Every finding on record at Jefferson County Nursing Home

Based on observation, interview, record review, and facility policy review, the facility failed to replace an enteral feeding syringe daily as ordered and care planned for one (1) of four (4) resident reviewed for enteral feedings. Resident #9. Findings Include:Record review of the facility policy Comprehensive Care Plan Policy with an effective date of January 2020 revealed, . [NAME] County Nursing Home shall develop, implement, evaluate, and revise an individualized care plan for every resident .Record review of the Care Plan Report revealed Focus: The resident requires tub feeding per peg tube.Interventions/Task.Change enteral syringe daily on night shift.On 7/27/26 at 11:20 AM, Resident #9 was observed in bed receiving Isosource enteral formula at 50 milliliters per hour. The resident's head of bed was elevated. The enteral syringe was dated 7/26/26 and had not been replaced as ordered and care planned.During an interview on 7/27/26 at 11:28 AM, Licensed Practical Nurse (LPN) #1 observed the syringe and confirmed it was dated 7/26/26 and had not been replaced. LPN #1 stated the night-shift nurse should have replaced the syringe with a new one. LPN #1 stated the syringe was changed daily to reduce the resident's risk of infection. LPN # 1 acknowledged she should have identified the outdated syringe during her morning rounds. LPN #1 stated that if the night-shift nurse failed to replace the syringe, it became her responsibility to replace it.During an interview on 7/29/26 at 1:54 PM, the Director of Nursing (DON) confirmed the enteral syringe should have been changed during the midnight shift. The DON stated the syringe required daily replacement to reduce the possibility of infection. The DON stated the day-shift nurse should check the enteral feeding equipment during the first morning round to ensure the syringe was properly dated and changed. The Director of Nursing stated she expected all staff to follow the resident's physician orders, care plan, and facility procedures to ensure resident safety.During an interview on 7/29/26 at 2:10 PM, the Minimum Data Set (MDS) and Care Plan Nurse stated the comprehensive care plan directed staff regarding each resident's individualized care needs. The Care Plan Nurse confirmed nursing staff failed to follow Resident #9's care plan when they did not replace the enteral syringe daily. The Care Plan Nurse stated she expected staff to follow residents' comprehensive care plans while providing care.A record review of Resident #9's admission Record revealed the resident was admitted on [DATE] with diagnoses that included Dysphagia and Alzheimer's disease.A record review of Resident #9's Minimum Data Set assessment (MDS), with an Assessment Reference Date (ARD) of 6/3/26, revealed the resident was severely cognitively impaired.A record review of Resident #9's Order Summary Report revealed orders dated 4/21/26 for Isosource 1.5 enteral formula at 50 milliliters per hour with a 200-milliliter water flush every four hours. The orders directed staff to change the enteral syringe daily and to label the formula container, syringe, and administration set with the resident's name, date, time, and nurse's initials.

Based on observation, interview, record review, and policy review, the facility failed to ensure a resident with a feeding tube received appropriate treatment and services, as evidenced by failure to replace an enteral feeding syringe daily as ordered for one (1) of four (4) residents reviewed for enteral feeding. Resident #9.Findings Include:A record review of the facility policy, Policy and Procedure: Percutaneous Endoscopic Gastrostomy (PEG) and Gastrostomy Management with a review date of January 2026 revealed, .To establish standardized procedure for the safe care, effective and individualized eternal nutrition therapy for residents requiring PEG or Gastrostomy (G)-tubes .During an observation on 7/27/26 at 11:20 AM, Resident #9 was observed in bed receiving Isosource enteral formula at 50 milliliters per hour. The resident's head of bed was elevated. The enteral syringe was dated 7/26/26 and had not been replaced as ordered.During an interview on 7/27/26 at 11:28 AM, Licensed Practical Nurse (LPN) #1 observed the syringe and confirmed it was dated 7/26/26 and had not been replaced. LPN #1 stated the night-shift nurse should have replaced the syringe with a new one. LPN #1 stated the syringe was changed daily to reduce the resident's risk of infection. LPN # 1 acknowledged she should have identified the outdated syringe during her morning rounds. LPN #1 stated that if the night-shift nurse failed to replace the syringe, it became her responsibility to replace it.During an interview on 7/29/26 at 1:54 PM, the Director of Nursing (DON) confirmed the enteral syringe should have been changed during the midnight shift. The DON stated the syringe required daily replacement to reduce the possibility of infection. The DON stated the day-shift nurse should check the enteral feeding equipment during the first morning round to ensure the syringe was properly dated and changed. The Director of Nursing stated she expected all staff to follow the resident's physician orders, care plan, and facility procedures to ensure resident safety.A review of Resident #9's admission Record revealed the resident was admitted on [DATE] with diagnoses that included Dysphagia and Alzheimer's disease.A review of Resident #9's Minimum Data Set assessment (MDS) with an Assessment Reference Date (ARD) of 6/3/26, revealed the resident was severely cognitively impaired.A review of Resident #9's Order Summary Report revealed orders dated 4/21/26 for Isosource 1.5 enteral formula at 50 milliliters per hour with a 200-milliliter water flush every four hours. The orders directed staff to change the enteral syringe daily and to label the formula container, syringe, and administration set with the resident's name, date, time, and nurse's initials.

Based on observation interview, facility policy review, and record review, the facility failed to follow infection prevention guidelines for one (1) of one (1) residents observed for catheter care. Resident # 4Findings include :A record review of facility policy titled Catheter Care for Male Policy, undated revealed, It is the policy of this facility to provide catheter care to prevent infection of the resident's urinary tract .A record review of facility policy titled Infection Prevention and Control Program revealed, This facility has developed and maintains an infection prevention and control program that provides a safe, sanitary, and comfortable environment to help prevent the development and transmission of infection .A review of the facility policy titled Hand Hygiene Policy reviewed 2/2017 revealed, Policy: Staff involved in direct resident contact will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors .3. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to the attached hand hygiene table . Condition: After handling contaminated objects . Before and after handling clean or soiled dressings, linens, etc. After handling items potentially contaminated with blood, body fluids, secretions, or excretions, after assistance with personal body functions (e.g., elimination, hair grooming, smoking) .During an observation on 7/29/26 at 1:41 PM, Resident #4 was observed receiving urinary catheter care from Registered Nurse (RN) #1. RN #1 cleaned the catheter using three soap-soaked gauze pads, rinsed the area using three water-soaked gauze pads, and dried the area with a washcloth. RN #1 did not remove her gloves or perform hand hygiene during or after the procedure. While wearing the same soiled gloves used to handle the catheter, RN #1 pulled up the resident's bed covers, touched the bed remote control, and adjusted the bed's height.During an interview on 7/29/26 at 1:44 PM, RN #1 acknowledged she should have removed her gloves and performed hand hygiene before transitioning from the wet gauze to the washcloth used to dry the resident. RN #1 stated this was necessary to prevent cross-contamination. RN #1 further acknowledged that touching the catheter area and then touching the resident's bed remote control with the same gloves could have caused cross-contamination. RN #1 confirmed that failing to change gloves, failing to perform hand hygiene, and touching clean items with soiled gloves increased the risk of spreading infection within the facility.During an interview on 7/30/26 at 9:35 AM, the Director of Nursing (DON) stated the facility's catheter care policy did not specifically direct staff to change gloves at a particular point during the procedure. However, the facility's infection prevention policy directed staff to prevent cross-contamination by removing soiled gloves before touching clean objects, including the resident's bed linens and bed remote control. The DON stated she expected staff to follow the facility's infection prevention policies when providing catheter care.During an interview on 7/30/26 at 9:42 AM, the Infection Control Nurse stated that wearing soiled gloves and touching objects in a resident's room increased the risk of spreading organisms from the catheter area to other surfaces through cross-contamination. The Infection Control Nurse stated the treatment nurse had called in on 7/29/26, which required RN #1, the charge nurse, to perform care usually completed by the treatment nurse. The Infection Control Nurse stated all licensed nursing staff had demonstrated competency in the procedure and were capable of performing the care. The Infection Control Nurse stated she expected staff to follow infection prevention policies to prevent the transmission of infection to residents.A review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/1/26 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 5 which indicated severe mental impairment. A review of the admission Record revealed the resident was admitted on [DATE] with diagnoses that included unspecified dementia, unspecified severity, without behavioral disturbance psychotic disturbance, mood disturbance and anxiety.

