Every finding on record at Manor, The

Based on observation, interview, and record review, facility staff failed to wear gloves when administering insulin for two residents (Residents #7, and #49) out of two sampled residents and one resident (Resident #22) out of the sample. The facility also failed to maintain appropriate infection control practices by not following enhanced barrier precautions (EBP) and by not performing proper hand hygiene and glove changing techniques during wound care and catheter care for two residents (Residents #38 and #61) out of sampled residents. The facility's census was 70. Review of the facility's policy titled, Enhanced Barrier Precautions, not dated, showed: - Enhanced barrier precautions will be initiated for residents with any of the following: wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic stasis ulcers) and/or indwelling/implanted medical devices (e.g., central lines, ports, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a multi-drug resistant organism (MDRO); - Personal protective equipment (PPE) for EBP is only necessary when performing high-contact care activities and may not need to be put on prior to entering the resident's room; - High-contact resident care activities include: dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes), wound care; - EBP should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk. Review of the facility's policy titled, Handwashing/Hand Hygiene, revised October 2023, showed: - Single use disposable gloves should be used prior to: before aseptic procedures; when anticipating contact with blood or body fluids; when in contact with a resident, or the equipment or environment of a resident, who is on contact precautions; - The use of gloves does not replace hand washing/hand hygiene. 1. Review of Resident #7's April 2025 Physician Order Sheet (POS) showed: - An admitted [DATE]; - An order for insulin lispro (a fast acting insulin) inject subcutaneously (injection under the skin) before meals per sliding scale for 151-200=3 units, 201-250=5 units, 251-300=7 units, 301-350=9 units, 351-400=11 units, 401-450=13 units, 451-500=15 units, and 501 to notify physician, dated 12/30/24; Observation on 04/17/25 at 10:41 A.M., of the resident's insulin administration showed: - Licensed Practical Nurse (LPN) A performed hand hygiene and did not put on gloves; - LPN A administered the resident's insulin lispro subcutaneously to the right; - LPN A performed hand hygiene. 2. Review of Resident #22's April 2025 POS showed: - An admitted [DATE]; - An order for insulin aspart (a rapid-acting insulin) inject 29 units subcutaneously before meals and inject as per sliding scale for 60-150=0 unit, 151-200=2 units, 201-250=4 units, 251-300=6 units, 301-350=8 units, 351-400=10 units , 401-450=12 units, 451-500=14 units , 501-999 notify physician if over 500, dated 03/31/23. Observation 04/17/25 at 10:51 A.M., of the resident's insulin administration showed: - LPN A performed hand hygiene and did not put on gloves; - LPN A administered the resident's insulin aspart subcutaneously to the left abdomen - LPN A performed hand hygiene. 3. Review of Resident #38's April 2025 POS showed: - An admitted [DATE]; - An order to apply Medihoney (type of wound treatment) to the right buttock wound bed then cover with bordered foam dressing daily, dated 04/01/25. Observation on 04/17/25 at 9:21 A.M., of the resident's wound care showed: - EBP signage on the mailbox by the resident's door; - LPN A and Certified Nurse Aide (CNA) B entered the room, did not put on a gown, performed hand hygiene, and put on gloves; - CNA B placed the resident on his/her right side; - LPN A cleansed the right buttock wound with wound cleanser-soaked gauze, did not change gloves, and did not perform hand hygiene; - LPN A applied Medihoney to the wound bed and covered with a bordered foam dressing; - LPN A changed gloves and did not perform hand hygiene;; - LPN A cleansed the resident's catheter tubing from the insertion site outward using a cleansing wipe; - LPN A removed the gloves and performed hand hygiene. 4. Review of Resident #49's April 2025 POS showed: - An admitted [DATE]; - An order for insulin aspart inject 7 unit subcutaneously before meals, dated 05/24/24; - An order for insulin aspart inject subcutaneously before meals and at bedtime per sliding scale for 151-200=3 units, 201-250=5 units, 251-300=7 units, 301-350=9 units, 351-400=11 units, 401-450=13 units, 451-500=15 units, and 501 or greater to notify the physician or go to the emergency room , dated 05/24/24. Observation on 04/17/25 at 10:44 A.M., of the resident's insulin administration showed: -LPN A performed hand hygiene and did not put on gloves; - LPN A administered the resident's the resident's insulin aspart subcutaneously to the right abdomen; - LPN A performed hand hygiene. During an interview on 04/17/25 at 11:00 A.M., LPN A said he/she didn't wear gloves when administering insulin subcutaneously. 5. Review of Resident #61's April 2025 POS showed: - An admitted [DATE]; - An order to cleanse the gluteal cleft (the horizontal skin crease that forms below the buttocks, separating the upper thigh from the buttocks) wound with wound cleanser, apply Santyl (a type of wound treatment) nickel thick to the wound bed and cover with bordered foam dressing daily, dated 04/10/25; - An order to cleanse the left heel wound with facility wound cleanser of choice, apply Santyl to the wound bed, cover with non-bordered foam dressing and secure with Kerlix (a type of dressing) and tape, dated 04/17/25. Observation 04/17/25 at 1:00 P.M., of the resident's wound care showed: - EBP signage on the mailbox by the resident's door; - LPN A and CNA C entered the room, did not put on a gown, performed hand hygiene, and put on gloves; - CNA C positioned the resident on his/her left side; - LPN A cleansed the gluteal fold wound with saline-soaked gauze, did not change gloves, and did not perform hand hygiene; - LPN A applied Santyl to the wound bed and covered with a bordered foam dressing; - LPN A removed the glove from his/her right hand, did not remove the glove from his/her left hand, and did not perform hand hygiene; - CNA C positioned the resident on his/her back; - CNA C held the resident's leg up for the wound care; - LPN A removed the dressing from the left heel wound with the gloved left hand; - LPN A did not perform hand hygiene, did not change the glove to the left hand, and put on new glove to the right hand; - LPN A cleaned the left heel wound with saline-soaked gauze, did not change gloves, and did not perform hand hygiene; - LPN A applied Santyl to the left wound wound bed, covered with a non-bordered foam dressing, wrapped with Kerlix, and taped; - LPN A and CNA C removed the gloves and performed hand hygiene. During an interview on 04/18/25 at 1:28 P.M., LPN A said EBP should be used for residents with wounds or indwelling devices and gloves and gown should be worn during wound care and catheter care. During an interview on 04/18/25 at 2:40 P.M., the Administrator and Director of Nursing (DON) said that they would expect staff to use EBP during high-contact resident care. During an interview on 04/17/25 at 2:35 P.M., the DON said that she would expect staff to wear gloves with insulin injections or coming in contact with any bodily fluids. 49150

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #68) was free from significant medication errors when staff failed to administer medications as ordered by the physician. The facility census was 70. Review of the facility's policy titled, Medication and Treatment Orders, revised July 2016, showed: - Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state; - Orders for medications must include: name and strength of the drug; number of doses, start and stop dates, and/or specific duration of therapy; route of administration; clinical condition or symptoms for which the medication is prescribed; any interim follow-up requirements (pending culture and sensitivity reports, repeat labs, therapeutic medication monitoring, etc.). 1. Review of Resident #68's April 2025 Physician Order Sheet (POS) showed: - admitted [DATE]; - Diagnoses of end stage renal disease, (a condition where the kidneys have permanently stopped working), (COPD - a chronic, progressive lung disease that makes it difficult to breathe), type II diabetes mellitus type 2 diabetes mellitus (when the body cannot use insulin correctly and sugar builds up in the blood) with hyperglycemia, anemia (condition where the blood doesn't have enough healthy red blood cells or enough hemoglobin, a protein that carries oxygen) in chronic kidney disease, transient cerebral ischemic attack (when the blood supply to part of the brain is briefly blocked), essential primary hypertension (high blood pressure), atrial fibrillation (an irregular heart rate), depression (common mental health condition that causes a persistent feeling of sadness and changes in how you think, sleep, eat and act), emphysema (chronic lung disease that causes permanent damage to the air sacs in the lungs), and syncope (a sudden, temporary loss of consciousness due to decreased blood flow to the brain) and collapse; - An order for dialysis (a treatment that filters waste and excess fluid from the blood when the kidneys can no longer do so) three times a week, dated 03/28/25; - An order for sodium polystyrene sulfonate (a medication to treat high levels of potassium in the blood) powder one packet by mouth one time a day for hyperkalemia (high potassium levels in the blood), dated 03/29/25. Review of the resident's Medication Administration Records (MAR), dated March and April 2025, showed: - An order for sodium polystyrene sulfonate powder one packet by mouth one time a day for hyperkalemia, dated 03/29/25; - The sodium polystyrene sulfonate powder one packet daily not administered 03/31/25, 04/01/25, 04/02/25, 04/03/25, 04/06/25, 04/07/25, 04/08/25, 04/13/25, 04/14/25, 04/15/25, and 04/17/25; - A total of 12 missed opportunities out of 20 opportunities for the sodium polystyrene sulfonate oral powder one packet to be administered as ordered. Review of the resident's medical record showed: - No documentation the physician was notified the resident's sodium polystyrene sulfonate powder was not administered daily as ordered for 03/29/25 - 04/17/25. Observation on 04/17/25 at 9:00 A.M., of the resident's medication administration showed: - Certified Medication Technician (CMT) D did not administer the resident's sodium polystyrene sulfonate oral powder one packet by mouth one time a day. During an interview on 04/17/25 at 9:15 A M., CMT D said he/she wasn't able to find Resident #68's sodium polystyrene sulfonate oral powder packets in the medication cart or in the medication room. The sodium polystyrene sulfonate oral powder was ordered from the pharmacy on 03/28/25. He/She normally worked evenings and the medication was given in the mornings. CMT D spoke with CMT E about where staff kept the resident's sodium polystyrene sulfonate oral powder and was told by CMT E the medication was sent to the facility by the hospital when the resident was discharged to the facility on [DATE]. The hospital sent the powder and staff were unsure how to measure how much powder to administer to the resident. Resident #68 had not received the medication since he/she was admitted to the facility. During an interview on 04/17/25 at 3:30 P.M., the Director of Nursing Director of Nursing (DON) and the Administrator said that they would expect physician orders to be followed as written. They would expect staff to notify them, the pharmacy, and the physician if orders were not understood. During an interview on 04/25/25 at 12:03 P.M., Pharmacist G said the resident's discharge orders were received on 03/29/25. Documentation at the pharmacy showed there was a note on the resident's discharge order that the pharmacy didn't have the sodium polystyrene sulfonate powder and would need a physician order for the liquid form and an end date which wasn't on the powder form order. Typically the pharmacy would call the facility and speak to a charge nurse and explain if changes were needed. There was no documentation on who called the facility from the pharmacy to notify of the changes needed. During an interview on 04/28/25 at 1:33 P.M., Registered Nurse (RN) F from the dialysis center said all dialysis patient's labs were obtained monthly then sent to an outside lab in another state so the results were received back in a day or two later. RN F said the resident's monthly labs were obtained on 04/10/25, and the final results came back to the dialysis center on 04/12/25. RN F notified the dialysis medical director and the nurse practitioner of the lab results and received order to call the facility to send the resident to the emergency room . During an interview on 04/28/25 at 4:50 P.M., the facility Medical Director said Resident #68 had an elevated potassium level was due to non-compliance with going to his/her scheduled dialysis treatments as ordered. It was uncommon for dialysis patients to take medications to lower potassium to the dialysis treatments maintained the normal potassium levels.

