Every finding on record at Maries Manor

Based on interview and record review, facility staff failed to ensure one resident (Resident #1) remained free from accidents when Resident #1 received Resident #2's medications. The facility census was 66. 1. Review of the facility's Medications, Errors and Drug Reactions policy, undated, showed staff are directed to safeguard the resident and provide emergency care as needed. Complete a resident assessment every shift for at least seventy-two hours. The policy did not address contacting the pharmacy after a medication error.Review of the facility's Medication Administration Guidelines policy, undated, showed it is the purpose of this facility that residents receive their medications on a timely basis and accordance with established policies. Drug administration shall be defined as an act in which an authorized person, in accordance with all laws and regulations governing such acts, gives a single dose of a prescribed drug or biological to a resident. The complete act of administration entails removing an individual's dose from a previously dispensed, properly labeled container (including a unit dose container), verifying it with the physician's orders, giving the individual dose to the proper resident, and promptly recording the information. Medications may not be prepared in advance and must be administered within one hour of preparation.2. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 11/10/25, showed staff assessed the resident as cognitively intact.Review of the resident's plan of care plan, dated 11/15/25, showed staff were directed to administer medications as ordered.Review of the resident's Physician Order Sheet (POS), undated, showed the POS did not contain an order for Lithium (used to stabilize mood) 1500 milligram (mg) tablet, Sertraline (used to treat antidepression) 75 mg tablet, Synthroid (used to treat an underactive thyroid gland) 200 microgram (mcg) tablet, or Topiramate (used to treat seizures and prevent migraines) 150 mg tablet.Review of the resident's progress note, dated 11/29/25, showed Licensed Practical Nurse (LPN) C documented Resident #1 received Resident #2's medications of Lithium 1500 mg, Sertraline 75 mg, Synthroid 200 mcg and Topiramate 150 mg. Review showed the nurse prepared medication to administrated and resident had noted he/she wanted to take his/her medications closer to 10:00 P.M., LPN C documented Resident #1 approached him/her at approximately 9:45 P.M., requesting medication be placed in pudding. He/She documented he/she grabbed a pudding container out of cart and opened it. He/She documented at the time the nurse he/she placed the pudding onto medication cart, Resident #1 picked up medication cup that was placed on top of med cart and dumped them into the pudding and consumed them. During an interview on 12/10/25 at 3:10 P.M., LPN C said there were a lot of behaviors by residents during the day of the medication error. He/She had got Resident #1's medications together, took it to him/her, but the resident refused and wanted it later. He/She said he/she went back to the cart and locked the medications in the top cart. He/She said he/she had taken Resident #2's medication to him/her and he/she refused, so he/she placed the medications in the medication cart. He/She said he/she was helping other resident's, when Resident #1 approached him/her about his/her medication. He/She said he/she pulled the medications out of the cart, without looking at the marked cup, and sat the medications on the cart. LPN C said Resident #1 wanted pudding to put the medications in, so he/she reached to grab a spoon. He/She said while he/she grabbed a spoon, Resident #1 picked up Resident #2's medications off the cart and ingested before he/she had a chance to verify he/she had pulled the correct medications from the cart. He/She said he/she never handed the medications to Resident #1. During an interview on 12/09/25 at 12:22 P.M., the administrator said staff are directed to identify the resident prior to administering medications. He/She said staff are directed to administer medication to one resident at a time. He/She said LPN C was assisting several other residents at the same time, which caused him/her to be overwhelmed, at the time of the medication error. During an interview on 12/09/25 at 12:23 P.M., the DON said staff are educated to verify the identity of the resident prior to administering medications. He/She said staff are directed to administer medication to one resident at a time. He/She said LPN C was overwhelmed when assisting several other residents at the same time of the medication error. Complaint #2682543

Based on observation and interview, the facility staff failed to maintain the kitchen ceiling in good repair to prevent contamination of food items. This failure has the potential to affect all residents. The facility census was 65.1. Observation on 08/12/25 at 11:40 A.M. showed the kitchen with the following: -Ceiling was covered with a white textured, plaster like material;-A 33-inch crack in the ceiling above the end of the steam table with the ceiling sagging on one side of the crack;-A 22-inch crack in the ceiling and areas of white flaking ceiling material above the ware storage rack near the service window;-A 16-inch crack between the prep counter and bakery;-A 3-inch area of white flaking ceiling material above the steam table;-A 4-inch area of white flaking ceiling material above the ceiling mounted utensil hanger;-Two areas of white flaking ceiling material and a sagging, water stained area near the coffee pots.During an interview on 08/12/25 at 1:00 P.M., the Dietary Manager (DM) said he/she was aware of the cracks in the ceiling. The DM said there were issues with small water leaks in the ceiling. The DM said the maintenance director was aware of the ceiling issues.During an interview on 08/13/25 at 11:30 A.M., the maintenance director said he/she was aware of the cracks in the kitchen ceiling. The maintenance director said there was an issue with condensation over the past few weeks and he/she had to wait for the areas to dry before he/she could make repairs.During an interview on 08/14/25 at 12 10 P.M., the administrator said kitchen staff were responsible for telling maintenance about any building issues. The administrator said the kitchen ceiling should not have cracks or flaking areas since the materials could fall into food. The administrator said he/she was not aware of any kitchen ceiling issues prior to the survey. The administrator said the facility did not have a policy related to facility ceiling maintenance but staff followed regulatory guidance.

Based on observation, interview, and record review, facility staff failed to appropriately sanitize a multi-use glucometer (a device for monitoring blood sugars) between use for two (Resident #3, and #51) out of five sampled residents. Staff failed to perform appropriate hand hygiene and glove changes in a manner to prevent or reduce the spread of bacteria and other infection causing organisms during blood glucose checks for three (Resident #28, #45, and #51) out of five sampled residents. Staff failed to utilize personal protective equipment (PPE) for two (Resident #7 and #47) out of two sampled residents on enhanced barrier precautions (EBP) during wound care and/or catheter care The facility census was 65.1. Review of the facility's policies showed staff did not provide a policy on glucometer disinfection.Review of the facility's Blood Glucose Monitoring System Manual, undated, showed the manual directs staff as follows:-Meter should be cleaned and disinfected between each patient;-The following products have been approved for cleaning and disinfecting the meter:i. Dispatch hospital cleaner disinfectant towels with bleach;ii. Medline Micro-Kill+ Disinfecting, Deodorizing, Cleaning Wipes with Alcohol;iii. Clorox Healthcare Bleach Germicidal and Disinfecting Wipes;iv. Medline Micro-Kill Bleach Germicidal Bleach Wipes.-To clean meter, use a moist (not wet) lint-free cloth dampened with a mild detergent. Wipe all external areas of the meter including both front and back surfaces until visibly clean;-To disinfect your meter, clean the meter surface with one of the approved disinfecting wipes. Other Environmental Protection Agency (EPA) registered wipes may be used for disinfecting the meter, however these other wipes have not been validated and could affect the performance of your meter;-Wipe all external areas of the meter including both front and back surfaces until visibly wet.2. Observation on 08/13/25 at 11:43 A.M., showed Licensed Practical Nurse (LPN) B obtained Resident #51's blood sugar with the multi-use glucometer, exited the room, and wiped the glucometer with an alcohol pad. LPN B did not use an approved EPA registered healthcare disinfectant for the meter. LPN B then used the glucometer to obtain Resident #3's blood sugar. During an interview on 08/13/25 at 11:50 A.M., LPN B said he/she did know that the multi-use glucometer needs to be cleaned with the Sani-Cloth wipes in the tubs, but they were not available. The LPN said he/she did not ask for any either.3. Review of the facility's Gloves policy, undated, showed staff are directed to wear gloves when it can be reasonably anticipated that hand will be in contact with mucus membranes, nonintact skin, any moist body substances (blood, etc.) Gloves should be changed between residents and between contacts with different body sites of the same resident.4. Observation on 08/11/25 at 12:20 P.M., LPN A entered Resident #45 room, did not wash or sanitize his/her hands, placed gloves on and obtained the resident's blood sugar. LPN A pulled the blood glucose test strip from the glucometer by the blood saturated tip to remove. With the same soiled gloves, the LPN touched his/her computer mouse and computer. Observation on 08/11/25 at 12:24 P.M., LPN A entered Resident #28's room, did not wash or sanitize his/her hands, placed gloves on and obtained the resident's blood sugar. LPN A pulled the blood glucose test strip from the glucometer by the blood saturated tip to remove. With the same soiled gloves, the LPN touched his/her mouse, misc. items on cart and the computer.Observation on 08/11/25 at 12:28 P.M., LPN A entered Resident's #51's room, did not wash or sanitize his/her hands, placed gloves on and obtained t blood sugar. He resident's blood sugar. LPN A pulled the blood glucose test strip from the glucometer by the blood saturated tip to remove. With the same soiled gloves, the LPN touched his/her mouse and computer. During an interview on 08/14/25 at 2:05 P.M., the Director of Nursing (DON) said staff should wash or sanitize hands before and between blood sugar checks. Gloves should be removed after checks and hands washed or at least sanitized. The DON said it is not appropriate to use alcohol pad to clean the glucometer, staff are expected to use the approved disinfectant. The DON said the Sani-Wipes are available and that is what staff should use. The DON said the facility does use agency nurses a lot, but they have been educated. He/She said unknown how good training was if she was not there when they come, but she/he would consider these things to be standard nursing practices. During an interview on 08/14/25 at 2:40 P.M., the administrator said staff are expected to clean their hands between any resident task. The administrator said she would expect staff to follow policy and procedures that pertain to blood sugar checks. 5.Review of the facility's EBP to infection Control Guidance, undated, showed:-Implement EBP on residents with indwelling medical device including catheters and residents with a wound, regardless of their multidrug-resistance organism (MRDO) status;-When to implement EBP;-High-contact resident care activities: providing hygiene, caring for a resident with an indwelling device, and performing wound care.Review of the Centers for Disease Control (CDC) website, https://www.cdc.gov/hicpac/workgroup/EnhancedBarrierPrecautions.html article, Consideration for Use of Enhanced Barrier Precautions in Skilled Nursing Facilities, dated June 2021, showed:-Facilities should develop a method to identify residents with wounds or indwelling medical devices, and post clear signage outside of resident rooms indicating the type of PPE required and defining high risk resident care activities;-Gowns and gloves should be available outside of each resident room, and alcohol-based hand rub should be available for every resident room (ideally both inside and outside of the room).7.Review of Resident #7's admission MDS, dated [DATE], showed staff assessed the resident as-Cognitively intact;-At risk for developing pressure ulcers/injuries;-Has a stage 1 (non-blanchable redness over a bony prominence) unhealed pressure injury;-Has a catheter.Observation on 08/13/25 at 3:55 P.M., showed LPN B entered the resident's room to perform wound and catheter care. Observation showed the LPN did not put on a gown before he/she provided wound and catheter care.8. Review of Resident #47's Annual MDS, dated [DATE], showed staff assessed the resident as:-Cognitively intact;-At risk for developing pressure ulcers/injuries;-Has one [NAME] and arterial ulcers present. Review of the resident's care plan, dated 05/28/25, showed the plan it directed staff to use EBP for wound care.Observation on 08/13/25 at 11:03 A.M., LPN B entered the resident's room to perform would care. He/She did not put on a gown before he/she performed wound care.9. During an interview on 08/13/25 at 4:10 P.M., LPN B said residents with wounds or catheters should be on EBP. He/She said it is standard care for nurses to wear gowns when performing care on any residents on EBP including wound and catheter care. He/She said he/she did not wear a gown because he/she forgot. He/She said wearing PPE is important to prevent the spread of infections. During an interview on 08/14/25 at 1:57 P.M., the DON said residents with wounds and catheters are on EBP. He/She said they should have a PPE tower outside their room and a yellow sticker next to their name on their door to alert staff. He/She said staff have been educated and it is his/her expectation that they wear gowns and gloves when performing care on the residents who are on EBP. He/She said the PPE is to prevent cross contamination. He/She said he/she was not aware staff were not using PPE during care. During an interview on 08/14/25 at 2:30 P.M., the administrator said residents with wounds and catheters should be on EBP. He/She said the DON is responsible for educating the staff and it is his/her expectation that staff use the PPE when providing care to those residents.

Based on interview and record review, facility staff failed to implement an Antibiotic Stewardship Program with antibiotic use protocols and a system to monitor and track antibiotic use within the facility. The facility census was 65. 1. Review of the facility's policy titled, Antibiotic Stewardship Program , dated 4/10/25, showed: -The Director of Nursing (DON) will be responsible to audit the clinical assessment documentation at the time of the antibiotic prescription. This will include all relevant documents such as the Stop and Watch, Situation, Background, Assessment, Recommendation (SBAR), physician communication, and follow-up with diagnostic testing;-The DON will be responsible for auditing of the completeness of antibiotic prescribing documentation to include dose, route, start date, end date, days of therapy, and indication;-The Antibiotic Stewardship Program team will monitor antibiotic starts by indication;-All patients/residents transferred to or from the facility who are on an antibiotic will have adequate documentation of dose, duration, and indication for the antibiotic. This will aide in determining the appropriateness of treatment based on additional laboratory/clinical data and patient/resident response to treatment. This will also ensure discontinuation in a timely manner.Review of the facility's antibiotic stewardship program showed facility staff did not track antibiotic trends.During an interview on 08/12/25 at 2:12 P.M., the DON said the person who was responsible for the facility's Antibiotic Stewardship Program left two weeks ago. He/She said the binder provided is all the documentation he/she has for tracking and trending antibiotics and infections. He/She said their MDS Coordinator and himself/herself are both certified as an infection preventionist but neither have the time to fill the position, so no one is currently fulfilling the role.During an interview on 08/14/25 at 2:30 P.M , the administrator said the previous Assistant director of nursing (ADON) was responsible for maintaining the ASP. He/She said he/she was not aware that the Antibiotic Stewardship Program was not being completed.

Based on interview, and record review, facility staff failed to maintain professional standards of practice when staff failed to transcribe a treatment order for one resident (Resident #7) and accurately transcribe a medication order for a Fentanyl patch (to treat pain) for one resident (Resident #75) out of two sampled. The facility census was 65.1. Review of the Facility's Wound Care Treatment policy, undated, showed there must be a specific order for the treatment. 2. Review of Resident #7's admission Minimum Data Set (MDS), a federally mandated assessment tool, 06/30/25, showed staff assessed the resident as:-Cognitively intact;-At risk for developing pressure ulcers/injuries;-Has a stage 1 unhealed pressure injury (initial stage of skin and tissue damage caused by prolonged pressure).Review of the resident's Initial and Weekly wound documentation, dated 06/30/25, showed:-Resident admitted with stage 1 decubitus ulcer right inner buttock;-Treatment: Optifoam (a brand of foam dressing used for wound care) for protection.Review of the resident's Physician Order Sheet (POS), dated 06/30/25, showed the record did not contain an order for Optifoam treatment.Review of the resident's Treatment Administration Record (TAR), dated 06/30/25, showed the record did not contain a treatment for Optifoam. During an interview on 08/14/25 at 2:01 P.M., the Director of Nursing (DON) said when a resident admits to the facility, the nurse who admits him/her is expected to contact the doctor to verify orders. The DON said he/she is responsible to check and review orders are correct. The DON said he/she is unsure why the treatment order was never put in the resident's chart, but the expectation would be the order was put in the resident's chart and on their TAR. The DON said he/she was not aware the order was not put in, but also did not check to verify, it must have been missed. During an interview on 08/14/25 at 2:35 P.M., the administrator said the floor nurse who gets the order or does the admission should put treatment orders in the resident's electronic medical record (EMR). Once in, any nurse can see this order and make sure the treatment is done. The DON is responsible to review and verify orders are correct in the residents' EMR. 3. Review of the facility's Telephone Order Processing policy, undated, showed the following: -Obtain the telephone order from prescriber and write telephone order on the physician's order form;-Record date and time order was received and write order on telephone order form exactly as written on physician's order form. 4. Review of Resident #75's Annual MDS, dated [DATE], showed staff assessed the resident as:-Cognitively intact;-Experienced frequent pain. Review of the resident's plan of care, updated on 07/15/25, showed staff assessed the resident with a knee amputation due to a wound infection. Review showed the nurse will monitor pain levels, give medications as ordered by the physician, evaluate and record/report effectiveness and any adverse side effects. Review of the resident's POS, dated 06/26/25 through 08/13/25, showed an order for a Fentanyl patch 25 microgram (mcg)/hour every 72 hours as follows:-Special instructions to apply one patch every 72 hours;-Frequency of once a day every four days;-Order date of 06/26/25. Review of the residents Medication Administration Record (MAR), dated 06/26/25 through 08/13/25, showed the following order: -Fentanyl patch; 72 hour; 25 mcg/hr;-Special instructions to apply one patch every 72 hours;-Frequency of once a day every four days. Review of the resident's MAR, dated 06/26/25 through 08/13/25, showed staff documented they administered the Fentanyl patch every 96 hours instead of every 72 hours.During an interview on 08/14/25 at 11:39 A.M., the MDS Coordinator said he/she was the nurse who obtained the Fentanyl telephone order from the prescribing physician, and the nurse who entered the Fentanyl order into the facility's electronic MAR system. The MDS Coordinator said he/she entered the Fentanyl order incorrectly and instead of listing the repeat cycle as two days, he/she listed the repeat cycle as every three days. He/She said due to this error, the electronic MAR scheduled the Fentanyl patch to be replaced every 96 hours instead of every 72 hours. The MDS Coordinator said he/she just identified the error on 08/13/25 and called the prescribing physician who verified the order is to replace the Fentanyl patch every 72 hours. He/She said the facility started using the electronic MAR's a couple of months ago and are still getting used to the electronic system. During an interview on 08/14/25 at 1:58 P.M., the DON said the nurse who receives a medication telephone order is the one responsible to ensure the order is entered correctly into the residents POS and MAR. He/She expects facility staff to enter medication orders correctly. The DON said he/she runs a report daily to review new orders and said he/she did not realize the Fentanyl patch order was entered incorrectly until 08/13/25. During an interview on 08/14/25 at 2:27 P.M., the administrator said the nurse who receives a medication telephone order is the one responsible for entering the order. The administrator said he/she expects for the orders to be entered accurately and to follow up with the prescribing physician if any clarification is needed. He/She said staff should be running a report to double check whether orders are entered accurately.