Based on interviews, record reviews, and facility policy review, the facility failed to complete a significant change assessment and submit a required Level II Preadmission Screening and Resident Review (PASRR) for one (1) of two (2) residents reviewed for PASRR (Resident #16). Specifically, the facility failed to submit a PASRR Level II and complete a significant change assessment after Resident #16 was diagnosed with major mental illness, including bipolar disorder and Major Depressive Disorder, Recurrent, Severe with Psychotic Symptoms. Findings Include: A review of the facility's Pre-admission Screen policy revealed: Preadmission Screening and Resident Review (PASRR) aims to ensure individuals are not inappropriately placed in nursing homes for long-term care and to provide them with the services they need in those settings . A record review of Resident #16's Pre-admission Screen (PAS), dated 7/25/11, revealed no major mental illness at the time of screening. A record review of Resident #16's record revealed that a Level II PASRR was submitted on 4/1/22 related to an intellectual developmental disability. A record review of Resident #16's admission Record revealed an admission date of 8/9/2011, with new diagnoses of bipolar disorder and Major Depressive Disorder, Recurrent, Severe with Psychotic Symptoms with an onset date of 7/17/23. Further record review of Resident #16's clinical record revealed that a Level II PASRR was not submitted in response to the new diagnoses of major mental illness, and a significant change assessment was not completed as required. On 05/13/25 at 9:42 AM, during an interview, Registered Nurse (RN) #1, charge nurse, confirmed that a significant change assessment was not completed for Resident #16 following the new diagnoses of bipolar disorder and Major Depressive Disorder, Recurrent, Severe with Psychotic Symptoms. She acknowledged that it should have been done. On 05/13/25 at 3:43 PM, during an interview, the Social Services staff member stated that Resident #16 had the above mental health diagnoses and acknowledged that a significant change should have been completed at that time. She stated that completing a significant change ensures the resident receives the appropriate services and that staff are informed of the resident's needs. A record review of Resident #16's Minimum Data Set (MDS) with Assessment Reference Date (ARD) 4/10/25 revealed the resident was severely cognitively impaired.

Based on interviews, record reviews, and facility policy review, the facility failed to implement the comprehensive care plan as developed for one (1) of two (2) residents reviewed for skin conditions (Resident #34). Specifically, the facility failed to carry out weekly skin evaluations as required by the resident 's care plan and physician orders. Findings include: A record review of the facility's Comprehensive Care Plan policy with a revision date of 1/2025 revealed: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and time frames to meet a resident's medical, nursing . A record review of Resident #34's Comprehensive Care Plan initiated 4/22/25 revealed skin impairment related to moisture-acquired skin damage to the buttocks. The care plan directed staff to Monitor and Document weekly. A record review of Resident #34's weekly skin evaluations revealed they were not completed during April 2025. A record review of Resident #34's electronic Treatment Administration Record (eTAR) revealed: Weekly skin assessments every Wednesday date initiated 10/1/24. Wednesday 4/16/25 was not initialed as completed. In an interview with the Director of Nursing (DON) on 5/13/25 at 4:03 PM, she stated that weekly skin evaluations should be completed and documented weekly. She stated the purpose of the skin evaluation is to help staff identify any new breakdowns and to evaluate and treat skin accordingly. She confirmed that Registered Nurse (RN) #1 did not follow the care plan. On 05/14/25 at 3:09 PM, during an interview, RN #1 (Charge Nurse) acknowledged it was her responsibility to complete the weekly skin evaluations and stated she did not follow the care plan. On 5/14/25 at 1:05 PM, in an interview, RN #2, the facility's Minimum Data Set (MDS) Nurse, stated the care plan is created to guide staff in delivering care. She confirmed RN #1 did not follow the care plan related to weekly skin evaluations. She stated Resident #34 cannot receive quality care if the care plan is not followed. A record review of Resident #34's Minimum Data Set (MDS) with Assessment Reference Date (ARD) 2/28/25 revealed the resident was severely cognitively impaired. A record review of Resident #34's weekly skin evaluation dated 5/7/25 noted moisture-associated skin damage to the buttocks, further supporting the need for ongoing evaluation and documentation as outlined in the care plan. A record review of Resident #34's admission Record revealed an admission date of 3/16/22 with diagnoses including non-pressure chronic ulcer of other part of left foot with unspecified severity and atherosclerosis of native arteries of other extremities with ulceration.

Based on interviews, record reviews, and facility policy reviews, the facility failed to ensure that care and services were provided in accordance with professional standards of practice for one (1) of two (2) residents reviewed for skin conditions (Resident #34). Specifically, the facility failed to ensure that weekly skin assessments were completed and documented as ordered by the physician and in accordance with facility policy, resulting in a lack of monitoring for skin breakdown. Findings include: A record review of the facility's Skin Assessment policy dated 1/2025 revealed: It is our policy to perform a full body skin assessment as part of our systemic approach to pressure injury, prevention and management. The policy includes the following procedural guidelines .: A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission, re-admission, and weekly thereafter. A record review of Resident #34's weekly skin evaluations revealed that they were not completed during April 2025. A record review of Resident #34's weekly skin evaluation dated 5/7/25 revealed moisture-associated skin damage to the buttocks. A record review of the Weekly Skin Report dated 4/25/25 revealed Resident #34 was not listed as having a buttocks abrasion; however, it was listed on the 5/2/25 report. On 5/13/25 at 4:03 PM, in an interview with the Director of Nursing (DON), she stated the weekly skin evaluations should be completed and documented weekly. She stated she expects staff to perform and document them consistently. She explained that the purpose of the skin evaluations is for staff to identify any new skin breakdown and to evaluate and treat the skin accordingly. She stated that Registered Nurse (RN) #1 told her that she had completed the evaluations on a scratch sheet but forgot to enter them into the computer and could no longer locate the notes. The DON stated that if there is no documentation, it indicates the task was not completed. On 5/14/25 at 11:00 AM, an observation of wound care and a weekly skin evaluation was conducted by RN #1. Care was provided within standards of practice. During the skin evaluation, RN #1 assessed the buttocks area, which revealed four areas of healed pink skin and one open area. There were no signs of infection or drainage noted. On 5/14/25 at 3:09 PM, in an interview, RN #1 (Charge Nurse) stated it is her responsibility to complete the weekly skin evaluations. She stated she typically writes the results on the back of the report and enters them into the computer afterward. She acknowledged that the purpose of the evaluations is to identify any skin conditions, wound progression, or deterioration. She confirmed that although she performed the evaluations, she failed to enter them into the computer. A record review of Resident #34's Electronic Treatment Record (ETAR) revealed: Weekly skin assessments every Wednesday and cleanse moisture acquired skin damage to buttocks with normal saline, pat dry, apply calazine cream, apply nonadherent gauze and cover with bordered gauze twice daily. This review revealed that care for the open area on the buttocks was initiated on 4/21/25. A record review of Resident #34's Progress Notes dated 4/21/25 revealed: Cleanse open area to buttocks with normal saline, pat dry, apply calazine cream, apply nonadherent gauze and cover with bordered gauze twice daily and as needed until healed. A record review of Resident #34's Minimum Data Set (MDS) with Assessment Reference Date (ARD) 2/28/25 revealed the resident was severely cognitively impaired. A record review of Resident #34's admission Record revealed an admission date of 3/16/22, with diagnoses including non-pressure chronic ulcer of other part of left foot with unspecified severity and atherosclerosis of native arteries of other extremities with ulceration.

Based on observation, interviews, record reviews, and facility policy reviews, the facility failed to ensure incontinent residents received appropriate care and services to prevent the possibility of a urinary tract infection for one (1) of two (2) residents observed for incontinent care (Resident #8). Specifically, the facility failed to provide timely incontinence care and maintain cleanliness, which placed the resident at risk for skin breakdown and urinary tract infection. Findings Include: A record review of the facility's Perineal Care policy with a revision date of 1/2025 revealed: It is the practice of this facility to provide perineal care to all incontinent residents during routine bath and as needed in order to promote cleanliness and comfort, prevent infection to the extent possible and to prevent and assess for skin breakdown . On 05/13/25 at 3:15 PM, an observation of peri-care being performed by Certified Nursing Assistant (CNA) #1, assisted by CNA #2, revealed CNA #1 removed Resident #8's brief, which was heavily soiled with amber-colored urine and emitted a strong urine odor. The resident's wheelchair and pants were also soaked in urine. On 05/13/25 at 3:32 PM, in an interview, CNA #1 confirmed the brief was heavily soiled with amber-colored urine. She confirmed the resident 's chair and pants were also heavily soiled. She stated she was assisting CNA #2 and did not know when the resident was last checked or changed. On 05/13/25 at 3:36 PM, CNA #2 confirmed in an interview that the chair, pants, and brief were heavily soiled with urine. She stated she changed Resident #8 around 10:30 AM, right before lunch. CNA #2 acknowledged she was supposed to check the resident every two hours but had not done so because she was busy. She confirmed that the resident had not received peri-care for over four and a half hours. CNA #2 stated she is expected to provide peri-care every two hours. She acknowledged the resident could develop a urinary tract infection and skin infection from the delay in care. On 05/14/25 at 11:50 AM, the Director of Nursing (DON) stated in an interview that Resident #8 should be checked and changed every two hours if soiled. She further stated that if a resident is a heavier wetter, they should be checked every hour. She confirmed that her expectation of CNAs is to check and change residents every two hours to ensure they remain dry and clean. The DON acknowledged that residents left soiled for extended periods are at risk for skin breakdown and skin infections. A record review of Resident #8's admission Record revealed an original admission date of 08/22/06, with diagnoses including acute kidney failure and mild intellectual disabilities. A record review of the Minimum Data Set (MDS) for Resident #8, conducted 3/20/25, revealed a Brief Interview for Mental Status (BIMS) score of 3, indicating the resident was severely cognitively impaired and reliant on staff for care.