Based on observation, interview, and record review, the facility failed to follow physician orders regarding a medication for one resident (Resident #68) that received dialysis (a treatment that filters waste and excess fluid from the blood when the kidneys can no longer do so) out of one sampled resident. The facility also failed to follow oxygen orders for two residents (Residents #14 and #24) out of two sampled residents. The facility census was 70. Review of the facility's policy titled, Medication and Treatment Orders, revised July 2016, showed: - Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state; - Orders for medications must include: name and strength of the drug; number of doses, start and stop dates, and/or specific duration of therapy; route of administration; clinical condition or symptoms for which the medication is prescribed; any interim follow-up requirements (pending culture and sensitivity reports, repeat labs, therapeutic medication monitoring, etc.). Review of the facility's policy titled, Oxygen Administration, revised October 2010, showed: - Verify that there is a physician's order for this procedure. Review physician's orders of the facility protocol for oxygen administration; - Turn on oxygen. Unless otherwise ordered, start the flow of oxygen at the rate of 2 to 3 liters per minute; - Observe the resident upon setup and periodically thereafter to be sure oxygen is being tolerated; - Notify the supervisor if the resident refuses the procedure; - Report other information in accordance with facility policy and professional standards of practice. 1. Review of Resident #14's medical record showed: - admitted [DATE]; - Diagnoses of depression, chronic obstructive pulmonary disease (COPD - a chronic, progressive lung disease that makes it difficult to breathe), anemia (condition where the blood doesn't have enough healthy red blood cells or enough hemoglobin, a protein that carries oxygen), heart failure (condition that develops when the heart doesn't pump enough blood for the body's needs), hypertension (high blood pressure, multidrug resistant organism (MDROs - bacteria that have become resistant to certain antibiotics), pneumonia (lung infection causing inflammation and swelling in the air sacs of the lungs). type 2 diabetes mellitus (when the body cannot use insulin correctly and sugar builds up in the blood), and anxiety (feeling of fear, dread, and uneasiness). Review of the resident's Physician Order Sheet (POS), dated April 2025, showed: - An order for oxygen at 2 liters per minute (L/min) per nasal cannula (a tube delivering oxygen to a person's nose) continuously, every shift related to COPD, dated 08/25/24; - An order to change the oxygen tubing and humidifier at bedtime every Sunday night shift, dated 08/25/24. Observations of the resident showed: - On 04/15/25 at 10:45 A.M., 04/17/25 at 1:40 P.M., and 04/18/25 at 11:45 A.M., the resident lay in bed with oxygen on at 3 L/min per a nasal cannula and the oxygen tubing and humidifier dated 04/13/25. During an interview on 04/15/25 at 10:55 A.M., Resident #14 said he/she didn't know the oxygen was on at 3 L/min. It should be on 2 L/min. 2. Review of Resident #24's medical record showed: - admitted [DATE]; - Diagnoses of malignant neoplasm of colon (a cancerous tumor or growth in the colon), type II diabetes mellitus with hyperglycemia, atelectasis, (a condition where all or part of a lung collapses, meaning it loses its volume and air), acquired hemolytic anemia (caused by factors outside the red blood cell, such as antibodies from an autoimmune disorder, burns, or medications), anxiety disorder, chronic kidney disease, stage 3, (moderate loss of kidney function, where the kidneys are not filtering waste and fluids effectively), COPD, essential hypertension, atrial fibrillation (an irregular heart rhythm, and major depressive disorder (MDD - mental health condition characterized by persistent sadness, loss of interest, and difficulty functioning in daily life). Review of the resident's POS, dated April 2025, showed: - An order for oxygen at 2.5 L/min per nasal cannula continuously, every shift related to chronic obstructive pulmonary disease, dated 06/21/24; - An order to change the oxygen tubing and humidifier at bedtime every Sunday night shift, dated 06/21/24. Observations of the resident showed: - On 04/15/25 at 11:10 A.M., and 04/17/25 at 1:50 P.M., the resident sat in a wheelchair in the hallway with oxygen on at 3 L/min per nasal cannula. The oxygen tubing was stretched from oxygen concentrator at the resident's bedside in his/her room and the oxygen tubing and humidifier dated, 04/13/25; - On 04/16/25 at 2:30 P.M., the resident lay in bed with oxygen on at 3 L/min per a nasal cannula and the oxygen tubing and humidifier dated 04/13/25. During an interview on 04/16/25 at 11:55 A.M., Resident #24 said he/she didn't know the oxygen rate was increased to 3 L/min from 2.5 L/min which was what he/she thought was on the physician orders. During an interview on 04/18/25 at 02:00 P.M., the DON and the Administrator said they would expect residents' oxygen to be at the rate the physician ordered. 3. Review of Resident #68's April 2025 showed: - admitted [DATE]; - Diagnoses of end stage renal disease, (a condition where the kidneys have permanently stopped working), COPD, type II diabetes mellitus with hyperglycemia, anemia in chronic kidney disease, transient cerebral ischemic attack (when the blood supply to part of the brain is briefly blocked), essential primary hypertension, atrial fibrillation, depression (common mental health condition that causes a persistent feeling of sadness and changes in how you think, sleep, eat and act), emphysema (chronic lung disease that causes permanent damage to the air sacs in the lungs), and syncope (a sudden, temporary loss of consciousness due to decreased blood flow to the brain) and collapse; - An order for dialysis three times a week, dated 03/28/25; - An order for sodium polystyrene sulfonate (medication to treat high levels of potassium in the blood) powder one packet by mouth one time a day for hyperkalemia (high potassium levels in the blood), dated 03/29/25. Review of the resident's Medication Administration Records (MAR), dated March and April 2025, showed: - An order for sodium polystyrene sulfonate powder one packet by mouth one time a day for hyperkalemia, dated 03/29/25; - The sodium polystyrene sulfonate powder one packet daily not administered 03/31/25, 04/01/25, 04/02/25, 04/03/25, 04/06/25, 04/07/25, 04/08/25, 04/13/25, 04/14/25, 04/15/25, and 04/17/25; - A total of 12 missed opportunities out of 20 opportunities for the sodium polystyrene sulfonate oral powder one packet to be administered as ordered. Review of the resident's medical record showed: - No documentation the physician was notified the resident's sodium polystyrene sulfonate powder was not administered daily as ordered for 03/29/25 - 04/17/25. Observation on 04/18/25 at 9:00 A.M., of the resident's medication administration showed: - Certified Medication Technician (CMT) D did not administer the resident's sodium polystyrene sulfonate oral powder one packet by mouth one time a day. During an interview on 04/17/25 at 9:15 A M., CMT D said he/she wasn't able to find Resident #68's sodium polystyrene sulfonate oral powder packets in the medication cart or in the medication room. The sodium polystyrene sulfonate oral powder was ordered from the pharmacy on 03/28/25. He/She normally worked evenings and the medication was given in the mornings. CMT D spoke with CMT E about where staff kept the resident's sodium polystyrene sulfonate oral powder and was told by CMT E the medication was sent to the facility by the hospital when the resident was discharged to the facility on [DATE]. The hospital sent the powder and staff were unsure how to measure how much powder to administer to the resident. Resident #68 had not received the medication since he/she was admitted to the facility. During an interview on 04/17/25 at 3:30 P.M., the Director of Nursing Director of Nursing (DON) and the Administrator said that they would expect physician orders to be followed as written. They would expect staff to notify them, the pharmacy, and the physician if orders were not understood.

Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These practices had the potential to affect all residents. The facility census was 62. Review of the facility's policy titled, Food Preparation and Service, revised November 2022, showed: - Only pasteurized shell eggs are cooked and served when residents request undercooked, soft-served or sunny side up eggs and preparing foods that will not be thoroughly cooked example (e.g.) hollandaise sauce, French toast, ice cream, et cetera (etc); - Unpasteurized eggs are cooked until all parts of the egg (yolk and whites) are completely firm. Review of the facility's policy titled, Food Receiving and Storage, revised November 2022, showed: - Food shall be received and stored in a manner that complies with safe food handling practices; - Food services or other designated staff, maintain clean and temperature/humidity-appropriate food storage areas at all times; - When food is delivered to the facility, it is inspected for safe transport and quality before being accepted; - Non-refrigerated foods, disposable dishware and napkins are stored in a designated dry storage unit which is temperature and humidity controlled, free of insects and rodents and kept clean; - Other opened containers are dated and sealed or covered during storage. Review of the facility's policy titled, Refrigerators and Freezers, revised November 2022, showed: - Foods kept in the refrigerator/freezer are stored according to the Food Receiving and Storage Policy; - Supervisors inspect refrigerators and freezers monthly for gasket condition, fan condition, presence of rust, excess condensation, and any other damage or maintenance needs; - Necessary repairs are initiated immediately, maintenance schedules per manufacturer guidelines are scheduled and followed; - Refrigerators are kept clean, free of debris, and disinfected with sanitizing solution on a scheduled basis and more often as necessary. 1. Observation on 02/27/24 at 8:55 A.M., and 02/29/24 at 1:59 P.M., of the kitchen showed: - The commercial range with oily film and brown grime build-up along the top surface and black grime build-up on the oven's interior surfaces; - Food debris and oily film build-up on the floor beneath the range; - The floor was damp with scattered food debris in the food prep area; - Two chest type deep freezers with 1 inch (in.) thick frost build up along the upper 6 in. interior surface near the hinged top; - Floor below the reach-in freezer with scattered debris; - Five ceiling diffusers (one of the few visible parts of an air conditioning system) with gray grime and a brown substance on the front exterior surfaces and between the ventilation louvers; - The commercial dishwasher with gray grime build-up and oily film and food debris below; - Black grime build-up on the drain pipes below the dishwashing counter; - The commercial style can opener with a worn cutting edge, oily grime build-up, and base edges with a brown grime build-up; - A 4 foot (ft.) diameter (dia.) wall section with scratched and damaged paint and wallboard beside the reach-in refrigerator; - A 2 ft. dia. wall section with scratched and damaged paint and wallboard beside the commercial fryer. 2. Observation on 02/27/24 at 8:55 A.M., of the walk-in refrigerator showed: - Debris on the floor below the food shelves; - The wall base with a brown substance; - Dust and grime build-up between the ventilation louvers; - Large metal bowl with fruit salad partially covered with parchment paper; - Tray with small individual bowls of mixed fruit partially covered with parchment paper; - Contained one partially full, 15 dozen case box of non-pasteurized eggs, dated 02/21/24. During an interview on 02/27/24 at 9:28 A.M., Dietary Aide I said the residents were served the non pasteurized eggs made to order and they were normally not cooked well done when fried on the griddle. The dietary staff were expected to follow the facility policy on cleaning. There should not be standing water in the dry food storage room, but it was related to a clogged floor drain that was connected to a sump pump outside the facility. During an interview on 02/27/24 at 9:35 P.M., the Dietary Manager (DM) said dietary staff cook eggs to order using the fresh shell eggs that were not pasteurized. The residents that wanted fried eggs, like them medium or over easy, so they were not always cooked well done. During an interview on 02/27/24 at 10:30 A.M., Resident #29 said fried eggs are ordered often and eaten, they are cooked over easy. During an interview on 02/27/24 at 10:54 A.M., Resident #4 said the food is good and eaten daily, usually it is the same order for breakfast, two eggs over easy, oats and two cups of coffee are served. During an interview on 02/27/24 at 2:30 P.M., Resident #1 said staff are helpful and meals are brought to the room. Eggs were eaten last time for breakfast about 5 days ago, they were served over easy. 3. Observation on 02/29/24 at 2:03 P.M., of the walk-in refrigerator showed: - Debris on the floor below the food shelves; - Dust and grime build-up between the ventilation louvers; - The wall base with a brown substance. 4. Observation on 02/27/24 at 9:37 A.M., and 02/29/24 2:05 P.M., of the dry food storage room showed: - Two 3 quart (qt.) dented cans with diced tomatoes, dated received on 02/21/24, and one 3 qt. dented can with baked beans, dated received on 02/16/24, on the canned food rack; - A vertical 1 in. refrigeration polyvinyl chloride (PVC) drainage line dripped above a 2 ft. dia. section with standing water near a 4 in. floor drain in the corner below the stocked food shelves; - Scattered debris below the food storage shelves; - One 2 ft. section of vinyl baseboard missing behind the food shelving. During an interview on 02/27/24 at 3:30 P.M., the Administrator said the fried eggs were expected to be pasteurized. The unpasteurized eggs should have never been stocked and the supplier had been asked to take them off the ordering list, they will be returned. The facility should not stock any eggs that were not pasteurized. The residents enjoyed fried eggs and don't always like them cooked well done. She expected the dietary staff to keep the kitchen clean, report maintenance concerns and follow the facility policy. During an interview on 02/29/24 at 2:15 P.M., the DM said the issue with non-pasteurized eggs in the kitchen should be corrected but were not at the time of initial inspection. Eggs should not be served fried unless they were well done if they were not pasteurized. There should not be standing water in the dry food storage room and dented cans should not have been placed on the rack. Dented cans were supposed to be sent back to the supplier. Maintenance was possibly aware of the water that stands in the dry storage room. The can opener blade should be replaced. The ceiling vents should be clean and not have corrosion. During an interview on 03/01/24 at 12:45 P.M., the Maintenance Director said no one had mentioned the floor drain being clogged in the dry food storage room but it should be fixed. The ceiling vents should be kept clean and will be repainted. Dietary staff were expected to clean the dust from the vents and the refrigerator ventilation. Missing baseboards will be replaced in the kitchen and dry food storage. Inspections should be made, and concerns should be reported.

