Every finding on record at Mcclay Senior Care

Based on observation, interview and record review, the facility failed to conduct weekly skin assessments per their policy and complete a Braden Scale (a tool used to identify if a resident is at risk for the development of Pressure Ulcers (PU) for four residents (Resident #1, #2, #3 and #8) out of eight sampled residents who developed PU. Resident #1 admitted to the facility from a local hospital with a pressure ulcer to the coccyx. The facility failed to complete an admission skin assessment indicating that the resident had the PU, or document the size and characteristics of the PU. The facility failed to complete weekly skin assessments on the resident and the PU to the coccyx deteriorated to a Stage III PU (full-thickness skin loss involving damage to, or necrosis of, subcutaneous tissue, extending down to but not through underlying fascia, presenting as a deep crater with or without undermining). The resident was readmitted to the hospital. The facility failed to do weekly skin assessments and complete a Braden Scale for Resident #2 and the resident developed a Stage II PU (a partial-thickness skin loss involving the dermis and epidermis, presenting as a shallow, open ulcer with a red or pink wound bed, without slough or eschar) which progressed to a Stage III PU with no skin assessments or documentation of the characteristics of the wound. The facility failed to do weekly skin assessments for Resident #3, the resident had wounds on his/her feet, the facility had no documentation of the wounds or skin assessments. Resident #8 had no weekly skin assessments or Braden Score completed. The resident was receiving Hospice benefits, and Hospice documented that the resident had open areas on the coccyx/buttock area; the facility failed to document the characteristics of the wounds, there were no measurements of the wounds and no physician notification, or weekly skin assessments completed. The resident also had an unstageable PU to the right heel that was not identified by the facility. The facility census was 47. Review of the facility policy for Admissions dated 8/1/2023 showed the following: -The charge nurse will assume responsibility for the admission; -Receive report and the name of the physician from the discharging facility; -Perform a comprehensive nursing assessment of the resident that includes: skin assessment (Braden, a tool used to predict the risk of developing pressure ulcers or injuries, with scores ranging from 6 to 23, where lower scores indicate a higher risk. ); -Findings of the assessment will be documented in the electronic health record (EHR); -Contact the resident's physician and verify the admission/readmission orders including all needed medications including as needed (PRN) medication; -Complete the admission nurse's notes including: a summarized comprehensive assessment, vital signs, height and weight; -Initiate admission 48-hour care plan. Review of the facility policy for Skin assessment dated [DATE] showed the following: -The facility will ensure that a resident who enters the facility without pressure ulcers does not develop pressure ulcers unless the resident's clinical condition demonstrates that they are unavoidable; -The charge nurse will perform a skin assessment upon admission, weekly times four, monthly and when the resident has a change of condition; -Implement care planning for any resident at risk for pressure ulcers; -Complete a comprehensive head to toe assessment of the resident's skin with each scheduled assessment and with any significant change of condition, that includes evaluating risk factors such as: poor positioning in a chair, dementia, co-morbidities such as diabetes, end stage renal disease or thyroid disease, drugs like steroids that impair wound healing, friction and shearing ( friction is the force of rubbing two surfaces against each other, while shear is a force that causes tissues to move in opposite directions, often leading to deeper tissue damage), history of skin breakdown/pressure ulcers; impaired blood floor; impaired/decreased mobility; exposure of skin to urinary and/or fecal incontinence, nutrition or hydration deficit; skin desensitized to pain or pressure; -Supervise the Certified Nurse Aides (CNA) to ensure that each resident's skin is assessed for signs of breakdown with daily care and bathing; -Instruct CNA's to identify and report signs of skin breakdown such as: purple or dark area, edema, hardening of the skin (induration; redness (erythema), bogginess (refers to a soft, spongy, or wet texture of the skin that may feel like a sponge or a wet cloth); -Document the status of the resident's skin in the resident's electronic health record (HER) once per week and in the resident's monthly summary. Review of the facility policy for Pressure Ulcers: Prevention, Identification, Evaluation and Interventions dated 8/21/2025 showed: -Definition: a pressure injury is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. A pressure injury will present as intact skin and may be painful. A pressure ulcer (PU) will present as an open ulcer the appearance of which will vary depending on the stage and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may be affected by skin temperature and moisture, nutrition, perfusion, comorbidities and condition of soft tissue; -The facility will ensure that a resident who enters the facility without PU does not develop PU unless the resident's clinical condition indicates that they were unavoidable; -If the resident has a clinical condition that makes a PU unavoidable, this must be defined by the resident's physician and must be documented in the resident's chart; -The facility will ensure that all residents at risk for PU are identified and be given care to prevent the development of PU. Identification includes previous PU or pressure injury history. A Braden Scale will be completed upon admission/readmission, weekly for four weeks and with the quarterly, annual and significant change of condition assessments; -The facility will ensure that a resident with PU receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing; -The charge nurse will: Instruct and supervise CNA's to ensure that care and interventions are implemented to prevent skin breakdown including: -review of documentation of skin issues identified during the resident's shower; -application of creams/ointments with the provision of incontinent care; -monitor to ensue pressure relieving devices: mattresses, cushions and/or wedges, etc Are in place; -positioning protocols are followed to prevent skin breakdown; -Provide wound care as prescribed by the physician; mark each dressing with date and initials after treatment has been administered; document in the resident's EHR/Treatment Administration record (eTAR) that wound care was administered as prescribed; -The charge nurse will track the healing progress of PU and alter the plan of care and treatment when needed; -Completing skin integrity documentation for each resident with skin breakdown that includes: type of wound, location, shape, measurements in centimeters: width, length, depth; stage ( refers to a classification system used to categorize the depth and severity of skin and tissue damage, aiding in determining appropriate treatment and monitoring); color, redness, warmth, swelling; granulation (formation of new tissue), surrounding tissue, ulcer edges; exudate (drainage) bleeding; treatments, dressing changes, medication; presence of infection or other complications; pain; -Evaluating PU treatment weekly for effectiveness and inform the resident's physician of PU states; -Working with the care plan team to alter the PU care plan and implement new intervention(s) when healing is not adequate; -The Director of Nursing/Designee will monitor the weekly wound report: wounds present upon admission or acquired in the facility; wounds improving or worsening; wound types; proper documentation completed in the nurses' notes, treatment records, weekly skin sheets, care plans. Review of the facility's Wound Care Policy and Procedure with a review date of 8/2024 showed the following: -Purpose: to provide a standardized approach in the prevention, assessment, and treatment of wounds in our residents; -Policy Statement: Our facility is dedicated to delivering high-quality, evidence-based wound care to prevent the occurrence of pressure injuries and other wounds. We commit to comprehensive assessment, timely treatment, proper documentation, and continuous education. All wound care will be delivered in accordance with federal regulations and state agency standards; -This policy applies to all clinical staff, including licensed nurses, certified nursing assistants (CNA's), wound care specialists, and members of the interdisciplinary team involved in resident care at the facility; -Wound care team: the interdisciplinary group may include the Director of Nursing (DON), physicians, wound care nurses, dietitians, physical therapists, and specialists in wound management; -Wound Care Procedure: assessment and documentation: conduct a comprehensive head-to-toe skin inspection on admission, readmission, and with any significant change in condition; -Assess all wounds for location, type, size, stage, exudate, tissue type, and periwound (refers to the skin and tissues surrounding a wound) condition; -Reassess wounds at least weekly and document changes immediately; -Take photos of wounds with consent and per facility policy; -Risk identification and prevention: use the Braden Scale or another validated tool on admission, weekly, and with changes in health status; turn and reposition residents every two hours or as indicated; use pressure-reliving devices and provide prompt incontinence care; -Treatment and care planning: obtain specific wound care orders from the physician; use advanced therapies if ordered, coordinate with therapy services as needed; -Physician notification and orders; notify physician of new wounds, deterioration, infection or lack of healing, update and verify all treatment changes with physician orders; -Education: ensure staff complete training on wound care procedures and documentation; provide resident and family education and document it in the medical record. 1. Review of Resident #1's referral information to the facility from the resident's discharging local hospital dated 2/24/25 showed the following: -Discharge diagnosis of endocarditis (an infection of the inner lining of the heart chambers and heart valves, known as the endocardium. It is typically caused by bacteria that enter the bloodstream and settle on the heart valves, causing inflammation and damage; -Active wounds to the anterior (front) of the left and right knee, wounds on the left and right dorsal (back) knee; lower right arm and elbow and medial sacrum (middle of the sacrum, which is located at the base of the spine above the tailbone); -Utilize a low air loss mattress while in bed and a seat cushion while in a chair. Reposition frequently. Do not raise the foot of the bed, use off loading heel boots (reducing or redistributing pressure, force, or weight from a specific area of the body, particularly a wound or area prone to pressure injuries, to promote healing and prevent further complications. Review of the discharge orders from the local hospital dated 3/4/25 at 12:40 P.M. showed the following: -Mupirocin (medication commonly used to treat some skin infections) 2%, apply to affected area once daily with a start date of 3/5/25; -Zinc oxide (used to protect skin from being irritated and wet ) 40% paste, apply to affected area two times daily. Review of the resident's face sheet showed the resident admitted to the facility on [DATE] with diagnoses of endocarditis, sepsis (a life-threatening condition that occurs when the body's response to an infection damages its own tissues and organs, potentially leading to organ failure and death), acute kidney failure, type II diabetes, cognitive communication deficit and a history of falls. Review of the resident's Physician Order Sheet (POS) dated 3/4/25 showed no order for mupirocin or zinc oxide ointment. Review of the resident's admission nursing assessment completed on 3/4/25 at 2:25 P.M., and signed by Licensed Practical Nurse (LPN) B showed the following: -admitted to the facility on [DATE] via ambulance; -Generalized pain at a level 10 (one being minor or no pain to 10 being excruciating pain); -Alert and oriented to person, place and time; -No edema. Skin warm and dry, skin color within normal limits, turgor (refers to the elasticity and firmness of the skin. It indicates the body's hydration status) normal; -Area for skin issues was left blank. Review of the resident's assessments in the electronic medical record (EMR) dated 3/4/25 showed no skin assessment, or Braden Scale completed. Review of the resident's Skin Monitoring: Comprehensive CNA Shower Review (a tool used by the CNA's to document any issues with a resident's skin when giving a bath/shower) dated 3/4/25 and signed by LPN B, showed the following: -Admission. Picture of the body front facing: PICC (peripherally inserted central catheter -a long, thin, flexible tube inserted into a vein in the upper arm and threaded into a large vein near the heart, used for long-term intravenous access for medications, fluids, blood draws, or other treatments) noted in the right upper arm; -Picture of the body rear facing with a circle around the coccyx (tailbone) area and with Red written to the side. Heels circled with slightly red written to the side. Review of the resident's nursing notes dated 3/4/25, showed no documentation of any open areas, pressure ulcers, skin tears, or bruised areas. Review of the resident's undated baseline care plan showed the area for Skin Risk was left blank with no current skin issues marked and no interventions for the prevention of skin breakdown documented. During an interview on 4/3/25 at 3:40 P.M. CNA D said the following: -He/She was on duty when the resident was first admitted ; -He/She remembered the resident had sores on his/her knees, the sacrum had a small deep crack like area and his/her left heel was soft feeling. -LPN J was aware of the wounds, he/she was the admitting nurse and completed a skin assessment; -The resident refused to wear heel protectors and he/she did not have a low air loss mattress; -The CNA's complete a skin assessment when a shower was given, once completed it goes to the nurse. During an interview on 4/4/25 at 10:19 A.M. LPN J said the following: -He/She admitted the resident on 3/4/25. He/She did not complete the skin assessment in the medical record, he/she documented the resident's skin assessment on the Skin Monitoring Comprehensive CNA Shower Review sheet; -The resident's sacrum/coccyx area was red; he/she did not remember if the area was open; -He/She did not remember if the resident's heels were open, but had documented on the Shower Review sheet that they were red; -The resident did not have a low air loss mattress on the bed and did not have heel protectors; -The resident did not want to be turned, he/she was in a lot of pain; -He/She should have documented the condition of the resident's skin in the skilled admission nurses notes, but did not document anything; -Skin assessments should be done upon admission and with any issues noted with skin; the physician should be notified for a treatment order. During an interview on 4/3/25 at 3:30 P.M. LPN A said the following: -The resident admitted with endocarditis and reportedly had laid on the floor for over 30 hours before someone called the ambulance; -The resident had a foam dressing on his/her sacrum upon admission; -An admission skin assessment was not completed; -There were no skin assessments completed for the resident; -A skin assessment should have been completed upon admission; -In his/her review of the resident's medical record, he/she could not find any skin assessment completed. During an interview on 4/7/25 at 1:30 P.M. Registered Nurse (RN) E said the following: -He/She remembered the resident had a dressing to the sacrum/coccyx area and the wound nurse was aware; -The night shift would have changed the dressing, so he/she did not see the resident's skin; -A skin assessment should be done upon admission and documented in the resident's EMR under the assessment tab. Review of the resident's progress notes dated 3/5/25, signed by Nurse Practitioner (NP) A showed the following: -Nursing home visit for post hospitalization. The resident had skin breakdown to the coccyx that was present upon admission. Consulted with wound nurse; -Review of medications showed mupirocin and zinc oxide as discontinued. During an interview on 4/4/25 at 10:17 A.M. NP B said the following: -He/She saw the resident a couple of times; -He/She was aware of the wound on the resident's sacrum from the local/discharging hospital's documentation from the discharging hospital, but did not remember discontinuing any medications or treatments; -The facility had a wound nurse and a contracted outside wound care provider; residents who have wounds are referred to them for orders and treatments; -He/She did not see a skin assessment for the resident; -He/She had noticed that skin assessments were not always completed on the residents at the facility. Review of the resident's skilled nursing notes dated 3/6/25, showed no documentation of any skin breakdown on the resident's coccyx. Review of the resident's EMR for 3/6/25, showed no skin assessment or Braden Score completed. Review of the resident's progress note dated 3/6/25, and signed by Nurse Practitioner (NP) B showed the following: -While sitting on the end of the bed, the resident yelled out in pain (buttocks); -Medications: no mupirocin or zinc oxide noted as a current order; -Sacral wound/multiple abrasions, continue wound care. During an interview on 4/10/25 at 10:15 A.M. NP C said the following: -He/She had seen the resident several times, but had never seen the resident's skin; -He/She was aware that the resident had a wound on the sacrum/coccyx area from the documentation that was received from the hospital with a treatment order in place; -The facility had a treatment nurse that took care of all of the wounds. Review of the resident's Skin Monitoring: Comprehensive CNA (Certified Nurse Aide) Shower Review dated 3/7/25 showed a bed bath given, no skin issues noted. Review of the resident's EMR for 3/7/25 through 3/9/25 showed the following: -No documentation of the resident's skin in the skilled nursing notes, or in the progress notes; -No skin assessments completed, and no Braden Score completed. Review of the resident's comprehensive Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff dated 3/10/25, showed the following: -Able to make self understood and able to understand others; -Alert and oriented and able to make decisions; -Dependent upon staff for Activities of Daily Living (ADL's), bed mobility and transfers; -Incontinent of bowel and bladder; -At risk for pressure ulcers with one Stage III (full-thickness skin loss, where subcutaneous fat is visible, but bone, tendon, or muscle is not exposed. The ulcer may include undermining and tunneling) PU present. Review of the resident's Skin Monitoring: Comprehensive CNA Shower Review dated 3/11/25, showed the resident refused a shower, gave a bed bath as best that could be done; no skin issues noted. During an interview on 4/4/25 at 4:15 P.M. the Registered Nurse/Wound Nurse said the following: -He/She was aware that the resident was going to be admitted with wounds from the discharging hospital documentation; -The admitting nurse should have completed a skin assessment and documented any wounds; -He/She called the resident's primary physician and got an order for the contracted wound care provider to come in to assess the resident; -He/She did not see the resident's skin until 3/10/25 when the contracted wound care provider/Nurse Practitioner assessed the resident. Review of the resident's Initial Visit Case Report completed by the contracted wound care provider dated 3/10/25, showed the following: -Abrasions to left knee, right knee, skin tear to right and left forearms; -Review of systems: Integumentary (skin): wounds to left and right knee, left and right forearm; sacrum; -General Assessment and Plan: pressure injury to sacrum: cleanse wound, apply mupirocin 2% ointment and alginate (a highly absorbent wound care products that form a gel when exposed to wound fluid, maintaining a moist environment crucial for healing and managing moderate to heavy exudate) to wound bed, cover with a bordered foam dressing three times per week and as needed; -Wound location: sacrum, pressure, Stage III 3.0 centimeters (cm) long by 0.30 cm wide, 0.20 deep with mild pain, serosanguinous drainage (a fluid that contains both serum (clear, watery fluid) and blood. It typically appears as a pinkish-red or pale yellow discharge), with yellow slough (fibrous, dead tissue that can impede healing and harbor bacteria, often appearing as a yellowish, tan, or white, stringy material). During an interview on 4/10/25 at 10:00 A.M. NP A for the contracted outside wound care provider said the following: -When a resident admitted to the facility with skin issues or concerns, the wound nurse will get an order for consultation from him/her; -He/She received an order from the facility on 3/7/25 for a consultation for a wound on the sacrum/coccyx area; -He/She saw the resident at the facility on 3/10/25; -The wound to the coccyx was a Stage III PU and he/she ordered a treatment for the PU; -If a resident admitted with a PU or wound, the facility should notify the physician and get a treatment started until he/she could evaluate the wound. Review of the resident's Multidisciplinary Care Conference note dated 3/11/25 showed the following: -Attendees included the dietary manager, activity director, therapy director, nursing administration, family and administration: -Problems: the resident entered the facility with a wound on his/her coccyx and multiple areas in the lower extremities with an IV (intravenous, a needle inserted in a vein for medication/fluids to be administered) that was working well for endocarditis. However, the resident still seemed to be in a quite a bit of pain with these injuries. -No goals established for wounds, and no interventions indicated for the wounds, no treatments indicated for the wounds. Review of the resident's Medication Administration Record dated March 2025 showed mupirocin ointment 2%, apply to sacrum topically every day shift on Monday, Wednesday, and Friday, for wound care with alginate to wound and cover with a bordered foam gauze with a start date of 3/12/25. Review of the resident's medical record from 3/11/25 to 3/16/25 showed the following: -No skin assessments completed; -No documentation of the wound on the sacrum other than the contracted wound care provider note from 3/10/25. Review of the resident's nurses notes dated 3/16/25 and signed by LPN B, showed the following: -On 03/16/25 07:59 A.M., during resident care early this morning, CNA and this nurse observed a 2 1/2 inch purple area on resident's right heel and a red/purple area on the left hip (ischium) that was non-blanchable. Staff floated the resident's heels with two pillows and used Skin Prep ( used to create a protective barrier on the skin that forms a film to protect the skin by reducing friction on the right heel; -Staff put a pillow under resident's left hip area to help with the pressure. Notified the on-call physician of findings and on-call said the resident should have a low air loss mattress. Review of the resident's nurses note dated 3/16/25 at 6:20 P.M. and signed by LPN A, showed the resident refused all medications and meals during day shift. Resident observed as lethargic, blood pressure (BP) of 93/53 (normal BP 120/80), oxygen level of 94% on room air (normal oxygen level in an adult 95-100%), pulse of 88 (normal pulse range between 60 to 100), respirations 18 (normal respirations between 12 and 20 respirations), temperature 100.1 (normal temperature 98.6). No urine output during shift. Call placed to primary physician with an order to send the resident to the emergency room for evaluation due to change in condition. During an interview on 4/8/25 at 2:50 P.M. CNA F said the following: -He/She took care of the resident a couple of times while the resident was at the facility; -The resident's bottom was red when the resident admitted and he/she put barrier cream on the resident's bottom; -He/She last saw the resident the day before he/she went to the hospital , he/she did not look at the resident's heels; -The resident would lay on his/her left side and frequently refused to turn. On 3/16/25, before the resident went to the hospital he/she had a dark red round area on his/her left side; -He/she notified the nurse of the area on the left hip; During an interview on 4/8/25 at 9:30 A.M. LPN B said the following: -He/She had taken care of the resident and was off for a few days, when he/she came back to the facility, the resident was much weaker; -On 3/16/25 before the resident was sent to the hospital, he/she found a dark non-blanchable (a discoloration of the skin that does not turn white when pressed) on the resident's right heel and a dark round spot on his/her left hip; -He/She used skin prep to the heel and tried to position the resident on the right side, but the resident did not like to be turned; -The resident did not have a low air loss mattress, so he/she got an order for one; -He/She did not remember if the resident had an open are on the sacrum/coccyx area. During an interview on 4/3/25 at 1:05 P.M. Registered Nurse/Wound Nurse from the discharging hospital said the following: -When the resident discharged from the hospital on 3/4/25 the wound on his/her coccyx was in the final stages of healing and no longer open; the resident had no wounds on the heels; -When the resident readmitted to the hospital on [DATE], the resident had an area on the left mid back 3 centimeters (cm) by 3 cm that was a deep tissue injury (DTI-is a type of pressure ulcer where damage occurs to the underlying soft tissues, like muscles and fat, before the skin shows visible signs of injury. It often presents as a purple or maroon discolored area of intact skin or a blood-filled blister, and can be mistaken for a bruise. DTIs can develop rapidly and may lead to the formation of a pressure ulcer if not addressed promptly), two areas on the right heel; one measured 2 cm by 2 cm that was an intact blister and another area that measured 4 cm by 4 cm that was a DTI. The wound on the resident's coccyx/sacral area (tailbone) measured 12 cm by 3 cm and extended from the coccyx to the peri-rectal area (the area surrounding the rectum) also DTI; -When the areas opened, the wounds would be deep and extensive. During an interview on 4/4/25 at 1:30 P.M. the Director of Nursing said the following: -Skin assessments should be done upon admission and weekly thereafter; -The admitting nurse should be doing a full body skin assessment and documenting the findings in the admission assessment; -If the resident had wounds, these should have been documented upon admission and treatment orders obtained and if needed a referral to the contracted outside wound care provider for assessment and treatments; -She was aware that the resident had wounds from the discharging hospital documentation; -She did not see the resident's skin. 2. Review of Resident #8's face sheet showed the resident admitted to the facility on [DATE] with diagnoses of dementia and stroke. Review of the resident's care plans with a revision date of 1/11/25 showed no care plan for skin issues or prevention of PU. Review of the skin assessment dated [DATE] showed right medial thigh bruising, acquired in house. Review of the resident's EMR dated 1/17/25 showed no further documentation of the bruising to the thigh or any Braden Score completed. Review of the medical record dated 1/18/25 through 3/4/25 showed no skin assessments completed. Review of the resident's contracted hospice provider notes dated 1/21/25 through 3/4/25 showed no documentation of any skin alterations or PU's. Review of the quarterly MDS dated [DATE] showed: -Able to make self understood and usually able to understand others; -Unable to make decisions; -Dependent upon staff for all ADL's, turning and repositioning and transfers; -Incontinent of bowel and bladder; -At risk for PU, with no PU present. Review of the resident's POS dated March 2025 showed an order for weekly skin assessments with a start date of 3/4/25 Review of the resident's medical record dated 3/4/25 through 3/28/25 showed no skin assessments completed. Review of the contracted hospice provider notes dated 3/4/25 through 3/28/25 showed no documentation of any skin alterations or PU's. Review of the skin assessment completed 3/28/25 showed: -Skin issue - right medial thigh bruising and wound to coccyx area with treatment order in pace, house acquired; -No previous documentation of the wound to the coccyx; -There were no measurements or description of the wound. Review of the residents EMR dated 3/28/25 showed no documentation of physician notification of the wound to the coccyx or bruising to the right medial thigh. Review of the resident's POS dated March 2025 showed an order for mupirocin to coccyx Monday-Wednesday-Friday for wound care with a foam dressing with an order date of 3/28/25. Review of the resident's medical record dated 3/28/25 through 4/1/25 showed the following: -No skin assessments completed; -No description of the wound to the coccyx with no measurements. Review of the resident's contracted hospice provider notes dated 4/1/25 showed the following: -The resident currently has three PU's, two Stage II (a partial thickness loss of dermis, presenting as a shallow open ulcer with a red or pink wound bed, without slough or bruising. It can also manifest as an intact or open/ruptured blister) on the coccyx/buttock area and one Stage I (an area of intact skin with non-blanchable redness, usually over a bony prominence) to the heal. All are being treated by the facility staff. Observation on 4/4/25 at 2:11 P.M. showed the following: -CNA I and LPN A transferred the resident from a wheelchair to the bed via a mechanical lift; -CNA I said the resident had an open are on the coccyx; -The resident's right heel had a large area of discoloration on the bottom that was red in color; -A foam dressing was on the coccyx with no date or initials to indicate when or who applied the dressing; -LPN A removed the dressing; under the dressing was an oblong shape open area that was approximately 2-3 inches long with pink tissue surrounded by white, macerated tissue (tissue that has had prolonged exposure to moisture, Signs of Maceration: Skin that appears soggy, soft, or whiter than usual. A white ring around the wound, especially in areas with excessive moisture or drainage). During an interview on 4/4/25 at 2:30 P.M. RN/Wound Nurse said the following: -The resident recently acquired the PU to the coccyx and the heel; -The contracted hospice provider measured and documented the wound in their notes; -The facil[TRUNCATED]