Based on observation, staff interview, record review and service manual review the facility failed to assess residents for the risk of entrapment, obtain informed consent, and conduct routine preventative maintenance per the manufacturer's recommendations/specifications for bed rails for five (5) of fourteen (14) sampled residents. (Resident #4, #6, #28, #29 and #39) Findings Include: Observations of resident rooms on 1/23/24 from 10:00 AM to 12:17 PM, revealed Residents #4, #6, #28, #29, and #39 had beds that were the brand name of Basic American Matrix 709 Matrix II and had bilateral quarter (1/4) length bed rails. Review of the medical record for Residents #4, #6, #28, #29 and #39 revealed there were no resident entrapment risk assessments and no signed informed consent forms for the use of the bed rails. Record review of the Service Manual for Basic American's Matrix 709 Series, dated 2011, revealed, . When assessing the risk for entrapment, you need to consider your bed, mattress, head and footboards, half rails, assist bars, and other accessories for an entire system A resident/patient's condition could lead to resident patient entrapment. It is extremely important to review the resident patient's physical and mental condition . address any entrapment risk .Recommended Maintenance & Inspection Schedules .Mechanical inspection of assemblies (6 months) .Inspect all fasteners for wear and looseness . During an interview on 01/24/24 at 11:36 AM, with the Director of Nursing (DON), she confirmed there were side rails on most of the beds in the facility. She stated they were not used as a restraint, and there were no consents signed by the resident or the resident representative (RR) for the use of bedrails. During an interview on 01/24/24 at 2:03 PM, with Maintenance Director #1, he stated that he checked bed rails if someone complained about them. He confirmed there was no maintenance schedule to check the bed rails periodically. An interview on 01/25/24 at 11:36 AM, with the Administrator, revealed bed rails were used in the facility and there was no maintenance plan regarding checking the bed rails. Resident #4 Record review of the Face Sheet revealed the facility admitted Resident #4 on 4/26/22 and had current medical diagnoses including Atherosclerotic Heart Disease and Hypertension. Record Review of the Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/21/23 revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 11 which indicated her cognition was moderately impaired. Resident #6 Record review of the Face Sheet revealed the facility admitted Resident #6 on 07/08/05 and had current medical diagnoses including Osteoarthritis. Record review of the Admission MDS, with an ARD of 12/12/23, revealed Resident #6 required a staff interview to assess cognition and her cognition skill for daily decision making was severely impaired. Resident #28 Record review of the Face Sheet revealed the facility admitted Resident #28 on 08/28/23 and he had current medical diagnoses including Type 2 Diabetes Mellitus, Hypertension, and Peripheral Vascular Disease. Record review of the Quarterly MDS with an ARD of 11/28/23 revealed Resident #28 had a BIMS score of 6 which indicated his cognition was severely impaired. Resident #29 Record review of the Face Sheet revealed the facility admitted Resident #29 on 10/25/22 and had current medical diagnoses including Type 2 Diabetes Mellitus. Record review of the Annual MDS with an ARD of 10/20/23, revealed Resident #29 had a BIMS score of 14 which indicated he was cognitively intact. Resident #39 A record review of the Face Sheet revealed the facility admitted Resident #39 on 8/11/23 with current medical diagnoses including Hemiplegia following Cerebral Infarction affecting left dominant side. Record review of the Quarterly MDS with an ARD of 11/14/23 revealed Resident #39 had a BIMS score of 14 which indicated he was cognitively intact.

Based on observation, interviews, record review, and facility policy review, the facility failed to protect a resident's right to be free from misappropriation of property and exploitation for one (1) of fourteen (14) sampled residents. Resident #40 Findings include: Review of the facility's policy titled, Abuse, Neglect and Exploitation, with a revision date of 4/17, revealed, Policy: Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation .Residents must not be subject to abuse by anyone, including, but not limited to; facility staff, other residents .Policy Explanation and Compliance Guidelines .9. Exploitation means taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats, or coercion . A review of the facility's Vulnerable Adult Act, undated, revealed, .Any nursing home resident is considered to be a vulnerable adult .the following situation are considered CRIME OF ABUSE against vulnerable adults .theft or misuse of a resident's personal belongings, personal funds, or bank accounts . A record review of the Reportable Incident Form dated 12/18/23, revealed the Director of Nursing (DON) began an investigation because Resident #40 reported that she had several incidents where she had given staff members money or allowed them to use her debit card. Resident #40 stated that she helped Certified Nurse Aide (CNA) #2 because she had three small children. The resident stated that she gave them money of her own free will. The resident stated that she sent CNA #3 to a local sandwich shop to get her something and she allowed her to buy something for herself. Both CNAs denied taking money from the resident and both CNAs were placed on suspension pending the completion of the investigation. The facility held a Quality Assurance and Performance Improvement (QAPI) meeting to discuss the allegation and the recommendation was to continue the investigation. In-services of the Abuse and Neglect Policy were initiated for staff. A record review of the Face Sheet revealed the facility admitted Resident #40 on 8/12/23 and she had current medical diagnoses including Right Heart Failure and Morbid Obesity. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/14/2023, revealed Resident #40 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated she was cognitively intact. On 1/23/24 at 10:46 AM, in an observation and interview with Resident #40, she reported that CNA #2 frequently entered her room while on the phone with her boyfriend and she would overhear her complaining to him about needing money to care for her two children and the one she was presently pregnant with. The resident expressed that she understood what it is like to raise children independently while struggling financially, so she volunteered to assist CNA #2 by sending her some money via Cash App (a mobile payment service). She stated that CNA #2 provided her Cash App username, and she gave her $75.00. An observation of the information on Resident #40's cell phone revealed a Cash app transaction for $75 to CNA #2 on 9/25/23 at 11:51 AM. The resident stated that the CNA returned to her room again after the baby was born, and they began to talk about her baby. She stated that during the chat, CNA #2 mentioned that she had nothing for her newborn baby and so she ordered CNA #2 a $50 (Proper Name) online retail gift card, so she could buy some things for her baby. She stated that the card was mailed to the facility, and when it arrived, she gave it to CNA #2. An observation of the resident's (Proper Name) of online retailer account on her cell phone revealed a transaction, dated 11/28/23 for $50.00. The resident also stated that she told the DON about the gifts, but it was not to get anyone in trouble; however, she knew that CNA #2 got suspended for a few days. Resident #40 stated that when CNA #2 returned to work, she came into her room and gave her home address to Resident #40, indicating that she should send all future purchases for the baby to her home address rather than to the facility. An observation of Resident #40's Notes application on her cell phone revealed a mailing address had been entered on 12/17/23. Resident #40 stated that she would also allow CNA #3 to use her bank card to purchase herself (Resident #40) and CNA #3 food. An observation of electronic transactions on Resident #40's cell phone revealed transactions on 12/3/23 for $18.33 to (Proper Name) of sandwich shop and $10.87 to (Proper Name) of a liquor store which she stated was purchased with her card by CNA #3. The resident stated that she did not drink or smoke and indicated that the transaction for the liquor store was for CNA #3. In addition, the resident stated that she provided CNA #3 with her bank card for gas for her car on 11/27/23. An observation of the transaction on Resident #40's cell phone revealed a transaction for $26.02 (Proper Name) of local convenience store and was dated 11/28/23. The resident pointed out that the transaction occurred on 11/27/23 but did not post to her account until 11/28/23. CNA #3 On 1/24/24 at 1:51 PM, in a phone interview with Certified Nursing Assistant #3 (CNA), she claimed that 12/3/23 Resident #40 asked her to pick up lunch from (Proper Name) of sandwich shop. CNA #3 agreed to go but declined to get lunch for herself. She stated that she went out multiple times for Resident #40 and used the resident's bank card to buy food for her because she did not think it was a problem. CNA #3 denied using the resident's card at the convenience and the liquor store. CNA #3 verified that she understood the meaning of exploitation and vulnerable adults, but she disputed that using the resident's card to buy the resident something did not resemble exploitation. She stated she was suspended pending a facility investigation. However, following the investigation, she stated that she was asked to come back to work but was unable to do so due to her child's illness. A record review of the Time/Attendance Detail report revealed CNA #3 clocked in on 11/27/23 at 2:57 PM and clocked out 7:37 PM. She clocked back in at 8:01 PM and clocked out at 10:30 PM. On 12/3/23, CNA #3 clocked in at 2:57 PM and out at 7:41 PM, and clocked in at 8:04 PM and out at 10:21 PM A record review of the Transaction Details for Resident #40's prepaid banking card revealed a transaction dated 11/28/23 at 7:49 AM for $26.02 to (Proper Name) of local convenience store. A record review of the banking transactions on 12/3/23 for Resident #40 revealed a transaction for $10.87 for (Proper Name) liquor store and $18.33 for (Proper Name) sandwich shop. A record review of the Vulnerable Adult Act document revealed CNA #3 was trained by the facility regarding the vulnerable adult act on 2/12/2016. CNA #2 On 1/24/24 at 2:26 PM, in a phone interview with CNA #2, she acknowledged that she was suspended from her position as a CNA because she received $75.00 via cash app from Resident #40 on 9/25/23. She stated that it all began when she entered the resident's room to provide care. She stated that after the resident saw she was pregnant, she asked if she could buy something for the baby. CNA #2 stated that she told the resident she did not want her to do so, but the resident insisted and sent the money away. CNA #2 stated that it slipped her mind to notify the Administrator that she had received the money. CNA #2 acknowledged that she did not return the money to Resident #40. CNA #2 denied that Resident #40 had given her a $50.00 (Proper Name) online retail gift card. She was unable to explain how Resident #40 had her home address. CNA #2 confirmed that she returned to work after the facility's investigation was completed and she currently worked the 3 PM to 11 PM shift. A record review of the Time/Attendance Detail report revealed CNA #2 clocked in on 11/28/23 at 3:18 PM and clocked out 8:52 PM. She clocked back in at 9:06 PM and clocked out at 11:36 PM. On 12/17/23, CNA #3 clocked in at 3:05 PM and out at 11:33 PM. A record review of the Cash App screenshot on Resident #40's cell phone revealed a payment of $75 on 9/25 (2023) at 11:51 AM to CNA #2's Username. A record review of the Order Details dated 11/28/23, revealed a transaction for $50 for a gift from an online retailer with the Purchase Details indicating the gift card was from Resident #40 with a Message of Hope you enjoy this gift card! A record review of the Notes application screenshot on Resident #40's phone revealed a note dated 12/17/23 at 4:39 PM of a home address. A record review of the Application for Employment for CNA #2, dated 3/31/23, revealed the home address indicated on the application matched the home address that was entered in the Notes application of Resident #40's cell phone. A record review of the Vulnerable Adult Act document revealed CNA #2 was trained by the facility regarding the vulnerable adult act on 4/18/2023. In an interview on 1/25/24 at 8:20 AM, with the Administrator, she confirmed knowledge of the incident involving CNA #2, CNA #3, and Resident #40. She revealed that she did not believe that Resident #40 was exploited by the CNAs based on her understanding of the company policies and because Resident #40 had a high BIMS score. The Administrator explained that the previous Director of Nursing (DON) wrote the entire investigation, and she was not involved in the initial investigation because she had been out of the building for three (3) days. Upon her return to the facility, she said she and the DON consulted with their Board Attorney and all agreed that the resident was of sound mind with a high BIMS score and that she was not exploited. As a result, she could not substantiate the complaint and approved CNA #2 and CNA #3 to return to work after their 3-day suspension. She explained CNA #2 returned to work, however CNA #3 elected not to return to work.

