Every finding on record at Lebanon South Nursing & Rehab

Based on record review, observation, and interview, the facility failed to ensure all residents were treated with respect and dignity when one staff (Certified Nurse Aide (CNA) B) laid on one resident's (Resident #5) bed, next to the resident, while the resident was sleeping to try and wake the resident. The facility census was 71.Review of the facility policy titled, Resident Rights not dated, showed the following: -The resident has a right to a dignified existence, self-determination and communication with and access to persons and services inside and outside the facility. A facility much protect and promote the rights of each resident;-Resident Rights are to be fully respected and adhered to.Review of the facility policy titled, Patient [NAME] of Rights, not dated, showed the resident shall be treated with consideration, respect and full recognition of their dignity and individuality, including privacy in treatment and in care of your personal needs.1. Review of Resident #5's face sheet (a brief summary of the resident's medical and admission history) showed the following: -admission date of 12/29/23;-Diagnoses included Alzheimer's disease, general anxiety disorder (worrying constantly and cannot control the worry), and high blood pressure.Review of the resident's care plan, reviewed 02/17/26, showed the following: -The resident had anxiety, and staff should maintain a calm environment and approach with him/her;-The resident received hospice services;-The resident had confusion related to Alzheimer's disease.Review of the resident's annual Minimum Data Set (MDS - a federally required assessment tool completed by facility staff), dated 02/20/26, showed the following: -The resident had severe cognitive impairment;-The resident was dependent on staff for all activities of daily living (ADL - grooming, eating, dressing, etc.).During an interview on 03/16/26, at 12:13 P.M., the Administrator said the following: -On 03/13/26, at 8:13 A.M., CNA A sent through text messaging with a picture of CNA B lying on the bed with the resident;-CNA A said that he/she felt that CNA B's behavior was inappropriate;-CNA A said that CNA B wanted to snuggle the resident;-CNA B said that he/she was being kind to the resident.Observation of a picture identified by as CNA B and the resident showed the following: -The resident was in bed under the covers laying on his/her side facing the wall;-The staff member, fully dressed in scrubs) was lying next to the resident in bed on his/her side with one arm around (hugging) the resident;-There was no indication of any sexual contact. During an interview on 3/16/26, at 1:38 P.M., CNA B said the following: -CNA B laid down beside the resident in the resident's bed;-CNA B said he/she was seeing if the resident was ready to get out of bed for dinner;-CNA B said he/she had not done that before and wanted the resident to be in a good mood when he/she woke up;-CNA B said he/she was not thinking when he/she laid down on the bed with the resident;-CNA B said the Administrator talked to him/her regarding the incident;-CNA B said it was inappropriate for him/her to lie on the bed with a resident.During an interview on 03/16/26, at 12:25 P.M., CNA C said the following: -CNA C said that he/she would report any concerns regarding staff behavior to the Director of Nursing (DON);-CNA C said that he/she had seen CNA B sit on the side of a resident's bed and give the resident a side hug but had not seen CNA B lie in bed with a resident.During an interview on 03/16/26, at 1:21 P.M., CNA G said the following: -CNA G would report any concerns about staff behavior to DON;-It would be inappropriate for a staff member to lie on the bed with a resident.During an interview on 03/16/26, at 12:57 P.M., with Certified Medical Technician (CMT) F said the following: -CMT F would report any concerns regarding staff behavior to the DON;-CMT F said staff lying on the bed with a resident would be inappropriate and should be reported to the DON.During an interview on 03/16/26, at 12:35 P.M., Licensed Practical Nurse (LPN) D said the following: -If LPN D had concerns regarding other staff behavior, he/she would report it to the DON;-LPN D said that staff lying on the bed with a resident was inappropriate if the resident was unable to communicate. During an interview on 03/16/26, at 12:43 P.M., Registered Nurse (RN) E, said the following: -CNA A reported to RN E that CNA B had been inappropriate with the resident;-CNA A reported that CNA B was hugging and joking inappropriately with the resident;-RN E said that he/she told CNA A to report the incident to the DON.During an interview on 03/16/26, at 2:29 P.M., the DON said staff lying on the bed with a resident was inappropriate.During an interview on 3/16/26, at 2:38 P.M., the Administrator said the following: -It was inappropriate for staff to lie on a resident's bed;-She counseled CNA B about the incident involving the resident.Complaint #2802980

Based on interview and record review, the facility failed to implement an effective and complete grievance policy when staff failed to document and track residents' grievances,failed to make prompt efforts to resolve the residents' grievances and failed to provide a written summary of conclusions regarding the residents' grievances filed in resident council when the resident council members filed grievances/complaints regarding missing items, untimely responses to call lights, and rude/disrespectful staff. The facility census was 71.Review of the facility's policy titled, Grievance Protocol, not dated, showed the following: -The purpose of the grievance/complaint report and grievance log is to provide a written record of each resident and family concern and to ensure proper follow-up through the appropriate discipline;-The Social Service Director (SSD) is responsible for the program, although the Administrator is ultimately responsible for the proper implementation of the program. The social service director informs the administrator of each incident;-The appropriate situations for use of the grievance complaint report were resident articles that are lost or cannot be located, laundry concerns, resident care or personal hygiene issues that cannot be immediately resolved, any resident or family concern with a staff member, and any resident or family issue that would require a resolution;-The SSD will obtain the original grievance complaint report, record the grievance on the monthly grievance log, inform the Administrator of the grievance and forward a copy of the grievance to the appropriate discipline;-The Administrator and SSD evaluate the monthly grievance log for trends or patterns a devise an action plan to correct the issues;-A new grievance log should be completed each month. It should be present at the QAA meeting quarterly.Review of the facility's Grievance/Complaint Log showed no grievances/complaints filed/documented for January 2026, February 2026, and March 2026.Review of the Resident Council Minutes, dated January 21, 2026, showed the following:-Resident said he/she pushes call light for his/her roommate who needs assistance and isn't able to push call light herself. Aides assume he/she can wait because he/she is mobile and alert, meanwhile roommate needs help;-A CNA told a resident he doesn't have time to put on compression socks on resident. The CNA leaves and doesn't come back. Resident tries to put them on his/herself. Resident said aide has bad attitude and tells the resident you can wait;-Resident missing sweatpants;-Trash on floor in rooms and hallways;-Staff did not document resolution of these concerns. Review of the Resident Council Minutes, dated February 10, 2026, showed the following: -Concern regarding call lights, aides playing with hair in dining room, two-hour checks not being done, and no shower aides means no showers;-Residents reported horse blanket missing, sweatpants missing, and three coats missing;-Staff did not document resolution of these concerns.Review of the Resident Council Minutes, dated February 18, 2026, showed the following: -Care concerns of no hot water, no towels or wash rags, staff need to knock before coming in, and call lights; -Resident reported missing blankets and clothes, horse blanket, and blue blanket;-Staff did not document resolution of these concerns.Review of the Resident Council Minutes, dated March 10, 2026, showed the following:-Care concerns included clothes in other people's closet, flies, talk nasty to residents, Hoyer lift left in rooms, bad attitudes, call lights, playing with hair and respect of a resident needing help;-Staff did not document resolution of these concerns.During an interview on 03/16/26, at 2:59 P.M., Registered Nurse (RN) E said the following: -A grievance was a complaint filed by a family member or resident;-Grievances should be documented;-RN E was not aware of any grievances or concerns filed by residents or their families.During an interview on 03/16/26, at 3:10 P.M., the Social Service Director (SSD) said the following: -The SSD tells residents to come to him/her with any complaints;-If a resident files a grievance the SSD refers it to the department head to address the issue;-The SSD follows up with the resident to see if the issue was resolved;-The SSD attends resident council meetings;-The Activities Director (AD) provides the department heads with a copy of the resident council minutes after each meeting;-The SSD was not aware of the complaints/grievances filed at the January 2026, February 2026, and March 2026 resident council meetings;-The SSD said if the residents would have come to him/her with the complaints she would have filled out a grievance form;-Call lights not being answered would be considered a grievance and should be documented.During an interview on 03/16/26, at 3:33 P. M. the Activity Director (AD) said the following: -A grievance was a complaint/concern that a resident had;-All staff were responsible for handling grievances. If a department head does not handle a grievance, it was then taken to the Administrator;-Grievances are documented on resident council minutes;-If a resident complains about an issue for more than a month the AD takes that complaint to the department head;-Call lights not being answered were considered a grievance and were reported to the DON;-Grievances were discussed in morning meeting the day following the resident council meeting;-The AD was not sure if grievances were documented anywhere other than the resident council minutes;-The AD was not aware of a grievance logbook being kept by any staff;-If a resident came to the AD outside of a resident council meeting with a complaint the AD reported that to the appropriate department head;-Every department gets a copy of the resident council minutes;-Department heads were responsible for correcting complaints through in-service with their staff;-Complaints weren't always handled immediately.During an interview on 03/16/26, at 3:43 P.M., the DON said the following: -A grievance was a complaint/grievance filed by a resident or family member of a resident;-The SSD kept a log of complaint/grievances;-There are two types of grievances: a complaint and a formal grievance;-A formal grievance required an investigation, an in-service with staff, and was handled by staff immediately;-A resident complaint did not include harm and was not documented. The residents were told to write a statement regarding the complaint and staff would follow up on the complaint;-Every department head received a copy of the resident council minutes after the meetings;-Call lights not being answered could be a grievance.During an interview on 03/16/26, at 4:04 P.M., the Administrator said the following: -Grievances were to be filed with the SSD;-Grievances were discussed every morning during the stand-up meeting;-Grievances were written down and given to the appropriate department head;-Examples of documented grievances were missing money, missing clothing if it cannot be found, etc;-Grievances are documented in resident council minutes or in stand-up meetings;-Grievances/complaints against a staff member were to be documented;-Any grievance/complaint filed against a staff member were to be addressed and then filed in the employee's personnel file;-There were no grievances/complaints filed against any staff members this year;-Grievances/complaints voiced during resident council meetings were passed on to the department heads by the AD;-The AD would then follow up with the resident to make sure the issue had been resolved;-Grievances filed during the resident council meetings should be documented in the grievance log after the meeting;-The administrator was not aware of the complaint filed by a resident on January 21, 2026, resident council meeting regarding a CNA;-The Administrator was not aware of the complaint filed by residents for three consecutive months regarding call lights not being answered.Complaint #2802980

Based on observation, interview, and record review, the facility failed to provide care per standards of practice when staff failed to ensure staff obtained, clarified, and followed physician's orders for the use of one resident's (Resident #1) implanted port (device placed under the skin that provides long-term access to a vein for treatments like chemotherapy, intravenous (IV) fluids, nutrition, or for drawing blood, eliminating repeated needlesticks through the skin) to administer an IV antibiotic when staff failed to de-access the port as ordered and failed to obtain orders regarding port site dressing changes. A sample of four residents were reviewed. The facility census was 65. Review of facility policies showed the facility did not provide a policy or procedure pertaining to the use of a port for treatments or medications. 1. Review of Resident #1's face sheet showed the following:-admission date of 07/17/24 with re-admission date of 01/05/26;-Diagnoses included chronic kidney disease, presence of vascular implants and grafts, altered mental status, chronic autoimmune liver disease, urinary retention, and urinary tract infection (UTI). Review of the resident's care plan, last updated 11/19/25, showed the resident had a port in the right upper chest due to history of cancer. Resident to have no issues from implanted device through next review. Review of the resident's discharge Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 01/03/26, showed the following information:-Mild cognitive impairment;-Dependent on others for most activities of daily living (ADLs - dressing, grooming, etc.);-Presence of indwelling catheter (tubing placed to drain the bladder to outside the body into a collection bag);-Indication for and use of an antibiotic. Review of the resident's Physician Order Sheet (POS), current as of 01/06/26, showed an order, dated 11/03/25, for meropenem (broad-spectrum antibiotic used to treat severe bacterial infections, typically administered IV in a hospital or clinic setting) reconstituted solution, 1 gram (gm), intravenous (in vein), every 8 hours for urinary tract infection (UTI). Review of the resident's electronic Medication Administration Record (eMAR), dated 11/01/25 to 11/30/25, showed staff documented administration of meropenem, 1 gm per IV as follows:-On 11/03/25 at 8:00 P.M.;-On 11/04/25 at 4:00 A.M. and 12:00 P.M.Review of the resident's nurses' progress notes dated 11/04/25, at 3:37 P.M., showed Registered Nurse (RN) A contacted the physician regarding access to resident's power port in right upper chest for current antibiotic therapy. Physician gave orders to access port and use for IV therapy and new order to access port monthly and flush with 10 cubic centimeters (cc) normal saline, then de-access. Staff updated orders accordingly. (Staff did not document orders or follow-up pertaining to dressing changes related to the use of the port.)Review of the resident's eMAR, dated 11/01/25 to 11/30/25, showed staff documented administration of meropenem, 1 gm per IV as follows:-On 11/04/25 at 8:00 P.M.;-On 11/05/25 at 4:00 A.M. Review of the resident's POS, current as of 01/06/26, showed an order, dated 11/05/25, to access port (once) for IV antibiotic therapy and then de-access once treatment was complete for diagnosis of urinary tract infection. (Staff did not document orders or follow-up pertaining to dressing changes related to the use of the port.) Review of the resident's nurses' notes showed the following:-On 11/05/25, at 10:58 A.M., RN A successfully accessed resident's port to right upper chest on one attempt using a 20-gauge Huber needle (specialized for port access), sterile technique maintained for procedure. Flushed without difficulty. Resident tolerated procedure well, without complaint or concern;-On 11/05/25, at 12:36 P.M., resident complained of pain at port location upon beginning IV antibiotic therapy. Port flushes but resident complained of pinpoint pain with flushing and no blood return noted. RN A attempted to adjust needle placement with no avail. RN A de-accessed port related to continued complaint of pain/discomfort. Nurse contacted physician for further instruction, awaiting response.-On 11/05/25, at 5:16 P.M., staff noted resident's family insisted that he/she be transferred to the hospital for possible sepsis. Nurse contacted physician, who said the resident was stable on assessment earlier that day. Transported to hospital via ambulance at 5:22 P.M.;-On 11/07/25, at 5:21 P.M., resident readmitted via ambulance transport and assessment done and documented. Only medication change made was meropenem was reinstated for the 16 doses remaining ABT therapy. Staff will continue with the current orders;-On 11/07/25, at 10:46 P.M., ABT therapy continued for meropenem to end 11/11/25. IV ABT infused without difficulty. Review of the resident's POS, current as of 01/06/26, showed an order, dated 11/07/25, for meropenem reconstituted solution, 1 gram IV, every 8 hours. (Staff did not document orders or follow-up pertaining to dressing changes related to the use of the port.) Review of the resident's eMAR, dated 11/01/25 to 11/30/25, showed the following:-On 11/07/25, staff documented administration of meropenem, 1 gm per IV, at 8:00 P.M.;-On 11/08/25, staff documented administration of meropenem, 1 gm per IV, at 4:00 A.M., 12:00 P.M., and 8:00 P.M.;-On 11/09/25, staff documented administration of meropenem, 1 gm per IV, at 4:00 A.M., 12:00 P.M., and 8:00 P.M.;-On 11/10/25, staff documented administration of meropenem, 1 gm per IV, at 4:00 A.M., 12:00 P.M., and 8:00 P.M.;-On 11/11/25 staff documented administration of meropenem, 1 gm per IV, at 4:00 A.M., 12:00 P.M., and 8:00 P.M.;-On 11/11/25, 6:00 A.M. to 6:00 P.M. de-access port once final antibiotic dose was administered; frequency - one time. Staff documented Not administered: on hold and last dose is tomorrow evening;-On 11/12/25, staff documented administration of meropenem, 1 gm per IV, at 4:00 A.M. and 12:00 P.M. Review of resident's nurse's notes dated 11/12/25, at 11:05 A.M., showed physician in-house and gave orders to continue meropenem VI for UTI at 500 milligrams (mg) twice daily for one more week. IV site flushes well with dressing intact. (Staff did not document orders or follow-up pertaining to dressing changes related to the use of the port.) Review of the resident's POS, current as of 01/06/26, showed an order, dated 11/12/25, for meropenem reconstituted solution, 500 milligrams (mg), IV, twice a day for UTI,. (Staff did not document orders or follow-up pertaining to dressing changes related to the use of the port.) Review of the resident's eMAR, dated 11/01/25 to 11/30/25, showed the following:-On 11/12/25 staff documented administration of meropenem, 500 mg per IV, at 8:00 P.M.;Oon 11/13/25 staff documented administration of meropenem, 500 mg per IV, at 8:00 A.M. and 8:00 P.M.;-On 11/14/25 staff documented administration of meropenem, 500 mg per IV, at 8:00 A.M. and 8:00 P.M.;-On 11/15/25 staff documented administration of meropenem, 500 mg per IV, at 8:00 A.M.; medication refused at 8:00 P.M.;-On 11/16/25 staff documented medication refused at 8:00 A.M. and 8:00 P.M.;-On 11/17 25 staff documented medication refused at 8:00 A.M.; administered at 8:00 P.M.;-On 11/18/25 staff documented medication refused at 8:00 A.M. and 8:00 P.M.;-On 11/19/25 staff documented medication refused at 8:00 A.M. and 8:00 P.M.(Staff did not document a scheduled date/time to de-access the port after final antibiotic dose was administered.) Review of the nurses' noted showed staff did not document the port was de-accessed after the final antibiotic dose was administered. Observation and interview on 01/06/25, at 10:10 A.M., showed the resident said he/she had an implanted port previously used for cancer treatments that the facility had used for administering antibiotics. The port was not currently in use, and the skin was bare over the site. During an interview on 01/06/25, at 1:20 P.M., Licensed Practical Nurse (LPN) B said an LPN was not allowed to access/de-access a port, only a RN could do so. LPN B said he/she did administer IV medications through the resident's port, but only after an RN accessed it and set it up for use. He/she said there was always a dressing in place during the port use, but he/she did not change that dressing. During an interview on 01/06/26, at 1:25 P.M., LPN C said he/she thought a port dressing should be changed every seven days or according to nursing standards. He/she did not access the resident's port; only an RN could do that. During an interview on 01/06/25, at 1:41 P.M., RN D said he/she had not worked with a port at this facility. The RN said the port dressing change frequency would depend on the type of access needle/kit was used; either every seven days or daily. RN D was unable to locate a facility policy pertaining to the use of a resident's port. During an interview on 01/06/26, at 2:05 P.M., RN E said he/she did access the resident's port on 11/05/25, but was unable to maintain the line access during that day. The resident was sent to the hospital that day and returned a couple of days later with a new access line in place. RN E said the port dressing should be changed every seven days and as needed. The RN said he/she was not asked to de-access the port before his/her last day working at the facility (on either 11/17/25 or 11/18/25). During an interview on 01/06/25, at 2:17 P.M., the Director of Nursing (DON) said the facility did not have a policy and procedure pertaining to the use of a resident's port for treatment. The DON said an LPN could not access or de-access a port; they would need to enlist the assistance of an RN for those processes. The DON said the port dressing should probably be changed with every dosing of the antibiotic or at least every 24-72 hours as is done with a central line dressing. The port should be de-accessed after the last dose of antibiotic is administered. Regarding the scheduled de-access of Resident #1's port, LPN B had used the space to document not done; on hold due to the physician's extension of the orders through the next day. Staff should have input a new scheduled date to de-access the port to alert other staff of that need. During an interview on 01/06/25, at 3:30 P.M., the Administrator and the DON both said they had not been able to locate a policy or procedure pertaining to the use of a resident's port. The DON said staff should get specific orders for a dressing change frequency and get clarification on orders as needed. Staff should follow all physician orders. If an LPN is not allowed to perform a procedure based on their scope of duties, they should ask one of the RN's to complete and document the procedure. The port dressing should be changed at least weekly, but possibly every 72 hours. During an interview on 01/20/26, at 10:51 A.M., the physician said the nursing staff should have done routine dressing changes to the accessed port and followed the physician order to de-access the port after the last dose of the antibiotic. Staff should obtain and/or clarify all orders regarding any treatment or dressing changes. Complaint 2683316