Based on observation, interview, and record review, facility staff failed to destroy medications weekly and failed to store the medication behind a lock cabinet for 27 residents (Resident #2, #10, #26, #29, #30, #31, #32, #37, #42, #46, #53, #56, #59, #65, #66, #67, #68, #76, #77, #80, #81, #82, #83, #84, #85, #86, and #87). The facility census was 65.1. Review of the facility's Storage of Medications policy, undated, showed the following guidelines: -All medications for residents must be stored at or near the nurse's station in a locked cabinet, a locked medicine room, or one or more locked mobile medication carts;-Medications must be stored in the container in which they were received;-Drugs must be stored in an orderly manner in cabinets, drawers, or carts. Review of the facility's Destruction of Medications policy, undated, showed the following guidelines:-The facility will destroy and dispose of medications in a safe manner and in accordance with applicable law;-All medications not returned to the issuing pharmacy will be destroyed;-When a medication has been discontinued, the Nurse/Certified Medication Technician (CMT) will discontinue the medication on the physician order sheet and the medication administration record (MAR);-The Nurse/CMT will document the amount of medication to be discontinued on the MAR;-The Nurse/CMT will then log the medication on the individual resident's destruction of record to include the date the medication discontinued, the prescription number, and amount left on card or bottle;-The medication may then be placed in the locked cabinet for destruction;-Medications will be destroyed at least weekly. 2. Observation on 08/13/25 at 1:56 P.M., showed the Minimum Data Set (MDS) Coordinator's office unlocked. Observation showed the MDS Coordinators office with an unlocked closet that contained one small cardboard box, one small blue plastic container, one large cardboard box, one large trash bag, one small grocery bag with a plastic container inside, and one small trash bag that all contained resident medications. 3. Observation on 08/13/25 at 1:58 P.M., showed the MDS office closet contained the following:-23 tablets of Mirtazapine (anti-depressant) with a pharmacy fill date of 02/18/23 and 48 tablets of Quetiapine (anti-psychotic) with a pharmacy fill date of 01/05/24 for Resident #2; - Nine tablets of Metformin (to treat type 2 diabetes) with a pharmacy fill date of 11/25/23 and four tablets of Glipizide (to treat type 2 diabetes) with a pharmacy fill date of 01/13/24 for Resident #10;-21 tablets of Atorvastatin (to treat high cholesterol) with a pharmacy fill date of 11/10/23 for Resident #26; -28 tablets of Citalopram (anti-depressant) with a pharmacy fill date of 06/15/23 for Resident #29;- 14 capsules of Fluoxetine (anti-depressant) with a pharmacy fill date of 01/24/23 and five tablets of Atorvastatin with a pharmacy fill date of 11/15/23 for Resident #30;- 30 capsules of Celecoxib (anti-inflammatory) with a pharmacy fill date of 09/21/23 for Resident #31; - 24 tablets of Mirtazapine with a pharmacy fill date of 12/19/23 and five tablets of Citalopram with a pharmacy fill date of 02/3/23 for Resident #32;- 29 tablets of Trazadone (anti-depressant) with a pharmacy fill date of 12/19/22 for Resident #37; - 30 tablets of Famotidine (to treat heartburn) with a pharmacy fill date of 11/1/23 for Resident #42;- 18 tablets of Metformin with a pharmacy fill date of 05/11/23 for Resident #46; - 21 tablets of Levocetirizine (to treat allergies) with a pharmacy fill date of 06/30/23, three tablets of Levocetirizine with a pharmacy fill date of 11/2/23, and nine tablets of Sertraline (anti-depressant) with a pharmacy fill date of 01/12/23 for Resident #53;- 30 tablets of Warfarin (to treat blood clots) with a pharmacy fill date of 02/12/24 and 26 capsules of Fluoxetine with a pharmacy fill date of 02/16/24 for Resident #56;- 15 tablets of Escitalopram (anti-depressant/anti-anxiety) with a pharmacy fill date of 02/7/23 for Resident #59;- Six tablets of Atorvastatin with a pharmacy fill date of 01/3/24, 30 tablets of Sertraline with a pharmacy fill date of 02/13/23, and 15 tablets of Zoloft (anti-depressant) with a pharmacy fill of 01/16/23 for Resident #65;- Nine tablets of Lurasidone (anti-psychotic) with a pharmacy fill date of 11/21/23 for Resident #66;- 30 tablets of Famotidine with a pharmacy fill date of 09/13/23 for Resident #67;- 30 tablets of Sertraline with a pharmacy fill date of 02/7/24 and six tablets of Sertraline with a pharmacy fill date of 01/11/24 for Resident #68;- 28 tablets of Risperidone (anti-psychotic) with a pharmacy fill date of 02/06/24, 27 tablets of Metoprolol Tartrate (to treat high blood pressure) with a pharmacy fill date of 07/16/24, and 30 tablets of Metoprolol Tartrate with a pharmacy fill date of 06/21/24 for Resident #76;- 27 tablets of Citalopram with a pharmacy fill date of 01/06/23 for Resident #77;- 19 tablets of Citalopram with a pharmacy fill date of 02/15/23 for Resident #80;- 21 tablets of Risperidone with a pharmacy fill date of 10/23/23 and 15 tablets of Risperidone with a pharmacy fill date of 01/17/24 for Resident #81;- 17 tablets of Bupropion (anti-depressant) for with a pharmacy fill date of 02/26/24 for Resident #82;- 30 tablets of Mirtazapine with a pharmacy fill date of 11/7/22 for Resident #83;- 17 tablets of Escitalopram with a pharmacy fill date of 09/06/23 for Resident #84;- 30 tablets of Amantadine (to treat Parkinson's) with a pharmacy fill date of 12/26/22 for Resident #85;- 22 tablets of Valacyclovir (anti-viral) with a pharmacy fill date of 10/23/23, 20 tablets of Benztropine (anti-cholinergic) with a pharmacy fill date of 01/23/24, and four capsules of Celecoxib with a pharmacy fill date of 11/20/23 for Resident #86;- Four tablets of Metformin with a pharmacy fill date of 09/23/23, 30 tablets of Metformin with a pharmacy fill date of 11/01/23, 14 tablets of Rexulti (anti-psychotic) with a pharmacy fill date of 10/31/23, and 14 tablets of Rexulti with a pharmacy fill date of 11/15/23 for Resident #87. 4. Observation on 8/13/25 at 2:13 P.M., showed the MDS office closet contained one plastic container half full of loose tablets and capsules wrapped in a grocery bag. 5. Observation on 8/13/25 at 2:14 P.M., showed the MDS office closet contained one trash bag and one box filled with numerous over the counter medications. 6. Observation on 8/13/25 at 2:23 P.M., showed the MDS office closet contained one large trash bag filled with nicotine patches and multiple medication cards with various medications. 7. During an interview on 08/13/25 at 1:56 P.M., the MDS Coordinator said the medications had been in the closet for at least a year, and the medications are waiting to be destroyed. The MDS Coordinator said he/she is not sure how the medications got in there and said the medications should have been destroyed. He/She said the medications require two nurses for destruction and when he/she had gone to find the pill buster, the medication room did not have the pill buster. During an interview on 8/14/25 at 1:58 P.M., the Director of Nursing (DON) said he/she was not aware there were any medications stored in the MDS office. The DON said he/she does not know how the medications ended up in the MDS office and the medications should not have been stored in that office. The DON said he/she expects discontinued or expired medications to be destroyed or sent back to the pharmacy within a couple of days. The DON said he/she is responsible to ensure the medications are either destroyed or sent back to the pharmacy. During an interview on 8/14/25 at 2:27 P.M., the Administrator said he/she is uncertain how the medications got into the MDS office. The Administrator said he/she should have checked the MDS office closet and that this shouldn't have happened. The Administrator said he/she would expect for staff to destroy or return medications to the pharmacy monthly.

Based on observation, interview, and record review, facility staff failed to follow professional standards when staff prepared 40 medication cups with medications prior to the timed medication pass and performed resident blood sugar tests with expired test strips for four residents (Resident #14, #58, #61, and #62) out of four sampled residents. The facility census was 64. 1. Review of the facility's policy titled, Medication Administration Guidelines, dated ,d+[DATE], showed facility staff are directed as follows: -The complete act of administration entails removing an individual dose from a previously dispensed, properly labels container, verifying it with the physician's orders, giving the individual dose to the proper resident, and promptly recording the information; -Medications may not be prepared in advance and must be administered within one hour of preparation; -The same person preparing the doses for administration must administer the medications. 2. Observation on [DATE] at 9:08 A.M., showed the east side medication cart contained the following: -One medication cup labeled with a first name contained one pill; -One medication cup labeled with a first name contained half of a pill; -One medication cup labeled with a first name contained two pills; -Two medication cups labeled with a illegible name contained one pill; -Two medication cup labeled with a first name contained two pill; -One medication cup labeled with a first name contained 11 loose pills; -One medication cup labeled with a first name contained seven loose pills; -One medication cup labeled with a first name contained six loose pills; -One medication cup labeled with a first name contained 12 loose pills. During interview on [DATE] at 9:10 A.M., Certified Medication Technition (CMT) C said he/she only pre-pops medications for his/herself. He/She said that at least six of the pre-popped medications are narcotics. He/She said he/she pre-popped the narcotics this morning at 6:45 A.M. because the facility does not have enough cards for both medication carts. He/She said that is why he/she pre-pops the narcotics early. 3. Observation on [DATE] at 11:51 A.M., showed the east side medication cart drawer contained seven medication cups with various pills inside labeled with only first names. At this time, CMT C said he/she will give the medications in a bit. He/She said, actually I will go give them now. Observation showed CMT C went and delivered the pre-popped medications to the residents. 4. Observation on [DATE] at 8:55 A.M., east side medication cart contained the following: -One medication cup labeled with a first name contained four various pills; -One medication cup labeled with a first name contained eight various pills; -One medication cup labeled with a first name contained six various pills. During interview on [DATE] at 9:00 A.M., CMT C said he/she normally does not pre-pop medications. CMT C said risk of pre-popping medications and leaving them in the medication cart could be if cart was left unlocked another resident could get inside cart and take medications. He/She said if something was to happen and he/she had to leave, he/she would make sure the medications were administered before leaving. Is the CMT aware of the faciity policy of pre-popping medication? 5. Observation on [DATE] at 11:06 A.M., showed the memory care unit medication cart top drawer contained 27 medication cups labeled with first names only contained various medications inside each medication cup, stacked inside each other in three different rows. During interview on [DATE] at 11:10 A.M., Licensed Practical Nurse (LPN) D said one row of pre-popped medications were for the noon medication pass, one row was for 2 P.M. medication pass, and the other row were for the supper medication pass. He/She said the pharmacist said it is okay to pre-pop pills as long as he/she is the one giving the medications. The LPN said he/she would not be able to identify pills without looking at medication cards. During interview on [DATE] at 3:20 P.M., LPN D said he/she was not aware of what the policy said about pre-popping medications. LPN D said he/she spoke with the Director of Nursing (DON) and the DON said it is okay to pre-pop medications if he/she is the one administering them. During interview on [DATE] at 4:41 P.M., the Director of Nursing (DON) said per the medication technician instructors, they now allow pre-popping of medications. He/She said it is not acceptable to pre-pop medications more then one hour before giving medications. He/She said there are specific times medication are given during the day. He/She said he/she was not aware the facility policy stated pre-popping medication was not allowed. During interview on [DATE] at 4:45 P.M., the administrator said the only time pre-popping medication is allowed is if the person administering them can identify all the pills in the cup. He/She was not aware the policy said medication can not be pre-popped. 6. Review of the facility's policies showed staff did not provide a glucose strip policy. 7. Observation on [DATE] at 11:26 A.M., showed LPN E used a blood sugar test strip with an expiration date of [DATE] to obtain Resident #58's blood sugar. Observation on [DATE] at 11:41 A.M., showed LPN E used a blood sugar test strip with an expiration date of [DATE] to obtain Resident #14's blood sugar. Observation on [DATE] at 11:59 A.M., showed LPN E used a blood sugar test strip with an expiration date of [DATE] to obtain Resident #61's blood sugar. Observation on [DATE] at 12:04 A.M., showed LPN E used a blood sugar test strip with an expiration date of [DATE] to obtain Resident #62's blood sugar. During an interview on [DATE] at 12:06 P.M., LPN E said he/she did not know if the blood sugar test strips needed to be labeled with an open date, but he/she said it would probably be a good idea to have. He/She said he/she did not realize the test strips were expired when he/she used them for the residents. He/She said since they were expired, they were probably not very accurate. He/She said the nurse or CMT who is administering insulin is in charge of checking the insulin cart and the insulins as they are given. During an interview on [DATE] at 4:46 P.M., the DON said the nurse or CMT who is responsible for medication pass is also responsible for checking to ensure blood sugar test strips are not expired and should be check on every shift. He/She said it is his/her expectation staff would re-test the residents blood sugar if they discovered the test strips were expired to ensure its accuracy. During an interview on [DATE] at 4:48 P.M., the administrator said it is his/her expectation nurses or CMT's who are checking blood sugars are also looking at expiration dates of the glucose strips. He/She said using expired test strips runs the risk of not getting accurate readings. He/She said if a staff member realizes the testing strips are expired, they should discard the old ones and re-check the blood sugars with new testing strips.

