Every finding on record at Merit Health Wesley

Based on observation, interview, record review, and facility policy review, the facility failed to ensure Resident #37's right to dignity by leaving the resident's urinary catheter drainage bag uncovered and visible for one (1) of (13) sampled residents.Findings include:A review of the facility's policy, Resident Rights, published 2/18/26, revealed, .Each resident has the right to be treated with dignity and respect.Policy Interpretation and Implementation.1. The resident has the right to have a dignified existence.9. Refraining from practices demeaning to residents such as leaving urinary catheter bags uncovered.On 2/17/26 at 8:50 PM, during an observation, Resident #37's urinary catheter drainage bag was hanging uncovered on the side of the bed. The bag was positioned in a manner that made it visible when the resident's room door was opened. No privacy bag was in place.On 2/17/26 at 8:55 PM, during an observation and interview with Registered Nurse (RN) #1, the uncovered catheter drainage bag was observed. RN #1 confirmed the drainage bag should have been covered with a privacy bag.On 2/19/26 at 11:26 AM, during an interview, the Director of Nursing (DON) stated staff are expected to keep catheter drainage bags covered to maintain resident privacy and dignity. The DON reported she did not recall whether a recent in-service specifically addressed catheter bag coverage but stated education is provided.On 2/19/26 at 12:30 PM, during an interview, the Administrator stated staff are aware catheter drainage bags are to be covered. He reported privacy bags are readily available in supply areas and stated his expectation is for staff to keep catheter drainage bags covered to maintain resident dignity.A record review of the Patient Registration Form revealed the facility admitted Resident #37 on 2/12/26 with diagnoses including Emphysematous Cystitis.A record review of the Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/18/26 revealed Resident #37 had a Brief Interview for Mental Status (BIMS) score of seven (7), which indicated the resident's cognition was severely impaired.A record review of the facility's Assessment/Plans revealed Resident #37 had a Foley (type of indwelling catheter) catheter in place and was evaluated by urology, who recommended continued catheter drainage.

Based on observation, staff interview, and facility policy review, the facility failed to ensure food items in the freezer were sealed properly, scoops for sugar and flour were stored properly, and facial hair was restrained in the food preparation area for two (2) of two (2) kitchen observations. Findings Include: A review of the facility's policy, Productions Purchasing Storage- Food and Supply Storage, revised 01/24, revealed: .All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption . Dry Storage .Hang scoops. Scoops may be stored in bins on a scoop holder .Frozen Storage .Wrap food tightly to prevent cross-contamination . A review of the facility's policy, Orientation and Education- Uniform Dress Code revised on 01/24, revealed, .Associates Working with Food . Restrain all facial hair with a beard net/restraint . On 09/03/24 at 9:30 AM, during an observation of the freezer with Dietary Staff #1 and Dietary Staff #2, there were unsealed food items in the freezer, including tater tots, beef patties, and pizza dough. Both Dietary #1 and Dietary #2 confirmed the items were not sealed and acknowledged that all food items should be properly sealed to prevent contamination. At 9:40 AM on 09/03/24, during an observation of the dry storage area, there were silver square food containers submerged in the sugar and flour bins. Dietary #1 and Dietary #2 confirmed that the food containers were being used as scoops and should not be stored in the bins. Dietary #2 explained the kitchen used the silver square food containers, known as a 1/6th pan, because of the large quantities used in food preparation. At 9:50 AM on 09/03/24, during an observation and interview, Dietary Staff #3 was preparing chicken for lunch. He had a full beard and was not wearing a hair restraint to cover the facial hair. During an interview, Dietary #3 confirmed that he was not wearing a hair restraint because the facility did not have any for his facial hair and he was aware he should be wearing a hair restraint. Dietary #1 and Dietary #2 confirmed that Dietary #3 should have been wearing a facial hair restraint and confirmed that all facial hair should be covered at all times during food preparation. Dietary #2 stated she was unaware that the facility was out of facial hair restraints. On 09/04/24 at 8:55 AM, during an interview with Dietary #2, she confirmed she was aware of the standards and stated that she expected her staff to properly seal all food items in the freezers and to properly store flour and sugar scoops after each use. She acknowledged that these practices are essential to prevent food contamination and confirmed that the facility had since purchased facial hair restraints for the staff. She stated in situations where facial hair restraints were unavailable, staff could use hairnets as a temporary solution. She reiterated that hair restraints are mandatory for all staff while preparing or standing over food. On 09/04/24 at 10:55 AM, during a follow-up kitchen observation and temperature check with Dietary #1 and Dietary #4, Dietary #4 was observed taking the food temperatures for all items to be served. Although he wore a hat to cover his hair, Dietary #4 had a full beard and was not wearing a facial hair restraint. During an interview at 11:05 AM, Dietary #4 confirmed that he was aware of the requirement to wear a facial hair restraint in the food area and admitted that he had not worn one. Dietary #1 confirmed that facial hair restraints were available for staff use. At 11:15 AM on 09/04/24, during an interview with Dietary #2, she stated Dietary #4 should have worn a hair restraint to cover his facial hair while checking the food line temperatures, reiterating that facial hair restraints were available and should be worn as required. On 09/04/24 at 1:40 PM, during an interview with the Administrator, he explained that he had been informed by the kitchen staff about the concerns raised during the survey. He stated that he expected all kitchen staff to follow the guidelines and regulations regarding food storage and hair restraints.