Based on interview and record review, the facility failed to ensure an appropriate diagnosis for the use of psychotropic (medications used to treat mental health disorders) medication and to ensure a medication regimen was free from unnecessary medications when the facility failed to implement gradual dose reductions (GDR) for one resident (Resident #27) out of one sampled resident. The facility census was 62. Review of the facility's policy titled, Residents Drug Regimen Review, undated, showed: - The consultant pharmacist shall review the drug regiment of each resident at least monthly or more often if necessary; - The consultant pharmacist will report any irregularities noted in writing to the Director of Nursing (DON), the attending physician, and the facility's medical director; - The attending physician must document in the resident's medical record that the irregularity has been reviewed and what, if any, action has been taken to address it; - If there is to be no change in the medication, the attending physician should document his/her rational in the resident's medical record; - Nursing personnel will take appropriate action on all reports returning from the physicians; - It is the facility's responsibility to make sure the physicians return these reports in a timely manner so as to benefit the resident's health. The facility did not provide a GDR policy. 1. Review of Resident #27's medical record showed: - admitted [DATE]; - Diagnoses of major depressive disorder (long-term loss of pleasure or interest in life) and anxiety disorder (persistent worry and fear about everyday situations); - An order for Lexapro (an antidepressant medication) 20 milligrams (mg) by mouth daily, dated 08/09/23; - An order for Lamictal (an anticonvulsant and/or mood stabilizer medication) 25 mg by mouth daily, dated 05/13/23; - An order for Abilify (an antipsychotic (medication used to to treat psychosis (a mental disorder characterized by a disconnection from reality)) medication) 5 mg by mouth daily, for mood disorder (a mental health problem that primarily affects a person's emotional state), dated 05/13/23; - No documentation of an appropriate diagnosis for the Lexapro; - No documentation of an appropriate diagnosis for the Lamictal; - No attempt by the physician for a GDR of the Abilify and Lamictal. Review of thee resident's Pharmacist's Monthly Review Record (MRR) log, dated 11/21/23, showed: - The GDR's requested by the pharmacist for Ability and Lamictal; - No documentation from the physician regarding the GDR's requested for Abilify and Lamictal. During a phone interview on 03/08/24 at 10:20 A.M., the Administrator said she would expect GDR's to be completed on psychotropic medications and a documented rational why a GDR was not attempted by the physician. She said the pharmacist reviews the residents' medications each month, then each physician completed the GDR's. She would expect GDR's to be completed when recommended, and for them to be documented. She would expect residents' medications to have an appropriate diagnosis.

Based on observation, interview and record review, the facility failed to properly monitor the refrigerator temperatures in which medications, including insulin (medication used to lower blood sugar), were stored. This had the potential to affect all residents. The facility census was 62. Review of the facility's policy titled, Medication Labeling and Storage, dated February 2023, showed: - The facility stores all mediations and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys; - The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner; - Medications requiring refrigeration are stored in a refrigerator located in the medication room at the nurses' station or other secured location. Medications are stored separately from food and are labeled accordingly. Review of the facility's policy titled, Refrigerators and Freezers, revised November 2022, showed monthly tracking sheets for all refrigerators and freezers are posted to record temperatures. Review of Invega (a medication used to treat symptoms of psychosis (a mental disorder characterized by a disconnection from reality)) manufacture's instructions showed to store at room temperature, between 59 degrees Fahrenheit (F) and 86 degrees F. 1. Observation on 03/01/24 at 1:15 P.M., of the medication refrigerator showed: - No documentation of the refrigerator temperature log; - Current temperature 32 degrees Fahrenheit; - Novolog (an insulin) and Lantus (an insulin) in the door; - One unopened box of Invega medication on a shelf; - One opened bottle of ranch dressing in the door; - One cup of applesauce, dated 2/24; - One chocolate health shake; - Ice buildup in and around the freezer; - A 4 inch (in.) x 6 in. freeze pack embedded in ice in the freezer; - An 1 in. brown substance in the middle of the frosted area of the freezer. During an interview on 03/01/24 at 2:15 P.M., Certified Nursing Assistant (CNA) K said the refrigerator temperature was supposed to be checked twice daily. He/She did not know where the log was or why a log had not been completed for this month. During an interview on 03/01/24 at 2:25 P.M., Registered Nurse (RN) L said the refrigerator temperature was supposed to be checked daily but it had not been done. The refrigerator temperature was currently 40 degrees F, but he/she did not know what it should be. During a phone interview on 03/07/24 at 11:40 A.M., the Director of Nursing (DON) said the refrigerator temperatures should be checked and logged daily. The temperature log should be kept on the refrigerator. If the temperature was incorrect, she would expect staff to make sure they were checking the correct area of the refrigerator. If the temperature was out of range, staff should check if the control was set at the right temperature zone and report it to maintenance immediately. No personal items or food should be kept in the medication refrigerator, unless it was the health shakes for a resident that were given with medications. She would expect the refrigerator to be clean, and any frosted freezers to be addressed. The Invega should be kept in the refrigerator if that was what the manufacturer's instructions said to do. The Invega should not be kept in the refrigerator if it said to be stored at 59 to 86 degrees F.

Based on observation, interview and record review, the facility failed to ensure staff treated residents with dignity and in a respectful manner by leaving one resident (Resident #55) out of nine sampled residents exposed during care. The census was 62. Review of the facility's policy titled, Dignity, dated February 2021, showed: - Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem; - Residents are treated with dignity and respect at all times; - When assisting with care, residents are supported in exercising their rights; - Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures; - Demeaning practices and standards of care that compromise dignity are prohibited, for example, promptly responding to a resident's request for toileting assistance. Review of the facility's policy titled, Catheter (a tube inserted into the bladder to drain urine) Care, Urinary, revised August, 2022 showed to provide privacy. 1. Review of Resident #55's medical record showed: - admitted [DATE]; - Diagnoses included obstructive uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow); Review of the resident's Physician Order Sheet (POS), dated February 2024, showed: - An order to place an indwelling Foley catheter, dated 01/04/24; - An order to change the catheter monthly, dated 01/04/24; - An order for catheter care twice a day, dated 01/04/24. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/29/23, showed: - Required partial to moderate assist of staff for dressing, bed mobility, transfers, and toileting; - Frequently incontinent of bladder; - Always continent of bowel. Observation of the resident on 02/29/24 at 9:49 A.M., showed: - The resident lay in bed; - Licensed Practical Nurse (LPN) A entered the room to perform catheter care; - LPN A did not pull the curtain or close the blind to the window; - Through the window, the yard and a road could be seen; - LPN A failed to provide privacy during catheter care for the resident. During an interview on 02/29/24 at 11:00 A.M., LPN A said the curtain or blind should be closed when performing resident care. During an interview on 03/01/24 at 2:40 P.M., the Director of Nursing and Administrator said they expect privacy to be maintained and provided during resident care.

Based on interview and record review, the facility failed to issue a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) for one resident (Resident #22) out of three sampled residents. The facility census was 62. The facility did not provide a policy for SNF ABNs. 1. Review of Resident #22's Advanced Beneficiary Notice (ABN) form showed: - The resident discharged from skilled Medicare services on 12/13/23, and remained in the facility; - The resident received and signed the form on 01/16/24; - The facility failed to provide the correct SNF ABN form to the resident at least two calendar days before the skilled Medicare services ended. During a phone interview on 03/07/24 11:40 A.M., the Director of Nursing said the Social Services Designee (SSD) was responsible for the SNF ABNs. If the SSD was not available, they go to the Business Office Manager. She said it should have been signed prior to 01/16/24. During a phone interview on 03/07/24 at 11:55 A.M., the Business Office Manager said SNF ABNs were completed when the social worker received notification of the resident coming off therapy. If the resident was their own person, the social worker took the SNF ABN and Notice of Medicare Non-Coverage (NOMNC) documents to them to sign. If the resident was not their own person, the social work mailed the documents to the family with a self-addressed envelope to be signed and returned. He/she would expect SNF ABNs and NOMNC to be provided and signed prior to the date of last covered day. He/she would expect Resident #22's to have been signed prior to 01/16/24.