Based on staff interview, record review, and facility policy review, the facility failed to provide appropriate corrective action to prevent further potential misappropriation and exploitation by allowing a Certified Nurse Aide (CNA #2) access to a previous victim (Resident #40) for one (1) of 14 sampled residents. Findings include: Review of the facility's policy, Abuse, Neglect and Exploitation, with a revision date of 4/2017, revealed, Policy: Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation .The facility must .8. Resident Protection after Alleged Abuse, Neglect and Exploitation-The facility will make efforts to protect all residents after alleged abuse, neglect and/or exploitation . A record review of the Reportable Incident Form dated 12/18/23, revealed the Director of Nursing (DON) began an investigation because Resident #40 reported that she had several incidents where she had given staff members money or allowed them to use her debit card. Resident #40 stated that she helped CNA #2 because she had three small children. The resident stated that she gave the money of her own free will. CNA #2 was placed on suspension pending the completion of the investigation. During an interview on 1/23/24 at 10:46 AM, with Resident #40, she stated that she had told the DON about money and gifts she was providing to CNA #2, but it was not to get anyone in trouble. However, she knew that CNA #2 got suspended for a few days. Resident #40 said that when CNA #2 returned to work, she came into her room and gave her home address, indicating that she may send all future purchases for the baby to her home address rather than the facility. On 1/24/24 at 2:26 PM, in a phone interview with CNA #2, she confirmed that she was suspended from her position as a CNA during the investigation related to Resident #40, and she returned to work after the investigation was completed. CNA #2 verified that she currently worked at the facility on the 3 PM to 11 PM shift. On 1/25/24 at 8:20 AM, in an interview with the Administrator, she confirmed knowledge of the incident related to CNA #2. She stated that Resident #40 was not exploited based on her understanding of their company policies and Resident #40's high BIMS score. She advised that the previous DON wrote the entire investigation because she had been out sick. When she returned, she consulted with the facility's Board Attorney and all agreed that the resident was of sound mind with a high BIMS score and was not a victim of exploitation. As a result, she could not substantiate the complaint and approved CNA #2 to return to work after the 3-day suspension. The Administrator added that as part of their correction plan, the CNA #2 was reassigned to another hall in the facility which was located away from the resident. The Administrator stated that although CNA #2 was reassigned, she could not guarantee that CNA #2 would not walk over to the resident's room. A record review of the Face Sheet revealed the facility admitted Resident #40 on 8/12/23 and she had current medical diagnoses including Right Heart Failure and Morbid obesity. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/14/2023, revealed Resident #40 had a BIMS score of 13 which indicated she was cognitively intact.

Based on record review and staff interviews, the facility failed to accurately complete the Minimum Data Set (MDS) reflecting anticoagulant medications for four (4) residents of twelve (12) sampled residents whose MDS Assessments were reviewed for accuracy. (Resident #1, Resident #10, Resident #20, Resident #36). Findings include: A record review of the facility's statement, dated 12/29/21 and signed by the Director of Nursing (DON) revealed, (Proper Name of facility) uses the Resident Assessment Instrument (RAI) manual for Minimum Data Set (MDS) completion. A record review of the Davis's Drug Guide for Nurses Fifteenth Edition 2015 revealed the classification of [MEDICATION(S)] ([MEDICATION(S)]) is listed as therapeutic: antiplatelet agents and Pharmacologic: platelet aggregation inhibitors. On 12/29/21 at 2:29 PM, during an interview with Registered Nurse (RN) #2 MDS nurse, she reviewed the most recent MDS assessments as well as the corresponding Medication Administration Records (MARs) for Resident #1, Resident #10, Resident #20, and Resident #36 and confirmed they did not receive an anticoagulant medication during the look back periods. She stated Resident #10 was previously on an anticoagulant medication, but several of her medications had been discontinued and that it was just my error to code the resident as receiving an anticoagulant. The MDS nurse stated she is new in the MDS nurse position and it is a learning curve because she incorrectly coded [MEDICATION(S)] as an anticoagulant medication. On 12/29/21 at 2:40 PM, during an interview with the DON, she confirmed [MEDICATION(S)] should not have been classified as an anticoagulant medication. She stated that the MDS assessments should be coded accurately. Resident #1 A record review of the resident's Face Sheet revealed the facility admitted Resident #1 on 8/28/2011 and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Resident #1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Resident #1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/11/21 revealed coding in Section N as Resident #1 received anticoagulant medication for seven (7) days out of the seven (7) day look back period. A record review of Resident #1's Medication Record (Administration Record) (MAR) for December 2021 revealed [MEDICATION(S)] 75 mg was administered daily and there were no anticoagulant medications administered. Resident #10 A record review of Resident #10's Face Sheet revealed the resident was readmitted by the facility on 1/11/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] A record review of the MDS with an ARD of 10/6/21 revealed Resident #10 was coded as receiving an anticoagulant for seven (7) days. A record review of the MAR for October 2021 revealed an anticoagulant medication was not given. Resident #20 A record review of Resident #20's Face Sheet revealed the facility admitted the resident on 6/25/18 with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of annual MDS with an ARD of 11/04/21 revealed Resident #20 received five (5) days of an anticoagulant in the seven (7) days look back reference period. A record review of the MAR for Resident #20 for October 2021 and November 2021 revealed no anticoagulant medication was given in the seven (7) day look back reference period. Resident #36 Review of the Face Sheet revealed Resident #36 was readmitted by the facility on 12/15/20 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no orders for an anticoagulant medication. A record review of the MDS with an ARD of 12/4/21 revealed it was coded as Resident #36 received an anticoagulant for seven (7) days. A record review of the MAR for November and December 2021 revealed no anticoagulant medication was given.