Based on interview and record review, the facility staff failed to employ a qualified dietary manager for food and nutrition services with accredited education in food service management when the Dietary Manager's certified was expired. The facility census was 65. Review of the facility policy titled, Dining Services Department, dated May 2015, showed the following: -Dining services department supervision was to be under the guidance of a full-time person qualified by training and experience; -The Dining Services Manager (DSM) was to make sure that procurement and production and food products was carried out to ensure the resident a sufficient quantity of wholesome and nourishing food acceptable variety and quality. 1. Review of the Dietary Manager's (DM) certification showed the DM(DM) had a ServSafe Certification for completing the standards set forth for the ServSafe Food Protection Manager Certification Examination, dated 03/02/20, with a date of expiration 03/04/25. During an interview on 05/23/25, at 10:00 A.M. the DM said the following: -She had been DM since March of 2024; -Her ServSafe certification expired on 03/04/25; -She told the Administrator the certification was expiring; -She has not received any other trainings, nor does he have any other credentials. During an interview on 05/23/25, at 12:02 P.M., the Registered Dietician (RD) said the following: -She is at the facility three times monthly, and the DM can consult with her via email or phone; -The DM should have a completed and current ServSafe Food Protection Manager Certification; -She just learned the DM's ServSafe certification was expired. During an interview on 05/23/25, at 2:10 P., the Administrator said the following: -The DM should have a current ServSafe certification; -The DM advised her ServSafe certification was going to expire, and the Administrator told her it was her responsibility to ensure the certification was renewed.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards of practice and in a manner to prevent possible contamination when the facility staff failed to keep dented cans separate from other canned goods, failed to maintain contact surfaces in a manner that would prevent possible contamination of food, failed to sanitize the food thermometer between items, failed to ensure all food items were properly labeled and sealed, and when staff failed to use only food items stored in a safe manner when preparing food. The facility census was 65. 1. Review of the 2022 Food and Drug Administration (FDA) Food Code showed the following information: -Depending on the circumstances, rusted, and pitted or dented cans may present a serious potential hazard; -Damaged or incorrectly applied packaging may allow the entry of bacteria or other contaminants into the contained food; -If the integrity of the packaging has been compromised, contaminants may find their way into the food. Review of the facility policy titled, Nutrition and Dining Services Manual, dated May 2015, showed the following: -The Dietary Service Manager (DSM) or a trained dietary employee designated this responsibility receives all deliveries; -Orders will be inspected when received to ensure quality, quantity, and condition; -Leaking or severely dented cans should be disposed of promptly to prevent contamination of other foods. Observations on 05/19/25, at 9:53 A.M., of the canned food rack in the dry storage room showed the following: -A 7.12 pound (lb) can of baked beans with a large dent on side; -A 6.56 lb can of apricot halves with small dent on side; -A 6.56 lb can of [NAME] pears with large dent on side; -No signed designated area for dented cans. Observation on 05/21/25, at 10:59 A.M., of the can racks in the dry storage room showed the following: -A 7.12 lb can of baked beans with large dent on side; -A 6.56 lb can of apricot halves with small dent on side; -A 6.56 lb can of [NAME] pears with large dent on side; -A 6.75 lb can of black eyed peas with large dent on side; -A 6.8 lb can of fancy shredded sauerkraut with dent on side; -No signed designated area for dented cans. During an interview on 05/22/25, at 1:38 P.M., Dietary Aide (DA) G said the following: -Staff put dented cans in the back storage room and notify the Dietary Manager (DM); -Dented cans should not be on the rack and staff should not open them or serve any food from them. During an interview on 05/23/25, at 9:20 A.M., Dietary [NAME] (DC) H said the following: -He/she did not know what to do with a dented can; -He/she had not seen a dented can, but his/her best guess was it is okay to use it; -He/she was not aware of a designated spot to put dented cans. Observations and interview on 05/23/25, at 10:00 A.M., with the Dietary Manager (DM) showed the following: -Staff should place dented cans in the back room on a crate; -Dented cans should not be on the rack and should not be used; -When the DM was shown the dented cans on the rack, the DM said she thought they could be used, and only the cans dented on the bottom and top around the seal could not be used. During an interview on 05/23/25, at 12:02 P.M., the Registered Dietician said the following: -Dented cans should not be used and should not be on the rack; -Staff should put dented cans in a designated with a sign and off of the floor. During an interview on 05/23/25, at 2:10 P.M., the Administrator said the following: -Staff should not use dented cans; -Dented cans should not be on the rack; -Staff should place dented cans in a specified area to be sent back to the vendor. 2. Review of the 2022 Missouri Food Code showed the following: -The objective of cleaning focused on the need to remove organic matter from food contact surfaces so that sanitization could occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate, and insects and rodents will not be attracted; -Microorganisms may be transmitted from a food to the other foods by utensils, cutting boards, thermometers, or other food contact surfaces; -Food-contact surfaces and equipment used for time/temperature control for safety foods should be cleaned as needed throughout the day, but must be cleaned no less than every four hours to prevent the growth of microorganisms on those surfaces; -The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food if these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. Review of the facility policy titled, Nutrition and Dining Services Manual, dated May 2015, showed the following: -It was the responsibility of the Dining Services Manager to enforce the cleaning schedules and to monitor the completion of assigned cleaning tasks; -Daily, weekly, and monthly cleaning schedules were prepared by the Dining Services Manager with all cleaning tasks listed will be posted in the dietary department; -Specify the days the cleaning schedule will be done, who was responsible to do the cleaning by shift and position, post the schedule prior to the beginning of each week, and staff will initial in the column under the day the task is completed. Observation on 05/19/25, at 9:53 A.M., of the kitchen showed the following: -The ice machine back splash was dirty with specks of brown, yellow, and reddish particles; -The bottom shelf of steam table was dirty and had food particles and noticeable crumbs; -The stand up cooler had a syrup bottle with syrup all around the lid and down the side of the container. The left side of the back of the stand-up cooler had a brown substance streaming down the side of the wall and a red substance streaming down the back of the wall. The right side of the stand-up cooler had orange spots on the back wall; -The standing oven was greasy inside; -The vent fan over the prep table and silverware had dirt and dust on it; -The dry storage bin, containing what appeared to be flour, was dirty and grimy on the outside and sticky to the touch; -The microwave had splatters all over; -The large seasoning containers were visibly dirty and sticky to the touch; -The wire shelf containing seasoning containers was grimy and sticky; -The large plastic container with a powder substance labeled dry milk was dirty and sticky with food debris on top; -The large plastic storage container with cereal bags inside had pieces of various cereal in the bottom of it; -The area above the fan blades in the walk-in cooler had dirt and grime on it and was over the milk jugs; -The metal baking sheet in the walk-in cooler with condiment jugs sitting on it had dead flies, some smashed on the sheet. Observations on 05/21/25, at 10:59 A.M., of the kitchen showed the following: -The ice machine back splash was dirty with specks of brown, yellow, and reddish particles; -The bottom shelf of steam table dirty had food particles and noticeable crumbs; -The left side of the back of the stand-up cooler had a brown substance streaming down the side of the wall and a red substance streaming down the back of the wall; -The right side of the stand-up cooler had orange spots on the back wall. During an interview on 05/22/25, at 1:38 P.M. DA G said the following: -He/she did not know if there was a cleaning schedule; -He/she had received handwritten list to clean for the day; -He/she did not know who had the responsibility of cleaning the ice machine; -All surfaces should be wiped down and free of grime in the kitchen. During an interview on 05/23/25, at 9:20 A.M., DC H said the following: -He/she was not aware of a cleaning list; -He/she did not know who had the responsibility of cleaning the ice machine, but it should not have particles on the back splash; -The microwave and shelves are everyone's responsibility to clean; -Staff should clean seasonings, shelving, plastic containers if used, not one person was responsible; -He/she had been told night shift was responsible for cleaning the stand-up cooler, walk-in cooler and freezer, and they should be clean inside; -Fans should not have dirt or grime on them; -There should not be dead flies anywhere in the kitchen. During an interview on 05/23/25, at 10:00 A.M., the DM said the following: -There was a cleaning schedule for daily and monthly, but staff rarely have time to follow it; -The ice machine was probably the team's responsibility to clean. She did not know who was supposed to clean the inside of the ice machine and was not aware it was dirty; -Cleaning the coolers was whoever can get to them, and she never looked at the fans; -There should be no dirt, food particles, syrup, lint, or grime on surfaces or on fans; -All staff are responsible for cleaning the microwave and it should not have splatter; -Seasoning containers and plastic bins should be wipes down and free of grime; -There should not be dead flies in the cooler. During an interview on 05/23/25, at 12:02 P.M., the Registered Dietician (RD) said the following: -There should be a monthly cleaning schedule to include daily, weekly, and monthly cleaning; -All surfaces should be wiped down and free of grime, grease, and dirt. During an interview on 05/23/25, at 2:10 P.M., the Administrator said the expectation was all surfaces in the kitchen should be clean and free of grime and dust, and the DM was responsible for audits for cleanliness. 3. Observations on 05/21/25, at 10:59 A.M., 11:29 A.M., and 11:47 A.M., of the kitchen showed the following: -DC H cooking ground beef and spaghetti sauce. He/she placed the ground beef in a metal pan and wiped the thermometer with a towel that had been sitting on the counter with intermittent utensils being placed on it after stirring the ground beef and spaghetti sauce. DC H did not use an alcohol wipe before or after taking the temperature of the ground beef; -DC H returned to the stove area and placed a ladle and spatula back on the same towel used to wipe the thermometer and continued to pick up the utensils and use them in the cooking ground beef and spaghetti sauce; -At 11:29 A.M., DC H placed the spaghetti sauce on the steam table and placed the ladle laying on the towel in the sauce to be served to residents; -DC H used a spaghetti spoon to stir cooking spaghetti and would place intermittently on the same towel; -At 11:47 A.M., DC H removed a pan of green beans out of the oven and placed the thermometer he/she had wiped with the towel previously in the green beans to obtain the temperature. DC H then placed the uncovered open thermometer on the table next to the oven; -DC H drained the spaghetti and took the spaghetti spoon from the same towel and scooped the spaghetti noodles into a large pan on the steam table and placed the thermometer laying open in the spaghetti noodles without cleaning with alcohol wipes prior to or after. During an interview on 05/22/25, at 1:38 P.M., DA G said the following: -Staff should clean the thermometer with alcohol wipes in between uses; -He/she would not put a utensil on a kitchen towel in between uses. Staff should use a paper towel as a barrier or just wash the utensil in between uses. During an interview on 05/23/25, at 9:20 A.M., DC H said staff the following; -Staff can use a clean rag to place utensils on while cooking; -Staff can use the same rag to wipe off the thermometer after temping foods, but staff should not leave the thermometer laying opened on the table. During an interview on 05/23/25, at 10:00 A.M., the DM said the following: -Staff should not put utensils on a kitchen towel while cooking. Staff should either wash the utensil or place on parchment paper; -Staff should not wipe the thermometer with a kitchen towel. Staff should clean the thermometer with an alcohol wipe, then wipe paper towel, then place paper towel in sanitizer bucket and wipe the thermometer again. During an interview on 05/23/25, at 12:02 P.M., the Registered Dietician (RD) said the following: -Staff should use a plate to place utensils on while cooking; -Staff should use alcohol wipes for cleaning the thermometer not a kitchen towel; -Staff should not leave the thermometer opened on the kitchen counter. During an interview on 05/23/25, at 2:10 P.M., the Administrator said the following; -Staff should clean thermometers with alcohol wipes in between uses and should not clean with a kitchen towel nor leave the thermometer open and laying on the table. -Staff should not use a kitchen towel as a barrier for utensils. 4. Review of the 2022 Missouri Food Code showed food shall be protected from contamination by storing the food in a clean, dry location, and where it is not exposed to splash, dust, or other contamination. Review of the facility policy titled, Nutrition and Dining Services Manual, dated May of 2015, showed the following: -The Dietary Services Manager (DSM) was responsible for receiving and storing food and nonfood items; -Follow the rule of First in, First Out; -Keep all foods in clean and in undamaged wrappers or packages; -Reseal open boxes effectively. Observation on 05/19/25, at 9:53 A.M., in the kitchen showed the following: -Two squeeze bottles with a red substance inside. The tops were not closed/sealed, and there was no label identifying the substance or dates; -Large plastic container of yellow liquid with no label in stand-up cooler; -The storage cart next to table with utensils had a box of brown sugar unsealed and open to air; -Dry storage bin appeared to contain flour, but was unlabeled; -Container of dry grated parmesan cheese less than 1/4 full was unlabeled with a best used by date of 02/12/24; -Plastic container open to air, containing a crumb like substance, labeled graham crackers with a date of 06/04/24, not securely closed and open to air; -Bag of imitation bacon bits with top cut open, open to air and unlabeled; -Opened 24 ounce gelatin mix open to air; -Bag of instant pudding mix torn open, not sealed and open to air; -Open bag of green gelatin inside two-gallon plastic bag unsealed and open to air; -An opened 35 ounce bag of raisin bran unsealed and open to air; -One-gallon plastic container of Italian dressing in the dry storage room. The product had been opened and about ¾ was gone. There was a manufacturer label that read to refrigerate after opening; -Plastic 64 ounce jug of sweet and sour sauce in dry storage room with just under half used with a manufacturer label that read refrigerate after opening; -Spaghetti noodles open to air; -Enriched egg noodles opened and unsealed; -Inside the walk in cooler were two pieces of bread with cheese in between wrapped in butcher paper unsealed and unlabeled; an opened, unsealed one pound box of solid margarine; one quart plastic measuring cup containing what appeared to be margarine or butter open to air unlabeled; a baking sheet of bacon somewhat covered with parchment labeled bacon prep 5/19 for 5/20, with bacon visible and open to air with a cardboard box sitting on top of the parchment paper and a carton of eggs on top of the box; a five lb container of classic tuna salad over half used and unlabeled; a tray of salad in styro foam containers undated, not sealed and partially covered with plastic wrap; a sandwich in an opened plastic bag unlabeled; and a bowl of sliced tomatoes uncovered and unlabeled. During an interview on 05/22/25, at 1:38 P.M. DA G said the following: -Staff should place opened food items in a plastic container and labeled with date opened and use by date of five days; -Staff should seal and label opened dry products with the date opened; -Staff should label unrecognizable food items with the name; -Staff should throw all expired foods away; -Staff should wrap prepped bacon in saran wrap and should not set a box or carton of eggs on top; -Staff should label open tuna salad with date opened and use by date within five days; -Staff should ensure all food is in sealed bags or containers. During an interview on 05/23/25, at 9:20 A.M., DC H said the following: -Staff should clip or tape opened dry foods or place inside a sealed plastic bag and label with the date open, use by date of three days, and product name if not known; -All food items should be in sealed or closed containers; -The parmesan cheese should not be in rotation if expired. All expired food should be thrown out. He/she had no idea who had the responsibility of checking dates; -Staff should label dry storage bins of food with product name and date opened; -Staff should seal and label opened cooler items with the date opened and use by three days; -Staff should cover prepped bacon with parchment and place pans on top to cover. Staff do not have to put saran wrap around the bacon. Staff should not place boxes or egg cartons on top. During an interview on 05/23/25, at 10:00 A.M., the DM said the following: -Staff should label dry opened foods with two dates, opened and use by date of 30 days; -He/she was unsure of use by dates for seasoning, flour, sugar, and dry milk; -Staff should label food items with product name if not obvious; -Staff should seal all food with masking tape or place in a sealed plastic storage bag; -All expired foods should be thrown out and it was everyone's responsibility; -Staff should label cold foods with date opened and use by date; -Leftovers have a use by date of three days; -Staff should ensure all food items are sealed; -Staff should not prep bacon, but if they do it should be covered in saran wrap and to have items placed on top such as a box or carton of eggs. During an interview on 05/23/25, at 12:02 P.M., the Registered Dietician (RD) said the following: -Staff should place all opened dried foods in a sealed container and label with date opened and use by date; -Staff should label dried food storage containers with product name, date opened, and use by date of six months; -Staff should label items in the cooler for three days us by; -Staff should prep bacon by putting on sheet pans the day before and cover with saran wrap. The bacon must be sealed. During an interview on 05/23/25, at 2:10 P.M., the Administrator said the following: -Staff should label all foods with date opened and use by date, and ensure the items are sealed and contained so nothing can get in and nothing can get out; -Cooler items have a use by date of three days; -Staff should refrigerate food items requiring refrigeration and label with opened date and use by date of 30 days; -Staff should throw all expired food out. 5. Review of the 2022 Missouri Food Code showed temperature is one of the prime factors that controls the growth of bacteria in food. Many, though not all, types of pathogens and spoilage bacteria are prevented from multiplying to microbiologically significant levels in properly refrigerated foods that are not out of date. Observation on 05/21/25, at 1:05 P.M., showed DC I poured a jug of Italian dressing into a container of pasta. During an interview on 05/21/25, at 1:11 P.M., DC I said the following: -He/she obtained the Italian dressing for the pasta salad from the shelf in the dry storage unit, poured it on the pasta, then placed it in the fridge afterwards because it was supposed to go in the fridge. He/she didn't think about it being previously open, but it had been opened and part of the product was gone; -The container should have been labeled with the date opened and then placed in the fridge. During an interview on 05/21/25, at 3:31 P.M., the DM said staff should have labeled the Italian dressing with date opened, use by date (30 days), and placed in the fridge. During an interview o 05/22/25, at 1:38 P.M. DA G said staff should place Italian dressing in the refrigerator after opening and label with the open date. During an interview on 05/23/25, at 9:20 A.M., DC H said staff should place Italian dressing in the cooler after opening and label with the date opened and use by date. During an interview on 05/23/25, at 12:02 P.M., the Registered Dietician (RD) said staff should have labeled the opened Italian dressing with open date and use by date and placed in the refrigerator. Staff should refrigerate all items requiring refrigeration after opening. During an interview on 05/23/25, at 2:10 P.M., the Administrator said staff should refrigerate all items requiring to be refrigerated after opening and label with open date and use by date of 30 days.

Based on observation, interview, and record review, the facility failed to maintain an effective infection prevention and control program when the facility staff failed to follow standard precautions (the infection prevention measures that apply to all resident care, regardless of suspected or confirmed infection status of the resident, in any setting where healthcare is being delivered) during medication passes, when the facility staff failed to perform hand hygiene between residents during medication passes, and failed to disinfect the multi-use glucometers (a medical device that measures the amount of glucose (sugar) in the blood stream. The facility also failed to ensure employees were screened to identify communicable diseases when facility staff failed to obtain and document tuberculosis (TB - an infectious disease caused by bacteria that most often affects the lungs) testing/screening (also known as a Mantoux test, or tuberculin skin test (TST)) results for one staff member and failed to record the skin test results in millimeters (mm) induration as required. The facility census was 65. 1. Review of the facility's policy, titled Hand Washing, undated, showed the purpose was to reduce the transmission of organisms from resident to resident, nursing staff to resident, and resident to nursing staff. Review of the facility's policy, titled Blood Glucose Monitoring, undated, showed the following information: -Check physician's order for blood glucose testing; -Place equipment on a clean surface; -Explain procedure to the resident, don gloves, load strip into glucose monitor, assess the resident's fingertips for good blood supply and choose a site on the lateral surface of the fingertip, clean the selected finger with an alcohol wipe and allow to air dry, use safety lancet to obtain blood sample from the lateral side of the fingertip, place strip to blood to obtain the sample, allow monitor to calculate glucose level, check puncture site to be sure bleeding has stopped, discard strip and lancet in sharps container; -Disinfect glucose monitor and return to cart; -Remove gloves and wash hands; -Document glucose level. Review of the facility's policy, titled Blood Glucometer Disinfecting, undated, showed the following information: -Approved wipes with 10% bleach or comparable product are used; -Wash hands and don gloves; -Provide a clean field in which to place the glucose meter; -Clean the blood glucose meter prior to using with approved wipes with 10% bleach or comparable product, place on clean field, and let air dry. Do not touch the clean field with gloves including the test port. Glucometer may be wrapped in another wipe and store; -Remove gloves and wash hands. Observation on 05/21/25, at 11:45 A.M., showed Registered Nurse (RN) D prep to obtain Resident #57's blood glucose. RN D donned gloves obtained glucose strip and loaded it into the glucometer which laid on the medication cart. No clean barrier or disinfection of glucometer was provided prior to use. RN D entered the resident's room, obtained the resident's blood glucose level, laid the glucometer down onto the resident's bed, and discarded trash. RN D obtained the glucometer from the resident's bed and exited the room. RN D removed gloves and placed the glucometer down onto the medication cart. The RN did not complete hand hygiene. RN D documented blood glucose into the resident's EMR, touched the medication cart keys, and opened the medication cart. RN D then sanitized his/her hands, obtained a sani-cloth and cleansed the glucometer and medication cart. After disinfecting, RN D laid glucometer down onto the medication cart to dry with no clean barrier. Observation on 05/21/25, at 4:46 P.M., showed Licensed Practical Nurse (LPN) A don gloves without sanitizing his/her hands. He/she entered the resident's room and obtain the resident's blood glucose level. He/she exited the resident's room with the same gloves, returned the glucometer device to the medication cart without cleaning it, and obtained the resident's Humalog pen from the medication cart in the hall. He/she applied the needle on the pen and dialed the pen to 1 unit. He/she returned to the resident's room with the same gloves on, cleaned the resident's right quadrant with an alcohol wipe, and administered the 1 unit of insulin. He/she went back to the medication cart in the hall and removed his/her gloves. The LPN did not complete hand washing or hand sanitizing the resident's room before he/she exited. Hand sanitizer was used at the medication cart after he/she removed his/her gloves. The insulin pen was placed back in the medication cart, but it was not cleaned prior to replacing it in the cart. Observation on 05/21/25, at 4:52 P.M., showed LPN A prepped to obtain Resident #15's blood glucose level. The LPN did not perform hand hygiene prior to putting on the gloves. He/she took the same glucometer machine into the resident's room that was used in the previous room, which had not been cleaned, and obtain the resident's blood glucose level. With his/her gloves still on, he/she returned to the medication cart, placed the glucometer device on the cart without cleaning it, and obtained the resident's Humalog pen. LPN A applied the needle to the pen, uncapped the pen and dialed the dose to 9 units. He/she returned to the resident's room, cleaned the right lower quadrant injection site with an alcohol wipe and administered the insulin. LPN A exited the resident's room and returned to the medication cart with his/her gloves still on. The LPN did not complete hand hygiene. Observations on 05/21/25, at 4:55 P.M., showed LPN A utilize hand sanitizer, donned gloves, entered Resident #61's room, cleaned the resident's finger and obtained his/her blood sugar. LPN A returned to the medication cart with his/her gloves on. LPN A obtained the Humalog pen from the medication cart, placed the needle on the pen, uncapped the pen and dialed 10 units. He/she entered the resident's room, cleaned the abdominal area with an alcohol wipe, and administered the insulin. He/she wore his/her gloves to the med cart in the hall. LPN A did not perform hand hygiene wash his/her hands before exiting the resident's room. The insulin pen was placed back in the medication cart, but it was not cleaned prior to replacing it in the cart. During an interview on 5/23/25, at 12:10 P.M., RN D said the following: -Residents do not have their own glucometer devices; -The facility has a glucometer device that is shared among all residents; -Glucometer devices should be disinfected between resident's by using a one-minute sanitation/kill time wipe; -It is not appropriate to not disinfect the glucometer device between residents; -It is not appropriate to obtain a blood sugar, lay the glucometer device down on the bed, then exit the room and lay it down on the medication cart without cleaning it; -It is not acceptable to come out of a resident's room after obtaining blood glucose/blood sugar and put hands in pockets, obtain keys, open the cart, lay the glucometer device down onto the medication cart, then pick the glucometer device back up, touch the computer mouse, use a pen, etc. prior to sanitizing the glucometer device and hands; -Staff should wash their hands between residents and when their gloves are soiled. It would not be acceptable to not hand sanitize or wash your hands in between medication passes or blood glucose checks or insulin administration. During an interview on 5/23/25, at 12:20 P.M., LPN C said the following: -The facility shared glucometers should be disinfected with Microkill (sani) wipes as soon as it is brought out of the resident's room; -The device should be wiped down and wrapped with the wipe for at least one minute; -It is not appropriate to not disinfect the glucometer in between residents; -It is not appropriate to obtain a blood sugar on a resident, lay the glucometer device down on the bed, then exit the room and lay it down on the medication cart without cleaning it; -It is not acceptable to come out of a resident's room after obtaining a blood glucose/blood sugar and put hands in pockets, obtain keys, open the cart, lay the glucometer device down onto the medication cart, then pick the glucometer device back up, touch the computer mouse, use a pen, etc. prior to sanitizing the glucometer device and hands; -Handwashing should be done anytime staff enter a resident's room, before doing direct patient care, after removing gloves, and upon leaving a resident's room. It would not be acceptable to not hand sanitize or wash hands in between medication passes or blood glucose checks or insulin administration. During an interview on 05/23/25, at 1:48 P.M., the Director of Nursing (DON) said the following: -Glucometers should be cleaned in between use of residents; -After glucometers are cleaned, they should be put on a clean barrier and left to dry; -It is not appropriate for staff to not clean the glucometers between residents; -It is not appropriate for staff to stick their hands in their pockets and continue handling the glucometer without ever cleaning it; -She expected staff to wash their hands before they enter the resident's room, with any resident care, before serving meals, after they pick something up off the floor, and after using the restroom; -Staff have hand sanitizer to use in between residents, but they should wash their hands in between residents if they touch a resident. During an interview on 05/23/25, at 12:10 P.M., the Administrator said the following: -She expected staff to wash their hands for 20 seconds anytime their hands are contaminated; -She expected staff to use hand sanitizer in between residents when medications are being passed; -She expected glucometers to be disinfected after each use and to be placed on a clean barrier; -It was not appropriate for staff to obtain a blood sugar, lay the glucometer down onto the bed, and/or the medication cart. 2. Review of facility policy named Tuberculosis Control, undated, showed the following: -Initially, the facility provides a TB test to all employees prior to employment. If the initial skin test result are 0 to 9 mm, a second test should be given at least one week later and no more than three weeks after the first test; -All TB test results will be documented on the employee Immunization record including new hires and annual administration; -After the test has been administered, the results will be documented in mm; -Documented evidence of prior PPD will be maintained with facility employee immunization records. Review of Certified Nurse Aide (CNA) J's personnel file showed the following: -A hire date of 12/06/23; -Staff did not have documentation of a first and second step TB test completed prior to CNA J starting work at the facility. Review of Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) Coordinator's personnel file showed the following: -A hire date of 02/03/25; -Staff administered the first TB test on 02/03/25. Staff recorded the results on 02/05/25 as negative, with no mm induration indicated. -Staff administered the second TB test on 02/17/25. Staff recorded the results on 02/19/25 as negative, with no mm induration indicated. Review of Dietary [NAME] K's personnel file showed the following: -A hire date of 03/06/25; -Facility staff administered the first TB test on 03/04/25. Staff recorded the results on 03/06/25 as negative, with no mm induration indicated; -Facility staff administered the second TB test on 03/18/25. Staff recorded the results on 03/20/25 as negative, with no mm induration indicated. Review of Nurse Aide (NA) L's personnel file showed the following: -A hire date of 01/19/25; -Facility staff administered the first TB test on 01/13/25. Staff recorded the results on 01/15/25 as negative, with no mm induration indicated; -Facility staff administered the second TB test on 01/28/25. Staff recorded the results on 01/30/25 as negative, with no mm induration indicated. During an interview on 05/23/25, at 1:32 P.M., the Director of Nursing (DON) said all employees should have a TB test or screen prior to starting work at the facility with residents. She did not know TB test results were required to be noted in mm induration. During an interview on 05/23/25, at 1:52 P.M., the Administrator said all employees should have a negative TB test (or other screening, like an x-ray), prior to working in the building. All TB test results should be recorded in mm. She didn't know some employee records only showed results as negative, and not in 'mm' induration.

Based on observation, interview, and record review, the facility failed to ensure a sanitary environment for all staff and residents, when staff failed to maintain the floors, deep fryer, and plastic containers clean and free of dirt. The facility census was 65. Review of the facility policy titled, Nutrition and Dining Services Manual, dated May of 2015, showed the following: -It is the responsibility of the Dining Services Manager (DSM) to enforce the cleaning schedules and to monitor the completion of assigned cleaning tasks; -Daily, weekly, and monthly cleaning schedules prepared by the DSM with all cleaning tasks listed will be posted in the dietary department; -Specify the days the cleaning schedule will be done, who is responsible to do the cleaning by shift and position, post the schedule prior to the beginning of each week, and staff will initial in the column under the day the task is completed. Review of the Food and Drug Administration (FDA) 2022 Food Code showed the non-food contact surfaces of facilities, equipment, and utensils used in the operation of the establishment must be cleaned and sanitized as frequently as necessary to prevent the creation of unsanitary conditions for the adulteration of product. 1. Review of the facility weekly cleaning schedule showed the last posted cleaning schedule was dated February of 2025, and was only partially filled out with the last date of any cleaning completed as 03/29/25. Observations on 05/19/25, at 9:53 A.M., and on 05/21/25, at 10:59 A.M., of the kitchen showed the following: -The area under the ice machine was dirty with gunk on the floor; -The floor around the stacked dishes had a brown like substance sticking to floor under the shelf; -The floor under the utensil/pot table was dirty with black particles; -The plastic container on bottom shelf under the can opener was dirty and grimy all over and sticky to the touch; -The side of the deep fryer was covered in greasy substance, and the floor and wheels under the deep fryer were covered in greasy substance. During an interview on 05/22/25, at 1:38 P.M., Dietary Aide G said the following: -Floors should be cleaned every night by the night shift staff and day shift spot cleans throughout the day; -He/she did not know if there was a cleaning schedule; -He/she had received a handwritten list to clean for the day; -He/she did not know who had the responsibility of cleaning the fryer; -All surfaces should be wiped down and free of grime in the kitchen. During an interview on 05/23/25, at 9:20 A.M., Dietary [NAME] H said the following: -Night shift mops the floors at the end of their shift; -He/she had worked night shift two times, and staff don't have a lot of time to mop because they are to leave by 8:30 P.M.; -There should not be dirt/grime substances on the floor; -He/she was not aware of a cleaning list; -He/she did not know who had the responsibility of cleaning the deep fryer; -He/she was not aware of the deep fryer being cleaned since he/she was hired. During an interview on 05/23/25, at 10:00 A.M., the Dietary Manager (DM) said the following: -Floors should not be dirty and grimy; -The deep fryer should be free of grease and grime; -There is a cleaning schedule for daily and monthly, but staff rarely have time to follow it. During an interview on 05/23/25, at 12:02 P.M., the Registered Dietician (RD) said the following: -She completed kitchen inspections, including checking for cleanliness; -There should be a monthly cleaning schedule to include daily, weekly, and monthly cleaning; -All surfaces should be wiped down and free of grime, grease, and dirt. During an interview on 05/23/25, at 2:10 P.M., the Administrator said the expectation is all surfaces in the kitchen should be clean and free of grime and dust and the DM was responsible for audits for cleanliness.

