Every finding on record at Monroe City Manor Care Center

Based on observation, interview, and record review, the facility failed to ensure the range hood was free of an accumulation of grease and debris, failed to ensure the floors in the kitchen were free of a buildup of grease and debris, and failed to properly store food items. The facility census was 54.1. Review of the facility policy, Cleaning Instructions: Hoods and Filters, dated 2020, showed hoods and filters will be cleaned regularly, at least once a month. Review of the Dietary Sanitation Evaluation, dated 6/6/25 and completed by the facility's consultant dietitian, showed the hoods and filters were not clean and dust was noted. Review of the Dietary Sanitation Evaluation, dated 7/11/25 and completed by the facility's consultant dietitian, showed the hoods and filters were not clean and had dust. Observation on 8/18/25 at 10:35 A.M., of the kitchen range hood showed the following:-A moderate buildup of yellow grease and dark-colored debris on the baffle filters under the range hood;-The range hood protected a six-burner stove, flat-top griddle and a double fryer. During an interview on 8/18/25 at 10:35 A.M., the Dietary Manager said staff were supposed to clean the hood and filters weekly. She was unsure if staff cleaned the range hood last week. 2. Review of the Dietary Sanitation Evaluation, dated 6/6/25 and completed by the facility's consultant dietitian, showed the floor was not clean. Review of the Dietary Sanitation Evaluation, dated 7/11/25 and completed by the facility's consultant dietitian, showed the floor was sticky. Observation on 8/18/25 at 10:38 A.M. and on 8/19/25 at 8:53 A.M. showed an extremely heavy buildup of yellow and brown pooled grease and food debris on the floor underneath the six-burner stove, griddle, double fryer, and metal preparation counter. Yellow grease visibly ran down the front of the stove and dripped into the existing puddle of grease on the floor. During an interview on 8/19/25 at 8:53 A.M., the Dietary Manager said staff was supposed to clean the grease off the floor weekly. Staff was behind in the scheduled duties and it was overwhelming to try to get caught up. The grease trap didn't always catch the grease, and the grease leaked out inside the stove. 3. Review of the Dietary Sanitation Evaluation, dated 6/6/25 and completed by the facility's consultant dietitian, showed the floor of the walk-in freezer was not clean. Observation on 8/18/25 at 9:33 A.M. of the walk-in freezer showed a heavy accumulation of paper trash, potato wedges. and other food debris/crumbs on the floor of the unit. During an interview on 8/19/25 at 8:53 A.M., the Dietary Manager said staff were to clean spills and messes as they occurred. 4.Observation on 8/18/25 at 9:34 A.M. of the walk-in cooler showed a black crate sat on the cooler floor that held a plastic bag of liquid ice cream mix that directly touched the floor. Observation on 8/18/25 at 10:27 A.M. of the kitchenette refrigerator showed an open 1-pound stick of butter. The paper wrapper loosely covered the butter and left the butter open to air. During an interview on 8/19/25 at 8:53 A.M., the Dietary Manager said the ice cream mix should not be stored on the floor.