Based on observations, interviews, record review, and facility policy review, the facility failed to prevent the possible spread of infection by not changing gloves after removing a soiled dressing during wound care for one (1) of three (3) residents observed during wound care. (Resident #30). Findings include: Record review of the facility policy titled, Hand Hygiene Policy , reviewed 11/21, revealed, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors .Hand Hygiene Table .After handling contaminated objects .Before and after handling clean or soiled dressings, linens, etc After handling items potentially contaminated with blood, body fluids, secretions, or excretions . (marked X) Either Soap and Water or Alcohol Based Hand Rub . Record review of the facility policy titled Infection Prevention and Control Program Policy dated 8/21, revealed .4. Standard Precautions: .b. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. Record review of the facility policy titled, Wound Treatment Policy Reviewed 2021, revealed Policy: It is the policy of this facility to provide wound care in a manner to decrease potential for infection and /or cross-contaminations .Policy Explanation and Compliance Guidelines: .12. Loosen the tape and remove existing dressing .13. Remove gloves, pulling inside out over the dressing .14. Wash hands and put on clean gloves . During the wound care observation, on 12/28/21 at 11:26 AM, for Resident #30, Registered Nurse (RN) #1 did not change her gloves, wash or sanitize her hands, or don clean gloves after removing the soiled wound dressings and before touching clean supplies to clean and dress the wounds on the left trochanter and sacrum. During an interview with RN #1 on 12/29/21 at 1:19 PM, she stated she had gotten nervous during the procedure and thought she had completed the procedure correctly. She confirmed she should have removed her gloves, performed hand hygiene, and donned a new pair of gloves before touching clean supplies. She also confirmed this infection control breach could cause the resident to have a wound infection. During an interview with the Director of Nursing (DON) on 12/29/21 at 1:32 PM, she stated RN #1 should have changed her gloves and performed hand hygiene after removal of the soiled dressing and before handling clean supplies as per the facility's policies. She confirmed that by not changing her gloves and using hand hygiene, the resident could acquire an infection. A record review of NIPP: Nursing Home Infection Prevention Program .Nipping Infections in the Bud Hand Washing with Soap and Water Evaluation Form revealed on 1/19/21, RN #1 performed hand washing skills indicating she has been trained on hand washing. A record review of Validation Checklist Hand Hygiene dated 12/8/21, revealed RN #1 was observed performing hand hygiene correctly. A record review of training dated 7/21/21 revealed RN #1 received training on Skin/wound care, Pressure Injury/Ulcer Prevention. A record review of training dated 11/3/21 revealed RN #1 received training on Pressure Ulcers. A record review of training dated 8/17/21 revealed RN #1 received training on Infection Control. A record review of Physician Orders for the December 2021 revealed an order dated 12/27/21 to Clean unstageable decubitus to sacrum (slough) with NS(Normal Saline)/Wound Cleanser Pat dry apply calcium alginate and cover with a bordered gauze daily and prn (as needed) and an order dated 12/10/21 to Clean Stage II decubitus to left trocanter with NS/Wound Cleanser Pat dry apply hydrogel and cover with a bordered gauze daily. A record review of the Face Sheet revealed Resident #30 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, staff interview, record review, and facility policy review, the facility failed to implement the comprehensive care plan for two (2) of 16 care plans reviewed. For Resident #9's pressure ulcer and Resident #37's Percutaneous Endoscopic Gastrostomy (PEG) tube site care. Findings include: A review of the facility's policy titled, Comprehensive Care Plans, with a revision date of 02/2017, revealed qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. Resident #9 Review of Resident #9's Comprehensive Care Plan revealed the following: Problem/Need, dated 09/13/14, for potential for Pressure Ulcer related to (R/T) immobility and incontinence of bowel and bladder, [MEDICAL CONDITION] following unspecified [MEDICAL CONDITION] Disease affecting left nondominant side. Goal & Target Date: skin will remain intact with no red or broken areas, and will be kept clean and dry during next review. Interventions included: Turn and position resident every two hours as indicated by individual turning schedule posted in resident's room. Skin sweep every shift by CNA (Certified Nursing Assistant) staff and Weekly skin assessment by nursing staff. Problem/Need, dated, 04/29/19, for a Stage 2 decubitus to the left knee. Goal & Target Date: To show signs of healing by next review on 07/30/19. Interventions included: Cleanse Stage 2 decubitus to left knee with NS (Normal Saline), pat dry, apply hydrogen and powder collagen, non-stick [MEDICATION NAME], and secure with kerlix daily until healed. Problem/Need for use of geri chair for socialization and mobility, dated 07/01/15, revealed the Goal & Target Date stated: All safety measures will be maintained with use of geri chair by next review on 06/30/19. Interventions included: Staff will make sure all safety measures will be maintained. Staff will reposition resident every two hours and as needed. Pressure relief every two hours. A review of Residents #9's facility form titled, Assessment of Pressure Sore Potential, dated 03/22/19, revealed a total score of 11, which indicated the facility should follow pressure sore protocol. An observation, on 05/28/19 at 3:14 PM, revealed Resident #9 was in a geri chair with a sheep skin covering the left arm rest. Resident #9's left leg was bent at the knee, and rested against the arm rest. An observation, on 05/29/19 at 11:15 AM, revealed Resident #9 was in a geri chair. Resident #9 had his left leg bent at the knee, and was laying on the arm rest with a sheep skin over the arm rest. On 05/29/19 at 2:13 PM, an observation revealed Resident #9's wound care was performed by Licensed Practical Nurse (LPN) #1/Treatment Nurse. LPN #1 measured the wound bed at 0.6 centimeters by 0.6 centimeters. Resident #9's wound bed was pink with dark scars surrounding the wound located on the side of the left knee. The wound had no foul odors or discharge. An interview at this time with LPN #1 revealed she said Resident #9's wound on his left knee was found over a weekend, and treatment was started on 04/28/19. LPN #1 said she completed the weekly skin checks, and did not remember the wound on the resident the week before it was found on 04/28/19. LPN #1 said the left knee had several scars from previous wounds. LPN #1 said the sheep skin was not being used prior to the wound treatment that started on 04/28/19. LPN #1 confirmed Resident #9 had not been out to the hospital and said the pressure ulcer was acquired in the facility. An interview, on 05/29/19 at 11:36 AM, with Certified Nursing Assistant (CNA) #1 revealed she said she was Resident #9's CNA, and the resident needed assist to move his left side. She said the resident could move his right leg independently. An interview, on 05/30/19 at 10:21 AM, with LPN #2/Minimum Data Set Nurse, revealed she said she would expect staff to follow the care plan and carry out the interventions listed on the comprehensive care plan. An interview, on 05/30/19 11:18 AM, with the Director of Nursing (DON), revealed she said Resident #9 did have interventions for propping his left leg up with a pillow, but the resident would remove it. The DON said Resident #9 received a new chair about a year ago because the previous one was too short. The DON confirmed that she believed the pressure ulcer on Resident #9 was preventable, and was caused by the left leg leaning on the arm rest. The DON said she thought the sheep skin on the geri chair armrest would keep his skin from breaking down again. A review of Resident #9's Minimum Data Set (MDS), with an Assessment Reference Date of 03/25/19, revealed Section M - Skin Conditions listed M0150 is resident at risk of developing pressure ulcers/injuries was marked Yes. Section M0210 Resident has 1+ unhealed pressure ulcers/injuries marked as No. Further review of the MDS revealed Resident #9 had a Basic Interview for Mental Status (BIMS) score of 13, which indicated no cognitive impairment. Resident #9 was also coded for upper and lower extremity Range of Motion (ROM) impairment on one side. Resident #9 required extensive assistance with two person physical assist for bed mobility, and was totally dependent on two persons for transfers. Resident #9 was totally dependent on one person assist with locomotion on and off the unit Review of the Face Sheet revealed Resident #9 was admitted by the facility, on 05/29/08, and readmitted on [DATE], with the included Diagnoses: [REDACTED]. Resident #37 Review of the Comprehensive Care Plan revealed the Problem/Focus, dated 08/19/18, for a need for use of a Percutaneous Endoscopic Gastrostomy (PEG) tube related to disease process, NPO (Nothing by Mouth). Goal & Target Date revealed resident will remain free of complications related to use of the PEG tube as evidenced by no sign and symptoms (s/s) of aspiration, nausea, vomiting, diarrhea, and no abdominal distention through next review on 08/28/19. Interventions included: Provide skin care to insertion site. Absence or presence of drainage and or presence of distention and or s/s of infection to PEG tube. On 05/29/19 at 11:07 AM, an observation revealed, Resident #37 lying in bed with the head of bed (HOB) up at least 45 degrees. Resident #37 had a tube feeding of [MEDICATION NAME] 1.5 at 45 cubic centimeter per hour (CC/HR) per a feeding pump. An observation of the gastric tube feeding site care revealed, Licensed Practical Nurse (LPN) #1 applied clean gloves and removed the resident's soiled dressing. She removed her gloves, applied clean gloves, moistened the 4x4 gauze with normal saline (NS), then wiped around the resident's tube feeding site underneath the tube in a half circular motion from right to left and backwards in a half circular motion from left to right. She then wiped around the tube feeding site over the top of the resident's tube in a half circular motion from right to left and backwards from left to right and disposed of the 4x4 gauze. LPN #1 went out into the hallway to get another pair of gloves, returned to the resident's room, washed her hands, applied clean gloves, and placed a clean dressing to the resident's gastric tube site. On 05/30/19 at 10:34 AM, an interview with LPN #1, revealed she should not have wiped the tube feeding site backwards while she was cleaning the site, and she should have wiped once and then throw the gauze away. Record review of the (MONTH) 2019 Physician order [REDACTED]. On 5/30/19 at 10:52 AM, an interview with the Minimum Data Set (MDS) Nurse/LPN #2, revealed the staff should implement the interventions from the care plan. Review of the most recent Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/6/19, revealed Resident #37 was coded for tube feeding in the section K. Swallowing/Nutritional Status. Resident #9's BIMS score was 9, which indicated moderate cognitive impairment. Review of the Significant Change MDS, with an ARD of 08/26/18, revealed Resident #37 was coded to include tube feeding. Review of the Face Sheet revealed Resident #37 was admitted by the facility, on 10/27/12, and readmitted on [DATE], with the included Diagnoses: [REDACTED].