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety and sanitation. Staff failed to practice proper hygienic practices, including hair restraint use, handwashing and gloving, and consumption of personal food and beverage items, when preparing and serving food to residents. Staff failed to ensure food and beverage containers and utensils were handled in a sanitary manner and were protected from moisture and other contaminants. Staff failed to ensure food items were in good condition and were sealed, labeled, dated, and stored in accordance with the manufacturer's label. Staff failed to ensure resident food items, including items located in a unit refrigerator outside of the kitchen, were stored under sanitary conditions. Staff also failed to ensure the ice machine and ceiling vent were clean to prevent potential contamination to food preparation and dish storage areas. The facility census was 46. 1. Review of the facility's policy, Personal Hygiene Policy, dated 6/2/21, showed the following: -Employees are expected to maintain the highest standard of personal cleanliness and present a neat, professional appearance at all times; -Facial hair that is longer than chin length must be secured away from the face; -All dietary staff are required to wear hair nets or a head covering to keep hair out of their face to maintain a sterile environment for all persons; -All persons with facial hair must wear a beard guard at all times while in the kitchen. Observation on 4/1/24 at 11:07 A.M., of the kitchen wall by the dining room door entrance, showed a black holder with a sign that read, Hairnets, All Hair Must Be Covered. Observation on 4/1/24 at 12:42 P.M., in the kitchen, showed the following: -Dietary Aide E prepared food items at the food preparation area for the lunch meal service; -He/She poured margarine into a pan of noodles, stirred the noodles and margarine, and brought it to the serving area; -He/She then poured milk into a food processor of dessert to make a pureed dessert and scooped the dessert into individual bowls; -He/She had 0.5-inch long facial hair that covered approximately 40% of his/her face; -He/She did not wear a beard restraint. Observation on 4/1/24 at 12:52 P.M., in the kitchen, showed the following: -At the beverage preparation counter, located inside the kitchen and near the food preparation and serving counters, Certified Nurse Assistant (CNA) G prepared beverages for residents; -He/She poured beverages into cups, added contents from individual packets into the cups, and stirred the beverage contents in the cups; -He/She wore a hairnet but his/her hair was not completely covered by the hairnet; -Two-inch sections of exposed hair hung down on each side of his/her face. Observation on 4/1/24 at 1:33 P.M., in the kitchen, showed the following: -The dietary manager served food onto seven resident's trays that were spread out on the food preparation counter; -Dietary Aide D leaned over the opposite side of the counter, approximately one foot away from the trays of food, and read the facility's recipe binder; -Dietary Aide D had one-inch long facial hair that covered approximately 40% of his/her face; -He/She did not wear a facial hair/beard restraint. During an interview on 4/2/24 at 1:16 P.M., the dietary manager said she expected staff to wear hair and beard restraints when working in the kitchen and for staff to wear the hair/beard restraints properly. 2. Review of the facility's policy, Hand Washing and Glove Use, dated 10/20/19, showed the following: -Hand washing is a priority for infection control; -Hands must be washed prior to beginning work, after using the restroom, after smoking, when working with different food substances (i.e. raw chicken to fresh fruit), following contact with any unsanitary surface (i.e. touching hair, sneezing, opening doors); -Washing procedure: wet hands, apply soap, lather vigorously rubbing hands together for approximately 11 seconds, rinse hands to remove soap and debris, dry hands with a disposable paper towel, discard of paper in a foot pedal trash can; -Gloves may be used when working with food to avoid contact with hands, gloves must be worn when touching any ready-to-eat food; -When gloves are used, hand washing must occur per above procedure prior to putting on gloves and whenever gloves are changed; -Gloves must be changed as often as hands need to be washed, gloves may be used for one task only; -Gloves can often give a false sense of security and can carry germs same as our hands. Observation on 4/1/24 from 12:20 P.M. to 12:44 P.M., in the kitchen, showed the following: -The dietary manager used her gloved hands to grasp the handles of utensils to serve food onto resident plates during the lunch meal service; -With her same gloved hands, she used potholders to obtain additional pans of food items from the convection oven, placed the pans into the countertop steam table, uncovered the foil on the pans, used a thermometer to take the temperature of the food items, and used an alcohol preparation pad to clean the thermometer probe; -She then opened the utensil drawer, obtained serving utensils, placed the utensils in the pans of food at the steam table, and continued serving resident's plates; -She removed her gloves and used potholders to obtain additional items from the convection oven, used the thermometer to take the temperature of the food items, and used an alcohol pad to clean the thermometer probe; -She flipped through pages of a binder (located on the food preparation counter), then opened the utensil drawer, obtained a scoop, and placed the scoop in a food item on the steam table; -She opened the utensil drawer again then closed it without obtaining any utensils; -Without washing her hands, she obtained a clean plate and touched the top eating surface of the plate and continued serving residents' plates; -She grasped a cabinet handle to obtain two cans of soup and opened one of the cans of soup; -She poured the soup into a bowl, placed the soup into the microwave by grasping the microwave handle and pushed buttons on the microwave to turn it on; -She continued serving resident's plates, then obtained serving utensils from the utensil drawer and walked across the kitchen to place the utensils on the portable food cart headed to the lower level dining room; -She obtained two small plates from a cabinet (located across the kitchen by the ice machine), brought the plates to the serving area, placed the warmed bowl of soup from the microwave onto one plate to serve to a resident, and prepared the second bowl of soup in the microwave. Observation on 4/1/24 at 12:45 P.M., in the kitchen, showed the following: -Dietary Aide E was in the dishwashing area and wore gloves on his/her hands; -He/She adjusted his/her pants and walked into the food preparation area; -He/She opened the utensil drawer by the handle, grasped a measuring spoon by the food contact surface, returned the spoon to the drawer, and closed the drawer; -He/She touched the surface of the food preparation counter, walked into the dishwashing area, and closed the door of the dishwashing machine to start a new load of dishes; -He/She discarded his/her gloves, did not wash his/her hands, and donned new gloves; -He/She grabbed a small stack of laminated resident meal cards from on top of the dishwashing machine, carried them to the serving area across the kitchen, and spread out the meal cards on the counter; -He/She removed his/her gloves, opened the convection oven door handle and used a white cloth as a potholder to obtain a pan of noodles; -He/She did not wash his/her hands and donned new gloves; -Using his/her gloved hands, he/she poured milk from a jug into a measuring cup and added it to the food processor to prepare a pureed food item. Observation on 4/1/24 at 12:56 P.M., at the kitchen serving area, showed the following: -CNA G leaned over and rested his/her bare hands on his/her face and mouth on the dining room side of the food serving counter; -Without washing his/her hands, he/she then used his/her bare hands to carry and serve plates of food and cups of desserts to residents in the dining room. Observation on 4/1/24 from 12:59 P.M. to 1:18 P.M., in the kitchen and adjacent dining room, showed the following: -The dietary manager used her bare hands to open the convection oven, use a thermometer to take the temperature of noodles in a pan, and sanitize the thermometer probe with an alcohol pad; -She used a silicone plate gripper to carry the pan of noodles to the serving area and used a scoop to serve noodles onto a resident's plate; -She used tongs to carry a piece of chicken from the countertop steam table to a cutting board on the preparation counter, cut the chicken into pieces, and placed the chicken on the plate with the noodles; -She served other food items onto the plate and carried the plate of food to a resident in the dining room; -She re-entered the kitchen, did not wash her hands, and used her bare hands to obtain a lid and placed it on the countertop steam table; -She touched and rearranged laminated resident meal ticket cards on the serving counter, touched the handles of serving utensils located in food items at the countertop steam table, and carried dirty dishes to the dishwashing area; -She opened the reach-in refrigerator and placed a food item inside, used an ink pen to write on the paper temperature log located on the refrigerator, and wiped down a tray cart with a white cloth and spray from a spray bottle in the dishwashing area; -She did not wash her hands and walked from the dishwashing area to the preparation area with a stack of clean black trays and laid them out on the counter; -She placed resident meal cards and wrapped silverware onto the trays; -She covered bowls of dessert with plastic wrap and placed the wrapped bowls on the trays. Observation on 4/1/24 at 1:24 P.M., in the kitchen, showed the following: -The dietary manager washed her hands at the handwashing sink, rubbed her nose with her clean hands, and did not discard the paper towel she used to dry her hands; -While she carried the used paper towel in her right bare hand, she picked up clean plate bases with both hands and put the bases on the preparation counter; -She carried three plate covers to the dirty side of the dishwashing area, pulled down the door of the dishwashing machine, and started the dishwashing machine; -She stopped at the handwashing sink (she did not wash her hands) and used the paper towel she was carrying to turn off the handwashing sink faucet handle and discarded the paper towel; -She obtained additional clean plate covers and placed them on the trays on the preparation counter; -She served food items onto residents' plates, placed the food plates on the trays, and put the plate covers on the plates to be served to residents on the halls. During an interview on 4/2/24 at 1:06 P.M., Dietary Aide F said staff should wash their hands constantly, such as before handling clean dishes and utensils, after completing dirty tasks, or when changing tasks. During an interview on 4/2/24 at 1:16 P.M., the dietary manager said staff should wash their hands frequently, such as when entering the kitchen, after completing dirty tasks or touching unsanitary items (i.e. door handles, items dropped on the floor), between glove changes, prior to handling clean utensils and dishes. Changing staff's gloves did not substitute the need for staff to wash their hands. 3. Review of the facility's policy, Staff Food and Drink Policy, dated 3/4/21, showed the following: -Dietary staff will keep all personal items including food and drink in the office area; -Dietary staff will consume food and beverages in the office area, no personal items will be stored or consumed near food production areas or food storage areas. Observation on 4/1/23 at 1:14 P.M., in the kitchen, showed the following: -A bottle of soda sat near a tray of clean mugs located in the beverage preparation counter; -Dietary Aide F picked up the bottle, took a drink from the bottle, and sat the bottle back on the counter; -He/She did not wash his/her hands after drinking from the bottle; -He/She touched and leaned on the beverage preparation counter. During an interview on 4/2/24 at 1:06 P.M., Dietary Aide F said staff should store personal beverage items in the dietary manager's office. During an interview on 4/2/24 at 1:16 P.M., the dietary manager said staff should store and use their personal items, such as beverages and phones, in the dietary manager's office and wash their hands after using personal items. 4. Review of the facility's policy, Dish and Utensil Procedure, dated 5/28/20, showed the following: -Spoons, knives, and forks shall be touched only by their handles; -Cups, glasses, bowls, and plates shall be handled without contact with inside surfaces or surfaces that contact the user's mouth; -Dishes and utensils shall be handled with clean hands; -Dishes and utensils shall be air dried before storage. Review of the facility's policy, Dish Handling and Dish Storage Policy, dated 2/14/21, showed the following: -Dietary staff will use ensure dishes are clean and dry before putting them into the storage areas while using clean hands; -Dietary staff will ensure that serving utensils are handled by handles only; -Dietary staff will ensure silverware is handled by the handles while transferring into the silverware container or being rolled up in a napkin for service; -Dietary staff will ensure cups, glasses, bowls, and plates are handled without touching the inside surfaces or the surface that contact users mouths. Observation on 4/1/24 at 11:48 A.M., in the kitchen, showed the following: -CNA G entered the kitchen with a cart of approximately 20 pink plastic handled cups with lids; -He/She did not wash his/her hands upon entering the kitchen; -With his/her bare hands, he/she removed lids from the cups and placed the lids on the cart, emptied water from the cups into the food preparation counter sink, and filled the cups with new water from the sink faucet; -He/She dropped a cup lid on the floor, picked it up, rinsed the cup lid with water at the sink faucet, and placed the lid back on the cart with the other lids; -He/She did not wash or sanitize the dropped cup lid nor did he/she wash his/her hands after he/she picked up the lid from the floor; -Using his/her bare hands, he/she continued preparing drinks and grasped the cup lids and cups by the upper exterior drinking surfaces; -He/She used a scoop from the ice machine to fill the cups of water with ice; -As he/she filled the cups of water with ice, he/she held the cups at an angle over the exposed ice machine bin that held fresh ice; -He/She positioned his/her left index finger on the upper interior drinking surface of the cups and some of the ice spilled from the cup of ice and water back into the ice machine bin; -When he/she returned the ice scoop to the ice machine's interior slot, his/her bare hand touched the surface of the fresh ice in the machine bin; -He/She took the lids from the cart (which included the lid that had been dropped on the floor) and put them back onto the cups. Observation on 4/1/24, in the kitchen, showed the following: -At 12:04 P.M., Dietary Aide F used his/her bare hands to move clean silverware from a green upright dishwashing utensil holder to a brown horizontal divided silverware tray. As he/she moved the silverware, he/she touched the eating surfaces of the silverware; -At 12:55 P.M., Dietary Aide F used his/her bare hands to grab silverware from the brown divided tray, place the silverware onto napkins, and wrap the silverware inside the napkins. As she moved and wrapped the silverware, he/she touched the eating surfaces of the silverware. Observation on 4/2/24 at 12:26 P.M., in the kitchen, showed the following: -Dietary Aide D used his/her bare hands to move clean silverware from a blue flat dishwashing utensil tray to a brown horizontal divided silverware tray; -As he/she moved the silverware, he/she touched the eating surfaces of the silverware; -Several drops of water dripped from the silverware as he/she moved it from the flat tray to the divided tray. Observation on 4/2/24 at 1:18 P.M., in the kitchen, showed the following: -A stack of inverted trays sat under the serving counter; -The top tray had dried brown food debris on the corner of the tray's inverted surface; -Dietary Aide E placed a clean tray (inverted) on the stack of trays; -The clean tray was visibly wet on all sides and the foodware contact surface of the tray touched the dried brown food debris (located on the previous top tray). During an interview on 4/2/24 at 1:06 P.M., Dietary Aide F said staff should handle utensils by their handles and cups, glasses, and dishes by their sides or bottoms. During an interview on 4/2/24 at 1:16 P.M., the dietary manager said the following: -If staff drop a cup lid on the floor, staff should ensure it is washed and sanitized before using it. Rinsing the cup lid under water would not be sufficient to clean/sanitize the item; -Staff should handle utensils and food/beverage items by the non-eating and non-food contact surfaces (i.e. handles, bottoms, and sides) of the items; -Food and beverage ware should be stored clean and dry. 5. Review of the facility's policy, Food Storage, dated 10/20/19, showed the following: -Food items will be stored, thawed, and prepared in accordance with good sanitary practice; -All products shall be dated upon receipt or when they are prepared; -Use date shall be marked on all food containers according to the timetable in the Dry, Refrigerated, and Freezer Storage Chart. Observation on 4/1/24 at 11:07 A.M., in the kitchen, showed the following: -Two open 17.5-pound containers of liquid margarine sat unrefrigerated on the shelf below the food preparation counter near the dry spice storage area; -The label of each container read: Refrigerate for Best Quality. Observations on 4/1/24 at 11:07 A.M., 11:58 A.M., and 1:16 P.M., in the kitchen, showed the following: -An 8.5-ounce pouch of microwavable rice sat open on top of the microwave near the serving counter; -The pouch was approximately one-third full and the top edge was loosely folded over; -The label of the pouch read, Refrigerate Unused Portion; -No staff were observed in the area nor were actively using the food item. Observation on 4/1/24 at 2:25 P.M., in the lower level dining room, showed the following: -The freezer portion of the refrigerator contained three unlabeled and undated Styrofoam cups of an ice cream-like substance, two 18-ounce bags of hot dog buns with an excessive amount of ice crystal buildup visible on the buns, and one unopened 20-ounce can of pineapple chunks. The label on the pineapple can read 'Do Not Freeze' and the can was bulging slightly at the bottom of the can; -A wadded paper towel was visible on the bottom floor of the freezer; -The refrigerated portion contained six various colored liquids in unlabeled and undated beverage pitchers, an open half-full 33.8-ounce box of orange juice concentrate that was not marked with an open date or sealed to the air, and an open half-full 12-ounce bottle of soda (on a shelf that read 'Residents Only;' -A 12-inch by 12-inch section of dried brown residue was visible on the bottom floor of the refrigerated portion; -The cabinets contained a clear plastic container of brown sugar with a disposable spoon inside and touching the food contents, a half-full opened 18-ounce strawberry lemonade powder with no open date and was unsealed to air, a Styrofoam cub with light pink powder that was unlabeled and undated, a stack of unlabeled and undated cookies that was loosely wrapped with plastic wrap (25% of the food item was exposed to air), two half-full open bags of potato chips loosely folded over with one bag's 'Use Product By' date of 3/26/24; -The exterior handles of the refrigerator felt sticky to the touch; -The entire surface of the floor, located in front of the refrigerator and cabinets, was sticky. During an interview on 4/2/24 at 1:16 P.M., the dietary manager said the following: -She expected staff to store food items according to the manufacturer's food label; -Spoons and scoops should not be stored inside food storage bins. -She monitored the lower-level dining room refrigerator and cupboards on a weekly basis to ensure food was properly stored, labeled, and dated; -She cleaned the lower-level dining room refrigerator monthly and also expected staff to clean it if they found that it was dirty; -She was unaware of the can of pineapple located in the freezer in the lower level dining room refrigerator. 6. Review of the facility's policy, Ice Machine and Equipment Policy, dated 6/2/21, showed the following: -The ice machine and equipment will be cleaned out completely semi-annually to maintain a clean and sanitary condition. Clean the exterior of the machine with a detergent solution, rinse, and allow to air dry; -The exterior of the machine should be cleaned weekly using a sanitizing solution; -Follow the manufacturer's cleaning and sanitizing instructions if available. Observation on 4/1/24 at 11:07 A.M., in the kitchen, showed several dried white drips and a moderate accumulation of brown and white crusty debris on the left exterior surface of the ice machine. During an interview on 4/2/24 at 1:16 P.M., the dietary manager said she cleaned the ice machine's exterior surface once a week but the encrusted deposits came back quickly and thought it might need to be cleaned with a calcium, lime, and rust cleaner. Staff cleaned and sanitized the interior and exterior of the machine every six months. 7. Observation on 4/2/24 at 8:30 A.M., of the kitchen ceiling above the dishwashing machine and clean dish storage area, showed an approximate 20-inch by 20-inch ceiling vent was coated with a heavy accumulation of brown fuzzy debris. During an interview on 4/2/24 at 1:16 P.M., the dietary manager said dietary staff last cleaned the dishwashing machine ceiling vent about three months ago.