Based on observation, interview, and record review, facility staff failed to store and label medications in a safe and effective manner when staff failed to date the opened multi-dose medication bottles, insulin vials, and medications were left unattended on top of one medication cart. The facility census was 64. 1. Review of the facility's Storage of Medication policy, undated, shows facility staff were directed as follows: -All medications for residents must be stored at or near the nurse's station in a locked medicine room or one or more locked mobile medication carts; -All mobile medication carts must be under visual control of the staff at all times when not stored safely and securely; -No discontinued, outdated, or deteriorated drugs or biologicals may be retained for use. All such drugs must be returned to the issuing pharmacy or destroyed in accordance with established guidelines; -Drugs must be stored in an orderly manner in cabinets, drawers, or carts. 2. Observation on [DATE] at 9:08 A.M., showed the east side medication cart contained: -One opened bottle of magnesium oxide, undated; -One opened bottle of vitamin D, undated; -One opened bottle of vitamin B-1, undated; -One opened bottle of one-a-day multi vitamin, undated; -One opened bottle of saline nasal spray, undated; -One opened bottle of latanoprost oph (used to treat glaucoma) 0.005%, undated; -One opened bottle of fluticasone (treats allergy symptoms) nasal spray, undated. During an interview on [DATE] at 3:30 P.M., Certified Medication Tech (CMT) C said when opening bottles of medications, he/she should always put the open date on the bottle. He/She said if there is no open date then he/she is not sure how long is has been opened and the medication may not be effective anymore. He/She said it is the person opening the bottles responsibility to put the open date on bottle when it is opened. During an interview on [DATE] at 2:29 P.M., Licensed Practical Nurse (LPN) E said multidose medication bottles should always be labeled with an opened date. He/She said if there is no opened date then he/she would not know how long the bottle has been open and the medication may not be effective if it has been open to long. He/She said the medication should be disposed of if no open date and open a new bottle. He/She said it is the nurse or CMT's responsibility to label with open date when opening the bottle. During an interview on [DATE] at 4:41 P.M., the Director of Nursing (DON) said multidose medication bottles need to be labeled with an opened date when bottle is opened. He/She said if there is no open date on medication then the medication may be old and not effective. He/She said it is the CMT's and Nurse's responsibility to insure multi dose medication have open dates on them each shift. During an interview on [DATE] at 4:45 P.M., the administrator said all multidose medications should be dated when opened otherwise the medication may be expired and not effective anymore. He/She said the staff opening the bottle should label with open date. 3. Review of the facility's Insulin and Injectable Diabetic Medication Chart, undated, showed staff is to follow the insulin expiration dates after opening: -Humolog (treat diabetes) Kwik Pen 28 days; -Humulin R (treat diabetes) 3 milliliter (ml) vial 31 days; -Lantus (treat diabetes) SoloStar pen 28 days; -Levemir (treat diabetes) Flex touch pen 42 days; -Novolog (treat diabetes) Flex pen 28 days. 4. Observation on [DATE] at 9:12 A.M., showed the insulin cart contained: -Three opened Levemir Flex touch pens, undated; -Two opened Lantus SoloStar pens, undated; -One opened Humalog Kwik pen, undated; -One opened 3 ml vial of Humlin R labeled with an open date of [DATE]; -One opened Novolog flex pen labeled with an open date of opened [DATE]. Observation on [DATE] at 8:52 A.M., showed the insulin cart contained one opened Novolog flex pen with an open date of [DATE]. During an interview on [DATE] at 9:24 A.M., LPN E said insulin should be labeled when opened. He/She said the expiration date of insulins vary. He/She said there is a cheat sheet they use to keep track of insulin expiration dates once opened. He/She said it is the responsibility of the DON and their MDS coordinator to check medication carts and medication storage rooms. He/She said he/she believes they check the carts and storage rooms weekly. During an interview on [DATE] at 8:54 A.M., LPN E said insulin just got switched to one cart. He/She said opened dates and expiration dates should be checked at change of shift. He/She said he/she missed the expired and not dated medications the previous day during his/her checks. He/She said he/she must have missed that insulin pen the day before and today. During an interview on [DATE] at 4:46 P.M., the DON said the nurse or CMT who is responsible for the medication pass is also responsible for checking to ensure medications are labeled with opened dates. He/She said the expectation is it is done per shift. He/She said insulin pens are good for a limited time from the date of open. He/She said there is a list in each medication book and pharmacy also provided an insulin chart that gives the specific expiration dates from time of open. During an interview on [DATE] at 4:48 P.M., the administrator said it is his/her expectation that insulin pens are dated upon opening. He/She said the nurses or CMT's who are giving the insulins on the cart are responsible for maintaining the cart and making sure they are labeled. He/She said not labeling insulin pens runs the risk of giving an insulin that won't be effective. 5. Observation on [DATE] at 8:56 A.M. showed the west side medication cart, left unattended with a medication on top which contained: -One bottle of Senna-Plus 50 mg; -One bottle of Tylenol 325 mg; -One Fluticasone Propionate nasal spray; -One tube of Betamethasone Valerate cream (treat a variety of skin conditions). During an interview on [DATE] at 9:01 A.M., CMT C said he/she was not sure why medications were on left unattended on top of the medication cart. He/She said the cart was last used by the night shift and the medications were night time medications. He/She said medications should not be left unattended on top of medication carts. During an interview on [DATE] at 3:43 P.M., LPN H said it is his/her expectation medications not be left unattended on top of medication carts. He/She said it is very important medications are locked up and not accessible to residents. He/She said if he/she walks away he/she would lock it in his/her medication cart. he/she said if he/she found medications unattended on top of medication carts he/she would put it away and he/she would not leave it out. During an interview on [DATE] at 4:46 P.M., the DON said it is his/her expectation medications be in the medication storage room or a locked medication cart. He/She said he/she expects staff who find medications left out and unattended, to store the medications locked and away. He/She said he/she was unaware medications were left out and unattended on top of medication carts. During an interview on [DATE] at 4:48 P.M., the administrator said it is his/her expectation medications be kept in a locked medication cart or medication room. He/She said there is a risk a resident or visitor could get into the medications. He/She was not aware there were medications left out and unattended on top of medication carts. 50422

Based on interview and record review, facility staff failed to designate a person to serve as the Director of Food and Nutrition Services with the appropriate qualifications, when the facility did not employ a qualified dietitian or other clinically qualified nutrition professional full-time. This failure has the potential to affect all residents. The facility census was 64. 1. Review of the facility's Dining Services Supervision policy, dated May 2015, showed Overall supervisory responsibility of the Dining Services Department shall be assigned to a full-time qualified Dining Services Manager. This Dining Services Manager, if not qualified, functions with frequent regularly scheduled consultation from a person so qualified. Review showed the policy did not contain information related to the education and experience requirements for the dining services manager. Review of the facility's Dining Services Manager policy, dated May 2015, showed the policy listed the minimum qualifications for the Dining Services Manager as: -High school diploma or GED equivalent; -Two years of experience in a supervisory capacity of a hospital, skilled nursing care facility or other medical facility; -Certified Dietary Manager if required by state regulations. Review of the dietary manager's (DM) personnel records, showed a hire date of 03/26/24. Review showed the records did not contain documentation of at least two years prior dietary manager experience in a nursing facility and certification or other education required for the director of nutritional services position. During an interview on 05/20/24 at 9:05 A.M., the DM said he/she became the DM in March 2024 and had previously worked at the facility as the dietary manager from 2012 to 2014. The DM said prior to 2012 he/she was a certified nursing assistant and he/she did not have a degree, certification or education related to food service management. The DM said the administrator told him/her the facility would enroll him/her in a certification class after his/her 90-day probationary period and he/she did not know he/she needed to meet the qualifications upon hire. The DM said the facility has a part-time consultant registered dietician who comes to the facility on ce a month and they did not have any certified or clinically qualified nutrition staff employed full-time. During an interview on 05/21/24 at 3:05 PM, the administrator said he/she hired the DM in March 2024. The administrator said the DM had previously been the dietary manager, but the DM did not have a degree, certification or the required education required to be the director of nutritional services. The administrator said the facility policy is to wait until 90 days after hire to enroll the DM into a certification course and he/she did not know that the DM needed to meet the requirements upon hire. The administrator said the facility has a part-time registered dietician consultant and they did not have any certified or clinically qualified nutrition staff employed full-time.

Based on observation, interview and record review, the facility staff to wear facial hair restraints to protect food and food contact surfaces from potential contamination. The facility staff failed to allow sanitized dishes to air dry prior to stacking in storage and use to prevent the growth of food-borne pathogens. These failures have the potential to affect all residents. The facility census was 64. 1. Review of the facility's Dietary Personnel Guidelines policy, dated May 2015, showed the policy directed hairnets or bouffant disposable caps should be worn at all times and should cover the entire head of hair. Review showed the policy did not contain information related to facial hair restraints. Review of a sign posted on the back of the door to the mechanical dishwashing station, undated, showed Food employees shall wear hair restraints such as hats, hair coverings or nets and beard restraints that cover hair exceeding 1/4 of 1 inch and are designed to effectively keep their hair from contacting exposed food, clean equipment, utensils, linens and unwrapped single-service and single-use articles. Food employees shall also wear clothing that covers excessive body hair following the above stipulations. Observation on 05/20/24 at 10:01 A.M., showed [NAME] A had facial hair. Observation showed the cook prepared potatoes and ham and beans for service to residents at the lunch meal without use of a facial hair restraint. Observations on 05/20/24 from 10:50 A.M. to 11:06 A.M., showed [NAME] A continued to prepare food items, including ham and beans, potatoes and rice, for service to residents at the lunch meal without the use of a facial hair restraint. During an interview on 05/20/24 at 11:14 A.M. [NAME] A said he/she had worked at the facility for about three years and had always been told that if his/her facial hair was a quarter inch long or less, he/she did not need to wear a facial hair restraint. During an interview on 05/20/24 at 11:15 A.M., the dietary manager (DM) said the hair restraints sign was posted on the door in the kitchen when he/she became the manager in March 2024. The DM said he/she had questioned the cook about wearing a facial hair restraint and the cook said that he/she was told that if it was a quarter inch long or less then he/she did not need to wear one. The DM said based on the sign posted and the information from the cook, he/she did think the staff with facial hair needed to wear facial hair restraints. During an interview on 05/21/24 at 2:58 P.M., the administrator said staff should put on hair restraints, including facial hair restraints, when they enter the kitchen. The administrator said he/she did not know about the sign posted in the kitchen that directed for staff to only wear facial hair restraints if their facial hair was a quarter inch long or less. The administrator said the information on the sign was not correct and he/she did not know the DM did not know dietary staff with facial hair of any length should wear a facial hair restraint. 2. Review of the facility's Dishwashing policy, dated April 2011, showed the policy directed staff to allow cleansed dishes to thoroughly dry before storage. Observation on 05/20/24 at 9:31 A.M., showed four metal food preparation/service pans stacked together wet on the shelf by three compartment sink and eight plastic food storage containers stacked together wet on the shelf beneath the preparation counter. During an interview on 05/20/24 at 9:38 A.M., the DM said staff should allow dishes to air dry before they are put away and staff had been trained on this requirement. Observation on 05/20/24 at 9:58 A.M., showed 28 plastic food service trays stacked together wet in the upright position on the counter by the plate heater. Observation on 05/20/24, during the lunch meal service which began at 11:20 A.M., showed staff used the wet stacked trays to serve food to the residents. Observation on 05/20/24 at 1:13 P.M., showed dietary aide (DA) B removed sanitized trays from the mechanical dishwasher, stacked them together while wet and put them in storage. During an interview on 05/20/24 at 1:14 P.M., the DA said he/she did not know the dishes needed to be dry before he/she put them away. During an interview on 05/21/24 at 3:01 P.M., the administrator said staff should allow dishes to air dry before they are put away and staff should be trained on this requirement. The administrator said the dietary manager is responsible to monitor dish storage and he/she believed that the DM had trained the staff to allow dishes to air dry.

Based on observation, interview, and record review, facility staff failed to ensure call lights were within reach for three residents (Resident #18, #44, and #51) out of 16 sampled residents. The facility census was 64. 1. Review of facility's Call Light, Use of policy, undated, showed the following: -Respond promptly to resident's call for assistance; -When providing care to residents, be sure to position the call light conveniently for the resident's use. -Be sure all call lights are placed on the bed at all times, never on the floor or bedside stand. -Check the call light system at regular intervals. 2. Review of Resident #18's Quarterly Minimum Data Set (MDS) a federally mandated assessment tool, dated 02/27/24, showed staff assessed the resident as: -Moderate cognitive impairment; -Diagnoses: Dementia, and Traumatic brain injury (TBI); -Dependent assistance needed for toilet transfers, tub/shower transfers, and personal hygiene. Review of the resident's care plan, last reviewed on 02/23/24, showed staff are directed to keep call light in reach. Observation on 05/21/24 at 1:12 P.M., showed the resident in his/her in his/her broda chair (a type of wheelchair that gives patients the ability to tilt and recline) with the call light on the bed, not within reach. Observation on 05/21/24 2:45 P.M., showed an unidentified staff member pushed the resident to his/her room. The staff member left the resident in the broda chair in front of the TV, with the call light on the bed behind the resident, not within reach. 3. Review of Resident #44's Annual MDS, dated [DATE], showed staff assessed the resident as: -Cognition not assessed; -Diagnoses of dementia and TBI; -Total dependent for activities of daily living (ADL)s and transfers. Review of the resident's care plan, last reviewed on 03/08/24, showed the facility are directed to keep call light within reach. Observation on 05/21/24 1:23 P.M. and 2:48 P.M., showed the resident in his/her room in his/her broda chair in front of the TV with the call light on the bed behind the resident, not within reach. Observation on 05/22/24 3:02 P.M., showed the resident in his/her room in his/her broda chair in front of the TV with the call light on the bed behind the resident, not within reach. Observation on 05/23/24 9:57 A,M, showed the resident in his/her room in his/her broda chair in front of the TV with the call light on the bed behind the resident, not within reach. 4. Review of Resident #51's quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Total dependent for activities of daily living (ADL)s and transfers. Review of the resident's care plan, last reviewed on 05/03/24, showed the facility are directed to keep call light within reach. Observation on 05/21/24 at 1:32 P.M., showed the resident in his/her bed with the call light draped over the bedside table next to the recliner not within reach. Observation on 05/22/24 at 9:00 A.M., showed the resident in his/her bed with the call light on the arm of the recliner not within reach. 5. During an interview on 05/23/24 at 3:15 P.M., Certified Nurse Aide (CNA) F and CNA G said resident call lights are to be in reach of residents at all times, and should be placed back into the residents reach after care is provided. CNA G said they make rounds to check for call light placement. During an interview on 05/23/24 at 4:37 P.M., Licensed Practical Nurse (LPN) H said call lights should be in reach of residents, sometimes they are pinned to the resident, or might be on their bed or chair. LPN H said even residents who are confused should still have their call lights within reach. During an interview on 05/23/24 at 4:58 P.M., the Director of Nursing said call lights should be within the resident's reach. During an interview on 05/23/24 at 4:59 P.M., the administrator said call lights should be within reach for all residents and staff should check when doing rounds that they are in place.

Based on observation, interview, and record review, facility staff failed to review and revise care plan for one resident (Resident #3) out of one sampled resident with interventions for cellulitis and for one resident (Resident #47) out of one sampled resident with medication noncompliance. The facility census was 64. 1. Review of the facility's policies showed staff did not provide a policy for care plans. 2. Review of the facility's Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, 3.0 and Care Planning Policy, undated, showed: -The Comprehensive Care Plan will also be individualized to each resident; -Comprehensive Care Plan will be updated when a change of condition is warranted; -Included in the Comprehensive Care Plan will be the resident's right to refuse treatment, any specialized services the facility will provide, the resident's goals for admission, desired outcomes, and discharge plans; -The Comprehensive Care Plan will be revised on an ongoing basis to reflect changes in the resident and/or changes in the care the resident is receiving including interventions, measurable objectives, goals, and care instructions; -The Comprehensive Care Plan shall be adhered to in caring for the resident and outline the resident's care needs; -All staff will have access to the comprehensive care plan and know that is it located in the resident's chart under the care plan tab. 3. Review of Resident #3's quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Diagnoses of peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), diabetes, and dementia -Dependent for activities of daily living (ADL)s and putting on/taking off footwear; -Application of dressings to feet. Review of the resident's care plan, dated 12/18/23, showed the care plan did not contain direction or interventions for the use of a compressive boot. Review of the resident's Physician Order Sheet (POS), dated 05/2024, showed an order to check legs daily, apply compression boot to lower left extremity and bilateral, change every three days for cellulitis. Observation on 05/20/24 at 12:30 P.M. showed the resident in his/her wheelchair in the dining room with compression boot to lower left extremity. Observation on 05/21/24 at 8:30 A.M., showed the resident in his/her wheelchair in the hallway by the nurses station with compression boot to lower left extremity . Observation on 05/22/24 at 3:20 P.M., showed the resident in his/her wheelchair in their room with compression boot to lower left extremity. Observation on 05/23/24 at 12:15 P.M., showed the resident in his/her wheelchair in the dining room with compression boot to lower left extremity. 4. Review of Resident #47's quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Does not reject care; -Non-traumatic brain injury. Review of the resident's nurses note, dated 12/14/23 at 1:23 P.M., showed staff documented a nurse witnessed the resident attempted to conceal his/her pills when staff administered his/her medication to the resident. Review of the resident's nurses note, dated 03/13/24 at 1:48 P.M., showed staff documented to monitor the resident closely with medications as he/she has been found to conseal and store medications. Review of the resident's care plan, date 03/08/24, showed the care plan did not contain direction for staff in regard to the resident's noncompliant behavior to conceal and store his/her medications in his/her room. During an interview on 05/23/24 at 9:30 A.M., LPN E said the resident has had this behavior before, hiding pills instead of taking them, he/she believes they are poison. The doctor is aware, but he/she is not aware of any specific intervention in place other then watching the resident take their medications. During an interview on 05/23/24 at 10:15 A.M. LPN H said resident specific information is what is expected to be on the residents care plan. LPN H said when staff administer medication they are expected to watch residents take them before they walk away. During an interview on 05/23/24 at 10:19 A.M. MDS Coordinator Registered Nurse said he/she is responsible for MDS and Care plans. The MDS Coordinator said any treatments or interventions should be on the care plan. If they are not on the care plan, it is because he/she was not made aware of it. During an interview on 05/23/24 at 4:58 P.M., the Director of Nursing (DON) said behaviors such as a medication refusals or hoarding pills should be care planned with interventions. The DON said any resident specific treatments and interventions are expected to be on a care plan. During an interview on 05/23/24 at 4:59 P.M. the Administrator said staff are expected to watch medications being given to each resident. The Administrator said she would expect medication issues or concerns, treatment and interventions to be on a residents care plan.

