She was not told the resident was found entrapped in the side rails. Record review of the resident's Medical Examiner's Office Report of Death, dated [DATE], showed: -The resident [DIAGNOSES REDACTED]. -The resident had a recent fall or trauma that could be attributed to his/her cause of death on [DATE]; -The resident had a recent or remote injury which was contributory to his/her death related to a fall; -The injury occurrence had not been determined; -The resident cause of death was to be determined. During an interview with Coroner Investigator A, on [DATE] at 8:01 [NAME]M., he/she said: -The cause of death had not yet been determined; -The determination could take up to six to eight weeks; -He/She observed the resident in bed with the his/her eyes closed on his/her back; -He/She was told in report the resident was found entrapped in the side rail of the bed. 2. Record review of Resident #2's face sheet showed he/she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].>-Muscle weakness; -Dementia; -Anxiety (anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus) -Restless Leg Syndrome; -[MEDICAL CONDITION] (decrease in bone mass and density and enlargement of bone spaces producing fragility); -Abnormal posture; -Low back pain. Record review of the resident's quarterly MDS dated [DATE], showed: -He/She was severely cognitively impaired; -Required extensive assistance of two persons for bed mobility and transfer; -The bed rail was not used. Observation of the resident's bed on [DATE] at 3:15 P.M., showed he/she had a side hoop rail on his/her bed. Record review of the resident's medical record showed: -No device evaluation for the resident prior to [DATE]; -No physician order or a consent for the use of side rails; -The care plan did not contain any information or interventions for the use of side rails for the resident. 3. Record review of Resident #3's face sheet showed he/she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].>-Muscle Weakness; -History of falls; -Dementia; -Anxiety. Record review of the resident's entry tracking record MDS dated [DATE], showed no specific assessment. Observation of the resident's bed on [DATE] at 3:15 P.M., showed he/she had a side hoop rail on his/her bed. Record review of the resident's medical record showed: -No device evaluation for the resident prior to [DATE]; -No physician order or a consent for the use of side rails; -The care plan did not contain any information or interventions for the use of side rails for the resident. 4. Record review of Resident #4's face sheet showed he/she admitted to the facility on [DATE] with [DIAGNOSES REDACTED].>-Muscle Weakness; -Difficulty in Walking; -Lack of Coordination; -Anxiety. Record review of the resident's admission MDS dated [DATE], showed: -He/She was cognitively intact; -Required limited assistance of two persons for bed mobility and transfer; -The bed rail was not used. Observation of the resident's bed on [DATE] at 3:15 P.M., showed he/she had a side hoop rail on his/her bed. Record review of the resident's medical record showed: -He/she was evaluated for the use of side rails on [DATE]; -He/she had no physician order or a consent for the use of side rails; -The care plan did not contain any information or interventions for the use of side rails for the resident. 5. Record review of Resident #5's face sheet showed he/she admitted to the facility on [DATE] with [DIAGNOSES REDACTED].>-Muscle Weakness; -Difficulty Walking; -Cognitive Communication Deficit; -Heart Failure. Record review of the resident's PPS 30 Day assessment MDS dated [DATE], showed: -He/She was mildly cognitively impaired; -Required extensive assistance of two persons for bed mobility and transfer; -The bed rail was not used. Observation of the resident's bed on [DATE] at 3:15 P.M., showed he/she had a side hoop rail on his/her bed. Record review of the resident's medical record showed: -He/she was evaluated for the use of side rails on [DATE]; -He/she had no physician order or a consent for the use of side rails; -The care plan did not contain any information or interventions for the use of side rails for the resident. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level [NAME] Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s). MO 431