Based on observation, interview, and record review the facility failed to ensure a medication error rate less than 5 percent when facility staff made three mediation errors out of 25 opportunities resulting in in a medication error rate was 12 % affecting three residents (Resident #15, #39, and #61). The facility census was 65. Review showed the facility did not provide a policy regarding insulin administration. Review of Humalog (insulin lispro injection - a rapid acting insulin) Manufacturer's Instructions, dated 03/2013, showed the following: -Pull the pen cap straight off and wipe the rubber seal with an alcohol swab; -Pull off the paper tab from outer needle shield; -Push the capped needle straight onto the pen and turn the needle forward until it is tight; -Pull off the outer needle shield, but do not throw it away; -Pull off the inner needle shield and throw it away; -Turn the dose knob to select 2 units; -Hold the pen with the needle pointing up, tap the cartridge holder gently to collect air bubbles at the top and while holding the pen up, push the dose knob in until it stops and 0 is seen in the dose window. -Prime the pen before each injection. Priming ensures the pen is ready to dose and removes air that may collect in the cartridge during normal use. If it is not primed before each injection, there may be too much or too little insulin; -Turn the dose knob to select the number of units needed. The dose indicator should line up with the needed dose; -Choose the injection site and insert the needle into the skin. 1. Review of Resident #15's face sheet (brief look at resident information) showed the following information: -admission date of 07/16/24; -Diagnoses included diabetes. Review of the resident's admission Minimum Data Set (MDS- a federally mandated assessment tool filled out by facility staff), dated 07/19/24, showed the following information: -Cognitively intact; -Received insulin injections seven days a week. Review of the resident's care plan, dated 08/02/24, showed staff to administer Humalog per physician order. Review of the resident's Physician Order Sheet (POS), dated 04/23/25 through 05/23/25, showed a current order for Humalog Insulin 100 units (u) / milliliter (ml), give 1 u for every 20 milligrams per deciliter (mg/dL) over 150 mg/dL (blood sugar reading) subcutaneously (under the skin) before meals. Observation on 05/21/25, at 4:50 P.M., showed Registered Nurse (RN) A donned gloves and obtained the resident's blood glucose level of 340 mg/dL. RN A obtained the resident's Humalog pen, pushed the needle into the pen, uncapped the pen, dialed the dose dial up to 9 u, and administered the insulin to the resident. He/she did not prime the insulin pen. 2. Review of Resident # 39's face sheet, showed the following information: -admission date of 08/15/24; -Diagnoses included diabetes. Review of the resident's admission MDS, dated [DATE], showed the following: -Cognitively intact; -Received insulin injections seven days a week. Review of the resident's care plan, dated 09/02/24, showed staff to administer Humalog per physician orders. Review of the resident's POS, dated 04/23/25 through 05/23/25, showed a current order for Humalog Insulin 100 u/ml, give 1 u every 20 mg/dL over 150 mg/dL subcutaneously before meals and at bedtime. Observation on 05/21/25, at 4:45 P.M., showed RN A donned gloves and obtained the resident's blood glucose level of 181 mg/dL. RN A obtained the resident's Humalog pen, pushed the needle into the pen, uncapped the pen, dialed the dose dial up to 1 u, and administered the insulin to the resident. He/she did not prime the insulin pen. 3. Review of Resident #61's face sheet, showed the following information: -admission date of 03/20/24; -Diagnoses included diabetes. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Received insulin injections seven days a week. Review of the resident's care plan, dated 09/26/24, showed staff to administer Humalog per physician orders. Review of the resident's POS, dated 04/23/25 through 05/23/25, showed a current order for Humalog Insulin 100 u/ml, give 1 u every 20 mg/dL over 150 mg/dL subcutaneously before meals. Observation on 05/21/25, at 4:55 P.M., showed Licensed Practical Nurse (LPN) A utilize hand sanitizer, donned gloves, entered the resident's room, cleaned the resident's finger and obtained his/her blood sugar, which was 349 mg/dl. The LPN said that he/she had an order to administer Humalog 1 unit for every 20 mg/dL over 150 mg/dL. He/she stated that he/she would round up the insulin dose and administer 10 units. LPN A obtained the Humalog pen from the medication cart, placed the needle on the pen, uncapped the pen and dialed 10 units. LPN A did not prime the insulin pen prior to dialing the 10 unit dose. He/she entered the resident's room, cleaned the abdominal area with an alcohol wipe and immediately administered the insulin. 4. During an interview on 5/23/25, at 1:48 P.M., the Director of Nursing (DON) said the following: -Nursing staff are expected to follow physician orders, including insulin orders; -Staff are expected to prime insulin pens before each administration. During an interview on 05/23/25, at 3:00 P.M., the Administrator said the following: -Staff are expected to prime insulin pens before each administration; -Staff are expected to follow physician order/sliding scale.

Based on observation, interview, and record review the facility failed to ensure resident were free of significant medication errors when staff failed to prime insulin pens before insulin administration for three residents (Resident #15, #39, and #61). The facility census was 65. Review showed the facility did not provide a policy regarding insulin administration. Review of Humalog (insulin lispro injection - a rapid acting insulin) Manufacturer's Instructions, dated 03/2013, showed the following: -Pull the pen cap straight off and wipe the rubber seal with an alcohol swab; -Pull off the paper tab from outer needle shield; -Push the capped needle straight onto the pen and turn the needle forward until it is tight; -Pull off the outer needle shield, but do not throw it away; -Pull off the inner needle shield and throw it away; -Turn the dose knob to select 2 units; -Hold the pen with the needle pointing up, tap the cartridge holder gently to collect air bubbles at the top and while holding the pen up, push the dose knob in until it stops and 0 is seen in the dose window. -Prime the pen before each injection. Priming ensures the pen is ready to dose and removes air that may collect in the cartridge during normal use. If it is not primed before each injection, there may be too much or too little insulin; -Turn the dose knob to select the number of units needed. The dose indicator should line up with the needed dose; -Choose the injection site and insert the needle into the skin. 1. Review of Resident #15's face sheet (brief look at resident information) showed the following information: -admission date of 07/16/24; -Diagnoses included diabetes. Review of the resident's admission Minimum Data Set (MDS- a federally mandated assessment tool filled out by facility staff), dated 07/19/24, showed the following information: -Cognitively intact; -Received insulin injections seven days a week. Review of the resident's care plan, dated 08/02/24, showed staff to administer Humalog per physician order. Review of the resident's Physician Order Sheet (POS), dated 04/23/25 through 05/23/25, showed a current order for Humalog Insulin 100 units (u) / milliliter (ml), give 1 u for every 20 milligrams per deciliter (mg/dL) over 150 mg/dL (blood sugar reading) subcutaneously (under the skin) before meals. Observation on 05/21/25, at 4:50 P.M., showed Registered Nurse (RN) A donned gloves and obtained the resident's blood glucose level of 340 mg/dL. RN A obtained the resident's Humalog pen, pushed the needle into the pen, uncapped the pen, dialed the dose dial up to 9 u, and administered the insulin to the resident. He/she did not prime the insulin pen. 2. Review of Resident # 39's face sheet, showed the following information: -admission date of 08/15/24; -Diagnoses included diabetes. Review of the resident's admission MDS, dated [DATE], showed the following: -Cognitively intact; -Received insulin injections seven days a week. Review of the resident's care plan, dated 09/02/24, showed staff to administer Humalog per physician orders. Review of the resident's POS, dated 04/23/25 through 05/23/25, showed a current order for Humalog Insulin 100 u/ml, give 1 u every 20 mg/dL over 150 mg/dL subcutaneously before meals and at bedtime. Observation on 05/21/25, at 4:45 P.M., showed RN A donned gloves and obtained the resident's blood glucose level of 181 mg/dL. RN A obtained the resident's Humalog pen, pushed the needle into the pen, uncapped the pen, dialed the dose dial up to 1 u, and administered the insulin to the resident. He/she did not prime the insulin pen. 3. Review of Resident #61's face sheet, showed the following information: -admission date of 03/20/24; -Diagnoses included diabetes. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Received insulin injections seven days a week. Review of the resident's care plan, dated 09/26/24, showed staff to administer Humalog per physician orders. Review of the resident's POS, dated 04/23/25 through 05/23/25, showed a current order for Humalog Insulin 100 u/ml, give 1 u every 20 mg/dL over 150 mg/dL subcutaneously before meals. Observation on 05/21/25, at 4:55 P.M., showed Licensed Practical Nurse (LPN) A utilize hand sanitizer, donned gloves, entered the resident's room, cleaned the resident's finger and obtained his/her blood sugar, which was 349 mg/dl. The LPN said that he/she had an order to administer Humalog 1 unit for every 20 mg/dL over 150 mg/dL. He/she stated that he/she would round up the insulin dose and administer 10 units. LPN A obtained the Humalog pen from the medication cart, placed the needle on the pen, uncapped the pen and dialed 10 units. LPN A did not prime the insulin pen prior to dialing the 10 unit dose. He/she entered the resident's room, cleaned the abdominal area with an alcohol wipe and immediately administered the insulin. 4. During an interview on 5/23/25, at 1:48 P.M., the Director of Nursing (DON) said the following: -Nursing staff are expected to follow physician orders, including insulin orders; -Staff are expected to prime insulin pens before each administration. During an interview on 05/23/25, at 3:00 P.M., the Administrator said the following: -Staff are expected to prime insulin pens before each administration; -Staff are expected to follow physician order/sliding scale.

Based on observation, interview, and record review, the facility failed to ensure all food was prepared in a manner that conserved the nutritional value of the food when staff failed to follow approved recipes for preparation of pureed recipes potentially affecting the nutritional value of the food prepared. The facility census was 65. Review of the facility policy titled, Types of Diets, dated May of 2015, showed the following: -Regular mechanical soft was a diet that followed the regular diet and was modified mainly in the method of preparation to accommodate residents when chewing is difficult/limited. Meat will be chopped or ground; -Pureed diet was the diet for the edentulous resident and residents with swallowing difficulties. Foods were blended to mashed potato consistency or altered to meet the needs of the resident, using as little liquid as possible. 1. Review of the approved recipe for spaghetti with meat sauce showed the following: -Brown meat until product temperature reaches 160 degrees Fahrenheit (F) for 15 seconds and pour off excess fat. -Combine sauce (canned marinara sauce) and meat and simmer 30 minutes until the final product temperature reaches 165 degrees F for 15 seconds. -Bring water to a boil with vegetable oil added to prevent foaming. Add pasta gradually while stirring and return to a boil. [NAME] uncovered on a fast boil until tender. Drain. -For ground texture modifications, cut spaghetti noodles to bite size pieces; -For ground or chopped menu items, grind or chop food to appropriate consistency; Review of the approved recipe for pureed spaghetti with meat sauce showed the following: -Cook meat per regulator recipe; -Using stock beef/soup base and food thickener, prepare slurry and process until smooth using one ounce of slurry per portion. Observation and interview on 05/21/25, at 10:59 A.M., with Dietary [NAME] (DC) H showed the following: -DC D placed ground beef with no sauce in the blender to puree without measuring; -He/she said he/she guestimates how much food is needed for puree and mechanical meals and does not refer to a recipe or menu; -He/she always uses water to puree and put water in the ground beef to puree; -He/she sometimes will add thickener if too runny; -He/she said he/she pureed the green beans and bread prior to the observation and eyeballed the amounts and did not refer to a recipe; -He/she used the juice from the can of green beans to puree the green beans and water to puree the bread; -He/she said he/she was not trained to follow a recipe; -He/she eyeballed an amount of spaghetti to blend for mechanical soft; -He/she did not initially puree noodles or sauce for the puree spaghetti and meat sauce puree meal. He/she then took some spaghetti noodles and mechanical meat sauce off the steam table without measuring and added to the pureed ground beef and pureed all together for the puree meal. During an interview on 05/22/25, at 1:38 P.M., Dietary Aide (DA) G said the following: -He/she prepared purees and followed the recipe book for measurements; -He/she used water for purees unless the recipe says broth. During an interview on 05/23/25, at 10:00 A.M., the Dietary Manager (DM) said staff should follow the recipes when preparing puree meals. During an interview on 05/23/25, at 12:02 P.M., the Registered Dietician said staff should follow the recipe when preparing purees and should be using whatever the liquid the recipe calls for to use. During an interview on 05/23/25, at 2:10 P.M., the Administrator said staff should follow recipes to prepare puree meals.

Based on observation, interview, and record review, the facility failed to provide a clean, comfortable, and homelike environment, for all resident when the facility failed to maintain a sanitary and orderly interior room for two residents (Resident #10 and Resident #15. The facility census was 65. Review of the facility's policy titled, Cleaning Guidelines-Bed Mattress, undated, showed the following information: -Mattress are to be cleaned when soiled, on bath days, and when the room is deep cleaned; -Bed linen should be removed and placed in dirty linen barrel and any debris should be removed; -Spray the mattress with disinfectant and wipe clean. Allow the bed to air dry; -Make the bed with fresh linen after mattress has dried. Review of the facility's policy, titled Pest Control, undated, showed the following information: -The facility will have a pest control contract which provides frequency treatment of the environment for pests; -Monitoring the environment will be done by the facility's staff; -Pest control problems will be reported promptly. 1. Review of Resident #10's face sheet (brief look at resident information) showed the following information: -admission date of 05/06/24; -Diagnoses include diarrhea, dementia, and Escherichia coli (E-coli-a bacterial disease that can cause watery diarrhea, nausea, vomiting, stomach pain, fever, and fatigue). Review of the resident's care plan, revised 08/27/24, showed the following: -Keep linen clean, dry, and wrinkle free; -Keep the resident clean and dry; -Required assistance from staff for toileting/hygiene. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool filled out by facility staff), dated 02/09/25, showed the following information: -Moderate cognitive impairment; -Required substantial to maximum assistance from staff for toileting; -Required partial to moderate assistance from staff for personal hygiene. Observations on 05/19/25, at 11:00 P.M., showed the resident lay on his/her left side in his/her bed with eyes closed. The resident was laying on top of the covers and a bed pad which was noted to have brown staining. The resident was dressed in a sweatshirt and a brief. The brief was notably soiled with brown and yellow coloring. While observing the resident, multiple flies were noted in the room, some landing on the residents bedding, the resident, and this surveyor's tablet. Observations 05/19/25, at 2:00 P.M., showed the resident lay on his/her left side in his/her bed with eyes closed. The resident was laying on top of the covers and a bed pad which continued to have brown staining. The resident was dressed in a dress and a brief. The brief was notably soiled with brown and yellow coloring. The residents call light is on the right side of the bed was in the floor. While observing the resident, multiple flies were noted in the room. At 2:07 P.M., facility staff entered the room to assist the resident's roommate (Resident #15). The staff member did not address the odor, brown staining, or soiled brief and exited the room after assisting the resident's roommate. During an interview on 05/23/25, at 11:30 A.M., Certified Nursing Assistant (CNA) B said the following: -The resident was incontinent, and often refused to be changed; -It was unacceptable for a resident to sit in soiled clothing/linen. During an interview on 05/23/25, at 1:00 P.M., Licensed Practical Nurse (LPN) C said the following: -The resident was incontinent and often refused to be changed; -It was unacceptable for a resident to sit in soiled clothing/linen; -If the resident did refuse care, that should be documented in the resident's record. During an interview on 05/25/23, at 2:35 P.M., The Care Plan Coordinator said frequent care refusals should be documented in the resident's care plan. During an interview on 05/23/25, at 2:00 P.M., the Director of Nursing (DON) said the following: -The resident was incontinent and refused care at times, which should be care planned; -It was not appropriate for a resident to sit in soiled clothing/linen. 2. Review of Resident #15's face sheet showed the following information: -admission date of 07/16/24; -Diagnoses included diabetes, kidney failure, and high blood pressure. Review of the resident's admission MDS, dated [DATE], showed the following: -Cognitively intact; -Required supervision from staff for toileting and personal hygiene. Review of the resident's care plan, revised 08/02/24, showed the following: -Keep linen clean, dry, and wrinkle free; -Keep the resident clean and dry. During an interview on 05/19/25, at 2:03 P.M., the resident said there are and had been multiple flies in the room. He/she has addressed this with staff, and they tell him/her, that it is his/her and his/her roommate's fault due to having incontinent episodes. The flies and odor are bothersome, and no one will do anything about it. Observation and interview on 05/20/25, at 11:33 A.M., showed flies remained in the resident's room and were landing on the resident as he/she was speaking with the surveyor. The resident said the staff help his/her roommate however, his/her roommate is suffering from diarrhea and has been for the last three days and that has really contributed to the odor and flies in the room. Staff have continued to not address the issue. During an interview on 05/23/25, at 11:30 A.M., CNA B said the following: -There are flies in the room. Both residents are incontinent and don't notify staff when they have an incontinent episode, which draws flies; -He/she had not reported the issue due to the residents not complaining directly to him/her about it. During an interview on 05/23/25, at 1:00 P.M., LPN C said the following: -He/she was not aware of the flies in the residents' room; -Had he/she been notified, he/she would have reported it to the Administrator for correction. During an interview on 05/23/25, at 2:00 P.M., the Director of Nursing (DON) said the following: -She was not aware of the flies in the room,. She would have reported it to the Administrator to get pest control in the room. 3. During an interview on 05/23/25, at 3:00 P.M., the Administrator said the following: -She was not aware of any issue with flies; -It was not acceptable for a resident to sit in soiled clothing/linen; -All aspects of care including refusals are expected to be seen within the resident's care plan.

Based on record review and interview, facility staff failed to complete a significant change Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff) within the required 14 days after hospice service admission for one resident (Residents #4) of twenty sampled residents. The facility had a census of 65. 1. Review of Resident #4's face sheet showed the following: -admission date of 06/01/23; -Diagnoses included Alzheimer's dementia, anxiety, arthritis, and type 2 diabetes. Review of the residents physician's orders showed an order, dated 06/25/24, for hospice consultation. Review of the resident's hospice agreement showed the agreement signed on 06/27/24. Review of the resident's care plan, last reviewed 04/03/25, showed on 12/20/24, staff care planned the resident had chosen to be placed on hospice services (186 days after hospice services were started). Review of the resident's quarterly MDS, dated [DATE], showed the the resident was not on hospice services (78 days after hospice services started). Review of the resident's quarterly MDS, dated [DATE], showed the resident was on hospice (170 days after hospice had first begun for the resident). Review on 05/21/25 showed staff had not completed a significant change MDS to address the change in the resident's hospice status. During an interview on 05/23/25, at 1:20 P.M., the MDS Coordinator said the following: -Staff should complete a significant change MDS when a resident has changed from their baseline; -Staff would be informed of the need for a significant change assessment based on information given in the staff stand-up meetings daily; -He/she would complete a significant change MDS as soon as he/she knew one was needed; -He/she had not completed any significant change assessments since she started in February 2025; -The facility's Corporate Reimbursement Consultant comes to the building once or twice a month to see if assessments have been completed timely and appropriately; -Staff have only completed quarterly and annual MDS assessments for the resident. Staff had not completed a significant change MDS for the resident; -Hospice would require staff to complete a significant change assessment. The resident started on hospice services on 06/27/24. During an interview on 05/23/25, at 1:32 P.M., the Director of Nursing (DON) said the following: -Staff should complete a change of condition MDS assessment any time a resident has a significant change; -After reviewing resident records, the DON said the resident should have had a significant change MDS completed within a few days of starting hospice; -The resident started hospice services on 06/27/24, but staff had never completed a significant change MDS. During an interview on 05/23/25, at 1:52 P.M., the Administrator said the following: -The resident care and status are discussed almost daily, in staff stand-up meetings; -A Medicare consultant comes in once a month to audit MDS assessments and to see if they have been completed; -One of the regional nurses audits assessments to see if staff have completed them timely and accurately; -Starting hospice services would require staff to complete a change in condition MDS assessment; -She would like for staff to complete change in condition assessments 24 to 72 hours after the change was made or observed; -The Administrator confirmed the resident started hospice services on 06/27/24, but staff had never completed a significant change MDS.

Based on observation, interview, and record review, the facility failed to provide services that met professional standards of quality when the facility failed to document completion of proper notification and post fall assessments/monitoring for one resident (Resident #16) who was found on the floor by staff. The facility census was 65. Review of the facility's policy, titled Event Investigation, undated, showed the following information: -Complete a report of event form as soon as possible whenever there is an unusual, unexpected, and/or unintended event that is not consistent with the routine operation of the facility, the routine care of the resident and/or adversely effects or has the potential to adversely affect a resident or visitor; -The form should be completed with falls or when a resident is found on the floor; -The report should include facility name, resident identification, date and time of the event, description of the event, witness information, primary diagnoses, cognitive status, location of the event, equipment involved, type of event, observations, location of injuries, vital signs, neuro status, range of motion, pain, if first aid was given, if seen by physician, if transferred to hospital, notifications of physician, responsible party, and administration, any new physician orders, actions to prevent reoccurrence, and documentation of follow up in the progress notes. 1. Review of the Resident #16's face sheet (brief look at resident information) showed the following: -admission date of 02/26/25; -Diagnoses included dementia, kidney disease, and diabetes. Review of the resident's fall risk assessment, dated 02/26/25, showed staff assessed the resident as a high fall risk. Review of the resident's admission Minimum Data Set (MDS- a federally mandated assessment tool filled out by facility staff), dated 03/02/25, showed the following information: -Cognitively impaired; -Dependent on staff for mobility. Review of the resident's care plan, reviewed on 03/11/25, showed the following: -Staff needed to assess the resident for proper footwear; -Keep call light within the resident's reach; -Maintain the bed in the lowest position; -Orient the resident. Review of the resident's progress note dated 05/04/25, at 1:08 A.M., showed staff was called into the resident's room related to the resident being found on the floor mat beside his/her bed. The resident was assessed for injury with no obvious deformities noted. The resident said that he/she had pain to his/her right knee, but it was not unbearable. The resident denied pain medication. The resident was assisted back into bed with help of a certified nursing assistant (CNA). The resident's skin was assessed and an abrasion to the right buttock was found. Staff applied barrier cream. Staff checked vital signs which were stable. (Staff did not document notifications of the resident's physician, the Director of Nursing (DON), or the resident's family.) Review of the resident's progress notes, dated 05/04/25 through 05/10/25, showed staff did not document follow-up monitoring of the resident's fall. Review of the resident's electronic medical record (EMR) showed staff did not document an event for the resident's fall. During an interview on 05/23/25, at 11:30 A.M., CNA B said the following: -If a resident falls, he/she reports it to the charge nurse; -The charge nurse will come assess the resident and determine if it is safe to move the resident; -After assessing the resident, the charge nurse will obtain vital signs and begin monitoring of the resident; -The resident was a high fall risk. During an interview on 05/23/25, at 12:45 P.M., Licensed Practical Nurse (LPN) C said the following: -If a resident were to fall, he/she would go and assess the resident; -After assessing the resident for injury, he/she and the CNA's would assist the resident back into his/her chair/bed; -He/she would start fall documentation which included neurochecks; -He/she would initiate an event in the resident's EMR; -Progress notes of fall monitoring to include neurochecks and vital signs would be documented for 72 hours; -He/she would notify the resident's family, physician, and nurse on call; -The resident was a high fall risk and is non-compliant with asking for assistance for transfers. During an interview on 05/23/25, at 1:45 P.M., the Director of Nursing (DON) said the following: -If a resident fell, she expected staff to assess the resident, start neurochecks, notify the physician, family, and herself, and initiate event charting; -The resident was a high fall risk; -The DON looked in the resident's EMR and verified there was no event initiated for the resident's fall, and said she expected it to be there. During an interview on 05/23/25, at 3:00 P.M., the Administrator said the following: -She expected staff to do an assessment, incident report, and notify the proper people if a resident were to fall; -Additionally, policy says the staff should start neurochecks and document.