Based on observation, interviews, and record reviews, facility staff failed to ensure florescent light bulbs were protected; to maintain kitchen environment equipment in a clean and sanitary manner, and to properly store open food to prevent cross contamination and outdated usage. The facility staff also failed to perform hand hygiene as often as necessary; to wash, rinse, and sanitize the food preparation sink between uses to prevent cross-contamination and the growth of food-borne pathogens and to ensure the ice bin drained through an air gap. This failure had the potential to affect all residents in the facility. The census was 58 with a capacity of 98. 1. Review of the facility's Weekly Preventative Maintenance Checklist, undated, showed: - The policy did not address the kitchen lights; - The policy did not address protecting light bulbs. Review of the facility's Monthly Preventative Maintenance Checklist, undated, showed the policy did not address kitchen lighting. Observations on 2/22/23 at 9:15 A.M., showed four florescent light bulbs over the three compartment warewashing sink not protected. During an interview on 2/24/23 at 11:56 A.M., the maintenance director (MD) said he was aware the lights over the three compartment warewashing sink were not covered. He said the light cover was on order, and they do not have any other way to protect the lights until the cover arrives. The maintenance director was not aware the lights could be covered with plastic sleeves. During an interview on 2/24/23 at 1:13 P.M., the administrator and the quality assurance (QA) nurse said the MD is responsible to inspect and maintain the lighting in the kitchen, and he checks the lights according to facility policy. They said the dietary staff can also submit a work order for the lights. The administrator and the QA nurse did not know if the light bulbs should be covered. 2. Review of the facility's Cook's Daily Cleaning Schedule, undated, showed the schedule did not address cleaning or checking the ceiling, to include vents, fans, and sprinkler heads. Review of the facility's Aide's Daily Cleaning Schedule, undated, showed aides directed to wipe down microwave and refrigerator. The schedule did not address cleaning or checking the ceiling, to include vents, fans, and sprinkler heads. Review of the Cook Weekly Deep Cleaning Schedule, undated, showed cooks directed to clean the plate warmer. The schedule did not address showed cleaning or checking the ceiling, to include vents, fans, and sprinkler heads. Review of the Aide Weekly Deep Cleaning Schedule, undated, showed the schedule did not address showed cleaning or checking the ceiling, to include vents, fans, and sprinkler heads. Observation on 2/21/23 at 9:42 A.M., showed the two fans in the facility's walk-in refrigerator visibly dirty with dirt and debris. Further observation showed the fans on and blew air above the food stored in the cooler. Observation on 2/22/23 at 9:30 A.M., showed: - The ceiling over the three compartment warewashing sink and the two compartment food prep sink with cracks, unfinished and peeling drywall mud; - Two sprinkler heads over the food preparation area visibly loaded with dust; - Plate warmer with plates visibly dirty with crumbs; - Inside microwave with debris on inside top; - Vents over dishwashing area visibly dirty with dust accumulation; - Vents over entrance to walk-in refrigerator visibly dirty with dust accumulation. During an interview on 2/24/23 at 9:30 A.M., Cook H said all kitchen staff are responsible for cleaning the walk-in cooler and fans. The cook said the staff have a cleaning schedule, but he/she is not sure if the walk-in cooler fans are on the cleaning schedule. The cook said the DM checks the cleaning schedule to ensure the cleaning is completed. During an interview on 2/24/23 at 10:49 A.M., the DM said he/she would guess the MD or DM are responsible to clean the fans in the walk-in refrigerator. The DM said he/she had never cleaned the walk-in cooler fans in the two years he/she had been at the facility. He/she said he/she would be afraid he/she would break the fans. During an interview on 2/24/23 at 11:56 A.M., the MD said the dietary staff are responsible to clean the entire kitchen to include the sprinkler heads, fans, and the vents. He is responsible to maintain the ceilings in the kitchen to prevent peeling and chipping. The MD said it is expected the dietary staff would submit a work order for any issues with the ceiling. The staff have been trained on how to submit a work order, but he did not have any for the ceiling in the kitchen. During an interview on 2/24/23 at 1:13 P.M., the administrator and the QA nurse said maintenance is responsible to inspect and maintain the sprinkler heads in the kitchen, and he checks them monthly. The maintenance director is also responsible to maintain the ceiling in a manner that is not peeling. They said the ceiling in the kitchen has been a consistent issue, but it should be maintained in order to prevent chips from falling into the food preparation and service areas. The administrator and the QA nurse said the dietary staff are responsible to ensure the vents, fans, and equipment are maintained in a sanitary manner It is expected they would clean the kitchen according to the schedule and as necessary if items are visibly dirty. 3. Review of the facility's Receiving and Storage of Food policy, dated 4/2011, showed the policy did not direct staff to label and date food items. Review of the facility's Cook's Daily Cleaning Schedule, undated, showed cooks directed to make sure opened items are dated and to check dates on cooler items Review of the facility's Aide's Daily Cleaning Schedule, undated, showed aides directed to check all items are dated. Observation on 2/21/23 at 9:34 A.M. of the walk-in refrigerator, showed: - Ten crates containing 29 gallons of milk and three containers of cottage cheese, stored directly on floor; - A ziplock storage bag of sliced ham undated; - A plastic container of cooked chicken dated 2/13/23; - A half full bag of raw chicken undated. Observation on 2/22/23 at 10:10 A.M. of the pantry, showed: - Open bag of brown crumbs unlabeled and not dated; - Open bag of spaghetti noodles not dated. Observation on 2/22/23 at 10:35 A.M. of the walk-in refrigerator, showed: - Open package of corn tortilla not dated; - One sandwich in ziplock bag unlabeled and not dated; - Open package of mini carrots unprotected and not dated; - Open bag of shredded lettuce with dressing packet unlabeled and not dated; - Open bag of potato wedges not dated; - Small metal container with white substance unlabeled and not dated. Observation on 2/22/23 at 10:43 A.M. of the walk-in freezer, showed: - Bag of breaded rounds unlabeled and not dated; - Bag of breaded disks unlabeled and not dated. During an interview on 2/24/23 at 9:30 A.M., Cook H said staff should place a tag on opened food with the date opened and the date the food item will go out. He/she did not know why the ham and chicken were not dated. The cook said staff can store opened food items for four days in the cooler, but staff store cooked food items for three days and then discard the food item on the fourth day. The cook said staff should be checking dates on food in the cooler every day. The cook said staff are expected to label, date, and stack food on the day it is delivered. He/she said food should not be stored on the floor. During an interview on 2/24/23 at 10:49 A.M., the DM said staff are expected to label and date food items when they are opened. The label should have a three day date on it, and staff should dispose of food after the third day. The DM said nothing should be stored on the floor in the kitchen or the walk-ins. During an interview on 2/24/23 at 1:13 P.M., the administrator and the QA nurse said dietary manager is responsible to ensure food in the kitchen is labeled, dated, and protected to prevent cross contamination and outdated use. The facility has a policy for food storage, and the dietary staff is trained on the policy. The administrator and the QA nurse said it is expected the dietary manager would check daily to ensure food is stored according to facility policy. 4. Review of the facility's Sink Usage policy, undated, showed: - Handwashing sink: handwashing according to guidelines; - Two compartment sink: Handwashing in the right compartment according to guidelines; - Thee compartment sink: Handwashing in the second compartment according to guidelines; - The policy did not contain the guidelines; - The policy did not address sanitizing the sink, to include the faucet handles, after performing hand washing in the two compartment food preparation sink and the three compartment warewashing sink. Review of the facility's Dietary Personnel Guidelines, dated 4/2011, showed staff directed perform hand washing at any time deemed necessary. Observation on 2/22/23 at 10:22 A.M., showed the DM washed his hands in the two compartment food preparation sink. The DM did not sanitize the food preparation sink after washing his hands. Further observation showed dietary staff used the unsanitized food preparation sink to prepare drinks and other meal related items for the residents' lunch service. The dietary staff did not perform hand hygiene after touching the unsanitized sink and before touching food related items. Observation on 2/22/23 at 10:25 A.M., showed the DM donned gloves and removed sausages from container. The DM handed the sausages to Cook H, and the cook places the sausages on a cooking sheet. The DM removes his gloves and washes in his hands in the three compartment warewashing sink. The DM does not sanitize the warewashing sink after washing his hands. Further observation showed dietary staff used the unsanitized food preparation sink to prepare food for the resident's lunch service. The dietary staff did not perform hand hygiene after touching the unsanitized sink and before touching food related items. During an interview on 2/22/23 at 10:30 A.M., the DM said the two compartment sink is for food preparation and the three compartment sink is for washing pots and pans. The DM said it is okay to wash your hands in those sinks because there is soap and paper towels in those locations. The DM said the sinks should be sanitized after performing a dirty task in the sink. During an interview on 2/24/23 at 1:13 P.M., the administrator and the QA nurse said dietary staff should perform hand hygiene in the handwashing sink and in sinks where staff do not prepare food or drinks. They said the three compartment warewashing sink and the two compartment food preparation sink should be disinfected, to include the faucet handles, after each handwashing. 5. Review of the facility's Monthly Preventative Maintenance Checklist, undated, showed staff directed to inspect the ice machine and to verify there is at least a two inch air gap above the floor drain. Observation on 2/22/23 at 12:42 P.M., showed the ice machine located in the main dining room did not drain through an air gap. Further observation showed the ice machine used for resident meal service. During an interview on 2/23/23 at 10:10 A.M., the MD said he is responsible to ensure the ice machine is maintained according to regulations. He said he only checks the ice machine in the kitchen, because that is the one that produces the ice. Dietary staff bring the ice from that machine and pour it into the ice machine in the main dining room. The MD did not know if the ice machine in the main dining room needed an air gap. During an interview on 2/24/23 at 1:13 P.M., the administrator and the QA nurse said the MD is responsible to inspect and maintain the ice machines in the kitchen. They said the ice machines should drain through an air gap.

Based on observation, interview, and record review, facility staff failed to provide a comfortable and homelike environment, when staff failed to ensure resident areas were in good repair. Additionally, staff failed to ensure one resident's (Resident #12) wheelchair was free of rips and tears. The facility census was 58. Review of the policies provided by the facility showed they did not contain a policy for environmental concerns. 1. Observations from 2/21/23 at 10:45 A.M. through 2/24/23 at 3:00 P.M., showed the 100 hall walls with chipped paint and black marks. Further observation showed multiple door frames with broken trim and the spa with missing baseboard. 2. Observation on 2/22/23 at 1:47 P.M., showed room [ROOM NUMBER] with a sticky floor, and gouged walls. 3. Observation on 2/22/23 at 4:30 P.M., showed room [ROOM NUMBER] with a torn floor mat, and walls with missing paint. 4. Observation on 2/23/23 at 10:53 A.M., showed room [ROOM NUMBER] with dead bugs on the floor, chipped paint, gouged walls, and missing baseboard trim. Further observation, showed no water in the toilet bowl with a black substance, and a soiled brief in the trash can. 5. Observations on 2/23/23 at 9:50 A.M., during the Life Safety Code (LSC) tour showed: -room [ROOM NUMBER] without a faceplate on the cable box; -room [ROOM NUMBER] with a towel bar on the floor; -room [ROOM NUMBER] without a toilet paper holder in the bathroom; -room [ROOM NUMBER] with missing baseboard under the window and without a towel bar; -room [ROOM NUMBER] with missing baseboard in the bathroom; -room [ROOM NUMBER] with a towel rack on the floor; -room [ROOM NUMBER] with half of the window shutters on the floor; -room [ROOM NUMBER] with missing drywall at the corner of the closet door; -room [ROOM NUMBER] without a towel bar; -room [ROOM NUMBER] without a towel bar and without a toilet paper holder in the bathroom; -room [ROOM NUMBER] with a broken face plate on the cable box; -room [ROOM NUMBER] with a hole in the wall near the bathroom door and one outlet without a faceplate; -room [ROOM NUMBER] without a towel bar; -room [ROOM NUMBER] without a towel bar and without a toilet paper holder in the bathroom. 6. Observation on 2/21/23 at 2:57 P.M., showed Resident #12's wheelchair had a torn seat and arm rests. Further observation showed the resident's room had a towel rack on the floor, broken door and wall trim, and paint peeled from the wall. Observation on 2/22/23 at 9:14 A.M., showed the resident's wheelchair had a torn seat and arm rests. Further observation showed the resident's room had a towel rack on the floor, broken door and wall trim, and paint peeled from the wall. Observation on 2/24/23 at 9:04 A.M., showed the resident's wheelchair had a torn seat and arm rests. Further observation showed the resident's room had a towel rack on the floor, broken door and wall trim, and paint peeled from the wall. During an interview on 2/22/23 at 9:23 A.M., the resident said he/she has used the same wheelchair since being admitted to the facility ten years ago. 7. During an interview on 2/23/23 at 2:25 P.M., Certified Nurse Aide (CNA) D said staff should fill out the maintenance log they notice environmental issues. The CNA said he/she has reported the maintenance issues, but the repairs haven't been completed. During an interview on 2/24/23 at 9:14 A.M., Licensed Practical Nurse (LPN) C said staff should fill out the maintenance log book if they notice environmental issues. He/She said he/she didn't know how often maintenance checked the log book. The LPN said he/she knows there is chipped paint, missing trim and other issues, and he/she reported the issues to the maintenance department. Further, he/she said he/she had not noticed Resident #12's wheelchair was in poor condition, but he/she could order a new one. He/She said he/she believed the resident may be correct by stating the wheelchair has not be replaced since he/she was admitted to the facility. During an interview on 2/24/23 at 11:16 A.M., the Director of Nursing (DON), Administrator and MDS (Minimum Data Set) Coordinator said staff are directed to report environmental and medical equipment concerns to a nurse or upper management. Further, the Administrator said he/she did not notice Resident #12's wheelchair had a torn seat and arm rests. He/She said no one had brought it to his/her attention. During an interview on 2/23/23 at 3:27 P.M., the Maintenance Supervisor said staff are directed to write any maintenance concerns in the log book, which he/she checked every week. He/She said he/she prioritizes concerns, since he/she is the only member of the maintenance staff. He/She said he/she has noticed the missing and chipped paint, towel rack on the floor, and missing or broken pieces of trim throughout the facility.