Based on observation, interview and record review, the facility failed to assure staff practiced infection control measures when staff failed to wash their hands when caring for a resident with a history of Multi drug Resistant Organism (are bacteria and other microorganisms that have developed resistance to antimicrobial drugs), and was currently being treated for [REDACTED].# 175), when staff did not use personal protective equipment (PPE, equipment worn to minimize exposure to a variety of hazards examples include gloves, gowns, and masks) correctly, and did not use proper handwashing techniques including washing their hands upon entering resident rooms and exiting, when staff replaced the plastic bags for residents' nebulizers, which affected all residents who resided on the A- and C-Wings and potientially affected all residents in the facility, and failed to wash their hands and change gloves during incontinent care, during dressing changes, after administering a nasal medication, when providing a tube feeding for a resident with a J-tube, when staff failed to store residents supplies appropriately which affected three of 18 sampled residents (Residents #41, #9, and # 60). The facility census was 83. Review of the facility's policy on Hand Hygiene revised on (MONTH) (YEAR), showed: - This community considers hand hygiene the primary means to prevent the spread of infection. Wash hands with soap and water for the following situations: When visibly soiled, after contact with a resident with infectious diarrhea including, but not limited to infections caused by norovirius, salmonella, and [DIAGNOSES REDACTED]icile; - Use and alcohol-based hand rub containing at least 60% alcohol: or alternatively, soap and water for the following situations: before and after coming on duty, before and after direct contact with residents, before preparing or handling medications, before applying gloves, before handling clean or soiled dressings, gauze pads, before moving from a contaminated body site to a clean body site during resident care, after handling used dressings, after removing gloves. - Hand hygiene is the final step after removing and disposing of personal protective equipment (PPE) Review of the Center for Disease Control and Prevention (CDC) website (used by the facility staff as guidance) showed: - Respiratory [MEDICAL CONDITION] (RSV) is a common respiratory virus that usually causes mild, cold-like symptoms. - Most people recover in a week or two, but RSV can be serious, especially for infants and older adults. - It is also a significant cause of respiratory illness in older adults. RSV can spread when an infected person coughs or sneezes. You can get infected if you get droplets from the cough or sneeze in your eyes, nose, or mouth, or if you touch a surface that has [MEDICAL CONDITION] on it, like a doorknob, and then touch your face before washing your hands. - In hospitals and long-term care settings: Options for patient placement include single patient rooms, two patient rooms, and multi-bed wards. Of these, single patient rooms are preferred when there is a concern about transmission of an infectious agent. - In long-term and other residential settings, make room placement decisions balancing risks to other patients. - Use PPE appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient 's environment. - Use Droplet Precautions for patients known or suspected to be infected with pathogens transmitted by respiratory droplets that are generated by a patient who is coughing, sneezing, or talking. Review of the facility's policy on Transmission-Based Precautions dated (MONTH) 2019, showed the purpose was to provide guidelines for identification and care of resident's with communicable infections, in the least restrictive means possible. Standard precautions does the following: - Operates under the assumption that every person is potentially infected or colonized with an organism that could be transmitted in the health care setting and apply the following infection control practices. - Are utilized when contact is expected with: blood, all body fluids, non-intact skin, mucous membranes. Associates adhere to the following or situations in which there might be exposure to body fluids, blood, draining wounds, or mucous membranes. - Gloves -worn during procedures or situations in which there is or might be exposure to blood, body fluids, secretions and excretions (except sweat), regardless of whether or not they contain visible blood, draining wounds, or mucous membranes. - Gown- worn during procedures or situations in which there might be exposure to body fluids, blood, draining wounds, or mucous membranes. - Mask and Protective Eyewear- worn during procedures that are likely to generate droplets of body fluids or blood or when the resident is coughing excessively. - Hand Washing- wash hands or use alcohol based hand rub before gloving, after gloves are removed, if visibly soiled, and after resident care activities. - Droplet precautions- indicated for residents infected with microorganisms that are transmitted by droplets and can be generated by the resident during coughing such as the following: Invasive Haemophilius Influenza Type -B Disease including Meningitis, and Pneumonia. Re-usable equipment will be terminally cleaned or disinfected upon removal from the resident's room. Review of the facility's policy on Wound Care /Dressing Change revised on (MONTH) (YEAR), showed the purpose of this procedure is to provide guidelines for dressing changes of wounds in a sterile and non-sterile technique to promote healing. Steps in the procedure for non-sterile technique included: - After removing a dressing staff should pull their gloves over the dressing and discard into appropriate