Based on observation, interview, and record review, the facility failed to implement care plans with specific interventions to meet individual needs for seven residents (Residents #13, #19, #27, #34, #41, #49, and #63) out of 16 sampled residents. The facility's census was 62. Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised March 2022, showed: - The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident; - The comprehensive, person-centered care plan is developed within seven days of the completion of the required Minimum Data Set (MDS) (a federally mandated assessment completed by facility staff) assessment, and no more than 21 days after admission; - The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment; - The comprehensive, person-centered care plan includes: measurable objectives and timeframes; describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; and reflects currently recognized standards of practice for problems areas and conditions. 1. Review of Resident #13's medical record showed: - An admitted [DATE]; - Diagnoses of atrial fibrillation (abnormal heart rhythm), congestive heart failure (CHF) (an inability of the heart to pump sufficient blood flow to meet the body's needs), and chronic obstructive pulmonary disease (COPD) (a chronic inflammatory lung disease that causes obstructed airflow from the lungs); - An order for oxygen tubing change and clean concentrator weekly on Sunday, dated 06/08/24; - An order for oxygen at 2 liters per minute per nasal cannula continuously, dated 06/08/23. Review of the resident's care plan, undated, showed did not address the resident's use of oxygen. Observation of Resident #13 showed: - On 02/28/24 at 11:10 A.M., the resident lay in bed not wearing a nasal cannula and the oxygen concentrator turned off at the bedside; The oxygen tubing, undated, stored coiled in the trash can. The portable oxygen tubing, undated, hung coiled on the brake handle of the wheelchair without a sealed container; - On 02/29/24 at 8:05 A.M., and 02/29/24 at 4:08 P.M., the resident lay in bed not wearing a nasal cannula and the oxygen concentrator turned off at the bedside. The portable oxygen tubing, undated, hung coiled on the brake handle of the wheelchair without a sealed container; - On 03/01/24 at 8:17 A.M., the resident lay in bed not wearing a nasal cannula and the oxygen concentrator turned off at the bedside. The portable oxygen tubing, undated, hung coiled on the brake handle of the wheelchair without a sealed container. The concentrator tubing, undated, was coiled in a bag placed on the concentrator. During an interview on 02/28/24 at 11:10 A.M., Resident #13 said he/she slept with the oxygen tubing on at night and normally could take it off without help, but sometimes it fell off. 2. Review of Resident #19's medical record showed: - An admitted [DATE]; - Diagnoses of hypertension (high blood pressure), coronary artery disease (CAD) (a condition causing damage to the major blood vessels that supply the heart with blood, oxygen and nutrients), benign prostatic hyperplasia (BPH) (enlargement of the prostate causing difficulty in urination), gastroesophageal reflux disease (GERD) (stomach acid being forced back into the throat region), falls, sacral (the bottom of the spine, between the bottom of the lumbar spine and tailbone) decubitus (damage to the skin and/or underlying tissue as a result of pressure), impaired mobility, and chronic bladder outlet obstruction (a blockage at the base of the bladder); - No oxygen or oxygen tubing change orders. Review of the resident's care plan, last revised 02/14/24, showed did not address the resident's use of oxygen. Observation of Resident #19 showed: - On 02/27/24 at 9:45 A.M., the resident lay in bed and not wearing the oxygen tubing, dated 02/18/24, but with the oxygen concentrator (a medical device that provides extra oxygen) on 2 liters (L) at the bedside; - On 02/29/24 at 8:10 A.M., the resident lay in bed with the oxygen concentrator on 2 L at the bedside and the resident removed the nasal cannula, dated 02/18/24, from his/her nostril. 3. Review of Resident #34's medical record showed: - An admitted [DATE]; - Diagnoses of metabolic encephalopathy (a brain disorder caused by a chemical imbalance in the blood), myocardial infarction (a blockage of blood flow to the heart; heart attack), and seizures; - Smoking assessment, dated 01/14/24, showed resident smoked safely but required staff supervision. Review of the resident's care plan, dated 02/27/23, showed did not address the resident's smoking with specific interventions. 4. Review of Resident #41's medical record showed: - An admitted [DATE]; - Diagnoses of dyspnea (shortness of breath), failure to thrive, anemia, diabetes mellitus (DM) (a disease where the body's ability to produce or respond the the hormone insulin is impaired), hypertension, end stage renal disease (ESRD) (when the kidneys are no longer able to work at a level needed for day-to-day life), right lower extremity amputation, and impaired mobility; - Smoking assessment, dated 01/12/24, showed resident smoked safely but required staff supervision. Review of the resident's care plan, revised 02/14/24, showed did not address the resident's smoking with specific interventions. 5. Review of Resident #49's medical record showed: - An admitted [DATE]; - Diagnoses of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), osteoarthritis (degenerative joint disease), DM, muscle weakness, and history of falling; - Risk of Elopement/Wandering review, dated 4/26/22, showed the resident was at risk for elopement/wandering as evidenced by the resident wandered aimlessly in the hallway and in and out of common rooms. Review of the resident's care plan, dated 07/20/22, showed did not address the resident's elopement/wandering with specific interventions. 6. Review of Resident #63's medical record showed: - An admitted [DATE]; - Diagnoses of atrial fibrillation, decubitus ulcer (damage to the skin and/or underlying tissue as a result of pressure) to buttocks, weakness, DM, lower extremity pain, bed bound, constipation, asthma (a condition where a person's airways become inflamed, narrow and swell, and produce extra mucus which causes difficulty breathing), hypertension, sacral (the bottom of the spine, between the bottom of the lumbar spine and tailbone) deep tissue injury (a pressure-related injury to subcutaneous tissues under intact skin), and shortness of breath; - No oxygen order. Review of the admission MDS, dated [DATE], showed the resident received oxygen. Review of the resident's care plan, dated 02/12/24, showed did not address the resident's use of oxygen. Observation of Resident #63 showed: - On 02/27/24 at 2:01 P.M., the resident lay in bed with oxygen on at 2 L per nasal cannula, dated 02/18/24; - On 02/28/24 at 8:15 A.M., and 02/29/24 at 9:40 A.M., the resident lay in bed with oxygen on at 3 L per nasal cannula, dated 02/18/24. During an interview on 02/27/24 at 2:01 P.M., Resident #63 said he/she used oxygen a lot. During an interview on 03/01/24 at 2:37 P.M., the MDS Coordinator said that care plans should be individualized. He/She just started in November 2023 and the MDS's had been behind and care plans were not up to date. The care plans were basic for now but he/she was working on them. The care plans should be updated and individualized. During an interview on 03/01/24 at 3:40 P.M., the Administrator and Director of Nursing said that care plans should be individualized and the new MDS Coordinator was working on that. Anything that told the staff how to care for a resident that was specific should be included, such as smoking, oxygen, and wandering. 46521 47445 47447

Based on interview and record review, the facility failed to follow oxygen orders for one resident (Resident #13) out of three sampled residents. The facility also failed to follow physician orders regarding a medication on a resident (Resident #41) that received dialysis (a process for removing waste and excess water from the blood) out of one sampled resident. The facility census was 62. Review of the facility's policy titled, Medication and Treatment Orders, revised, July 2016, showed: - Orders for medications and treatments will be consistent with principles of safe and effective order writing; - Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state. Review of the facility's policy titled, Dialysis Critical Element Pathway, dated, May 2017, showed for residents receiving dialysis at a certified dialysis facility, assess and document vitals, weights and resident's status with the dialysis facility prior to and post dialysis, administer medications or meals before or after dialysis as ordered, and provide direct visual monitoring of the access site before and after dialysis. 1. Review of Resident #13's medical record showed: - admitted [DATE]; - Diagnoses of atrial fibrillation (abnormal heart rhythm), congestive heart failure (CHF) (an inability of the heart to pump sufficient blood flow to meet the body's needs), chronic obstructive pulmonary disease (COPD) (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Review of the resident's Physician Order Sheet (POS), dated February 2024, showed; - An order to change the oxygen tubing and clean the concentrator (a machine that produces extra oxygen) weekly on Sundays, dated 06/08/24; - An order for oxygen at 2 liters per minute (L/min) per nasal cannula (a tube delivering oxygen to a person's nose) continuously, dated 06/08/23. Observation of Resident #13's showed: - On 02/28/24 at 11:10 A.M., the resident lay in bed not wearing a nasal cannula and the oxygen concentrator turned off at the bedside; The oxygen tubing, undated, stored coiled in the trash can. The portable oxygen tubing, undated, hung coiled on the brake handle of the wheelchair without a sealed container; - On 02/29/24 at 8:05 A.M., and 02/29/24 at 4:08 P.M., the resident lay in bed not wearing a nasal cannula and the oxygen concentrator turned off at the bedside. The portable oxygen tubing, undated, hung coiled on the brake handle of the wheelchair without a sealed container; - On 03/01/24 at 8:17 A.M., the resident lay in bed not wearing a nasal cannula and the oxygen concentrator turned off at the bedside. The portable oxygen tubing, undated, hung coiled on the brake handle of the wheelchair without a sealed container. The concentrator tubing, undated, was coiled in a bag placed on the concentrator. 2. Review of Resident #41's medical record showed: - admitted [DATE]; - Diagnoses of end stage renal disease (ESRD) (when the kidneys are no longer able to work at a level needed for day-to-day life), dyspnea (shortness of breath), failure to thrive, diabetes mellitus (DM) (a condition that affects the way the body processes blood sugar), hypertension (high blood pressure), right lower extremity amputation, and impaired mobility. Review of the resident's POS, dated February 2024, showed an order for sodium polystyrene sulfonate (a medication used to remove potassium from the blood) 15 milligram mg/60 milliliters (ml) give 60 ml by mouth daily for 30 days, hold on dialysis days (Tuesdays, Thursdays and Saturdays), dated 01/12/24. Review of the resident's Medication Administration Record (MAR) dated, February 2024, showed: - An order for sodium polystyrene sulfonate 15 mg/60 ml give 60 ml by mouth daily for 30 days, hold on dialysis days (Tuesdays, Thursdays and Saturdays), dated 01/12/24; - A total of 15 missed opportunities out of 16 opportunities for the staff to administer the medication to the resident on non-dialysis days. During an interview on 02/28/24 at 5:38 P.M., Certified Medication Technician (CMT) J said the bottle wasn't in the medication cart with his/her medication. CMT J looked in the other medication cart and found it. He/She said it was located in the wrong medication cart. The medication was not given some days because the resident refused it and didn't get it on the dialysis days anyway. If the resident refused, it should be documented. During an interview on 02/28/24 at 5:45 P.M., the resident said he didn't get offered a liquid medication in the morning, but he/she did refuse the water pill on dialysis days because dialysis was going to get rid of the water for him/her. During an interview on 03/01/24 at 3:40 P.M., the Administrator and Director of Nursing (DON) said they would expect medications not be routinely circled as not given without documentation of the reason. If the bottle was misplaced, it should be found or reordered. If the resident refused it, the medication should be documented and in this case, dialysis and the physician should be notified of the resident's refusal of the medication. 46521

Based on observation, interview, and record review, the facility failed to ensure staff utilized safe transfer techniques for one resident (Resident #7) out of one sampled resident using a sit-to-stand lift (a mechanical lift used to help a person to transfer from a seated position to a standing position or vice versa). The facility census was 62. Review of the facility's policy titled, Sit to Stand Lift, undated, showed the policy did not address the number of staff required to perform the transfer safely. Review of the instructional sticker on the sit to stand lift showed, when possible, use two staff to perform a sit to stand safely. 1. Review of Resident #7's medical record showed: - An admitted [DATE]; - Diagnoses of falls, altered mental status, atrial fibrillation (an irregular heart rate), diabetes mellitus (DM) (a condition that affects the way the body processes blood sugar), hypertension (high blood pressure), depression (a serious medical illness that negatively affects how you feel, the way you think and how you act), anxiety (persistent worry and fear about everyday situations), and acute metabolic encephalopathy (an alteration of the brain function resulting from other internal organ failure). Review of the resident's quarterly Minimum Data Set (MDS) (a federally mandated assessment completed by facility staff), dated 02/13/24, showed the resident required substantial to maximal assist for transfers. Review of the resident's care plan, revised on 02/13/24, showed the resident required assistance of two staff of all transfers using the sit to stand lift. Observation on 02/29/24 at 10:34 A.M., showed: - Certified Nurse Assistant (CNA) B pushed the sit to stand lift into Resident #7's room; - CNA B put the sling on the resident and lifted the resident into a standing position with the lift; - CNA B pushed the lift with the resident standing up and bearing weight while holding onto the grip bars from the resident's room into the bathroom; - CNA B lowered the resident onto the toilet with the lift; - CNA B failed to transfer the resident with the sit to stand lift with two staff. During an interview on 03/01/24 at 11:24 A.M., Nurse Assistant (NA) D said a sit to stand was always used with two staff. During an interview on 03/01/24 at 11:25 A.M., CNA B said a sit to stand should always be used with two staff. During an interview on 03/01/24 at 12:27 P.M., Registered Nurse (RN) C and Physical Therapist (PT) E said a sit to stand was always used with two staff. During an interview on 03/01/24 at 3:31 P.M., the Administrator and Director of Nursing (DON) said that a sit to stand should be performed with two staff at all times.