Based on observation, interview and record review, the facility failed to ensure three residents (Resident #2, #5 and #44), in a review of three sampled residents who received insulin injections, were free from significant medication errors. Staff failed to prime (remove the air) the Humalog/Novolog Kwik pen (prefilled pen of fast acting insulin) (medication injected under the skin used to treat diabetes) needle as instructed by the manufacturer prior to administration of the medication, resulting in administration of less than the ordered dose of Humalog/Novolog. Staff failed to hold the needle against the resident's skin for the manufacturer's suggested time after the administration of the medication. The facility census was 48. Review of the undated facility policy, Medication Administration, showed the following: -The facility will provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing and administering of all medications to meet the needs of each resident; -If the charge nurse/Certified Medication Technician (CMT) is unfamiliar with the medications, he/she should look it up in the nurse's drug handbook, call the pharmacist and/or physician for clarification, and/or look for the manufacturer guidelines if it is a recently released medication. Review of the Humalog Kwik pen/Novolog Flex pen package insert showed the following in part: -Humalog Kwik Pen was a disposable single-patient-use prefilled pen containing 300 units of Humalog insulin. Each turn (click) of the dose knob dialed one unit of insulin. You could give from one to 60 units in a single injection; -Novolog Flex pen was a disposable single-patient use prefilled pen containing 300 units of Novolog insulin. Each turn (click) of the dose knob dialed one unit of insulin. You could give from one to 60 units in a single injection; -Pull the pen cap off, wipe the rubber seal with alcohol swab, check the liquid in the pen and ensure the liquid was clear. Select a new needle, remove the paper tab from the outer needle shield, push the capped needle straight onto the pen and twist the needle on until tight. Pull off the outer needle shield and remove the inner needle shield; -Prime (remove the air from the needle and cartridge). If you do not prime before each injection you may get too much or too little insulin. Turn the dose knob to select two units, hold the pen with the needle pointed up, tap the cartridge holder gently to collect air bubbles at the top, push the dose knob in until it stops and 0 is seen in the dose window. Hold the dose knob in and count to five slowly. You should see insulin at the tip of the needle. Repeat the priming procedure if you did not see insulin at the tip of the needle; -Turn the dose knob and select the number of units you need to inject and administer the medication; -Choose your injection site. Humalog/Novolog is injected subcutaneously (under the skin) in your stomach area, buttocks, upper legs, upper arms; -Wipe skin with an alcohol swab and let the skin dry before you inject your dose; -Insert the needle into the skin. Push the dose knob all the way in; -Continue to hold the dose knob in and slowly count to five before removing the needle. 1. Review of Resident #5's April 2024 Physician Order Sheets (POS) showed the following: -Diagnosis of type 2 diabetes mellitus with hyperglycemia (high amount of sugar in the blood); -Humalog Kwik Pen Insulin 100 units/milliliter (ml) subcutaneous (tissue just below the skin) inject 15 units three times a day. Observation on 4/2/24 at 8:08 A.M showed the following; -CMT B obtained the resident's Humalog Kwik pen from the top medication cart drawer, removed the lid, cleaned the tip with an alcohol pad and attached a new sterile needle; -CMT B did not prime the insulin pen; -CMT B dialed up 15 units of Humalog insulin and administered the medication in the resident's subcutaneous tissue of the abdomen; -CMT B did not hold the dose knob in for five seconds before removing the needle. Observation on 04/02/24 at 12:27 P.M. showed the following: -CMT I obtained the resident's Humalog Kwik pen from the medication cart, cleaned the tip with an alcohol pad and attached a new sterile needle; -CMT I did not prime the the insulin pen; -CMT I prepared the resident's Humalog insulin, cleansed the site and administered the medication in the subcutaneous tissue of the right abdomen. 2. Review of Resident #44's April 2024 Physician Order Sheets (POS) showed the following: -Diagnosis of type 2 diabetes without complications; -Novolog flex pen Insulin 100 units/ml subcutaneous per sliding scale (a dose amount to be determined based on a finger stick procedure that determines the amount of sugar in the blood); for blood sugar of 100-151 administer two units, blood sugar 151-200 administer four units, blood sugar 201-250 administer six units, blood sugar 251-300 administer eight units, blood sugar 301-350 administer 10 units, blood sugar greater than 351 call physician for orders. Observation on 4/2/24 at 12:25 P.M. showed the following: -CMT B obtained the resident's blood sugar level with results of 155 milligrams per deciliter (mg/dL) (measurement of the amount of glucose or sugar in the blood) and determined Novolog sliding scale Insulin dose was to be four units; -CMT B obtained the resident's Novolog flex pen from the top medication cart drawer, removed the lid, cleansed the tip with an alcohol pad and attached a new sterile needle. CMT B did not prime the insulin pen; -CMT B dialed up four units of Novolog insulin and administered the medication in the resident's subcutaneous tissue of the abdomen; -CMT B did not hold the dose knob in for five seconds before removing the needle. 3. Review of Resident #2's quarterly Minimum Data Sheet (MDS), a federally mandated form completed by facility staff, dated 01/04/24, showed his/her diagnoses included Type 2 diabetes mellitus with diabetic polyneuropathy. Review of the resident's April 2024 POS showed the following: -Accu check (a rapid test of glucose concentration in the blood) before meals and at bedtime; -Humalog Injection Solution, inject as per sliding scale: if blood sugar 150-200, administer two units; blood sugar 210-300, administer four units; blood sugar 301-350, administer six units; blood sugar 351-400, administer eight units; blood sugar 401-450, administer 10 units, subcutaneously before meals and at bedtime for hyperlgycemia. Observation on 04/02/24 at 11:37 A.M. showed the following: -CMT B obtained the resident's blood sugar level with results of 306 mg/dL and determined Humalog insulin sliding scale dose was to be six units; -CMT B obtained the resident's Humalog Kwik pen from the medication cart, cleaned the tip with an alcohol pad and attached a new sterile needle; -CMT B did not prime the insulin pen; -CMT B dialed up six units of Humalog insulin, cleansed the site and administered the medication in the subcutaneous tissue of the left upper arm; -CMT B did not hold the dose knob in for six seconds after administration. 4. During an interview on 04/02/24 at 12:28 P.M., CMT I said the following: -He/She does not prime pre-filled insulin pens; -He/She had been taught to place the new sterile needle, then dial up the dose, this pulls the air from the needle, which acted as priming. During an interview on 04/03/24 at 8:36 A.M., CMT B said he/she primes the new sterile needle by placing the needle, then dialing up the insulin at least one unit past the ordered dose, then dialing back down to the ordered dose. During an interview on 04/04/24 at 10:07 A.M., Licensed Practical Nurse (LPN) J said the following: -When administering insulin by pre-filled pen route, two units should always be wasted after placing the needle. This is the act of priming the needle; -Without priming the needle, the full dose will not be administered. During an interview on 04/05/24 at 11:17 A.M., the Director of Nursing said the following: -She expected staff to prime insulin needles; -She expected staff to hold following administration; -She expected staff to administer insulin in accordance with facility policy, physician orders, and manufacturer guidelines.

Based on observation, interview, and record review, the facility failed to keep lorazepam (a schedule IV narcotic anxiety medication with the potential for abuse) behind two locks when it was stored in the unlocked refrigerator in the lower level medication room, without evidence of when the medication was dispensed or a narcotic sheet for reconciliation. The facility failed to remove and destroy discharged resident medications from the lower level medication room for eight discharged residents (Residents #100, #101, #102, #103, #104, #105, #106, and #107) as directed by facility policy. The facility census was 48. Review of the facility undated policy, Medications - Narcotics/Controlled Substances, showed the following: -Narcotics must always be stored under a double locking system; -They must be kept in the locked box in the unit's locked medication; -Each narcotic that the pharmacy dispenses to the facility is accompanied by a narcotic sheet with: a. Medication name, amount, dose, and strength; b. Date dispersed to facility; c. Resident's name; d. Lines to record each dose removed, date and time, and signature; -Discontinued narcotics must be placed in the locked box in the medication room with their narcotics sheets attached; -Controlled substances that are no longer needed in the facility may be disposed of in the facility; -The Director of Nursing (DON)/Designee and one additional licensed person (licensed nurse or consultant pharmacist) will destroy discontinued narcotics together and sign the necessary documentation for that action. Review of the facility policy, Medication Storage in The Facility, dated February 2020, showed the following: -All drugs classified as Schedule II of the Controlled Substance Act will be stored under double locks; -Schedule III-V medications must be maintained in separately locked, permanently affixed compartments and cannot be stored with other nonscheduled medications. Review of the facility undated policy, Medication Destruction, showed the following: -The facility will dispose of unused and/or expired medications according to state, federal, local ordinances and current standards of practice; -Expired and/or discontinued medications should be removed from the medication cart and brought to the DON office; -The DON will place the medications in a locked cabinet awaiting disposal; -A record will be kept of the name of the resident, medication name, number of remaining pills, patches or liquid amount along with the narcotic count sheet, if applicable; -The DON, along with a second licensed nurse, will dispose of all unused and/or expired medications every 30 days; -The DON will maintain the records according to facility guidelines. Review of the Bureau of Narcotics and Dangerous Drugs, Controlled Substance Guidelines for Missouri Practitioners, dated 8/28/23, showed if controlled substances are stored in a refrigerator, then the refrigerator must have a lock. 1. Review of Resident #100's physician orders, dated 5/19/21, showed an order for ketorolac tromethamne solution (eye drops used to treat itching, pain, burning, and inflammation of the eye) 30 milligrams (mg)/milliliter (ml). Review of the facility clinical census showed the resident was discharged on [DATE]. Observation on 4/02/24 at 4:00 P.M., of the lower level medication storage room, in the middle drawer of the cabinet, showed 16 vials of ketorolac tromethamne solution 30 mg/ml labeled to be used for the resident. The medication had not been pulled for destruction or destroyed per facility policy and remained in the facility 671 days after the resident was discharged . 2. Review of Resident #101's physician orders, dated 3/12/23, showed an order for NovoLog insulin (injectable medication to lower blood sugar) solution 100 unit/ml. Review of the facility clinical census showed the resident was discharged on [DATE]. Observation on 4/02/24 at 4:00 P.M., of the refrigerator in the lower level medication storage room, showed one unopened bottle of NovoLog injection solution 100 unit/ml labeled to be used for the resident. The medication had not been pulled for destruction or destroyed per facility policy and remained in the facility 387 days after the resident was discharged . 3. Review of Resident #102's physician orders, dated 5/23/23, showed no orders for Heparin Lock Flush Solution 100 Unit/ml (a blood thinner that prevents the formation of blood clots. Heparin flush is used to flush an intravenous (IV) catheter (indwelling single-lumen plastic conduit that allows medications to be introduced directly into a peripheral vein) which helps prevent blockage in the tube after an individual receives an IV infusion (a method to put medications into the blood stream). Review of the facility clinical census showed the resident was discharged on [DATE]. Observation on 4/02/24 at 4:00 P.M., of the lower level medication storage room, in the lower middle cabinet, showed the following medications labeled for the resident: -Nine Heparin Lock Flush Solution 100 unit/ml; -One normal saline flush 0.9 percent solution 3 ml (this product is used to help prevent IV catheters from becoming blocked and also to help remove any medication that may be left where the IV is placed through the skin); -One normal saline flush 0.9 percent solution 12 ml. The medications had not been pulled for destruction or destroyed per facility policy and remained in the facility 306 days after the resident was discharged . 4. Review of Resident #103's physician orders, dated 8/04/23, showed no orders for Heparin Lock Flush Solution 100 unit/ml. Review of the facility clinical census showed the resident was discharged on [DATE]. Observation on 4/02/24 at 4:00 P.M., of the lower level medication storage room, in the lower middle cabinet, showed 70 Heparin Lock Flush Solution 100 Unit/ml, labeled for the resident. The medication had not been pulled for destruction or destroyed per facility policy and remained in the facility 202 days after the resident was discharged . 5. Review of Resident #104's physician orders, dated 11/03/23, showed NovoLog Flex Pen subcutaneous solution pen-injector 100 unit/ml. Review of the facility clinical census showed the resident was discharged on [DATE]. Observation on 4/02/24 at 4:00 P.M., of the refrigerator in the lower level medication storage room, showed an unopened NovoLog Flex Pen subcutaneous solution pen-injector 100 unit/ml, labeled for the resident. The medication had not been pulled for destruction or destroyed per facility policy and remained in the facility 149 days after the resident was discharged . 6. Review of Resident #105's physician orders, dated 11/15/23, showed no orders for BD PosiFLush injection 0.9 percent (saline flush). Review of the facility clinical census showed the resident was discharged on [DATE]. Observation on 4/02/24 at 4:00 P.M., of the lower level medication storage room, in the right lower cabinet, showed ten BD PosiFLush injection 0.9 percent (saline flush), labeled for the resident. The medication had not been pulled for destruction or destroyed per facility policy and remained in the facility 125 days after the resident was discharged . 7. Review of Resident #106's physician orders, dated 11/02/23, showed no orders for insulin glargine (injectable medication to lower blood sugar) 100 unit/ml and Heparin Lock Flush Solution 100 unit/ml. Review of the facility clinical census showed the resident was discharged on [DATE]. Observation on 4/02/24 at 4:00 P.M., of the lower level medication storage room showed the following: -One open bottle of insulin glargine 100 unit/ml labeled for the resident; -Twelve Heparin Lock Flush Solution 100 unit/ml labeled for the resident. The medications had not been pulled for destruction or destroyed per facility policy and remained in the facility 124 days after the resident was discharged . 8. Review of Resident #107's physician orders, dated 2/19/24, showed the following: -Glucagon Emergency Kit (medication to treat severe low blood sugar) which included glucagon 1 mg vial and the diluent; -Naloxone hydrochloride (HCI) (used along with emergency medical treatment to reverse the life-threatening effects of a known or suspected opiate (narcotic) overdose) injections solution 0.4 mg/ml. Review of the facility clinical census showed the resident was discharged on [DATE]. Observation on 4/02/24 at 4:00 P.M., of the lower level medication storage room, in the upper middle cabinet, showed one Glucagon Emergency Kit and six Naloxone hydrochloride (HCI) injections, labeled for the resident. The medications had not been pulled for destruction or destroyed per facility policy and remained in the facility 40 days after the resident was discharged . 9. Observation on 04/02/24 at 4:00 P.M. showed the following medications were found in the upper middle cabinet of the lower medication room and were unlabeled (not labeled for any specific resident): -Nine Glucose 5 oral glucose gel (to treat low blood sugar levels); -One Glucagon Emergency Kit. Observation on 4/02/24 at 4:00 P.M. showed the following medications were found in the refrigerator, in the lower level medication room, and were unlabeled (not labeled for any specific resident): -Two vials of lorazepam 2 mg/ml (There was no narcotic control count log attached and no evidence staff reconciled the medication every shift); -Two vials of Solu-Medrol (steroid for inflammation) 40 mg; -23 acetaminophen 650 mg suppositories; -67 Bisacodyl 10 mg suppositories; -One Glucagon Emergency Kit; -53 acetaminophen 650 mg suppositories; -118 bisacodyl 10 mg suppositories; -Ten loperamide hydrochloride (anti-diarrheal) 2 mg; -Four ondanestron (nausea) disintegrating tablets 2 mg; -Two dairy relief (help to digest dairy products) 9000 Foods Chemical Codex (FCC) lactase units. During an interview on 4/03/24 at 12:30 P.M., Licensed Practical Nurse (LPN) J said there were no stock medications stored in the lower level medication room. During an interview on 4/02/24 at 4:00 P.M., Registered Nurse (RN) M said the facility does not keep stock medications in the lower level medication room. 10. Observation on 4/03/24 at 12:30 P.M., showed the following: -Licensed Practical Nurse (LPN) J had removed pharmacy pill packs of medications (for an unknown resident) from the active medication cart; -LPN J was destroying the medications using the Drug Buster medication disposal system (quickly turns most non-hazardous medications into a non-toxic slurry (change the tablet form of a medication to a liquid) that can be safely put in the trash); -LPN J was by his/herself; there were not two licensed staff destroying medications together as facility policy instructed. During an interview on 4/03/24 at 12:30 P.M. and 4/11/24 at 4:55 P.M., LPN J said the following: -The only time medication were stored in the lower level medication room, was if a resident who was out of the facility, like at the hospital, and the resident was expected to return to the facility; -When a resident was discharged from the lower level, the nurse was responsible to destroy the resident's medications; -The medications he/she destroyed by himself/herself were extra medications sent from the pharmacy. These medications belonged to discharged residents; -He/She destroyed one tablet of aspirin 81 mg, senna 8.6 mg (medication to treat constipation), levothyroxide (thyroid medication) 50 micrograms (mcg) and finasteride (prostate medication) 5 mg; -He/She used the Drug Buster medication disposal system; -The medications he/she destroyed were not narcotics and did not need another licensed staff as a witness; -He/She did not document the medications destroyed; -He/She was not aware of a facility policy requiring two licensed staff being needed to destroy medications; -There was no stock medications stored in the lower level medication room. 11. During an interview on 4/02/24 at 4:00 P.M., Registered Nurse (RN) M said the following: -The nurses who worked on the lower level were responsible for maintaining the medication storage room on the lower floor; -The nurse discharging a resident was responsible for discarding medications when a resident was no longer a resident in the facility; -There was no specific time frame which medications were destroyed; -There was no specific policy or protocol for the medication destruction on the lower level of the nursing facility; -The lorazepam vials should not have been in the refrigerator. If a narcotic has to be refrigerated, it should be kept in a locked box in the refrigerator; -He/She could not recall who any of the unlabeled medications belonged to. During an interview on 4/03/24 at 2:30 P.M., 4/04/24 at 11:35 A.M. and 4/15/24 at 4:07 P.M., the DON said the following: -There should be no medications for discharged residents in the lower level medication room; -When a resident is discharged , two nurses should destroy the resident's medications; -When a resident is discharged , the facility has 30 days to destroy the medication; -Lorazepam 2 mg/IM should not be stored in an unlocked refrigerator; it should be in a lock box in the refrigerator; -A private contracted pharmacy consultant checked the medication storage room located in the lower level; -The pharmacy consultant checked the facility's medication rooms every month, as well as quarterly, for medications that need to be destroyed; -The last two times the pharmacy consultant checked the lower level medication storage room was on 3/06/24 and 4/12/24 and there were no reported medications that needed to be destroyed; -She was unaware there were any medications in the lower level medication storage room that needed to be destroyed; -There were no medications in the DON's office waiting to be destroyed. During an interview on 4/15/24 at 4:25 P.M., the administrator said the following: -She expected staff to destroy medications after a resident was discharged ; -She would not expect medications to be in the lower level storage room for 671 days, 387 days, 306 days, 202 days, 149 days, 125 days, 124 days, or 40 days; -The pharmacy consultant checked the medication rooms each month and sends a report to the facility of medication which need to be destroyed; -She was unaware there were medications in the lower level storage room which needed to be destroyed; -She would expect a narcotic to placed in a lock box in the refrigerator, if the medication needed to be refrigerated.

Based on observation, interview, and record review, the facility failed to provide food items at a safe and appetizing temperature. The facility census was 50. Review of the undated facility policy for Food Temperatures showed: -Foods will be served at proper temperature to insure food safety; -Inset thermometer into center of product. Allow time for stabilization. Wait until there is no movement for 15 seconds. Several readings may be required to determine hot and cold spots; -Record reading on Food Temperature Chart form at beginning of tray line and end of tray line. If temperatures to not meet acceptable servicing temperatures, reheat the product or chill the product to the proper temperature. Take the temperature of each pan of product before serving; -Acceptable serving temperatures are in part: -casseroles - greater than 140 degrees but preferable 160 degrees to 175 degrees; -meat - greater than 140 degrees but preferable 160 degrees to 175 degrees; -potatoes, pasta - greater than 140 degrees but preferable 160 degrees to 175 degrees; -vegetables - greater than 140 degrees but preferable 160 degrees to 175 degrees; -pastries, cake - greater than 60 degrees -hazardous salads and desserts - less than 41 degrees -If temperatures are not acceptable levels and cannot be corrected in time for meal service, make an appropriate menu substitution and discard out of temperature range foods; -Cold food needs to be put in the freezer one half hour to three quarters of an hour prior to meal service. Bring only one tray at at time out on the tray line. Put on ice. Ice down all cold foods on tray line. Chill dishes to be used for cold foods; -Do not put food on tray line until one half hour prior to meal service. Heat hot plates. 1. Observation in the kitchen and in the lower level dining room on 9/13/23 at 11:50 A.M. showed: -A sign posted that the noon meal is served at 12:00 P.M.; -A portable steam table plugged in; -At 12:17 P.M., the Dietary Manager (DM) removed a pan of oven baked chicken, mashed potatoes and broccoli from the oven, placed them on the portable steam table and took the steam table to the down stairs unit; -The DM took the following temperatures of the food once taken out of the oven: chicken 158 degrees, mashed potatoes 168 degrees and broccoli 148 degrees; -At 12:20 P.M. the DM manager began serving six residents who sat in the dining room and prepared two hall trays; -Staff served the last tray at 12:27 P.M.; -Temperatures of a sample tray of food were: chicken 120 degrees, mashed potatoes 160 degrees and broccoli 120 degrees; -The DM did not take the temperatures of the food before meal service in the lower level dining room. Observation on 9/13/23 at 12:35 P.M. of the main dining room showed: -The main dining room had been served; -The cook began preparing the three plates for the hall service at 12:54 P.M. and finished at 12:55 p.m.; -Staff served the first tray at 12:56 P.M., the second tray at 12:58 P.M. and the third tray at 12:59 P.M.; -Temperatures of the food on the sample tray at 1:00 P.M. were: chicken 110 degrees, mashed potatoes 130 degrees, broccoli 105 degrees and lemon cake with a vanilla glaze frosting 70 degrees. During an interview on 9/13/23 at 4:30 P.M. the DM said: -She was not aware that the portable steam table for the lower level dining room did not hold the food temperatures; -She had heated the plates for the hall meal service, but there is no thermal plate for the plates to hold the temperatures; -She was not aware that the warmed plates did not hold the temperatures well; -She would expect the food to be served at a safe and tasteful temperature. During an interview on 9/13/23 at 5:15 P.M. the Administrator said: -She would expect the DM to follow the facility policy for take the temperature of the food; -She would expect the food to be served at acceptable temperatures per guidelines and the facility policy. MO222299