Based on staff interview, record review, and facility policy review, the facility failed to revise the Comprehensive Care Plan related to medication changes for one (1) of 16 care plan reviewed, Resident #23. Findings include: A review of the facility's policy titled, Comprehensive Care Plans, with a revision date of 02/2017, revealed the comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS (Minimum Data Set) assessment. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. A review of Resident #23's Comprehensive Care Plan revealed the Problem/Need for potential bleeding/bruising related to the use of blood thinner, dated 12/06/17. The Goal & Target Date revealed the resident would have no bleeding/bruising during next review period on 08/30/19. Interventions included: [MEDICATION NAME] Sodium (blood thinner) 5 milligrams (mg) by mouth (po) daily at 5 PM. A review of Resident #23's physician's orders [REDACTED].>An interview, on 05/30/19 at 10:21 AM, with Licensed Practical Nurse (LPN) #2/Minimum Data Set (MDS) Nurse revealed she was notified of changes in the resident's medications by the physician's orders [REDACTED]. LPN #2 also confirmed she was responsible for most of the additions and changes on the care plan in the computer. An interview, on 05/30/19 at 10:45 AM, revealed the Director of Nursing (DON) said all updates to the care plan were made in the computer. An interview, on 05/30/19 at 11:53 AM, revealed the DON said Resident #23 had not been on [MEDICATION NAME] since a hospital return, and the MDS nurse should have updated the care plan at the time of the medication change .

Based on observation, staff interview, record review, and facility policy review, the facility failed to prevent a pressure ulcer for one (1) of one (1) residents reviewed for pressure ulcers, Resident #9. Findings include: Review of a facility's policy titled, Pressure Injury Prevention Guidelines, dated 04/2017, revealed to avoid positioning the resident directly onto medical devices and utilize pillows and wedges to maintain proper positioning. On 05/29/19 at 2:13 PM, an observation revealed Resident #9's wound care was provided by Licensed Practical Nurse (LPN) #1/Treatment Nurse. LPN #1 measured the wound bed at 0.6 (centimeters) cm length and 0.6 cm width. Resident #9's wound bed was pink with dark scars surrounding the wound located on the side of the left knee. The wound had no foul odors or discharge. A review of Resident #9's Physician Orders, dated 04/28/19, revealed an order to clean the wound on the left leg with Normal Saline or wound cleanser. Pat dry, Apply triple antibiotic ointment daily until healed. Further review of the the physician's orders [REDACTED]. Review of the (MONTH) 2019 physician's orders [REDACTED]. Review of Resident #9's Treatment Record for (MONTH) 2019, revealed staff documentation for the wound care to the left knee per the physician's orders [REDACTED]. A review of Resident #9's, Wound Assessment Report, dated 04/29/19, revealed the wound was identified, on 04/28/19, on the left knee that was not present upon admission, and indicated the wound was a Stage 2 that measured 2.0 centimeters (cm) length, 1.7 cm width and 0.10 cm depth. An observation, on 05/28/19 at 3:14 PM, revealed Resident #9 was in a geri chair with a sheep skin covering the left arm rest. Resident #9's left leg was bent at the knee and rested against the arm rest. An observation, on 05/29/19 at 11:15 AM, revealed Resident #9 was in a geri chair. Resident #9 had his left leg bent at the knee, and was rested on the arm rest with a sheep skin over the arm rest. On 05/30/19 at 11:07 AM, Resident #9 was observed up in a geri-chair with his left leg bent towards, but not resting on the arm rest. Resident #9's left leg was not propped up on anything. A sheep skin covered the arm rest. A review of Residents #9's facility form titled, Assessment of Pressure Sore Potential, dated 03/22/19, revealed a total score of 11, which indicated the facility should follow pressure sore protocol. A review of Resident #9's, Activity of Daily Living (ADL) Assistant and Support, revealed Resident #9 was coded 4/2 in bed mobility and locomotion on the unit, which indicated he was totally dependent on one person for the Activities of Daily Living (ADLs). A review of Resident #9's Minimum Data Set (MDS), with an Assessment Reference Date of 03/25/19, revealed Section M - Skin Conditions listed M0150 is resident at risk of developing pressure ulcers/injuries was marked Yes. Section M0210 Resident has 1+ unhealed pressure ulcers/injuries marked as No. Resident #9's Comprehensive Care Plan revealed Resident #9 had a Stage 2 decubitus to the left knee with an onset date of 04/28/19. The care plan also listed Resident #9 used a geri chair for socialization and mobility with an onset date of 07/1/15. The interventions listed for the geri chair included staff to reposition the resident every two hours, and as needed with pressure release every two hours. An interview, on 05/29/19 at 11:36 AM, with Certified Nursing Assistant (CNA) #1 revealed she said she was Resident #9's CNA, and the resident needed assist to move his left side. She said the resident could move his right leg independently. An interview, on 05/29/19 at 2:13 PM, revealed LPN #1/Treatment Nurse said Resident #9's wound on his left knee was found over a weekend, and treatment was started on 04/28/19. LPN #1 said she completed the weekly skin checks, and did not remember the wound on the resident the week before. LPN #1 said the left knee had several scars from previous wounds. LPN #1 said the sheep skin was not being used prior to the wound treatment that was started on 04/29/19. LPN #1 confirmed Resident #9 had not been out to the hospital, and the pressure ulcer was acquired in the facility. An interview, on 05/29/19 at 3:55 PM, with the Director of Nursing (DON) revealed the nurses on admission do the assessments for needs for mobility, and therapy will screen to see if the resident needs therapy. An interview, on 05/30/19 at 11:14 AM, with the Certified Occupational Therapist Assistant (COTA) revealed she said she had assisted nursing with putting the sheep skin on the geri chair arm rest for Resident #9. The COTA said that nursing staff had to request an evaluation for appropriate chair use, but had not done one for Resident #9. An interview, on 05/30/19 11:18 AM, revealed the DON said Resident #9 did have interventions for propping his left leg up with a pillow, but the resident would remove it. The DON said Resident #9 received a new chair about a year ago because the previous one was too short. The DON confirmed she believed the pressure ulcer on Resident #9 was caused by the left leg leaning on the arm rest. The DON said with the sheep skin on the geri chair armrest she thought that would keep his skin from breaking down again. Review of Resident #9's Comprehensive Care Plan revealed the Problem/Need, dated 07/11/18, for the potential for exhibiting moods/ behaviors such as cursing and refusing care. A review of Resident #9's Minimum Data Set (MDS), with an Assessment Reference Date of 03/25/19, revealed Resident #9 had a Basic Interview for Mental Status (BIMS) score of 13, which indicated no cognitive impairment. Resident #9 was also coded for upper and lower extremity Range of Motion (ROM) impairment on one side. Resident #9 required extensive assistance with two person physical assist for bed mobility, and was totally dependent on two persons for transfers. Resident #9 was totally dependent on one person assist with locomotion on and off the unit Review of the Face Sheet revealed Resident #9 was admitted by the facility, on 05/29/08, and readmitted on [DATE], with the included Diagnoses: [REDACTED].

Based on observation, staff interview, record review, facility policy review, the facility failed to provide gastric tube site care in a manner to prevent the possibility of an infection and/or cross contamination for one (1) of three (3) resident reviewed with gastric tubes, Resident #37. Findings include: A review of the facility's policy titled, Gastrostomy Status, dated 4/2017, revealed maintain a clean technique, and gently clean the area around the tube and continue in an outward circular fashion, ensuring that under the bolster is cleaned. On 5/29/19 at 11:07 AM, an observation revealed, Resident #37 lying in bed with the head of bed (HOB) up at least 45 degrees. Resident #37 had a tube feeding of [MEDICATION NAME] 1.5 at 45 cubic centimeter per hour (CC/HR) per a feeding pump. An observation of gastric tube feeding site care revealed, Licensed Practical Nurse (LPN) #1 applied clean gloves and removed the resident's soiled dressing. She removed her gloves, applied clean gloves, moistened the 4x4 gauze with normal saline (NS), then wiped around the resident's tube feeding site underneath the tube in a half circular motion from right to left and backwards in a half circular motion from left to right. She then wiped around the tube feeding site over the top of the resident's tube in a half circular motion from right to left and backwards from left to right and disposed of the 4x4 gauze. LPN #1 went out into the hallway to get another pair of gloves, returned to the resident's room, washed her hands, applied clean gloves, and placed a clean dressing to the resident's gastric tube site. On 5/30/19 at 10:34 AM, an interview with LPN #1, revealed she should not have wiped the tube feeding site backwards while cleaning the area. LPN #1 stated she should have wiped once and thrown the gauze away. A record review of the (MONTH) 2019 Physician order [REDACTED]. [MEDICATION NAME] 1.5 at 45 ML/HR, flush with 150 ML of water every 6 hours provides 1620 calories, 69 grams (grms) of protein, 1640 ML of free water, 2500 total fluids. Clean PEG (Percutaneous Endoscopic Gastrostomy) tube site with NS, pat dry, and cover with 4x4 daily. On 5/30/19 at 10:35 AM, an interview with the Director of Nursing, (DON) revealed, wiping in a back and forth motion is cross contamination and she (referring to LPN #1) should have wiped in a circular motion. A review of the facility's Face Sheet revealed, the facility admitted Resident #37 on 10/27/12 with a [DIAGNOSES REDACTED]. Review of the most recent Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/6/19, revealed Resident #37 was coded for tube feeding in the section K. Swallowing/Nutritional Status. Resident #9's BIMS score was 9, which indicated moderate cognitive impairment. Review of the Significant Change MDS, with an ARD of 08/26/18, revealed Resident #37 was coded to include tube feeding. Review of the Face Sheet revealed Resident #37 was admitted by the facility, on 10/27/12, and readmitted on [DATE], with the included Diagnoses: [REDACTED].