Based on interview and record review, the facility failed to offer and/or administer the pneumococcal vaccine as indicated by the current Centers for Disease Control and Prevention (CDC) guidelines for three residents (Residents #1, #38 and #47), in a review of 17 sampled residents. The facility census was 54. Review of the CDC's Pneumococcal Vaccine Timing for Adults, updated October 2024, showed the following:-For adults 50 years or older who have never received any pneumococcal vaccine or whose previous vaccination history is unknown, administer PCV15, PCV20, or PCV21; -If PCV15 is administered, administer a dose of PPSV23 at least one year after the dose of PCV15. If the PPSV23 is not available, the PCV20 or PCV21 may be used;-If PCV20 or PCV21 is administered, regardless of which vaccine is used, their pneumococcal vaccinations are complete;-For adults 50 years or older who received the PPSV23 only at any age, administer the PCV15, PCV20 or the PCV 21 at least one year after the PPSV23 was administered;-For adults 50 years or older who received the PCV13 only at any age, administer the PCV20 or PCV21 at least one year after the PCV13 was administered;-For adults 50 years or older who received the PCV13 at any age and the PPSV23 when less than [AGE] years of age, administer the PCV20 or PCV21 after at least five years after the last pneumococcal vaccine dose;-For adults 65 years or older who received the PCV13 at any age and the PPSV23 at 65 years or older, the individual and their vaccination provider may choose to administer the PCV20 or PCV21 after at least five years after the last pneumococcal vaccine dose. (Refer to the CDC's Shared Clinical Decision-Making PCV20 or PVC21 Vaccination for Adults 65 Years or Older for additional information on clinical decision making.) 1. Review of the Resident #38's undated face sheet showed the following:-He/She admitted to the facility on [DATE];-He/She was over age [AGE];-He/She had a diagnosis of diabetes mellitus (medical condition characterized by abnormally high blood sugar levels) and asthma (chronic respiratory illness);-He/She had a representative responsible for making medical decisions. Review of the resident's preventative health documentation, located in his/her electronic health record (EHR), showed the following:-No documentation the resident received pneumococcal vaccinations;-No documentation the resident was offered or refused any pneumococcal vaccinations.(The resident was not up to date on the pneumococcal vaccination per CDC recommendations.) Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility, dated 05/24/25, showed the following:-His/Her cognition was severely impaired;-The resident's pneumococcal vaccinations were up to date. During an interview on 08/21/25 at 12:30 P.M., the resident's representative said he/she thought resident was up to date with pneumococcal vaccinations. He/She expected the resident to be up to date with all immunizations. 2. Review of the Resident 1's undated face sheet showed the following:-He/She was admitted to the facility on [DATE];-He/She was over the age of 65;-He/She had a diagnosis of diabetes mellitus;-He/She was his/her own person. Review of the resident's quarterly MDS, dated [DATE], showed the following:-His/Her cognition was intact;-The resident's pneumococcal vaccination was up to date. Review of the resident's preventative health documentation, located in his/her EHR, on 8/20/25 showed the following: -The resident received the pneumonia vaccination of unknown type on 12/31/19;-No documentation the resident was offered, received, or refused any additional pneumococcal vaccine.(The resident was not up to date on the pneumococcal vaccination per CDC recommendations.) During an interview on 08/21/25 at 12:40 P.M., the resident said he/she was not sure if he/she was up to date with the pneumonia vaccination. No one from the facility had offered him/her the pneumonia vaccination. He/she would take the pneumonia vaccination if offered. 3. Review of Resident #47's undated face sheet showed the following:-He/She admitted to the facility on [DATE];-He/She was over the age of 65;-Diagnoses included pneumonitis (inflamed lung tissue) due to inhalation of food and vomit, chronic obstructive pulmonary disease (COPD; obstructed airflow causing breathing difficulty), altered mental status and dementia (loss of memory and judgement);-He/She had a listed durable power of attorney (DPOA). Review of the resident's significant change MDS, dated [DATE], showed the following:-Moderately impaired cognition;-Pneumonia vaccine up to date. Review of the resident's preventive health record, located in the EHR, on 08/18/25 showed the following:-The resident received the PPSV23 (Pneumococcal Polysaccharide Vaccine 23-valent) out of the facility on 11/30/20;-No documentation the resident was offered, received, or refused any additional pneumococcal vaccines.(The resident was not up to date on the pneumococcal vaccination per CDC recommendations.) During an interview on 08/21/25 at 12:40 P.M., the resident's DPOA said he/she expected staff to offer any available vaccinations and wanted the resident to have them as needed. 4. During an interview on 08/20/25 at 11:30 A.M., the Director of Nursing said the facility did not track residents' pneumonia vaccination status. The current MDS Coordinator checked vaccination history for the new residents who are admitted . During an interview on 08/20/25 at 11:15 A.M., the MDS Coordinator said the following:-The nurse who had been tracking the residents' vaccinations quit a few months ago; -Upon a resident's admission, she assessed for vaccination history, including pneumococcal vaccinations, to see if vaccinations were up to date; -If resident and/or resident representative were unaware of the resident's vaccination history, the facility contacted the resident's primary care physician (PCP) for further instruction and orders. During an interview on 08/21/25 at 3:30 P.M., the Administrator said she expected all residents to be up to date with all immunizations, including the pneumococcal vaccination, per the CDC guidelines.