Based on interview and record review, the facility failed to follow professional standards of care for two residents (Residents #1 and #2), in a review of six sampled residents when staff failed to administer medication as ordered by the physician. The facility census was 50. Review of the facility policy for Following Physician Orders dated 11/18 showed: -Drugs will be administered only upon a clean, complete and signed order of a person lawfully authorized to prescribe; -Each medication order is documented in the resident's medical record with the date and signature of the person receiving the order. The order is recorded on the physician order sheet (POS) or the telephone order sheet if it is a verbal order, and the Medication Administration Record (MAR) or Treatment Administration Record (TAR. Review of the undated facility policy for Admissions showed the Charge Nurse will assume responsibility for the addition of contacting the resident's physician and verify the admission/readmission orders including all needed medications including as needed (PRN) medications; notify the pharmacy of the admission and order the medications. 1. Review of Resident #1's face sheet showed the resident admitted to the facility on [DATE] and discharged on [DATE]. The resident presented with diagnosis of Parkinson's disease ( a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination. Symptoms usually begin gradually and worsen over time. As the disease progresses, people may have difficulty walking and talking). Review of the resident's admission orders dated 7/10/23 showed an order for Senna -S (a medication used to treat constipation) 8.6 milligrams (mg), give two tables two times a day for constipation. Review of the resident's Physician Order Sheet (POS) dated 7/23 showed no order for Senna-S. Review of the resident's Medication Administration Record (MAR) dated 7/23 showed no order for the Senna-S. During an interview on 9/19/23 at 9:00 A.M. the resident's Family Member (FM) A said: -He/She took the resident's physician orders from the hospice provider to the facility the day he/she took the resident to be admitted ; -The order for Senna-s was on the orders as the resident took this same medication at home; -The resident was only at the facility for respite care for five days; -The resident did not receive the Senna-s at the facility and was very constipated when he/she returned back home. 2. Review of Resident #2's face sheet showed the resident admitted to the facility on [DATE]. Review of the resident's discharge orders from a local hospital dated 1/20/23 showed the following medication orders: -Acetaminophen (pain reliever), 325 mg, take two tables by mouth (PO) every 6 hours as needed (PRN); -Albuterol (used to treat or prevent bronchospasm in patients with asthma, bronchitis, emphysema, and other lung diseases) 108 (90 base micrograms (mcg) inhaler, inhale 2 puffs every 4 hours PRN; -buspirone (an antidepressant) 10 mg, take one tablet by mouth in the morning and one at bedtime; -Carbidopa-levodopa ER (a medication used to treat Parkinson's disease) 50-200 mg five times a day; -Cyclobenzaprine (a medication used to treat muscle spasm) 5 mg three times a day (TID) PRN; -Famotidine (a medication used to treat heartburn) take 20 mg two times a day (BID); -Gabapentin 600 mg (a medication used to treat nerve pain) 600 mg, take one tablet TID; -Guaifenesin (a medication used to treat congestion) 600 mg BID PRN; -Heparin ( a medication used to prevent blood clots) 5000 units/ml, inject 1 ml under the skin every 12 hours Melatonin 3 mg at bedtime PRN; -Pantoprazole (a medication used to treat acid reflux 40 mg, take one tablet at 6:00 AM daily -Polyethylene glycol (used to treat constipation) 17 grams daily PRN; -Rotigotine (a medication used to treat Parkinson's disease) 4 mg, one patch on the skin in the morning. Review of the resident's admission Minimum Data Set (MDS), federally mandated assessment instrument completed by staff, dated 1/26/23 showed: -Required extensive assistance of one staff member for Activities of Daily Living (ADL's); -Diagnoses of hypertension, arthritis, Parkinson's disease and depression. Review of the resident's MAR January 2023 showed: -Carbidopa-levodopa 50-200 mg, give one tablet 5 times a day not documented as given at 6:00 A.M. on 1/21/23 and 1/24/23, and not documented as given at 5:30 P.M. on 1/24/23; -Heparin 5000 units, inject ml not documented as given at 6:00 A.M. on 1/21/23 and 1/24/23, no documented as given at 6:00 P.M. on 1/24/23; -Buspirone HCL 10 mg give one table BID not documented as given at 5:00 P.M. on 1/24/23 -Pantoprazole 40 mg give one table one time a day not documented as given 6:00 A.M. on 1/21/23 or 1/24/23; -There was no reason documented for not administering the medication as ordered. Review of the resident's MAR for February 2023 showed: -Carbidopa-levodopa 50-200 mg, give one tablet 5 times a day not documented as given at 6:00 A.M. on 2/9/23 , and not documented as given at 5:30 P.M. on 2/21/23; -Pantoprazole 40 mg give one table one time a day not documented as given 6:00 A.M. on 2/9/23; -Buspirone HCL 10 mg give one table BID not documented as given at 5:00 P.M. on 2/21/23; -Famotidine 20 mg one tablet BID not documented as given at 5:00 P.M. on 2/21/23. During an interview on 9/19/23 the resident's Family Member B said: -The resident was telling him/her that he/she had not received all of his/her medication; -He/She tried to verify the medication with facility staff; -He/She never did get a medication list from the facility that he/she had requested. During an interview on 9/13/23 Licensed Practical Nurse (LPN) A said when a resident is admitted to the facility, the nurse will review the orders received and notify the physician for approval, then fax the orders to the pharmacy. During an interview on 9/13/23 at 2:30 P.M. the Director of Nursing said: -She would expect medications to be given as ordered by the physician; -Nurses should verify the admitting medications with the physician and order the medication from the pharmacy and transcribe the medication accurately on the MAR. During an interview on 9/13/23 at 5:15 P.M. the Administrator said she would expect staff to follow physician orders and ensure that all medications ordered are available. MO222299 MO222164

Based on interviews and record review, the facility failed follow their policy when staff failed to assess residents implement the 72 hour observations, or put interventions in place after the fall. This affected two residents (Resident #2, and #3) of six sampled residents. The facility census was 50. Review of the undated facility policy for Falls-Risk Assessment and Identification showed: -The facility will protect residents from injury by falls through risk assessment and identification; -Every resident is considered at high risk for falls until the admission fall assessment is completed; -Fall risk assessment must be completed: the first day of admission or readmission; with each quarterly and annual assessment; with every significant change in the resident's condition; after any fall; -If the admission fall assessment indicates a risk of falls, the charge nurse will initiate a fall care plan. Review of the undated facility policy for Falls-Prevention and Risk Reduction showed: -The Minimum Data Set (MDS) coordinator will complete a comprehensive care plan with input from the interdisciplinary team for all residents who are identified at risk for falls; communicate the falls care plan to the health care team; after each new occurrence of a fall, review the working care plan to ensure updated interventions(s) added by the charge nurse. Review of the undated facility policy for Falls: Post-Fall Protocol showed: -Definitions: an intercepted fall is still a fall; a fall without an injury is still a fall; when a resident is found on the floor, the most logical conclusion is that a fall has occurred. The facility is obligated to investigate and try to determine how he/she got there, and to put into place an intervention to prevent this from happening again. The distance to the next lower surface if not a factor in determining whether or not a fall occurred. If a resident rolled off a bed or mattress that was close to the floor is considered a fall; -Staff members who discover that a resident has fallen must notify the charge nurse immediately; -The charge nurse will assess the resident from head to toe, and make sure it is safe to assist the resident to a chair before moving him/her, obtain a full set of vital signs, complete a neurological assessment if the resident has struck his/her head or if it is unknown if he/she has struck his/her read, interview the resident and any witnesses of the fall to determine the exact circumstances and cause of the fall. After the assessment and treatment is done, notify the resident's responsible family member and physician, document the fall in the resident's electronic health record (EHR) including his/her explanation of the event, implement seventy-tow (72) hour incident follow-up charting, and fill out and follow through with an incident report; -The incident report and nurse's notes must include the time and location of the fall; location of any injury; results of the head to toe assessment; vital signs; the cause of the fall if know, resident explanation when possible; treatment; post-fall interventions; time the family was notified; new fall interventions implemented to prevent reoccurrence of falls with the addition to the working care plan. 1. Review of Resident #2's medical record showed a Fall Risk Assessment completed on 1/20/23 with the resident at low risk for falls. Review of the admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 1/26/23 showed: -admitted to the facility on [DATE]; -Alert and oriented and able to answer questions, able to make self understood and able to understand others; -Required extensive assistance of one staff member for Activities of Daily Living (ADL's); -Diagnoses of hypertension, arthritis, Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination.) and depression; -Has a history of falling with one fall at the facility without injury. Review of the resident's nurses notes dated 1/25/23 at 6:30 P.M. showed the resident was in the bathroom with the caregiver and stood up at the bar, got shaky, lost his/her balance and slid to the floor with the help of the caregiver. No injuries, vital signs within in normal limits (WNL). Resident stood up and sat in wheelchair with no complaints. Review of the resident's medical record dated 1/25/23 through 1/28/23 showed: -No fall assessment completed after the fall on 1/25/23; -No 72 hour post fall assessment was completed; -No documentation of any interventions to prevent the fall from reoccurring. Review of the resident's care plan for falls dated 1/29/23 showed: -Interventions in part: attempt to anticipate needs, ensure call light is within easy reach, floors free from spills and clutter, keep personal items within reach, proper fitting shoes, offer reminders and cues, offer toileting, orient to surroundings, provide activities, provide adequate lighting. -No intervention or update for the fall on 1/25/23. Review of resident's nurses notes dated 2/13/20 at 7:18 P.M. showed: -Staff informed the morning nurses the resident was on the floor. Entered into room and noted resident laying flat on his/her back with his/her head in the direction of the bathroom. The wheel chair was behind resident but not locked. Resident was assessed and said he/she did not hit his/her head. Able to move lower extremities and left upper extremity without noted changes or complaint of pain/discomfort. Right upper extremity is weak and resident wears a sling. No noted current injuries. No noted mental status changes per staff. Skin warm and dry to the touch. Review of the resident's medical record dated 2/13/23 through 2/16/23 showed: -Post 72 hour follow-up not completed; -No fall assessment completed; -No interventions put on the fall care plan for the fall on 2/13/23. 2. Review of Resident #3's care plan for falls revised on 6/2/23 showed: -Potential for falls related to a fall, impaired mobility, impaired balance at times, impaired memory and recent falls. 5/10/23 the resident had a fall resulting in being sent to the hospital for evaluation, diagnosis of a broken clavicle (collarbone) and radial head fracture (broken elbow); -Interventions: anticipate needs, ensure call light is with reach, floors free of spills and clutter, keep personal items within reach, offer reminders and cues. Review of the resident's nurses notes dated 8/9/23 at 2:33 P.M. showed -Post Fall Evaluation dated 8/9/23; Fall details was blank; -Contributing factors showed no documentation for vital signs and no interventions for the fall. -No documentation in the nurses notes to show that the resident had a fall. Review of the resident's quarterly MDS dated [DATE] showed: -The resident is usually understood and usually understands; -Requires extensive assistance of one staff member for ADL's; -Diagnoses of hypertension, Alzheimer's disease and schizophrenia (a serious mental disorder in which people interpret reality abnormally); -History of falls with one fall with no injury since admission. Review of the resident's nurses notes from 7/19/23 through 8/9/23 showed: -No documentation of any fall; -No documentation of any fall assessment; -No documentation of any vital signs. Review of the care plan for falls showed no interventions in place for the fall on 8/9/23. During an interview on 9/13/23 at 2:00 P.M. Licensed Practical Nurse (LPN) A said: -Nurses should assess the resident after a fall, document in the record the fall, vital signs and the assessment; -Should notify the physician and the responsible party; -Not for sure who puts interventions on the care plan. During an interview on 9/13/23 at 4:30 P.M. the LPN/MDS coordinator said when a resident has a fall, the fall should be documented on the care plan and interventions put in place after every fall; During an interview on 9/13/23 at 2:30 P.M. the Director of Nursing said: -When a resident falls, staff who finds the resident should notify the charge nurse that the resident has had a fall, or is found on the floor; -The nurse should assess the resident, provide first aide if needed, obtain vital signs, complete an assessment of the resident, make a note in the nurses notes, complete an incident report, notify the physician and the responsible party; -A post incident follow up should be completed along with 72 hour follow up. During an interview on 9/13/23 at 5:15 P.M. the Administrator said: -Nurses should document in the residents EHR the fall and the assessment; -Nurses should complete a post fall assessment and update the care plan for interventions for the fall; -A 72 hour post fall should be completed in the EHR.; -She would expect the nursing staff to follow the facility policy for falls. MO222299

Based on observation, interview, and record review, the facility failed to ensure sanitary practices in the kitchen. The facility census was 48. Review of the facility kitchen cleaning policy, dated December 2018, showed the following: -It is policy to follow the cleaning schedule as directed by the dietary manager. -Dietary staff will maintain a clean and sanitary kitchen. -The dietary manager delegates the cleaning to the cook or the aide for the day. -Daily cleaning: floors, and sink and countertops are cleaned and sanitized throughout the day; -Weekly cleaning: walls, doors, drains, and reach-in chillers; -Monthly cleaning: lighting and freezers; -Twice yearly the extraction ducts are cleaned. -The nightly aide is responsible for a checklist that is followed up by the dietary manager. Review of the facility's hairnet policy, dated December 2018, showed all persons working in direct contact with food, food-contact surfaces, and food packaging materials are to wear a hairnet or cap while in the kitchen for hygienic purposes. 1. Observations on 08/22/22 between 11:23 A.M. and 2:49 P.M. showed the following: -The top and bottom of the convection oven had a thick buildup of black debris; -Food was scattered all over the floor in the food preparation area, during food preparation and after the meal service; -Staff prepared tuna casserole for the noon meal and left tuna all over the sink on the serving counter. Staff did not clean the tuna from the sink after meal preparation. The tuna remained on the sink after meal service and throughout the observation; -The griddle, the counter under the stove, and the front of the stove were covered in food debris. 2. Observations on 8/22/22 between 11:23 A.M. and 2:49 P.M. showed the following: -The refrigerator by the convection oven contained fruit covered with plastic wrap that was labeled 8/17, applesauce covered with plastic wrap that was labeled 8/10, red sauce labeled 8/15, an opened jar of cherry halves with no open date, a jar of mayonnaise with no open date, a container of cooked bacon labeled 1/18, and an open bag of potatoes sat on an open bag of sliced turkey; -A bag of powdered sugar was open and sat on the window sill along with dirt, a black sharpie, a cell phone, a thermometer, keys, and a personal daily pill planner. 3. Observations on 8/22/22 showed between 11:23 A.M. and 2:49 P.M. showed the following: -At 12:01 P.M., while dietary staff were serving the noon meal, nursing staff came in the kitchen to get the food cart that contained the residents' prepared meal. The nursing staff did not wear a hair net while in the kitchen; -At 12:02 P.M. and 12:12 P.M., while dietary staff were serving the noon meal, evening dietary staff came in the kitchen not wearing a hair net. The staff walked through the kitchen, and by the food serving counter, to get a hair net. Staff them placed a hair net on, the staff's hair from the back of his/her head to mid back was not covered by the hair net; -Between 12:23 A.M. and 2:49 P.M., the dietary manager was in the kitchen. She had long hairs on the side and back of her head hanging out from under his/her hairnet. 4. During interview on 08/23/22 at 8:40 A.M., the administrator said she expected all food in the kitchen to be labeled and dated with an open date. Staff should throw away food items three days after they are opened. Staff should cover all of their hair with a hair net or cap. Staff should leave food or debris on the griddle, stove, or sink. During interview on 08/23/22 at 12:27 P.M., the dietary manger said he/she expected staff to label and date food items. Staff should throw away food items three days after they are opened. Anyone who comes in the kitchen should have all their hair covered. He/She was not aware of the debris buildup in the convection oven. There hadn't been a lot of time to clean since the kitchen was short staffed. He/She was aware cleaning needs done in the kitchen. MO 3

Based on observation, interview and record review the facility failed to ensure the resident call light system in place was adequately equipped to allow residents to call for staff assistance through a communication system which relayed the call directly to a staff member or to a centralized staff work area. In addition the facility failed to answer call lights in a timely fashion for two residents (Resident #39 and #405) in a review of 16 sampled residents. The facility census was 48. Review of the undated facility policy Call Lights showed the following: -It is the policy of the facility to provide a working call light at each resident bedside and toilet; -The call light should be placed within reach; -Call lights should be answered promptly by staff; -The call light indicator will be displayed on the monitor at the nurses station and front desk; -An audible pager will be utilized by a staff member. Review of the undated facility policy Arial Call Light Logs showed the following: -It is the policy of the facility to keep record of call lights for seven days; -The call light log is available for review by the resident or responsible party upon request; -The purpose of the call light log is to identify trends and for quality improvement for optimal response times. During interview on 8/24/22 at 5:43 A.M. the administrator said the following: -As of this date, Certified Nurse Assistant's (CNA's) need to look at the screens at the desk to see if a call light was on; -The screen would turn red when staff entered or exited the room; -The CNA's used to carry pagers, but the devices would not clear, and went off constantly and it was frustrating for staff so they no longer carried them; -The nurses are the only ones currently carrying a pager and they alert the CNA's if a call light is on; -Registered Nurse (RN) M does not currently have a pager on his/her person as this was only his/her second day. During interview on 8/24/22 at 5:50 A.M RN M said the following: -He/She did not have a pager on his/her person; -This was only his/her second day; -He/She looked at the screen at the nurse's desk to see if a call light was on; -The CNA's viewed the screen for call lights at each desk. During interview on 8/24/22 at 6:22 A.M. CNA Z said the following: -He/She was not carrying a pager at this time; -It was sporadic if he/she did carry a pager; -He/She looked at the board (monitor screen) to see if a call light was on. During interview on 8/24/22 at 6:24 P.M. the administrator said the following: -Staff have not carried pagers for a while (about a month); -They began researching phones (as an alternative) about the same time. 1. Review of Resident #39 ' s care plan, dated 4/19/22, showed the following: -He/She is moderately hard of hearing and usually understands when spoken to; -Call light within reach and answer in a timely manner. Review of the resident ' s significant change MDS, dated [DATE], showed the following: -Moderately impaired hearing; -Sometimes makes self understood; -Usually understands others; -Moderately impaired cognition; -No behavior symptoms or rejection of care; -Totally dependent on two staff assist for transfers; -Totally dependent with one staff assist for bed mobility, dressing, locomotion on and off the unit, toileting, and personal hygiene. Review of the facility provided call light log for the resident showed the following: -On 8/18/22 the call light was activated at 7:10 P.M. and cleared (answered) at 7:54 P.M., 44 minutes after activation; -On 8/18/22 the call light was activated at 9:40 P.M. and cleared at 11:14 P.M., 93 minutes after activation; -On 8/18/22 the call light was activated at 11:43 P.M. and cleared at 12:21 A.M., 37 minutes after activation; -On 8/19/22 the call light was activated at 12:28 P.M. and cleared at 1:05 P.M., 36 minutes after activation; -On 8/19/22 the call light was activated at 3:36 P.M. and cleared at 4:50 P.M., 74 minutes after activation; -On 8/19/22 the call light was activated at 5:25 P.M. and cleared at 7:00 P.M., 95 minutes after activation; -On 8/20/22 the call light was activated at 1:12 P.M. and cleared at 1:55 P.M., 43 minutes after activation; -On 8/20/22 the call light was activated at 6:53 P.M. and cleared at 7:44 P.M., 51 minutes after activation; -On 8/21/22 the call light was activated at 9:51 A.M. and cleared at 12:32 P.M., 161 minutes after activation; -On 8/22/22 the call light was activated at 11:44 A.M. and cleared at 12:32 P.m., 47 minutes after activation. Observation on 8/23/22 at 3:46 P.M., showed the following: -The resident sat up awake in his/her geri-chair with complaints of stomach pain and wanting to go to the hospital; -The resident's call light showed red as activated; -Family was at bedside and said the call light had been on for about 30 minutes; -The monitor at the nurse's station showed the call light activated at 3:09 P.M.; -Certified Nurse Aide (CNA) S entered the room at 3:48 P.M. and turned off the call light (39 minutes after activation), and said he/she would tell the nurse the resident did not feel well; -At 4:14 P.M. the call light was activated and cleared by staff at 4:38 P.M., 23 minutes after activation with no care given; -At 4:40 P.M. the call light was activated again by the resident; -At 4:37 P.M. Certified Medication Technician (CMT) R entered the residents room to give medication, the call light was cleared, audible sound noted indicating a call light was sounding when CMT R entered the room; -At 4:40 P.M. the call light was activated. -From 4:14 P.M. to 5:11 P.M. the resident yelled out for help nine times; -At 5:18 P.M. CNA S and CMT R entered the room to put the resident to bed; -At 5:28 P.M. the call light was turned off by CNA S, 48 minutes after activation. During an interview on 8/23/22 at 5:15 P.M., and on 8/24/22, at 2:26 P.M., CMT R said the following: -Staff know if a call light is going off in a room by watching the monitors; -When a call light was turned on a light turns red in the room; -Sometimes he/she has a pager that sounded when the call light turns on, but not always. During an interview on 9/12/22, at 10:47 A.M., CNA S said the following: -He/She checked the monitor frequently at the nurse's station to see if a call light is going off; -He/She has never carried a call light beeper. Observation during annual survey on 8/22/22 and 8/23/22 showed no audible tones from any beepers indicating a call light had been activated. Observation on 8/24/22 at approximately 6:00 A.M. noted the charge nurse to have been given a beeper and audible sounds noted. 2. Review of Resident #405's admission Care Plan (CP) dated 08/10/22 showed the following: -I have frequent moderate pain; -Encourage me to report any pain. -I require assist with ADL's r/t impaired mobility and impaired balance; -Ensure call light is within easy reach and answer in a timely manner. -Potential for injury r/t fall r/t impaired mobility, impaired balance, impaired memory, and history of falls. Review of the resident's electronic medical record, undated, showed the following diagnoses: -[CONDITION(S)] (RA), a chronic [CONDITION(S)] disorder affecting many joints, including those in the hands and feet; -Acquired absence of left leg above knee (surgically amputated due to poor blood flow); -[CONDITION(S)], an eye disease that causes vision loss. Review of the resident's admission MDS, dated [DATE], showed staff assessed the resident as follows: -Cognition intact; -Extensive assistance, one person physical assistance for toilet use; -Supervision, oversight, encouragement or cueing, one person physical assistance for personal hygiene. -Health conditions: reports moderate, frequent pain that makes it hard to sleep at night and limits day to day activities; -Functional limitations: impairment on one side, upper and lower extremities. Review of the facility's Device Activity Report showed the resident initiated his/her call light on 08/18/22 at 12:03:46 a.m. and the device was reset at 257 minutes, 48 seconds. During an interview on 08/22/22 at 12:10 p.m. the resident said the following: -Staff leave him/her sitting on a bedpan, one night it was for five hours; -The resident said this occurred on the night shift. During an interview on 08/24/22 at 06:07, CNA E said the following: -He/She always walks around the unit and He/She will check the computers at each end of the hallway to see if they have gone off; -If He/She was working in a resident's room, he/she cannot hear the call lights; -He/She did not carry a pager or use a walkie talkie. During an interview on 08/24/22 at 05:40 a.m., Licensed Practical Nurse (LPN) G said the following: -Call lights will send a sound to each of the two desktop computers on the nursing hall; -LPN G demonstrated use of a call light; when initiated the call light sent a soft ping sound to the computer with the resident's room number and time of initiation; -This sound was not repeated while the room number remained illuminated; -If He/She was away from the computer, there are walkie talkies at the nurse's desk used by the staff to alert them of the call light; -There were no lights outside of the resident's room to indicate the call light has been activated. During an interview on 08/25/22 at 09:20 a.m., LPN F said the following: -When a resident turns on a call light, his/her room number will come up on the computer screen at the nurses' station; -The computer might make a sound; -If the resident was in the bathroom and turns on the call light, the room number on the computer screen will flash; -If staff are in a resident's room, they would not know if the resident's call light was on because staff could not see or hear it; -Residents are checked on by staff making rounds in the hallways. During an interview on 08/29/22 at 11:25 a.m. the Director of Nurses (DON) said the following: -The system there was a new system, they have to look at the computer system frequently; -Anybody can answer a call light to provide care; -She would expect everyone to be looking at the monitors; -Nursing staff should have pagers. During an interview on 08/29/22 at 12:10 p.m. the administrator said the following: -Call lights are visual at the nurse's station and the beepers are the audible section; -The charge nurse carried the beepers and they are audible; -The direct care staff are told by the nurses or they look at the monitor and sometimes they carry a walkie-talkie. -She has at least four or five beepers. Having staff carry them became a problem. A few weeks ago she tried purchasing phones, but that has not been completed. The beepers were not an effective system; -At night time staff sit at the nurses' station to watch for call lights. MO 4 MO 8 MO 8