Based on staff interview and facility policy review, the facility failed to insure the facility's Infection Preventionist (IP) completed specialized training in infection prevention and control for two (2) of two (2) days of the recertification survey. Findings include: A review of the facility's policy, Infection Preventionist, dated 3/15/23, revealed, .The Infection Preventionist is responsible for coordinating the implementation and updating of our established Infection prevention and control policies and practices. Policy Interpretation and Implementation .2. The Infection Preventionist will .d. Have completed specialized training in infection prevention and control . On 09/04/24 at 07:30 AM, in an interview with the IP, he revealed he had not completed all the modules that are required for the specialized training in infection prevention and control. On 09/04/24 at 08:52 AM, an interview with the Administrator revealed the facility's IP had not completed the specialized training modules. The Administrator stated there had been recent transitions in leadership, including the IP position. The previous IP had left the facility in July of this year, and she had specialized training in infection prevention and control and the current IP had completed at least one (1) module in the training. The Administrator confirmed he was responsible for ensuring the facility's IP had the required specialized training.

Based on observations, record review, staff and resident interviews, and facility policy review, the facility failed to maintain an effective surveillance program to prevent the possible spread of infection as evidenced by the failure to ensure that staff, visitors and other hospital departmental employees who entered the Transitional Care Unit (TCU) were screened related to signs and symptoms (S/S) of COVID-19 and failed to ensure Personal Protective Equipment (PPE) was worn appropriately for staff and visitors while on the TCU for three (3) of three (3) days of survey. Findings include: A review of the facility's policy, Infection Prevention and Control Program, revised 11/5/2021, revealed, .Policy Interpretation and Implementation .c. Outbreak .screen everyone entering the facility symptoms, such as for COVID-19 .implement source control for everyone entering the facility, regardless of symptoms . On 2/27/23 at 2:00 PM, during an observation, Certified Nurses Aide (CNA) #1 was observed exiting a resident's room and walking in the hallway wearing her face mask below her nose. On 2/28/23 at 3:00 PM, an interview with the Infection Preventionist (IP), revealed the TCU required everyone to always wear a face mask. She stated that all staff are trained on the proper use of PPE on hire and annually including face masks. The annual training involves a return demonstration for all skills, including wearing face masks. The IP explained that face masks should be worn covering the nose and mouth, and should not be underneath their nose or chin, and that if the staff touch their face mask, they would be contaminating their hands and everything they touched spreading infection. On 2/28/23 at 3:30 PM, an observation and interview with a visitor, revealed the visitor entered the TCU and did not obtain her temperature using the stationary thermometer, and did not complete the visitor's log to answer questions related to S/S of COVID-19. The visitor was not wearing a face mask as she walked down to a patient's room. An interview with the visitor revealed that the facility had instructed her to read the policy on visitation when her mother was admitted . She said the policy did say to always wear a mask and to be screened before entering the unit. She revealed that she had been coming to the facility for three (3) weeks and she just does not do it anymore. She revealed that she thought the reason for the screening and wearing a face mask would be to keep from spreading or catching an infection. On 2/28/23 at 3:45 PM, in an observation and interview with Housekeeper #1, she was wearing her face mask below her chin. She confirmed that the mask was pulled below her chin and explained it was because she was about to get off and wanted to breath. Housekeeper #1 revealed she was trained on the proper use of face masks, and that they should always cover the nose and mouth, and not be worn underneath the chin. She revealed that the reason the face mask should not be worn under the chin is because you want to keep things from getting in. She revealed that if your mask does not cover your nose and mouth, you could catch or spread germs. On 2/28/23 at 4:00 PM, in an interview with the Administrator, he stated that the facility follows the guidelines related to the Centers for Disease Control and Prevention (CDC) and that everyone on the TCU is instructed to wear face masks. He stated that he provided training daily during the Huddle for staff regarding COVID-19, infection control, and wearing PPE which included wearing face masks appropriately. On 3/01/23 at 12:00 PM, during an observation, the facility provided stationary thermometers at both entrances into the TCU. The Visitor Screening Log was in binders at both entrances in which visitors would record their temperature and answer questions related S/S of COVID-19. At the back entrance, there was a log for hospital departmental staff who enter the TCU, which included Dietary, to indicate their vaccination status. On 3/01/23 at 12:10 PM, in an interview the Minimum Data Set (MDS) nurse, she stated that staff who work on the TCU do not complete any documentation related to their temperature or S/S of COVID-19. The staff are required to check their own temperature using the stationary thermometers located at each entrance prior to going on the Unit daily, and if they have an abnormal temperature, they do not proceed onto the Unit. On 3/01/23 at 12:29 PM, in an interview with the Respiratory Therapist (RT), she stated that she checks her temperature on her first rounds every morning on the TCU. She confirmed that she does not record her temperature or complete any documentation regarding S/S of COVID-19. On 3/01/23 at 2:50 PM, in an interview with the Director of Nursing (DON) and the Administrator, the Administrator stated that the staff mostly use the back entrance to enter the TCU and use the thermometer there to check their temperature. He confirmed that the hospital staff who enter the unit, such as Dietary and Housekeeping, usually use the back entrance, check their temperature, and sign a log regarding vaccination status. This log requests hospital departmental staff to record the date, their name, and vaccination status and it is used more to track who is coming onto the Unit. He confirmed that the staff do not document the results of the temperature or complete questions related to the S/S of COVID-19. The DON confirmed that the current screening process probably does not help mitigate the spread of COVID 19. The Administrator said that previously, when the staff would log on to their computers, they would be asked screening questions by attestation by logging on to the computer. The Administrator stated that all staff have been educated about being physically responsible not to work while they are sick. A record review of the facility's Visitor COVID-19 Screening Log revealed the facility used this form for visitors to record their name and temperature and were asked yes and no questions regarding S/S of COVID-19. A record review of the facility's log, Transitional Care Unit revealed, Please print name and answer yes if full vaccinated or no if you have not received vaccination or if you have not been fully vaccinated . A record review of the facility's, Safety Huddle, dated 2/13/23, revealed the Administrator provided training on wearing masks to employees.