Based on observations, staff interviews, and the facility policy review, the facility failed to maintain dining room chairs free from stains, tears, and loose bolts for 15 out of 15 dining room chairs, and 2 (two) of 3 (three) dining room observations. Findings Include: Review of the facility's policy, Maintaining a Safe, Clean, Comfortable, and Homelike Environment, (no date), revealed This facility will accommodate, to the extent possible, a personalized, homelike environment that recognizes the individuality and autonomy of each resident. 5. Report any furniture in disrepair to Maintenance promptly. 6. Maintain a clean, comfortable and homelike environment (i.e., ceiling tiles, wallpaper, floor tiles). Observation during the initial tour on 2/8/2017 between 10:00 AM and 10:50 AM, revealed stained striped fabric on wooden chairs in the common dining room. Observation on 2/9/2017 at 3:35 PM, revealed 15 out of 15 wooden chairs with striped fabric had stains on the seating portions, and were not sturdy. The portion of the chairs made of wood-products were moveable, and affixed with screws. Upon touching the chairs, the seating and back portions were unsteady. There were 3 (three) residents sitting in three of the chairs at this time. Observation on 2/10/2017 11:20 AM, with the Maintenance Staff #1 revealed the use of an electric drill to tighten screws on the chairs in the dining room. Interview on 2/10/2017 at 11:25 AM, with Maintenance Staff #1 revealed no one had fallen from the chairs that he knew of, and that the screws, backed out easy. Interview on 2/10/2017 at 11:25 AM, with the facility's Administrator revealed the chairs in the dining room had been discussed at the board meeting in December, and plans were in place to replace the chairs. She further stated that bids had to be obtained. Interview on 2/10/2017 at 11:50 AM, with Maintenance Staff #1 revealed he stated those kind of chairs didn't need to be in a nursing home, residents could fall, and the chairs couldn't be cleaned. Maintenance Staff #1 stated he had tightened up the screws that morning, and in the past. No cleaning schedules were kept as a paper record.

Based on observation, staff interview, record review, and facility policy review, the facility failed to perform hand hygiene during medication pass for three (3) of seven (7) residents observed for medication administration, Unsampled Residents A, B, and F, and failed to dispose of soiled linens after incontinent care was completed for one of eight (1 of 8) unsampled residents observed, Unsampled Resident B. Findings Include: Review of the facility's policy titled, Medication Administration, dated 10/01/12, revealed hands are to be cleansed using antimicrobial soap and water, or facility approved hand sanitizer before beginning med pass, before handling medications, and before contact with the resident. Review of the facility's policy titled, Linen and Disposables undated, revealed linens are to be discarded in designated containers. All soiled laundry, linen, towels, and washcloths, should be discarded in the soiled laundry container. Dispose of disposable gloves into the designated containers. Hands are to be washed and dried thoroughly after handling any used or discarded material. Unsampled Resident A An observation during the medication pass on 02/09/17 at 8:45 AM, revealed Licensed Practical Nurse (LPN) #1 opened Unsampled Resident A's medication packages, and administered the medications to Unsampled Resident A. LPN #1 left the resident's room, and went to her med cart to assess information on the laptop. LPN #1 donned gloves, entered the resident's room, and then left the room to go to the medication room to obtain a bottle of Tylenol 325 milligrams (mg). LPN #1 brought the bottle of Tylenol to her medication cart, and placed the Tylenol tablets in a medication cup. LPN #1 looked at medications on the computer for Unsampled Resident A, donned gloves, and entered the resident's room, and administered the Tylenol tablets. LPN #1 removed her gloves, and returned to the medication cart. LPN #1 donned gloves, and re-entered the resident's room to assess his bilateral lower extremities. LPN #1 removed her gloves, and returned to the medication cart to begin setting up medications for the next resident (Unsampled Resident B). LPN #1 did not perform any hand hygiene before, during, or after the medication administration for Unsampled Resident A. During a staff interview with LPN #1 on 02/09/17 at 4:30 PM, LPN #1 confirmed she did not perform any hand hygiene before, during, or after she administered medications to Unsampled Resident A or Unsampled Resident B. LPN #1 confirmed she had several breaks in infection control during the medication administration. Review of the facility's Face Sheet revealed the facility admitted Unsampled Resident A on 10/25/13, with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), with an Assessment Reference date (ARD) of 11/21/16, revealed Unsampled Resident A had a Brief Interview for Mental Status (BIMS) score of 14, indicating Unsampled Resident A was cognitively intact. Unsampled Resident B Observation of the medication pass administration on 02/09/17 at 9:00 AM, revealed LPN #1 set up the medications for Unsampled Resident B. She entered the resident's room, and administered the medications to the resident. LPN #1 went back to her medication cart, looked at medications on the laptop, donned gloves, and re-entered the resident's room. LPN #1 exited the room, and did not perform hand hygiene. During the medication pass on 02/09/17 at 4:15 PM, an observation with LPN #5 revealed un-bagged soiled linens on Unsampled Resident B's bathroom floor, and an opened trash bag containing soiled gloves, and a soiled brief laying on the counter next to the sink. LPN #5 confirmed the Certified Nursing Assistants (CNAs) caused a break in infection control by leaving the soiled items in Unsampled Resident B's bathroom. During a staff interview with CNA #1 on 02/10/17 at 10:35 AM, CNA #1 confirmed she caused breaks in infection control after she performed incontinent care on Unsampled Resident B. CNA #1 stated she left un-bagged soiled linens on the bathroom floor, and an opened trash bag of soiled gloves and a soiled brief on the bathroom counter top of the resident's bathroom. CNA #1 said she should have disposed of the linen and trash in the linen and trash containers. Review of the facility's Face Sheet revealed the facility admitted Unsampled Resident B on 3/21/13, and readmitted her on 01/08/16, with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with an Assessment Reference date (ARD) of 01/14/17, revealed Unsampled Resident B had a Brief Interview for Mental Status (BIMS) score of 15, indicating Unsampled Resident B was cognitively intact. Unsampled Resident H Observation during the medication pass administration on 02/09/17 at 1:30 PM, revealed LPN #2 entered the resident's room to administer the bolus tube feeding to the resident. While the bolus tube feeding was flowing by gravity, the resident began coughing, and the feeding overflowed from the syringe onto a large towel, and the nurse's gloves. LPN #2 stopped the feeding, left the resident's room to dispose of the soiled towel, gloves, and the remainder of the feeding in the appropriate containers. LPN #2 removed a clean cup from the top of the medication cart, entered the medication room to pour water from the gallon water jug into the cup. LPN #2 gathered two pairs of gloves, and returned to the resident's room. LPN #2 administered Tylenol 650 mg, the bolus tube feeding, and water flushes via the feeding tube. While exiting the resident's room, LPN #2 placed her soiled gloves, towel, and used cups on the cubby hole counter located next to the exit door. LPN # 2 did not perform any hand hygiene after initially setting up the resident's medications, prior to administering the medications, upon exiting and re-entering the room, touching soiled linen, or touching other objects in the room. During a staff interview on 02/10/17 at 11:50 AM, LPN #2 confirmed she caused multiple breaks in infection control during Unsampled Resident H's medication administration per the feeding tube. LPN #2 stated she did not wash her hands when administering the medications, handling the soiled towels, trash and linen containers, touching the door knobs, entering and exiting the room. An interview with the Director of Nursing (DON) on 02/10/17 at 9:45 AM, revealed the staff failed to wash their hands during medication pass, and when touching soiled items. The DON said each staff should wash their hands after the procedure, and as often as needed. She said the staff should not have left soiled linens, soiled briefs, and gloves in the resident's bathroom. The DON stated the staff should have placed them in the appropriate containers.` Review of the facility's Face Sheet revealed the facility admitted Unsampled Resident H on 02/21/05, and readmitted her on 12/08/12, with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), with an Assessment Reference date (ARD) of 12/19/17, revealed Unsampled Resident H had a cognitive skills score of three (3) indicating severe cognitive impairment.