Based on observation, interview and record review, the facility failed to ensure staff maintained proper positioning and placement of the indwelling urinary catheter (a tube inserted into the urinary bladder to drain urine) tubing and drainage bags and the facility also failed to ensure documentation of the catheter changes and the catheter care were maintained for two residents (Resident #19 and #55) out of three sampled residents. The facility census was 62. Review of the facility's policy titled, Catheter Care, revised on 02/26/21, showed: - The facility will ensure any resident with a urinary catheter will be maintained to prevent infection; - Staff will make sure urine flows out of the the catheter into the drainage bag; - Staff to keep the urinary drainage bag below the level of the bladder to prevent back flow of the urine; - Staff to make sure the urinary drainage bag and catheter tubing does not touch the floor; - Catheter drainage bags will be placed in privacy bags to promote the resident's dignity. 1. Review of Resident #19's medical record showed: - admitted [DATE]; - Diagnoses of hypertension (high blood pressure), coronary artery disease (CAD) (a condition causing damage to the major blood vessels that supply the heart with blood, oxygen and nutrients), benign prostatic hyperplasia (BPH) (enlargement of the prostate causing difficulty in urination), gastroesophageal reflux disease (GERD) (stomach acid being forced back into the throat region), falls, sacral (the bottom of the spine, between the bottom of the lumbar spine and tailbone) decubitus (damage to the skin and/or underlying tissue as a result of pressure), impaired mobility, and chronic bladder outlet obstruction (a blockage at the base of the bladder). Review of the resident's Physician Order Sheet (POS), dated February 2024, showed: - An order to change the Foley (an indwelling catheter) catheter with 16 French every 30 days, dated 01/05/24; - An order to perform Foley catheter care every shift, dated 01/05/24. Review of the resident's Treatment Administration Records (TAR), dated January 2024, and February 2024, showed: - For January 2024, and February 2024, no documentation the Foley catheter was changed; - For January 2024, Foley catheter care every shift showed 10 out of 84 opportunities missed; - For February 2024, Foley catheter care every shift showed 20 out of 70 opportunities missed. Observations on 02/27/24 at 2:07 P.M., 02/28/24 at 8:26 A.M., 02/29/24 at 8:10 A.M., and 02/29/24 at 10:21 A.M., of the resident showed the resident lay in bed with the catheter bag hanging from the bed frame in a privacy bag with an open bottom, touching the floor, and amber colored urine flowed from the tubing into the bag. During an interview on 02/27/24 at 2:07 P.M., Resident #19 said he/she didn't know how often the catheter got changed but he/she didn't like it. The catheter had to hang low to flow correctly. During an interview on 02/29/24 at 3:00 P.M., the Director of Nursing (DON) said Resident #19's catheter had been changed in the hospital recently because they had to use a scope. The doctor's office will continue to change the catheter at this time because of how complicated it was to do so. 2. Review of Resident #55's medical record showed: - admitted [DATE]; - Diagnoses of unspecified convulsion (a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements like stiffness, twitching or limpness, behaviors, sensations, or states of awareness), essential hypertension (high blood pressure), hypokalemia (decreased blood level of potassium), unspecified symbolic dysfunctions (language impairment), cognitive communication deficit (difficulty with thinking and how someone uses language), acidosis (a condition in which there is too much acid in the body fluids), acute kidney failure, type two diabetes mellitus (DM) (a condition that affects the way the body processes blood sugar), unspecified lack of coordination, difficulty in walking, muscle weakness, abnormal posture, and obstructive uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow); - Nurses note, dated 01/04/24, showed the urologist's (a physician that deals with diseases of the male and female urinary tract) office called and requested to place an indwelling catheter due to urinary retention. A 16 French Foley catheter placed per sterile technique. Received 100 milliliters (ml) or amber urine. Review of the resident's POS, dated January, 2024, showed: - An order to place indwelling Foley catheter, dated 01/04/24; - An order to change the catheter monthly, dated 01/04/24; - An order for catheter care twice a day, dated 01/04/24. Review of the resident's TAR, dated January 2024 and February 2024, showed: - For January 2024, catheter care twice a day showed 16 out of 53 opportunities missed; - For February 2024, catheter care and monthly catheter change not addressed. Observation on 02/29/24 at 9:45 A.M., showed the resident to sat in a wheelchair with his/her catheter tubing hanging out of the bottom of his/her pants with the catheter bag hooked under the wheelchair in a privacy bag. The catheter tubing dragged on the floor under the wheelchair. During an interview on 03/02/24 at 12:27 P.M., Registered Nurse (RN) C said the catheter tubing and bags should not touch the floor. Catheter care should be done at least every shift and documented. During an interview on 03/02/24 at 3:50 P.M., the Administrator and DON said the catheter bags and tubing should be kept off of the floor. Catheter care should be done as ordered and documented.

Based on observation, interview and record review, the facility failed to obtain a physician's order for oxygen use and orders for oxygen tubing (a small, flexible tube that contains two open prongs that sit in the nostrils and attaches to an oxygen source) changes for two residents (Resident #19 and #63) out of two sampled residents. The facility census was 62. Review of the facility's policy titled, Physician Medication Orders, revised April 2010, showed: - Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state; - No drugs or biologicals shall be administered except upon the order of a person lawfully authorized to prescribe for and treat human illnesses; - Orders for medications must include name and strength of drug, quantity or specific duration of therapy, dosage and frequency of administration, route of administration if other than oral, and reason or problem for which given; - Drug and biological orders must be recorded on the physician's order sheet in the resident's chart. Such orders are reviewed by the pharmacist on a monthly basis. Review of the facility's policy titled, Oxygen Administration, revised 05/14/20, showed: - Check physician order for liter flow and method of administration; - For the use of reusable humidifiers: Set the flow meter to the rate ordered by the physician, place mask or cannula (a device that delivers extra oxygen through a tube into your nose) on the resident; - Label the humidifier with the date and time opened. Change the humidifier and tubing per facility policy. The facility did not provide a policy that addressed the timing of when to change the oxygen tubing and humidifiers. 1. Review of Resident #19's medical record showed: - An admitted [DATE]; - Diagnoses of hypertension (high blood pressure), coronary artery disease (CAD) (a condition causing damage to the major blood vessels that supply the heart with blood, oxygen and nutrients), benign prostatic hyperplasia (BPH) (enlargement of the prostate causing difficulty in urination), gastroesophageal reflux disease (GERD) (stomach acid being forced back into the throat region), falls, sacral (the bottom of the spine, between the bottom of the lumbar spine and tailbone) decubitus (damage to the skin and/or underlying tissue as a result of pressure), impaired mobility, and chronic bladder outlet obstruction (a blockage at the base of the bladder). Review of the resident's Physician's Order Sheet (POS), dated February 2024, showed: - No order for oxygen use; - No order for oxygen tubing or humidifier changes. Review of the resident's care plan, last revised 02/14/24, showed oxygen not addressed. Observation of Resident #19 showed: - On 02/27/24 at 9:45 A.M., the resident lay in bed and not wearing the oxygen tubing, dated 02/18/24, but with the oxygen concentrator (a medical device that provides extra oxygen) on 2 liters (L) at the bedside; - On 02/29/24 at 8:10 A.M., the resident lay in bed with the oxygen concentrator on 2 L at the bedside and the resident removed the nasal cannula, dated 02/18/24, from his/her nostril. During an interview on 01/23/24 at 1:05 P.M., the resident said staff changed the tubing, but he/she wasn't sure how often. 2. Review of Resident #63's medical record showed: - An admitted [DATE]; - Diagnoses atrial fibrillation (an irregular heart rate), decubitus ulcer to the buttocks, weakness, type two diabetes mellitus (a disease where the body's ability to produce or respond to the hormone insulin is impaired), lower extremity pain, bed bound, constipation, asthma (a condition where a person's airways become inflamed, narrow and swell and produce extra mucous making it difficult to breathe), hypertension, sacral deep tissue injury, and shortness of breath. Review of the resident's POS, dated February 2024, showed: - An order to check oxygen saturation (a measure of how much oxygen is in the blood) two times a day, dated 07/07/23; - An order for the head of bed to be elevated for shortness of breath, dated 01/30/24; - No order for oxygen use; - No order for oxygen tubing or humidifier changes. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 02/12/24 showed the resident received oxygen. Review of the resident's care plan, dated 02/12/24, showed oxygen not addressed. Observation of Resident #63 showed: - On 02/27/24 at 2:01 P.M., the resident lay in bed with oxygen on at 2 L per nasal cannula, dated 02/18/24; - On 02/28/24 at 8:15 A.M., the resident lay in bed with oxygen on at 3 L per nasal cannula, dated 02/18/24 ; - On 02/29/24 at 9:40 A.M., the resident lay in bed with oxygen on at 3 L per nasal cannula, dated 02/18/24. During an interview on 02/27/24 at 2:01 P.M., Resident #63 said he/she was on oxygen a lot. During an interview on 03/01/24 at 3:50 P.M., the Administrator and Director of Nursing said they would expect residents who receive oxygen to have an order for oxygen and an order to change the tubing. 46521

Based on interview and record review, the facility failed to provide documentation of ongoing assessments, monitoring, and communication between the facility and the dialysis (a process for removing waste and excess water from the blood) center for one resident (Resident #41) out of two sampled residents. The facility census was 62. Review of the facility's policy titled, Dialysis Critical Element Pathway, dated, May 2017, showed: - Review of Physician's orders to include: dialysis access care; dialysis schedule; and individualized dialysis prescription such as number of treatments per week length, type of dialyzer, specific parameters of the dialysis delivery system, anticoagulation, fluid restrictions, target weight, blood pressure monitoring; - Pertinent diagnosis; - Individualized care plan; - For residents receiving dialysis at a certified dialysis facility, assess and document vitals, weights and resident's status with the dialysis facility prior to and post dialysis, administer medications or meals before or after dialysis as ordered, and provide direct visual monitoring of the access site before and after dialysis. 1. Review of Resident #41's medical record showed: - admitted [DATE]; - Diagnoses of end stage renal disease (ESRD) (when the kidneys are no longer able to work at a level needed for day-to-day life), dyspnea (shortness of breath), failure to thrive, diabetes mellitus (DM) (a condition that affects the way the body processes blood sugar), hypertension (high blood pressure), right lower extremity amputation, and impaired mobility; - No documentation of the resident's condition before and after dialysis treatments; - Documentation of the communication between the facility and the dialysis center with 15 out of 18 opportunities missed by the facility post dialysis. Review of the resident's Physician Order Sheet (POS), dated February, 2024, showed: - No order for dialysis with the specific days dialysis was received; - No documentation of an order to assess and monitor the resident's dialysis access site; - No documentation of an order to assess and monitor the resident before and after dialysis treatments. Review of the resident's Treatment Administration Record (TAR), dated February 2024, showed: - No documentation of assessments and monitoring of the resident's dialysis access site; - No documentation of assessments and monitoring of the resident before and after dialysis treatments. Review of the resident's care plan, last reviewed on 01/31/24, showed the resident required renal dialysis and monitor the resident's shunt for patency (open and unobstructed). During an interview on 02/28/24 at 5:44 P.M., Resident #41 said the nurses didn't check his/her dialysis port after dialysis. The staff did take his/her vital signs most of the time. He/She went to dialysis on Tuesdays, Thursdays and Saturdays. During an interview on 03/01/24 at 1:30 P.M., Registered Nurse (RN) C said the resident's vital signs and the access site should be assessed upon a resident's return from dialysis. Resident #41 was pretty cognitive so he/she could let the staff know if there was a problem. The dialysis communication form was filled out by dialysis staff with the pre and post weights, but nothing by the facility staff. Resident #41 went to dialysis on Tuesdays, Thursdays and Saturdays. During an interview on 03/01/24 at 3:50 P.M., the Director of Nursing (DON) and the Administrator said the dialysis access site should be checked upon the resident's return from dialysis. There should be an order for it so it can be documented. The communication sheets should be completed by the facility staff as well as the dialysis staff.