Based on interview and record review, the facility failed to implement policies and procedures to ensure residents' trust accounts were not allowed to go into a negative balance which affected one resident (Resident #40), in a review of seven sampled residents for which the facility maintained accounts. The facility census was 54. Review of the undated facility policy, Management of Residents' Personal Funds, showed the following:-The resident may have the facility hold, safeguard, and manage his or her personal funds;-Should the facility manage the resident's funds, the facility acts as a fiduciary of the resident funds and holds, safeguards, manages and accounts for the personal funds of the resident;-Inquiries concerning the facility's management of resident funds are referred to the administrator or to the business office. 1. Review of petty cash vouchers for the month of March, showed Resident #40 was allowed to obtain cash on the following dates:-On 03/07/25, the resident signed a facility petty cash voucher for $25.00 cash;-On 03/25/25, the resident signed a facility petty cash voucher for $30.00 cash;-On 03/28/25, the resident signed a facility petty cash voucher for $50.00 cash;-The sum of the resident's petty cash vouchers for the month of March was $105.00. Review of the facility-maintained Resident Trust Fund Statement, dated 04/01/25 through 04/30/25 showed the following: -On 04/01/25, the resident's beginning balance was $100.00;-On 04/06/25, check #2769 was taken out of the resident fund account and transferred to the facility account for $105.00 to replace the petty cash the resident had withdrawn for the month of March;-On 04/06/25, the resident's resident trust balance was -$5.00.-On 04/18/25, receipt of $80.00 cash from family was deposited into the residents' trust fund account. Review of petty cash vouchers for the month of April, showed Resident #40 was allowed to obtain cash on the following dates:-On 04/22/25, the resident signed a facility petty cash voucher for $30.00 cash;-On 04/28/25, the resident signed a facility petty cash voucher for $50.00 cash;-The sum of the resident's petty cash vouchers for the month of April was $80.00. Review of the facility-maintained Resident Trust Fund Statement, dated 04/01/25 through 04/30/25 showed the following: -On 04/30/25 interest distribution of $0.01 was deposited into the residents' trust fund account;-On 04/30/25 the resident's ending balance was $75.01. Review of petty cash vouchers for the month of May showed Resident #40 was allowed to obtain cash on the following dates:-On 05/01/25, the resident signed a facility petty cash voucher for $40.00 cash;-On 05/05/25, the resident signed a facility petty cash voucher for $35.00 cash;-The sum of the resident's petty cash vouchers for the month of May was $75.00. Review of the facility-maintained Resident Trust Fund Statement, dated 05/01/2025 through 05/30/25 showed the following:-On 05/01/25, the resident's beginning balance was $75.01;-On 05/07/25, check #2882 was taken out of the resident fund trust account and transferred to the facility account for $80.00 to replace the petty cash the resident had withdrawn for the month of April;-On 05/07/25 the resident's resident trust balance was -$4.99. Review of the facility-maintained Resident Trust Fund Statement, dated 06/01/25 through 06/30/25 showed the following:-On 06/01/25, the resident's beginning balance was -$4.99;-On 06/09/25, check #2885 was taken out of the resident fund trust account and transferred to the facility account for $75.00 to replace the petty cash the resident had withdrawn for the month of May;-On 06/09/25, the resident's resident trust balance was -$79.99. Review of the facility-maintained Resident Trust Fund Statement, dated 07/01/25 through 07/31/25 showed the following:-On 07/01/25 the resident's beginning balance was -$79.99;-On 07/31/25 the resident's ending balance was -$79.99. During an interview on 08/21/25 at 8:45 A.M., Resident #40 said