receptacle. - Wash and dry hands thoroughly. - Put on clean gloves and clean the wound using the one swipe method. - One circular motion with each gauze starting at the center and working to outer edge of the wound. - Remove gloves and wash hands and apply clean gloves apply topical agent to wound bed per physician orders. - If needed tape the dressing in place as indicated. - Discard disposable items remove gloves and wash hands. Review of the facility's policy on Respiratory Care-Prevention of Infection, revised on (MONTH) (YEAR), showed: - Purpose: Guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and associates; -Keep the oxygen cannula and tubing used as needed (PRN) in a plastic bag when not in use; -Perform hand hygiene after manipulation. -Documentation includes the date and time the respiratory therapy was performed. Review of the facility's policy on Health Care Providers Orders, revised on (MONTH) (YEAR), showed: - Oxygen Orders: When recording orders for oxygen, specify the rate of flow, route and rationale. Review of the facility's policy on Administering Medications through a small volume handheld nebulizer, revised on (MONTH) (YEAR), showed: - Purpose: to safely and aseptically administer aerosolized particles of medications into the resident's airway; - Review the resident's care plan, current orders, and [DIAGNOSES REDACTED]. - After administering the treatment staff should document the date, time, and length of the treatment; - Including the resident's tolerance of the treatment 1. Observation on 2/25/19, at 9:45 A.M., showed: - The double doors to the A-wing were closed and a sign was posted that directed visitors to see the nurse before entering the unit; - A trash can with a lid was outside the double doors where face masks were being discarded by staff and visitors; - A cart was next to the trash can that contained face masks, hand sanitizer, and a container of disinfecting wipes. During an interview on 2/25/19, at 9:50 A.M., Licensed Practical Nurse (LPN) A said: - The unit remains on quarantine, staff, residents, and visitors are instructed to wear a mask upon entering or exiting the wing; - There are about twenty residents on this unit; - Currently Resident #23 is the only resident that tested positive for RSV; - Resident #23 is on droplet precautions and staff should wear gown, gloves, and mask when entering this resident's room; - In an attempt to maintain and contain, administration decided that the entire wing should be quarantined; - The wing has been on this status for about two weeks; - Each day, Registered Nurse (RN) A, who is also the Infection Control Nurse, obtains a verbal report from the charge nurse, including any new onset of residents presenting with respiratory symptoms; - The criteria for the quarantine to be lifted is the wing must have no residents that present with respiratory symptoms for 72 hours; - This will be very difficult to achieve; - A few staff have also exhibited respiratory symptoms and last week he/she too was sick. Observation on 2/25/19, at 10:10 A.M., showed Certified Nurse Aide (CNA) A on the A wing carrying plastic bags down the hall and he/she did the following: - Entered room A 14, did not wash his/her hands upon entering the resident's room, did not put on clean gloves and picked up Resident #51's nebulizer that was laying on his/her bedside table and placed it in a plastic bag, did not wash his/her hands after touching the nebulizer and exited the resident's room with the plastic bags; - Entered room A 12 with plastic bags that had previously been in room A 14, did not wash his/her hands upon entering the resident's room, did not put on gloves and picked up Resident #14's nebulizer that was laying on his/her bedside table and placed it in a plastic bag, did not wash his/her hands after touching the nebulizer and exited the resident's room without washing his/her hands; - Walked down the hall, removed his/her face mask, did not wash his/her hands after removing the face mask and obtained another face mask from a box in the hall that rested on a railing by the wall and put the face mask on his/her face and entered the storage room; - Exited the storage room with additional plastic bags and re-entered room A 12, did not wash his/her hands upon entering the resident's room, did not put on gloves and picked up Resident #18's nebulizer that was laying on his/her bedside table and placed it in a plastic bag, did not wash his/her hands after touching the nebulizer and exited the resident's room; - CNA A continued down the hall with several plastic bags going room to room, not washing his/her hands upon entering resident rooms and putting on clean gloves before he/she touched the residents' nebulizers with bare hands, placing the nebulizers in plastic bags and not washing his/her hands before exiting the residents' rooms. During an interview on 2/25/19, at 10:30 A.M., CNA A said: - The charge nurse recently instructed him/her to make sure all residents' nebulizers are stored in plastic bags; -Nearly