Based on interview, and record review, the facility failed to identify, assess and provide supportive interventions for one resident (Resident #21) with a diagnosis of post-traumatic stress disorder (PTSD) (a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event) out of two sampled residents. The facility's census was 62. Review of the facility's policy titled, Trauma-Informed and Culturally Competent Care, revised August 2022, showed: - Perform universal screening of the resident, which includes a brief, non-specialized identification of possible exposure to traumatic events; - Utilize screening tools and methods that are facility-approved, competently delivered, culturally relevant and sensitive; - Assessment involves an in-depth process of evaluating the presence of symptoms, their relationship to trauma, as well as the identification of triggers; - Develop individualized care plans that address past trauma in collaboration with the resident and family, as appropriate; - Identify and decrease exposure to triggers that may re-traumatize the resident. 1. Review of Resident #21's medical record showed: - admitted [DATE]; - Diagnoses of PTSD, major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and seizures (a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements like stiffness, twitching or limpness, behaviors, sensations, or states of awareness); - No documentation of a PTSD assessment. Review of the resident's Physician Order Sheet (POS), dated March 2024, showed an order for Lamictal (a seizure medication) 25 milligram (mg) by mouth twice a day for mood stabilization, dated 03/16/17. Review of the resident's Preadmission Screening and Resident Review (PASARR) (a federal program to prevent inappropriate admission and retention of people with mental disabilities in nursing facilities), dated 02/03/17, showed: - Seizure disorder; - No behaviors documented. Review of resident's care plan, undated, showed: - Did not identify PTSD as a problem; - Did not address personalized triggers or interventions associated to the resident or triggers. During an interview on 03/01/24 at 1:55 P.M., Resident #21 said PTSD was an issue and some things at the facility were triggers. He/She said the facility didn't do anything to help with the PTSD. The resident became tearful and did not want to speak about it anymore. During an interview on 03/01/24 at 2:00 P.M., the Social Services Designee (SSD) said expectations were that a resident with a diagnosis of PTSD should be assessed for triggers. It was not clear if Resident #21 had an accurate diagnosis of PTSD, but there was a diagnosis of major depressive disorder. It was not clear how a PTSD diagnosis wound up on the resident's POS, but it might have came from the hospital. During an interview on 03/01/24 at 2:04 P.M., the Minimum Data Set (MDS) (a federally required assessment completed by the facility staff) Coordinator said the PTSD diagnosis came in on Resident #21's admission. During an interview on 03/01/24 at 2:43 P.M., the Director of Nursing (DON) said she would expect a resident with a diagnosis of PTSD to be assessed for triggers. Residents with a history of traumatic events were expected to be assessed on admission and monitored for triggers. Resident #21 should have a PTSD assessment, an updated care plan, and a list of triggers. During an interview on 03/01/24 at 3:50 P.M., the Administrator said Resident #21 was admitted to the facility with the diagnosis of PTSD. There should have been a PTSD assessment and care plan that addressed the concerns. All residents with a history of traumatic events were expected to be assessed on admission and monitored for triggers.

Based on interview and record review, the facility failed to ensure they developed and implemented a Quality Assurance and Performance Improvement (QAPI) plan pertaining to on-going monitoring for correction of identified systemic failures. This deficient practice had the potential to affect all residents. The facility census was 42. Review of the facility's policy titled, QAPI Program, revised 2019, showed: - The primary purpose of the QAPI Program is to establish data-driven, facility-wide processes that improve the quality of care, quality of life and clinical outcomes of the residents. To develop ongoing and comprehensive procedures that ensures the facility identified and corrects facility deficiencies, identifies opportunity for improvement, and addresses failures in systems or processes; - Develop and utilize a systemic approach to determine an in-depth analysis is needed to fully understand a problem, its cause, and implications of change. A thorough, organized, and structured approach in identifying problems that may be caused or exacerbated by the way care and services are organized or delivered will be used along with proficient root cause analysis components utilized to comprehensively evaluate all involved systems to prevent future events and promote sustained improvement and continual learning. Review of the facility's Monthly QAPI/Risk Report, dated November 2023, showed: - Finger stick blood sugar (FSBS) documentation listed as a performance improvement project (PIP); - The concern was improper/incomplete documentation; - The plan of action was to in-service the nurses responsible. Review of the Monthly QAPI/Risk Report, dated December 2023, showed: - No documentation of any PIPs; - No documentation of follow-up monitoring for the November PIP. Review of Monthly QAPI/Risk Report, dated January 2024, showed: - No documentation of any PIPs; - No documentation of follow-up monitoring for the November PIP. During an interview on 03/01/24 at 9:20 A.M., the Administrator said the QAPI committee meets monthly. During an interview on 03/01/24 at 9:30 A.M., the Director of Nursing (DON) said the facility did not currently have any PIPs in process. During an interview on 03/01/24 at 10:15 A.M., the DON said that as a result of the PIP regarding FSBS documentation, an in-service was conducted with all nursing staff and the responsibility for insulin administration was switched from Certified Med Technicians (CMT) to the nurses. She did ongoing medical record audits but that she did not keep a log or other written record of the audits. During an interview on 03/01/24 at 10:20 A.M., the Corporate Nurse said the DON did daily audits of the medical records and any problems found were discussed during the daily stand-up meetings. During an interview on 03/01/24 at 10:25 A.M., the Administrator said that if a problem was identified during the DON's medical record audits, the facility notified the resident's physician and family, then the facility honed in on the problem and fixed it right then.

Based on interview and record review, the facility failed to ensure residents and/or responsible parties were notified in a timely manner when a resident's account was within the $200.00 Social Security (SSI) limit ($5,726.00) or when the resident's account was over the SSI limit. This affected two residents (Residents #22 and #47) reviewed who received Medicaid benefits. The census was 62. Review of the facility's policy titled, Resident's Trust Fund Management, revised, June 2022, showed: - Maintain the Trust Funds module of the American Health Tech (AHT) program to track resident trust fund; - Provide for the delivery of a quarterly accounting of the activity of transactions in the resident's account to the resident or the resident's responsible party; - When a resident's account balance exceeds $4800.00 in the resident fund accounts, the bookkeeper will advise the resident or fiduciary, in writing, that the resident may lose eligibility for Medicaid. This balance should include any credit balance held in Accounts Receivable. 1. Review of Resident #22's Resident Trust Statement, dated 02/29/24, showed: - On 11/30/23, ending monthly balance of $6,943.65; - On 12/31/23, ending monthly balance of $7,033.60; - On 01/31/24, ending monthly balance of $6,927.50. Review of the resident's fund documentation showed no resident fund notifications were provided to the resident or his/her representative. 2. Review of Resident #47's Resident Trust Statement, dated 02/29/24, showed: - On 11/30/23, ending monthly balance of $5,496.04; - On 12/31/23, ending monthly balance of $5,694.81; - On 01/31/24, ending monthly balance of $5,940.58. Review of the resident's fund documentation showed no resident fund notifications were provided to the resident or his/her representative. During an interview on 02/29/24 at 1:30 P.M., the Business Office Manager (BOM) said he/she was responsible for identifying when the residents got close to the need of a spend down. A notification letter should be sent to the resident/resident's representative. He/She did not send a letter to Resident #22 or Resident #47, just their quarterly statements. During an interview on 03/01/24 at 2:40 P.M., the Administrator said she expects the residents' accounts to be kept below the limit and notification to be sent when they were close to their limit.

Based on observation, interview, and record review, the facility failed to maintain an error rate of less than five percent (%) when medications were given. There were 32 opportunities with two errors made, for an error rate of 6.25 %. This affected two residents (Residents #7 and #25) out six sampled residents with the potential to affect all residents. The facility's census was 62. Review of the facility's policy titled, Insulin Administration, revised September 2014, showed the nursing staff will have access to specific instructions (from the manufacturer if appropriate) on all forms of insulin delivery system(s) prior to their use. Review of NovoLog Flex Pen (insulin in a pen-type device) instructions, revised 06/2023, showed: - Remove the cap; - Attach the needle; - Prime the pen by turning the dose selector to select two units; - Hold the pen with the needle pointing up. Tap the top of the pen gently a few times to let any air bubbles rise to the top; - Hold the pen with the needle pointing up. Press and hold in the dose button until the dose counter shows zero. The zero must line up with the dose pointer; - A drop of insulin should be seen at the needle tip. If you do not see a drop of insulin, repeat steps (priming), no more than 6 times. If you still do not see a drop of insulin, change the needle and repeat steps (priming); - Check to make sure the dose selector is set at zero; - Turn the dose selector to select the number of units needed to inject; - Insert the needle into the skin; - Press and hold down the dose button until the dose counter shows zero; - Keep the needle in the skin after the dose counter has returned to zero and slowly count to six; - Pull the needle out of the skin, remove the needle from the pen and place in a sharps container. Review of Fiasp (insulin) FlexTouch Pen instructions, revised 02/2023, showed: - Remove the cap; - Attach the needle; - Prime the pen by turning the dose selector to select two units; - Hold the pen with the needle pointing up. Tap the top of the pen gently a few times to let any air bubbles rise to the top; - Hold the pen with the needle pointing up. Press and hold in the dose button until the dose counter shows zero. The zero must line up with the dose pointer; - A drop of insulin should be seen at the needle tip. If you do not see a drop of insulin, repeat steps (priming), no more than 6 times. If you still do not see a drop of insulin, change the needle and repeat steps (priming); - Check to make sure the dose selector is set at zero; - Turn the dose selector to select the number of units needed to inject; - Insert the needle into the skin; - Press and hold down the dose button until the dose counter shows zero; - Keep the needle in the skin after the dose counter has returned to zero and slowly count to six; - Pull the needle out of the skin, remove the needle from the pen and place in a sharps container. 1. Review of Resident #7's Physician's Order Sheet (POS), dated 02/14/24, showed an order for Novolog subcutaneous (an injection just below the skin) four times daily before meals and hours of sleep per sliding scale for blood sugar of 0 -150 = 0 units, 151-200 = 5 units, 201-250 = 7 units, 251-300 = 10 units, dated 01/30/23: Observation on 02/29/24 at 4:25 P.M., of the resident showed: - Licensed Practical Nurse (LPN) M obtained a blood sugar reading of 164 for the resident; - LPN M administered 5 units of Novolog subcutaneously per order of the sliding scale for a blood sugar of 164 with the resident's Novolog Flex Pen; - LPN M failed to prime the Novolog Flex Pen per the manufacturer's instructions prior to the administration of the insulin to the resident. 2. Review of Resident #25's POS, dated 02/08/24, showed an order for Fiasp insulin subcutaneous four times of day per sliding scale for blood sugar of less than 150 = 0 units, 151 - 200 = 2 units, 201 - 250 = 4 units, 251 - 300 = 6 units, 301 - 400 = 8 units, 351 - 400 = 10 units, 401 - 450 = 12 units, 451 - 500 = 14 units, if more than 500, call physician, dated 02/15/24. Observation on 02/29/24 at 4:10 P.M., of the resident showed: - LPN M obtained the a blood sugar of 302 for the resident; - LPN M administered 8 units of Fiasp subcutaneously per order of the sliding scale for blood sugar of 302 with the resident's Fiasp Flextouch Pen; - LPN M failed to prime the Fiasp Flextouch Pen per the manufacturer's instructions prior to the administration to the resident. During an interview on 02/29/24 at 4:29 P.M., LPN M said he/she turned the dial to pull up the exact amount with an insulin pen and didn't need to prime the insulin pen. During an interview on 03/01/24 at 3:50 P.M., the Director of Nursing said she would expect insulin pens to be primed before each use. During an interview on 03/01/24 at 3:50 P.M., the Administrator said she would expect insulin pens to be primed before each use.