the following:-His/Her spouse provided money for his/her resident trust account;-He/She always gets his/her money from the receptionist;-He/She was told by the receptionist about six months ago, he/she did not have any money. During an interview on 08/20/25 at 12:07 P.M., the receptionist said the following:-If a resident asked for cash, she would have the resident sign a petty cash voucher and give them money from the facility's petty cash drawer;-She always checked a resident's account balance on the computer before giving a resident cash;-The computer system never showed Resident #40 was in debt;-She would not have given Resident #40 any money if he/she was in debt;-She balances the petty cash box monthly and gives the petty cash vouchers to the Business Office Manager (BOM) for reimbursement;-She did not check the slips in her petty cash drawer before giving Resident #40 money;-There was no accurate fund balance during the month until the slips are given to the BOM for reimbursement. During an interview on 08/20/25 at 10:07 A.M., 12:01 P.M. and 12:35 P.M., the BOM said the following:-If she was not available, the receptionist provided money for residents out of the facility petty cash drawer;-A resident would go to the receptionist and sign a petty cash voucher to obtain money;-The receptionist kept the petty cash vouchers in the facility's petty cash drawer for one month;-The receptionist turned the petty cash vouchers in to her for repayment one time per month;-There were two petty cash drawers at the facility - one is at the receptionist's desk and is the facility petty cash and the other is in the business office, and it is the resident trust petty cash drawer;-She was the only person who was authorized to get into the resident trust petty cash drawer; -The receptionist was the only person who had access to the facility's petty cash drawer;-She would only know the accurate balance after she reimbursed the cash vouchers the receptionist brought her one time a month; (this is when the computer would show the resident's actual balance);-The resident's spouse provided money for the resident's trust fund account;-The resident's spouse was in another state and had not sent money for the resident's trust fund account;-She had asked the resident to stay under $100.00 in debt;-The resident's spouse was told the resident was in debt and needed money for the resident's trust fund account, but the resident's spouse had not sent any money for the resident fund trust account;-She did not think the resident's debt in the resident fund trust account affected any of the other residents with funds in the resident trust fund account. During an interview on 08/21/25 at 10:40 A.M., the Administrator said the following:-When a resident wanted cash, they would go to the receptionist and ask for money and the receptionist will give them money;-She did not think the receptionist had access to check a resident's resident trust fund balance before giving the resident money;-The receptionist keeps the petty cash receipts in her drawer and gives them to the BOM one time a month for reimbursement;-The BOM would not have known how much money a resident was given out of the petty cash drawer; she was not updating the balances timely with every petty cash withdrawal because the receptionist was giving money, keeping a voucher in the petty cash drawer and only turning them in once a month; -Residents should not be able to withdraw money that was not available in their trust account;-Resident #40's spouse had not been able to send money for his/her trust account;-She was not aware Resident #40 went into debt in April 2025;-She did not consider Resident #40 was using other resident's money from the trust fund if he/she had a negative balance;-If all the residents wanted to withdraw their money today from the resident trust account there would not be enough money to cover all the accounts;-There should be a better system for cash disbursement to the residents.