Based on observations, staff interviews, record review and facility policy review, the facility failed to ensure cautionary and safety signs indicating the use of oxygen were posted for two (2) of (2) sampled residents. Resident #4 and Resident #215 Findings include: A review of the facility's Piped Medical Gas and Vacuum Systems Policy, revised 1/19/2018, revealed the facility required precautionary signage on each door or gate of a cylinder storage room. The policy did not include the posting of cautionary and safety signs wherever oxygen was being administered. Resident #4 On 2/27/23 at 4:52 PM, during an observation, Resident #4 was at sitting in a chair at bedside and was wearing a nasal cannula. She stated that she needed oxygen at all times. There was no signage on the door of the room or inside the room indicating that oxygen was in use. Observation on 2/28/23 at 2:28 PM, revealed Resident #4 ambulating in the hallway with assistance. Oxygen per nasal cannula was noted with a small oxygen tank on a rolling stand. A record review of the Patient Registration Form revealed the facility admitted Resident #4 on 2/8/23 and she had diagnoses including Acute on Chronic Respiratory Failure and Acute Kidney Injury on Chronic Kidney Disease. A record review of the Order Sheet for Resident #4 revealed a Physician's Order, dated 2/18/23, for oxygen therapy. A record review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/14/23 revealed she had a Brief Interview for Mental Status (BIMS) score of 14, which indicated she was cognitively intact. Further review revealed Resident #4 was on oxygen therapy. Resident #215 On 2/27/23 at 11:56 AM, during an observation, Resident #215 was sitting in a chair next to his bed. He was wearing oxygen per nasal cannula. The oxygen tubing was connected to a flow meter in the wall of the patient's room. There was no signage on the door or inside of the room indicating that oxygen was in use. On 3/01/23 at 8:30 AM, in an interview with Respiratory Therapist (RT), she stated the rooms in which oxygen is administered do not display signs on the doors and that there was a flow meter in every room on the floor. On 3/01/23 at 8:42 AM, in an interview with the Director of Nursing (DON), she explained that there are no Oxygen in Use signs posted on individual patient doors. She stated that there is signage related to oxygen on the storage unit doors, but each room has an oxygen flow meter. She stated that it is posted at every entrance of the facility that they are a No Smoking Facility. On 3/01/23 at 8:55 AM, in an interview with the Administrator, he confirmed that the Transitional Care Unit does not post safety signs related to oxygen use for the individual patients who are receiving oxygen therapy. He stated that oxygen is piped in to every room and that staff are aware that every room has an oxygen flow meter.

Based on observations, record review, staff and resident interviews and Resident Assessment Instrument review, the facility failed to accurately code the Minimum Data Set (MDS) assessment for a resident with a chair alarm for two (2) of five (5) resident MDS reviewed. Resident #65 and Resident #67. Findings include: Review of the CMS's RAI (Resident Assessment Instrument) Version 3.0 Manual revealed .Coding Instructions: Identify all alarms that were used at any time (day or night) during the 7- day look-back period. After determining whether or not an item listed in PO200 was used during the 7-day look-back period, code the frequency of use . Resident #65 Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/23/23 revealed in Section P Restraints and Alarms that P0200 was marked as 0 B. Chair Alarm, indicating that a chair alarm was Not used. Review of Section C revealed a Brief Interview for Mental Status Score (BIMS) of an 11 revealing mild cognitive impairment. On 02/27/23 at 2:33 PM, the State Agency (SA) observed Resident #65 sitting in her room in a geri chair with a chair alarm that is fastened to the corner edge of her hospital gown at the back of the right shoulder and has a string that runs to an alarm device that is clipped to a sheet that is covering the geri chair. Interview with Certified Nursing Assistant (CNA) #1 on 02/28/23 at 1:15 PM, SA asked CNA #1 what the device was on the resident's chair and she stated that it is used to let us know if the resident is trying to get up on her own. She stated that all the residents in the high back chairs (geri chairs) have them when they sit up in their chairs. Interview with Licensed Practical Nurse (LPN) #1 on 02/28/23 at 1:20 PM, stated that each resident has a MORSE score (fall score) completed to evaluate their risk for falls on admission and that each resident has an assessment and is scored lower than 44, no/low risk fall; greater than 45 is protective and prevention, but that this resident scored a 65, so protective interventions are consider use of chair alarms when patient is sitting up. Interview with Director of Nursing (DON) on 02/28/23 at 2:00 PM, stated If they are in a chair they all get a chair alarm. It just alerts us quickly so we can get to her to prevent falls. The DON confirmed that it is a hospital policy that they follow that stated to place a chair alarm on all residents while up in the geri chairs. Record review of the Patient Registration Form revealed that the resident was admitted to the facility on [DATE] with diagnosis of Fracture of left pubis, Diabetes and Macular Degeneration. Resident #67 An observation on 02/28/23 at 2:30 PM, revealed Resident #67 was in the therapy unit in a geri chair with an alarm device connected to his hospital gown on the upper right shoulder and attached to a device that is adjacent to a white sheet that is covering his lounge chair while the resident is receiving therapy services. During an interview and observation with Resident #67 on 03/01/23 at 11:30 AM, he stated that he has noticed that if they place him in the chair to go to therapy that they have a Thing that they put there on my back and I guess it tells them if I need to get up. It doesn't bother me. When I get back to my room they put me back in the bed and I don't have it then. I ain't had any problems here and it don't bother me. During an interview and record review with the MDS Nurse on 02/28/23 at 3:43 PM, stated that The chair alarm is to alert us if the residents attempted to get up because we don't want them falling and getting hurt. If the person can remove them then we don't mark it on the MDS because it's not a restraint. She confirmed that everyday Resident #65 and Resident #67 did have the chair alarm attached when they went to and from therapy and the MDS nurse confirmed that the MDS in section P0200 under Alarms, revealed that 0 to indicate not used is entered into the box labeled B to indicate if the resident had a chair alarm. The MDS nurse confirmed that the MDS dated [DATE] with a 7 day look back indicated that the resident did not use a chair alarm any days for the last 7 days when in fact the resident did have a chair alarm device daily in use and the MDS nurse confirmed that it was coded inaccurately because she was not considering it as a restraint or an alarm. Record review of the most recent MDS with an ARD date of 02/23/23 revealed a BIMS score of 9, indicating moderate cognitive impairment. Record review of the Patient Registration Form revealed the resident was admitted on [DATE] with diagnosis of Seizures with left sided upper extremity weakness.