Based on observation, interview, and record review, the facility failed to maintain adequate infection control practices to prevent the transmission of infection by ensuring a clean barrier for wound care supplies in the resident's room for four residents (Resident #8, #13, #19, and #39) out of five sampled residents. The facility failed to maintain adequate infection control practices during catheter (a tube inserted into the bladder to drain urine) care for two residents (Resident #19 and #55) out of two sampled residents. The facility also failed to maintain adequate infection control practices during incontinent care for two residents (Resident #39 and #63) out of three sampled residents. The facility census was 62. Review of the facility's policy titled, Wound Care, revised October 2010, showed: - Use disposable cloth (paper towel is adequate) to establish clean field on resident's overbed table. Place all items to be used during procedure on the clean field; - Wash, dry hands, put on gloves; - Remove dressing. Wash and dry hands, put on gloves. - Pour liquid solutions directly on gauze sponges on the papers; - Wear sterile gloves when physically touching the wound or holding a moist surface over the wound; - Apply treatments as indicated. Review of the facility's policy titled, Handwashing/ Hand Hygiene, revised October 2023, showed: - All personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections; - All personnel are expected to adhere to hand hygiene polices and practices; - Hand hygiene is indicated: immediately before touching a resident; before performing an aseptic task; after contact with blood, body fluids, or contaminated surfaces; after touching a resident, after touching the resident's environment, before moving to work from a soiled body site to a clean body site and immediately after glove removal. Review of the facility's policy titled, Urinary Continence and Incontinence - Assessment and Management, revised August 2022, showed the management of incontinence will follow relevant clinical guidelines. 1. Review of Resident #8's Physician Order Sheet (POS), dated February 2024, showed an order to clean the posterior (the back of the body) left thigh wound, pat dry, apply Triad (for light-to- moderate levels of wound exudates (fluid that leaks out of blood vessels into nearby tissue). Helps maintain an optimal wound healing environment) paste topically to the wound three times a day until resolved and as needed related to being soiled, dated 01/27/24. Observation on 02/28/24 at 3:04 P.M., for the resident's wound care treatment showed: - Licensed Practical Nurse (LPN) G put on gloves; - LPN G placed the wound care supplies on the bedside table with no barrier; - LPN G performed the wound care treatment. 2. Review of Resident #13's POS, dated February 2024, showed an order to cleanse the wound with normal saline, apply collagen powder (a wound treatment) and Medihoney (a wound treatment), pack the wound with normal saline moist gauze, and cover with border foam (a dressing) everyday and as needed, dated 02/05/24. Observation on 02/28/24 at 10:13 A.M., of the resident's wound care showed: - LPN G entered the resident's room and put the wound supplies on the bedside table with no barrier; - LPN G performed hand hygiene and put on clean gloves; - LPN G removed the dirty dressing and packing from the wound, picked up the wound cleanser bottle with the dirty gloves, and sprayed the wound cleaner directly into the wound; - LPN G twisted a piece of gauze and inserted it into the wound hole and twisted it inside and removed the pink tinged gauze covered with healthy tissue; - LPN G changed gloves but did not perform hand hygiene; - LPN G applied collagen powder and Medihoney to the wound and touched the bedside table with his/her gloved hand; - LPN G did not change gloves and perform hand hygiene; - LPN G packed the wound using a cotton-tipped applicator to push the saline soaked gauze into the wound. 3. Review of Resident #19's POS, dated February 2024, showed an order to clean the coccyx wound with wound cleanser and apply bordered foam every day, dated 02/05/24. Observation on 02/28/24 at 2:09 P.M., of the resident's wound care treatment showed: - LPN G put on gloves; - LPN G placed the wound care supplies on the bedside table with no barrier; - LPN G left the room to get a bag and touched the door knob with his/her gloved hand; - LPN G did not change gloves or perform hand hygiene; - LPN G removed the old dressing and cleansed the wound; - LPN G changed gloves but did not perform hand hygiene; - LPN G put on new gloves and applied the new dressing. Observation on 02/29/24 at 10:21 A.M., of the resident's catheter care showed: - LPN A put on clean gloves and didn't perform hand hygiene; - LPN A lowered the resident's pants below the waist, unfastened the brief, wet a washcloth in a prepared basin of soapy water; - LPN A wiped the catheter from the insertion site with the same area of the wash cloth two times; - LPN A wiped the catheter with the wash cloth and scrubbed the tubing back and forth in a small spot; - LPN A held the tubing up to drain the urine down into the catheter collection bag with the bottom of the bag touching the floor; - LPN A did not change gloves or perform hand hygiene; - LPN A used a clean dry wash cloth to wipe down the catheter and tubing away from the insertion site; - The bottom of the collection bag continued to touch the floor where it hung from the bed frame; - LPN A did not change gloves or perform hand hygiene; - LPN A touched the resident's top sheet, blanket, the resident's shirt, and the outside and inside doorknob of the bathroom door; - LPN A removed his/her gloves but did not perform hand hygiene and touched the resident's call light, the blanket, and the resident's shirt. 4. Review of Resident #39's POS, dated February 2024, showed an order to apply skin prep (forms a barrier between the patient's skin and adhesives to help preserve skin integrity and prevent insult or injury) on the toe and ankle and Triad cream to the resident's bottom, dated 01/30/24. Observation on 02/28/24 at 2:01 P.M., of the resident's wound treatment showed LPN G put the resident's wound supplies on the bedside table with no barrier and beside an unclean urinal. Observation on 02/29/24 at 9:34 A.M., of the resident's incontinent care showed: - Certified Nurse Aide (CNA) B and CNA F performed hand hygiene and put on gloves; - CNA F rolled the resident; - CNA B cleansed the resident of fecal material; - CNA F left while CNA B cleaned the resident and returned with LPN A; - CNA B finished cleaning the resident; - CNA B did not change gloves and perform hand hygiene; - LPN A squirted Triad cream onto CNA B's soiled gloved hand; - CNA B applied the Triad cream to an open area on the resident's coccyx; - CNA B did not change gloves and perform hand hygiene; - CNA B put a new brief and clothes on the resident with the same soiled gloves. 5. Observation on 02/29/24 at 9:49 A.M., of Resident #55's catheter care showed: - LPN A performed hand hygiene and put on gloves; - LPN A wiped from the insertion site of the catheter down; - LPN A did not change gloves and perform hand hygiene; - LPN A, with the same gloves, touched the catheter tubing in different areas down to the collection bag to ensure no kinks in the tubing; - LPN A picked up the catheter collection bag out of the privacy bag and put the bottom of the bag on the floor; - LPN A put the collection bag back in the privacy bag; - LPN A changed gloves but did not perform hand hygiene and emptied the collection bag; - LPN A removed the gloves but did not perform hand hygiene and touched the resident's shirt, pants, a clean wash cloth, the bedside table, the wheelchair, and the door. 6. Observation on 02/27/24 at 2:23 P.M., of incontinent care on Resident #63 showed: - CNA B and CNA H performed hand hygiene and put on gloves; - CNA H rolled the resident while CNA B cleansed the resident of urine and fecal material; - CNA B did not change gloves or perform hand hygiene after cleaning the resident and before touching the resident's clean brief; - CNA B touched the resident's thigh and fecal material transferred from his/her gloves onto the resident's clean brief, pad and sheet; - CNA H rolled the resident toward him/her and removed the dirty brief, pad, and sheet; - CNA H did not change gloves and perform hand hygiene; - CNA B handed the new clean sheet, pad and brief to CNA H who put it under the resident; - CNA B rolled the resident and touched the clean sheet, pad and brief with the same soiled gloves. During an interview on 02/28/24 at 2:20 P.M., LPN G said he/she should have performed hand hygiene between dirty and clean care and between glove changes. During an interview on 03/01/24 at 3:40 P.M., the Administrator and DON said gloves should be changed and hand hygiene performed anytime staff went from dirty to clean in incontinent care, catheter care, or wound care. The catheter collection bag should not be placed on the ground or touching the ground at any time. 46521 47445 47447