Based on observation, interview and record review, the facility failed to follow physician orders for one resident (Resident #51), in a review of 17 sampled residents, when staff did not compare the pharmacy label of a medication card against the medication administration record and administered the wrong dose of medication to the resident. Staff also failed to follow manufacturer's recommendation and professional standards when administering eye drops for one resident (Resident #2), when pressure was not applied and held to the inside corner of the eye (inner canthus), after administration. The facility census was 54. Review of the facility's policy, Administering Medications, revised April 2019, showed the following:-Medications are administered in a safe and timely manner, and as prescribed;-Medications are administered in accordance with prescribed orders, including any required time frame;-The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication;-As required or indicated for a medication, the individual administering the medication records the dosage in the resident's medical record. Review of the undated facility policy, Procedure: Prepare, Administer, Report and Record Ophthalmic (Eye) Medications, showed the following:-The purpose of this procedure is to provide guidelines for instillation of eye drops to treat medical conditions, eye infections and dry eyes;-Hold lower eyelid away from the eye to form a pouch;- For eye drops instill drop into the pouch, never directly onto the center of the eyeball;- With a finger, apply pressure to the inside corner of the eye (inner canthus) for one minute;- Instruct resident to close eye gently and keep eyes closed for a few minutes;- Blot excess medication from cheek with tissue. 1. Review of Resident #51's Physician Order Report, dated 07/01/25 through 07/31/2025, showed the following:-Diagnosis of major depressive disorder (a common mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities);-Fluoxetine (medication for major depressive disorder), 20 milligram (mg) capsule, one capsule daily, by mouth, discontinued 07/24/2025;-Fluoxetine 20 mg capsule, one capsule daily, by mouth, start date 07/24/25 end date 07/25/25. Review of pharmacy records showed on 07/24/25, two fluoxetine 20 mg capsules and 15 fluoxetine 10 mg capsules were delivered to the facility. Review of the resident's MAR, dated 07/24/25 thru 07/25/25, showed the following:-07/24/25, staff documented fluoxetine 20 mg was administered;-07/25/25, staff documented fluoxetine 20 mg was administered. Review of the resident's Physician Order Report, dated 07/01/25 through 07/31/2025, showed an order for fluoxetine 10 mg capsule, one capsule daily, by mouth, start date 07/26/25. Review of the resident's MAR, dated 07/26/25 thru 07/31/25, showed staff documented fluoxetine 10 mg was administered. Review of the resident's Medication Administration Record (MAR), dated 08/01/25 through 08/19/25, showed an order for fluoxetine capsule, 10 mg, administer one capsule by mouth, once a day, start date 07/26/25. Review of pharmacy records showed on 08/11/25, 15 fluoxetine 20 mg capsules were delivered to the facility. Observation on 08/19/25 at 8:55 A.M., during medication administration, showed the following:-Registered Nurse (RN) C pulled a fluoxetine 20 mg medication card from the 100-hall medication cart, labeled for the resident; -He/She did not administer the medication. During an interview on 08/19/25 at 8:55 A.M. and 4:48 P.M., RN C said the following:-The fluoxetine 20 mg capsule card should not have been in the medication cart;-The medication was the incorrect dose;-The resident did not have a fluoxetine 10 mg medication card in the medication cart;-He/She did not administer fluoxetine 20 mg because it was the incorrect dose;-Several capsules had been taken out of the medication card labeled fluoxetine 20 mg;-The resident had been receiving the wrong dose of medication;-The staff member who put in the new fluoxetine 10 mg medication order would have been responsible for pulling the discontinued fluoxetine 20 mg medication card from the medication cart. During a phone interview on 08/27/25, Licensed Practical Nurse (LPN) D said the following:-On 07/24/25 he/she had transcribed the physician's order to decrease the resident's fluoxetine from 20 mg to 10 mg;-He/She had reported to the oncoming nurse the medication order had been sent;-He/She did not remove the fluoxetine 20 mg medication card from the medication cart because he/she