Based on interview and record review, the facility failed to provide care in accordance with professional standards when facility staff failed to complete an ordered x-ray and follow-up with the ordering provider for one resident (Resident #1) who had complaints of leg pain and swelling until, three days after the initial order resulting in delayed treatment of a fractured ankle. The facility census was 74. Review showed the facility did not provide a policy related to resident change in condition. 1. Review of the Resident #1's face sheet (brief information sheet about the resident), showed the following: -admitted [DATE]; -Diagnoses included cerebral infarction (stroke - condition where blood flow is interrupted, causing brain tissue to die), heart failure (chronic condition in which the heart doesn't pump blood as well as it should), disorder of bone density and structure (medical condition where the bones lose mineral density and experience changes in their architectural makeup, leading to weakened bones that are more prone to fractures), and pain. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 01/28/25, showed the following: -Cognitively intact; -Limited range of motion both lower extremities; -Use of walker and wheelchair; -Supervision required for transfers to bed, chair, and toilet; -Dependent on staff for wheelchair mobility. Review of the resident's care plan, last reviewed 12/23/24, showed the following: -Resident had pain related to osteoarthritis (degeneration of joint cartilage and the underlying bone, causes pain and stiffness), spinal stenosis (condition where the spinal canal, the bony tunnel that contains the spinal cord and nerve roots, becomes narrowed) and bone density disorder, -Resident's pain will be recognized and effectively treated to promote his/her comfort and well-being, lessening symptoms and functional decline; -Staff should administer acetaminophen (analgesic drug used to relieve mild or chronic pain) and Aleve (nonsteroidal anti-inflammatory drug (NSAID) that reduces pain) per physician order and monitor for effectiveness; -Staff should identify any causative factors and ways to alleviate; -Staff should monitor pain every shift and as needed; -Staff should offer non-drug interventions such as repositioning, relaxation, increased or decreased active, etc.; -Resident had reduced activity of daily living (ADL) functioning related to impaired mobility; -Staff should provide standby assist for ADL's to include toileting, bathing, grooming, dressing and eating; -Staff should notify physician and responsible party with changes in care as needed. Review of the resident's medical record showed the following: -A physician order, written on 01/31/25, by nurse practitioner (NP - nurse who is qualified to treat certain medical conditions without the direct supervision of a doctor) for left ankle x-ray (medical imaging technique that uses radiation to create pictures of the inside of the body) three view due to pain and swelling; -A note written across the order that stated physician said no. Review of the resident's medical record showed staff did not document follow-up with the NP regarding the ordered x-ray and did not document a reason the physician said no. Review of the resident's progress notes showed the following: -On 02/03/25, at 10:50 A.M., a phone call was received from NP asking about the x-ray of left ankle. The nurse informed the NP that the physician said not to do the x-ray. The NP informed the nurse he/she spoke with the physician and he/she okayed the order and to proceed with the x-ray. Order placed and awaiting mobile x-ray company. Staff will continue with current plan of care; -On 02/04/25, at 10:47 A.M., the preliminary results of x-ray showed a tibia and fibula (two long bones in the lower leg that connect the knee to the ankle) fracture determined by NP. NP ordered resident sent to the emergency room . Staff notified the resident's family; -On 02/04/25, on 6:00 P.M., the nurse took report from the emergency room nurse. The resident was returning via ambulance. Resident had a fractured left tibia/fibula. The left leg was splinted with long-leg posterior splint with stirrups (device that immobilizes the lower leg and foot to treat injuries to the knee, ankle, and leg) and resident was to be non-weight bearing to left leg. Resident will need follow up with orthopedic (branch of medicine related to bones). Review of the resident's emergency room records, dated 02/04/25, showed the following: -Patient presented to the emergency room with complaints of left ankle pain and swelling; -Patient stated had imaging done at nursing home and had broken ankle in two spots; -Patient stated that he/she had not walked in years and pretty much was in a wheelchair; -X-ray results showed non-displaced medial malleolus (the inner bony bump on the ankle) fracture and non-displaced fracture of the distal meta-diaphysis (long tubular (long round) mid-portion of bone) of the fibula; -Patient placed in a long-leg posterior splint with stirrups. During an interview on 02/25/25, at 8:20 A.M., the resident said that he/she had an x-ray of left lower leg because of pain and swelling. The x-ray showed a fracture. He/she did not remember bumping or injuring the leg. This also had happened to his/her right leg about five years ago. He/she said that there was initially mild pain that increased to severe pain for about one week and the NP ordered an x-ray. During an interview on 02/25/25, at 12:35 P.M., the resident's Nurse Practitioner said that the resident had complained of leg pain for about one month. He ordered an x-ray and the primary physician denied the x-ray request because of the past history of right leg fracture. The nursing staff did not notify the NP that the x-ray order was not approved or completed. He called several days later for the results and was notified at that time. He contacted the primary physician and discussed that it was the left leg not the right leg and the physician then approved the x-ray. He said that he was not always notified if the orders he recommended were not carried out. He was not notified that the x-ray was not done. During an interview on 03/03/25, at 9:20 A.M., the resident's Physician said that all orders have to come through her. She denied the x-ray order because she was not told which leg and the right leg had been x-ray multiple times and it was not necessary to x-ray that leg again. It was a miscommunication and the resident should have gotten the care sooner. During an interview on 02/25/25, at 11:10 A.M., Nurse Aide (NA) B said that any time a resident had complaints of new pain or other new symptoms, he/she would immediately notify the charge nurse. If the NA felt the nurse was not evaluating the complaint, the NA would go up the chain of command. The resident rarely complained of pain prior to the recent leg fracture. During an interview on 02/25/25, at 12:40 P.M., Certified Nurse Aide (CNA) C said that if a resident had complaints of new pain or other new symptoms, he/she would immediately notify the charge nurse. The resident had no complaints of any injury to his/her leg. He/she went with the resident to the appointment. The resident only complained of pain when standing to transfer. During an interview on 02/25/25, at 12:50 P.M., CMT D said that any time a resident had any complaints of pain or other symptoms he/she would immediately notify the charge nurse. During an interview on 02/25/25, at 1:10 P.M., Registered Nurse (RN) A said that for any resident change in condition he/she would go assess the resident and note the type of pain, see if the pain was new or chronic and usually document a progress note. The resident had complaints of chronic pain to the right leg and did not complain of left leg pain until the fracture was noted. When the NP provides an order the nurses notify the physician to get approval. This can be frustrating and is more time consuming and may have delayed the resident care due to waiting to get the second order. At the time of the x-ray order for the resident denied the order. The physician was the overall provider for the resident's care plan. Prior to the fracture the resident had chronic pain of the right leg. There was some swelling of the left leg with no significant change or bruising noted on the leg. During an interview on 02/25/25, at 1:25 P.M., RN E said that he/she would assess any resident's complaints of new pain or change in health condition. He/she would notify the Assistant Director of Nursing (ADON), Director of Nursing (DON), and the physician. During an interview on 02/25/25, at 1:30 P.M., Licensed Practical Nurse (LPN) F said if a resident had complaints of new symptoms, including pain, he/she would notify the charge nurse. He/she completed skin assessments weekly and noted no redness or bruising of the resident's left leg. He/she said that when the NP provided the x-ray order for the resident, he/she texted the primary physician and the physician said not to get the x-ray. He/she was unsure if the nurses notified the NP of the denied x-ray order. The resident complained of increased pain from 01/31/25 to 02/04/25. The x-ray results were received on 02/04/25. During an interview on 02/25/25, at 2:05 P.M., the DON said that the nursing staff should notify the physician for orders for any resident complaint of new pain. The nursing staff should notify the NP for any residents under the NP care. They also notify the physician for approval of any orders the NP provided. She was not aware of the x-ray order being denied until after the second x-ray ordered was approved on 02/03/25. She expected the nursing staff to follow the physician orders. She did not know if staff notified the NP that the order was denied. It would be a good idea to notify the NP. The resident had swelling and pain in the left leg. She did not know if the staff notified the physician of that along with the request for left leg x-ray. During an interview on 02/25/25, at 2:25 P.M., the Administrator said she expected staff to notify the charge nurse with any new complaints of pain or change in health. The nurse should evaluate and contact the physician and family of new pain or change in health. When the NP provided an order the staff should contact the physician for approval. When the x-ray order for the resident was not completed the staff should have contacted the NP and should have told the Administrator and DON. Any resident change in condition should be discussed in morning meetings. MO00249046

Based on observation, interview, and record review, the facility failed to provide respiratory care per standards of practice when staff failed to ensure oxygen and nebulizer tubing were stored properly when not in use when the nebulizer tubing and mouthpiece was noted to be on the floor and not in protective cover for one resident (Resident #2 ), noted to be on the chair and not in protective covering for one resident (Resident #4), and oxygen nasal cannula (thin, flexible tube that delivers oxygen through the nose) and tubing was on the back of the resident's wheelchair not in a protective bag for one resident (Resident #3) in a common area. The facility census was 74. Review of facility policy titled Oxygen Administration, undated, showed the following: -Purpose of policy was to administer oxygen to the resident when insufficient oxygen is being carried by the blood to the tissues; -Connect nasal cannula tubing to humidifier outlet and adjust liter flow as ordered; -Place prongs of cannula into the resident's nares (nose); -Adjust elastic loosely around head above ears; -At regular intervals, check and clean oxygen equipment, masks, tubing and cannulas; -Place cannula tubing in plastic bag attached to concentrator when tubing is not in use. Review of facility policy titled Aerosol Therapy Treatments (medical procedure that involves delivering medications in the form of tiny droplets (aerosols) into the respiratory tract), undated, showed the following: -Medication can be given in many forms. One way is to inhale the medication in aerosol form; -Staff should gather all equipment needed for the procedure; -Remove the top part of the nebulizer cup (small, cup-shaped device that holds liquid medicine that is then turned into a mist); -Place medication in the bottom of the nebulizer cup; -Attach the top portion of the nebulizer cup and connect the mouthpiece or face mask to the cup; -Turn on the compressor; -Continue the treatment until all the medication is gone; -Turn off the compressor; -Clean equipment per guidelines after each use. 1. Review of Resident #2's face sheet (brief information sheet about the resident) showed the following: -admitted [DATE]; -Diagnoses included chronic obstructive pulmonary disease (COPD - group of lung diseases that block airflow and make it difficult to breathe), chronic respiratory failure (medical condition where the lungs are unable to adequately exchange gases, resulting in low levels of oxygen (hypoxemia) and/or high levels of carbon dioxide (hypercapnia) in the blood) with hypercapnia, and bronchitis (inflammation of the lining of bronchial tubes, which carry air to and from the lungs). Review of the resident's care plan, last updated 01/02/25, showed the following: -Resident had shortness of breath related to COPD and chronic respiratory failure; -Staff should administer oxygen at 2 liters (amount to be delivered through oxygen device) via nasal cannula; -Staff should observe oxygen precautions; -Staff should administer albuterol via nebulizer and ipratropium-albuterol via nebulizer; -Staff should change oxygen tubing weekly and nebulizer tubing per facility protocol. Review of the resident's physician orders, active as of 02/25/25, showed the following: -An order, dated 12/24/24, for albuterol sulfate solution (used to prevent and treat wheezing and shortness of breath caused by breathing problems) for nebulization: 2.5 milligram (mg)/3 milliliter (ml), one vial inhalation every 4 hours as needed; -An order, dated 01/21/25, ipratropium-albuterol solution (combination solution used to help control the symptoms of lung diseases, such as asthma, chronic bronchitis, and emphysema) for nebulization: 0.5 mg-3 mg/3 ml, one vial twice per day with mask; -An order, dated 05/04/24, to change nebulizer tubing monthly. Observation on 02/25/25, at 8:50 A.M., showed the resident resting in bed with oxygen on by nasal cannula. A nebulizer machine with tubing and mouthpiece attached was setting directly on the floor with the mouthpiece touching the tile with no protective covering. 2. Review of Resident 3's face sheet showed the following: -admitted [DATE]; -Diagnoses included Parkinson's disease (progressive neurological disorder that affects movement, balance, and coordination), bacterial pneumonia (lung infection caused by bacteria), and acute respiratory disease (number of conditions that affect the lungs). Review of the resident's care plan, last updated 02/04/25, showed staff did not care plan related to oxygen usage; -No information related to use of oxygen. Review of the resident's physician orders, active as of 02/25/25, showed the following: -Standard wheelchair. -No order noted for oxygen. Observation on 02/25/25, at 9:00 A.M., showed the resident in the hallway in his/her wheelchair. The resident had his/her eyes closed. There was an oxygen tank on the back of the resident's wheelchair with tubing and nasal cannula attached. The nasal cannula was setting on the back side of the wheelchair exposed to air with no protective covering. 3. Review of Resident #4's face sheet showed the following: -admitted [DATE]; -Diagnoses included shortness of breath and cognitive communication deficit. Review of the resident's physician orders, active as of 02/25/25, showed an order, dated 11/25/24, for ipratropium-albuterol solution for nebulization; 0.5 mg-3 mg/3 ml; amount to administer: one vial every 6 hours as needed. Review of the resident's care plan, last updated 12/16/24, showed staff did not care plan regarding nebulizer use. Observation on 02/25/25, at 9:15 A.M., showed the resident in bed with staff in the room for catheter care. There was a nebulizer machine with tubing and mouthpiece attached setting on a bedside chair, with the mouthpiece touching the chair with no protective covering. 4. During an interview on 02/25/25, at 12:40 P.M., Certified Nurse Aide (CNA) C said when a resident had oxygen or nebulizer tubing that was not in use, the tubing should be in a plastic bag next to the machine to keep the tubing clean until the next use. The tubing, mouthpiece, or nasal cannula should not be touching the floor or open to air. During an interview on 02/25/25, at 12:50 P.M., Certified Medication Tech (CMT) D said oxygen and nebulizer tubing should not be on the floor or bedside chair. It should be protected and in a plastic bag when not in use. During an interview on 02/25/25, at 1:10 P.M., Registered Nurse (RN) A said oxygen and nebulizer tubing should be covered when not in use and should not be on the floor or in a chair. During an interview on 02/25/25, at 1:20 P.M., RN E said oxygen and nebulizer tubing should be in a plastic bag when not in use. The tubing should not be on the floor. During an interview on 02/25/25, at 1:29 P.M., Licensed Practical Nurse (LPN) F said oxygen and nebulizer tubing should be in a plastic bag when not in use to keep clean. During an interview on 02/25/25, at 2:05 P.M., the Director of Nursing (DON) said oxygen and nebulizer tubing should be in a plastic bag when not in use. The tubing should not be on the floor or exposed to air without protection to keep clean until next use. During an interview on 02/25/25, at 2:25 P.M., the Administrator said oxygen and nebulizer tubing should be in a plastic bag when not in use. Tubing should not be on the floor or any other non-clean surface.

Based on observation, record review, and interview, the facility failed to establish and maintain an effective infection prevention and control program when staff failed to educate staff on and implement a process for Enhanced Barrier Protection (EBP - are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes) policy and procedure when staff did not wear gowns when completing catheter (a flexible tube that drains urine from the bladder) care for two residents (Resident #2 and #4). The facility census was 74. Review of the Centers for Disease Control and Prevention (CDC)'s Considerations for Use in Skilled Nursing Facilities, dated 06/2021, showed the following information: -MDRO transmission is common in skilled nursing facilities, contributing to significant morbidity and mortality for residents and increased costs for the health care system; -EBP involves gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices); -EBP may be applied (when Contact Precautions do not otherwise apply) to residents with wounds or indwelling medical devices, regardless of MDRO colonization status, and infection or colonization with an MDRO; -Effective implementation of EBP required staff training on the proper use of personal protective equipment (PPE) and the availability of PPE with hand hygiene products at the point of care; -EBP to routine care of residents with wounds or indwelling medical devices requires that staff participate in initial and on-going training on the facility ' s expectations about hand hygiene and gown and glove use, along with proof of competency regarding appropriate use and donning and doffing technique for PPE; -Facilities should develop a method to identify residents with wounds or indwelling medical devices, and post clear signage outside of resident rooms indicating the type of PPE required and defining high risk resident care activities; -Gowns and gloves should be available outside of each resident room, and alcohol-based hand rub should be available for every resident room (ideally both inside and outside of the room); -A trash can (or laundry bin, if applicable) large enough to dispose of multiple gowns should be available for each room. Review of the facility policy titled Enhanced Barrier Precautions to Infection Control Guidance, dated March 2024, showed the following: -Purpose to prevent broader transmission of MDROs and to help protect patients with chronic wounds and indwelling devices; -EBP should be implemented for the period of the stay or until wounds have resolved or indwelling medical devices have been removed; -Resident who are known to be infected or colonized with a MDRO, residents with an indwelling medical device including urinary catheter regardless of their MDRO status, and residents with a wound, regardless of the MDRO status a require EBP; -Use EBP when providing high-contact resident care activities such as bathing, transferring resident from one position to another, providing hygiene, changing bed linens, changing briefs or assisting with toileting, caring for or using an indwelling medical device, performing wound care; -Conduct proper hand hygiene before starting care; -Gloves and donning and doffing of gown are required when conducting high-contact resident care activities; -Gloves and gown should be removed and discarded after each resident care encounter; -Attempt to arrange cares to be grouped together to assist in reducing consumption of supplies with practical; -EBP should be performed when performing transfers or assisting during bathing in a shared/common shower and when working with residents in the therapy gym; -Residents that are placed on EBP should have PPE in close proximity outside the door and a trash can in the resident's room for disposal prior to leaving the room; -Multi-resident medical equipment must be sanitized between resident uses. 1. Review of Resident #2's face sheet (brief information sheet about the resident) showed the following: -admitted [DATE]; -Diagnoses included chronic obstructive pulmonary disease (COPD - group of lung diseases that block airflow and make it difficult to breathe) and urinary tract infection (bacterial infection of urinary tract, which includes kidneys and bladder). Review of the resident's physician orders, active as of 02/25/25, showed the following: -An order, dated 12/24/24, for catheter type indwelling, size 16 French (universal sizing system for internal urinary catheters), 10 ml balloon (inflated to hold catheter in place); -An order, dated 12/24/24, to change catheter at physician discretion; -An order, dated 12/24/24, for catheter care every shift; -An order, dated 12/24/24, to change catheter monthly. Review of the resident's care plan, last updated 01/02/25, showed the following: -Resident had an indwelling urinary catheter; -Staff should change catheter per physician orders; -Staff should provide catheter care per physician orders. (Staff did not care plan related to EBP.) Observation on 02/25/25, at 11:00 A.M., showed Certified Nurse Aide (CNA) C entered the resident's room to drain the resident's catheter bag. The CNA applied prepared supplies and applied gloves. The aide opened the drain tip of the catheter bag (opening that allows urine to drain from the catheter into a collection container) and drained the urine into a collection cup. The aide then wiped the drain tip with an alcohol wipe and secured to the catheter bag. The aide disposed of the urine into the toilet and rinsed the container with water. The aide removed his/her gloves and washed hands and left the room. The aide did not apply a gown for EBP. There was no signage regarding EBP use and there was no PPE near the resident's room. 2. Review of Resident #4's face sheet showed the following: -admitted [DATE]; -Diagnoses included cognitive communication deficit, benign prostatic hyperplasia (non-cancerous enlargement of prostate (gland surrounding the tube that empties the bladder)) with lower urinary tract symptoms (pain or burning when urinating, frequent urination). Review of the resident's physician orders, active as of 02/25/25, showed the following: -An order, dated 11/25/24, for catheter care every shift; -An order, dated 11/25/24, to change catheter monthly; -An order, dated 11/25/24, to change catheter as needed; -An order, dated 11/25/24, to change catheter at physician discretion; -An order, dated 11/25/24, to flush catheter with 30 ml normal saline daily as needed. Review of the resident's care plan, last updated 12/16/24, showed the following : -Resident had a catheter related to benign prostatic hypertrophy (enlargement); -Staff will perform catheter care per physician orders; -Staff will report signs of urinary tract infection. (Staff did not care plan related to EBP.) Observation on 02/25/25, at 9:15 A.M., showed Registered Nurse (RN) A and Licensed Practical Nurse (LPN) F entered the resident's room to change the resident's catheter. The nursing staff prepared supplies and washed their hands at the sink and applied gloves. RN A opened a syringe and removed fluid from the catheter balloon. RN A removed the catheter from the resident's bladder and disposed of the catheter into the trash. RN A removed gloves and washed hands at sink. He/she applied new gloves. LPN F opened the supplies and attached the new catheter tubing to the new catheter bag. RN A attempted to put on sterile gloves and the gloves were too small and caused the gloves to tear. The nurses removed gloves and washed hands at the sink. RN A left the room to find another nurse with smaller hands. RN A returned with supplies and asked LPN F to try the catheter change. LPN F washed hands at sink and attempted to put on sterile gloves and the gloves tore. He/she removed the gloves and washed hands at sink. The staff covered the resident and left the room to find another nurse. The staff did not apply gowns for EBP. Observation on 02/25/25, at 9:55 A.M., showed RN E entered the resident's room with supplies and disinfected the bedside table, prepared supplies on the table, and then washed his/her hands at the sink. He/she opened the sterile glove package and applied the gloves. The nurse cleaned the resident's private region appropriately for catheter care, attempted to insert the catheter tubing and it would not advance. The nurse removed the catheter tubing. Covered the resident and disposed of supplies, removed gloves, and washed hands at the sink. The nurse left the room and notified the charge nurse, who notified the physician and advised to send the resident to the emergency room for catheter insertion. The nurse did not apply a gown for EBP. There was no signage regarding EBP use and there was no PPE near the resident's room. 4. During an interview on 02/25/25, at 11:10 A.M., Nurse Aide (NA) B said that when preparing a resident for catheter care he/she would wash hands and apply gloves. After completing the resident care, he/she would remove gloves and wash his/her hands. He/she said that EBP included the use of barrier creams to protect resident skin. He/she said that use of gowns was for residents that were on contact precautions, such as when a resident had an infection. The nurses notify the staff when to use PPE and sometimes there were signs and PPE carts near the residents' rooms. He/she did not wear a gown to complete catheter care or toileting hygiene with a resident that had a wound. During an interview on 02/25/25, at 12:40 P.M., CNA C said that he/she had not heard of EBP. He/she said that when working with residents he/she was required to wear a gown, gloves, and sometimes a mask if a resident had the flu. There were no signs related to EBP and no PPE near any resident rooms at this time. During an interview on 02/25/25, at 12:50 P.M., Certified Medication Tech (CMT) D said that he/she had not heard of EBP. He/she said that if a resident had flu or COVID then he/she would wear a gown and gloves in a resident room. The nurse would tell him/her when this was required. During an interview on 02/25/25, at 1:10 P.M., Registered Nurse (RN) A said he/she had not received any training about EBP. He/she only wore a gown in a resident room if the resident was on isolation or if there were specific organism present in a resident wound. During an interview on 02/25/25, at 1:20 P.M., RN E said that he/she had EBP training at a previous place of employment. He/she was aware that EBP included a resident that had any type of tube or open area. Staff should wear a gown, gloves, and sometimes masks when completing resident cares. He/she said that the staff at the facility were not using EBP. During an interview on 02/25/25, at 1:29 P.M., Licensed Practical Nurse (LPN) F said if there was a substantial wound when completing wound care then he/she would need to use EBP. Generally, he/she did not use gown when completing wound care. The PPE could be found in the supply closet, but it was not readily available at resident rooms. During an interview on 02/25/25, at 2:05 P.M., Director of Nursing (DON) said if residents that had wounds or indwelling devices that were leaking, staff should wear a gown and gloves. She was not aware that gowns should be worn any time direct resident care completed with residents with chronic wounds or indwelling devices. PPE was available in all storage room. She did not think that staff needed to wear a gown if the wound was covered when completing personal cares. During an interview on 02/25/25, at 2:25 P.M., the Administrator said that with residents with catheters, wounds, or indwelling medical devices, staff should wear gloves when completing direct cares. Gowns are used if a resident was on isolation precautions. EBP was used when residents were higher risk and usually have PPE out by the resident door at that time. The facility just got all resident off isolation precautions recently. He/she was not aware that gowns and gloves should be used for EBP with high-contact care of residents with chronic wounds and indwelling medical devices regardless of MDRO status.