Based on interview and record review, the facility failed to provide ongoing skin assessments, documentation of treatments, and progress of a facility acquired pressure ulcer (areas of localized damage to the skin and underlying tissue generally the result of pressure, shear, and/or friction) for one resident (Resident #1) of four sampled resident. The facility census was 56. Record review of the facility's Wound and Skin Care Protocols and Procedures policy, dated 1/2012, showed: - The purpose will be to promote a systemic approach and monitoring process for the care of residents with existing wounds or those at risk for skin breakdown; - To prevent pressure ulcer formation by identifying who would be at risk for pressure ulcers (an injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear and/or friction) and to develop appropriate interventions; - To promote healing of pressure ulcers in a cost efficient and timely manner; - A complete wound assessment and documentation will be done weekly on all pressure ulcers until healed, the criteria will include site location, stage, size; appearance of wound bed, undermining/tunneling, surrounding skin, and drainage; - The Director of Nursing (DON) will be responsible for ensuring that wound care protocols will be instated and followed; - The DON will be responsible for reviewing weekly wound reports and monitoring progress/decline of any wound and assuring compliance with current standards of wound care practice. 1. Record review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/18/22, showed: - An admitted [DATE]; - Diagnoses of a hip fracture, dementia (an impaired ability to remember, think or make decisions), and coronary artery disease (damage or disease in the heart's major blood vessels); - Severely cognitively impaired; - Required extensive assistance of one staff for bed mobility, transfers, toileting, personal hygiene, and bathing; - Always incontinent of bowel and bladder; - At risk of developing pressure ulcers; - No pressure ulcers on admission; - admitted with a surgical wound. Record review of the resident's Physician Order Sheet (POS), dated August 2022, showed: - The resident admitted on [DATE]; - A diagnosis of a right hip fracture, status post open reduction internal fixation (ORIF) (a type of surgery used to stabilize and heal a broken bone), cardiovascular disease (disease of the hearts major blood vessels), mild dementia (a group of thinking and social symptoms that interferes with daily functioning); - A telephone order, dated 8/3/22 to cleanse the wound daily, apply skin prep (a liquid film-forming dressing that, upon application to intact skin, forms a protective film to help reduce friction during removal of tapes) to the peri-wound, apply a nickel size of medi-honey (a treatment that draws moisture out of the environment and dehydrates bacteria) to the wound bed, cover the wound with a silicone dressing (a dressing coated with soft silicone as an adhesive or a wound contact layer) daily for seven days, and re-evaluate in seven days. - A telephone order, dated 8/18/22 for wound care plus to evaluate and treat as indicated; - An order for weekly skin assessments on every Saturday A.M. shift. Record review of the Daily Skilled Nurse's Notes, related to skin, dated 7/12/22 through 8/2/22, showed: - No pressure ulcers or any other skin concerns, with exception of surgical wound. Record review of the resident's Daily Skilled Nurse's Notes, related to skin, dated 8/3/22, showed: - A wound to the resident's right buttock; - The wound to be unstageable (an ulcer that has full thickness tissue loss, covered by necrotic tissue or by eschar (a dry dark scab or falling away of dead skin); - A measurement of 2.8 centimeters (cm) by 3.0 cm; - A dark area under the slough (dead tissue separating from living tissue) on the wound bed a 12 o'clock; - The peri-wound (the tissue surrounding a wound), firm with a soft area noted at 7 o'clock; - A new order to cleanse the wound daily, apply skin prep to the peri-wound, apply a nickel size of medi-honey to the wound bed, cover the wound with a silicone dressing as an adhesive daily for seven days, and re-evaluate in seven days. Record review of the resident's Daily Skilled Nurse's Notes, related to skin, dated 8/7/22 through 9/7/22, showed: - On 8/4/22 through 8/7/22, the skin to be within normal limits and no skin breakdown; - On 8/8/22, the skin with a pressure injury; - On 8/9/22 and 8/10/22, the skin within normal limits and no skin breakdown; - On 8/11/22 through 8/14/22, the skin with a pressure injury; - On 8/15/22, the dressing to the resident's buttock intact; - On 8/16/22, the skin with a pressure injury; - On 8/17/22, the skin within normal limits and no skin breakdown; - On 8/18/22, a change of condition with a wound to the sacrum area of 3.8 cm X 3.5 cm, little drainage, minimal blood flow, peri wound area at 4 and 5 o'clock soft to palpation (examine by pressing the surface to feel the tissue underneath), wound edges rolled at 12 to 6 o'clock, and an odor noted; - On 8/18/22, a communication note to the physician with a request for a wound center consult due to the possible undermining (occurs when significant erosion occurs underneath the outwardly visible wound margins, resulting in damage beneath the skin surface) of the area and the wound also with an odor; - On 8/19/22, the skin within normal limits with no skin breakdown; - On 8/20/22, a treatment to the right buttock and skin with a pressure injury; - On 8/21/22, the skin with a pressure injury; - On 8/22/22, the dressing intact to the wound; - On 8/23/22, the skin not addressed; - On 8/24/22, skin within normal limits and with no skin breakdown; - On 8/25/22, the skin with a pressure injury; - On 8/26/22 through 8/29/22, the skin within normal limits and no skin breakdown; - On 8/30/22, the skin with a pressure injury; - On 8/31/22 and 9/1/22, the skin not addressed; - On 9/2/22 through 9/7/22, the skin with a pressure injury; - The facility failed to document the resident's skin condition consistently and accurately; - No documentation of three weekly wound assessments out of five opportunities; - The facility failed to complete a weekly wound assessment with documentation of the wound. Record review of the resident's Weekly Skin Assessments, dated 8/3/22 through 9/8/22, showed: - On 8/20/22, the resident with a pressure ulcer (injury to the skin and underlying tissue, primarily caused by prolonged pressure on the skin) to the right buttocks; - No weekly skin assessments provided; - No documentation for four weekly skin assessments for 8/6/22, 8/13/22, 8/27/22 and 9/3/22, out of five opportunities. Record review of the resident's Wound Care Clinic notes showed: - On 8/22/22, a Stage III pressure ulcer (extends into the tissue under the skin, forming a small crater) to the right buttock with a status of not healed, wound measurements of 2.6 cm length x 2 cm width x 0.7 cm depth, a moderate amount of purulent (a white, yellow, or brown fluid, slightly thick in texture and a sign of infection) drainage, with a mild odor, and the peri-wound skin presented with signs and symptoms of an infection; - On 8/29/22, a Stage III pressure ulcer to the right buttock with a status of not healed, wound measurements of 2.5 cm length x 2 cm width x 1.5 cm depth, and a moderate amount of purulent drainage with a mild odor; - On 9/6/22, a Stage III pressure ulcer to the right buttock with a status of not healed, wound measurements of 2.2 cm length x 2 cm width x 1.2 cm depth with undermining of 1 cm, and a moderate amount of sero-sanguineous (a thin watery fluid, pink in color, secreted by an open wound in response to tissue damage) drainage with a mild odor. Record review of the resident's Treatment Administration Record (TAR), dated August 2022, showed: - An order to cleanse the right buttock wound with the facility cleanser of choice, apply skin prep to the peri-wound, apply a nickel-thickness of medi-honey to the wound bed, cover the wound with a silicone dressing daily for seven days and re-evaluate, dated 8/4/22 and with an end date of 8/23/22; - For 8/4/22 through 8/23/22, no documentation of four of the wound treatments administered out of 20 opportunities; - An order to cleanse the right buttock wound with normal saline, apply skin prep to the peri-wound, apply a nickel-thickness of santyl to the wound bed, and cover the wound with a bordered gauze dressing daily, dated 8/24/22; - For 8/24/22 through 8/31/22, no documentation of two of the wound treatments administered out of eight opportunities; - The facility failed to administer the resident's wound treatments as ordered. Record review of the resident's TAR, dated September 2022, showed: - An order to cleanse the right buttock wound with normal saline, apply skin prep to the peri-wound, apply a nickel-thickness of santyl to the wound bed, and cover the wound with a bordered gauze dressing daily, dated 8/24/22; - For 9/1/22 through 9/8/22, no documentation of two of the wound treatments administered out of eight opportunities; - The facility failed to administer the resident's wound treatments as ordered. Record review of the resident's care plan, dated 7/12/22, showed: - The care plan did not address the pressure ulcer or the treatments started on 8/4/22. Observations of wound care on 9/8/22 at 9:54 P.M., showed; - The resident lay in bed; - Licensed Practical Nurse (LPN) A, completed wound care as ordered, with no concerns; - Measurements of wound 2.8 cm length by 2.2 cm depth by 0.7 cm depth. During an interview on 9/8/22 at 7:25 P.M., LPN A said he/she was first made aware of the wound on 8/3/22, it was on the resident's right buttock and had a necrotic appearing area, and he/she didn't know how something wasn't seen before this point, unless the way the resident's hands were placed during care. Physician orders were obtained and treatments began at that time. During an interview on 9/8/22 at 10:45 P.M., the Director of Nursing (DON) said she and the Assistant Director of Nursing (DON) were responsible for making sure the skin assessments were completed and they should be done weekly. The daily skilled notes should reflect the resident's condition. Skin was observed during showers, repositioning, and incontinent care, so it was seen numerous times a day and if there were changes, they should be reported and documented. All care and treatments should be documented and physician's orders should be followed. During an interview on 9/8/22 at 10:55 P.M., LPN A said he/she tried to document on the wound measurements, but it was often hard to find the time to do the weekly skin assessments and often relied on the shower sheets. During a telephone interview on 9/27/22 at 12:51 P.M., with the wound center nurse said: - The wound center received an order on 8/18/22 for evaluation and treatment for a wound; - On 8/22/22, was the first time the nurse observed the resident; - A facility nurse made rounds with him/her when he/she sees the residents and should be doing the weekly assessments at that time, when the measurements were completed, description of the wound, and the staff see the orders were changed; - The facility staff should be following the physicians orders; - Initially the wound treatment was a daily dressing change, then on 9/12/22, the order was changed to every other day and as needed; - The wound treatments should have been completed, documented and in his/her opinion, the wound was avoidable. During an telephone interview on 9/28/22 at 4:29 P.M., the Physician said: - He/she was not aware the resident had a wound on his/her buttock; - He/she had seen the resident in the facility on 9/8/22, and was told he/she had candida (a fungal infection) and ordered Nystatin (an anti-fungal powder) at that time; - He/she said the resident was up in a wheelchair in a pleasant mood on 9/8/22, and he/she did not observe his/her buttocks; - He/she expected to be notified anytime there was a wound and usually would ask the facility to contact the wound care clinic to evaluate and treat, because they were very good at treating wounds; - He/she expected the facility staff to assess and document all wound descriptions weekly; - He/she expected the facility staff to complete and document the wound treatments as ordered. Complaint #MO206691

Based on interview, and record review the facility failed to monitor an anticoagulant (blood thinner) medication, consistent with the current standard of practice and manufacturer's guidelines for potentially clinically significant adverse consequences for one resident (Resident #12) out of 15 sampled residents. The facility census was 71. Record review of Resident #12's face sheet showed an admission date of [DATE]. Record review of Resident #12's physician's orders [REDACTED]. - [DIAGNOSES REDACTED]. - an order for [REDACTED]. - Another order for [MEDICATION NAME] 6 mg, by mouth on Monday/ Wednesday; - Start date for the current [MEDICATION NAME] therapy of 6/12/14. - No lab orders for monitoring [MEDICATION NAME] levels. Record review of the resident's laboratory results showed thier normal range for [MEDICATION NAME] time (PT) as 11.0- 14.0 seconds; and their normal range for International Normalization Ratio (INR) for [MEDICATION NAME] treatment of [REDACTED]. Review of Resident #12's PT/INR lab results showed: - On 4/10/14, the PT/INR results were 31.5/2.87. Staff noted the resident's physician had been notified of the abnormal PT level and no new orders were received. - On 5/08/14, the results were 26.0/2.36. Staff noted the resident's physician had been notified of the abnormal PT level and no new orders were received. - On 6/12/14, the results were 31.1/2.83. Facility staff noted at the bottom of the result page the resident's physician had been notified of the abnormal PT level and the [MEDICATION NAME] orders were changed to the current dose. - On 7/10/14, the results were 25.3/2.3. Staff noted the resident's physician had been notified of the abnormal PT level and no new orders were received. - On 8/14/14, the results were 23.5/2.13. Staff noted the resident's physician had been notified of the abnormal PT level and no new orders were received. There were no PT/INR lab results for the months of September, October and November 2014. Review of Resident #12's nurse's notes showed on 12/10/14, the resident's doctor contacted the facility and gave orders to have the resident sent to the hospital per family request for general complaints of illness. On 12/10/14, the hospital admitted Resident #12 for pneumonia. The results of Resident #12's PT/INR lab drawn during the emergency room visit prior to admission were 90.6/7.9. During an interview on 12/18/14 at 7:45 A.M., Licensed Practical Nurse (LPN) A said: - If he/she would have received a critical lab result, he/she would have called the physician immediately; - The facility has no protocol for residents on [MEDICATION NAME] that he/she is aware of; - He/she guessed Resident #12's doctor assumed the facility had a protocol for residents on [MEDICATION NAME] to receive routine labs. During an interview on 12/18/14 at 8:00 A. M., the Director of Nursing (DON) said: - The facility did not have a protocol for routine lab tests for residents on [MEDICATION NAME]; - He/she could not find in Resident #12's record the initial order for labs to be drawn monthly or an order for [REDACTED]. - The DON did not know why the resident's labs for PT/INR levels were stopped; - He/she would expect there to be an order made each month if the physician wanted the labs done. During an interview conducted via telephone on 12/19/14 at 10:59 A.M., Resident #12's doctor said if a patient is on [MEDICATION NAME], he expected labs to be drawn monthly if not more often. That is a standard practice. He/she understood that the facility conducted monthly PT/INR tests. The resident's doctor said he had not been notified by the facility of any abnormal labs for this resident since August, but as they had notified him the months before August, he thought Resident #12's labs were within normal limits. During an interview conducted via telephone on 12/30/14 at 3:16 P.M., an employee of the laboratory used by the facility said: - It is the facility's responsibilty to ensure the lab orders are correct; - It is also the facility's responsibilty to see that the results of the lab testing are reported to the physicians. According to the United States Food and Drug Administration (FDA), [MEDICATION NAME] sodium ([MEDICATION NAME]) is a narrow therapeutic range drug, and its action can be affected by factors such as other medications and dietary vitamin K. Therefore, anticoagulation must be carefully monitored during [MEDICATION NAME] sodium therapy. It is recommended that after stabilization, maintain dosing within the therapeutic range by performing periodic International Normalization Ratios (INR) and [MEDICATION NAME] times (PT). These are laboratory tests conducted with a sample of the patient's blood that measure in seconds how long it takes the blood sample to clot. A normal coagulation range for PT is 11.0 - 14.0. A recommended INR is 2.0 - 3.0. The frequency of performing PT/INRs should be based on the clinical situation but generally acceptable intervals for PT/INR determinations are one to four weeks. This information can be found on the FDA website made available to the public at www.drugs.com. MO 470 .