Based on observation, interview, and record review, the facility failed to create an environment that was respectful of the rights of each resident to make choices about aspects of their lives that were significant to them for four residents (Residents #10, #27, #30 and #39) in a review of 16 sampled when the facility failed to honor residents' preferences for time to awaken or be out of bed and the choice of bathing provided. The total facility census was 48. Review of the facility Resident Bill of Rights provided in the Admission Agreement showed residents had the right to make decisions and choices in the management of their personal affairs. Review of the undated facility Bathing Policy showed the following: -Residents will be offered two showers per week and more frequently if requested; -Resident rights will be respected as to self-determination related to bathing however, if a resident declines bath care the staff member will leave the room and come back later to offer the bath again; -If a resident refuses a bath because he or she prefers a shower or a different bathing method, such as in-bed bathing, prefers to bathe at a different time of day or on a different day, does not feel well that day, or is worried about falling, the facility will make reasonable efforts to accommodate residents' preferences. 1. Review of the facility's undated get up list located at the nurse's station showed the following: -Residents on the list were expected to be up/dressed or wakened by 7:00 A.M. every day; -Resident #10 and #27 were to be dressed and out of bed. 2. Review of Resident #27's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/22/22, showed the following: -His/Her cognition was severely impaired; -He/She required extensive assistance of one staff with transfers. Review of the resident's care plan, dated 6/28/22, showed the following: -He/She would be able to make decisions pertaining to his/her care to his/her ability on a daily basis; -Staff were to allow him/her to make choices pertaining to his/her care and ability; -If he/she was unable to communicate, staff were to base his/her care on his/her known preferences. - The resident's care plan did not include information regarding the resident's preferred time to awaken. Observation on 8/24/22 at 5:30 A.M. showed the resident was fully dressed and sleeping in a wheelchair beside his/her bed. 3. Review of Resident #10's annual MDS, dated [DATE], showed the following: -His/Her cognition was severely impaired; -He/She was dependent on two staff and mechanical lift for transfers. Review of the resident's care plan, last revised on 3/28/22, showed the following: -He/She required assistance with activities of daily living (ADLs) due to impaired mobility and impaired balance; -He/She liked to get up around 8:00 A.M. Observation on 8/24/22 at 5:30 A.M. showed the resident was dressed and in his/her Geri-chair (large padded chair that is designed to help seniors with limited mobility) in his/her room watching TV with the lights off. During interview on 8/24/22 at 5:35 A.M., Certified Nurse Assistant (CNA) A said he/she didn't usually work overnights and picked up this shift. He/She asked another CNA to help him/her get up residents who were supposed to get up. There was a get up list which indicated which residents he/she was supposed to get up. Resident #10 and #27 were on the list. These residents were non-verbal and could not communicate if they wanted to get up, but the residents were up and ready for the day. 4. Review of Resident #30's care plan, dated 4/14/22, showed the following: -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -He/She requires assist with activities of daily living; -Allow him/her to make personal care decisions daily. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderately impaired cognition; -No behaviors or rejection of care; -Extensive assist of two staff members for bed mobility, transfers, dressing, toilet use and personal hygiene; -Total dependence of one staff member for bathing; -Always incontinent of bowel and bladder. Observation on 8/22/22 at 1:38 P.M. showed the resident lay awake in bed. During an interview on 8/22/22, at 1:38 P.M., the resident said the following: -He/She has been made to stay in bed longer that he/she wanted; -He/She guessed they don't have enough staff to get him/her up; -He/She is supposed to get at least six baths a month and only got three last month; -He/She would like to have his/her two baths a week; -He/She would prefer to get up every day and would like to go to the dining room. Observation on 8/23/22, at 9:10 A.M., showed the resident lay awake in bed waiting for breakfast. During an interview on 8/23/22, at 9:10 A.M., the resident said the following: -He/She did not get to get out of bed yesterday (the 22nd); -He/She did not get his/her shower yesterday like staff told him/her would happen; -He/She wanted to get out of bed and get his/her shower yesterday. Observation on 8/24/22, at 7:55 A.M. showed the resident sitting up in his/her wheelchair in the dining room. During an interview on 8/24/22, at 7:55 A.M., the resident said the following: -He/She was glad to be out of bed and able to come to the dining room to eat; -He/She got a bed bath the evening before; -He/She was not satisfied with a bed bath, he/she would prefer a shower; -He/She did not get his/her hair washed during the bed bath; -He/She feels like a little pig being washed during a bed bath and does not feel clean. Observation on 8/24/22 at 7:55 A.M. noted the resident to have disheveled hair with a slight greasy appearance. 5. Review of Resident #39's care plan, dated 4/19/22, showed the following: -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -He/She is moderately hard of hearing and usually understands when spoken to; -Ensure he/she has understood directions and repeat as needed; -Allow him/her to make decisions about his/her care to give a sense of control; -Assume unhurried manner and allow ample time for tasks; -Call him/her by name; -Introduce yourself with each interaction; -Obtain his/her attention before speaking to him/her and speak face to face; -Talk to him/her during care and explain all procedures. Review of the resident's significant change MDS, dated [DATE], showed the following: -Moderately impaired hearing; -Moderately impaired cognition; -No behavior symptoms or rejection of care; -Daily preference choices are important to the resident. Observation on 8/23/22 at 4:47 P.M. showed the following: -Certified Medication Technician (CMT) R entered the resident's room and attempted to give liquid [MEDICATION(S)] (a medication to treat anxiety) via a syringe; -The resident asked what the medication was while turning his/her head to the side away from the syringe; -CMT R told the resident it was medication to help him/her calm down; -The resident moved his head multiple times saying he did not want the liquid medication; -CMT R continued two other times to attempt to put the syringe in the resident's mouth, all the while the resident is moving his/her head back and forth refusing the medication; -CMT R remarked, after attempting three times to give the medication, so you don't want your [MEDICATION(S)] and left the resident's room. During an interview on 8/29/22, at 11:29 A.M., and 9/12/22 at 8:55 A.M. the Director of Nursing said the following: -If a resident turns their head when a medication is being administered the medication should not continue to be pushed at a resident's face for them to take; -The resident has the right to refuse medication; -She expected residents to be given a bath at least twice a week and more frequently if needed; -If a resident can safely be given a shower, they should be given a shower if they want one; -Bed baths are to be given only if medically necessary; -Staff should follow care plan preferences and residents should be allowed to get up when they wanted to; -She did not like get up lists and was unaware the facility had one; -For residents who were dependent on staff and could not express their needs, family and/or responsible parties should be involved as much as possible and those decisions, such as wake up time should be addressed on resident's care plan. During an interview on 9/12/22, at 10:58 A.M., the administrator said the following: -A resident has the right to refuse medication; -Resident's should be allowed to make the choice of getting out of bed and what time to get out of bed; -Residents should be allowed to make the choice of taking a shower or a bed bath; -No resident is required to be up and dressed by 7:00 A.M.; -There was no get up list in the facility. MO 8 MO 8

Based on interview, observation, and record review, the facility failed to follow professional standard of care by failure to follow physician orders and medications manufacture's recommendations with administration of [MEDICATION(S)] (medication used to treat [CONDITION(S)] which is a condition caused by abnormally low activity by the [CONDITION(S)]) for one resident (Resident #27), failed to apply ace wraps and perform treatments to edematous extremities per physician orders for one resident (Resident #43) in a review of 16 sampled residents and failed to change a PICC (Peripherally Inserted Central Catheter access to the large central veins near the heart) line dressing as ordered by the physician for one additional resident (Resident #155). In addition the facility failed to administer and insulin pen (a medication used to treat diabetes/high blood sugar) for one resident (Resident #30). Facility census was 48. Review of the undated facility policy Medication Administration showed the following: 1. The facility will provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing and administering of all medication to meet the needs of each resident; 2. When getting the medication out of the resident's drawer check to make sure it is the: d. Right time; 11. Check for any special instructions the medication has for administration such as: e. Giving medications with or between meals. Review of the facility policy Insulin Pen Injection Administration dated November 2018 showed the following: Purpose: -The appropriate and safe administration of insulin will aide in the management of diabetes by the control of blood sugar levels; Procedure: 1. Follow general medication administration policy and procedures; 6. Remove pen cap and wipe rubber stopper with alcohol swab; 7. Always use a new needle for each injection. Remove protective tab from needle and screw it into the pen device; 8. To prime: turn the dose selector to two units. Hold pen with the needle pointing up and tap the cartridge gently to move air bubbles to the top. Press the button all the way in. A drop of insulin should appear at the tip of the needle; 9. Selecting the dose: turn the dose selector to the number of units needed to inject. The device will not allow you to select a dose greater than the number of units left in the pen; 10. Wipe the injection site with an alcohol swab and allow the area to dry. Insert the needle into the skin; 11. Press the button all the way until the dose selector is back to zero. Keep the needle in the skin for 10 seconds; 12. After injection, remove the needle (do not recap). Place used needle and empty insulin pens in sharps container as per facility protocol; 13. Replace the cap on the pen and store at room temperature without a needle attached. 1. Review of Resident #27's face sheet dated 8/24/22 showed his/'her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of resident's Physician Order Sheet (POS) dated 8/24/22 showed an order to administer [MEDICATION(S)] sodium ([CONDITION(S)] replacement hormone) 88 micrograms (mcg) daily at 6:00 A.M. Review of resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M. Observation of medication administration on 8/24/22 at 8:22 A.M , showed Certified Medication Technician (CMT) B administered the resident's [MEDICATION(S)] 88 mcg while the resident sat at dining room table eating breakfast. Review of the American [CONDITION(S)] Association recommendations for [MEDICATION(S)] administration dated 10/15/2018 showed [MEDICATION(S)] should be consistently administered 60 minutes before breakfast or at bedtime, or at least three hours after dinner. 2. Review of Resident #30's POS, dated 8/2022, showed the following: -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] KwikPen solution (a rapid acting injectable medication to lower blood sugar) inject 8 units three times a day; -[MEDICATION(S)] KwikPen sliding scale insulin three times a day. Observation on 8/23/22, at 5:15 P.M., showed the following; -CMT S administered 12 units of [MEDICATION(S)] Kwik Pen (8 scheduled units and 4 units sliding scale) to resident #30; -CMT S did not clean the rubber stopper of the [MEDICATION(S)] Kwik Pen prior to attaching a new needle to the pen; -CMT S did not prime the pen with 2 units of insulin prior to administering the insulin. During an interview on 8/23/22, at 5:18 P.M., CMT R said the following: -He/She did clean the rubber stopper prior to attaching a needle, the SA observing must have missed it; -He/She primed the Kwik pen the first time he/she was going to give resident #30 his/her insulin around 4:30 P.M.; -He/She removed the needle attached to the pen with first attempt to administer; -He/She was not aware the Kwik pen had to be primed with each administration and each needle. 3. Review resident #155's care plan dated 6/8/22 showed the following: -IV (fluids administered through a needle in a vein), fluids for hydration as ordered, see Treatment Medication Record (TAR); -Medications and treatments as ordered; -The care plan did not address the presence of or the care of a PICC line. Review of the resident's POS dated 8/22 showed the following: -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Sodium chloride solution 1000 milliliters (ml) intravenously (IV) (7/11/22); -Using sterile technique and change PICC line dressing every Friday and as needed (PRN) if soiled (6/24/22); Review of the resident's TAR dated 8/1 to 8/31/22 showed the following: -PICC line dressing change. Using sterile technique change PICC line dressing every Friday (day shift) and PRN if soiled; -Dressing change due 8/5, 8/12, 8/19 and 8/26; -TAR blank with no initials to show treatment completed on 8/5 and 8/12; -TAR with initials to show treatment completed on 8/19, however observation showed treatment dressing remained dated 7/31/22. Observation on 8/22/22 at 2:29 P.M. showed the following: -The resident sat dressed in his/her chair; -Licensed Practical Nurse (LPN) I entered the room and prepared to hang IV fluids. The nurse pulled the resident's shirt back to access the PICC line site. The date on the dressing read 7/31/22. Observation on 8/25/22 at 6:30 P.M showed the following: -The resident sat dressed in his/her chair in his/her room; -The PICC line dressing was intact and dated 7/31/22. During interview on 9/12/22 at 10:05 A.M. Registered Nurse (RN) P said the following: -Treatments should be completed as ordered; -PICC line dressing changes should be completed as ordered.; -There was one resident (Resident #155) who had a PICC line and the order was for the dressing to be changed every Friday and PRN if soiled. 4. Review of resident #43's care plan dated 5/3/22 showed the following: -Monitor [CONDITION(S)] of legs and feet; -Treatments as ordered. Review of the resident's POS, dated 8/22 showed the following: -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Apply ace wraps to bilateral lower extremities every morning and remove every night. Ace wraps must be placed on the night shift at 6:00 A.M every morning for [CONDITION(S)] (8/23/22); -Wound care treatment to left medial lower extremity (LE), right medial LE, right anterior LE, cleanse wounds, apply [MEDICATION(S)] 2% ointment and alginate (topical preparations to treat wounds) to wounds, cover with a dry dressing/ABD (abdominal) pad, secure with kerlix (dressing) every other day and PRN. Review of the resident's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] -Apply ace wraps to bilateral lower extremities every morning and remove every night. Ace wraps must be placed on the night shift at 6:00 A.M every morning for [CONDITION(S)] (8/16/22), (8/23/22); -Ace wraps documented as applied at 6:00 A.M. and removed at 9:00 P.M. on 8/23/22; -No dressing orders for wounds on the MAR. Observations of the resident on 8/23/22 showed the following: -At 9:26 A.M. the resident lay in his/her bed with three to four plus (rating scale: plus one to plus four with four being the most [CONDITION(S)]) [CONDITION(S)] (occurs when tiny vessels in your body (capillaries) leak fluid which builds up in surrounding tissues, leading to swelling), noted to his/her bilateral lower extremities. There were no ace bandages or dressings on the resident's lower extremities; -At 11:00 A.M. the resident sat in his/her room on the side of the bed with his/her legs unwrapped and no dressings to wounds; -At 3:50 P.M. the resident sat in his/her wheelchair in his/her room with legs unwrapped and no dressings to wounds; -At 4:05 P.M. the resident sat in his/her wheelchair in the doorway of his/her room with legs unwrapped and no dressings to wounds. The resident said his/her legs did not swell so badly when staff applied ace wraps. Observations of the resident on 8/24/22 showed the following: -At 5:51 A.M. the resident sat on the side of his/her bed with legs unwrapped and no dressings to wounds; -At 6:30 A.M. the resident remained on the side of his/her bed with legs unwrapped and no dressings to wounds; -At 8:52 A.M. the resident sat in his/her wheelchair with his/her legs unwrapped and no dressings to wounds. During interview on 8/25/22 at 9:58 A.M. LPN O said nursing was responsible for the completion of treatments and they should be completed every shift and PRN as ordered. Review of the A hall communication binder dated 8/24/22 showed Resident #43 had increased [CONDITION(S)] to his/her bilateral lower extremities. Must wear ace wraps (on 6:00 A.M.) physician here and aware. During an interview on 8/29/22 at 11:29 A.M., the Director of Nursing (DON) said the following: -[MEDICATION(S)] should be given on an empty stomach and before breakfast, around 6:00 A.M.; -PICC line dressings should be changed per physician orders and should be dated; -She would not expect a PICC line dressing observed on 8/22/22 and thereafter up to 8/25/22 to be dated 7/31/22; -She would expect ace wraps to be applied to edematous extremities and treatments to be completed as ordered by the physician; -She would not expect a resident to go an entire day without their ace wraps applied or treatments not completed. MO 4 MO 4 MO 2 MO 5

Based on observation, interview and record review, the facility failed to ensure staff washed their hands after each direct resident contact and when indicated by professional standard of practice during personal care for four residents (Resident #10, #26, #20, and #39) in a review of 16 sampled residents, failed to ensure one resident's (Resident #39's), urinary collection bag was kept off the floor, and failed to appropriately wear and change Personal Protective Equipment (PPE) upon entering a Covid positive resident's (Resident #155's) room, wearing a contaminated N95 mask to other resident rooms to deliver meals. Facility's census was 48. Review of the CNA in Long Term Care- 2001 Revision Manual shows the following: -Handwashing is the single most important means of preventing the spread of infections; -Instructions to wash hands before and after contact with residents; -Instructions to start with the cleanest area and work toward the dirtiest area when cleaning an item or body part; -Instructions to always wash hands for at least 15 seconds before and after glove use. Review of the Infection Control Guidelines for Long Term Care Facilities, January 2005 edition, Section 3.0, Body Substance Precautions, Subsection 3.2 Implementing the Body Substance Precautions System, showed the following regarding gloves and handwashing: -Instructions should be followed by ALL personnel at all times regardless of the resident's diagnosis; -Gloves: Wear gloves when it can be reasonably anticipated that hands will be in contact with mucous membranes, non-intact skin, any moist body substances (blood, urine, feces, wound drainage, oral secretions, sputum, vomitus, or items/surfaces soiled with these substances) and/or persons with a rash; gloves must be changed between residents and between contacts with different body sites of the same resident; -REMEMBER: Gloves are not a cure-all; they should reduce the likelihood of contaminating the hands, but gloves cannot prevent penetrating injuries due to needles or sharp objects; dirty gloves are worse than dirty hands because microorganisms adhere to the surface of a glove easier than to the skin on your hands; and handling medical equipment and devices with contaminated gloves is not acceptable; -Handwashing: Handwashing remains the single most effective means of preventing disease transmission; wash hands often and well, paying particular attention to around and under fingernails and between the fingers; wash hands whenever they are soiled with body substances, before food preparation, before eating, after using the toilet, before performing invasive procedures and when each resident's care is completed. Review of the undated facility policy Hand Hygiene showed the following: Hand hygiene is necessary to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection; 1. When to wash hands: a. Before and after direct contact with residents; b. Before putting on gloves; c. After removing gloves of other personal protective equipment (PPE) i.e. gown, masks; d. After contact with blood, body fluids or articles/surfaces visibly contaminated with body substances or after contact with objects in resident's environment; e. After contact with resident's skin; k. It may be necessary to wash hands between tasks or procedures on the same resident to prevent cross contamination of different body sites; 7. Employees will be educated on hand hygiene procedures during new hire orientation, annually and on an as needed basis. Review of the undated facility policy Urinary Catheter Care showed the following: 2. Catheter Tubing and Bag: a. Tubing should be secured to keep from falling on the floor; c. Keep the bag below the level of the resident's bladder at all times; -No direction to staff regarding keeping the catheter bag off the floor to prevent contamination. Review of the facility policy for PPE protocol dated 1/1/21 showed all staff will wear surgical masks or KN95's while on duty at all times. Non cloth masks will be changed for new masks only. During an outbreak, staff will wear N95 masks while entering any COVID positive room. Clean PPE will be stored outside of the COVID positive room. The mask (that is worn in all other areas) will be stored in a paper bag and hung outside the room, clearly labeled and designated with the staff member name. Once departing the room, PPE (with exception of the N95 mask) will be discarded or hung within the room The N95 mask will be removed outside the room and placed in the bag and general mask (donned for wear) throughout the other areas. 1. Review of the Resident #10's care plan, last updated on 3/28/22, showed the following: -The resident had potential for development of pressure ulcers related to impaired mobility and incontinence; -The resident was incontinent of both bladder and bowel; -Staff were to provide incontinence care after each incontinence episode. Review resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 6/21/22, showed the following: -He/She required extensive assistance with bed mobility; -He/She was dependent on two staff with toilet use; -He/She was dependent on one staff with personal hygiene; -He/She was always incontinent of bowel and bladder. Observation on 8/23/22 at 4:53 P.M. showed the following: -The resident was incontinent of urine which had soiled through his/her clothing, incontinence brief, and sheets; -Certified Nurse Assistant (CNA) F cleaned the resident's front perineal area with disposable wipes, assisted the resident to the resident's left side by touching the resident with soiled gloves and Nurse Aide (NA) F cleansed the resident's buttock areas. With soiled gloves, CNA F placed a clean incontinence brief under the resident. Without removing soiled gloves and performing hand hygiene, both CNA F and NA G placed clean clothes on the resident and placed a mechanical lift pad under the resident. 2. Review of Resident #26's care plan, last revised 03/31/22, showed the following: -The resident is incontinent of both bladder and bowel; -Perineal cleansing and apply protective skin barrier after each incontinent episode; -Toilet upon rising, before and after meals, bedtime and as needed with assistance of one. Review of the resident's quarterly MDS dated [DATE] showed the following: -Short and long term memory problems; -Required extensive assist of one for toilet use and personal hygiene; -Always incontinent of bladder and bowel; -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Observation on 08/23/2022 at 4:25 P.M. in the resident's bathroom showed the following: -The resident was incontinent of stool; -CNA S with gloved hands provided rectal peri care; -CNA S wiped the resident's rectal area four times and changed his/her gloves between each wipe without washing his/her hands when he/she applied clean gloves; -Without changing his/her gloves or washing his/her hands, CNA S applied a clean incontinence brief; -With the same gloved hands CNA S removed the resident's soiled sweat pants and applied clean sweat pants; -With the same gloved hands CNA S applied the resident's tennis shoes; -CNA S then removed his/her gloves and washed his/her hands. During an interview on 9/12/22, at 11:23 A.M., CNA S said the following: -He/She normally washed his/her hands before and after resident care, as well as before and after using gloves; -He/She is not sure why he/she did not perform hand hygiene before and after care provided to the resident. 3. Review of Resident #20's care plan, last revised 04/04/22, showed the following: -The resident was incontinent of both bladder and bowel; -Perineal cleansing and apply protective skin barrier after each incontinent episode; -Toilet upon rising, before and after meals, bedtime and as needed with assistance of one. Review of the resident's Quarterly MDS dated [DATE] showed the following: -Severely impaired cognition; -Total dependence on two plus persons for transfer assist; -Total dependence on one person for toileting; -Extensive assist of one for personal hygiene; -Always incontinent of bladder and bowel; -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Observation on 08/24/2022 at 8:12 A.M. in the resident's room showed the following: -The resident lay in his/her bed; -The resident was incontinent of urine; -With gloved hands CNA E provided peri care and removed the soiled brief; -Without changing gloves or washing his/her hands, CNA E applied a clean incontinence brief; -CNA E removed his/her gloves without washing his/her hands and applied clean sweat pants and rolled resident from side to side; -CNA E opened resident's dresser drawer and removed a clean pair of socks; -CNA E gathered soiled linens and left resident's room without washing his/her hands. During interview on 09/07/2022 at 2:15 P.M. CNA E said the following: -He/She could not recall the facility providing any training on hand washing; -He/She had just forgotten to wash his/her hands between glove changes while providing care for resident. 4. Review of Resident #39's care plan, dated 4/19/22, showed the following: -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . -He/She has an indwelling urinary catheter related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -He/She will not have complications related to the urinary catheter; -Provide catheter care per protocol. Review of the resident's significant change MDS, dated [DATE], showed the following: -Moderately impaired cognition; -Totally dependent on two staff assist for transfers; -Totally dependent with one staff assist for bed mobility, toileting, and personal hygiene; -Has an indwelling catheter (a tube inserted into the bladder for urine drainage); -Always incontinent of bowel. Observation on 8/22/22 at 1:15 P.M. showed the resident lay in bed sleeping The resident's urinary drainage bag and tubing touched the floor. The urinary bag was not in a dignity cover, as it had a dignity flap attached to the clear side of the bag. Urine was present in the bag and tubing, purple in color and cloudy in nature. Observation on 8/23/22 at 9:35 A.M. showed the resident lay in bed with eyes open. The resident's urinary drainage bag hung from the bed frame with the bag and tubing touching the floor. The urinary bag was not in a dignity cover, as it had a dignity flap attached to the clear side of the bag. Urine was present in the bag and tubing, maroon tinged with a small amount of sediment noted. Observation on 8/23/22 at 5:18 P.M. showed the following: -The resident sat up in his/her geri-chair in his/her room: -CNA S entered the room to provide care for the resident; -CNA S did not wash his/her hands prior to putting on gloves; -CNA S assisted the resident and other staff to mechanically transfer the resident to bed with a lift; -CNA S removed his/her gloves after transferring the resident and attaching the urinary drainage bag to the bed frame and did not wash his/her hands prior to exiting the resident's room. During an interview on 9/12/22, at 11:23 A.M., CNA S said he/she was not sure why he/she did not perform hand hygiene before and after care provided to Resident #39. Observation on 8/24/22 at 5:45 A.M. showed the resident lay in bed sleeping. The resident's urinary drainage bag hung on the bed frame with the bag and tubing touching the floor. The urinary bag was not in a dignity cover, as it had a dignity flap attached to the clear side of the bag. Urine was present in the bag and tubing, light tan in color, slightly cloudy in nature with a small amount of sediment. Observation on 8/24/22 at 8:04 A.M. showed the following: -The resident was awake and in bed; -The resident's urinary drainage bag hung on the bed frame with the bag and tubing touching the floor; -The urinary bag was not in a dignity cover, as it had a dignity flap attached to the clear side of the bag;. -Urine was present in the bag and tubing, light tan in color, slightly cloudy in nature with a small amount of sediment; -The resident had a small bowel movement; -Registered Nurse (RN) P provided peri-care and touched the resident's body in numerous places, left hip, left knee and inner thigh with the same soiled gloves he/she wore to provide peri-care. During an interview on 9/12/22, at 9:46 A.M., RN P said the following: -Hands should be washed before and after providing resident care; -Gloves should be changed when they become soiled; -Hand hygiene should be performed after removing soiled gloves and before putting on a clean pair of gloves; -The urinary drainage bag and tubing should not touch the floor. 5. Review of Resident #155's Covid-19 testing document dated 8/18/22 showed the test result was positive. During interview upon entrance to the facility on [DATE] at 10:56 A.M. the Administrator said they had one Covid positive resident who would be coming off of isolation today. Observation on 8/22/22 at 11:30 A.M. showed the resident's door to his/her room closed with signage on the door instructing visitors to don an N-95 mask, gown, and gloves before entering the room. A PPE storage bin sat outside the room. A string hung across the outside of the door with brown paper bags (labeled with names) clipped to the string. The bags contained staff's N-95 masks. During interview on 8/23/22 at 11:53 A.M. the assistant administrator said that the facility thought the quarantine period for the resident was five days but then realized it was ten days. The resident would not come off of isolation as soon as they had thought. During interview on 8/23/22 at 5:06 P.M. CNA S that before entering Resident #155's room, staff should knock on the door and don gown, gloves and an N95 mask. Observation on 8/25/22 at 6:00 P.M. showed the following: -Nurse Assistant (NA) K opened the resident's door and wearing the N95 mask he/she had on, entered the resident's room without donning a gown, gloves or changing his/her mask. He/She delivered the resident his/her supper tray and juice glass and then exited the room. During interview on 8/25/22 at 6:01 P.M NA K said the following: -He/She was only told to wear a mask in the resident's room and was not told to change the mask; -NA K walked back to the PPE station, pulled out a clean N95 mask, left the contaminated mask on, looped the clean mask over his/her wrist and continued to push the meal cart to the next room; -NA K picked up a supper plate and drink, entered room [ROOM NUMBER], delivered the tray and exited the room with the clean mask still hanging from his/her wrist; -He/She pushed the cart to the next room, picked up a supper plate and drink, entered room [ROOM NUMBER], delivered the plate and exited the room with the clean mask on his/her wrist; -At 6:08 P.M. he/she pushed the cart to the next room, picked up a supper plate and drink, entered room [ROOM NUMBER], delivered the plate and exited the room with the clean mask on his/her wrist; -At 6:10 P.M. He/She pushed the cart to the next room, picked up a supper plate and drink, entered room [ROOM NUMBER], delivered the plate and exited the room with the clean mask on his/her wrist; -At 6:12 P.M. He/She picked up the last supper plate and drink , entered room [ROOM NUMBER], delivered the plate and exited the room with the clean mask on his/her wrist. During interview on 8/25/22 at 6:14 P.M. the resident said the mask on his/her wrist was the clean mask he/she took out of the PPE bin and he/she had not changed masks. Observation on 8/25/22 at 6:16 P.M showed the following: -CNA AA entered the resident's room with a glass of juice, without donning a gown, gloves and only wore a surgical mask; -He/She said that he/she did not think the resident was still on isolation, no one had told him/her either way; -He/She should put a gown, gloves and an N-95 mask prior to entering the resident's room if the resident was still on isolation; -The red signage remained on the outside of the resident's door and the PPE station remained just outside the room. During interview on 8/25/22 at 6:20 P.M. Licensed Practical Nurse (LPN) D said the following: -He/She first became aware that the resident was in isolation last Friday (8/19/22) when he/she returned from being off of work; -That was the first day he/she noticed PPE outside of the room; -When residents were put on isolation he/she would relay that information to staff through verbal report; -Staff should apply a clean gown, gloves and an N95 mask prior to entering the room, doff inside the room and wash their hands. During interview on 8/29/22 at 11:25 A.M the Director of Nurses (DON) said the following: -There was a PPE station outside of Covid positive resident rooms; -She would expect staff to utilize the PPE per protocol, donning when entering a room and doffing when exiting; -Staff should take their mask off and apply an N95 mask at the threshold of the resident's doorway; -There were gowns hung inside the room as they are re-using them; -She would not expect staff to deliver a food tray with only their N-95 mask on; -She would not expect staff to continue to wear the same N-95 (contaminated) mask that was worn in a Covid positive room; -Staff should wash hands frequently, before and after gloving, when removing soiled gloves, and always wash before entering and when exiting a resident room; -Catheter drainage bags and tubing should not touch the floor. MO 1