all the residents on the A wing required their nebulizers to be placed into a new plastic bag as most of them were not being stored in plastic bags. Observation on 2/25/19, at 10:40 A.M., showed Certified Nurse Aide (CNA) A and CNA F wearing a face mask on the A wing and they did the following: - CNA A entered room A 10, did not wash his/her hands upon entering the room, did not put on clean gloves, gathered the resident's trash, removed the resident's clothing protector from around his/her neck and exited the room without washing his/her hands; - CNA A entered room A 12, did not wash his/her hands upon entering and assisted Resident #18 with the television remote and handed him/her the call light; did not wash his/her hands before exiting the room; - CNA F entered room A 12, did not wash his/her hands upon entering and straightened Resident #18's bed, touching his/her bedding and pillows, did not wash his/her hands and exited the resident's room; -CNA A entered room A 14, did not wash his/her hands upon entering the room; Resident #14 sat up in his/her wheelchair and CNA A adjusted his/her clothing, straightened his/her room, gathered the trash and exited the room without washing his/her hands. Observation on 2/25/19, at 10:00 A.M., showed: - A med cart in the common area outside the closed door to A-wing with a large trashcan with a lid next to it; - An unidentified CNA came out of A-wing, sat a dining tray on top of the med cart that he/she had carried off the quarantined unit, lifted the lid of the trashcan, removed a face mask and threw it in the trashcan, picked up the tray from the med cart and carried the tray to the kitchen; - Came back into the common area where several residents sat in a circle batting balloons with swimming noodles or their hands; - Picked up a balloon and batted it back to the residents who played the game, then entered the quarantined unit. Review of residents on A wing Interdisciplinary Notes for the month of (MONTH) 2019, showed: -Activity staff charted the resident's hallway quarantined this week due to illness. Observation on 2/27/19 at 11:30 AM of the meal preparation on the kitchen showed: - The Kitchen Manager entered the kitchen wearing full PPE carrying a pan of food, walked to the oven, opened the oven door, placed the pan in the oven and said the food was from C Hall and needed re-heating. - The Kitchen Manager did not remove and dispose of her PPE prior to entering the kitchen and did not wash her hands - The Kitchen Manager left the kitchen and returned ten minutes later, did not wash her hands upon entering the kitchen and retrieved the pan from the oven and left the kitchen. Observation on 2/27/19, at 12:30 P.M., on C-wing, the locked dementia care unit, showed Dietary Staff (DS) A walked down the hall with the Director of Nursing (DON). As they walked, the DON gave instructions regarding infection control standards. DS A wiped off tables in the dining area after residents finished eating, using only a wet rag, which looked like a dish towel. He/she did not have a red bucket used for sanitaizer on the cart. He/she wiped down tables and the seats and backs of the hard chairs. When not using the rag, he/she drapped it over the end of the cart, then placed his/her hands on that end to push the cart off the quarantined unit. Review of the facility's documentation titled Line List Template Reporting to the Local County Health Department, dated 2/27/19, showed: - Five confirmed cases of RSV with known exposure; - One confirmed case of RSV with unknown exposure. - Two cases confirmed on A-wing; - Five cases confirmed on C-wing. During an interview on 2/28/19, at 6:30 A.M., RN A said: -Additional resident's were tested (testing detects the presence RSV in nasal secretions to help diagnose the infection), last evening 2/27/19, and another resident from the A wing tested positive for RSV; -A wing was put on droplet precautions and staff and visitors must wear PPE, to include gowns, gloves, and face masks; -The facility is attempting to identify possible modes of Cross-Contamination (this occurs when bacteria or pathogens are transported from one object to another); -The facility is reviewing the way the dietary cart that contains resident trays is being disinfected after it leaves the unit; -This includes the cleaning carts that Housekeeping staff use. During an interview on 2/28/19, at 10:04 A.M and 4:00 P.M., the Dietary manger said: -She expected staff to remove and dispose all PPE prior to entering the kitchen and staff should wash their hands when they enter the kitchen for food preparation. - Should have been using the red buckets to wipe everything down. Now they are using Clorox wipes. 