thought it would take some extra time for the medication to be sent from the pharmacy;-Normally any medication which was discontinued would be pulled from the medication cart and any remaining medication in the card would be destroyed. Review of the resident's pharmacy profile, dated 07/01/2025 thru 08/28/25, showed the following:-Pharmacy profile provided via email from the dispensing pharmacy;-On 08/11/25, fifteen fluoxetine 20 mg were dispensed. Review of the resident's MAR, dated 08/01/25 thru 08/19/25, showed the following:-Staff documented the resident's fluoxetine 10 mg dose was administered on 08/12/25, 08/13/25, 08/14/25, 08/15/25, 08/16/25, 08/17/25 and 08/18/25 (a total of seven administrations);-Staff documented the resident's fluoxetine 10 mg dose was not administered on 08/19/25 because the medication was not available. During a phone interview on 08/27/25, LPN D said the following:-On 08/13/25 he/she administered one fluoxetine 20 mg (a green and white capsule) to the resident and documented he/she gave one fluoxetine 10 mg capsule on the resident's MAR; it was a mistake;-The best practice when administering medications to a resident is to compare the medication card to the MAR before administering the medication to the resident. During an interview on 08/19/25 at 8:55 A.M. and 4:48 P.M., RN C said the following:-He/She administered fluoxetine 20 mg, one capsule, on 08/14/25;-On 08/14/25 he/she had documented on the resident's MAR administration of fluoxetine 10 mg one capsule at 8:00 A.M.;-He/She had administered fluoxetine 20 mg capsule on 08/14/25 because he/she was in the habit of just checking the medication name and not checking the medication dosage to see if it matched the MAR;-It was best practice to check the medication order with the medication card and the dose of the medication before administering any medication. Review of the facility's Individual Resident's Disposition Record, dated 08/20/25, showed the following:-A label had been affixed under Resident column;-The label showed the prescription number, Resident #51's name, the medication, and the date the medication was dispensed;-The prescription number on the label showed 7362701;-The medication listed on the label showed fluoxetine 20 mg;-The dispensed date listed on the label showed 08/11/2025;-Seven doses of fluoxetine 20 mg had been administered from the medication card. During a telephone interview on 08/28/25 at 9:01 A.M., the pharmacist said the following:-On 08/11/25, the resident was dispensed fluoxetine 20 mg;-It was a mistake; -The pharmacy had been sent the correct order, but did not discontinue the fluoxetine 20 mg prescription and the 20 mg prescription was sent to the facility by mistake;-On 8/19/25 the charge nurse called the pharmacy and the pharmacy had to manually go into the residents record and discontinue the 20 mg prescription as it was still in their system;-The facility called on 08/19/25 to inform the pharmacy of the mistake. During an interview on 08/21/25 at 12:58 P.M. and 08/28/25 at 9:24 A.M., the Director of Nursing (DON) said the following:-Staff should follow physician orders;-Residents should receive the proper dose of medication;-Staff are supposed to transcribe new medication orders and send the order to the pharmacy; -Staff who transcribe the medication order should pull the discontinued medication from the medication cart;-Staff who transcribe a new medication order was responsible for following up to ensure the new medication was on the medication cart;-The discontinued medication card should be pulled from the cart and the medication destroyed;-Prescriptions are electronically sent to the pharmacy;-When medications are delivered from the pharmacy, the evening or night shift Certified Medication Technician (CMT) or the nurse checks the medications delivered with the list the pharmacy sends to ensure they match;-Staff then put the medication on the medication cart or in the medication storage room;-Staff administering medication should ensure a resident receives the correct dosage;-Staff should aways check the resident, the medication, the dose, and the route before any medication was administered;-Staff should not give a fluoxetine 20 mg capsule and document on the MAR fluoxetine 10 mg capsule was given. During an interview on 08/21/25 at 2:39 P.M. and 08/27/25 at 4:47 P.M., the Administrator said the following:-All discontinued medications are destroyed at the facility;-Staff should follow physician orders;-A resident should