Based on observation, interview, and record review, the facility failed to ensure four residents (Resident #43, #27 and #35), in a review of 16 sampled residents, received a gradual dose reduction (GDR), of their [CONDITION(S)] medications and/or a documented rationale as to why a GDR was decline and failed to ensure a PRN [CONDITION(S)] drug did not extend beyond 14 days without a stop date and/or renewed order. The census was 53. Review of the undated facility policy Medications-Antipsychotics showed the following: -Monitoring and assessment of antipsychotic medications use includes ensuring that: -Within the first year in which a resident is admitted on an antipsychotic medication or has been started on an antipsychotic medication, the charge nurse must request that the resident's physician evaluate the resident for a Gradual Dose Reduction (GDR); a. The request for GDR evaluation must be made in two separate quarters of the year, (with at least one month between the attempts), unless clinically contraindicated; b. After the first year, a GDR evaluation must be requested annually, unless clinically contraindicated; c. The charge nurse must document every request and the physician's response in the resident chart; 6. The GDR may be considered clinically contraindicated if: 1. The resident's target symptoms returned or worsened after the most recent attempt at a GDR within the facility; AND -The physician has documented why any additional attempted dose reduction at that time would be likely to impair the resident's function or increase distressed behavior; 1. Review of Resident #27's diagnoses documented on his/her face sheet showed the following: -Unspecified convulsions (uncontrolled jerking movement); -[CONDITION(S)] (acute disturbed state of mind characterized by delusions, and incoherence of thought and speech; -[CONDITION(S)] (inability to sleep). Review of the resident's POS dated 8/24/22 showed the following: -On 10/26/20, orders obtained for [MEDICATION(S)] (medication to aide with sleep) 5 mg to be administered at bedtime (HS); -On 5/12/21, an order was obtained to administer [MEDICATION(S)] 25 mg to be administered by mouth in the afternoon for treatment of [CONDITION(S)]. Review of resident's progress notes showed no documentation that indicated a GDR for either [MEDICATION(S)] or [MEDICATION(S)] was requested, attempted, and/or declined with physician rationale as to why GDR was not recommended. Record review of the resident's quarterly MDS, dated [DATE], showed the following: -His/Her cognition was severely impaired for daily decision making; -He/She had no [CONDITION(S)], including no hallucinations and no delusions; -He/She had no documented physical behavioral symptoms during the seven day look back period; -He/She had not rejected care; -Active diagnosis included medically complex conditions (there were no specific diagnoses listed); -In the last seven days, the resident had received an antidepressant and an anti-hypnotic medications seven days; -Resident did not receive any antipsychotic medications; -There was no documentation to show a GDR had not been attempted and medications had not been determined contraindicated by a physician. Review of the resident's care plan dated 4/6/22 showed: -Resident had the potential for adverse reaction to [CONDITION(S)] drug use. He/she was taking antidepressant and hypnotic medications; -Staff would consult with pharmacy and primary care physician to consider dosage reduction when clinically appropriate. Review of resident's POS dated 8/24/22 showed the following: - [MEDICATION(S)] (anti-hypnotic medication to aide with sleep) 5 mg to be administered at bedtime (HS); - [MEDICATION(S)] 25 mg to be administered by mouth in the afternoon for treatment of [CONDITION(S)]. Review of facility's GDR tracking log book on 8/25/22 showed no documented attempts and/or requests for GDRs for [MEDICATION(S)] and/or [MEDICATION(S)]. There was no documentation to support why GDRs had not been attempted. During an interview on 8/29/22 at 11:29 A.M., the director of nursing said she had not worked at the facility long enough, but she believed GDRs would be completed at least quarterly and/or as directed by resident's physician. 2. Review of resident #35's care plan dated 5/5/22 showed the following: -Potential for adverse reaction to [CONDITION(S)] drug use; -Consult with pharmacy, Primary Care Physician (PCP) to consider dose reduction when clinically appropriate; -Medications as ordered; -Psych visits PRN. Review of resident's progress notes dated 6/13/22 showed pharmacy reviewed medications and no new recommendations were made at that time. Review of resident's progress notes dated 7/14/22 showed pharmacy reviewed medications and no new recommendations were made at that time. Review of the resident's POS dated 8/22 showed the following: -Diagnoses included unspecified mood disorder, Autistic disorder (neurological and developmental disorder that affects how people interact with others, learn, communicate and behave), [CONDITION(S)] disorder (episodes of mood swings ranging from depressive lows to manic highs), [CONDITION(S)] disorder and intermittent explosive disorder; -[MEDICATION(S)] (anti-anxiety) 2 mg/ml intramuscularly (IM) every six hours PRN (4/8/22); -[MEDICATION(S)] (antipsychotic) 5 mg/ml every six hours IM PRN for agitation (4/8/22). Review of resident's progress notes dated 8/10/22 showed pharmacy reviewed medications and no new recommendations were made at that time. Review of the resident's pharmacist consultant documents did not show the [MEDICATION(S)] or [MEDICATION(S)] orders were addressed. Review of the resident's medical record did not show a stop date or new order for the PRN [MEDICATION(S)] or [MEDICATION(S)] orders. 3. Review of resident #43's care plan dated 5/3/22 showed the following: -Potential for adverse reaction to [CONDITION(S)] drug use. History of depression and anxiety; -I will have minimal/no side effects r/t [CONDITION(S)] drug use through next review; -Consult with pharmacy, PCP to consider dosage reduction when clinically appropriate; -Meds as ordered; -Psych visits as needed. Review of the Pharmacist's Medication Regimen Review dated 6/122 to 6/13/22, showed: Please note [MEDICATION(S)] is meant to be a scheduled medication and PRN [CONDITION(S)] orders are good for only two weeks and must be reordered with supportive documentation to be in compliance. Review of resident' progress notes dated 7/14/22 showed pharmacy medication review complete. No new recommendations. Review of the resident's POS dated 8/22 showed the following: -Diagnoses included anxiety and major depression; -[MEDICATION(S)] (anxiety) 10 mg one tab po every eight hours PRN/anxiety (4/26/22). Review of the resident's MAR dated 8/22 showed [MEDICATION(S)] 10 mg with a start date of 4/26/22. Review of resident's progress notes, dated 8/10/22 showed pharmacy medication review complete. Medical Doctor recommendations. During interview on 8/29/22 at 12:10 P.M. the administrator said PRN anti-anxiety medications should have a 14 day stop date and be renewed if necessary. MO 4

Based on observation, interview and record review the facility failed to ensure resident safety for four residents (Residents #1, #13, #35 and #39) in a review of 16 sampled residents. Staff failed to use a gait belt while assisting one resident (Resident #13) and lifted the resident under both arms, staff failed to ensure a mechanical lift pad was appropriately placed under a resident, or stop the transfer when the resident expressed pain during the transfer for one resident, (Resident #39) and staff failed to ensure two residents (Resident #1 and #35), had foot pedals on their wheelchairs prior to staff propelling the residents in the facility. The facility census was 48. Review of the facility Gait Belt Policy dated 4/2020 showed the following: It is the policy of the facility that the therapy director will gait belt train all new staff upon orientation with the following guidance: -Gait belts must be used when transferring a resident who requires assist; -Gait belts are kept in each resident room; -Gait belts should be applied low, above the hip bone; -Gait belts should be snug. Review of the undated facility policy Transfers and Lifts showed the following: 1. The facility will ensure that all staff members are instructed in safe transfer and lifting techniques and how to report suspected injuries; 6. Transfer and Lifting Equipment: d. Use the equipment as it is designed to be used, safely with attention and with good body mechanics; g. Gait belt-canvas belt without handles; 1. Fasten it securely around the resident's waist; 2. Grip the belt when moving the resident; h. Sling lift/Hoyer lift: 1. For residents who are totally dependent or partial or non-weight bearing; 7. Apply sling properly and position it above shoulders and below buttocks; 10. Secure the resident's arms and legs so they don't hang out of the sling during transfer. Review of the undated facility statement titled Leg Pedals Usage In-service showed the following: -All residents being propelled in a wheelchair must have leg pedals attached and utilized; -Residents legs should be placed on the leg pedals and not dangle through or be dragged on the floor; -If a resident propels themselves, they do not need leg pedals, unless staff propels them; -If the resident refuses to allow leg pedals, staff may not propel them; -It is acceptable for the resident to utilize just one leg pedal, at their request; -Every resident has been given their own individual pair of leg pedals. Each set have been labeled with their name; -There will be extra pairs of leg pedals stored at the front desk, near the dining room and in the activity therapy room; -Please use the stock for easy access but return them to the designated areas; -If you have any problems with applying the leg pedals, please contact the nursing staff. 1. Review of Resident #13's care plan, dated 4/12/22, shows the following: -Diagnoses include: heart failure (a chronic condition in which the heart does not pump blood as well as it should), delusional disorder (a condition in which an individual displays one or more delusions for a month or longer), hypertension (high blood pressure), unspecified dementia with behavioral disturbance (a group of thinking and social symptoms that interferes with daily function, often with agitation or aggression), chronic pain and Parkinson ' s disease (a disorder of the central nervous system that affects movement, often including tremors); -Potential for injury related to falls and impaired mobility, impaired balance, impaired memory and recent falls; -He/She requires assist with activities of daily living (ADL's) related to impaired mobility and impaired balance; -No documentation the resident refused to use a gait belt for transfers. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/18/22, showed the following: -Severely impaired cognition; -Extensive assistance by two staff for bed mobility and transfers; Observation on 8/24/22, at 5:54 A.M., showed the following: -Resident #13 lay awake in his/her bed; -CNA T and CNA U prepared the resident to get up for the day and assisted him/her to a sitting position on the side of the bed; -CNA T assisted the resident to a standing positing by lifting under the resident's left arm; -CNA U assisted the resident to a standing position by lifting under the resident's right arm and pulling up by the waist band at the back of the resident's pants; -The resident stood and pivoted to his/her wheelchair; -CNA T and CNA U did not use a gait belt to transfer the resident. During an interview on 8/24/22 at 6:21 A.M., CNA T said the following: -He/She did not use a gait belt to transfer Resident #13 from the bed to the chair; -He/She lifted under the resident's arm to assist in a pivot transfer; -Resident #13 refuses to use a gait belt; -If the resident were to lose his/her balance there was a potential he/she could get hurt without using the gait belt. During an interview on 8/24/22 at 6:21 A.M., CNA U said the following: -He/She did not use a gait belt to transfer Resident #13 from the bed to the chair; -He/She lifted under the resident's arm and he/she held on to the residents pants at the back to assist in the transfer; -Resident #13 has a history of refusing the gait belt so he/she did not even offer a gait belt. Review of the undated facility statement titled Leg Pedals Usage In-service showed the following: -All residents being propelled in a wheelchair must have leg pedals attached and utilized; -Residents legs should be placed on the leg pedals and not dangle through or be dragged on the floor; -If a resident propels themselves, they do not need leg pedals, unless staff propels them; -If the resident refuses to allow leg pedals, staff may not propel them; -It is acceptable for the resident to utilize just one leg pedal, at their request; -Every resident has been given their own individual pair of leg pedals. Each set have been labeled with their name; -There will be extra pairs of leg pedals stored at the front desk, near the dining room and in the activity therapy room; -Please use the stock for easy access but return them to the designated areas; -If you have any problems with applying the leg pedals, please contact the nursing staff. 2. Review of Resident #1's Care Plan (CP) dated 08/23/22 showed the following: -I require assist with ADL's r/t impaired mobility and impaired balance; -I require assist x1 at times to transfer; -Potential for injury r/t fall r/t impaired mobility, impaired balance, impaired memory, hx. of falls and [CONDITION(S)] drug use. Review of the resident's electronic medical record, undated, showed the resident with diagnosis including peripheral vascular disease (PVD), (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs) and [CONDITION(S)] Disease, (a disorder of the central nervous system that affects movement, often including tremors). Review of the resident's admission MDS, dated [DATE], showed staff assessed the resident as follows: -Cognition moderately impaired; -Supervision, oversight, encouragement or cueing, setup help only for locomotion on unit; -Extensive assistance-resident involved in activity, staff provide weight-bearing support, one person physical assist with locomotion off unit; -Mobility devices: walker. Observation of the resident on 08/22/22 showed the following: -At 11:55 a.m. the resident lay in bed on his/her back; -An unidentified staff member knocked on the resident's door and entered the room; -The staff member assisted the resident up to the wheelchair in his/her room; -Two foot rests lay on the floor against the wall in the resident's room; -The resident requested staff push him/her to the dining room for lunch; -Staff transported the resident without foot rests to the dining room with the resident holding his/her legs up approximately three to four inches off the floor during the transport. Observation of the resident on 08/23/22 showed the following: -At 9:30 A.M. an unidentified staff member removed the resident from the dining room by his/her wheelchair. Staff pushed the resident in his/her wheelchair back to his/her room. The resident held his/her feet up off of the floor by about three inches. There were no foot rests on the wheelchair; -At 11:18 A.M. an unidentified staff member pushed the resident in his/her wheelchair from the dining room to the resident's room. There were no foot rests are on the wheelchair. The resident held his/her feet up about three inches off of the floor while being transported. Observation of the resident on 08/24/22 showed the following: -At 08:15 A.M. an unidentified facility staff assisted the resident from his/her bed to the wheelchair to go to the dining room for breakfast. The resident propelled himself/herself in the wheelchair by taking small steps with his/her feet. No foot rests were attached to the wheelchair; -At 09:10 A.M. the resident propelled himself/herself down the hallway in the wheelchair by taking small steps. There were no foot rests on the wheelchair. Certified Occupational Therapy Assistant (COTA E) approached the resident about doing his/her physical therapy for the day. COTA E asked the resident to wait in the hallway while he/she got wheelchair foot rests. COTA E retrieved foot pedals from the resident's room and attached them to the wheelchair. COTA E assisted the resident in placing his/her feet on the foot rests and propelled the resident to the therapy room. During an interview on 08/24/22 at 09:15 a.m. COTA E said the following: -Foot rests should always be in place and used for all transfers by staff when the resident was in a wheelchair and not propelling himself/herself. -Foot rests should be used to prevent unintentional injury to the resident during the transport. During an interview on 08/25/22 at 09:20 a.m., Licensed Practical Nurse (LPN) F said the following: -Foot rests should always be used if a resident was being transported by staff; -If foot rests are not readily available in the resident's room, the staff should talk to the therapy department and not transfer the resident until the foot rests were put on the wheelchair. 3. Review of resident #35's care plan dated 7/22/21 showed the following: -I make poor safety decisions related to my diagnosis of Autism (neurological and developmental disorder that affects how people interact with others, learn, communicate and behave), [CONDITION(S)] disorder (episodes of mood swings ranging from depressive lows to manic highs), [CONDITION(S)] disorder and intermittent explosive disorder; -Assist with Activities of Daily Living r/t impaired mobility and impaired balance; -Wheelchair main mode of transportation with assist times one to propel. Review of the resident's significant change Minimum Data Set (MDS) a federally mandated assessment instrument to be completed by the facility and dated 7/10/22 showed the following: -Extensive assist of one staff for transfers; -Ambulation did not occur; -Used a wheelchair; -Totally dependent of one staff for locomotion. Observation on 8/23/22 at 4:50 P.M. showed the resident sat in his/her wheelchair Sitter L pushed the resident around the facility square in the wheelchair without foot rests. The resident did not wear shoes and his/her feet hung from the chair. Observation on 8/24/22 at 7:45 A.M. showed Certified Nurse Assistant (CNA) C and Registered Nurse (RN) P performed morning cares on the resident, transferred him/her to her wheelchair and CNA C pushed the resident out of his/her room (without foot rests) to the dining room. Observation on 8/25/22 at 9:46 A.M. showed Sitter L pushed the resident from the dining room to the resident's room without foot rests. During interview on 8/25/22 at 4:15 P.M. Certified Medication Technician (CMT) B said staff should never push a resident in a wheelchair without foot rests as it could cause an injury. During interview on 8/25/22 at 9:58 A.M. Licensed Practical Nurse (LPN) O said residents being transported in wheelchairs, by staff should have foot rests on the chair to prevent injury. During interview on 8/25/22 at 11:24 A.M. the Director Of Nursing (DON) said she expected staff and other caregivers to ensure foot rests were in place and used for a dependent resident in a wheelchair 4. Review of Resident #39's care plan, dated 4/19/22, showed the following: -Diagnoses include: unspecified dementia with behavioral disturbance (a group of thinking and social symptoms that interferes with daily function, often with agitation or aggression) and [CONDITION(S)] (a type of arthritis that occurs when flexible tissue at the ends of bones wears down); -He/She has generalized pain related to [CONDITION(S)]; -Reposition as needed to promote comfort; -Total assist for activities of daily living (ADLs) related to impaired mobility; -Requires assist of two staff to transfer with mechanical lift; -Assume unhurried manner. Review of the resident's significant change MDS, dated [DATE], showed the following: -Totally dependent on two staff assist for transfers; -Totally dependent with one staff assist for bed mobility, dressing, locomotion on and off the unit, toileting, and personal hygiene. Observation on 8/23/22, at 5:18 P.M., showed the following: -Certified Medication Technician (CMT) R and CNA S returned to the resident's room at 5:18 P.M. to put the resident to bed; -No explanation was given to the resident as to what was happening prior to hooking the lift pad that was under the resident to the mechanical lift; -The lift pad had shifted the while the resident was sitting up in his/her geri-chair, causing an excess of lift pad at the head of the resident; -When CMT R and CNA S hooked the lift pad to the lift the excess lift pad was placed over the resident's head; -When staff lifted the resident, he/she repeatedly said my neck hurts - you are breaking my neck; -CMT R and CNA S continued the lift transfer despite the residents' complaints of pain. During an interview on 8/24/22, at 2:26 P.M., CMT R said when the resident complained of neck pain staff just hurried up with the transfer because the family member present was just going to keep asking staff to put the resident to bed. During an interview on 9/12/22, at 11:23 A.M., CNA S said he/she continued the transfer because the resident always complains of pain with care given, not only during transfers. During an interview on 8/29/22 at 11:25 A.M., and 9/12/22 at 8:55 A.M., the Director of Nurses (DON) said the following: -She would expect a gait belt to be used for all assisted transfers; -Foot pedals should be used on the wheelchairs for any resident being transferred by staff; -If foot pedals are not readily available therapy should be contacted; -She would expect a transfer that causes pain to be ended and to investigate what is causing the pain; -She would not expect a transfer that is causing pain to be hurried and to continue. During an interview on 9/12/22, at 10:58 A.M., the administrator said the following: -New hires are instructed by the therapy department on wheel chair use, transportation and transfer policy including gait belt use; -Current staff are instructed by the therapy department on wheel chair use, transportation and transfer policy including gait belt use annually; -If a resident complains of pain during a mechanical lift transfer the transfer should be stopped and the cause of the pain should be determined. MO 574