2. Review of Resident #175's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/22/19, showed: - No cognitive impairment; - Extensive staff assistance with bed mobility, limited assistance with transfer and dressing; - [DIAGNOSES REDACTED]. - Oxygen therapy. Review of the resident's care plan showed dated 2/22/19, showed: - Administer pain medications as indicated and monitor for effectiveness. - Cardiovascular: monitor resident for changes in respiratory pattern such as new or increased shortness of breath, new or increased wheezing, abnormal breath sounds, new or increased difficulty with breathing; - The care plan did not include the oxygen therapy. Review of the Physicians' Order Sheet (POS) dated (MONTH) 2019, showed: - 2/22/19, admit to skilled care for [MEDICAL CONDITION] (a condition in which the body or a region of the body is deprived of adequate oxygen supply at the tissue level) and [MEDICAL CONDITION] exacerbation; - [MEDICATION NAME] 25 micrograms (mcg)/hour (hr) [MEDICATION NAME] (narcotic skin patch is used to treat severe pain) one [MEDICATION NAME] every 72 hours for [DIAGNOSES REDACTED]. - 2/22/19, clean wounds with wound cleanser to both lower extremities and cover with optiform wrap (dressing) with Kerlix and wrap with ace for a [DIAGNOSES REDACTED]. - Oxygen at 2 liters per minute (LPM) per nasal cannula (NC) for a [DIAGNOSES REDACTED]. - 2/25/19, stool culture for [MEDICAL CONDITIONS] ( a germ (bacteria) that can causes life-threatening diarrhea, It is usually a side-effect of taking antibiotics). Review of the nurses' notes dated 2/27/19, at 1:34 P.M., showed: - Remains on antibiotic for pneumonia - Cough with clear/yellow sputum, wheezing present in all lung quadrants. Observation and interview on 2/28/19, at 5:45 A.M., LPN C did and said the following as the resident sat up on the side of his/her bed: - Entered the resident's room, did not wash his/her hands upon entering the resident's room - Carried a cup of pills into the resident's room and informed the resident that he/she planned to administer his/her morning medication and he/she would need to go get his/her [MEDICATION NAME] 25 mcg [MEDICATION NAME] from upstairs as the resident recently admitted from the assisted living; - The resident was actively coughing and his/her cough sounded wet (a wet cough is caused by fluid secretions and mucus found in the lower respiratory tract); - He/she was receiving oxygen via a concentrator that was set a 2 LPM; - Administered the medication in the cup to the resident; - He/she assisted the resident to lay back in the bed, covered him/her up, moved the bedside table next to the bed, turned out the light, informed the resident he/she would be right back with his/her [MEDICATION NAME] 25 mgc [MEDICATION NAME], and exited the resident's room without washing his/her hands; - With dirty hands, opened the medication cart and obtained a vial of medication for a breathing treatment and walked down the hall; - Entered Resident #176's room, did not wash his/her hands and put on clean gloves upon entering picked up the resident's nebulizer with a bare hand that was not stored in a plastic bag and started to pour the contents from the vial into the nebulizer when the resident said I do not want a breathing treatment; - He/she set the nebulizer back down on the night stand and exited the room without washing his/her hands; - Stated he/she would be back as he/she planned to go upstairs and get Resident #175's [MEDICATION NAME]; - He/she returned approximately 10 minutes later with the [MEDICATION NAME] and walked down the hall and entered Resident #175's room; - Did not wash his/her hands upon re-entering the resident's room; - Turned on the light and moved the resident's bedside table away from the side of the bed; - Applied clean gloves and did not wash hands before putting on the gloves; - The resident continued to cough as LPN C removed the old patch and applied the new [MEDICATION NAME]; - Moved the bedside table next to the bed and turned off the resident's light; -Removed his/her gloves, did not wash his/her hands and exited the resident's room with dirty hands; - Walked down the hall to the nurses' station and obtained some papers from the printer; asked another staff member behind the desk to hand him/her the stapler; he/she stapled the papers and returned the stapler to the staff member. During an interview on 2/28/19, at 6:20 A.M. LPN C said: - It is not necessary to wash hands every time you enter and exit a resident's room - It can be done every three residents; - Staff should wash their hands after glove removal. 3. Review of Resident #41's quarterly MDS, dated [DATE], showed: - Moderate cognitive impairment; - Extensive assistance of two staff for activities of daily living (ADLs); - Mechanical soft diet; - Proportion of total calories the resident received through [MEDICATION NAME] or tube feeding 51% or more; - [DIAGNOSES REDACTED]. Review of the resident's care plan updated on 8/10/18, showed: - The resident has chosen to eat an oral diet/liquids despite counsel that this may cause aspiration up to and including premature death by choking; - Provide free water flushes as ordered; - Administer [MEDICAL CONDITION] medication as ordered and monitor for adverse side effects; - The care plan did instruct staff how the resident's medications should be administered per J-tube or orally; - The care plan did not include dressing changes for the resident's J-tube. Review of the resident's POS dated (MONTH) 2019, showed: - 2/14/19, [MEDICATION NAME] (prescription drug used to prevent and reduce nasal inflammation) 50 micrograms (mcg) nasal spray one spray each nostril every day for allergies [REDACTED].