Based on observation, interview, and record review, facility staff failed to ensure medications were stored in a safe manner, by not ensuring medications were contained in their original package and properly labeled in one medication cart on the Special Care Unit (SCU). Additionally, facility staff failed to maintain a correct count of controlled medications for two residents (Resident #37 and Resident #39). The facility census was 58. Review of the facility's Storage of Medications Policy, dated March of 2015, showed: -Medications must be stored in the container in which they are received; -Drugs must be stored in an orderly manner in cabinets, drawers or carts. 1. Observation on 2/21/23 at 3:00 P.M., showed the SCU medication cart with loose pills scattered throughout the drawers. Further observation showed the drawers contained the following pills: -One gray capsule with G220 150 printed on it; -One green capsule with E 88 printed on it; -Two light blue tablets inscribed with 87 on one side and H on the other side; -One light blue tablet with 40 inscribed on one side; -One yellow capsule with 104 printed on it; -One white capsule with 103 printed in blue on it; -One purple and white capsule with IP 212 printed on it; -Two pink round tablets inscribed with 10 on one side and R on the other side; -One pink oval tablet inscribed with H 147; -Five yellow oval tablets inscribed with MI 15 on one side, and APO on the other side; -Six white oval tablets inscribed with B 10; -Two white oval tablets inscribed with L 5 on one side and M on the other side; -One white oval tablet inscribed with EP 127; -One white oval tablet inscribed with APO on one side and ATV 20 on the other side; -One white round tablet inscribed with 3170 V; -One white round tablet inscribed with 40 on one side and EP 117 on the other side; -One orange round tablet inscribed with 123; -One dark yellow tablet inscribed with 151; -One white round tablet inscribed with N 32; -One white oval tablet inscribed with FF2; -Two unmarked pink tablets; -11 unidentified pills of varied shapes and sizes; -17 unidentified white round tablets of varied sizes. During an interview on 3/10/23 at 9:10 A.M., Licensed Practical Nurse (LPN) L said he/she checks the medication cart once a week for expired medications, and to ensure it's clean and organized. The LPN said staff doesn't clean the cart on a regular basis, but he/she expects it to be cleaned weekly. The LPN said loose pills should be taken out of the medication cart and thrown away. The LPN said he/she the medication cart did not get cleaned out the week before, if it had, the loose pills would have been found. During an interview on 3/10/23 at 9:18 A.M., the Administrator said loose pills in the medication carts is not acceptable. 2. Review of the facility's Narcotic Count Policy, undated, showed: -Complete a physical inventory of narcotics at each shift change to identify discrepancies; -One Registered Nurse (RN), LPN, or Certified Medication Technician (CMT) going off duty and one RN, LPN, or CMT coming on duty must count and justify accuracy of narcotic supply for each individual resident at the change of each shift; -After supply is counted and justified, the nurse/CMT records the date and his/her signature, verifying the count is correct; -If the count is not accurate, the nurse going off duty is to remain on duty until the count is reconciled and the Director of Nursing (DON) must be notified for further instruction. 3. Review of the facility's controlled medication log, dated 2/21/23, showed LPN C signed Resident #37's controlled medication count form for Morphine (narcotic pain medication), indicating 23.5 milliliters (ml) remained. Observation on 2/21/23 at 2:50 P.M., showed the resident's morphine bottle contained 14 ml of medication. 4. Review of the facility's controlled medication log showed it did not have a controlled medication count form for Resident #39's Morphine. Observation on 2/21/23 at 2:54 P.M., showed the medication cart contained a 40 ml unopened bottle of Morphine for resident #39. During an interview on 2/21/23 at 2:50 A.M., LPN C said he/she signed for the controlled medications, when he/she came on shift at 6:00 A.M. The LPN said he/she didn't notice the count for resident #37's Morphine was not correct. The LPN said, he/she didn't know where the controlled log for Resident #39's Morphine was, but it had been in the controlled log at some point. The LPN said he/she had to go get the DON. During an interview on 3/10/23 at 9:18 A.M., the Administrator said he/she would expect staff to count controlled medications at every shift change, and if the medication couldn't be accounted for, he/she should be notified.

Based on observation, interview, and record review, facility staff failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment when staff failed to use appropriate hand hygiene and infection control procedures during the provision of care for two residents (Resident #1 and #13), and during wound care for one resident (Resident #1). Additionally, facility staff failed to decrease the risk of infection when staff failed to ensure sanitary conditions for oxygen tubing for one resident (Resident #12) and a urinary catheter (tube placed in the bladder to drain urine) drainage bag for one resident (Resident #24). The facility census was 58. 1. Review of the facility's Handwashing policy, dated March 2015, showed the purpose is to reduce the transmission of organisms from resident to resident, nursing staff to resident and resident to nursing staff. Further review showed it did not contain direction in regard to when to perform hand hygiene. Review of the facility's Perineal Care policy, dated March 2015, showed the purpose is to prevent infection and odor. Further review, showed it did not contain direction for staff in regard to hand hygiene and glove changes during care. Review of the facility's Perineal Care with Hand Washing checklist, dated 3/15/22, showed: -Perform perineal care for the genital area; -Remove gloves; -Perform hand hygiene; -Put on new gloves; -Assist resident to turn onto side away from candidate; -Perform perineal care for the rectal area; -Further review showed it did not contain direction for staff in regard to hand hygiene and glove changes after completion of perineal care and before touching the resident or items in the resident's room. Review of the facility's Gloves policy, dated March 2015, showed: -Gloves must be changed between residents and between contacts with different body sites of the same resident; -Dirty gloves are worse than dirty hands because microorganisms adhere to the surface of a glove easier than to the skin on your hands. Handling medical equipment and devices with contaminated gloves is not acceptable; -Change gloves between contacts (as defined above) with different residents or with different body sites of the same resident. 2. Observation on 2/22/23 at 8:33 A.M., showed Certified Nurse Aide (CNA) I and CNA J entered Resident #1's room to provide perineal care. CNA I and CNA J performed hand hygiene, applied gloves, and CNA J wiped down the resident's right groin and up the left groin with the same portion of a disposable wipe. The CNA got a new wipe and wiped the resident back (rectal area) to front (genital area) multiple times with the same portion of the wipe. The CNA removed his/her gloves, performed hand hygiene, applied clean gloves, bagged dirty linens, and repositioned the resident, with the same gloves on. 3. Observation on 2/22/23 at 9:01 A.M., showed Licensed Practical Nurse (LPN) C and CNA D entered Resident #1's room to provide wound care. LPN C and CNA D performed hand hygiene and applied gloves. Further observation showed CNA D applied gloves from his/her pocket. LPN C removed a soiled dressing from a wound on the resident's right thigh, used his/her finger to remove tissue from the wound, and wiped the wound multiple times using the same portion of the gauze. LPN C packed the wound with calcium alginate foam (an absorbent foam dressing), removed gloves, did not perform hand hygiene, applied clean gloves, applied a new foam dressing to the resident's wound, removed his/her gloves, did not perform hand hygiene, removed a tubi-grip (a tubular elastic bandage) from the resident's right leg, and applied clean gloves, without performing hand hygiene. The LPN removed a dressing from the resident's right foot, wiped a wound to the right heel multiple times with the same portion of gauze, threw the gauze away and washed his/her hands. 4. Observation on 2/22/23 at 9:39 A.M., showed CNA D and Nurse Aide (NA) K entered Resident #13's room to provide perineal care. CNA D and NA K performed hand hygiene, applied gloves and CNA D removed a soiled pad from under the resident, and touched the resident's side, remote and call light with the same gloves on. Further observation showed multiple gloves hung out of CNA D's pants pocket. CNA D removed the exposed gloves from his/her pocket, applied the gloves, and provided care. During an interview on 2/22/23 at 9:57 A.M., CNA D said staff should change gloves, and wash hands after providing care. The CNA said he/she should not have touched the resident, call light and remote with soiled gloves on. The CNA said he/she always kept gloves in his/her pants pocket, because no one told him/her not to. He/She said he/she did go in and out of residents' rooms with the gloves hanging out of his/her pocket, and said it could potentially spread bacteria if he/she leaned against a contaminated surface. 5. During an interview on 2/23/23 at 2:54 P.M., LPN C said staff should wash their hands and apply gloves before and after providing care, and should wash hands between glove changes. The LPN said staff should also change their gloves and wash hands when moving from a dirty to clean task. He/She said staff should not touch anything with soiled gloves on, including the resident and residents' items. He/She said the staff members hands are contaminated after providing care, and they could spread bacteria by not performing hand hygiene or changing gloves appropriately. The LPN said staff should change gloves and perform hand hygiene after cleaning wound, and before applying a clean dressing. He/She said wounds should be cleansed in a circular motion until clean, and staff should use the same portion of the gauze to cleanse the entire wound. The LPN said staff should not keep gloves in their pockets, and he/she had seen the gloves sticking out of CNA D's pocket. He/She said the CNA had been told not to keep the gloves in his/her pocket anymore, because of cross contamination between residents. During an interview on 2/23/23 at 11:43 A.M., the Minimum Data Set (MDS) Coordinator said staff is inserviced monthly and hand hygiene and gloves changes during perineal care has been discussed. He/She said staff are trained in regard to infection control procedures upon hire and then as needed if there are concerns such as if he/she sees a trend of infections throughout the building. During an interview on 2/24/23 at 11:05 A.M., the MDS Coordinator the perineal care policy showed staff should provide perineal care and then reposition the resident before performing hand hygiene. He/She said staff should always remove gloves and use hand hygiene after providing perineal care and before repositioning a resident and touching items in the room. During an interview on 2/24/23 at 11:16 A.M., the Director of Nursing (DON) and the Administrator said staff are directed to use hand hygiene and change gloves when providing care and when moving from a dirty to clean body site. They said there is a concern for cross contamination if staff do not use appropriate hand hygiene and change gloves. They said staff can keep gloves in their pockets, as long as the gloves are not exposed while in the residents' rooms. They said the gloves would be considered dirty if exposed and out of the pockets. 6. Review of the facility's Oxygen Administration policy, dated March 2015, showed staff are directed to place oxygen cannula's and tubing in a plastic bag attached to concentrator when not in use. Observation on 2/21/23 at 11:18 A.M., showed Resident #12's oxygen concentrator did not have a plastic bag to store oxygen tubing. The oxygen tubing lay on the floor, unlabeled. Observation on 2/21/23 at 2:57 P.M., showed the resident's oxygen concentrator did not have a plastic bag to store oxygen tubing. The oxygen tubing lay on the floor, unlabeled. Observation on 2/22/23 at 9:14 A.M., showed the resident's oxygen concentrator did not have a plastic bag to store oxygen tubing. The oxygen tubing lay on the floor, unlabeled. During an interview on 2/22/23 at 9:27 A.M., the resident said he/she used oxygen, and the tubing should be stored in a bag, but there wasn't a bag on the concentrator. Observation on 2/23/23 at 4:21 P.M., showed the resident's oxygen tubing in a bag on the floor. Observation on 2/24/23 at 9:04 A.M., showed the resident's oxygen tubing in a bag on the floor. Observation on 2/24/23 at 9:06 A.M., showed the resident told LPN C his/her oxygen tubing storage bag was on the floor and asked the LPN to re-attach it to the concentrator. The LPN told the resident he/she would get another piece of tape to reattach the bag. During an interview on 2/23/23 at 4:21 P.M., the DON said the resident's oxygen tubing was on the floor, and he/she was going to ask a nurse to pick it up. During an interview on 2/23/23 at 2:25 P.M., CNA D said oxygen tubing should be in a bag on the concentrator when not in use. The CNA said he/she the night shift staff was responsible for changing the tubing and ensuring it's labeled with the date it is changed. During an interview on 2/24/23 at 2:54 P.M., LPN C said oxygen tubing should be changed weekly during the night shift, and labeled with the date it was changed. The LPN said the tubing should be placed in a bag when not in use, and should not be on the floor. The LPN did not know the last time the resident's oxygen tubing was changed. He/She said he/she noticed the residents oxygen tubing was unlabeled and not in a bag. He/She said if the oxygen tubing is not stored and replaced appropriately bacteria can build up in the tubing and cause an infection. During an interview on 2/24/23 at 11:16 A.M., the DON and the Administrator said oxygen tubing should be stored in a bag or attached to the concentrator, when not in use to prevent the spread of infection. They said oxygen tubing should be replaced monthly, and labeled with the date it is replaced. The DON said if the tubing is not labeled, staff don't know when if it's been replaced. They said the oxygen tubing should be kept off the floor. 7. Review of the facility's Catheter Care policy, dated March 2015, showed it did not contain direction for staff in regard to catheter drainage bag placement for the resident when in a wheelchair or their bed. Observation on 2/21/23 at 10:50 A.M., showed an unidentified staff member propelled Resident #24 down the hallway in a wheelchair as the resident's catheter bag touched the floor. Observation on 2/21/23 at 12:06 P.M., showed the resident's catheter bag touched the dining room floor. Staff members in the dining room did not reposition the catheter tubing. Observation on 2/22/23 at 1:52 P.M., showed an unidentified staff member assisted the resident to bed, and placed the catheter bag on the side of the bed. The staff member did not attach the catheter bag to the bed, and it touched the floor. During an interview on 2/23/23 at 2:25 P.M., CNA D said the catheter bag should be attached to be the bed or the wheelchair to keep it from touching the floor. He/she said staff should inform the nurse if the catheter bag touches the ground, even if the it's in a privacy bag, so it can be changed. He/She said if the bag touches the ground it becomes dirty, and it could have bacteria on it that could cause an infection. During an interview on 2/23/23 at 2:54 P.M., LPN C said the catheter bag should secured to the bed or the wheelchair to keep it from touching the floor. The LPN said he/she did see the resident's catheter bag touching the floor, and repositioned the bag, but didn't change it. He/She said the catheter bag should not touch the floor, because it can introduce bacteria to the resident. During an interview on 2/24/23 on 11:16 A.M., the DON said catheter bags should not touch the floor, but if it happens staff should change the bag. The DON said a catheter bag touching the floor is an infection control issue. 42815

Based on observation, interview, and record review, facility staff failed to maintain resident dignity when staff failed to sit and interact while assisting two residents (Resident #1 and Resident #39) during meal time and failed to allow one resident (Resident #17) access to his/her bathroom. The facility census was 58. Review of the facility's Patient Bill of Rights, undated, showed each resident shall be treated with consideration, respect and full recognition of his/her dignity and individuality, including privacy in treatment and care of his/her personal needs. Review of the facility's Resident Rights document, undated, showed: -The resident has a right to a dignified existence, self-determination and communication with and access to persons and services inside and outside of the facility. A facility must protect and promote the rights of each resident; -Right to confidentiality, privacy and respect. 1. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 12/16/22, showed staff assessed the resident as: -Severe cognitive impairment; -Required extensive assistance from one staff member for eating. Observation on 2/21/23 at 12:31 P.M., showed an unidentified staff member fed the resident. Further observation showed the staff member did not speak to the resident, or tell the resident what he/she fed him/her. The staff member spoke to other staff while he/she fed the resident. 2. Review of Resident #39's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Required total assistance from one staff member for eating. Observation on 2/21/23 at 12:38 P.M., showed an unidentified staff member stood over the resident and fed him/her. Further observation showed the staff member did not interact with the resident or tell the resident what he/she fed him/her. During an interview on 2/23/23 at 2:25 PM, Certified Nurse Aide (CNA) D said staff should sit with the residents when they are feeding them. He/She said he/she would not like someone standing over him/her while he/she ate. The CNA said staff should tell the resident what they are giving them a bite of. During an interview on 2/24/23 at 11:16 A.M., the Director of Nursing (DON) said staff are directed to sit next to the resident when assisting with feeding and should speak with the resident explaining what the staff member is feeding him/her. During an interview on 2/24/23 at 2:54 P.M., Licensed Practical Nurse (LPN) C said staff should sit beside the resident while assisting with feeding and explain what food is being fed to the resident. He/She said staff should interact with the resident and not other staff members. 3. Review of Resident #17's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Required extensive assistance from one staff member for bed mobility, transfers and toileting; -Did not exhibit behaviors. Observation 2/23/23 at 10:53 A.M., showed Resident #17's bathroom door locked and the bathroom inaccessible. During an interview on 2/23/23 at 10:30 A.M., the maintenance director said the staff lock the resident's bathroom door to keep the resident from going into it and falling. The maintenance director said the key to unlock the door is not in the resident's room. The charge nurse has the key. During an interview on 2/23/23 at 2:25 P.M., CNA D said the resident's bathroom door is locked because the resident's spouse wants to keep him/her from falling in the bathroom. During an interview on 2/23/23 at 2:54 P.M., LPN C said the staff locks the resident's bathroom door to keep him/her from going in the bathroom and falling. The LPN said staff should check on the resident frequently to see if he/she needs to use the bathroom. During an interview on 2/24/23 at 11:16 A.M., the DON and Administrator said the resident's guardian asked them to lock the bathroom because the resident had fallen trying to take himself/herself to the bathroom. They said it was not dignified to lock the bathroom door to prevent the resident from falling.