Based on observation, interview, and record review, the facility failed to keep all food safe from potential contamination when staff stacked clean, wet dishes tracking water in them, when staff failed to keep food containers sealed, when staff failed to keep the walk-in freezer clean, and when failed to complete proper hand hygiene and used bare hands to touch ready to eat food while proving meal assistance to six residents (Resident #36, #31, #8, #9, #20, and #62). The facility. The facility census was 64. 1. Review of the facility's policy titled General Dish Room Sanitation, by Nutrition and Dining Services Manual, dated May 2015, showed the following information: -All items are to be air dried; -No moisture can be found on any stacked item. Review of the 1999 Food Code, issued by the Food and Drug Administration, showed the following information: -After cleaning and sanitizing, equipment and utensils shall be air-dried or used after adequate draining before contact with food. -Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow. Observations on 10/03/23, beginning at 10:03 A.M., showed the following: -Twenty-two plastic coffee mugs stacked with water droplets trapped inside; -Twenty-nine plastic bowls stacked with water droplets trapped inside. Observation on 10/05/23, at 11:40 A.M., showed the following: -Sixty-two clear plastic cups stacked with water droplets trapped inside; -Fourteen coffee mugs stacked with water droplets trapped inside; -Fifty-one bowls stacked with water droplets trapped inside. During an interview on 10/05/23, at 1:30 P.M., Cook M said he/she was not aware that dishes had to be air dried before they could be stacked. During an interview on 10/05/23, at 1:30 P.M., Cook N said he/she thought the dishes needed to be air dried, but didn't say because he/she was not positive and does not do the dishes. During an interview on 10/05/23, at 1:30 P.M., Dietary Aide (DA) O said he/she did not know that dishes had to be air dried. During an interview on 10/05/23, at 1:30 P.M., the Kitchen Manager said he/she did know that the dishes are supposed to be air dried and just assumed the dish washer was doing it this way. During an interview on 10/05/23, at 2:15 P.M., the Administrator said everything should be air dried before being put away. 2. Observation on 10/03/23, beginning at 10:03 A.M., of the walk-in freezer, showed the following: -An open package of frozen pancakes was left exposed to other odors and the freezer elements; -An open package of sausage patties was left exposed to other odors and the freezer elements; -An open package of rolls was left exposed to other odors and the freezer elements. Observation on 10/03/23, that began at 10:03 A.M., of the dry storage area, showed the following: -Twelve cereal bowls that had cold cereal already in them with a drink lid covering up; -The drink lids were cracked in different areas and will not be able to keep the cereal from getting stale. Observation on 10/05/23, at 11:40 A.M., of the dry storage area, showed the following: -Seven bowls of cereal, covered with a drink lid; -The lids were cracked in several areas, so will not keep the cereal from going stale; -One open bag of cereal with tear exposing the cereal. During an interview on 10/05/23, at 1:30 P.M., Cook M said the following: -He/she does not usually put the food away and did not see any of the items in dry storage; -He/she was not sure what the cereal is doing already in the bowls. During an interview on 10/05/23, at 1:30 P.M., Cook N said the following: -He/she knows there is dry cereal on the shelves, already in bowls, but was unsure of what this is set up for; -He/she knows anything that was opened should be closed. During an interview on 10/05/23, at 1:30 P.M., DA O said the cereal that's already made up is to save them a little bit of time in the morning. During an interview on 10/05/23, at 1:30 P.M., the Kitchen Manager said the following: -He/she could not say why the cereal was already out in bowls; -He/she said staff know to close items in the freezer. 3. Record review of the facility's policy titled Developing Cleaning Schedules, by Dining Services Manual, dated May 2015, showed the following information: -To ensure sanitation is at acceptable standards list items to be cleaned within each area including walls, floors, vents, etc. Observation on 10/03/23, at 10:03 A.M., of the walk-in freezer, showed the following: -The ceiling had multiple area that appeared to be a build up grime or other substance; -Black, fuzzy material was near the fans, against the ceiling. Observation on 10/05/23, at 11:40 A.M., of the walk-in freezer, showed the following: -The ceiling had multiple area that appeared to be a build up grime or other substance; -Black, fuzzy material was near the fans, against the ceiling. During an interview on 10/05/23, at 1:30 P.M., Cook M said he/she did not realize the walk-in freezer was dirty. During an interview on 10/05/23, at 1:30 P.M., DA O said he/she was not sure how the walk-in freezer was able to get so dirty, so quick. During an interview on 10/05/23, at 1:30 P.M., the Kitchen Manager said he/she walked into the walk-In refrigerator and saw the fan and agreed that it was dirty with a film and grime of some sort. During an interview on 10/05/23, at 2:15 P.M., the Administrator said he/she would expect the kitchen staff to be following a cleaning schedule. The walk-in freezer should not be in this condition. 41787 4. Review of the facility policy titled Glove Use, dated May 2015, showed the following information: -To ensure safe and proper food handling during food preparation and service. The food code states that food items should not be handled with bare hands; -When serving, preference is not to use gloves unless only one task is being performed; -Hand washing per guidelines should occur between each task; -Gloves should be removed when changing or walking away from specific tasks and hands should then be washed per guidelines. -Hands should be washed after disposing of trash or food, after handling dirty dishes, after picking up anything from the floor; when changing tasks; and any other time deemed necessary. Review of the 2013 FDA Food Code showed the following: -Bare hand contact with ready-to-eat foods can contribute to the transmission of foodborne illness; -Even though bare hands should never contact exposed, ready-to-eat food, thorough handwashing is important in keeping gloves or other utensils from becoming vehicles for transferring microbes to the food. Observation on 10/03/23 showed the following: -At 12:20 P.M., Certified Nurse Aide (CNA) D sat next to Resident #36. The aide was assisting the resident with eating and using a spoon to give the resident bites; -At 12:23 P.M., CNA D moved over to the next picked up the grill cheese sandwich off of Resident #8's plate with his/her bare hands and tore the sandwich in half. The aide put one piece of the sandwich into the resident's hand. The aide moved back to assist Resident #36. The aide did not complete hand hygiene between residents or prior to touch ready to eat food; -At 12:25 P.M., CNA D got up from the table, did not complete hand hygiene, and got gloves off the counter. The aide put one glove on his/her right hand and picked up the second half of the sandwich on Resident #8's plate and put it into the resident's hand' -CNA D returned to Resident #36, took off the glove, and put it on the dining room table; -Without completing hand hygiene, the aide returned to assisting Resident #36 with the meal with a spoon; -Without completing hand hygiene the aide picked up the same glove from the table and put it on his/her right hand and picked up Resident #36's bread and put butter and jelly on the bread with a knife. The aide then took off the glove and put on the table. The aide did not complete hand hygiene prior to gloving or touching the ready to eat food; -CNA D then picked up the bread and butter with his/her bare hand and put it into Resident #36's hand; -At 12:29 P.M., CNA D got up and threw away the gloves into the trash and picked up two new gloves and put on the . The aide did not complete hand hygiene; -At 12:30 P.M., CNA D sat down at Resident #8's table and put on one glove and picked up the remaining grilled cheese and handed it to the resident. The aide took off the glove and put on the table. The aide then removed the wrapping from the cup of peaches and opened the resident's chocolate milk. The aide then cut up the hash browns with a fork and asked the resident if he/she would like some of the hash browns. The aide completed no hand hygiene; -At 12:32 P.M., CNA D moved back to Resident #36 and picked up the bread and butter that was on the resident's lap and put the bread back into the resident's hand. The aide opened the resident's vanilla shake and put in a straw by holding the straw by the top. The aide did not complete hand hygiene; -CNA D returned to Resident #8 without completing hand hygiene and picked up the resident's tea cup by the handle and put the handle into the resident's hand. The aide then fed a bite of hash brown to the resident with the fork that resident had in his/her hand. The aide took the teacup from the resident and picked up the grilled cheese with his/her bare hand and put the sandwich into the resident's hand; -At 12:35 P.M., CNA D moved over to another table where Resident #31 was seated in a wheelchair. The aide picked up a bowl by placing his/her index finger inside the bowl and remaining hand on the edge of the bowl. The aide then put the bowl to the resident's hand. The aide did not complete hand hygiene; -Without completing hand hygiene CNA D returned to Resident #8 and handed the resident his/her drink cup to the resident's hands. The aide picked up the fork that the resident had his/her hand on and assisted the resident with a bite of peaches. The aide took the tea cup from the resident's hands and fed the resident peaches. As the aide was feeding him the peaches dripped peach juice on the resident's shirt with every bite. The aide did not complete hand hygiene; -At 12:40 P.M., CNA G was taking meal trays from kitchen window and brought a meal tray to Resident #20, the aide opened the resident's food items and took the sandwich out of the bag with his/her bare hands and put on the plate. The aide went to the counter and got the ketchup, butter, and ranch dressing packets. Without completing hand hygiene, the aide returned to the resident's table and opened the ranch dressing and poured on the resident's salad. The aide then picked up the resident's bread roll with his/her bare hand and cut in half and then added butter and put down onto the plate. The aide then picked up the resident's peanut butter sandwich with his/her bare hands and tore the sandwich in half and handed the resident half the sandwich and put the other half on the plate. The aide then moved the tator tots to the side of the resident's plate with his/her bare hands and put ketchup on the plate. The aide then removed the packets of trash and put in the trash can; -At 12:44 P.M., CNA G returned to the kitchen window and took the next tray to Resident #9 across the dining room without completing hand hygiene; -CNA D moved from Resident #8 to Resident #36 and held the resident's shake and the aide put the straw in between his/her own fingers near the mouth end to assist the resident with a drink; -CNA D moved back to Resident #8 and picked up the fork and assist the resident with a bite of food. The aide did not complete hand hygiene. Observations on 10/04/23 showed the following: -At 12:10 P.M., CNA C picked up Resident #20's hamburger bun with his/her bare hands and put on ketchup, and put the bun back on the hamburger. The aide then picked up a knife and put his/her bare hand on the hamburger bun and cut the hamburger in half. The aide went to kitchen serving window and got the next meal tray and took to Resident #62 without completing hand hygiene. The aide cut Resident #62's food with a fork and knife and handed the fork to the resident. The aide then patted the resident on the back and went back to the kitchen serving window and took the next meal tray to another resident without completing hand hygiene. During an interview on 10/06/23, at 9:00 A.M., CNA C said that staff should complete hand hygiene between each resident tray when assisting in the dining room. Staff should wash hands or use hand sanitizer before and after assisting a resident with eating and complete hand hygiene again before assisting another resident. Staff should use hand sanitizer before and after touching the resident's food with their bare hands. During an interview on 10/06/23, at 9:15 A.M., CNA E said staff should complete hand hygiene between all meal trays and should use soap and water after every three trays. He/she said that staff should wash hands between providing meal assist to each resident and staff should put gloves on to touch residents' food with their own hands. During an interview on 10/06/23, at 10:20 A.M., CNA D said staff should complete hand hygiene between every resident in the dining room and that staff should complete hand hygiene after passing the third tray. Staff should use hand sanitizer between each resident receiving meal assist. He/she said that staff should not touch other items, such as cutting up food for a resident and then touch or feed another resident without completing hand hygiene. Staff should use hand sanitizer before touching a resident's food to cut sandwich or handle bread, and should then use hand sanitizer after. During an interview on 10/06/23, at 11:00 A.M., Licensed Practical Nurse (LPN) B said hand hygiene should be done before and after every resident in the dining room. Hand sanitizer should be used after each resident and gloves should be used if touching the residents food. During an interview on 10/06/23, at 2:03 P.M., with the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON), the DON said that during meal service, staff are expected to be washing their hands every three trays or if they touch their face, hair, or pick up something off the floor. This includes touching the wheels or handles on wheelchair. It is not okay to touch the resident'' food unless they have gloves on. The staff should not be holding sandwiches in their bare hands to hand to the residents. 31464

Based on record review and interview, the facility failed to notify the resident and/or the resident's representative of a transfer or discharge to the hospital, including the reason for the transfer, in writing for three residents (Residents #23, #45, and #21) of 21 residents sampled. The facility census was 64. Review showed the facility did not provide a policy regarding written transfer notices. Review of a facility form letter Emergency Transfer Notice showed the following: -Staff should fill in the spaces for: date, resident name, responsible party/representative name and address, transferring facility name, effective date, Ombudsman information, hospital/facility name and address, facility contact phone number, and name of Administrator. 1. Review of Resident #23's face sheet (gives basic profile information) showed the following: -admitted [DATE]; -Diagnoses included high blood pressure, metabolic encephalopathy (abnormal brain function caused by infection or other body organ misfunction), abnormal weight loss, constipation, fluid overload, insomnia, COVID-19 respiratory infection, fracture of left wrist, thyroid dysfunction, influenza, anxiety disorder, heartburn, shortness of breath, pain, unspecified injury of head, fracture of right shoulder, mild intermittent asthma, and muscle weakness. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), dated 07/07/23, showed the following: -Moderately to severely impaired cognition; -Required extensive assistance with bed mobility, transfers, dressing, toileting, hygiene, bathing, and eating. Review of the resident's nurses' notes showed the following: -On 08/13/23, at 8:22 A.M., the resident was extremely lethargic and hard to rouse. Staff notified the physician and the resident's family, who gave approval for resident to be sent to the hospital for evaluation. Emergency Medical Services (EMS) here at this time to transport resident to the hospital. (Staff did not document providing the resident or his/her representative a written copy of discharge.) Review of the resident's medical record showed staff did not have a copy of written discharge provided to the resident or resident's representative. 2. Review of Resident #45's face sheet showed the following: -admitted [DATE]; -Diagnoses included atrial fibrillation (irregular heart rhythm), congestive heart failure (CHF - a weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs), aortic valve stenosis (narrowing of large blood vessel from the heart to the body), urinary tract infection (UTI), adult failure to thrive with encounter for palliative (comfort) care, abnormal weight loss, COVID-19 respiratory infection, dyspnea (shortness of breath), stage 3 chronic kidney disease, high blood pressure and low blood pressure, benign prostatic hyperplasia (BPH - enlarged prostate gland that causes difficulty in emptying the bladder), intracardiac thrombosis (blood clot in the heart), anemia (low red blood cell count), type 2 diabetes mellitus, hyperlipidemia (high level of fat in blood stream), obstructive sleep apnea (intermittent airflow blockage during sleep), diplopia (double vision), and hearing loss. Review of the resident's significant change MDS, dated [DATE], showed the following: -admitted [DATE]; -Moderately impaired cognition; -Required extensive assistance with bed mobility, dressing, toileting, personal hygiene, and bathing; -Required limited assistance with transfers and eating; -Indwelling catheter (a tubing which is inserted into the bladder, via the urethra and remains in to drain urine); -On hospice services. Review of the resident's nurses' notes showed the following entries: -On 07/27/23, at 2:05 P.M., the resident's catheter was changed and new one was placed in with some slight resistance while putting the catheter in. Staff will continue to monitor new catheter; -On 07/27/23, at 2:44 P.M., nurse reported resident complained of pain rated 8 of 10 after Foley insertion. Assisted resident to room and upon assessment and deflating balloon, noted that catheter was out with balloon intact. There was observed blood draining. Staff cleaned up area and bleeding had stopped. Attempted to insert second catheter and noticed immediate blood draining into catheter. Staff stopped. Bleeding was hard to stop on second attempt. Resident started on blood thinner today. Staff notified physician and emergency medical services (EMS) was called; -On 07/27/23, at 6:37 P.M., resident was sent to the hospital. Resident left facility around 2:49 P.M. (Staff did not document providing the resident or his/her representative a written copy of discharge.) Review of the resident's medical record showed staff did not have a copy of written discharge provided to the resident or resident's representative. 41787 3. Review of Resident #21's face sheet showed the following information: -admitted [DATE]; -Diagnoses included CHF, anxiety disorder, chronic kidney disease (CKD - gradual loss of kidney function over time), generalized edema (too much fluid in the tissues - swelling), and type 2 diabetes mellitus. Review of the resident's nurses' notes showed staff documented the following information: -On 07/02/23, at 11:46 P.M., nursing staff documented the resident had complaints of right leg pain starting in the groin and radiating down his/her leg and into his/her back. Staff administer medication and repositioned the resident multiple times. The resident did have slight improvement of symptoms with urination and then immediately pain returned. The resident's urine was dark colored and had a foul odor. The resident was sent to the emergency room via EMS. The Director of Nursing was notified and the resident's family was notified at 11:33 P.M. (Staff did not document providing the resident or his/her representative a written copy of discharge.) Review of the resident's medical record showed staff did not have a copy of written discharge provided to the resident or resident's representative. During an interview on 10/05/23, at 8:42 A.M., the resident said that he/she had not received any information related to going to the hospital in July. 4. During an interview on 10/06/23, at 10:26 A.M., Licensed Practical Nurse (LPN) B said he/she sent the basic resident information with EMS when transferring a resident to the hospital. He/she was not aware of the Transfer Notice being sent with the resident or to the responsible party. 5. During an interview on 10/06/23, at 10:15 A.M., the Social Services Director (SSD) said he/she does not send out Transfer Notices. The SSD said the nurses may send them with the resident on transfer. 6. During an interview on 10/06/23, at 10:20 A.M., the Director of Nursing (DON) said the charge nurse sends the Transfer Notice with EMS when transferring a resident to the hospital. The forms are not sent to the resident's responsible party, but they are notified by phone of the transfer. 7. During an interview on 10/06/23, at 10:05 A.M., the Administrator said the facility did not use the Transfer Notices. They simply keep the resident's bed available and don't charge for the bed hold. The Social Services Director (SSD) does send a monthly list of transfers and discharge to the Ombudsman. The hospital will call the facility if there is a question about a bed hold.

Based on record review and interview, the facility failed to give written information to the resident and/or resident's representative of the facility's bed hold policy for three residents (Residents #23, #45, and #21) who were transferred out to the hospital. A sample of 21 residents was selected for review in a facility with a census of 64. Review of the facility's form entitled Bed Hold Guidelines, undated, showed the following: -This facility will notify all residents and/or their representative of the bed hold guidelines. This notification shall be given on admission to the facility, at the time of transfer to the hospital, and at the time of non-covered therapeutic leave; -Medicare does not pay for any type of bed hold. If the resident is discharged to the hospital, or goes out of the facility for overnight leave of absence, the bed may be held by paying the current room rate for bed being reserved; -Medicaid will pay for up to three hospital leave days when certain criteria are met. The criteria is that the facility must have had an average occupancy of 97% or greater during the quarter previous to the hospital stay, the hospital stay is three days or less, the resident has enough unused home leave days to use two home leave days for one hospital leave day and the resident or the resident's representative informs the facility of their intent to return to the facility following the hospital stay. If the resident is discharged to the hospital and the above criteria are not met, the bed may be held by paying the current Medicaid rate for each non-covered day; -Private pay residents discharged to the hospital or going on overnight leave of absence may reserve their bed by paying the current rate for the bed being reserved; -If a resident or resident representative wants to hold the bed, a signed authorization must be obtained with each discharge. Signed authorization must be received within 24 hours of the discharge if it occurs during the week. Signed authorization must be received by the first business day following the discharge if it occurs on weekend or holiday; - If the resident or resident representative does not choose to hold the bed, the bed will be released and any personal belonging must be picked up within three days; -Bed holds are strictly voluntary. If the bed is not held and is not available when the resident wants to be readmitted , the resident's name will be placed on a waiting list for the next available bed; -The resident or representative is to sign understanding of the bed hold guidelines and indicate whether or not to hold the bed at the indicated daily rate (to be filled in by facility staff). 1. Review of Resident #23's face sheet (gives basic profile information) showed the following: -admitted [DATE]; -Diagnoses included high blood pressure, metabolic encephalopathy (abnormal brain function caused by infection or other body organ misfunction), abnormal weight loss, constipation, fluid overload, insomnia, COVID-19 respiratory infection, fracture of left wrist, thyroid dysfunction, influenza, anxiety disorder, heartburn, shortness of breath, pain, unspecified injury of head, fracture of right shoulder, mild intermittent asthma, and muscle weakness. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), dated 07/07/23, showed the following: -Moderately to severely impaired cognition; -Required extensive assistance with bed mobility, transfers, dressing, toileting, hygiene, bathing, and eating. Review of the resident's nurses' notes showed the following: -On 08/13/23, at 8:22 A.M., the resident was extremely lethargic and hard to rouse. Staff notified the physician and the resident's family, who gave approval for resident to be sent to the hospital for evaluation. Emergency Medical Services (EMS) here at this time to transport resident to the hospital. (Staff did not document providing the resident or his/her representative a copy of the bed hold policy.) Review of the resident's medical record showed staff did not have a copy of a bed hold policy provided to the resident or resident's representative at discharge. 2. Review of Resident #45's face sheet showed the following: -admitted [DATE]; -Diagnoses included atrial fibrillation (irregular heart rhythm), congestive heart failure (CHF - a weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs), aortic valve stenosis (narrowing of large blood vessel from the heart to the body), urinary tract infection (UTI), adult failure to thrive with encounter for palliative (comfort) care, abnormal weight loss, COVID-19 respiratory infection, dyspnea (shortness of breath), stage 3 chronic kidney disease, high blood pressure and low blood pressure, benign prostatic hyperplasia (BPH - enlarged prostate gland that causes difficulty in emptying the bladder), intracardiac thrombosis (blood clot in the heart), anemia (low red blood cell count), type 2 diabetes mellitus, hyperlipidemia (high level of fat in blood stream), obstructive sleep apnea (intermittent airflow blockage during sleep), diplopia (double vision), and hearing loss. Review of the resident's significant change MDS, dated [DATE], showed the following: -admitted [DATE]; -Moderately impaired cognition; -Required extensive assistance with bed mobility, dressing, toileting, personal hygiene, and bathing; -Required limited assistance with transfers and eating; -Indwelling catheter (a tubing which is inserted into the bladder, via the urethra and remains in to drain urine); -On hospice services. Review of the resident's nurses' notes showed the following entries: -On 07/27/23, at 2:05 P.M., the resident's catheter was changed and new one was placed in with some slight resistance while putting the catheter in. Staff will continue to monitor new catheter; -On 07/27/23, at 2:44 P.M., nurse reported resident complained of pain rated 8 of 10 after Foley insertion. Assisted resident to room and upon assessment and deflating balloon, noted that catheter was out with balloon intact. There was observed blood draining. Staff cleaned up area and bleeding had stopped. Attempted to insert second catheter and noticed immediate blood draining into catheter. Staff stopped. Bleeding was hard to stop on second attempt. Resident started on blood thinner today. Staff notified physician and emergency medical services (EMS) was called; -On 07/27/23, at 6:37 P.M., resident was sent to the hospital. Resident left facility around 2:49 P.M. (Staff did not document providing the resident or his/her representative a bed hold policy at discharge.) Review of the resident's medical record showed staff did not have a copy of a bed hold policy provided to the resident or resident's representative at discharge. 41787 3. Review of Resident #21's face sheet showed the following information: -admitted [DATE]; -Diagnoses included CHF, anxiety disorder, chronic kidney disease (CKD - gradual loss of kidney function over time), generalized edema (too much fluid in the tissues - swelling), and type 2 diabetes mellitus. Review of the resident's nurses' notes showed staff documented the following information: -On 07/02/23, at 11:46 P.M., nursing staff documented the resident had complaints of right leg pain starting in the groin and radiating down his/her leg and into his/her back. Staff administer medication and repositioned the resident multiple times. The resident did have slight improvement of symptoms with urination and then immediately pain returned. The resident's urine was dark colored and had a foul odor. The resident was sent to the emergency room via EMS. The Director of Nursing was notified and the resident's family was notified at 11:33 P.M. (Staff did not document providing the resident or his/her representative a bed hold policy.) Review of the resident's medical record showed staff did not have a copy of a bed hold policy provided to the resident or resident's representative at discharge. During an interview on 10/05/23, at 8:42 A.M., the resident said that he/she had not received any information related to going to the hospital in July. 4. During an interview on 10/06/23, at 10:26 A.M., Licensed Practical Nurse (LPN) B said he/she sent the basic resident information with EMS when transferring a resident to the hospital. The LPN was not aware of the Bed Hold policy being sent with the resident or to the responsible party. 5. During an interview on 10/06/23, at 10:15 A.M., the Social Service Director said he/she does not send out Bed Hold Guidelines. The SSD said the nurses may send them with the resident on transfer. 6. During an interview on 10/06/23, at 10:20 A.M., the Director of Nursing (DON) said the charge nurse sends the Bed Hold policy with EMS when transferring a resident to the hospital. The forms are not sent to the resident's responsible party. 7. During an interview on 10/06/23, at 10:05 A.M., the Administrator said the facility did not use the Bed Hold Guidelines. They simply keep the resident's bed available and don't charge for the bed hold. The hospital will call the facility if there is a question about a bed hold.

Based on observation, interview, and record review, the facility staff failed to store refrigerated medications at the medication's recommended temperatures and failed to have a system in place to monitor and adjust the temperature as needed. The facility census was 64. Review of the facility's policy titled Storage of Medications, undated, showed the following: -All medications are stored in a safe and secure area; -Medications requiring refrigeration are stored in a refrigerator located in the medication room located behind the nurses' station. -Medications are stored separately from food and are labeled accordingly. Review of the Centers for Disease Control and Prevention (CDC) guidelines for vaccines, dated 03/26/21, showed the following: -Never freeze refrigerated vaccines; -Ideal temperature of refrigerated vaccines is 40 degrees Fahrenheit (F); -Refrigerator temperature should be between 36 and 46 degrees F; Review of the Levemir (insulin) package insert, dated December 2022, showed the following: -Keep the Levemir pen or vial in cool storage at 36 degrees F to 46 degrees F; -Do not allow to freeze. Review of the Humalog (insulin lispro) package insert, dated March 2022, showed the following: -Keep the Humalog pen or vial in a cool storage at 36 degrees F to 46 degrees F; -Do not allow to freeze. Review of the Novolog (insulin aspart) package insert, dated July 2022, showed the following: -Keep the Novolog pen or vial in a cool storage at 36 degrees F to 46 degrees F; -Do not allow to freeze. Review of the Trulicity (once weekly medication used to treat diabetes) package insert, dated July 2023, showed the following: -Keep the medication in a cool storage at 36 degrees F to 46 degrees F; -Do not allow to freeze. Review of the Tubersol (used to test for tuberculosis) package insert, undated, showed the following: -The vial should be stored at 35 degrees to 46 degrees F; -The medication should be discarded if exposed to freezing temperatures. Review of the lorazepam oral concentrate (used to treat anxiety disorders) package insert, dated January 2023, showed the following: -Keep the medication in a cool storage at 36 degrees F to 46 degrees F; -Do not allow to freeze. Review of the acetaminophen suppository (used to treat pain and or fever) package insert, dated February 2023, showed the following: -May keep the medication in a cool storage at 36 degrees F to 46 degrees F to prevent melting; -Do not allow to freeze. 1. Observation on 10/06/23, at 1:00 P.M., of the medication refrigerator located in the medication room showed the following: -Temperature of refrigerator per thermometer read 31 degrees F; -The refrigerator contained resident insulin pens, tuberculosis testing serum, resident liquid lorazepam, and resident acetaminophen suppositories. Review of the facility's medication refrigerator logs, obtained from the refrigerator located in the medication room, showed staff initialed and completed the logs each day: -On 10/02/23, staff documented the temperature was 32 degrees F; -On 10/03/23, staff documented the temperature was 33 degrees F; -On 10/04/23, staff documented the temperature was 34 degrees F; -On 10/05/23, staff documented the temperature was 32 degrees F; -On 10/06/23, staff documented the temperature was 31 degrees F. During an interview on 10/06/23, at 1:00 P.M., Licensed Practical Nurse (LPN B) said the following: -The refrigerator temperature is to be checked nightly by the night shift nurse; -The nurse is to write the temperature on the log that is located on the refrigerator; -If the temperature is outside of the parameters (36 - 46 degrees F), the nurse should notify maintenance. During an interview on 10/06/23, at 2:03 P.M., with the Administrator, Director of Nursing (DON) and Assistant Director of Nursing (ADON), the Administrator said that nursing is responsible for checking the medication refrigerator temperature every day and documenting on the temp log. The nurse should adjust the temperature up or down if the temperature is outside the range and notify maintenance. The DON is responsible for checking the temperature log weekly.