Based on observation, interview and record review, the facility failed to provide reasonable accommodations of needs for five residents (Resident #1, #13, #30, #31, and #43), in a review of 16 sampled residents when their call lights were not accessible for use. In addition the facility failed to accommodate preferences for one resident (Resident #30) when Resident #30 would prefer to get out of bed daily. The facility census was 48. Review of the undated facility policy Call Lights showed the following: -It is the policy of the facility to provide a working call light at each resident bedside and toilet; -The call light should be placed within reach. Review of the undated facility policy Rising from Sleep and Bedtime policy showed residents will rise in the morning and go to bed at times of their choosing. 1. Review of Resident #13's care plan, dated 4/12/22, shows the following: -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Allow to make decisions about his/her care to give him/her a sense of control; -He/She will be able to make decisions pertaining to care on a daily basis; -Potential for injury related to falls and impaired mobility, impaired balance, impaired memory and recent falls; -Ensure call light is within each reach and answer in a timely manner. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/18/22, showed the following: -Severely impaired cognition; -No behaviors or rejection of cares; -Extensive assistance by two staff for bed mobility, transfers, locomotion off the unit, dressing, toilet use, personal hygiene and bathing. Observation on 8/22/22, at 11:43 A.M. showed resident #13's call light laying on the floor near the recliner, and behind the resident. The resident sat up in his/her wheelchair and could not reach the call light. During an interview on 8/22/22, at 1:00 P.M., the resident said the following: -He/She could not use his/her call light last night because it was in the chair; -When he/she wanted to get up he/she had to call a friend to call the facility to have staff come get him/her out of bed; -It made him/her mad when he/she couldn't access his/her call light; -Staff put it there on purpose so they don't have to take care of me. Observation on 8/23/22, at 9:20 A.M. showed the resident sat up in his/her wheelchair with the call light sitting in the resident's recliner to the left and behind the resident. The resident could not reach his/her call light. During an interview on 8/23/22, at 9:20 A.M., the resident said the following: -His/Her call light was in the chair again last night so he/she could not reach it; -Staff will put his/her call light on the chair where she/she can't reach it on purpose; -That makes him/her angry and he/she starts yelling to get help; -He/She had to call out for help just to get staff to come in his/her room to use the bathroom; -He/She was very upset about having to yell for help. 2. Review of Resident #30's care plan, dated 4/14/22, showed the following: -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -He/She enjoys being invited to and attending activities; -He/She is social and interacts well with others; -Potential for injury related to falls and impaired mobility, ensure call light is within easy reach; -Encourage him/her to visit with family/friends in areas of the facility other than in his/her room; -Allow him/her to make personal care decisions daily. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderately impaired cognition; -No behaviors or rejection of care; -Extensive assist of two staff members for bed mobility and transfers. Observation on 8/22/22 at 11:28 A.M. showed the resident in bed asleep. The resident's call light was on the floor, out of reach of the resident. Observation on 8/22/22 at 1:38 P.M. showed the resident lay awake in bed with his/her call light on the floor, out of reach of the resident. During an interview on 8/22/22, at 1:38 P.M., the resident said the following: -He/She has been made to stay in bed longer that he/she wanted; -He/She guesses they don't have enough staff to get him/her up; -He/She would prefer to get up every day and would like to go to the dining room. Observation on 8/23/22, at 9:10 A.M., showed the resident lay awake in bed waiting for breakfast. During an interview on 8/23/22, at 9:10 A.M., the resident said the following: -Staff did not get to get out of bed yesterday (the 22nd); -He/She wanted to get out of bed. Observation on 8/24/22, at 5:32 A.M., show the resident in bed sleeping with his/her call light on the floor, out of reach of the resident. 3. Review of Resident #1's electronic medical record, undated, showed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident #1's Care Plan dated 08/10/22 showed the following: -Potential for injury r/t fall r/t impaired mobility, impaired balance, impaired memory and history of fall; -Ensure call light is within easy reach and answer in a timely manner. -Has frequent mild/moderate pain. -Encourage the resident to report any pain. Review of the resident's MDS, dated [DATE], showed staff assessed the resident as follows: -Cognition moderately impaired. -Supervision, oversight, encouragement or cueing with transfers. Observation of the resident on 8/22/22 showed the following: -At 11:55 A.M. the resident lay in bed on his/her back. The resident's call light was draped over resident's headboard, the push (activation) button hung down below the mattress behind the resident's head; -At 02:55 p.m. the resident lay in bed on his/her back. The resident's call light was strung from the wall attachment over to a wheelchair about three feet from the resident's bed. Observation of the resident on 08/23/22 showed the following: -At 03:35 p.m. the resident lay in bed on his/her back. The resident's call light was hanging over the headboard with push device (activation button) nearly touching floor; Observation of the resident on 08/24/22 showed the following: -At 05:30 a.m. the resident lay in bed on his/her back. The resident's call light was tucked under the pillow beneath the resident's head; -At 01:40 p.m. the resident lay in bed on his/her back. The resident's call light was draped over the headboard, activation button nearly touching the floor at the head the of bed and out of the resident's reach; Observation of the resident on 08/25/22 at 09:30 a.m. showed the the resident on his/her back in bed, the call light was draped over the headboard with push (activation) device down toward floor, past the mattress and out of the resident's reach. 4. Review of Resident #31's care plan dated 4/12/22 showed the following: -Assist with Activities of Daily Living related to impaired mobility and balance; -Ensure call light within easy reach and answer in timely manner. Review of the resident's quarterly MDS, dated [DATE] showed the following: -Limited assist of one staff for transfers; -Supervision only for ambulation; -Extensive assist of one staff for hygiene and toileting; -Always incontinent of bladder and bowel. Observation on 8/24/22 showed the following: -At 7:13 A.M. the resident lay in bed; -The resident's call light lay on the floor in front of the head board, out of the resident's reach; -CNA E entered the room and attempted to awaken the resident but exited the room after attempts unsuccessful, saying he/she would need to get assistance; -CNA E did not place the call light in reach of the resident as it remained on the floor; -CNA E did not return to the resident's room; -At 8:07 A.M. staff entered the room to perform morning cares. The call light remained on the floor in the same location. 5. Review of Resident #43's care plan dated 5/3/22 showed the following: -Required assist with ADL's related to impaired mobility and balance; -Assist of one staff for toileting and transfers; -Ensure call light is within easy reach and answered timely. Review of the resident's significant change MDS dated [DATE] showed the following: -Supervision and one staff assist with transfers and hygiene; -Extensive assist of one staff for toileting; -Always incontinent of bladder and bowel. Observations on 8/22/22 at 11:30 A.M. showed the resident sat in his/her wheelchair in his/her room visiting with another resident. The resident's call light lay on the floor near and in front of the bedside table. The resident said call lights took a long time or were never answered and he/she just went to the doorway and hollered when he/she needed someone. Observation on 8/23/22 showed the following: -At 9:26 A.M. the resident lay in his/her bed and the call light was out of reach, on the floor near the bedside table; -At 3:50 P.M. the resident sat in his/her wheelchair and the call light remained on the floor, out of reach. Observations on 8/24/22 showed the following: -At 5:51 A.M. the resident sat on the side of the bed and the call light lay on the floor, near the bedside table, out of the resident's reach; -At 8:52 A.M. the resident sat in his/her wheelchair in his/her room where the call light remained on the floor. During an interview on 8/29/22, at 11:25 A.M., the Director of Nursing said the following: -Call lights should always be within a resident's reach; -Call lights should not be hanging on the wall or on the floor for extended periods of time. During an interview on 9/12/22, at 10:58 A.M., the administrator said the following: -Call lights should always be within a resident's reach; -Call lights should never be placed in a resident's chair out of their reach; -Resident's should be able to make choices of when to get out bed.

Based on observation and interview the facility failed to ensure one resident (Resident #39), in a review of 16 sampled residents received personal care in a manner to protect the resident's personal privacy. The facility census was 48. Review of the facility policy, Resident Rights, dated 12/2018 showed the following: -All clients/residents have the right to be accepted and treated with dignity; -All clients/residents have the right to reasonable privacy, including privacy of self in their room and personal affairs. 1. Review of Resident #39's care plan, dated 4/19/22, showed the following: -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -He/She has an indwelling urinary catheter (a tube inserted into the bladder to drain urine); -Ensure privacy with all catheter care; -He/She was incontinent of bowel; -Perineal cleansing and apply protective skin barrier after each incontinent episode. Review of the resident's significant change MDS, dated [DATE], showed the following: -Daily preference choices are important to the resident; -Totally dependent on two staff assist for transfers; -Totally dependent with one staff assist for bed mobility, dressing, locomotion on and off the unit, toileting, and personal hygiene; -Has an indwelling catheter; -Always incontinent of bowel. Observation on 8/23/22, at 3:46 P.M., showed the following: -At 4:14 P.M. - 5:11 P.M. the resident's call light activated and the resident yelling out for help nine times; -Certified Medication Technician (CMT) R and CNA S entered the resident's room at 5:18 P.M. to put the resident to bed; -CMT R and CNA S transferred the resident from the Geri-care to bed, passing by the window facing the parking lot; -No blind was pulled to provide privacy during the transfer; -Observation showed a car pulled into the parking lot and an individual walked by the resident's window during the transfer, the resident would have been visible to this person. Observation on 8/24/22, at 8:04 A.M., showed the following: -The resident had a small bowel movement; -Registered Nurse (RN) P exposed the residents buttocks after removing a soiled brief; -RN P provided peri-care and placed a brief under the resident buttocks; -RN P then placed the resident on his/her back and provided catheter care, exposing the resident's genitals during catheter care; -During the time RN P provided personal cares to the resident, the window blinds were not closed exposing the resident to view from the window facing the facility parking lot; -Observation showed two individuals walked by the resident's window while RN P provided personal care. During an interview on 9/12/22, at 9:46 A.M., RN P said he/she did not close the blinds when providing care for resident #39. During an interview on 9/12/22 at 8:55 A.M., the Director of Nursing said she would expect blinds to be closed when providing resident care to provide privacy. During an interview on 9/12/22 at 10:58 A.M., the administrator said the following: -She would expect all residents to be treated with dignity and respect at all times; -Blinds should be closed at all times when providing care to provide privacy for the residents.

Based on interview and record review the facility failed to ensure one closed record (Resident #57), of 16 sampled residents and six closed records, received the necessary care and services in accordance with professional standards of practice. Resident #57 had oxygen saturation levels in the 80's on room air (normal range 95-100% on room air) in the morning on 7/27/22 which decreased even further when the resident spoke. Facility staff did not notify the resident's physician of the condition change or that oxygen was applied. The resident's condition continued to decline during the day and he/she was subsequently sent to the hospital. The facility census was 48. Review of the undated facility policy Change of Condition Notification showed the following: Policy statement: -The physician and family/responsible party will be notified when the charge nurse/designee identifies a change in the resident's condition; Procedure: 2. The charge nurse will notify the physician/designee of the noted change of the resident's condition; 3. The charge nurse should review current current orders, code status and advance directive decisions with the physician/designee to assist with his/her decision to allow the resident to remain in the facility for treatment or transfer to the hospital; 4. After review with the physician/designee, the charge nurse should notify the family/responsible party of the physician/designee treatment recommendations. If the family/responsible party is in agreement with the recommendations, the charge nurse will either implement care within the facility or make arrangements to transfer the resident to the hospital of choice; 5. The charge nurse will document in the electronic health record (EHR): a. The resident's change of condition; b. His/her conversation with the physician/designee; c. His/her conversation with the family/responsible party; d. Treatment and disposition of the resident. Review of the undated facility policy Oxygen showed the following: 1. There must be a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .e. continuous). Oxygen will be delivered through a concentrator or E tank (portable oxygen tank); 4. Only licensed nurses and respiratory therapists are authorized to set up oxygen administration or make changes to oxygen administration. 1. Review of Resident #57's face sheet showed the resident was admitted to the facility on [DATE]. He/She had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Symptoms include shortness of breath, fatigue, swollen legs, and rapid heartbeat). Review of the resident's Clinical Admission Evaluation dated 7/25/22 showed the following: -Lungs clear bilaterally. No difficulty breathing. No cough noted; -No oxygen use; -Most recent oxygen saturation level: 95% on room air. Review of the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's progress notes dated 7/26/22 at 1:37 P.M. showed the resident's oxygen saturation was 96% on room air. Review of the resident's progress notes dated 7/27/22 at 7:03 P.M. showed the following: -In A.M., resident's vital signs were taken along with his/her daily assessment by this nurse and oxygen saturations were in the 80's and lowered when he/she would talk; -Family member A present at time of assessment; -Informed them both that he/she would administer oxygen per protocol to stabilize the resident's oxygen levels; -Family member A was very concerned saying the resident had never had to use oxygen before; -Resident did sound congested (normal lung sounds clear) and had some wheezes in his/her lung bases; -Waiting for physician arrival today to see if he could assess the resident as well; -At 6:15 P.M., Family Member B called this nurse to room and said the resident had to go to the hospital, he/she was getting worse; -Family Member B said the resident got winded going very short distances; -Vital signs retaken: Blood pressure 92/56 (normal 120/80) and oxygen saturation 93% on 2 liters per minute/nasal cannula; -Family Member B was insistent he/she didn't want anymore to be done at the facility, he/she needed to call the ambulance; -Contacted the physician, he gave the order and resident was sent to the hospital; -No documentation facility staff notified the resident's physician of the resident's change in condition including decreased oxygen level and application of oxygen. During interview on 8/25/22 at 1:32 P.M. Licensed Practical Nurse (LPN) D said the following: -He/She was the charge nurse for the resident on 7/27/22; -At approximately 8:00 A.M. to 9:30 A.M. on 7/27/22 he/she assessed the resident; -Family Member A was at the bedside during the assessment; -The resident was not on oxygen prior to that day; -He/She told the family the resident had a change in condition from 7/26/22 to 7/27/22; -He/She applied oxygen; -He/She couldn't remember but he/she probably talked to the resident's physician several times during the day. He/She may not have documented contacting the physician in the progress notes if the physician just said monitor or no new orders received; -The resident's oxygen saturation level when up and down throughout the day as did the resident's need for oxygen; -The resident did not appear to be short of breath at rest, but his/her oxygen saturation level went down when he/she was talking; -Family Member B said staff took the resident to the bathroom and the resident was very short of breath; -Family Member B insisted the resident go to the hospital; -He/She was taught that all residents have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During interview on 8/25/22 at 12:45 P.M. Family Member B said the following: -On the morning of 7/27/22, Physical Therapy Aide (PTA) Y came into the resident's room to do therapy; -The resident was having problems breathing; -PTA Y called the nurse; -The nurse came in and put oxygen on the resident; -Staff left the resident all day long, he/she was sick and laying there, he/she did not want to eat; -At 10:45 A.M. the resident's oxygen level was 85%; -At 11:00 A.M. the previous Director of Nurses (DON) was called in to check the resident and said they would get the physician; -At 4:15 P.M. PTA Y checked the resident's oxygen level, it was 85% and the resident was dizzy; -At 4:30 P.M. he/she asked for a Certified Nursing Aide (CNA) to come in; -The resident woke up and needed to use the bathroom; -The resident had trouble getting back to the bed, he/she was very short of breath; -He/She was very upset no one came to check on the resident all day; -He/She demanded staff call the ambulance; -The resident had never required oxygen; -When the resident got to the hospital, he/she was diagnosed with pneumonia. During interview on 8/29/22 at 11:25 A.M. the DON said if a resident had new onset shortness of breath and required oxygen to keep his/her saturations within normal limits (WNL), she would expect staff to tend to the resident first then notify the physician as soon as physically possible of the condition change. During interview on 8/25/22 at 3:08 P.M. the resident's physician said the following: -He would expect to be notified with a change of condition including increased shortness of breath or oxygen saturations in the 80's; -If the resident does not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] -He would want to know why the resident's oxygen level was dropping so he could investigate further and do awork-upp; -He only received one phone call from staff on 7/27/22 about the resident and that is when he sent the resident to the hospital; -He was not notified of the resident's change of condition. MO 2 MO 5

Based on observation, interview, and record review, the facility failed to implement interventions to prevent the development of pressure ulcers (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) for two (Residents #10 and #27), in a review of 16 sampled residents. The facility failed to reposition two residents (Residents #10 and #27), who were identified as a risk for pressure ulcers, as directed per facility policy to prevent the potential development of pressure ulcers. The facility identified four residents had pressure ulcers on their Resident Matrix (mandated document used to identify resident's care areas). The facility census was 53. Review of facility's undated policy for positioning and preventative care showed the following: -It was the facility's policy to reposition residents who were not independent with movement. Preventing pressure sores and skin break down may be achieved by turning and positioning every two hours; -A pillow or cushion between bony prominence and heel protectors often were used to relieve or prevent pressure. Abductor pillows or bed pillows might assist in alternating positions from right, left, and back' -While in chairs, chair cushions would be utilized to help prevent breakdown. Shifting positions or alternating from chair to bed may be helpful to prevent skin breakdown if a resident was immobile and not independent to do so; -Hand contractures would be assessed by therapy for appropriate type of preventative device. Wash cloths, splints, or hand rolls may be utilized to prevent pressure. Review of the facility policy Pressure Ulcers: Prevention, Identification, Evaluation and Intervention showed the following: Facility responsibilities: 3. Ensure that all residents at risk for pressure ulcers are identified and given care to prevent development of pressure ulcers; Charge Nurse Responsibilities: 1.Instruct and supervise Certified Nurse Aides (CNAs) to ensure care and interventions implemented to prevent skin breakdown including: a. Review of documentation of skin issues identified during the resident's shower; 3. Positioning protocols followed; a. Repositioning; b. Incontinent care. 1. Review of Resident #27's last documented Braden assessment dated [DATE] showed the resident was at high risk for development of pressure ulcers. Review of resident's care plan dated 4/6/22 showed the following: -He/She had the potential for developing pressure ulcers related to impaired mobility and incontinence; -Toilet per protocol and as needed with assistance of one staff; - No documentation to direct staff to reposition the resident. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 6/10/22, showed the following: -Cognition was severely impaired; -He/She required extensive assist of one staff with bed mobility, transfers, toilet use, and personal hygiene; -He/She was always incontinent of bladder and frequently incontinent of bowel ; -He/She was risk for pressure ulcers; -He/She required a pressure relieving device for the bed. Review of resident's physician's order sheet (POS), dated 8/24/22, showed staff were to complete assessment of the resident's skin every Tuesday evening (ordered on 10/20/20). Review of resident's electronic medical record/assessments showed no documentation that staff assessed resident's skin as ordered. Observations of the resident on 8/24/22 showed the following: -At 5:30 A.M., the resident sat in his/her wheelchair; -At 7:30 A.M., the resident remained in his/her wheelchair; -At 9:00 A.M., the resident remained in his/her wheelchair. -At 10:00 A.M., the resident remained in his/her wheelchair; (The resident remained in his/her wheelchair for four and a half hours without repositioning) During an interview on 8/24/22 at 3:00 P.M., Certified Nurse Aide (CNA) C said he/she and Certified Medication Technician (CMT) B assisted the resident to lay down and provided incontinence care after lunch, but did not after breakfast. He/She had not assisted the resident after breakfast because he/she was busy with other residents. 2. Review of Resident #10's face sheet showed the following: -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of resident's Braden score last documented on 12/6/21 showed he/she was at risk for development of pressure ulcers. Review of the resident's care plan, last updated on 3/28/22, showed the following: -The resident had potential for development of pressure ulcers related to impaired mobility and incontinence; -Toilet per protocol and as needed with assistance of one staff (resident required mechanical lift for transfers); -The resident was incontinent of both bladder and bowel; -Toilet upon rising, before and after meals, bedtime, and as needed with one to two person assist; -If restlessness was noted, offer toileting/repositioning as needed; -There was no documentation to direct staff to reposition the resident. Review of the resident's quarterly MDS completed by facility staff, dated 6/21/22, showed the following: -Required extensive assistance with bed mobility; -At risk of developing pressure ulcers; -Pressure relieving device for bed. Observations on 8/24/22 showed the following: -At 5:30 A.M., the resident sat in the Geri-chair (large padded chair used to help seniors with limited mobility) in his/her room. -At 7:30 A.M., the resident continued to sit in G-chair in front of the dining room; -At 9:00 A.M., the resident sat in the sitting area watching TV; -At 9:30 A.M., staff moved the resident to the activity room for an activity. (The resident was not repositioned for approximately four hours) During an interview on 8/24/22 at 9:50 A.M., the activity director said she brought the resident from the sitting area directly to the activity room. She did not take the resident to her room prior to taking her to the activity. During an interview on 8/24/22 at 3:00 P.M., CNA C said the resident was incontinent, and staff was supposed to check the resident for incontinence and change him/her after every meal. Staff did not change the resident after breakfast. After breakfast, he/she peeked at the resident's incontinence brief to determine if it was soiled and did not thinks the resident was incontinent. Staff brought the resident back to his/her room and assisted him/her to bed after lunch. The resident was incontinent at that time. He/She did not check on or reposition the resident every two hours. He/she was busy that morning with other residents. During an interview on 8/25/22 at 10:00 A.M., Licensed Practical Nurse (LPN) D said that weekly skin assessments come up on resident's treatment administration record when they were due and also were supposed to be documented in resident's electronic medical record (EMR) under assessments. CNAs turn in shower sheets to the charge nurse for review and assess/address any concerns that CNAs may have brought to charge nurse's attention. He/She did not necessarily go in showers to physically assess unless there was a concern with resident's skin. During an interview on 8/29/22 at 11:29 A.M., the director of nursing said residents should be rounded on at least every two hours and as needed. A resident should not sit in a Geri-chair over seven hours without being repositioned, checked for incontinence, and/or provided incontinence care if needed. Residents should not be left up until after lunch if they are a Hoyer lif (mechanical lift). Skin assessments were supposed to be done by the nurses by using the shower sheets. MO 3 MO 8 MO 1 MO 8 MO 4 .