receive their ordered dose of medication;-Staff should not give 20 mg of a medication and chart 10 mg was given on the MAR. 2. Review of the Combigan (brimonidine tartrate and timolol maleate 0.2-0.5 percent (%) ophthalmic solution - medication used to decreases elevated intraocular (inside eye) pressure) website showed the following:- Instructions for applying eye drops:-Gently close your eyes and lightly press on the inside corners of your eyes;- Carefully blot away any excess liquid that may be on your skin. Review of Resident #2's face sheet showed diagnosis of ocular hypertension (a condition where the intraocular pressure (IOP) (pressure inside the eye) is higher than normal), bilateral (both eyes). Review of the resident's Physician Order Summary, dated August 2025, showed an order for Combigan 0.2-0.5 % drops, one drop in both eyes, administer two times a day. Observation on 08/19/25 at 8:59 A.M., during medication administration, showed the following:-RN C took brimonidine tartrate and timolol maleate 0.2-0.5% ophthalmic solution out of the medication cart;-RN C used hand sanitizer and applied gloves;-RN C gave the resident a Kleenex;-RN C pulled down the resident's lower right eye lid and instilled one drop of brimonidine tartrate and timolol maleate 0.2-0.5% ophthalmic solution into the eye lid pocket;-RN C did not apply pressure to the inside corner of the eye for one minute after instilling the eye drop;-RN C did not instruct the resident to close his/her eye or to keep his/her eyes closed for a few minutes;-RN C pulled down the resident's lower left eye lid and instilled one drop of brimonidine tartrate and timolol maleate 0.2-0.5% ophthalmic solution into the eye lid pocket;-RN C did not apply pressure to the inside corner of the eye for one minute after instilling the eye drop;-RN C did not instruct the resident to close his/her eye or to keep his/her eyes closed for a few minutes;-Liquid ran under the resident's right and left eye;-The resident used the Kleenex to wipe the liquid from under his/her eyes. During an interview on 08/19/25 at 9:55 A.M., RN C said the following:-When administering eye drops, pressure should be held on the corner of the eyelid by the nose for five minutes;-He/She started to tell the resident to hold pressure, but thought it was a missed opportunity because the resident was already wiping his/her eyes with a tissue;-He/She should have educated the resident on the proper administration of the eye drops. During an interview on 08/21/25 at 12:58 P.M., the DON said staff should hold pressure on the corner of the eyelid by the nose for one-two minutes after administering eye drops. During an interview on 08/21/25 at 2:39 P.M., the Administrator said staff should administer all medications properly.

Based on observation, interview, and record review, the facility failed to ensure dietary equipment was free of an accumulation of grease, oil, dust and debris, failed to remove damaged food containers from the dry storage room, failed to seal/date opened packages, and failed to ensure an ice machine drain contained a drainage air gap. The facility census was 54. Review of the facility's Cleaning Rotation Policy, 2011 Edition, showed the following: -Guideline - Equipment and utensils will be cleaned according to the following guidelines, or manufacturer's instructions; -Items cleaned after each use included can opener, small food preparation equipment, work tables and counters; -Items cleaned daily included stove top, grill, kitchen and dining room floors, toaster, and exterior of large appliances; -Items cleaned weekly included hoods, filters, shelves, ovens, and cupboards); -Items cleaned monthly included refrigerators and walls). Review of the facility's Ice Handling and Cleaning Policy, 2011 Edition, showed ice will be handled, transported, and stored in such a manner as to be protected against contamination. Ice storage bins shall be drained through an air gap. 1. Observations on 11/13/23 from 9:55 A.M. to 4:39 P.M., in the kitchen, showed the following: -A moderate buildup of oil and debris on the counter-mounted can opener; -A moderate buildup of dust and debris on the two bulb emergency light fixture; -A moderate buildup of grease, dust, and debris on top of the wall-mounted knife holder; -A moderate buildup of grease and debris on the counter top toaster; -A buildup of grease and debris on surfaces of the Ansul System Unit, metal conduits out of the unit, and to the kitchen hood and Ansul pull