Based on interview and record review, the facility failed to provide percutaneous endoscopic gastrostomy (PEG) tube (a medical procedure in which a tube is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate) feedings or water flushes through the PEG tube for one resident (Resident #1) from 9/2/16 through 9/13/16, after PEG tube placement on 9/2/16. The resident admitted to the hospital on [DATE] with altered mental status, severe dehydration, severe protein calorie malnutrition, and acute [MEDICAL CONDITION] (sudden inability of kidneys to function adequately). A sample of four residents was reviewed. The facility census was 90. Record review of the facility policy, Enteral Nutritional Therapy, dated March 2015, showed the following information: -The purpose of a tube feeding is to provide nourishment, through a tube in the resident's stomach; -Check position of the tube by placing a stethoscope over the stomach and instill a small amount of air into the PEG (enteral) tube. Listen for air to enter the stomach or aspirate stomach contents; -The staff will need to provide the correct prescribed formula and enteral (PEG) feeding pump; -The staff should check for stomach residual contents by reviewing the physician order for [REDACTED].>-The amount of residual may determine the amount of the current resident feeding; -Notify the physician as ordered. Record review of the facility Change of Condition policy, dated March 2012, showed the following information; -The staff should observe, record, and report any condition change to the attending physician so that proper treatment can be implemented; -After all resident falls, injuries or changes in physical or mental function, monitor the following: Alterations in consciousness, generalized weakness, balance disorder and vitals (including temperature) until the resident's condition is stable. 1. Record review of Resident #1's admission Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument, completed by facility staff, dated 5/25/16, showed the following information: -Entry date of 5/18/16 into the facility; -Cognitively intact; -[DIAGNOSES REDACTED]. -Required limited assistance of staff for bed mobility, transfers, toileting, and personal hygiene; -Required supervision with set-up for eating; -Weight of 140 pounds (lbs); -The staff placed the resident on a mechanically altered diet; -The resident has a Stage II pressure ulcer (partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present). Record review of the resident's physician progress notes [REDACTED]. -Review of weight indicated a significant decline from 138 pounds on 5/20/16 to 123 pounds on 7/19/16. Treatment discussed with the resident's responsible party who asked for a referral for a PEG tube to ensure adequate nutrition would be provided. The resident's appetite is poor. The physician agreed with the current plan of care and documented for nursing to continue to monitor and notify him/her of any issues or acute changes. The physician ordered a referral for PEG tube per the resident's responsible party. Record review of the resident's physician progress notes [REDACTED]. -Family wanted a PEG tube placed due to his/her overall poor appetite. The resident did not have any behaviors, required frequent cueing, and remained cognitively impaired. The physician documented per the resident and/or staff, the resident had a good appetite and required some assist with activities of daily living (ADLs). The physician's plan included follow up in four weeks for medication and chronic medical condition review unless there is a change in status. Nursing to continue to monitor and notify the physician of any issues or acute changes. Record review of the resident 's weekly weight report, dated 8/15/16, showed the resident weighed 117 pounds (loss of 4 lbs from 8/08/16). Record review of the resident's weekly weight report, dated 8/22/16, showed the resident weighed 111 lbs (loss of 6 lbs from 8/15/16). Record review of the resident's nursing progress notes, dated 8/23/16, showed the nurse received a call from the lab that the resident had critically high levels of calcium at 14.1. The nurse notified the physician on-call and received orders to transfer the resident to the emergency room for evaluation and treatment as indicated via ambulance. The resident left the nursing home at 9:00 P.M. Record review of the resident's hospital history and physical, for visit date 8/23/16, showed the following information: -Resident sent to hospital from nursing home with abnormal labs; -The resident had elevated calcium of 15.2, moderate dehydration, urinary tract infection [MEDICAL CONDITION], and acute [MEDICAL CONDITION]; -Past medical history included decreased oral intake, [MEDICAL CONDITION], and moderate protein-calorie malnutrition; -Active problems included hypercalcemia (greater than normal amounts of calcium in the blood) likely secondary to dehydration, acute [MEDICAL CONDITION], likely secondary to poor oral intake and dehydration, acute [MEDICATION NAME] (inflammation of the bladder), cognitive deficits, nutrition, he/she is underweight and had been previously diagnosed with [REDACTED]. Record review of the resident's hospital discharge summary, for visit date 8/23/16, showed the following information: -admitted to hospital with principle [DIAGNOSES REDACTED]. -Resident noted to be dehydrated and have a calcium level of 15.2. IV fluids given and calcium now in normal range. [MEDICATION NAME] (antibiotic) administered for the acute [MEDICATION NAME]; -Nutrition consult obtained and resident found to have severe protein calorie malnutrition and nutritional support provided; -Resident is stable and will be discharged to nursing home. Record review of the resident's physician order sheet (POS) dated, 9/01/16 to 9/15/16, included the following readmission physician orders dated 8/25/16: -Regular diet; -House shakes three times a day; -Weigh monthly unless otherwise ordered; -[MEDICATION NAME] (a medication used to stimulate appetite) 15 milligrams (mg); -[MEDICATION NAME] 200 mg twice a day (appetite stimulant). Record review of the resident's nursing progress notes, dated 8/25/16, showed the resident readmitted to the facility. The resident had a [DIAGNOSES REDACTED]. The resident wanted to eat supper upon arrival. Diet is regular with house shakes (nutritional supplement) at meals. The nurse notified dietary. The nurse documented will continue with plan of care. Record review of the resident's weekly weight report dated, 8/26/16, showed the resident weighed 118 lbs (gain of 7 lbs from 8/22/16 weight). Record review of the resident's care plan, developed on 8/28/16, showed the following information: -The resident had difficulty making his/her needs known at times; -The resident had cognitive impairment and the staff should repeat and rephrase questions as needed to the resident; -Eating with assist as needed; -Notify the physician and the responsible party when changes in care needed; -The resident has a history of declining to eat his/her meals; -Encourage fluids and monitor the resident for signs and symptoms of dehydration; -Monitor the resident for side effects from medications of drowsiness, dizziness, nausea, dyspepsia (upset stomach); -Potential for UTI secondary to poor oral intake; -Weigh the resident weekly; -Provide the resident his/her supplements; -Monitor the resident's meal consumption and notify the physician of any problems; -Refer to POS for current diet orders. Record review of the resident's weekly weight report showed the following information: -On 8/29/16, the resident weighed 120 lbs (gain of 2 lbs from weight on 8/26/16). Record review of the resident's nursing progress notes, dated 8/29/16, showed the resident eating meals in the main dining room. Record review of the resident's weekly weight report showed the following information: -On 9/01/16, the resident weighed 114 lbs (loss of 6 lbs from 8/29/16). Record review of the resident's nursing progress notes, dated 9/2/16, showed the following information: -At 12:09 P.M., the nurse documented the resident's vital signs before leaving to go to the hospital for surgery as ordered. -At 6:09 P.M., the nurse documented the resident left the facility at 8:30 A.M. and returned at 12:30 P.M. Resident to eat light with no new medicine orders. -Upon the resident's return, the nurse did not document any assessment of the PEG tube or notification of the placement of the PEG tube to the resident's physician or guardian. The nurse did not document any new orders for tube feeding or water flushes for the PEG tube. Record review of the resident's care plan, updated 9/02/16, showed the following information: -On 9/2/16, PEG tube placed. Refer to dietitian for orders for feedings; -Observe the PEG tube for signs and symptoms of infection; -Provide frequent oral hygiene as needed; -Staff did not document any nutritional feedings to be provided through the PEG tube or water flushes through the PEG tube. Record review of the vital report dated, 9/02/16, at 7:49 P.M., the staff documented the resident refused dinner. Record review of the resident's nursing progress notes, dated 9/3/16, showed no discomfort related to PEG tube placement on 9/2/16. Encouraged fluids and will continue with current plan of care. The nurse did not document notification to the physician regarding the placement of the PEG tube or obtain PEG tube feeding orders or water flush orders for the PEG tube. Record review of resident's vital report dated, 9/03/16, showed the following information: -At 10:39 A.M., the staff documented the resident ate 1-25 % of his/her breakfast; -At 4:24 P.M., the staff documented the resident at 1-25 % of his/her lunch; -At 9:52 P.M., the staff documented the resident did not eat any of his/her dinner. -Staff documented 960 ml of oral fluid intake for the day. Record review of the resident's nursing progress notes did not show any nursing notes for 9/04/16 related to providing PEG tube feedings or water flushes for the resident's PEG tube. The nurse did not document contact with the physician to obtain PEG tube feeding orders or water flushes for the PEG tube. Record review of the resident's vital report, dated 9/04/16, showed the following information: -At 10:12 A.M., the staff documented the resident ate 26-50 % of his/her breakfast; -At 1:40 P.M., the staff documented the resident at 1-25 % of his/her lunch; -At 9:37 P.M., the staff documented the resident ate none of his/her dinner. -Staff documented 420 ml of oral fluid intake for the day. Record review of the resident's nursing progress notes, dated 9/05/16, showed the nurses' did not document related to providing PEG tube feeding or water flushes through the resident's PEG tube. The nurse did not document contact with the physician to obtain the PEG tube feeding orders or water flushes for the PEG tube. Record review of the resident's vital report, dated 9/05/16, showed the following information: -The staff did not document the resident's breakfast intake; -At 1:56 P.M., the staff documented the resident ate 1-25 % of his/her lunch; -At 6:31 P.M., the staff documented the resident ate 1-25% of his/her dinner. -Staff documented 360 ml of oral fluid intake for the day. Record review of the resident's nursing progress notes, dated 9/6/16, showed the nurse documented the resident had a PEG tube placement with no signs and symptoms of infection. The nurse documented will continue to monitor and follow current plan of care. The nurse did not document notification to the physician to obtain PEG tube feeding orders or water flushes through the PEG tube. The nurse did not document administering PEG tube feeding or water flushes through the PEG tube. Record review of the resident's vital report dated, 9/06/16 showed the following information: -At 9:17 A.M., the staff documented the resident ate 1-25% % of his/her breakfast; -The staff did not document the resident's lunch; -At 7:16 P.M., the staff documented the resident did not eat his/her dinner; -Staff documented 360 ml of oral fluid intake for the day. Record review of the resident's vital report, dated 9/07/16, showed the following information: -At 12:28 P.M., the staff documented the resident ate 1-25% % of his/her breakfast; -At 1:49 P.M., the staff documented the resident ate 1-25 % of his/her lunch; -At 7:16 P.M., the staff documented the resident refused his/her dinner; -Staff documented 360 ml of oral fluid intake for the day. Record review of the resident's nursing progress notes, dated 9/7/16, at 2:29 A.M., showed the nurse documented the resident is being charted on for PEG tube he/she had placed recently. No signs or symptoms of infection. The nurse did not document administering PEG tube feeding or water flushes for the PEG tube. The nurse did not document notification of the physician to obtain orders for PEG tube feeding or water flushes for the PEG tube. Record review of the resident's nursing progress notes, dated 9/7/16, at 12:39 P.M., showed the nurse documented no adverse effects noted related to PEG tube placement. No signs and symptoms of infection. The nurse did not document administering feeding or water flushes through the PEG tube. The nurse did not document notification of the physician to obtain orders for PEG tube feeding or water flushes for the PEG tube. Record review of the resident's nursing progress notes, dated 9/8/16, at 6:45 A.M., showed the resident continued on observation related to a newly placed PEG tube. No signs or symptoms of infection. The nurse documented staff will continue with current plan of care. The nurse did not document administering PEG tube feeding or water flushes for the PEG tube. The nurse did not document notification of the physician to obtain orders for PEG tube feeding or water flushes for the PEG tube. Record review of the registered dietitian progress note, dated 9/8/16, at 12:45 P.M., (six days after placement of the PEG tube) showed the resident with a newly placed PEG tube, but not being used at this time. Diet order is regular with house shake three times a day with meals. Meal intake is poor. Weight loss is occurring. Recommend considering starting PEG tube feeding with water flushes. Recommend considering [MEDICATION NAME] (PEG tube feeding formula) or other tube feeding formula at 30 cc/hr continuous (approximately 23 hours to allow for water flushes) with total of 600 cc of water flushes and increase rate of TF 5 cc/hr each day as tolerated up to 60 cc/hour. The goal is to prevent further weight loss. Continue to encourage oral intake of meals and assist with eating. Recommend keeping physician aware of weight and any concerns. Record review of resident's vital report record, dated 9/08/16, showed the following information: -The staff did not document the resident's meal intake for breakfast and lunch; -The staff documented the resident refused the dinner meal; -Staff did not document any oral fluid intake for the day. Record review of resident's nursing progress notes and vital reports, dated 9/09/16, showed the following information: -At 1:09 A.M., the nurse documented the resident on observation for recent PEG tube placement. No signs or symptoms of infection at the PEG tube site. The nurse did not document any PEG tube feeding or water flushes provided through the PEG tube. The staff continued with the current plan of care; -At 9:30 A.M., the nurse documented contact with the physician's office regarding the newly placed PEG tube and dietary recommendations. The physician's nurse said she would notify the physician. -At 2:03 P.M., the nurse documented no new orders at this time and the physician will review for feeding formula on his/her next visit. The nurse did not document any PEG tube feeding or water flushes provided through the PEG tube; -At 6:27 P.M., the nurse aide (NA) documented the resident refused breakfast; -At 6:44 P.M., the NA documented the resident ate 1-25 % of his/her dinner; -At 7:03 P.M., the NA documented the resident refused lunch; -Staff documented 180 ml of oral fluid intake for the day. Record review of the resident's nursing progress note and vital report, dated 9/10/16, showed the following information: -At 7:37 A.M., the resident continued on observations related to the newly placed PEG tube. No signs or symptoms of infection noted. The nurse did not document administering any PEG tube feeding or water flushes through the PEG tube. -At 12:52 P.M., the certified nurse aide (CNA) documented the resident refused his/her breakfast; -At 2:26 P.M., the NA documented the resident at 1-25 % of his/her lunch; -At 2:32 P.M., the staff documented the resident's temperature of 100.8 degrees (normal is less than 98.6 degrees) at this time. The staff said the resident ate his/her meals in the main dining room. The nurse did not document any PEG tube feeding or water flushes provided through the PEG tube; -The staff did not document the resident's dinner intake; -Staff did not document any oral fluid intake for the resident for the day. Staff documented the resident refused fluids. Record review of the resident's nursing progress note and vital reports, dated 9/11/16, showed the following information: -At 11:22 A.M., the NA documented the resident ate 1-25 % of his/her breakfast; -At 12:44 P.M., the staff documented the resident's temperature of 99.7 degrees. Staff assisted the resident with his/her meals in the dining room. Resident noted to pull on the PEG tube, stating he/she wanted it out. The nurse did not document administering any PEG tube feeding or water flushes provided through the PEG tube; -At 2:34 P.M., the NA documented the resident ate 1-25 % of his/her lunch; -At 10:19 P.M., the NA documented the resident refused his/her dinner; - Staff did not document any oral fluid intake for the resident for the day. Staff documented the resident refused fluids. Record review of the resident's nursing progress note and vital reports, dated 9/12/16, showed the following information: -At 2:02 A.M., resident on observation for recent PEG tube placement. No signs or symptoms of infection noted at PEG tube site. -At 9:58 A.M., the CNA documented the resident ate 1-25 % of his/her breakfast; -At 11:58 A.M., the nurse documented the resident's temperature of 96.9 degrees. No adverse effects related to PEG tube placement. Staff assisted the resident with meals in the main dining room. The resident refused breakfast. The nurse documented notification of the physician of need for orders regarding feeding/PEG tube (10 days after placement of the PEG tube). The nurse asked for the resident to be placed on the rounding list. The nurse did not document providing any PEG tube feeding or water flushes through the PEG tube; -At 1:34 P.M., the NA documented the resident refused his/her lunch; -At 10:20 P.M., the NA documented the resident ate 76-100% of his/her dinner; -Staff documented 140 ml of oral fluid intake for the day. Record review of the resident's nursing progress note and vital reports, dated 9/13/16, showed the following information: -At 10:10 A.M., the NA documented the resident did not eat any of his/her breakfast; -At 12:40 A.M., the nurse documented the resident on observation for recent PEG tube placement. No signs or symptoms of infection. The nurse did not document providing any PEG tube feeding or water flushes through the PEG tube. The staff continued with the current plan of care. -At 2:43 P.M., the nurse documented the resident's temperature of 96.1 degrees, pulse 120, blood pressure 78/42, and oxygen saturation of 88%. A nurse aide reported he/she was concerned the resident was not acting him/her self today. The resident was lethargic and flaccid (weak, flabby muscle tone). The resident opened his/her eyes to name, but would not communicate. The nurse notified the physician and received orders to transfer the resident to the emergency room by ambulance for evaluation and treatment as indicated. Record review of the resident's hospital history and physical, dated 9/13/16, at 5:39 P.M., showed the following information: -Resident sent from nursing home to hospital with altered mental status and found to have severe dehydration and acute [MEDICAL CONDITION]. -Resident recently admitted to the hospital for similar complaints and discharged on [DATE] to nursing home. -Resident has severe protein calorie malnutrition and PEG tube placement two weeks ago for nutrition; -Physician's exam showed the resident's general appearance as lethargic, dehydrated, in mild to moderate distress. The resident had poor dental hygiene and dry mucosa. The resident had diminished skin turgor. -Problems noted by physician included acute [MEDICAL CONDITION]ly secondary to severe dehydration, [MEDICAL CONDITION] (greater than normal sodium concentration in the blood, caused by excessive loss of water and electrolytes resulting from inadequate water intake)and severe dehydration. It is unclear why the resident has recurrent episodes of the same, as with having the PEG tube, the resident should be getting adequate fluids and nutrition. The resident had hypercalcemia, secondary to above, acute [MEDICATION NAME], moderate to severe protein calorie malnutrition. Will obtain nutrition consult to resume tube feeding. Record review of the resident's hospital discharge summary, dated 9/17/16, showed the following information: -Resident admitted to hospital on [DATE] and found to have principle [DIAGNOSES REDACTED]. -resident underwent [REDACTED]. Resident resided at the nursing home and had very poor oral intake with risk for aspiration. -Resident not been given any fluids or nutrition through the PEG tube and presented with severe dehydration and acute [MEDICAL CONDITION]. Resident given fluid resuscitation and electrolyte replacement. -Nutrition consult obtained and PEG tube feedings were resumed. -Resident kept NPO (nothing by mouth) due to risk of aspiration. -Resident has improved and at his/her baseline. The resident will be discharged . Record review of the resident's nursing home care plan, updated 9/14/16, (while the resident resided at the hospital. The resident discharged from the hospital on [DATE]) showed the following information: -The staff should provide the resident PEG tube feedings as ordered; -The staff should monitor the resident's tolerance to his/her PEG tube feedings; -The staff should elevate the resident's head of the bed at least thirty degrees. Record review of the resident's physician telephone order, dated 9/14/16, showed the following information: -Staff should start the orders when the resident returns from the hospital; -The resident should have [MEDICATION NAME] 250 milliliters (ml) per PEG tube three times a day; -The staff should check for residual (contents left in the stomach) prior to administration. The staff should notify the physician if the residual is greater than 200 ml; -The staff should flush the PEG tube with 40 ml of water before and after each tube feeding. During an interview on 9/16/16, at 9:28 A.M., the resident's physician said the following: -The staff should monitor any resident who has a weight loss of 2- 3 pounds; -The staff should weigh the resident weekly until the resident's weight becomes stable; -The physician said a PEG tube would be considered for a chronically ill resident; -The staff will contact the physician to determine the right type of feedings a resident with a PEG tube will have (bolus feeding-a larger, gravity infused amount over a short amount of time, or a continuous feeding-a smaller amount infused by a pump over a longer period of time); -The physician said she wants notification from staff when a resident has a PEG tube placed; -She expects the staff to contact her after a resident has any hospital admission or procedure; -She did not know about the resident's lack of oral intake; -She did not know the resident had a PEG tube placed; -She was not aware of the facility staff contacting her for orders for the PEG tube; -She did not know the resident was recently sent to the hospital; -She is very comfortable with the dietitian's recommendations but was never informed. During an interview on 9/16/16, at 11:04 A.M., the assistant director of nurses (ADON) said the following: -The administration staff monitor the charge nursing staff; -The ADON reviewed new orders daily to ensure completeness; -The staff discuss the resident's progress in the weekly (residents' at risk for weight concerns) meetings; -The staff include any residents with a weight loss in the weight loss meetings on Fridays and develop new interventions or make changes for the resident; -The staff discussed the resident's eating history and contact the physician and document in the nursing notes; -The nurse should contact the resident's physician for new orders when a resident returned to the facility following a hospital procedure; -The staff should contact the physician with the registered dietitian recommendations; -The staff should notify the physician the same day to make sure orders are obtained for flushing and nutrition for a newly placed feeding tube; -It is not facility practice to provide a medical service without an order; -The ADON said the staff did not provide any flushes or nutritional support through the resident's PEG tube before he/she went to the hospital (on 9/13/16); -The ADON said the staff did not report this information to the physician prior to the registered dietitian's recommendations; -The ADON would expect the staff to contact the physician for orders for a Peg tube. During an interview on 9/19/16, at 11:35 A.M., Licensed Practical Nurse (LPN) A said the following: -Staff are expected to notify the physician when a resident returned to the facility following a medical procedure and a nursing assessment has been completed; -The nurse places the resident's information on the 24 hour report and the paperwork in the resident's chart from the procedure; -The nurse added ordered treatments on the treatment administration record (TAR) or the Medication Administration Record [REDACTED] -The staff should contact the physician and the registered dietitian for recommendations for flushing the PEG tube. All staff contact should be documented in the nursing notes; -The staff did not have any orders for the resident to receive PEG tube feedings or flushes; -The staff observed the resident eating various amounts by mouth and the staff tried to assist the resident but he/she often refused; -The staff did not routinely notify the physician with the resident's meal intake because this was consistent for him/her. During an interview on 9/19/16, at 12:45 P.M., LPN B said the following: -Staff are expected to contact the physician the following day whenever the physician did not return the call from the previous day regarding a resident. -The staff are expected to monitor each resident every four hours and send a nurse aide in at least every two hours; -The staff would be expected to contact the physician for new orders on a newly placed PEG tube); -The staff documented new orders for a PEG tube on the MAR indicated [REDACTED]. On 9/19/16, at 3:05 P.M., the Director of Nurses (DON) said the following: -She expected staff to request orders for a resident's medication when a resident returned from the hospital. If the staff do not have orders, then the staff should contact the physician and obtain orders; -The DON, medical records, and the resident's primary nurse are expected to check residents' orders; -For a resident who does not receive nutritional supplements in a PEG tube, the nurse is expected to maintain the tubing, which includes flushing the tubing and applying a dressing to the site according to the physicians' orders; -The staff are expected to contact the DON or the assistant director of nurses (ADON) if they cannot reach the resident's physician. The DON would then contact the medical director. The DON could not recall having to contact the medical director due to not being able to reach a physician. During interview on 9/20/16, at 11:18 A.M., the facility's Medical Director (MD) said the following: -He expected the nursing staff to contact the resident's primary physician whenever a resident is admitted or readmitted to the facility following a procedure; -The nursing staff should contact the resident's primary physician the day of or the following day for non-emergent situations to obtain orders; - The nursing staff should contact their director of nurses whenever they are unable to contact a resident's primary physician; - The MD said he was unaware of any problems with the facility staff not being able to reach the resident's primary physician; -The MD said he spoke with the resident's primary care physician and confirmed his office did not have any record of the facility contacting his office regarding obtaining PEG tube orders for the resident; -The MD said the resident waited a long time for orders on (the PEG tube); -The MD said that he would expect the staff to notify the provider if the resident was eating 25 % or less of his/her meals. Complaint#: MO 071

This complaint was substantiated, please refer to event # U44L12 for details. Complaint MO 412