Based on observation, record review, staff interview, review of the Mississippi Nursing Practice Law, Mosby's Pocket Guide to Nursing Skills & Procedures, Perry.Potter Eighth Edition, and facility policy review, the facility failed to administer medications as prescribed by the physician's orders [REDACTED]. (Un-sampled Resident B). Findings include: Review of the Mississippi Nursing Practice Law, with an effective date of July 1, 2010, revealed the practice of nursing by a licensed practical nurse means the performance for compensation of services requiring basic knowledge of the biological, physical, behavioral, psychological and sociological sciences and of nursing procedures which do not require the substantial skill, judgement and knowledge required of a registered nurse. These services are performed under the direction of a registered nurse or a licensed physician or licensed dentist and utilize standardized procedures in the observation and care of the ill, injured, infirm; in the maintenance of health; in action to safeguard life and health; and in the administration of medications and treatments prescribed by any licensed physician or licensed dentist authorized by the state law to prescribe. On a selected basis, and within safe limits, the role of the licensed practical nurse shall be expanded by the board under its rule-making authority to more complex procedures and settings commensurate with additional preparation and experience. Review of the Facility's Administration Procedures For All Medications policy, dated 10/01/12, revealed review the resident's five (5) rights, which included checking the medications three times prior to removing the medication from the cart/drawer; consult a drug reference if the drug is unfamiliar; and check the medication label against the order on the Medication Administration Record [REDACTED] Review of Mosby's Pocket Guide to Nursing Skills & Procedures, Perry.Potter Eighth Edition, Copy Right 2015, on page 321, Skill 46 Oral Medications revealed: Compare name of medication label with MAR (Medication Administration Record) or computer printout. Rationale: Reading label first time and comparing it against transcribed order reduces errors. This is the first check for accuracy. Observation during the medication pass on 02/09/17 from 9:12 AM to 9:30 AM, with Licensed Practical Nurse (LPN) #1, revealed LPN #1 administered Calcium 600 milligrams (mg)/Vitamin D3 800 International Units (IUs) to Unsampled Resident B. Review of Unsampled Resident B's physician's orders [REDACTED]. Review of Unsampled Resident B's February 2017 Medication Administration Record [REDACTED]. The Tylenol 500 mg tablets, two tablets by mouth (po) every eight hours for pain was scheduled for 9 AM, 5 PM, and 1 AM. LPN #1 did not administer Unsampled Resident B's Tylenol 500 mg tablets during the med pass observation this morning between 9:12 AM and 9:30 AM. Staff interview with LPN (Licensed Practical Nurse) #1 on 02/09/17 at 4:35 PM, confirmed the Calcium 600mg/Vitamin D3 400 International Units (IUs) tablet was not administered to Unsampled Resident B, and she administered Calcium 600mg and [MEDICATION NAME] + D3 800 IUs per the medication packet. LPN #1 confirmed she did not give Tylenol 500 mg tablets times two (2) tablets to the resident. She confirmed she did not check Unsampled Resident B's physician's orders [REDACTED]. Review of the (Name of Pharmacy) fax dated 01/18/17, revealed an Alternate Strength Form stating the Calcium 600/D3 800 IU was stocked by the pharmacy, and not the Calcium 600 mg/Vitamin D3 400 International Units (IUs) tablet which Un-sampled Resident B's physician prescribed on 01/18/17. The form further stated the pharmacy was sending the correct total dose, with directions to make appropriate changes to the MAR. Staff interview on 02/09/17at 4:50 PM, with the Director of Nursing (DON), revealed the nurses are trained, and have to abide by the resident's five rights. She said if the nurses question a medication then, the nurse should find out why. The DON said the nurses are responsible for checking the physician's orders [REDACTED]. Review of Unsampled Resident B's medical record with the DON revealed the physician's orders [REDACTED]. Review of the resident's medication packet revealed Calcium 600 mg and [MEDICATION NAME] Plus (+) D3 800 IUs to be given at 9:00 AM. Review of Unsampled Resident B's MAR indicated [REDACTED]. An interview on 2/10/17 at 9:30 AM, revealed the DON stated the Pharmacy should not have sent over the Calcium 600 mg./D-3 800 IU tablet without the nurses calling the doctor to give an order stating his preference. The Pharmacy faxes over an Alternate Strength Form (ASF) request to reveal a dosage change, insurance won't pay for the med, but reveals what med the insurance will pay for. Once the nurses notifies the doctor, and receives a new med order or clarification order, it is faxed over to the Pharmacy. The DON stated in this case, the Pharmacist changed the dosage without a physician's orders [REDACTED]. The DON stated the pharmacy sent over the Calcium 600 mg/D-3 800 IU tablet PO BID, and the ASF dated 1/18/17. The DON stated the form was not in the resident's medical record. The DON confirmed there was not a physician's orders [REDACTED]./D-3 400 IU tablet to Calcium 600 mg/D-3 800 IU. Staff interview on 02/10/17 at 12:14 PM, with the Pharmacy Director, confirmed the Pharmacy sent the Calcium 600 mg and Vitamin D3 800 IUs tablets to the facility in place of the Calcium 600 mg/Vitamin D3 400 IUs tablets. He said an Alternate Strength Form was faxed to the facility on [DATE], revealing the Calcium 600/D3 800 IU was stocked by the pharmacy and not the Calcium 600mg/Vitamin D3 400 International Units (IUs) tablet. The Registered Pharmacist Director revealed he does not follow-up with the nursing staff to confirm them obtaining a physician's orders [REDACTED]. He confirmed the pharmacy sent the incorrect dosage of the medication to the facility. Review of the facility's Face Sheet revealed the facility admitted Unsampled Resident B on 3/21/13, and readmitted her on 01/08/16, with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with an Assessment Reference date (ARD) of 01/14/17, revealed Unsampled Resident B had a Brief Interview of Mental Status (BIMS) score of 15 indicating Unsampled Resident B was cognitively intact.

Based on staff interview, record review, and facility policy review, the facility failed to follow the care plan to obtain and monitor routine labs for two (2) of eleven (11) resident care plans reviewed for laboratory tests, for Resident #3, and Resident #4 Findings Include: A review of the facility's policy titled, Comprehensive Care Plan, (no date) revealed the care plan is developed by the interdisciplinary team to coordinate and communicate care approaches and goals for the resident, related to clinical [DIAGNOSES REDACTED]. Outcome objectives will be reflected. The facility staff will use the objectives to monitor resident progress. Resident #4 A review of Resident #4's Care Plan revealed a problem and need related to the use of a Percutaneous Endoscopic Gastrostomy (PEG) tube with an onset date of 09/13/2014, and the approach to monitor lab/diagnostics as ordered and report results to the Medical Doctor (MD). During an interview on 02/09/2017 at 4:20 PM, Licensed Practical Nurse (LPN) #3, revealed the care plan is developed from the resident's comprehensive assessments, documentation, physician orders, and specific needs. LPN #3 stated the nursing staff uses the care plan for guidance to provide care for the resident. LPN #3 stated the approach to monitor lab/diagnostics as ordered, and to report results to the MD related to resident's need for a peg tube, and is expected to be followed by the nursing staff. An interview on 02/10/2017 at 1:05 PM, revealed the Director of Nursing (DON) confirmed the care plan documented an approach related to the use of a peg tube to monitor lab and diagnostic test, and to report results to the Medical Doctor. A review of the Face Sheet revealed Resident #4 was admitted by the facility on 05/29/2008, with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/22/2016, revealed the resident's Brief Interview for Mental Status (BIMS) score was eleven (11) indicating moderately impaired cognition. Resident #3 Review of Resident #3's Care Plan revealed the problem/need dated 9/09/16, for at risk for dehydration related to daily [MEDICATION NAME] use, with a target date of 02/01/16. Interventions included obtain lab work as ordered by the resident's physician. The intervention revealed the nurse as the responsible discipline for the task. Review of Resident #3's physician's orders [REDACTED]. Review of the Resident #3's Cardiology Consult Form dated 01/17/17, revealed the BNP and BMP were to be collected weekly. Review of Resident #3's lab results revealed the most recent, and only BNP and BMP collected was dated 1/18/17. During an interview on 02/09/17 at 10:32 AM, the Director of Nursing (DON) confirmed the weekly BNP and BMP were not done weekly as ordered by Resident #3's physician, and therefore the resident's care plan for obtaining labs as ordered by the physician was not followed. During an interview on 02/09/17 at 10:32 AM, Licensed Practical Nurse #3 confirmed the weekly BNP and BMP were not collected after 01/18/17, and she had mistakenly discontinued the lab orders. Review of the Face Sheet revealed the facility admitted Resident #3 on 7/07/15, and readmitted the resident on 9/25/16, with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/26/16, revealed Resident #3 had a Brief Interview of Mental Status (BIMS) score of seven (7), which indicated Resident #3 was severely cognitively impaired.