Based on observation, interview and record review, facility staff failed to post the telephone number for the Department of Health and Senior Services (DHSS) Adult Abuse and Neglect Hotline (used to report allegations of abuse and neglect) in a form and manner accessible to residents and visitors, and failed to post the name, address and phone number for the Long-Term Care Ombudsman and resident rights on the secured unit. The facility census was 58. Review of the facility's Resident Rights policy, undated, showed: -The resident has a right to a dignified existence, self-determination and communication with and access to persons and services inside and outside the facility; -Public information will be displayed throughout common areas of the facility, including Area Agency on Aging Posters, Resident Rights Universal Language, Picture Posters, and any other pertinent information obtained through Area Agency of Aging or local Ombudsman. Observation on 2/21/23 at 11:43 A.M., showed the facility did not post the name, address, and toll free telephone number for the Adult Abuse and Neglect Hotline in an accessible location for residents or visitors to use if needed or post the name, address and phone number for the Long-Term Care Ombudsman and resident rights in a form and manner accessible to the residents and visitors on the secured unit. Observation on 2/22/23 at 9:05 A.M., showed the facility did not post the name, address, and toll free telephone number for the Adult Abuse and Neglect Hotline in an accessible location for residents or visitors to use if needed or post the name, address and phone number for the Long-Term Care Ombudsman and resident rights in a form and manner accessible to the residents and visitors on the secured unit. Observation on 2/23/23 at 9:16 A.M., showed the facility did not post the name, address, and toll free telephone number for the Adult Abuse and Neglect Hotline in an accessible location for residents or visitors to use if needed or post the name, address and phone number for the Long-Term Care Ombudsman and resident rights in a form and manner accessible to the residents and visitors on the secured unit. Observation on 2/24/23 at 9:10 A.M., showed the facility did not post the name, address, and toll free telephone number for the Adult Abuse and Neglect Hotline in an accessible location for residents or visitors to use if needed or post the name, address and phone number for the Long-Term Care Ombudsman and resident rights in a form and manner accessible to the residents and visitors on the secured unit. During an interview on 2/23/23 at 2:45 P.M., Licensed Practical Nurse (LPN) M said the DHSS hotline number and ombudsman information is posted by the television on the secured unit. The LPN said if residents have issues or concerns they can ask staff for the numbers if not posted. He/She said residents can not call the abuse hotline and ombudsman anonymously if the numbers are not posted. During an interview on 2/23/23 at 2:46 P.M., Housekeeper N said the required postings were not in an area easily accessible to the residents. During an interview on 2/24/23 at 10:17 A.M., the Administrator said the information should be posted in high visibility areas and it should be posted on the secured unit. The Administrator said he/she didn't know the information was not posted. He/She said residents should have access to the information. During an interview on 2/24/23 at 10:50 A.M., the Director of Nursing (DON) said resident rights and other information is posted by the time clock. The DON said he/she did not think the information needed to be posted on the secure unit because it is posted by the main entrance, but it should probably be back there.

Based on observation, interview, and record review, the facility failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing disease such as Coronavirus Disease 2019 (COVID-19), when staff failed to wear facemasks appropriately while in the facility. The facility census was 54. 1. Review of the facility's Interim Guidance: Use and Maintenance of Face Masks policy, dated September 2021, showed it directs staff that a surgical mask must be applied upon entering the building and during work hours. Additional review showed it directs staff the appropriate way to wear a mask, effectively, is to ensure the mouth and nose remain covered by the mask. Observation on 5/22/22 at 8:35 A.M., showed Certified Nurse Assistant (CNA) A at the nurses station without a face mask on. Additional observation showed residents within six feet of him/her. Observation on 5/22/22 at 8:36 A.M., showed CNA B at the nurses station without a face mask on. Additional observation showed residents within six feet of him/her. Observation on 5/22/22 at 8:45 A.M., showed Licensed Practical Nurse (LPN) C walk through the hallway where several residents were and within 6 feet of him/her without a face mask on. Observation on 5/22/22 at 9:00 A.M., showed Certified Med Tech (CMT) D and Activity Director (AD) E at the medication cart within 6 feet of each other and residents. The AD and CMT did not have a face mask on. Observation on 5/22/22 at 9:06 A.M., showed CNA B walk through the hallway, with residents within 6 feet of him/her, with his/her mask down under his/her nose. During an interview on 5/22/22 at 9:13 A.M., LPN C said he/she just didn't put a mask on when he/she arrived and was not leading by example. He/She said he/she can't really expect his/her staff to have masks on if he/she didn't have one on. LPN C said staff are directed to wear masks and wear them in resident care areas and should have them donned to ensure they cover both their nose and their mouths. During an interview on 5/22/22 at 9:55 A.M., CNA A said he/she came in for his/her shift this morning and forgot to put a mask. During an interview on 5/22/22 at 11:00 A.M., the Administrator said he/she expects staff to have their masks on and they should have them on appropriately to cover both their nose and mouths. MO00201265

Based on observation, interview, and record review, facility staff failed to prevent the spread of bacteria and other infectious causing contaminants during the provision of care for two residents (Resident #2 and Resident #1), when staff failed to perform hand hygiene between glove changes and failed to sanitize equipment after resident use. Additionally, staff failed to implement infection control measures related to COVID-19, when staff failed to properly wear personal protective equipment (PPE). The facility census was 62. Review of a facility training record, undated, showed staff were instructed as follows: -Gloves are worn if there is potential contact with bodily fluids or blood, mucous membranes, or intact skin; -Gloves are to be removed after contact with any of the things listed above; -And gloves are changed and hand hygiene is performed before moving from a contaminated body site to a clean body site during resident care. Review of the facility's, Hydraulic Lift (Hoyer Lift) (a mechanical lift used to transfer residents who are unable to transfer themselves) Cleaning Policy, dated 03/13/20, showed staff are directed to clean the lift after every use, with the minimal 60% alcohol wipes or bleach wipes for 60 seconds. 1. Observation on 6/1/2020 at 10:15 A.M., showed Licensed Practical Nurse (LPN) A complete a glucose (blood sugar) check on Resident #2 in his/her room. Further observation showed LPN A returned to the medication cart, removed his/her contaminated gloves and applied a pair of new gloves, without first performing hand hygiene. Observation on 6/1/20 at 10:34 A.M., showed Resident #1 was incontinent of fecal matter. Certified Medical Assistant (CMA) D entered the resident's room to provide incontinence care. CMA D wiped the resident's buttocks, removed his/her gloves, and applied a new pair of gloves, without first performing hand hygiene. Additionally, the observation showed CMA D touched the resident's clean brief, bed controls, and the resident's call light before he/she performed hand hygiene. Observation on 6/1/20 at 10:50 A.M., showed CMA D removed the Hoyer lift from Resident #1's room after he/she transferred the resident. He/She did not sanitize the Hoyer Lift after he/she removed it from the resident's room. During an interview on 6/1/20 at 10:02 A.M., Certified Nursing Assistant (CNA) C said staff are to utilize gloves when providing resident care and are required to wash hands when they remove their gloves. Furthermore, he/she said staff are to remove their gloves, perform hand hygiene, and apply new gloves after touching anything dirty. During an interview on 6/1/20 at 10:50 A.M., CMA D said he/she realized he/she did not wash his/her hands between glove changes. He/She said staff are required to wash hands when entering the resident's room and before putting on gloves. He/she also said, staff are to remove gloves, wash hands, and apply new gloves when going from a dirty to clean area, during incontinence care, or other cares. Additionally, he/she said the Hoyer Lift is to be cleaned after each use. During an interview on 6/1/20 at 10:59 A.M., CNA F said staff are to wash hands after entering the resident's room and before they apply gloves. He/She said if the staff member touches anything dirty they should remove their gloves, wash hands, and apply new gloves, before moving to another area on the resident. During an interview on 6/1/20 at 11:12 A.M., Registered Nurse (RN) E said staff are to wash hands when they enter and before they exit a resident's room. Additionally, he/she said the staff are to perform hand hygiene between dirty and clean procedures. During an interview on 6/1/20 at 11:26 A.M., LPN A said staff are to wash hands before and after providing care, as well as, wash hands when gloves get dirty, or come into contact with bodily fluids. Additionally, he/she said staff are to change gloves and perform hand hygiene when going to different areas of the resident's body. 2. Review of a facility in-service training record, dated 4/20/20, showed staff were instructed that wearing a face mask was mandatory, and they had to wear one at all times. The Centers for Disease Control and Prevention (CDC) guidance, Preparing for COVID-19 in Nursing Homes, updated 5/19/20, showed core practices included implementing source control measures (actions taken in the process of care to help stop the spread of infection) as follows: -Health Care Professionals (HCP) should wear a facemask at all times while they are in the facility; -When available, facemasks are generally preferred over cloth face coverings for HCP, as facemasks offer both source control and protection for the wearer against exposure to splashes and sprays of infectious material from others. Guidance on extended use and reuse of facemasks is available. Cloth face coverings should NOT be worn by HCP instead of a respirator or facemask if PPE is required. The CDC guidance, How to Wear Cloth Face Coverings, reviewed 5/22/20, showed to wear a face covering correctly one should: -Wash their hands before putting on the face covering; -Put it over their nose and mouth and secure it under their chin; -Try to fit it snuggly against the sides of their face; -And make sure they can breathe easily. Observation on 6/1/20 at 11:00 A.M., showed the Dietary Manager (DM) wear a cloth face mask during an interview. His/Her cloth mask was positioned below his/her nose. Observation on 6/1/20 at 11:40 A.M., showed the DM speak to several residents, as well as, give drinks to the residents in the dining area. He/She wore his/her cloth face mask below his/her nose. During an interview on 6/1/20 at 3:34 P.M., and 6/2/20 at 9:11 A.M., the Administrator said she expected staff to wear a mask properly, and ensure it is over their nose. Furthermore, she said she expected staff to sanitize the Hoyer Lift with bleach wipes between uses.

Based on interview and record review, facility staff failed to seek alternate facility placement, failed to make home health arrangements, and failed to ensure one dependent resident (Resident #1) was discharged to a safe and appropriate location. Facility staff dropped the resident off at his/her home on 3/10/14, knowing the resident's spouse was not physically capable to care for the resident and without making arrangements for in-home care and services. The facility census was 80. 1. Record review of Resident #1's face sheet showed he/she was admitted to the facility on [DATE]. Record review of the resident's physician's orders [REDACTED]. Record review of the resident's comprehensive Minimum Data Set (MDS), a federally mandated assessment instrument, dated 8/30/13, showed staff assessed the resident as follows: -Moderately impaired cognitive skills for daily decision-making; -Required extensive assistance of two people for bed mobility, transfers, dressing, toileting, and personal hygiene; -Required extensive assistance of one person with eating; -The MDS did not include information regarding chewing or swallowing problems or that staff provided a pureed diet. Record review of the resident's comprehensive plan of care, dated 8/30/13, showed the plan instructed staff to: -Assist with all transfers; -Assist with dressing; -Assist with Activities of Daily Living (ADLs); -Provide oral hygiene at least daily; -Provide toileting every two hours and as needed; -Turn and reposition every two hours and as needed; -Provide incontinence care after each incontinent episode; -The plan of care did not provide information directing staff to provide a pureed diet or information regarding any chewing/swallowing problems. Record review of a written 30 day discharge notice issued to the resident's spouse, dated 11/27/13, showed staff issued a 30 day discharge notice for failure to pay the facility for the resident's care. The notice stated the facility would discharge the resident to the spouse in their home on 12/30/13. The notice stated the facility staff "would be willing" to contact other facilities regarding placement, but stated the other facilities "will not be interested" in accepting the resident when they found out the reason for discharge was for non-payment. Review of the letter showed the facility provided a carbon copy (cc) of the letter to the "regional ombudsman." During an interview on 3/14/14 at 10:50 A.M., the Regional Ombudsman said the facility did send a copy of the discharge notice, but the resident's spouse did not contact them for assistance so they did not get involved. Record review of a letter addressed to the resident's spouse from the Administrator, dated 1/16/14, showed the Administrator documented in the letter "after speaking to you, it became evident that you are not physically able to provide the care that is needed" for the resident. Additionally, the Administrator documented that it was "not feasible to transfer the resident to another facility because they will not take someone when they are not paying in their current facility." Record review of a second written 30 day discharge notice issued to the resident's spouse, dated 2/4/14, showed staff documented the reason for the discharge was due to lack of payment for room and board and nursing services. Staff documented "they could discharge" the resident to the spouse "regardless of your ability or inability to care" for the resident. Staff documented they would "be willing to take all the necessary steps to assist in discharge to your home." The notice stated staff would "be willing" to contact other facilities regarding placement, but stated the other facilities "will not be interested" in accepting the resident when they found out the reason for discharge was for nonpayment. Record review of the resident's POS, dated 3/1/14-3/31/14, showed [DIAGNOSES REDACTED]. The POS showed no diet order. Additionally, the POS showed the resident's physician directed staff to administer the following medications, including but not limited to: -[MEDICATION NAME] (an anticoagulant) 4 milligrams (mg) by mouth once daily for [MEDICAL CONDITION]; -[MEDICATION NAME] (an anti-depressant) 20 mg by mouth once daily for depression; -[MEDICATION NAME] (an anti-psychotic) 0.5 mg by mouth twice daily for mood disorder; -[MEDICATION NAME] .025 mg three tablets by mouth at bedtime for mood disorder. During an interview on 3/14/14 at 1:15 P.M., Licensed Practical Nurse (LPN) B said they provided the resident a pureed diet due to swallowing problems. Further review of the resident's POS, dated 3/1/14-3/31/14, showed the resident's physician directed staff to obtain a weekly [MEDICATION NAME] Time (PT/INR) test (a blood test to determine clotting time for patients on anticoagulants). Record review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, dated 3/2/14, showed staff assessed the resident as follows: -Severely impaired cognitive skills for daily decision-making; -Required extensive assistance of two people with bed mobility, transfers, dressing, toileting, and personal hygiene; -Required extensive assistance of one person with eating; -The MDS did not include information regarding chewing or swallowing problems or that staff provided a pureed diet; -There was not an active discharge plan in place for the resident to return to the community; -No referrals were made to the local contact agency regarding returning to the community. Record review of the resident's PT/INR results, dated 3/7/14, showed the INR result was 1.61. Further review showed the reference range for treatment of [REDACTED]. Record review of the resident's POS, dated 3/10/14, showed staff recorded a telephone order from Physician A to discharge the resident with his/her medications to his/her home. The order did not include direction to arrange home health or in-home services. Record review of the resident's medications list the administrator gave to the resident's spouse upon discharge on 3/10/14, undated, showed staff did not include any instructions or dosages for administering the medications. The list did not include directions for checking the resident's PT/INR or any follow-up with the resident's physician. During an interview on 3/13/14 at 9:30 A.M., a Division of Senior and Disability Services (DSDS) worker said the resident's spouse was not capable of caring for the resident. The DSDS worker said an ambulance was called to the home on 3/12/14 and transported the resident to a local emergency room . When the ambulance got to the home, they found the resident with an incontinence pad attached with electrical tape to contain his/her incontinence. It appeared this had not been changed since 3/10/14. When they asked the resident's spouse when the resident last had food or fluids, the spouse could not answer. During an interview on 3/13/14 at 1:00 P.M., the Administrator said she discharged the resident for non-payment on 3/10/14 to the resident's spouse, who could not care for him/her. She said she did not provide any discharge planning for the resident, including written discharge instructions, to the resident's spouse. The Administrator said when she dropped the resident off at the home, the resident's spouse was "more concerned about the dog" than the resident. The Administrator said the house was dirty, and the resident's spouse was a "hoarder." The Administrator said she did not contact home health to set up in-home services for the resident because the resident "was not appropriate to be in the home" and he/she required "round the clock care." The Administrator also said the resident's spouse could have arranged home health services because he/she "knew about the discharge for over a month." The Administrator said she did not attempt to have durable medical equipment set up in the home. The Administrator said she did not make any attempts to contact any other facilities to try to find alternative placement for the resident because "no one would take someone who is not paying their bill." The Administrator said she only provided verbal instructions to the resident's spouse. The Administrator said she told the resident's spouse how the resident should be positioned in bed, that he/she needed repositioning several times a day, and he/she needed toileting several times a day. The Administer told the resident's spouse he/she would need to blend the resident's food to a pureed consistency or give him/her baby food. The Administrator said she provided a list of the resident's medications to the resident's spouse along with the resident's medications, but she did not include instructions on how to administer the medications. The Administrator said she did not send the resident's psychiatric medications home with him/her. The Administrator said she called "family services" after she dropped the resident off at his/her home, and told the worker that the resident would need to be "looked in on" because the resident's spouse could not take care of the resident. During an interview on 3/13/14 at 1:29 P.M., the Social Service Director (SSD) said it would have been appropriate for the resident to be discharged to the home if he/she "had the appropriate people at home to care" for him/her. The SSD said the nurses usually did the discharge planning. The SSD said she contacts home health to set up services if there is a physician's orders [REDACTED]. The SSD said there was not a physician's orders [REDACTED]. The SSD said she did not make any attempts to contact other facilities for placement for this resident because they would not accept residents who were discharged for non-payment. The SSD said she initially helped the resident's spouse fill out the Medicaid application, but she did not assist with any other paperwork. The SSD said she later found out the resident's spouse did not submit the follow-up paperwork to Medicaid. During an interview on 3/13/14 at 4:00 P.M., emergency room Registered Nurse caring for the resident when the resident arrived on 3/12/14, said the resident was "saturated" in urine and had a "strong odor." The resident had dry lips and "seemed dehydrated." He/She said they administered intravenous fluids. Record review of a hospital note, dated 3/12/14 at 5:50 P.M., showed staff assessed the resident arrived saturated in urine with a "strong ammonia smell." The resident's incontinence brief was "held together with electrical tape." Staff assessed the resident had a "dime sized area of redness to the right buttocks." Further, hospital staff documented if the resident was discharged from the hospital "it is unsafe for patient to return home." During an interview on 3/14/14 at 1:00 P.M., the Administrator said she did not know the resident's spouse was incapable of caring for the resident until she dropped the resident off at home on 3/10/14, which is why she contacted DSDS. However, record review of a letter addressed to the resident's spouse from the Administrator, dated 1/16/14, showed the Administrator documented in the letter "after speaking to you, it became evident that you are not physically able to provide the care that is needed" for the resident. In addition, review of a second written 30 day discharge notice issued to the resident's spouse, dated 2/4/14, showed the administrator documented "they could discharge" the resident to the spouse "regardless of your ability or inability to care" for the resident. During an interview on 3/14/14 at 1:40 P.M., the DSDS worker said he/she found placement for the resident at another facility and made arrangements for payment through Medicaid for the resident's stay. He/she received a "frantic" call from the other facility asking where the resident's facility documentation was because they had not received it. The SSD at Maries Manor said she could not fax the resident's record because it was "locked up." The DSDS worker said it was another hour later before the facility staff finally faxed the information, and when they did it was not the current record of medications and physician's orders [REDACTED]." The DSDS said he/she "felt" the facility Administrator tried to "block" the resident's admission to another facility. The DSDS worker also said the reason the resident's Medicaid application was denied, was due to noncompliance with requested information. He/she said the resident's spouse is incapable of understanding what that would mean. The DSDS worker said the Public Administrator would become the resident's guardian due to the resident's spouse's inability to make good decisions for the resident. During an interview on 3/18/14 at 3:01 P.M., Physician A said staff did not tell him the reason for the resident's discharge. Physician A said had he known the facility was discharging the resident for non-payment, he would not have issued the order to discharge him/her to the home. Additionally, Physician A said he would not have issued the discharge order had he known the resident was going to be discharged to a spouse who was incapable of caring for him/her. During an interview on 3/18/14 at 3:10 P.M., the resident's spouse said he/she did not know how to care for the resident when he/she arrived home. The resident's spouse said he/she could not turn the resident by himself/herself, so the resident stayed in bed the entire time he/she was home. The resident's spouse said the facility did not provide any written discharge instructions. He/She said the facility did not help find alternative facility placement or set up any in-home services for the resident. Additionally, the resident's spouse said he/she wanted to visit the resident during his/her stay at the facility, however, he/she stopped visiting because he/she did not want to "get into a fight with the people in the office" regarding the outstanding bill. During an interview on 3/25/14 at 10:16 A.M., the Administrator at the accepting facility said the administrator at Maries Manor called him/her because she wanted to let him/her know that they had problems collecting on outstanding bill from the resident. MO 429