>- 2/17/19, 200 centimeter (cc) water every four hours during the day; - 2/18/19, transfer to hospital for J-tube replacement due to occlusion; - 2/18/19, [MEDICATION NAME] (antidepressant) 50 milligrams (mg) per J-tube every day for a [DIAGNOSES REDACTED].>- 2/26/19, (MONTH) use an ounce of regular cola to attempt to dislodge obstructions for a [DIAGNOSES REDACTED]. - 2/26/19, may administer medications orally crushed in pudding or oral liquid; - 2/28/19, 100 cc tap water flush via kangaroo pump three times per day for hydration.; - The POS did not contain dressing orders for the J-tube. Review of the resident's Treatment Administration Record (TAR) dated (MONTH) 2019, showed: - Start date 1/6/19, cleanse around tube site with wound cleanser; - Apply triple antibiotic cream (TAO); - Place gauze change daily and as needed. Review of the resident's nurse's notes dated 2/18/19, at 4:27 P.M., showed: - The resident returned from the hospital; - The nurse was informed that the hospital was unable to dislodge the obstruction; - The resident will need to return to the clinic on 2/19/19, at 1:00 P.M. Review of the resident's nurse's notes dated 2/19/19, at 1:00 P.M., showed: - The resident left the facility at 12:00 P.M., to have his/her feeding tube replaced. Review of the resident's nurse's notes dated 2/19/19, at 4:28 P.M., showed: - Resident returned to the facility with feeding tube intact. During an observation on 2/26/19, at 9:25 A.M., LPN D did and said the following: - Entered the resident's room with a medication cup of crushed medications and a bottle of [MEDICATION NAME] 50 mcg (nasal medication) and informed the resident and Resident #2 (the resident's spouse), that he/she planned to change the dressing to the resident's J-tube, administer his/her medications, and flush his/her J-tube; - Obtained a towel and laid the medication cup and the bottle of [MEDICATION NAME] on the towel on the resident's bedside table; - Washed his/her hands and put on clean gloves; - Administered the resident's nasal medication spraying one squirt in each nostril, then wiped the resident's nose with a Kleenex as liquid was running out of the resident's nose; - Removed his/her right glove, did not wash his/her hands after glove removal; used the dirty hand to obtain a clean glove and put the glove on his/her right hand; - Reported that he/she needed to obtain a new syringe and graduate as the one in the room was dated 2/25/19, and these are to be replaced daily; - He/she removed his/her gloves, did not wash his/her hands and asked the staff in the hall to obtain a new syringe and graduate and he/she put on the clean gloves; - Removed the dressing around the resident's J-tube, did not remove his/her gloves and wash hands after removing the soiled dressing; the gauze contained a small amount of dried pink colored secretions; - With dirty gloves, he/she sprayed gauze with wound cleanser and cleaned around the J-tube at the insertion site; - Did not remove his/her gloves and wash his/her hands before touching the clean dressing supplies and opened a clean gauze dressing; - Did not apply TAO around the J-tube as directed on the POS and applied the clean dressing around the newly inserted J-tube; - With dirty gloves, obtained a piece of retention tape (medical tape that can be used to secure or hold wound dressings) and took it out into the hall; laid the tape directly on top of the medication cart without a barrier; obtained a pen from the medication cart; wrote the date on the tape; returned to the resident's room and secured the gauze dressing with the dated retention tape; - Did not remove his/her gloves and wash his/her hands; - Staff came to the door and handed LPN D the new syringe and graduate and with dirty gloves, he/she laid it down on the towel on the bedside table; - Did not remove his/her gloves and wash his/her hands; - Gathered supplies and folded the wet gauze used to clean around the J-tube inside his/her gloves as he/she removed them, did not wash his/her hands after glove removal; - Staff brought him/her the new graduate and a syringe, and with dirty hands, he/she touched the new syringe and graduate then laid it down on the towel that was on the bedside table; - Washed his/her hands, put on clean gloves and used his/her stethoscope and checked placement of the J-tube; - He/she removed the piston from the syringe, reinserted the syringe into the end of the tube, raised the tube and syringe above the stomach and poured water into the syringe from the graduate; - The water slowly ran into the tube then stopped, he/she used his/her fingers and gently massaged the tubing (a technique to used to unclog tubes) with his/her fingers; , the water did not flow and he/she poured the water from the syringe back into the graduate and said the tube was clogged; - Removed his/her gloves, did not wash his/her hands and gathered supplies on the bedside table including the cup that contained the resident's medications, the bottle of [MEDICATION NAME] and exited the resident's room without washing his/her hands. 