Based on record review, resident and staff interviews and facility policy review, the facility failed to ensure advanced directives were available and readily retrievable by facility staff for one (1) of 22 residents reviewed for advanced directives. Resident #2 Findings Include: A review of the facility's policy, Patient Self-Determination Act/Advance Directives, effective 12/1/1991, revealed, .If the patient has an advanced directive and the hospital does not have a copy available at the time of admission, the patient/family will be questioned regarding the contents of the Advance Directive and the contents will be added to the medical record . A record review of the Patient Registration Form revealed Resident #2 was admitted to the Transitional Care Unit (TCU) on 2/6/23 with diagnoses including Acute on Chronic Respiratory Failure and Urinary Tract Infection (UTI). A record review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/12/23, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact. A record review of the Transitional Care Unit Admission Checklist, dated 2/6/23, which was located in the medical chart and signed by Resident #2, indicated that she had a living will and a durable power of attorney of health care. Upon review of the medical record, there was no copy of the advanced directed located in the medical chart. On 2/27/23 at 4:50 PM, in an interview with the Licensed Social Worker (LSW), she stated that the facility may not receive a copy of the advanced directive from patients who have indicated they have one. She explained that she asks all patients upon admission if they have an advanced directive, however, because most patients are at the TCU for only a week or two, it is difficult to obtain a copy of the advanced directive before the patient is discharged . She confirmed that advanced directives are not on the medical record and are not available for review. On 2/27/23 at 5:20 PM, in an interview with the Administrator, he confirmed that the facility policy states that the advanced directive must be placed on the medical record. He explained that Resident #2 has been admitted to the hospital on several occasions and that there is probably a copy of the advanced directive somewhere in medical records, but he cannot access it. He confirmed that the advanced directive copy for Resident #2 is not readily retrievable by facility staff and that the facility is not following the facility policy related to Advanced Directives. On 2/28/23 at 1:22 PM, in an interview with Resident #2, she stated that she developed a living will years ago. She advised that she has not brought a copy of the advanced directive to the hospital and that she does not remember being asked to bring a copy when she was transferred to the TCU.

Based on the observation, staff interview, care plan review, and the facility clinical skills information, the facility failed to follow the care plan to provide incontinent care for a dependent resident in a manner to prevent the potential for additional urinary tract infections for one (1) of six (6) bowels and bladder care observations, Resident #2. Findings Include: No policy and procedure for following the care plan was available for review. Review of the care plan, Urinary Elimination-Impaired last updated on 10/15/17, revealed an intervention for perineal (incontinent) care, toileting assistance and toileting schedule implementation. Observation of incontinent care on 10/24/17 at 10:40 AM, revealed Certified Nursing Assistant (CNA) #1 used of a wash cloth folded as a mitten. CNA #1 wiped down each area of Resident #2's genitalia using the same portion of the wash cloth and repeated wiping over each area. Resident #2 was assisted over onto her side and CNA #1 wiped the buttocks with the same area of the wash cloth more than once. CNA #1 did not turn the wash cloth to a clean portion each time she wiped. Interview on 10/24/17 at 1:55 PM, with CNA #1, revealed she was nervous and the effects of not wiping correctly could lead to infection. Interview on 10/25/17 at 2:30 PM with Registered Nurse (RN) #1 revealed the care plan was not followed if the incontinent care was done incorrectly. Review of the facility's face sheet revealed the facility admitted the resident on 10/05/17. Resident #2's [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/12/17, revealed Resident #2 had a Brief Interview of Mental Status (BIMS) score of 7, which indicated severe impairment. Section G for toileting revealed Resident #2 required extensive assistance of one (1) staff person for care.

Based on observation of incontinent care, staff interviews, record reviews, and the facility clinical skills for perineal care the facility failed to provide incontinent care for a dependent resident in a manner to prevent the potential for additional urinary tract infections [MEDICAL CONDITION] for one (1) of six (6) incontinent/catheter care observations, Resident #2. Findings Include: Review of the facility clinical skills for perineal care revealed, 11. With the dominant hand, wash downward from the pubic area toward the rectum in one (1) smooth stroke. Use a separate section of the cloth for each stroke. Observation of incontinent care for Resident #2, on 10/24/17 at 10:40 AM, revealed the Certified Nursing Assistant (CNA) #1 folded the washcloth into a mitten shape. CNA #1 then wiped Resident #2's perineal area using the same side of the washcloth without folding to another clean side. She continued to wipe over the same part of Resident #2's genitals using multiple [MEDICAL CONDITION]. In an interview, on 10/24/17 at 1:55 PM, CNA #1 revealed she was nervous and the resident could get an infection from using improper technique. Interview on 10/26/17 at 10:50 AM, with the Director of Nursing (DON), who was also the Quality Assurance Nurse, stated CNA #1 was probably nervous and her actual training had been done at the hospital. Review of the urine analysis for 10/15/17, revealed Resident #2 had a UTI. Physician orders [REDACTED].#2 required an intravenous (IV) antibiotic. Review of the facility's face sheet revealed the facility admitted Resident #2 on 10/05/17. Resident #2's [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/12/17, revealed Resident #2 had a Brief Interview of Mental Status (BIMS) score of 7, which revealed severe cognitive impairment. Section G for toileting revealed Resident #2 required extensive assistance of one staff member.