Based on interview and record review, the facility failed to consistently assess, monitor, and provide treatment in a timely manner for one resident (Resident #5) who had urethral erosion associated with urinary catheter use, signs of infection at the site of the urethral erosion and a urinary tract infection. The facility failed to identify, monitor, and obtain treatment in a timely manner for one resident (Resident #6) who had a change in condition resulting in admission to the hospital intensive care unit with [DIAGNOSES REDACTED].#4) in a sample selection of 12 residents in a facility with a census of 96. 1. Record review of Resident #5's care plan, dated 5/11/12, reviewed on 12/4/12, showed the following information: -Indwelling urinary catheter (a sterile tube inserted into the bladder to drain urine) with potential for injury and/or infection related to use for [MEDICAL CONDITION] (benign prostate hypertrophy or enlarged prostate); -Monitor for signs and symptoms of urinary tract infection, including elevated temperature, unusual frequency, burning, flank pain, blood/pus in urine; -Urinary catheter care every shift and as needed; -Urinalysis as ordered/indicated for signs and symptoms of urinary tract infection; -Monitor urine for sediment, cloudy color, odor, blood, and amount; -Change catheter monthly; -At risk for pressure ulcers; -Daily observation of skin with routine care; -Full skin evaluation weekly with bath/shower. Record review of the weekly skin condition report, dated 9/12/12, showed the head of the resident's penis had an approximate "1/2" slit, (which is not of a new onset) at the catheter insertion site near the urethra, with a pea-sized dark scab, from where it was bleeding prior, per resident report. Licensed practical nurse (LPN) E, the wound nurse, discussed this with the charge nurse and Director of Nursing (DON). Staff did not document any follow-up treatment or action in response to the slit. During interview on 1/25/13, at 8:34 A.M., the former wound nurse, LPN E said the resident had the split in his penis for years. When the nurse first documented about it in September 2012, the resident said it had been split for years and he had no feeling there. The nurse said there was no redness, just a black scab from dried blood. The nurse did not know from where the blood came. The nurse said he/she did not chart that he/she reported it to the physician. The nurse had started as wound nurse a couple weeks before that. The nurse said he/she looked for changes and reported them to the charge nurse and DON. If he/she notified the physician, he/she would have documented it there. The nurse said he/she did not know the cause. Record review of the Ostomy Wound Management website showed the following information: -Medical devices often are overlooked as a potential cause of pressure ulcers. -Indwelling catheters have been described as a cause of urethral erosion. -Urethral erosion in men ranges from a partial-thickness wound involving a small area of the glans penis to a full-thickness pressure ulcer, or erosion, cleaving the glans or penile shaft. In extreme cases, gangrene (death of tissue) of the penis can result. -Erosion secondary to catheter placement can cause bleeding from the edges of the urethra and increases the risk of urinary tract infection. -If a urinary catheter is used, proper securement is a priority. Improper urinary catheter securement is associated with urethral erosion (wearing away or gradual destruction of a surface). -Several best practices models recommend securing the catheter to the abdomen on a man. -Caring for patients with urethral pressure ulcers is challenging. Unlike other pressure ulcers, erosion is permanent and standard wound care may not be of benefit. -If the catheter cannot be removed, a securement method that is consistently applied, works for the individual patient, and prevents further erosive injury and/or discomfort is a must. Nursing caregivers need to continue monitoring device securement because no method is infallible and adhesive devices also can cause skin damage. -The goal of care should include preventing further erosion and protecting exposed mucosa. Based on expert opinion, regular catheter care using soap and water is important for hygiene and may help prevent urinary tract and skin infections. For painful areas, wound care using antibiotic ointment or advanced wound dressings may be appropriate. Record review of a urinalysis (UA), dated 10/2/12, showed the following indicators of urinary tract infection: -Cloudy urine (normal would be clear); -2+ blood (normal would be negative); -3+ leukocyte esterase (normal would be negative, a urine test for the presence of white blood cells and other abnormalities associated with infection); -Positive [MEDICATION NAME] (normal would be negative, a finding that is a by-product of bacterial growth); -2+ bacteria (normal would be negative); -20-40 red blood cells (normal would be none seen); -Greater than 150 white blood cells (normal would be none seen). Record review of the urine culture, dated 10/3/12, showed greater than 100,000 proteus mirabilis. The physician documented on the laboratory report the resident had an indwelling catheter secondary to retention and was not able to cure the infection. The physician documented the resident was currently asymptomatic, not septic (no [MEDICAL CONDITION]) and the UTI should not be treated. Record review of the weekly skin condition report, dated 10/4/12, showed the resident's penis head was "slit, not a new condition, urinary catheter indwelling". The nurse did not further describe the skin surrounding the catheter insertion site. Record review of the nurses' notes, from 11/1/12 through 11/4/12, showed the nurse did not document any changes to the resident's catheter insertion site and penis condition. Record review of the weekly skin condition report, dated 11/5/12, showed the resident's penis head was swollen and red. The resident reported the catheter change was due that night, which might be the reason for the inflammation. The wound nurse documented catheter care administered. The wound nurse reported it to the charge nurse. Record review of the November 2012 treatment administration record (TAR), showed the nurse changed the catheter on 11/5/12, on the 10 P.M. to 6:00 A.M. shift. During interview on 1/25/13, at 8:34 A.M., LPN E, the former wound nurse, said on 11/5/12, the penis was swollen and red as he/she documented in the weekly skin assessment. The LPN reported it to the charge nurse. The LPN said he/she could not find where someone notified the physician. Record review of the nurses' notes, from 11/5/12 through 11/9/12, showed the nurse did not document regarding the condition of the resident's catheter insertion site, or penis condition. Record review of the nurses' notes, dated 11/10/12, at 7:01 P.M. (five days after the observation of penis head swollen and red in weekly skin condition report), showed the resident's family member reported to the nurse the resident had swelling and drainage from the penis. The nurse went in to assess at that time and noted swelling to the end of the penis with yellow/green drainage and very strong foul odor. The resident's urine in the catheter bag was amber colored with sediment (visible cells and other debris) noted. The resident reported no pain, but discomfort when touching penis. The nurse attempted to contact the physician and left a message. At 6:00 P.M., the physician ordered to send the resident to the emergency room for evaluation and treatment. At 6:33 P.M., the ambulance left with the resident. Record review of the emergency room provider notes, dated 11/10/12, showed the resident presented to the emergency room with a chief complaint of urinary pain. The resident said his penis was swollen and painful and also stated this was not new and was ongoing. The emergency room physician examined the resident and documented the urinary catheter in place with [MEDICAL CONDITION] noted to glans/shaft of penis. The meatus had split/eroded, consistent with long-term placement of urinary. The resident exhibited pain upon examination of both urinary catheter and penis. Record review of the urinalysis, dated 11/10/12, completed in the emergency room showed the following indicators of urinary tract infection: -Slightly cloudy urine; -2+ leukocyte esterase (normal would be negative); -Positive [MEDICATION NAME] (normal would be negative); -1+ protein (normal would be negative); -3+ blood (normal would be negative); -2+ bacteria (normal would be negative). Record review of the emergency room 's clinical impression was the resident had a lower urinary tract infection and prescribed [MEDICATION NAME] (antibiotic) 500 mg daily for five days. Discharge instructions included resident needed follow-up with urology for evaluation of penile erosion. The resident would likely benefit from urology evaluation and suprapubic catheter placement. During interview on 1/25/13, at 8:34 A.M., LPN E said the emergency room physician started the resident on the antibiotic [MEDICATION NAME]. The resident did not have any treatment related to the split in the penis before that. Record review of the nurses' notes, dated 11/10/12, at 11:06 P.M., showed the resident returned to the facility at 9:45 P.M., via ambulance. The hospital reported the resident needed to see an urologist (specialist in the urinary tract) in Springfield due to penis erosion and infection. The hospital ordered [MEDICATION NAME] 500 mg, one tablet every day for five days. The nurse informed the family member the resident was back at the facility and regarding the needed appointment with an urologist for possible suprapubic catheter (catheter surgically inserted through the abdomen into the bladder). The resident's penis appeared to have less drainage at time of return. Record review of the nursing communication form, dated 11/10/12, at 10:30 P.M., showed the hospital emergency room was recommending a suprapubic catheter due to penis erosion. The resident needed an appointment in the coming week with the urologist. Record review of the transportation form, attached to the nursing communication form, dated 11/12/12, did not show an appointment date and time for the urologist. Record review of the nurses' notes, dated 11/11/12, at 3:28 P.M., showed the end of the resident's penis remained swollen and draining yellow/green thick drainage with a strong odor. The resident complained of no pain except when being touched. Record review of the weekly skin condition report, dated 11/14/12, showed the resident's head of the penis had no redness, warmth, or swelling. The resident was seen in the emergency roiagnom on Saturday (11/10/12) for swelling of the penis head. The resident was placed on antibiotic and told to see his urologist for possible suprapubic catheter put in, due to splitting skin at ureter and penis opening. The wound nurse discussed this with the transportation staff and the transportation aide had a call into the office to get it set up. The transportation aide had been waiting for a call back from the physician's office. During interview on 1/25/13, at 8:34 A.M., LPN E said on 11/15/12, he/she documented no redness, swelling in the weekly skin assessment. The nurse said he/she did not remember if he/she knew the emergency room physician said the resident had penile erosion. The nurse said it surprised him/her that they said that. The nurse said he/she did not see it as eroded, but saw it as split until the penis became "big" (swollen) and then it was infected. The nurse said he/she did not see any documentation that the physician was aware of the penis skin issues. The nurse said he/she did not see any documentation that the physician looked at the resident's penis skin condition after the emergency room visit. LPN E talked to the transportation aide about setting an appointment with the urologist. Record review of the physician order [REDACTED]. Record review of the nurses' notes, dated 11/15/12, at 2:24 P.M., the nurse documented an order for [REDACTED]. Record review of the social services note, dated 11/15/12, at 3:40 P.M., showed the family scheduled the appointment with the urologist for 11/20/12 at 10:30 A.M., however, the transportation driver was unable to take the resident on that date due to conflicting appointments and short notice. The driver left a message with the urologist's office to reschedule the appointment. Record review of the nurses' notes, dated 11/19/12, showed a new order to tape the catheter to the abdomen. The nurse documented the resident went on a leave of absence (LOA) for an appointment during the evening shift. The nurse did not document where or why the resident had an appointment. Record review of the progress note for an urologist appointment, dated 11/19/12, at 4:54 P.M., showed the resident was seen with a history of [MEDICAL CONDITION] (the inability of the bladder to effectively expel urine). The physician had discussed options with the resident previously and he elected to have an indwelling urinary catheter and have it changed every month. The resident went to the emergency room with swelling of his penis and it was noted that he had erosion of his urethra. The catheter is kept dependent taped to his leg. The urologist examined the resident and documented the resident had erosion of several centimeters of his distal urethra (tubular structure that passes from the bladder to the outside opening/meatus of the penis that drains urine from the bladder). The resident had some [MEDICAL CONDITION] of his foreskin, but not phimotic (condition of tightness of the foreskin of the penis that prevents retraction that may be the result of infection) as the foreskin has been eroded as well. The physician discussed options with the resident and documented the resident would probably benefit from a suprapubic tube. The procedure risks and complications, possible benefits, and alternatives were discussed with the resident. The resident gave informed consent for the planned procedure. During interview on 1/23/13, at 2:55 P.M., the social services director (SSD) F and the transportation driver said they rescheduled the appointment to 11/19/12 due to a conflict with the date the family had scheduled the appointment. At the appointment on 11/19/12, the family member signed the consent forms, but the transportation driver explained to the nurse the guardianship situation and followed-up with the guardian who signed the consent forms. The procedure was scheduled for 1/9/13 at 7:00 A.M. During interview on 1/25/13, at 8:34 A.M., LPN E said did not know for sure when the resident went to the urologist. The resident had cancelled several appointments with different physicians in the past. After the resident went to the urologist, he/she did not order any treatment. The nurse said there was no change. Record Review of the POS [REDACTED]. Record review of the weekly skin condition report, dated 11/22/12, showed the wound nurse documented the periarea (perineal area- around the genitalia) was red and "improvement to penis". The resident had an appointment set-up with the urologist this week. The nurse documented treatment in place and barrier cream applied. Record review of the weekly skin condition report, dated 11/29/12, showed the wound nurse documented periarea red and penis head red. The nurse documented catheter care and perineal care administered and barrier cream applied. Record review of the nurses' notes, dated 11/29/12, showed sediment noted to urine and urine is dark yellow color. The nurse notified the guardian of the new order for Bactrim DS twice a day for seven days. Record review of the weekly skin condition report, dated 12/3/12, showed redness noted to penis/testicles/perineal area. The penis head and urethral area was tore, not of new onset. The resident had a urinary indwelling catheter and has had for years. The resident to see the urologist soon about possible suprapubic catheter insertion. The nurse applied barrier cream, catheter care, and perineal care. Record review of the nurses' notes, dated 12/3/12, showed sediment to the catheter and urine was amber-colored. Record review of the resident's quarterly Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument completed by facility staff, dated 12/5/12, showed the following information: -Resident was cognitively intact; -Required extensive assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene; -Indwelling urinary catheter; -Frequently incontinent of bowel; -[DIAGNOSES REDACTED]. -Resident had shortness of breath on exertion and when laying flat; -Oxygen therapy. Record review of the nurses' notes, dated 12/6/12, showed the catheter taped high on leg (instead of abdomen as ordered by the physician on 11/19/12). The resident's urine had sediment and amber-color. Record review of the weekly skin condition report dated 12/12/12 showed no redness, warmth, or [MEDICAL CONDITION] to the penis head. The wound nurse provided catheter care and noted slit present to penis head, "ureter" (urethral) opening, not a new onset. The nurse documented there was no bleeding or drainage noted. During interview on 1/25/13, at 8:34 A.M., LPN E said he/she was no longer the wound nurse after 12/12/12 and he/she did not see the resident's skin after that but it split more in January. The LPN said he/she never measured the split in the resident's penis. LPN E had been told that due to being an LPN, he/she could not measure, but only give an approximation. LPN E said he/she did not measure pressure ulcers or any other skin concerns. The nurse would document his/her assessment and document to refer to the weekly RN wound skin assessment. The RN completed a weekly skin assessment. If it was a pressure area, the RN measured it. If it was not pressure, the wound nurse (LPN) documented an approximation of the wound size. The nurse said no one measured the split in the resident's penis. LPN E said the weekly skin assessment was a head to toe assessment. The nurse did not know for sure if he/she documented every time about the condition of the penis split. Record review of the weekly skin condition reports showed the following information: - On 12/19/12, a charge nurse documented the catheter was intact at assessment with no penile swelling or pain noted. -On 1/1/13, LPN B documented excoriation to scrotum, but no documentation regarding the condition of the catheter insertion site and penis head. Treatment applied per current orders. During interview on 1/24/13, at 9:25 A.M., charge nurse LPN B said he/she did the weekly skin assessment on 1/1/13. The nurse said he/she looked at and did not see any skin problem around the insertion/urethral area. Record review of the weekly skin condition reports dated 1/8/13 showed LPN B documented "penis noted to be split in ?" without redness, warmth, or drainage noted. Record review of the nurses' notes, dated 1/8/13, LPN B documented the resident's penis was split from the meatus down the shaft. The nurse notified the physician. The meatus did not have any redness, warmth, or drainage. During interview on 1/24/13, at 9:25 A.M., charge nurse LPN B said he/she occasionally took care of the resident in December 2012. No one had said anything about the resident's penis/urethra issues. The nurse had just recently started to work that hall. He/she completed an incident report on the date he/she first observed that the penis was split. He/she noticed it the day before the resident was supposed to have the suprapubic catheter placed. The nurse had not worked with the resident very many days and he/she had not noticed that it was split before that. On 1/8/13, the nurse said he/she did not put it in the weekly skin assessment, but did a narrative in the nurses' notes and the incident report. The nurse said he/she did the incident report because the DON said that was where and how to document it. The nurse said he/she did not know of any specific incident that caused it. Record review of the nurses' notes, dated 1/9/13, the nurse documented the resident was bathed with [MEDICATION NAME] (surgical prep cleanse) at bedtime last night and this morning to prep for surgery this morning. Record review of the nurses' notes, dated 1/9/13, at 5:30 A.M., the resident left the facility for an appointment at the hospital. At 10:50 A.M., the hospital called the facility related to the surgery appointment. The surgery was cancelled due to the need for medical clearance with the resident's cardiologist. The nurse notified the social services of the need to schedule an appointment with the cardiologist. Record review of the after visit summary, dated 1/9/13, for the appointment with the urologist showed case was cancelled. The resident had a future appointment scheduled for 10/18/13 with the cardiologist. The discharge instructions included to please obtain medical clearance for surgery and then reschedule with the physician. During interview on 1/23/13, at 2:55 P.M., the transportation aide said he/she took the resident to the appointment on 1/9/13 at 7:00 A.M. The hospital admitted the resident and then called the guardian to cancel the appointment due to clearance had not been obtained from the cardiologist for the procedure. The resident saw the cardiologist on 1/18/13 at 9:45 A.M. The resident has not had the procedure at this time. On 1/20/13, the family told the facility the resident was not strong enough to have the procedure. The physician is not planning on doing the procedure. The resident continues to have the indwelling urinary catheter. During interview on 1/24/13, at 2:12 P.M., the social services director said the resident saw the cardiologist on 1/18/13 and he/she did not give the resident clearance for surgery because the resident was too weak. During interview on 1/24/13, at 9:25 A.M., charge nurse LPN B said he/she knew the resident was going to the urology procedure on 1/9/13, but he/she did not know for what. The nurse just knew the resident was to have nothing by mouth (NPO) before it. The nurse said he/she had speculations about what was going on but no one had communicated to him/her what was going on. When the resident came back from the procedure on 1/9/13, the resident did not have a suprapubic catheter in and the nurse was told it was because the resident did not have medical clearance from the cardiologist. The nurse thought the transportation aide scheduled an appointment with the cardiologist for the resident for the first part of April 2013 because that was when it fit the family's schedule because they wanted to go with the resident. The nurse said he/she overheard the family say the cardiologist will not give clearance for surgery because the resident would not live through the surgery. Record review of the nurses' notes, showed the following information: -On 1/10/13, no adverse effects noted related to the split in the penis head with no blood or drainage noted. -On 1/12/13, at 2:37 P.M., the nurse observed the tear of the head of the penis from the urethra. The resident complained of pain of 5 out of 10 on pain scale. The nurse did not document any pain medicine administered to the resident at that time. -On 1/13/13, the resident's catheter drained milky yellow urine. -On 1/14/13, the penis continued to be split from the meatus down the shaft with no redness, warmth, or drainage noted from the meatus. -On 1/15/13, the penis continued to be split from the meatus down the shaft without redness, warmth, or drainage noted. -On 1/16/13, the resident's catheter drained cloudy yellow urine. -On 1/18/13, the resident's catheter drained thick yellow urine. -On 1/19/13, the penis continued to be split from the meatus down the shaft without signs and symptoms of infection. -On 1/20/13, at 4:37 A.M., the resident's catheter drained thick yellow urine. -On 1/20/13, at 2:15 P.M., the resident having left-sided chest pain and abdominal pain. The resident had a temperature of 101.1 degrees, and a heart rate of 104. When questioned about the pain, the resident pointed to the pacemaker (a small electrical appliance buried under the skin that stimulates the heart to beat) for the chest pain and the right flank for the abdominal pain. The penis continues to be split from the meatus down the shaft without signs and symptoms of infection. The nurse notified the physician and obtained an order to send the resident to the emergency room for evaluation and treatment due to condition change. At 5:30 P.M., the hospital notified the facility the resident was admitted related to the increased heart rate and for treatment of [REDACTED]. During interview on 1/24/13, at 9:14 A.M., registered nurse (RN) G said he/she started working at the facility at the end of November 2012. The head of the resident's penis had already split and staff were just monitoring it at that point. The nurse taped the tubing to the leg so that it would not pull. Staff provided catheter care every shift. The nurse said he/she was told it was hard to change the catheter because of the split. The nurse said the catheter was changed on night shift and so he/she had never changed it on his/her shift. The nurse said he/she had heard the resident was supposed to get a suprapubic catheter, but the resident never got it. During interview on 1/25/13, at 11:52 A.M., the DON said she expected staff to report to the physician based on their assessment in a timely fashion. The nurse should notify the physician of changes in the urine appearance, odor, discharge, discoloration of the urine or the skin, or any signs and symptoms of infection, including an increase in temperature. The DON said she could not verify the history of a long-term split in the penis. 2. Record review of Resident #6's care plan, last reviewed on 11/15/12, showed the following information: -Potential for fluid volume overload deficit/overload related to infection and diuretic ("water pills" - medication to rid the body of excess fluid) use; -Administer diuretic as ordered; -Document intake and output each shift as ordered; -Monitor for [MEDICAL CONDITION] (swelling from fluid retention) or respiratory problems and report to physician; -Record frequency and amount of diarrhea; -Monitor resident for signs and symptoms of dehydration (excessive loss of water from the body tissues, accompanied by disturbance in the balance of essential electrolytes, particularly sodium, potassium, and chloride. It may follow prolonged fever, diarrhea, vomiting, and any condition in which there is rapid depletion of body fluids); -Indwelling urinary catheter; -Ongoing assessment of color, clarity and character of urine; -Assess for symptoms of urinary tract infection; -Observe for acute behavioral changes that may indicate UTI; -Refer to urologist for evaluation of incontinence; -Change catheter tubing/bag monthly; -Catheter care every shift; -Evaluate fluid intake and hydration status. Record review of the physician's progress note, dated 11/21/12, showed the following information: -Resident had some diarrhea; -The resident was eating well; -Lungs clear to auscultation (listening with a stethoscope); -No [MEDICAL CONDITION] in extremities; -Assessment/plan: urosepsis with gram negative bacteria, status/post five days of [MEDICATION NAME] (antibiotic) intramuscularly (IM), [DIAGNOSES REDACTED] ([MEDICAL CONDITION]- bacteria that causes diarrhea) being treated with [MEDICATION NAME] (anti-infective medication), diarrhea better, awaiting result of repeating stool for [DIAGNOSES REDACTED] screening test. Record review of the resident's nurses notes, showed the following information: -On 11/25/12, the nurse documented the resident's temperature was 98.6 (normal) degrees, pulse 58 (normal range 60 - 100), blood pressure 132/62 (normal - below 140/90). -On 11/26/12 day shift (6:00 A.M. to 2:00 P.M.), the resident had an intake of 1,030 ml and output of 250 ml. -On 11/27/12, day shift, the resident had an intake of 1,200 ml and 300 ml urine output. The resident had slight [MEDICAL CONDITION] in his/her extremities. The nurse notified the physician. -On 11/28/12, at 3:30 A.M., the resident had a temperature of 99.1 degrees, pulse 60, respirations 20 (normal range 12 - 22). The resident refused to allow staff to check his/her blood pressure. The resident's family member said the resident had a poor appetite a couple days in the past two weeks; -On 11/28/12, at 7:24 P.M., the resident had a temperature of 98.1 degrees, pulse 68, respirations 18, and blood pressure 120/70. Record review of the physician's progress note, dated 11/29/12, showed the resident looked stable, pale, no acute distress; lungs clear to auscultation, no [MEDICAL CONDITION] in extremities, and urine clear. Record review of the nurses' notes, showed the following information: -On 11/29/12, at 8:03 P.M., the nurse documented the resident's urine had moderate sediment, straw-colored urine, and strong odor present. The resident's temperature was 97.6 degrees, pulse 60, respirations 16, blood pressure 116/64; -On 12/1/12, at 6:40 A.M., the resident's temperature was 99.1 degrees, pulse 63, respirations 15, and blood pressure 114/54; -On 12/1/12, at 7:21 P.M., the nurse documented the resident's temperature was 96.1 degrees, pulse 80, respirations 16, and blood pressure 120/74; -On 12/3/12, at 5:42 A.M., the resident's temperature was 97.8 degrees, pulse 66, respirations 16, and blood pressure 132/68; -On 12/4/12, at 3:06 A.M., the resident's temperature was 97.4 degrees, pulse 72, respirations 17, blood pressure 134/72; -On 12/4/12, at 8:33 P.M., the resident's temperature was 98.1 degrees, pulse 68, pulse 20, respirations 20, and blood pressure 120/60; -On 12/5/12, at 3:17 A.M., the nurse documented the resident had a temperature of 100.3 degrees, pulse 68, respirations 18, and blood pressure 98/60. The nurse documented Tylenol arthritis was given for the temperature on the evening shift (prior to night shift). The nurse documented urinary catheter patent, draining clear yellow urine. The nurse did not document any additional assessment of the resident or his/her lungs. -On 12/6/12, at 7:14 A.M., the nurse documented the resident had a temperature of 102.3 degrees, pulse 58, blood pressure 98/46 at 2:20 A.M. At 6:30 A.M., the resident's temperature was 98.7 degrees, pulse 71, and blood pressure 100/54. The nurse administered two [MEDICATION NAME] 5/325. The resident's urinary catheter was patent, draining clear yellow urine. The nurse notified the physician and family. The nurse did not document any additional assessment of the resident or his/her lungs. Record review of the nursing communication form showed the following information: -The form did not have a date that showed when it was sent to the physician; -It showed vital signs at 2:20 A.M. of temperature 102.3 degrees, pulse 58, respirations 16, blood pressure 98/46, and oxygen saturation 91% (normal is 90 - 100 %). The nurse gave [MEDICATION NAME] (a narcotic pain medication which contains Tylenol that would result in a temperature decrease) for the temperature. The nurse documented notification by phone to another physician who told the nurse "to monitor". The nurse documented vital signs at 6:30 A.M. of temperature 98.7 degrees, pulse 71, respirations 16, blood pressure 100/54, and oxygen saturation level of 96%. The nurse documented the resident "looked very pale. Please advise". The nurse did not document any fur