Based on observation, interview, and record review, the facility failed to provide appropriated treatment and services consistent with acceptable standards of practice for one resident (Resident #39), in a review of 16 sampled residents with an indwelling urinary catheter (a tube inserted into the bladder to drain urine). Staff failed to provide appropriate catheter care during personal cares and did not keep the level of the catheter tubing below the resident's bladder during a transfer. The facility census was 48. Review of the undated facility policy Urinary Catheter Care showed the following: 1. CNAs should do catheter and perineal care with A.M. and P.M. care, after each of the resident's bowel movements and as needed; a. Always wash your hands before and after handling the catheter, tube or bag and wear gloves following standard precautions for infection control; b. Clean the area where the catheter is inserted by wiping away from the insertion site to prevent germs from being moved from the anus to the urethra; c. Hold the end of the catheter tube to keep it from being pulled while cleaning; d. Wash the catheter with soapy water to remove any blood or other materials from the catheter wiping downwards from the urethra. Avoid frequent and vigorous cleaning at the entry point. 2. Catheter Tubing and Bag: a. Tubing should be secured to keep from falling on the floor; c. Keep the bag below the level of the resident's bladder at all times; -No direction to staff regarding keeping the catheter bag off the floor to prevent contamination. Review of Resident #39 ' s care plan, dated 4/19/22, showed the following: -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . -He/She has an indwelling urinary catheter; -He/She will not have complications related to the urinary catheter; -Provide catheter care per protocol; -Secure catheter to let to avoid tension on urinary meatus (opening of urethra) ; - The resident has recurrent urinary tract infections ([CONDITION(S)]); -Assess for adequate output, color and odor of urine; -Observe for signs and symptoms of UTIs (hematuria (blood in urine), sediment, dark color, cloudy appearance). Review of the resident's significant change MDS, dated [DATE], showed the following: -Totally dependent with one staff assist for toileting and personal hygiene -Has an indwelling catheter (a tube inserted into the bladder for urine drainage); -Always incontinent of bowel. Review of the resident's August 2022 physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 8/22/22 at 1:15 P.M. showed the resident lay in bed. The resident's urine was purple and cloudy in color. The urinary drainage bag and tubing touched the floor and the catheter tubing was not secure to the resident's leg. Observation on 8/23/22 at 9:35 A.M. showed the resident lay in bed. The resident's urine was maroon tinged in color with a small amount of sediment. The urinary drainage bag hung on the bed frame with the bag and tubing touching the floor. The catheter tubing was not secure to the resident ' s leg. Observation on 8/23/22 at 5:18 P.M. showed the resident sat in his/her geri-chair with staff preparing to transfer the resident to bed with a mechanical lift. Certified Nursing Aide (CNA) S unhooked the resident's urinary drainage bag from the side of the chair and raised it above the level of the resident's bladder. Urine flowed back towards the resident's bladder. CNA S sat the urinary drainage bag on the residents left side near his/her hip. During an interview on 9/12/22, at 11:23 A.M., CNA S said he/she did not recall raising the catheter bag above the bladder during the mechanical lift transfer for the resident. Observation on 8/24/22 at 5:45 A.M. showed the resident lay in bed. Urine draining into the urinary drainage bag was light tan in color, slightly cloudy with a small amount of sediment. The urinary drainage bag hung on the bed frame with the bag and tubing touching the floor. The catheter tubing was not secure to the resident's leg. Observation on 8/24/22 at 8:04 A.M. showed the resident in bed. The urinary drainage bag hung on the bed frame with the bag and tubing touching the floor. Registered nurse (RN) P provided catheter care during peri-care. The resident was noted to have dried blood on his her genitalia where the catheter entered the urethra and surrounding area. RN P cleansed the dried blood from the genitalia, using a clean side of the wipe each time, then cleaned the catheter tubing at the insertion site with a clean wipe. RN P did not complete catheter care by cleaning the tubing from insertion site toward the urinary drainage bag. The catheter tubing was not secure to the resident's leg. During an interview on 9/12/22, at 9:46 A.M., RN P said the following: -The insertion point of the catheter should be cleansed with a wipe/cloth, then the tubing cleaned with a clean wipe/cloth from the point of entry outward toward the end of the tube attached to the drainage system; -He/She provided care at the insertion point of the catheter for resident #39; -The urinary drainage bag and tubing should not touch the floor. During an interview on 8/29/22, at 11:25 A.M., the Director of Nursing (DON) said the following: -She would expect nursing standards to be followed for catheter care; -The urinary drainage system should never touch the floor. MO 4 MO 8 MO 8 MO 2

Based on observation, interview and record review, the facility failed to ensure facility staff provided two residents (Resident #15 and #405) in a review of 16 sampled residents that were unable to perform their own activities of daily living (ADL), the necessary care and services to maintain good personal hygiene and prevent body odor. The facility census was 48. Review of the undated facility policy ADL Care for Dependent Residents Policy showed the following: -Residents who are unable to carry out activities of daily living should receive necessary services provided by facility staff to maintain good nutrition, grooming and personal and oral hygiene; -Assistance to the bathroom; may include commode, bedpan, urinal, transfer on / off toilet, peri-cleaning as necessary, changing absorbent pads or briefs, manage ostomy or catheter and adjust clothing will be provided by staff as necessary to ensure proper hygiene; -Shaving of face, legs and underarms as needed or requested by resident. Review of the undated facility Bathing Policy showed the following: -Residents will be offered two showers per week and more frequently if requested; -Resident rights will be respected as to self-determination related to bathing however, if a resident declines bath care the staff member will leave the room and come back later to offer the bath again; -If a resident refuses a bath because he or she prefers a shower or a different bathing method, such as in-bed bathing, prefers to bathe at a different time of day or on a different day, does not feel well that day, or is worried about falling, the facility will make reasonable efforts to accommodate residents' preferences. 1. Review of Resident #15's care plan, dated 3/28/22, showed the following: -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . -He/She requires assist with ADL's related to impaired mobility and impaired balance; -He/She requires assist with bathing body parts that he/she is unable to clean; -He/She is incontinent of both bowel and bladder. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Sometimes is able to be understood; -Sometimes is able to understand others; -Severely impaired cognition; -Total dependence on two staff for bed mobility, transfers, dressing, and toileting; -Total dependence on one staff for locomotion on and off the unit; -Extensive assist of one person for eating and personal hygiene; -Bathing did not occur during the observation period; -Limited range of motion bilateral upper and lower extremities; -Always incontinent of bowel and bladder. Observation on 08/22/22 at 11:39 A.M. showed the resident with his/her eyes closed and reclined in his/her geri-chair in the day room. The resident had a dried brown substance around his/her, curly whiskers on the chin approximately 1/4 inch long, yellow drainage on corner of left eye and his/her eye was watering. The resident's fingernails were long with brown debris under the nails. The resident's hair was disheveled and unkempt with a slight oily appearance. Observation on 08/23/22 at 9:17 A.M. showed the resident with his/her eyes closed and reclined in his/her geri-care in the day room. His/her face was dry with white flakes of skin around his/her nose, on forehead and cheeks. The resident had yellow eye drainage dried on eye lashes and in corner of both eyes. The resident's facial hair was approximately 1/4 inch long on the chin and upper lip. The resident's hair was disheveled and unkempt with a slight oily appearance. Review of the shower schedule showed thee resident was to get showers on day shift on Tuesday and Friday. Review of the resident's shower sheets showed staff documented showers given on 7/1/22, 7/8/22, 7/22/22 and 8/12/22. The resident missed six showers for the month of July and six showers in August. During an interview on 9/12/22, at 11:23 A.M., Certified Nursing Aide (CNA) S said the following: -Resident's are given a shower or bath two times a week; -Resident showers are documented on the resident shower sheet and then given to the charge nurse; -The shower sheets are the only place a shower/bath is documented. 2. Review of Resident #405's Care Plan dated 08/10/22 showed the following: -I require assist with ADL's r/t impaired mobility and impaired balance; -Assist me with bathing body parts that I am unable to clean. Assist x1; -I require assist x1-2 to transfer. -Attempt to establish a routine in daily care so I know what to expect. Review of the resident's electronic medical record, undated, showed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's admission MDS, dated [DATE], showed staff assessed the resident as follows: -Cognition intact; -Extensive assistance, one person physical assistance for toilet use; -Supervision, oversight, encouragement or cueing, one person physical assistance for personal hygiene. Observation of the resident on 08/22/22 at 12:00 P.M. showed the resident lay in bed on his/her back. The resident has uncombed, disheveled hair and has dark material/discoloration beneath his/her first two fingernails on his/her right hand (index and second finger). The resident's fingernails were all long and extend over the finger pads on both hands. During an interview on 08/22/22 at 12:10 p.m. the resident said the following: -He/She does not get a washcloth to wash his/her hands and face; -He/She asked for a comb the other day but never got one; -He/She was not aware of any shower or bathing schedule; -He/She would like a washcloth for his/her hands and face; -He/She asked for a washcloth before but did not receive one. Observation of the resident on 08/23/22 at 9:15 A.M. showed the resident lay in bed on his/her back. The resident's hair was uncombed and disheveled. His/Her fingernails were long (extend over finger pads) and had dark material/discoloration beneath them. During an interview on 08/23/22 at 9:15 A.M. the resident said the following: -He/She asked for a washcloth to wash his/her face and hands but did not get one - At 3:30 P.M. the resident said he/she had not gotten a washcloth for his/her hands or face yet today. Observation of the resident on 08/24/22 at 5:35 A.M. showed the resident lay in bed on his/her back. The resident's hair was uncombed and disheveled. The resident's fingernails were long and extend over his/her finger pads. The resident wore the same pajama top as yesterday. During an interview on 08/24/22 at 06:00 a.m. Licensed Practical Nurse (LPN) G said the following: -The resident was scheduled for showers on Wednesdays and Saturdays on the evening shift; -There were no shower sheets for the resident in the shower books. Observation of the resident on 08/25/22 at 9:00 A.M. showed the resident lay in bed on his/her back. He/She wore the same pajama top for the past two days. There was an area of spillage of an orange liquid on the upper lapel of the resident's pajama top. The resident's hair was uncombed and disheveled. Dark material was present beneath the first and second fingernails on the resident's right hand. The resident's fingernails were all long and extended past the finger pads. During an interview on 8/29/22, at 11:25 A.M., the Director of Nursing said the following: -Bathing should occur twice a week or more frequently if a resident requests more frequently; -Facial hair should be removed during the bathing process for males and females; -A bed bath should only be given if preferred by the resident or if medically necessary. During an interview on 9/12/22, at 10;58 A.M., the administrator said she would expect all residents to receive at least two baths a week and more if needed. MO 4 MO 8 MO 3 MO 2 MO 4 MO 1 MO 8 MO 4

Based on observation, interview, and record review, the facility failed to document assessment of - including characteristics, failed to re evaluate weekly per facility policy, or revise one resident's (Resident #41), in a review of two sampled residents with wounds, care plan during the development and treatment of [REDACTED]. The resident presented with a pressure injury described as a fluid filled blister on the heel following a change in mobility status which deteriorated to a Stage III pressure ulcer (full thickness loss of skin, where adipose (fat) is visible in the ulcer and granulation tissue and rolled wound edges are often present). The facility census was 53. 1. Review of NPUAP guidelines, dated (MONTH) (YEAR), showed the following definitions: -Stage I pressure injury is intact skin with localized area of non-blanchable (when you press on the area of redness the redness does not go away) [DIAGNOSES REDACTED] (redness). Presence of blanchable [DIAGNOSES REDACTED] changes in sensation, temperature, or firmness may precede visual changes; -Stage II pressure injury is a partial-thickness loss of skin with exposed dermis (the thick layer of living tissue below the top layer of skin that forms the true skin). The wound bed is viable, visible and deeper tissue are not visible. Granulation tissue (new connective tissue), slough (dead tissue in the process of separating from the body which is usually light colored, soft, moist, or stringy), and eschar (dead tissue that sheds or falls off from health skin) are not present; -Stage III pressure injury is a full thickness loss of skin, where adipose (fat) is visible in the ulcer and granulation tissue and rolled wound edges are often present. Slough and eschar may be visible, but do not obscure the extent of tissue loss. The depth of tissue damage varies by the location on the body. Undermining and tunneling may occur. Fascia (a thin sheath of fibrous tissue), muscle, tendon, ligament, cartilage or bone are not exposed; -Stage IV pressure injury is a full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and or eschar may be visible, but do not obscure the extent of tissue loss. Rolled edges, undermining and or tunneling often occur. Depth varies by location; -Unstageable pressure injury is a full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar; -Deep Tissue Pressure Injury is an intact or non-intact skin with localized area of persistent non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle, or other underlying structures are visible, this indicates a full thickness pressure injury (unstageable, Stage III or Stage IV pressure injury). 2. Review of the facility's policy Skin Assessment, undated, showed the following: -Residents who enter the facility without pressure ulcers do not develop pressure ulcers unless the resident's clinical condition demonstrates that they were unavoidable; -Skin assessments will be conducted by the nurse on admission, weekly for four weeks, then monthly; -CNAs will monitor for signs of skin breakdown daily with care and bathing and report : a. purple or dark areas; b. [MEDICAL CONDITION]; c. hardening of skin; d. redness; e. bogginess; -Document the status of the resident's kin in the resident's record once per week and in the resident's monthly summary. Review of the facility's Pressure Ulcer policy, undated, showed the following: -Pressure ulcer is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device; -Residents who enter the facility without pressure ulcers do not develop pressure ulcers unless the resident's clinical condition demonstrates that they were unavoidable; -At risk residents are identified and given care to prevent the development of pressure ulcers; -Braden scale (pressure ulcer risk assessment tool) assessment will be completed upon admission/readmission, with the quarterly, annual, and significant change of condition assessments; -Residents with pressure ulcers will receive necessary treatment and services to promote healing, prevent infection and prevent new sores from developing; -Staff will monitor interventions are implemented to prevent skin breakdown: a. instruct CNAs on interventions implemented to prevent kin breakdown; b. monitor skin issues identified during the resident's showers; c. monitor devices are in place; -Provide wound care as prescribed by the physician; -Pressure ulcers identified may be: a. non-open areas or areas covered with stable eschar; b. Unruptured serous(fluid)-filled or blood filled blisters; c. open areas; d. open areas with slough or unstable eschar; e. deep tunneling wounds; -Licensed nurses will track the healing progress of pressure ulcers and alter the plan of care and treatment when needed: a. Complete skin integrity documentation for each resident with skin breakdown that includes: 1. Type of wound; 2. Location; 3. shape; 4. Measurements in centimeters: width, length, and depth; 5. Stage; 6. Color, redness, warmth, swelling; 7. Granulation, surrounding tissue, ulcer edges; 8. Exudate (drainage), or bleeding; 9. odor; 10. Treatments, dressing changes, medications; 11. Presence of infection or other complications; 12. Pain; b. Evaluating pressure ulcer treatments weekly for effectiveness and inform the resident's physician of pressure ulcer status; c. Care plan team to alter the pressure ulcer care plan and implement new interventions when healing is not adequate; -The director of nursing (DON) will monitor the weekly wound report, and ensure proper documentation is completed. 3. Review of Resident #41's face sheet showed the resident was admitted to the facility on [DATE]. Review of the resident's Braden assessment, dated 7/24/19, showed a score of 14 indicating moderate risk for development of pressure ulcers. Review of the resident's admission Minimum Data Set (MDS),a federally mandated assessment instrument completed by facility staff dated 8/7/19, showed the following: -Moderate cognitive impairment; -Requires supervision of staff for bed mobility; -Requires limited assistance of one staff member for transfers, and toilet use; -At risk to develop pressure ulcers; -No pressure ulcers present. Review of the resident's care plan, dated 8/15/19, showed the following: -At risk for pressure ulcers due to incontinence; -Check and change the resident every two hours; -Any evidence of skin break down the nurse will be notified immediately so a treatment can be started. Review of the resident's nurses notes, dated 10/30/19, showed the following: -Late entry for 10/7/19: -Resident found by staff on the side of his/her bed on the floor; -Resident said he/she had fallen out of bed. Review of the resident's nurses notes, dated 10/17/19, showed the resident guarding and complained of pain in the right hip. Review of the resident's care plan showed no new interventions after the resident complained about the pain in his/her hip related to decreased mobility. Review of the resident's shower sheet, dated 10/22/19, showed no documentation of any skin breakdown or bruising. During an interview on 11/21/19, at 4:46 P.M., RN H said the following: -The resident developed a pressure ulcer before he/she went to the hospital; -Staff found the wound around 10/22/19, and it was a large fluid filled blister on his/her left heel; -The resident had not been moving himself/herself around much because of the hip pain, they later found out it was fractured; -He/She did not remember if interventions were started to float the heels when the wounds were found. Review of the resident's physician's orders [REDACTED]. Review of the resident's treatment administration record, dated 10/23/19 through 10/25/19, showed staff documented treatment for [REDACTED]. Review of the resident's record, dated 10/1/19-10/25/19, showed no documentation of measurements in centimeters: width, length, and depth; stage; color, redness, warmth, swelling; granulation, surrounding tissue, ulcer edges; exudate (drainage), or bleeding for the identified left heel presssure injury the resident developed while in the facility. Review of the resident's care plan showed the plan did not address the resident's left heel pressure injury. Review of the resident's nurses notes, dated 10/25/19, showed the following: -Treatment to left heel completed; -X-ray results obtained and called to physician; -Order to send to the emergency room for further evaluation. Review of the resident's census record showed the resident transferred to the hospital on [DATE] and the resident returned on 10/31/19. Review of the resident's hospital physician progress notes [REDACTED]. Review of the resident's facility admission nursing assessment, dated 10/31/19, showed an unstageable pressure ulcer to the left heel. Review of the resident's nurses notes, dated 10/31/19, showed the following: -Resident returned from the hospital with right hip hemiarthroplasty (surgical procedure); -Dressing applied to left heel; -Pressure reduction boots applied bilaterally. Review of the resident's medical record, dated 11/1/19-11/18/19, showed no documentation of measurements in centimeters: width, length, and depth; stage; color, redness, warmth, swelling; granulation, surrounding tissue, ulcer edges; exudate (drainage), or bleeding for the identified pressure ulcer on the left heel. Review of the resident's wound assessment, dated 11/19/19, showed the resident has a left heel blister, measures 4 inches in length, and 3.2 inches in width, and the treatment order changed to Santyl (an ointment that removes dead tissue enzymatically). Review of the resident's care plan, dated 11/1/19-11/22/19, showed no update the resident developed a pressure ulcer, new interventions to treat the pressure ulcer, pressure relieving boots, or to float the resident's heels. During an interview on 11/21/19 at 7:22 [NAME]M., Certified Nurse Aide (CNA) N said the resident did not want to get up because his/her heel hurt. Observation on 11/21/19 at 4:31 P.M., showed the following: -Registered Nurse (RN) H changed the resident's dressing to the left heel; -The soiled dressing showed serosanguinous (blood and yellowish fluid) drainage; -A large open area on the left heel approximately the size of a baseball, center of the wound bed covered with slough (dead tissue in the process of separating from the body which is usually light colored, soft, moist, or stringy), the edges of the wound bed were shiny, the wound had depth, the wound edges were hard and calloused. During an interview on 11/21/19, at 4:46 P.M., RN H said the following: -The resident had a large fluid filled blister on his/her left heel prior to going to the hospital; -The blister had opened while in the hospital; -The wound was the size of a medium orange and was at least a Stage III. The wound could be deeper, but there was slough in the center of the wound; -Staff were doing a treatment to protect the blister before the resident went to the hospital. During an interview on 11/22/19, at 8:23 [NAME]M., the Director of Nurses said the following: -The facility had a wound nurse that did weekly measurements and wound tracking; -He/She was not working at this time and was out with medical issues; -The wound nurse's documentation on the resident's heel was missing and could not be accessed; -If a resident developed a wound the physician and resident/responsible party should be notified, the care plan should be updated, a treatment obtained, and the wound should be fully documented; -Staff were expected to re-evaluate pressure ulcers weekly, and document findings in the resident's medical record. During an interview on 12/5/19, at 1:30 P.M., the resident's physician said the following: -He was notified and gave a treatment order for the resident's pressure ulcer to the left heel on 10/23/19; -He expected staff to measure the wound/ulcer when discovered and document weekly the measurements, tissue type, stage, drainage, etc. and notify him of any deterioration; -Staff were expected to update the care plan with the development of a wound especially with turnover of staff so they know what interventions are in place to treat the wound, and prevent new wounds; -There was a wound nurse and something happened to him/her and the facility could not find the documentation; -The resident had hip pain that caused more immobility and this may have contributed to the development of the pressure ulcer/wound.