Based on observation, record review, staff interview and facility policy review the facility failed to develop a care plan for indwelling urinary catheter for one (1) of nine (9) records reviewed; Resident #2. Findings include: Review of the facility's policy entitled, Interim Plan of Care, dated 2/23/12, revealed all appropriate disciplines would assess residents and develop a plan of care in a timely manner. Review of Resident #2's care plans revealed no care plan for the care of an indwelling urinary catheter. Observation of Resident #2 on 3/08/16 at 12:30 PM revealed this resident had an indwelling urinary catheter. During an interview on 3/08/16 at 4:30 PM, Registered Nurse (RN) #1 confirmed there was no care plan for the care of an indwelling urinary catheter for Resident #2. RN #1 stated she was responsible for developing care plans and Resident #2 should have a care plan for an indwelling urinary catheter. RN #1 stated she didn't know why Resident #2 did not have one and that she must have overlooked it. Review of the facility's face sheet revealed this facility admitted Resident #2 on 2/18/16 with the [DIAGNOSES REDACTED]. Review of the Minimum Data Set with an Assessment Reference Date of 2/25/16 a Brief Interview of Mental Status was conducted with a score of 15 indicating this Resident had no cognitive impairment.

Based on observation, record review and facility policy review, the facility failed to ensure a medication error rate of less than five (5) percent as evidenced by two (2) of 33 opportunities for error. The facility error rate was six (6) percent (6%). Findings include: Review of a letter provided by facility stated the Transitional Care Unit (TCU) did not have a policy addressing medication errors specific to Percutaneous Endoscopic Gastrostomy (PEG) tubes. An article from Lippincott Manual of Nursing Practice was attached to the letter which stated "... need the skills to be able to administer a drug capably, minimizing your patient's anxiety and maximizing the drug's effectiveness". Observation on 4/30/14 at 3:20 PM revealed Registered Nurse (RN) #1 crushed [MEDICATION NAME] 2.5 mg and [MEDICATION NAME] 5/325 mg, mixed together, and administered the medications through Resident #3's PEG tube. The PEG tube was flushed prior to medications being administered and following medications administered. The PEG tube was not flushed between each of the two medications administered. Interview with RN #1 on 1/30/14 at 3:45 PM confirmed the two medications were mixed together in a cup and administered together through the PEG tube. RN #1 stated they (nurses) were in-serviced on administering medications using a PEG tube last year, but giving all of the medications separately was not part of the in-service. Observation on 1/31/14 at 9:50 AM revealed RN #2 crushed [MEDICATION NAME] 0.4 mg and [MEDICATION NAME] 2.5 mg, and mixed together, and administered the medications together through a PEG tube. The PEG tube was flushed prior to medications being administered and following medications administered. The PEG tube was not flushed between each of these medications. Interview with RN #2 on 1/31/14 at 9:50 AM revealed RN #2 was in-serviced on administering medications through a PEG tube, however, the in-service did not address administering medications separately when using a PEG tube. RN #2 said "we only give them (medications) separately when using a Naso-Gastric (NG) tube". Interview with the Director of Nursing (DON) on 1/31/14 at 12:05 PM revealed the facility does not have a policy on administering medications through a PEG tube.

Based on observation, record review, staff interview and policy review, the facility failed to provide catheter/incontinent care in a manner to decrease the possibility of infection for one (1) of two (2) care observations (Resident #1). The facility also failed to have medical justification for an indwelling catheter for one (1) of two (2) urinary catheters reviewed (Resident #1). Findings include: Resident # 1 Observation of Resident #1 on 4/12/13 at 10:30 a.m., revealed that he was lying in bed while facility staff performed catheter care. During the catheter care, Certified Nursing Assistant (CNA) #2 cleaned less than four (4) inches down the catheter from the meatus. The urinary catheter was not secured as the care was given, and the catheter was cleaned with water. Record review for Resident #1 revealed that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/9/13, revealed that he had severely impaired decision making. Further record review for Resident #1 revealed that there was no documented evidence of medical justification for the use of the urinary catheter, which included review of the History and Physical dated 3/27/13. Interview with Resident #1's Medical Doctor on 4/12/13 at 9:05 a.m., revealed that when the Doctor was asked about the reason for the urinary catheter, he replied "Probably to stop him from wetting his wound". Resident #1 had a Stage I Pressure Ulcer on his coccyx. Interview with Social Services Staff #1 on 4/12/13 at 9:10 a.m., regarding Resident #1 confirmed "He came from assisted living. He did not have a Foley (urinary drainage catheter) there, so they put in the catheter here (at the hospital connected to the facility)". Interview with CNA #2 on 4/12/13 at 10:40 p.m., confirmed "I cleaned down the catheter maybe 2 (two) to 3 (three) inches. When asked if she secured the urinary drainage catheter when she cleaned it, she stated "no". CNA #2 also confirmed that she cleaned the urinary drainage catheter with water. Review of the facility's policy "Catheter Care", reviewed 3/06, documented "II. Procedure: Because of the risks associated with urinary catheterization, the following procedures based on current scientific recommendations will be adhered to for all patients requiring urinary catheterization. A. Considerations prior to Catheterization, Because of the infection risk associated with urinary catheterization, avoiding catheterization should be practiced whenever possible. The following are examples of indicators when urinary catheterization would be acceptable: Patients who have urinary incontinence and a Stage III or IV pressure ulcer(s) on trunk" .II. Procedure, E. Catheter Insertion, Care and Maintenance, 6. The meatal area should be cleansed with soap and water at least once daily, and as needed". The Mississippi Nurse Aide Candidate Handbook, dated 2/13, documented "8. While holding catheter near meatus without tugging, cleans at least four (4) inches of catheter nearest meatus (with soap and water), moving in only one direction, away from meatus, using a clean area of the cloth for each stroke. 9. While holding catheter near meatus without tugging, rinses at least four (4) inches of catheter nearest meatus, moving only in one direction, away from meatus, using a clean area of the cloth for each stroke".