At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level "J." A monitoring visit was completed on April 2, 2014. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at this time. The facility implemented changes including inservicing staff on proper discharge planning, including a home assessment in which staff or a designee visits the home to ensure it is an appropriate placement for the resident, notifying the physician of the discharge and reason for discharge, arranging home health services, assessing the need for durable medical equipment, and educating the caregiver or resident on medications, treatments, and diet. Staff were continuing to provide inservice training regarding discharge planning at the time of the revisit. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. The severity of the deficiency was lowered to a "D" level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violations.

Based on observation, interview, and record review, facility staff failed to provide appropriate care and services to prevent and treat facility acquired pressure ulcers for two residents (Resident #1 and #3) out of three sampled residents. For Resident #1, facility staff failed to prevent the development of an unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, or brown) and/or eschar (tan, brown, or black) in the wound bed) on the left heel, and a stage IV (full thickness tissue loss with exposed bone, tendon or muscle, including possible slough or eschar present on some parts of the wound bed) coccyx (tailbone) wound infected [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus -a bacteria that is resistant to certain antibiotics). Staff failed to provide weekly skin assessments to monitor potential problem areas or detect areas of altered skin integrity before they worsened, failed to document an initial wound assessment of the resident's left heel wound, and failed to apply heel boots and a pressure reducing pad in the resident's wheelchair as directed by facility policy and the resident's plan of care until after the pressure ulcers developed. Additionally, staff failed to update the resident's care plan with new interventions to treat and promote healing of the resident's wounds. For resident # 3 staff failed to provide appropriate care and services to prevent and treat three unstageable pressure ulcers. Facility staff failed to apply heel boots as directed by care plan, failed ensure resident was on air mattress as directed by their policy after he/she developed unstageable pressure ulcers, and failed to ensure the resident's dressing did not become wet during a shower that resulted in a macerated (softening and breaking down of skin resulting from prolonged exposure to moisture) wound. The facility census was 75. 1. Review of the facility's Guidelines for the Assessment and Documentation of Skin (wound) Issues, undated, showed staff were directed to: - Charge Nurse: Initially (following report of the wound) assess the reported skin issue and document the condition of the wound, sizing, color, drainage etc. in the nurses notes, the weekly non-decubitus skin assessment, or the dermal wound assessment. Notify the doctor for treatment orders. Notify the family/DPOA of the wounds. (Documentation is necessary as soon as the wounds are identified); - Weekly Skin Assessment: Completed and documented on the Non-decubitus skin condition weekly assessment (bruises, scratches etc) or the Dermal Wound Assessment Form (open wounds etc.). This assessment can be completed by the charge nurse, the night charge nurse, a wound assessment nurse, the Director of Nursing (DON) etc. 2. Review of the facility's Pressure Sores/Wound Assessment for Compliance of F314, undated, showed direction for staff to complete the following: - When a potential pressure sore develops, all stages, the following must immediately be initiated (if unable to obtain orders, then comment in nursing notes, need to address request for the order was refused at this time--- need to reassess every two to four weeks); - Special Pressure Relieving Mattress: Rent an Air Bed if a stage III (full thickness tissue loss) or stage IV (Full thickness tissue loss with exposed bone, tendon or muscle). Document every week that the mattress is in use. Record the type of mattress used. Every resident with a pressure sore MUST be on a special mattress unless approval by the QA nurse; - Wheelchair and Chair Pad: Apply a pressure relieving or gel pad for every pressure sore on the buttocks, coccyx, etc. Document every week that the pad is in use; - Booties/Moon Boots: Apply for all residents with ankle, foot, heel or leg ulcer areas (whether pressure or stasis). These boots need to be on 100% of the time in the bed and when up unless walking. The wheelchair foot pedals need to be padded, preferably with the "L" shaped padded foot rest. Assess for the need for a cradle to raise th blanket weight. Document weekly concerning the boots and the padded wheelchair legs/footrest; - Care Plan: Need to address every pressure or potential pressure area. The treatments on this list all need to be recorded, or noted that physician refused a treatment request at this time. The care plan needs to address location and treatment changes. The care plan information must be conveyed to the nurse aides on all shifts through oral or written documentation (all aides must have the information and be able to address). The care plans must be individualized and changed every time an order changes; - Treatment Order: Follow orders. If the pressure sore declines over two weeks, the treatment is no longer effective. If infection or necrotic tissue develops then orders are needed to address the decline. The order needs to be written on the doctor's orders and recorded on the treatment record (exactly as written). 3. Review of the facility's Wound Care Protocol, dated 2009, showed staff were directed to: - Evaluate the need for a pressure reduction surface for bed and/or chair, as well as the need for heel/elbow protectors or specialized protection; - Educate residents, families, friends and staff on interventions (such as weight shifting in bed or chair) to prevent skin breakdown. 4. Review of Resident #1's Braden scale assessment form showed staff assessed the resident on 5/3/13 with a score of 17, which according to facility policy is considered "at risk" for skin breakdown. Review of the resident's Physician order [REDACTED]. Review of the resident's Treatment Administration Record (TAR) showed: - From 5/3/13 to 5/31/13, staff documented they did a weekly skin assessment on 5/6/13, 5/13/13, and 5/30/13. Staff did not document they performed a weekly skin assessment as ordered by the physician, between 5/13/13 and 5/30/13, or 17 days. Review of the resident's Minimum Data Set (MDS), a federally mandated assessment instrument, dated 5/16/13, showed staff assessed the resident as follows: - Long and short term memory problem; - Moderately impaired cognitive skills for daily decision making; - Required limited assistance of two plus persons physically assist for bed mobility; - Required extensive assistance of two plus persons physically assist with transfers, dressing and personal hygiene; - Frequently incontinent of urine, occasionally incontinent of bowel; - No pressure ulcers. Review of the resident's plan of care, dated 5/16/13, showed staff documented the resident was at risk for developing pressure ulcers related to poor mobility, and staff planned the following interventions: - Conduct a systematic skin inspection weekly. Pay particular attention to the bony prominences; - Help to turn and reposition every two hours and as needed; - Keep bony prominences from direct contact with one another with pillows, foam wedges, etc.; - Keep clean and dry as possible. Minimize skin exposure to moisture; - Maintain the head of the bed at the lowest degree elevation possible; - Report any signs of skin breakdown (sore, tender, red, or broken areas); - Use a cushion for pressure reduction when in chair; - Use heel protectors to relieve pressure on the heels; - Use moisture barrier product to perineal area. Review of the resident's Treatment Administration Record (TAR) showed: - On 5/30/13, staff documented "Coccyx red. Zinc applied"; - Staff did not document they performed a weekly skin assessment as ordered by the physician, from 6/5/13 to 6/17/13, or 12 days, to monitor for improvement or decline of the area. Review of the resident's nurses' notes showed the licensed staff documented the following: - 7/14/13 2:57 P.M. Noted 1 centimeter (cm) by 1 cm purple area to coccyx and 2 cm by 2 cm red area around purple area. Also noted very prominent coccyx which sticks off buttocks. Cushion changed to chair and barrier applied to coccyx, turned side to side. Physician notified of area. No new orders; - 7/15/13 (6:00 A.M. to 2:00 P.M.) Resident noted to have open area to coccyx. Area is black and skin surrounding very red. Will use [MEDICATION NAME] (an adherent wound dressing), change every three days until healed. Resident has pressure relieving cushion in wheelchair. Review of the resident's wound report showed staff first documented the following: - 7/15/13 New unstageable coccyx wound. Wound type: pressure ulcer/other. Initial cause: pressure/trauma? "from fall onto buttocks"/moisture. Acquired in house, 7/15/13. Measures 1 cm by 0.7 cm by 0 cm. Tissue type: closed, necrotic (eschar). No exudate (drainage). Area is dark purplish black color with reddened skin around. Possible deep tissue trauma (has dark purple color). Likes to sit up in wheelchair all the time. Encourage resident to turn from side to side. Gel cushion. Area cleansed and apply [MEDICATION NAME] to coccyx, then apply calmo (barrier cream) or protective barrier cream to other areas as needed. Review of the resident's Physician order [REDACTED]. Review of the resident's nurses' notes and wound reports dated 7/15-7/19/13 showed staff did not document an assessment of the resident's left heel. Review of the resident's POS, dated 7/19/13, showed the resident's physician directed staff to insert a Foley catheter (tube used to drain urine from the bladder) due to wound on coccyx; apply skin prep (a protective barrier wipe) to left heel and wrap with gauze; apply heel protectors when in bed; discontinue [MEDICATION NAME] and change treatment to [MEDICATION NAME] (a foam wound dressing) change every three days and as needed. Review of the resident's nurses' notes, dated 7/19/13 (no time), showed staff documented, "New orders received from the resident's physician per pharmacy recommendation; 7:00 P.M., Foley catheter inserted using sterile technique." Review of the resident's wound report, dated 7/22/13, showed staff documented the unstageable coccyx wound was healing. Wound type: pressure ulcer/other. Initial cause: pressure ulcer/trauma/"infection?" Acquired in house, 7/19/13. Measures 1 cm by 0.5 cm by 0 cm. Tissue type: necrotic (eschar). Area appears to be possible bruising and looks to be fading. Will continue to monitor. Continue to apply [MEDICATION NAME] to coccyx, change every three days and as needed. Staff did not record an assessment of the resident's left heel to show ongoing monitoring for improvement or decline of the area. Review of the resident's nurses' notes, dated 7/25/13 4:12 A.M., showed staff document the resident's coccyx wound was black. Measures 2.8 cm by 3 cm with odorous, brownish-yellow drainage. Physician faxed and awaiting orders. Treatment done. Culture obtained for possible order. Repositioned side to side every two hours during the night to relieve pressure. Pressure relieving boots bilaterally. Left heel remains slightly boggy but treatment in place in addition to boots. Dependent for wheelchair mobility and activities of daily living (ADLs). Review of the resident's POS, dated 7/25/13, showed the physician directed staff to apply Santyl (a wound dressing used to remove necrotic (dead) tissue) to black eschar (thick, black, leathery, necrotic tissue) on coccyx, surround with zinc oxide (a barrier cream) then cover with [MEDICATION NAME]. Review of the resident's wound report, dated 7/29/13, showed staff documented the unstageable coccyx wound was "deteriorating". Wound type: pressure ulcer/other. Initial cause: pressure/stasis/trauma/decline. Acquired in house 7/19/13. Measures 3.5 cm by 1.5 cm by 0 cm. Tissue type: slough (non-adherent), necrotic (eschar). Wound base red. Purulent (pus) drainage. Very foul odor. Blood cultures ordered. Area covered with yellow slough and has small necrotic area at distal edge of wound, with copious amounts of foul drainage and a greenish/purulent discharge. Dressing order changed to [MEDICATION NAME] over the weekend, and due to decline, change order again to cleanse area, then apply santyl, cover with dry gauze and secure with border gauze dressing. Change twice a day and as needed. Ordering air mattress and wound clinic order. - In house acquired unstageable left heel wound, onset date 7/22/13, status unchanged. Wound type: pressure ulcer/other. Last measurement 0.8 cm by 0.5 cm by 0 cm. New measurement 1.5 cm by 0.7 cm by 0 cm. Initial stage: necrotic/no stage. Initial cause: pressure/stasis/trauma/failure to thrive/poor circulation. Note hard black area with some redness. Appears to be improving. Continue with skin prep three times a day and as needed to area. Heel protectors on at all times. Frequent position changes. Review of the resident's nurses' notes, dated 7/29/13 (No time recorded), showed staff documented they notified the resident's physician of wound condition to coccyx and feet and new orders obtained. Review of the resident's POS, dated 7/29/13, showed new orders for a wound consult at wound clinic; culture and sensitivity of wound; wound treatment changed to black eschar on coccyx, apply Santyl with zinc oxide then cover with border gauze twice daily. Review of the resident's Treatment Administration Record (TAR) showed on 7/30/13 staff did not document they performed the coccyx wound treatment twice a day as ordered. Review of the resident's nurses' notes, dated 7/30/13 (10:00 P.M. to 6:00 A.M.), showed staff documented they changed the dressing to coccyx per physician orders. Old dressing with yellow drainage and odor. Turn every two hours in bed. First one laid down, and last one up to reduce pressure to coccyx while up in wheelchair. Dressing clean dry and intact to left heel. Lab results ordered by physician received and faxed 7/31/13 at 4:20 A.M.; - 8/2/13 2:30 P.M. Order received for antibiotic for ten days; Review of the resident's plan of care showed staff did not update it to include treatments or new interventions to address the resident's unstageable pressure sores on the coccyx or the left heel, as directed by facility policy. Review of the resident's nurses' notes, showed staff documented the following: - 8/4/13 at 2:24 P.M., completed the treatment to buttocks with measurements of 3 cm in width and 3.5 cm in length, with a depth of 2 cm and 0.4 cm tunneling (a passageway of tissue destruction under the skin surface) upwards, and 2 cm tunneling to right side. Necrotic tissue to center of wound and noted brownish green drainage; - 8/5/13 12:11 P.M. Resident has a "decubitus ulcer" (pressure ulcer) on his/her coccyx with yellowish green drainage and foul odor. Continue on antibiotics for wound infection. Santyl applied to wound bed and slough (necrotic tissue that is usually light colored, soft, and moist) is starting to come off, and wound is approximately 2 cm deep. Turned and repositioned every two hours and lays on a "wound mattress to help heel wound." Heel protectors intact; Review of the resident's wound report, dated 8/5/13, showed staff documented the following: - Deteriorating unstageable coccyx wound. Wound type: pressure ulcer/other. Initial cause: pressure/stasis/trauma/failure to thrive. Moderate heavy exudate. Tissue type: slough (non-adherent), necrotic (eschar). Wound color base: yellow, some black. Purulent drainage. Area is red and open with slough and necrotic area, purulent drainage with odor. Drainage is brownish-green. Area cleansed with wound cleanser then apply santyl to area and cover with dry dressing