Based on observations, record review and interviews the facility failed to provide the assessments, monitoring, and services necessary to prevent the development of pressure ulcers for one resident (Resident #6) who acquired three Stage II pressure ulcers (a partial thickness loss of skin layers that presents as an abrasion, blister, or shallow crater) at the facility. The facility identified the resident as a high risk for the development of pressure ulcers but failed to develop and implement interventions to address pressure reduction and repositioning needs for the resident in a sample selection of 18 residents. The facility had a census of 103. Pressure ulcer staging according to State and Federal guidelines: -Stage I pressure ulcer (a persistent area of skin redness without a break in the skin, that is nonblanchable) -Stage II - Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough (dead tissue separating from good tissue). May also present as an intact or open/ruptured blister. -Stage III - 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. -Stage IV - Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Record review of the U.S. Department of Health and Senior Services, Agency for Health Care Policy and Research showed "a bed-bound individual may form pressure ulcers in as little as one to two hours, whereas those who are confined to chairs may form pressure ulcers in even less time because of the greater relative force on their skin. When a resident is identified as being at risk for pressure ulcer development or presents with a pressure ulcer, then preventative interventions should be instituted that address pressure reduction (or management of tissue loads) and repositioning needs. Reducing or eliminating the risk factors can prevent pressure ulcer formation or deterioration of existing ulcers". According to The Merck Manual of Geriatrics (third edition) Risk Factors for the development of pressure ulcers include the following: -Moisture (as it occurs with urinary and fecal incontinence) -Unrelieved pressure for more than two hours; -Immobility; -Inactivity; -[MEDICAL CONDITION]; -Infection; -[MEDICAL CONDITION]; -Declined ability to respond to pressure related discomfort; -History of pressure ulcers. According to Medical Surgical Nursing, Critical Thinking for Collaborative Care 4th edition, many residents require turning and repositioning every two hours. However, pressure ulcers can occur in less time, and the actual turning/repositioning schedule for each resident should be individualized based upon the resident's risk factors such as immobility and disease processes. Record review of the facility's policy and procedure titled, "Management of Pressure Ulcers" (undated) showed in part the following information: -To identify residents with a high risk of pressure ulcer development and to manage the occurrence of pressure ulcers through restorative nursing interventions. -A full body skin condition assessment will be completed on all residents at the time of admission, weekly for four weeks following admission, upon readmission, and prior to each care plan conference or as significant changes in condition occur. -Residents that are identified as "high risk' will be assessed weekly. The high risk assessment will be added to the care plan and preventative approaches will be implemented. -Incontinent residents will be assessed for bladder or habit training in order to keep them clean and dry. -Residents with mobility impairment should be placed on a turning and repositioning schedule; -All pressure areas should be observed daily for any redness or change in condition. 1. Record review of Resident #6's March 2012 physician's orders [REDACTED]. -Staff admitted the resident to the facility on [DATE]; -[DIAGNOSES REDACTED]. This narrowing causes a restriction to the spinal cord, resulting neurological deficits. Symptoms include pain, numbness, and loss of motor control). Record review of the admission assessment dated [DATE], showed the following information: -admitting [DIAGNOSES REDACTED]. -Extensive assistance from staff for all activities of daily living; -Open scab to left knee, bruise to throat from surgery, surgical incision to throat from surgery and surgical incision to back of neck. -Skin treatments, staff cleansed knee with [MEDICATION NAME] (skin cleanser), applied [MEDICATION NAME] (highly absorbent, non-adherent wound dressing) and covered with [MEDICATION NAME] (transparent dressings used to cover and protect wounds); -Staff did not indicate the resident had any other open areas, pressure ulcers or other skin issues. Record review of the facility's form titled Pressure Ulcer Risk- Formal Assessment instrument dated 03/09/12, showed the following information: -The resident had a score of 15; -A score of 18 or less showed the resident was at risk for development of pressure ulcers; -Staff to care plan for pressure ulcer risk; -Staff noted a pressure ulcer care plan was initiated. Record review of the resident's Temporary Care Plan, last updated on 03/09/12, 03/10/12, 03/13/12, and 03/15/12, showed the staff did not indicate problems, goals and approaches to address the resident's risk for pressure ulcers. Record review of the facility's form titled Weekly Skin Report dated 03/15/12, showed licensed practical nurse (LPN) G noted the following information: -Location: neck; -Size: incision;-Stage: intact with bruising: -Treatment: monitor;-Progress: skin intact;-LPN G did not indicate the resident had any other open areas or pressure ulcers. Record review of the resident's admission Minimum Data Set (MDS), a federally mandated comprehensive assessment tool, required to be completed by facility staff, dated 03/16/12, showed the following information: -Cognitively intact; -Required extensive assistance of two staff with bed mobility, and transfers;-Required extensive assistance of one staff for dressing and personal hygiene; -The resident had an indwelling urinary catheter; -Occasionally incontinent of bowel; -At risk for the development of pressure ulcers; -No unhealed pressure ulcers present. Record review of the resident's Temporary Care Plan, last updated on 03/19/12, showed the staff did not indicate problems, goals and approaches to address the resident's risk for pressure ulcers. Record review of the nurses notes beginning on 03/19/12, showed the following information: -The resident was alert and oriented; -The resident required assistance from staff for most activities of living; -The resident used a wheelchair to mobilize; -From 03/19/12 to 03/21/12, staff documented the resident's skin was within normal limits and was intact; -Skilled services provided included ulcer monitoring/prevention/management. Record review of the facility's form titled Weekly Skin Report dated 03/21/12, showed LPN G noted the resident's skin was intact. Record review of the facility's form titled Skin Monitoring: Comprehensive certified nurse assistant (CNA) Shower Review (a form used by the shower aide to note any areas of concern with a resident's skin) showed the CNA should perform a visual assessment of resident's skin when giving the resident a shower. Report any abnormal looking skin (as described below) to the charge nurse immediately. Forward any problems to the Director of nursing (DON) for review. Use this form to show the exact location and description of the abnormality. Using the body chart below describe and graph all abnormalities by number. The form dated 03/22/12 showed the following for the resident: -Bruising on the resident's arms; -Swelling on the resident's feet;-The charge nurse initialed the form; -The DON initialed the form. Record review of the nurses notes beginning on 03/23/12, showed the following information: - From 03/23/12 to 03/26/12, staff documented the resident's skin was within normal limits and was intact; -On 03/26/12, at 2:23 A.M., staff documented the resident's skin was within normal limits. Record review of the facility's form titled Skin Monitoring: Comprehensive CNA Shower Review dated 03/26/12, showed the following information: -Staff documented the resident had open areas on his/her bottom that were bleeding;-Staff did not show the exact location and description of the resident's open areas; -Staff did not use the body chart to describe and graph all of the resident's open areas by number; -Intervention-excoriation (an abraded/raw area where the skin is torn or worn off), treatment Sensi cream(skin barrier);-The charge nurse signed the form. -The DON initialed the form. Record review of the facility's weekly skin report showed LPN G did not note that he/she completed and/or documented a weekly assessment during the week of 3/22/12 to 3/28/12. Record review of the nurses notes on 03/26/12, showed the following information: -At 1:03 P.M., staff documented the resident's skin was pale, cool to touch and the physician was notified; (Staff did not indicate why the physician was notified) -On 03/27/12 and 03/28/12, staff documented the resident's skin was within normal limits. During an interview on 4/27/12 at 9:00 A.M., the DON said the staff turn the daily shower sheets into her. The shower aides gave the sheets to the charge nurse first, the charge nurse was supposed to review the sheets, sign them then turn them into her. She said the resident did have "excoriation" at the end of March and staff got an order for [REDACTED]. She expected the nurse to not just sign the sheet but to review the sheet. She expected the nurse that signed the sheet to get orders for a treatment and document a description of the area, in the notes. Record review of the resident's Temporary Care Plan, last updated on 03/27/12, showed the following information: -Staff did not indicate problems, goals and approaches to address the resident's risk for pressure ulcers;-Staff did not indicate problems, goals and approaches to address the resident's open areas. Record review of the facility's form titled Skin Monitoring: Comprehensive CNA Shower Review dated 03/28/12, showed the following information: -Staff documented open areas on bottom; -Staff marked approximately seven pinpoint dots on the body chart across the buttock area; -Intervention-excoriation, treatment Sensi cream;-The charge nurse did not sign or initial the form; -The DON initialed the form. Record review of physician's telephone orders showed on 03/28/12, at 5:00 P.M., staff noted the physician ordered Sensi care to the resident's buttocks and coccyx every shift and as needed. (staff had documented on the shower sheet an intervention of Sensi cream since 3/26/12). Record review of the resident's Temporary Care Plan, last updated on 03/28/12, showed the following information: -Staff documented the order for Sensi cream to the resident's buttocks and coccyx every shift and as needed;-Staff did not indicate problems, goals and approaches to address the resident's risk for pressure ulcers;-Staff did not indicate problems, goals and additional approaches to address the resident's open areas. Record review of the nurses notes on 03/29/12, showed staff documented the Sensi-care cream to the resident's buttocks per physician order. Staff did not document an assessment of the resident's open areas. Record review of the treatment administration record (TAR) showed the following information:-Between 3/1/12 to 3/28/12, staff did not indicate an order for [REDACTED]. -Between 3/29/12 to 4/5/12, day shift staff initialed they applied the Sensi cream 8 of 8 times;-Between 3/29/12 to 4/5/12, evening shift staff initialed they applied the Sensi cream 4 of 8 times; -Between 3/29/12 to 4/5/12, night shift staff initialed they applied the Sensi cream 6 of 8 times. Record review of the nurses notes on 03/30/12, showed staff documented the resident's skin was within normal limits. Staff did not document an assessment of the resident's open areas. Record review of the nurses notes on 03/31/12, showed staff documented multiple open areas continued to the resident's buttocks and coccyx. Sensi cream was applied and the resident said the area was tender to touch. Staff did not document an assessment of the open areas with staging, size, location, measurements, and characteristics. Record review of the nurses notes from 04/02/12 and 04/03/12, staff documented the resident's skin was within normal limits. Record review of the facility's form titled Skin Monitoring: Comprehensive CNA Shower Review dated 04/03/12, showed the following information: -Staff documented open areas on bottom; -Staff marked circle on the body chart across the buttock area; -Intervention-staff did not indicate any;-The charge nurse did not sign or initial the form; -The DON initialed the form. Record review of the nurse's notes on 04/04/12 (less than a month from admission on 03/08/12), showed the following information: -At 3:51 A.M., the staff documented a pressure ulcer but no further information was given. -At 3:58 P.M., staff documented skin was within normal limits. Record review of the facility's form titled Weekly Skin Condition Report dated 04/04/12 at 4:50 P.M., (14 days since the last weekly skin assessment report and nine days since staff first reported the resident had open areas) showed LPN G noted the following information:-Pressure relief devices utilized: pressure relief mattress on bed. (LPN G did not indicate the presence of a pressure relief cushion in the resident's wheelchair);-Skin concerns: pressure ulcer;-Site #1: -Location: buttock, top area, irregular shape;-Width: 1.5 centimeters (cm);-Length: 1.8 cm;-Color(color of wound bed): open, pink, with several pinpoint red dots;-Drainage: serosanguinous drainage (containing or consisting of both blood and serous fluid);-Odor: no;-Current treatment and effectiveness: Sensi care three times a day and as needed;-LPN G did not indicate the Stage of the pressure ulcer;Site #2: -Location: buttock, bottom, irregular shape;-Width: 1.3 centimeters (cm);-Length: 1.5 cm;-Color(color of wound bed): open, pink, with several pinpoint red dots;-Drainage: serosanguinous drainage;-Odor: no;-Current treatment and effectiveness: Sensi care three times a day and as needed;-LPN G did not indicate the Stage of the pressure ulcer. Record review of the facility's form titled Skin Monitoring: Comprehensive CNA Shower Review dated 04/05/12, showed the following information: -Staff documented open areas on bottom; -Intervention - on DON weekly skin assessment sheet;-The charge nurse signed the form; -The DON initialed the form. Record review of the facility's form titled Weekly Skin Condition Report dated 04/05/12, showed the DON noted the following information: -Pressure relief devices utilized: pressure relief mattress on bed and in chair;Skin concerns: pressure ulcer;-Site #1:-Location: right buttock-proximal;-Stage II; -Width: 1.0 cm;-Length: 2.0 cm;-Color(color of wound bed): superficial depth. Wound bed clean and moist, pink in color;-Drainage: no; -Odor: no;-Current treatment and effectiveness: [MEDICATION NAME] ([MEDICATION NAME] dressing, an opaque dressing used to provide a moist wound healing environment, while protecting from contamination) -new orders just started;-Additional narrative note: peri-wound (skin surrounding the ulcer) blanchable. Verbalized no tenderness. The resident was encouraged to turn side to side to relieve pressure to buttock (The staff noted on the 3/16/12, MDS the resident required extensive assistance from two staff with bed mobility, and transfers); Site #2: -Location: right buttock distal (lower);-Stage II;-Width: 1.0 cm;-Length: 1.5 cm;-Color (color of wound bed): superficial depth. Wound bed clean, moist and pink in color; -Drainage: no;-Odor: no;-Current treatment and effectiveness: [MEDICATION NAME]-new order just put in place. Will continue to monitor on DON's skin rounds; -Additional narrative note: periwound blanchable. Verbalized no tenderness. Record review of the TAR showed staff noted the following information: -On 04/06/12, discontinue the treatment of [REDACTED]. -A new order to cleanse the resident's buttocks with wound cleanser, pat dry; apply [MEDICATION NAME] and change every seven days and/or as needed. Record review of the nurse's notes showed the following information: -On 04/05/12 at 5:15 P.M., staff documented open areas continue to the resident's buttocks. Sensi cream was applied as ordered. -On 04/06/12 at 6:18 P.M., multiple open areas continue to the resident's buttocks, the DON present and measured the resident's wounds. (Refer to DON note for description of wound) -On 04/08/12 at 2:48 A.M., at 2:30 A.M., treatment done to resident's buttock area. Area cleansed with wound cleanser and [MEDICATION NAME] applied to areas, multiple open areas to right buttock and half dollar-sized open area to resident's left buttock (this is the first time staff noted an open area to the resident's left buttock), area has reddish purple peri wound, no tunneling, no odor. Resident tolerated treatment well. Encouraged resident to stay off back as much as possible. Resident lying on right side. (The charge nurse did not indicate he/she notified the physician and/or the DON of the new pressure ulcer on the resident's left buttock). Record review of the facility's form titled Weekly Skin Condition Report dated 04/10/12, showed the charge nurse noted the following information: -Skin concerns: pressure ulcer;-Skin comments/narrative notes: pressure ulcers to buttock covered with [MEDICATION NAME];-Site #1: coccyx (tailbone) (above noted the ulcers were present on the buttocks);-Color: dressing clean, dry and intact;-Drainage: no drainage;Record review of the resident's Temporary Care Plan, showed between 3/26/12 (when staff noted the resident had open areas) to 4/13/12, showed:-Staff still did not indicate problems, goals and approaches to address the resident's risk for pressure ulcers;-Staff still did not indicate problems, goals and approaches to address the resident's open pressure ulcers on the resident's right and left buttock. Record review of the resident's medical record showed staff discharged the resident to the hospital for pneumonia on 04/13/12, and staff readmitted the resident to the facility on [DATE]. Record review of the nursing admission/re-admission assessment dated [DATE] at 5:52 P.M., showed the charge nurse noted the following information: -The resident returned to the facility. Open areas to buttock present prior to leaving;-The charge nurse did not document an assessment of the resident's open areas. Record review of the April 2012, POS showed an order dated 4/19/12, to apply [MEDICATION NAME] to open area on coccyx.(Staff noted the resident had open areas on his/her buttock, not the coccyx). Check every seven days and as needed. Record review of the resident's care plan dated 4/19/12, showed in part the following information;-I have a Stage II pressure ulcer to my right buttock times two, left buttock (present on admission) (the staff noted on 04/08/12, six days prior to the staff discharging the resident to the hospital the presence of an open area on the resident's left buttock) and to my scrotum;-Reposition me at least every two hours;-Place my pressure-relieving device/product on my bed and chair;-Encourage me to weight shift while in my wheelchair;-Develop my turning/repositioning plan with my input;-Teach me the risk factors for development of pressure ulcers;-I need wound care as ordered by my physician;-I need assistance with repositioning to avoid skin friction/shearing;-I need a weekly evaluation of wound healing;-I need a daily observation of skin with routine care;-Adjust my treatment plan if no healing within 2-4 weeks. Record review of the facility's form titled Weekly Skin Condition Report dated 04/20/12, showed the following information: -Pressure relief devices utilized: pressure relief mattress on bed and in chair;-Skin concerns: pressure ulcer;-Skin comments/narrative note: Scrotum noted to have protruding area to dorsal side. Noted superficial open area to (scrotum) area classifying it as a Stage II. No odor or drainage. New order for Sensi care ordered. Education provided to staff. Measurements: 2.0 cm x 1.0 cm;-Site #1:-Location: right buttock-proximal (near the top);-Stage II; -Width: 0.7 cm;-Length: 2.5 cm;-Color (color of wound bed): wound bed with granulation tissue and superficial depth -Drainage: no; -Odor: no;-Current treatment and effectiveness: [MEDICATION NAME]-new order;-Additional narrative note: Therapeutic mattress in place. Education provided to staff on turning resident from side to side. -Site #2:-Location: right distal buttock;-Stage II; -Width: 1.2 cm;-Length: 1.5 cm;-Color(color of wound bed): wound bed with granulation tissue and superficial depth -Drainage: no; -Odor: no;-Site #3:-Location: left buttock;-Stage II; -Width: 2.0 cm;-Length: 2.0 cm;-Color(color of wound bed): wound bed with granulation tissue and superficial depth -Drainage: no; -Odor: no. Record review of the Yearly Physical Examination form dated 4/20/12, showed the resident's physician noted the resident's skin was within normal limits. The physician did not address the presence of the three Stage II pressure ulcers on the resident's right and left buttock and the open area on the resident's scrotum. During an interview on 04/23/12, at 8:05 A.M., CNA CC said Resident #6 was on "priority". This meant he was the last resident up for meals and first resident down after meals due to skin break down on his bottom. Staff were trying to keep the resident off his bottom. Observation and interview on 4/24/12, showed the following information: -At 8:20 A.M., the resident lay in bed. CNA O and CNA P rolled the resident from side to side and provided incontinence care. The resident had an oversized [MEDICATION NAME] covering his coccyx, right and left buttock. The resident had an open, reddened, raised area the size of a nickel on his scrotal area. The resident's wheelchair did not contain a pressure relieving device. Staff used the mechanical lift and a transfer sling and transferred the resident into the wheelchair for breakfast. The resident sat on the transfer sling in the wheelchair; -At 10:00 A.M., the Director of nursing (DON) said the staff were assisting the resident into bed so she and the charge nurse could complete the pressure ulcer measurements and dressing change. The DON said staff obtained new treatment orders today; -At 10:10 A.M., the resident lay in the bed. The resident's wheelchair did not contain a pressure relieving device. Licensed practical nurse (LPN) D and the DON set-up the supplies for the dressing change. Staff rolled the resident onto his side The resident was having a bowel movement and the patch was soiled with feces. The staff removed the soiled [MEDICATION NAME]. The resident's coccyx was pinkish red and appeared to have areas of scarring. The resident had one pressure ulcer on his left buttock, and two pressure ulcers on his right buttock. The wound beds were red with granulation with whitish colored wound edges and presented as Stage II pressure sores. The resident had a raised reddened open area on the back of his scrotum. The DON measured the pressure ulcers on the resident's right and left buttock as the following: the proximal right buttock (site #1) pressure ulcer measured 1.0 cm x 1.5 cm; the distal right buttock (site #2) pressure ulcer measured 1.5 cm by 1.0 cm; the left buttock (site #3) pressure ulcer measured 2.0 cm by 1.0 cm. The DON assisted LPN D with the dressing change. The staff cleansed the area with normal saline, applied the [MEDICATION NAME] directly to the pressure ulcers on the left and right buttock then applied two smaller [MEDICATION NAME]es to the resident's left and right buttock; -The DON said she had staged the areas on the resident's buttock as Stage II pressure ulcers. She staged the area on the resident's scrotum as a Stage II as well; -The DON said the resident had the two pressure ulcers on his right buttock prior to going to the hospital, then readmitted with the areas on the left buttock and scrotum (the staff noted on 04/08/12, six days prior to the staff discharging the resident to the hospital the presence of an open area on the resident's left buttock) -She does all the pressure ulcer measurements weekly to keep consistent measuring because everyone measures differently. If staff found a new area, she expected them to notify her. She expected them to describe the area, get a baseline measurement and document in the notes. During an observation and interview on 04/24/12, showed the following information: -At 4:15 P.M., the resident sat in his wheelchair near the nurse's station. -The resident sat on the transfer sling. The sling was wrinkled underneath his bottom.-The resident said he was waiting to go to supper to eat and was very hungry; -At 4:45 P.M., the resident remained in wheelchair near the nurse's station; -At 5:25 P.M., the resident sat in the same position in his wheelchair; -The resident said he was still waiting for staff to take him to the dining room for supper. The resident said he was very upset and did not like that staff just leave him sit there for hours. The resident said the staff keep walking by and leave him sitting in his wheelchair."I'm hungry and my bottom hurts, I have a lot of open areas due to the staff leaving me sitting like this in my wheelchair". The resident said staff always leaves him sitting like this and sometimes "I just want to give up". -At 5:35 P.M., staff propelled the resident into the back dining room for supper; -At 5:45 P.M., the resident's supper arrived at the table and the resident began feeding self; -At 5:55 P.M., the resident ate most of his meal; -At 6:05 P.M., an aide wheeled the resident from the dining room to his room, positioned the resident by the bed and placed the oxygen on the resident; -At 6:25 P.M., CNA E walked into the resident's room and said he/she would be back in a few minutes to lay the resident down in bed; -At 6:35 P.M., the resident remained in the same position in the wheelchair. NA F entered the room. NA F said he/she was waiting on CNA E to help him/her lay the resident in bed; -At 6:47 P.M., CNA E entered the resident's room with the mechanical lift. CNA E and NA F used the lift, attached the transfer sling and transferred the resident from the wheelchair to the bed. The resident had been sitting on the wrinkled transfer sling. The wheelchair now contained a pressure relieving device; -At 6:55 P.M., staff removed the resident's pants and soiled incontinence brief. The resident had a large bowel movement. Staff provided incontinence care. The resident's scrotum was red and the open area had been contaminated with feces. The resident had the [MEDICATION NAME]es present on the left and right buttock. The resident's skin above the two patches was bright red. The resident's left and right ischial tuberosities (bony area on which the body rests when in a sitting position) were bright red. The areas on the resident's coccyx and ischials blanched when CNA E pressed and released his/her finger on the reddened areas. Staff positioned the resident in bed. CNA E and NA F did not apply barrier cream to the reddened areas after providing incontinence care. During an interview on 04/27/12, at 8:45 A.M., LPN X said regarding positioning, it was different for each resident. The greater the risk, the more often a resident needed to be turned and repositioned. He/she wanted staff to reposition high risk residents every hour and to follow the care plan. LPN X said "priority" meant that the resident should be the first one laid down after meals and the last one up before meals. He/she did not want a resident to be sitting on their bottoms for any period of time. There were about four resident's on "priority". LPN X said Resident #6's was on "priority". LPN X said Resident #6 should not be left more than 30 minutes in his wheelchair. It was not acceptable for staff to have the resident waiting in his wheelchair for one to one and ? hours to go into the dining room. During an interview on 4/26/12 at 3:50 P.M., the DON said staff do pressure ulcer risk assessments upon admission. If a resident was a risk, pressure relieving mattress and cushions should be in place. The charge nurse was responsible for weekly skin assessments for four weeks. If staff identified a resident as a high risk for pressure ulcers, staff should add the risk to the temporary care plan then it would be added to the care plan. LPN G completed the assessments on the "at risk" residents. The assessments should be in the record. During an interview on 04/27/12, at 9:13 A.M., the treatment nurse LPN G said if he/she had time he/she would review the shower sheets. He/she would report any open areas to the DON. Regarding Resident #6, he/she completed the weekly skin assessments. If there was not an assessment on the form or on the computer he/she may have missed it. If staff discovered an open area, the charge nurse and/or DON should get any order from the physician for a treatment. During an interview on 04/27/12, at 9:25 A.M., the DON said staff should reposition residents every two hours. Staff should follow the care plan. "Priority" was any resident who had skin issues, fragile skin or any resident who wanted to be up early and laid down first. A resident on "priority" should be up 30 minutes prior to meals and laid down 30 minutes after the meals. Resident #6 should be on "priority" and should not be left in the wheelchair more that 30 minutes prior to going to the dining room and after he was done with his meal. DON said it was absolutely not acceptable for the resident to be left up in his wheelchair one to one and ? hours before a meal.