4. Review of Resident #9's quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 11/29/18, showed - No cognitive impairment; - Extensive assist of one staff for bed mobility, dressing, and transfers. - [DIAGNOSES REDACTED]. Review of the resident's care plan updated on 11/29/18, showed: - Assistance of one staff with transfers and toileting. Observation on 2/27/19, at 2:55 P.M., showed CNA A assisted the resident in the following manner: - Pushed the resident in his/her wheelchair to the bathroom and assisted the resident to the commode; - CNA B and Licensed Practical Nurse A entered the bathroom and CNA A assisted the resident to stand up from the commode; - CNA A used disposable wipes and cleaned the resident's frontal perineal skin folds as the resident held onto the metal bar next to the toilet - Making one swipe discarding the wipe and with dirty gloves reaching into the package of wipes with dirty gloves to obtain a clean wipe; - CNA A did not remove his/her gloves and wash his/her hands after providing peri care and he/she assisted CNA B with transferring the resident back to his/her wheelchair; - With dirty gloves, CNA A touched the resident's wheelchair as he/she pushed the resident out of the bathroom; - All three staff removed their gloves and washed their hands and exited the resident's room. 5. Review of Resident #60's quarterly MDS dated [DATE], showed - No cognitive impairment; - One Staff supervision with bed mobility and dressing and two staff for transfers; - [DIAGNOSES REDACTED]. Review of the resident's care plan last updated on 2/1/19, showed: - Independent/supervision and set up for transfers assist when unsteady. Observation on 2/27/19, at 3:11 P.M., showed CNA A and CNA B assisted the resident to transfer from his/her recliner to the bed to provide incontinent care and did the following: - Washed their hands and put on clean gloves before transferring the resident; - CNA A handed disposable wipes to CNA B and he/she used disposable wipes and cleansed the resident's front perineal skin folds; - CNA B did not remove his/her gloves and wash his/her hands before he/she touched clean linens and assisted the resident to roll to his/her side; - CNA B wiped the resident's rectal area, did not change or remove his/her gloves or wash his/her hands before he/she touched the tube of moisture barrier cream; - CNA B squeezed the moisture barrier onto his/her glove then applied the cream to the resident's buttock; - CNA B did not remove his/her gloves after applying the moisture cream to the resident's buttock and with dirty gloves assisted the resident to roll onto his/her back as both staff slid a clean brief under the resident; - CNA B repositioned the resident's legs, gathered supplies, and laid the moisture barrier, and disposable wipes on the resident's bed side table with dirty gloves; - Both staff removed their gloves and washed their hands and exited the room. During an interview on 2/27/19, at 3:30 P.M. CNA A and B said: - Staff should wash their hands and change gloves between dirty and clean tasks; - Staff should not touch clean items with dirty hands; - Staff should always wash their hands after glove removal; - Staff should remove gloves and wash their hands after applying barrier creams. 6. Observation on 2/28/19, at 10:45 A.M. of the North hall medication room showed: - Two boxes on the floor that contained over fifty rolls of Kerlix (dressings), ace bandages, two catheter insertion kits, ten urinary catheter drainage bags, one glucometer (a device to monitor blood glucose), and numerous packages of gauze and other dressing supplies, - A plastic bag sitting directly on the floor that contained additional rolls of Kerlix, gauze, and other dressing supplies. During an interview on 2/28/19, at 11:00 A.M. LPN E said: - The floor is considered dirty and items should never be stored on the floor. 7. During an interview on 2/28/19, at 6:30 A.M., RN A said: - Additional residents were tested (testing detects the presence RSV in nasal secretions to help diagnose the infection), last evening 2/27/19, and another resident from the A-wing tested positive for RSV; - A-wing was put on droplet precautions and staff and visitors must wear PPE, to include gowns, gloves, and face masks; - The facility is attempting to identify possible modes of Cross-Contamination (this occurs when bacteria or pathogens are transported from one object to another); - The facility is reviewing the way the dietary cart that contains resident trays is being disinfected after it leaves the unit; - This includes the cleaning carts that Housekeeping staff use. Durin