and secure with border gauze. Wound continues to decline despite frequent repositioning, low air loss mattress, gel cushion to wheelchair, and antibiotics for infection to coccyx. Air mattress to bed 7/31/13. To wound clinic 8/6/13. - In house acquired unstageable left heel wound, status deteriorated. Wound type: pressure ulcer/other. Measures 2.2 cm by 0.9 cm by 0 cm. Area is dark purple to black with no odor, drainage or signs of pain. Note legs cool to touch. Area cleansed then apply skin prep three times a day and as needed. Heel protectors on at all times. Review of the resident's nurses' notes, dated 8/6/13 at 12:04 P.M., showed staff documented they sent the resident to the wound care clinic. Call received stating they are admitting the resident to the hospital for wound treatment. Review of the resident's Wound Clinic notes, dated 8/6/13, showed the wound clinic staff documented: - Coccyx pressure ulcer, acquired 5/14/13. Stage IV, with undermining (underlying tissue damage extends underneath the skin border of the wound), large, foul, purulent exudate with a strong odor. Measures 2.6 cm by 3.3 cm by 2.4 cm deep. 76-100% slough. Bone exposed, suspected osteo[DIAGNOSES REDACTED] (infection of the bone). Review of the resident's hospital progress notes, dated 8/7/13 at 8:35 A.M., showed the plastic surgeon documented the following: - Approximately 2-3 cm Sacrococcygeal pressure sore; - Some necrotic tissue; - Undermines several centimeters on each side. Observation on 8/7/13 at 9:50 A.M., showed the resident lay in bed at the hospital on his/her right side. Registered Nurse (RN) F said wound culture results showed an infection [MEDICAL CONDITIONS]. He/she removed the old dressing and discarded it. The wound was approximately 2 cm by 3 cm round, and approximately 2 cm deep. The wound base was mostly covered with grayish/yellow slough, with some pink/red tissue visible. As RN F applied the ordered treatment, the resident voiced discomfort. During an interview on 8/7/13 at 10:02 A. M., Wound Center Nurse G said when the resident arrived to the wound center, the wound was filled with necrotic tissue. He/she did not feel the wound could have developed "overnight," but sometimes they develop under the skin. The resident had one black spot on the heel. During an interview on 8/7/13 at 2:27 P.M., Nurse assistant (NA) A said: - Before the resident developed the pressure sore, staff turned him/her in bed every two hours, checked for incontinence, and applied a barrier cream after perineal care; - Not until after the resident's skin broke down did staff utilize a wedge cushion to position the resident on his/her side, used a pressure reducing pillow in the chair and bed, removed the brief when in bed, and assisted the resident up last to meals; - The resident was typically not up "that long" in the wheelchair; - When the resident's wound worsened, staff repositioned the resident in his/her wheelchair every two hours or if complained of pain on his/her backside. If repositioning did not help, staff assisted the resident to bed. During an interview on 8/7/13 at 2:45 P.M. Licensed Practical Nurse (LPN) B said: - Weekly skin assessments are to be a full head to toe assessment, looking for open areas, bruising, [MEDICAL CONDITION], etc. If there are no skin issues noted, staff document "no concerns" on the back of the TAR; - Staff notify the DON (Director of Nursing) if they find a wound; - The DON does a wound assessment, notifies the resident's physician, decides on a treatment, updates the resident's care plan, and gets the dietitian involved; - Before the resident developed the coccyx wound, staff applied barrier cream after perineal care, turned and repositioned the resident in bed, and laid the resident down after meals; - After the resident developed the coccyx wound, staff began assisting him/her up last and down to bed first, and kept the resident positioned off his/her bottom with a wedge cushion; - He/she expects the new care interventions to be updated on the resident's plan of care; - The resident's heels were soft and "mushy," and the resident wore heel protectors. During an interview on 8/7/13 at 3:00 P.M. the DON said: - Every resident is assigned a weekly skin assessment, to be performed and documented by the night shift nurse; - Weekly skin assessments are to be documented on the TAR; - Staff are directed to perform a full body skin assessment, looking at the condition of the skin, bruises, skin tears, scratching, etc. - Before the resident developed the unstageable pressure ulcer on his/her coccyx, staff turned and repositioned the resident, and provided personal hygiene. Staff also provided increased calories; - Staff did not place a pressure reducing pad in the resident's wheelchair initially, because the resident was more mobile and a fall risk. The resident did not sit "for hours" in the wheel chair. When staff noted a red area on his/her coccyx, the DON put a pressure reducing pad in the resident's wheelchair. When the wound worsened, the DON replaced the pad with one that "had to be ordered;" - He/she was first notified of the coccyx wound on 7/15/13. It was a dark area, and he/she thought it might be a bruise because the resident fell on his/her bottom. She did not feel it looked like a suspected deep tissue injury (purple or maroon localized are of discolored intact skin due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue.); - The wound was closed when staff applied the [MEDICATION NAME] treatment; - On 7/25/13, the "whole area" of the wound was covered in slough, there was "copious" drainage and an odor. She contacted the physician and obtained new orders; - The DON and the MDS Coordinator are to follow up to ensure wound information, including new interventions, are on the resident's care plan. During a telephone interview on 8/14/13 at 11:52 A.M., Certified Nurse Aide (CNA) E said: - The resident did not have a pressure reducing cushion in his/her wheelchair initially, and was in a "regular bed." The DON did not give the wheelchair cushion to the resident until after they noticed the spot on his/her coccyx; - He/she was the staff person that first noted a "little spot" that was not open on the resident's coccyx. He/she reported it to the nurse, who went to the DON. The DON obtained a special mattress; - The next time he/she saw the wound it was "worse", and he/she noticed a spot on the resident's heel; - Staff did not apply heel protectors on the resident before he/she obtained the heel wound; - If residents "stay in bed a lot" and "don't move a lot" he/she will check their heels; - Residents' care plans are in "books" but he/she does not remember to look at them. Information about the residents are passed on in report. During a telephone interview on 8/14/13 at 12:00 P.M. Licensed Practical Nurse (LPN) H said: - He/she first heard in report that the area "was red." When he/she first observed the wound a "couple days later", 7/15/13, it was not open, but it was black, and he/she could tell if they didn't "do something" it was going to open up. He/she applied [MEDICATION NAME], faxed the physician and followed the wound protocol. - The resident did not want to stay on his/her side at first, but after some encouragement, he/she agreed. 5. Review of the Resident # 3's admission skin assessment, dated 6/12/13, showed staff assessed the resident had no open areas or redness. Review of the resident's most recent Braden scale assessment, (to predict a person's risk of developing a pressure ulcer), dated 6/12/13, showed staff assessed the resident scored 19 (at low risk for developing a pressure ulcer). Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment tool used to plan care, dated 6/25/13 showed staff assessed the resident as follows: - Severely impaired cognitive skills for daily decision making; - Required extensive staff assistance for bed mobility, transfers, dressing, toilet use, locomotion, eating, and personal hygiene; - Always incontinent of bladder and occasionally incontinent of bowel; - At risk for pressure ulcers; - Did not have pressure ulcers; - diagnosed with [REDACTED]. . Review of the resident's care plan, dated 6/25/13, showed staff identified the resident was at risk for pressure ulcers related to poor mobility. Review showed staff planned the following interventions for the resident: - Conduct a systematic skin inspection weekly. Pay particular attention to bony prominences; - Help turn and reposition every two hours and as needed; - Keep clean and dry as possible. Minimize skin exposure to moisture; - Report any signs of breakdown (sore, tender, red, or broken areas); - Use a cushion for pressure reduction when in wheelchair; - Use heel protectors to relieve pressure on heels; - Use moisture barrier product to perineal area. Review of the resident's weekly skin assessments showed staff documented the following: - 7/2/13 - Skin intact; - 7/9/13 - Heels mushy/boggy, left greater than right. Moon boots (heel protectors) in place while in bed. Review of the resident's nurses' notes showed staff documented the following: - 7/9/13 at 4:41 A.M. - Left heel mushy, more so than right. Heel protectors on when in bed; - 7/9/13 Hospice Nurse note - Heels mushy, received orders to wrap heels daily in Kerlix (a roll of gauze). Ordered new bed for resident for skin protection; - 7/10/13 at 3:49 A.M. - Boggy heel. Right with more skin involvement than left. Moon boots (heel protectors) in place while in bed. Review of the resident's significant change MDS, dated [DATE] showed staff assessed the resident as follows: - Severely impaired cognitive skills for daily decision making; - Required extensive staff assistance for bed mobility, transfers, dressing, toilet use, locomotion, eating, and personal hygiene; - Always incontinent of bladder and occasionally incontinent of bowel; - At risk for pressure ulcers; - Did not have pressure ulcers; - diagnosed with [REDACTED]. - Received hospice (service to give supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life, rather than a cure). Review of the resident's weekly skin assessments, dated 7/14/13, showed staff documented the resident's heels were purple. Review showed staff documented the entire right heel was purple and mushy and the left heel had a 2.0 cm by 2.0 cm purple soft area. Review of the resident's nurse's note, dated 7/14/13, showed staff documented they reported to the physician that resident's bilateral heels were purple and mushy and they received orders to apply skin prep (a liquid that forms a protective film over skin), continue to wrap heels and use heel protectors. Review of the resident's care plan showed staff did not update the care plan to include interventions to address the resident's pressure ulcers found on 7/14/13. Review of the resident's wound assessment, dated 7/15/13, showed facility staff documented the following: - Wound # 1 was an unstageable pressure ulcer on the left heel acquired in the facility on 7/14/13. The wound measured 2.0 cm long by 2.0 cm wide, did not have depth, was red, soft and mushy, purple in color, and appeared to be forming a blister. The wound was caused from pressure, trauma, and a decline in condition. The wound had no drainage, had necrotic (dead) tissue, the wound base was black and the surrounding skin was red. Staff to apply skin prep and heel protectors, elevate legs off of bed and reposition frequently; - Wound # 2 was an unstageable pressure ulcer on the resident's right heel acquired in the facility on 7/14/13. The wound measured 2.0 cm long by 2.0 cm wide, did not have depth, was red, purple and soft. The wound was caused from pressure, trauma, and a decline in condition. The wound had no drainage, had necrotic tissue, the wound base was black and the surrounding skin was red. Staff to apply skin prep to heels three times daily (TID) and as needed, keep heel protectors on at all times and reposition frequently; - Wound # 3 was an unstageable pressure ulcer on the resident's coccyx (tailbone) acquired in the facility on 7/14/13. The wound measured 1.0 cm by 1.0 cm, did not have depth, and was red with a purple area in the center. The wound was caused from pressure, trauma, and a decline in condition. The wound had no drainage, had necrotic tissue, the wound base was black and the surrounding skin was red. Staff to turn and reposition frequently and apply protective barrier cream TID and as needed. Review of the resident's nurses' notes showed staff documented the following: - 7/17/13 - Hospice Nurse note - The resident did not have heel protectors on or Kerlix to the right heel because he/she just got a shower. The Kerlix on the resident's left heel was wet and caused the heel to be macerated. Heels look worse; - 7/20/13 - The resident yelled out when treatment done to bilateral heels; - 7/22/13 - The resident yelled out when staff provided wound care. Review of the resident's wound assessment, dated 7/22/13, showed facility staff documented the following: - Wound # 1 was an unstageable pressure ulcer on the left heel acquired in the facility on 7/14/13. The wound measured 2.0 cm long by 2.0 cm wide, did not have depth, was dark purple and firm and remained closed. The wound was caused from pressure, stasis (a state in which the normal flow of a body liquid stops), trauma, and other. The wound had no drainage, had necrotic tissue, the wound base was black and the surrounding skin was red. Staff to apply skin prep frequently, change positions frequently, ensure heel protectors on at all times and elevate legs off of bed; - Wound # 2 was an unstageable pressure ulcer on the right heel acquired in the facility on 7/14/13. The wound measured 2.0 cm long by 2.0 cm wide, did not have depth, was dark purple and firm and remained closed. The wound was caused from pressure, stasis, trauma, and other. The wound had no drainage, had necrotic tissue, the wound base was black and the surrounding skin was red. Staff to apply skin prep frequently, change positions frequently, ensure heel protectors on at all times and elevate legs off of bed; - Wound # 3 was an unstageable pressure ulcer on the resident's coccyx acquired in the facility on 7/14/13. The wound measured 1.0 cm by 1.0 cm, did not have depth and was dark purple with a surrounding red area. The wound was caused from pressure, stasis, trauma, and other. The wound had no drainage, had necrotic tissue, the wound base was black and the surrounding skin was red. Staff to turn and reposition frequently and apply protective barrier cream TID and as needed. Review of the resident's weekly skin assessments showed the following: - 7/24/13 - Boggy heels. Small purple area on left heel. Heel protectors in place; - 7/27/13 - Eschar on both heels, right heel 3.5 cm by 3.5 cm, left heel 4.8 cm by 4.8 cm. Skin prep, Kerlix wrap and heelbos applied. Review of the resident's nurse's note, dated 7/27/13, showed staff documented "measures taken for eschar on bilateral heels. Skin prep and Kerlix applied to bilateral heels daily and heelbos." Review of the resident's wound assessment, dated 7/29/13, showed facility staff documented the following: - Wound # 1 was an unstageable pressure ulcer on the left heel acquired in the facility on 7/14/13. The wound measured 4.8 cm long by 4.8 cm wide, did not have depth, was dark purple and firm. The wound was caused from pressure, trauma, and a decline in condition. The wound had no drainage or odor, had necrotic tissue, the wound base was black and the surrounding skin was red. Staff to apply skin prep frequently, change positions frequently, ensure heel protectors on at all times and elevate legs off of bed; - Wound # 2 was an unstageable pressure ulcer on the right heel acquired in the facility on 7/14/13. The wound measured 3.5 cm long by 3.5 cm wide, did not have depth, was dark purple and firm. The wound was caused from pressure, stasis, trauma, and a decline in condition. The wound had no drainage or odor, had necrotic tissue, the wound base was black and the surrounding skin was red. Staff to apply skin prep frequently, change positions frequently, ensure heel protectors on at all times and elevate legs off of bed; - Wound # 3 was an unstageable pressure ulcer on the reside