Based on observation, record review, staff interview and policy review, the facility failed to decrease the potential of infection for one (1) of two (2) care observations (Resident #1). Findings include: Resident # 1 Observation of Resident #1 on 4/12/13 at 10:30 a.m., revealed that he was lying in bed while facility staff performed catheter care. During the catheter care, Certified Nursing Assistant (CNA) #2 cleaned less than four (4) inches down the catheter from the meatus. The urinary catheter was not secured as the care was given, and the catheter was cleaned with water. Record review for Resident #1 revealed that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/9/13, revealed that he had severely impaired decision making. Interview with CNA #2 on 4/12/13 at 10:40 p.m., revealed "I cleaned down the catheter maybe 2 (two) to 3 (three) inches". When asked if she secured the urinary drainage catheter when she cleaned it, she stated "no". CNA #2 also confirmed that she cleaned the urinary drainage catheter with water. Review of the facility's policy "Catheter Care", reviewed 3/06, "II. Procedure, E. Catheter Insertion, Care and Maintenance, 6. The meatal area should be cleansed with soap and water at least once daily, and as needed". The Mississippi Nurse Aide Candidate Handbook, dated 2/13, documented "8. While holding catheter near meatus without tugging, cleans at least four (4) inches of catheter nearest meatus (with soap and water), moving in only one direction, away from meatus, using a clean area of the cloth for each stroke. 9. While holding catheter near meatus without tugging, rinses at least four (4) inches of catheter nearest meatus, moving only in one direction, away from meatus, using a clean area of the cloth for each stroke".

Based on observation, record review, staff interview and policy review, the facility failed to provide care in a dignified manner for one (1) of seven (7) residents reviewed (Resident #1). Findings include: Resident # 1 Observation of Resident #1 on 4/11/13 at 12:10 p.m., revealed that he was lying in bed while facility staff fed him lunch. The urinary catheter drainage bag was observed without a privacy cover. Certified Nursing Assistant (CNA) #1 was standing at the Resident's bed side as she fed him. Observation of Resident #1 on 4/11/13 at 4:55 p.m., revealed that CNA #1 was seated in a chair as she fed the Resident his supper. There was a privacy bag covering the urinary catheter drainage bag. CNA #1 was wearing gloves as she fed the Resident, even though there were no special isolation measures in effect. Record review for Resident #1 revealed that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/9/13, revealed that he had severely impaired decision making. Interview with CNA #1 on 4/11/13 at 4:55 p.m., revealed "We put it (the privacy cover for urinary catheter drainage bag) on because he went out in the hall and it is supposed to be covered when they go outside the room". CNA #1 also added "It is not necessary in the room". CNA #1 also stated "They told me I'm supposed to have a chair" when feeding Residents. Interview with CNA #1 on 4/11/13 at 5:20 p.m., revealed "I feed with gloves all the time". Review of the facility's policy "Dignity", reviewed 3/06, documented "Policy: The facility will promote care for each resident in a manner and environment that maintains and enhances each resident's dignity and respect, Procedure: 3. Each resident's right to privacy, space and property will be respected at all times".

Based on observation, record review, staff interview and policy review, the facility failed to provide the dietary supplement for two (2) of eleven (11) meals observed (Resident #1). Findings include: Resident #1 Observation of Resident #1 on 4/11/13 at 12:10 p.m., revealed that he was lying in bed while facility staff fed him lunch. There was no Ensure plus on the Resident's tray, but there was a bottle on Ensure on the over bed table by the tray. Observation of Resident #1 on 4/12/13 at 12:20 p.m., revealed that there was no Ensure Plus or [MEDICATION NAME] on the lunch tray. Record review for Resident #1 revealed that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/9/13, revealed that he had severely impaired decision making. Further record review for Resident #1 revealed a Physician Order, dated 4/9/13, for "[MEDICATION NAME] 2 (two) scoops tid (three times daily) mixed with Ensure Plus". Review of the Diet paper, on 4/12/13, which was included with Resident #1's lunch tray, revealed "2 scoops [MEDICATION NAME], Ensure". Interview with Certified Nursing Assistant (CNA) #1 on 4/11/13 at 12:10 p.m., regarding Resident #1's lunch tray confirmed "He got two (2) Ensure on his breakfast tray, so this is an extra", referring to the bottle of Ensure on the over bed table. Interview with Dietary Staff #1 on 4/12/13 at 12:25 p.m., regarding Resident #1's tray confirmed "[MEDICATION NAME] would come up in a cup and it is mixed up here". Dietary Staff #1 also confirmed that there was no [MEDICATION NAME] or Ensure Plus on the lunch tray for Resident #1. Review of the facility's policy "Enteral Formula Feedings", revised 11/12, documented "II. Procedure: Nutrition Services will send the oral nutritional supplement/tube feeding formula with the food carts at each meal, unless otherwise specified in the comment text of the order".

Based on observation, record review, staff interview and policy review, the facility failed to obtain the specific area of application for topical medication for one (1) of ten (10) records reviewed (Resident #9). Findings include: Resident #9 Observation of Resident #9 on 4/12/13 at 8:25 a.m., revealed that she was lying in bed while facility staff administered medications. Record review for Resident #9 revealed that she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Brief Interview for Mental Status (BIMS), dated 4/12/13, revealed that she scored 15 of 15 which indicated that she was cognitively intact. Further record review for Resident #9 revealed that on the Physician Orders, there was an order dated 4/11/13, for "Voltarin Top (Topical) 2 gm (grams) per joint four times a day topically". The order did not include the specific joints the medication should be applied to. Interview during the aforementioned observation revealed, Registered Nurse (RN) #1 stated "I don't know where to put it (the Voltarin). I'll have to ask her". Resident #9 stated "Sometimes I use it on my right leg (indicating the right thigh and knee), but today I'll put some here (indicating left thumb and left shoulder)." Interview with Pharmacy Staff #1 regarding the Voltarin order for Resident #9 confirmed "This is pretty bad. This needs clarification". Review of the facility's policy "Medication Orders Including Range Orders", reviewed 11/12, documented "Policy: Medication orders will be written clearly, Medication orders must, at a minimum, contain the following elements: - Frequency of administration/Directions for use".

Based on observation, staff interview, and policy and procedure review, the facility failed to ensure that one (1) of eight (8) residents was assessed for self administration of drugs. The facility failed to follow the facilities self administration of drugs policy or obtain a physician's orders [REDACTED]. . Findings include: Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set 3.0 was not due at this time. On 3/23/12 at 8:45 a.m. Resident #7 was observed during medication pass. The resident stated she had already taken two (2) of her home medications, Adcirca 20 milligrams and Letairis 10 milligrams. On 3/23/12 at 8:50 a.m. RN #1 took these medications and placed them in the medication storage cabinet. On 3/23/12 at 10:00 a.m. Resident #7 revealed that she had been on this unit since Friday, March 16, 2012 and had been administering these medications each morning. Resident #7 also revealed that the nurses were aware that she had the medications. Interview on 3/23/12 at 10:10 a.m. with RN # 2 revealed that an assessment for self administration of medications had not been completed and a physician's orders [REDACTED]. Review of the facility's Self Administration of Medication Policy dated 12/30/09 revealed that patients will be assessed by the interdisciplinary team, and if assessed appropriate to give their medications safely, an order will be obtained and that medication can be stored at bedside, or in the medication room. If the patient is assessed to safely administer the medication, they will be instructed to tell the nurse when they medicated themselves, so it can be added to the MAR. Record review revealed that a Home Medication Identification form dated 3/19/12 at 1:00 p.m. revealed Adcirca 20milligrams and Letairis 10 milligrams had been identified by the pharmacist. This form noted, "Physician must separately authorize continuation of identified medications." Interview on 3/23/12 at 11:05 a.m. with the Director of Nurses confirmed that they had failed to assess resident for self administration of medications, failed to obtain a physician's orders [REDACTED].

Based on observation, staff interview and record review, the facility failed to have an individualized care plan that include the individual needs for one (1) of eight (8) records reviewed (Resident #4). Findings include: Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 dated 3/11/12 revealed that Resident #4 had a brief interview mental status (BIMS) score of nine (9) indicating poor cognition. This MDS indicated resident had a Stage II pressure on admission. The MDS 3.0 Care Area assessment dated [DATE] for Pressure Ulcer revealed the resident was admitted with a Stage II to the coccyx, that would continue to treat areas as ordered, will continue to monitor skin for further breakdown and will care plan. Review of the 2/27/12 care plan revealed that there was no care plan for the pressure ulcer area on admission or preventative measures, such as the heel suspension boots. On 3/22/12 at 9:25 a.m. Resident #4 was observed in bed with heels floated on pillows. On 3/23/12 at 11:15 a.m. Resident #4 left leg and buttocks were observed with RN #3. No broken skin was observed. During this observation heel suspension boots were observed in a cabinet. Interview with RN #3 revealed that when resident moves too much it is hard to keep them on. Record review of 3/5/12 wound care notes revealed right heel evaluated. No open areas. Heel is boggy. Recommend heel lift suspension boots to bilateral heels. Continue to float heels. Record review of the 3/5/12 physician's orders [REDACTED]. Observation on 3/23/12 at 11:35 a.m. of Resident #4's heels revealed no broken skin areas. Review of the Patient 24 hour assessment record with the Director of Nurses on 3/23/12 at 11:45 a.m. revealed that heels were floated on March 5, 6, 11, 12, 13, 17, 18, 19. There was no documentation that the boots were used. Interview with the Director of Nurses on 3/23/12 at 11:45 a.m. revealed that the boots should be used and documented in the nurses' notes. Interview on 3/23/12 at 11:30 a.m. with a family member revealed that the boots had not been on for over a week. Interview on 3/23/12 at 12:25 p.m. with CNA #1 confirmed that boots have not been put on today. Review of the Nursing Assistant Flowsheet for 3/19/12 through 3/22/12 revealed that the boots were not listed on this record to let them know that the boots were to be used. Interview on 3/23/12 at 12:45 p.m. with RN #2 confirmed there was no care plan for the preventative measures for skin care.

Based on observation, interview, and review of the facility's policy for Physician ' s Orders, the facility failed to ensure that physician's orders were obtained and/or followed for two (2) of (8) residents reviewed ( Resident #4 and Resident #7). Findings include: Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 dated 3/11/12 revealed that Resident #4 had a brief interview mental status (BIMS) score of nine (9) indicating poor cognition. This MDS indicated Resident #4 had a Stage II pressure ulcer on admission. The MDS 3.0 Care Area assessment dated [DATE] for Pressure Ulcer revealed the resident was admitted with a Stage II pressure ulcer to the coccyx, would continue to treat areas as ordered, would continue to monitor skin for further breakdown and will care plan. Review of the 2/27/12 care plan revealed that there was no care plan for the pressure area on admission or to monitor skin for further breakdown or preventive measures. On 3/22/12 at 9:25 a.m. Resident #4 was observed in bed with heels floated on pillows. On 3/23/12 at 11:15 a.m. Resident #4 left leg and buttocks were observed with RN #3. No broken skin was observed. During this observation heel suspension boots were observed in a cabinet. Interview with RN #3 revealed that when resident moves too much it is hard to keep them on. Record review of Resident #4's 3/5/12 wound care notes revealed right heel evaluated. No open areas. Heel is boggy. Recommend heel lift suspension boots to bilateral heels. Continue to float heels. Record review of the 3/5/12 physician's order revealed lift suspension boots to heels. Observation on 3/23/12 at 11:35 a.m. of Resident #4's heels revealed no broken skin areas and the heel lift suspension boots were not in place. Review of the Patient 24 hour assessment record with the Director of Nurses on 3/23/12 at 11:45 a.m. revealed that heels were floated on March 5, 6, 11, 12, 13, 17, 18, 19. There was no documentation that the boots were used. Interview with the Director of Nurses on 3/23/12 at 11:45 a.m. revealed that the boots should be used and documented in the nurses' notes. Interview on 3/23/12 at 11:30 a.m. with a family member revealed that the boots had not been on for over a week. Interview on 3/23/12 at 12:25 p.m. with CNA #1 confirmed that boots had not been put on today. Review of the Nursing Assistant Flowsheet for 3/19/12 through 3/22/12 revealed that the boots were not listed to let them know that the boots were to be used. Interview on 3/23/12 with RN #2 confirmed that the facility's policy had not been followed. RN #2 revealed that that the orders had not been transferred to Kardes, MAR indicated [REDACTED] The facility's policy and procedure for physician's orders revealed a) Orders are be transferred to Kardex, MAR (Medication Adminission Record) or Computer Order Entry as necessary. b) The unit secretary or nurse who enters orders into the computer will note the computer order entry number beside the order in black ink. c) The unit secretary will initial the order sheet to indicate that the computer orders have been entered. d) The nurse will check to see that all orders have been entered, or properly recorded and note the orders with first initial, last name, date and time. Resident #7 Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set 3.0 was not due at this time. On 3/23/12 at 8:45 a.m. Resident #7 was observed during medication pass. The resident stated she had already taken two (2) of her home medications (Adcirca 20 milligrams and Letairis 10 milligrams). On 3/23/12 at 8:50 a.m. RN #1 took these medications and placed them in the medication storage cabinet. On 3/23/12 at 10:00 a.m. Resident #7 revealed that she had been on this unit since Friday, March 16, 2012 and had been administering these medications each morning. Resident #7 also revealed that the nurses were aware that she had the medications. Interview on 3/23/12 at 10:10 a.m. with RN # 2 revealed that an assessment for self administration medications had not been completed and a physicians order for self administration of medications had not been obtained. Review of the facility's Self Administration of Medication Policy dated 12/30/09 revealed that patients will be assessed, and if assessed appropriate to give their medications safely, an order will be obtained and that medication can be stored at bedside, or in the medication room. If the patient is assessed to safely administer the medication, they will be instructed to tell the nurse when the medicated themselves, so it can be added to the MAR. Record review revealed that a Home Medication Identification form dated 3/19/12 at 1:00 p.m. revealed Adcirca 20 milligrams and Letairis 10 milligrams had been identified by the pharmacist. This form noted, "Physician must separately authorize continuation of identified medications." Review of Resident #7's care plans with an implementation date of 3/16/12 revealed that there was no care plan for self administration of medications. Interview on 3/23/12 at 11:05 a.m. with the Director of Nurses (DON) confirmed that a physician's order had not been obtained for the resident to self administer the medication. The DON confirmed there was no care plan for self administration of medications.

Based on observation, staff interview and policy review, the facility failed to ensure that drugs were store properly for one (1) of eighteen (18) resident rooms and failed to follow their policy for storage of drugs of two (2) of two (2) days of survey. Findings include: Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].A Minimum Data Set 3.0 was not due at this time. On 3/23/12 at 8:45 a.m. Resident #7 was observed during medication pass. The resident stated she had already taken two (2) of her home medications (Adcirca 20 milligrams and Letairis 10 milligrams). On 3/23/12 at 8:50 a.m. RN #1 took these medications and placed them in the medication storage cabinet. On 3/23/12 at 10:00 a.m. Resident #7 revealed that she had been on this unit since Friday, March 16, 2012 and had been administering these medications each morning. Resident #7 also revealed that the nurses were aware that she had the medications. Record review revealed that a Home Medication Identification form dated 3/19/12 at 1:00 p.m. revealed Adcirca 20 milligrams and Letairis 10 milligrams had been identified by the pharmacist. This form noted, "Physician must separately authorize continuation of identified medications." Review of the facility's policy Medication Storage and Security dated 1/1/2012 revealed "Medications will be stored under appropriate storage conditions in a designated storage area at all times." Interview on 3/23/12 at 11:05 a.m. with the Director of Nurses confirmed that medications should have been locked in the medicine cabinet.