station; -A moderate buildup of dust and debris on the eight support pipes above the kitchen hood; -A buildup of dust and debris on the shelving above the three-compartment sink, the back splash, and on the flooring underneath and between the sink and the up-right refrigerator; -The contact paper on the bottom shelving of the three preparation tables was worn and peeling away from the metal surfaces (not easily cleanable); -A moderate buildup of grease, dust, and debris on the metal wall shelving, located above the food preparation counter; -A moderate buildup of grease, debris, and dark stains on the metal back splash, above and to the right side of the griddle top oven; -A buildup of grease, debris, and dark stains on the right side of the griddle top oven; -A moderate buildup of grease and debris on the left side of the stove top oven; -A buildup of grease and debris under stove top burner grates; -A moderate buildup of dust and debris on the left wall in the walk-in cooler. 2. Observation on 11/13/23 at 9:55 A.M., in the dry storage room, showed the following: -Three 6 pound, 10 ounce cans of pineapple tidbits, located on the the shelving with products for use, were dented/damaged; -A 1 pound, 8 ounce package of gelatin dessert, labeled as opened on 10/29/23, was not sealed; -An opened 5 pound package of fudge brownie mix was not sealed. 3. Observation on 11/13/23 at 2:51 P.M., showed the ice machine, located in the 200 hall clean utility storage room, had no drainage air gap under the machine or entering into the main sink drain. During an interview on 11/13/23 at 10:33 A.M., the Maintenance Supervisor said unaware an ice machine was required to have an air gap. 4. During an interview on 11/14/23 at 8:34 A.M., the Dietary Manager said the following: -She expected staff to clean and sanitize the kitchen and dietary equipment daily and as needed; -Dietary staff should remove dented and damaged cans from the dry food storage room and return the cans to the vendor; -Dietary staff should seal and date open packages of food in the dry food storage room. During interviews on 11/17/23 at 12:02 P.M. and 11/21/23 at 11:00 A.M., the Registered Dietitian said the following: -She expected the dietary or maintenance staff to clean and sanitize the kitchen and dietary equipment daily, weekly and as needed; -She expected dented/damaged cans to be removed and returned to the vendor; -She expected open packages to be sealed and dated. During an interview on 11/14/23 at 2:45 P.M., the Administrator said the following: -She expected the dietary and maintenance staff to clean and sanitize the kitchen and dietary equipment daily, weekly, or as needed; -She expected the ice machine in the 200 hall clean utility room to have air gaps at the machine's drain locations.

Based on observation, interview, and record review, the facility failed to conduct regular inspections of bed frames, mattresses and bed rails to identify areas of possible entrapment and to ensure the bed rails, mattresses and bed frames were compatible for five residents (Residents # 2, #3, #4, #36, #48) with bed rails, in a review of 14 sampled residents. The facility census was 54. Review of the facility's bed assist device policy, updated on 2/20/23, showed maintenance staff will install all bed assist devices using the manufacturer's instructions and regularly check the mattress and assist device for areas of possible entrapment and other safety concerns. Review of the Food and Drug Administration's Guide of Bed Safety, Bed Rails in Hospitals, Nursing Homes and Home Health Care: The Facts, revised April 2010, showed the following: -Potential risks of bed rails may include strangling, suffocating, bodily injury or death when patients or part of their body are caught between rails or between the bed rails and mattress, more serious injuries from falls when patients climb over rails, skin bruising, cuts, and scrapes, feeling isolated or unnecessarily restricted, and preventing patients, who are able to get out of bed, from performing routine activities such as going to the bathroom or retrieving something from a closet; -Use a proper size mattress or mattress with raised foam edges to prevent patients from being trapped between the mattress and rail; -Reduce the gaps between the mattress and side rails; -A process that requires ongoing patient evaluation and monitoring will result in optimizing bed safety; 1. Observation on 11/15/23, at 1:30 P.M., showed 17 beds in the facility (currently in use) had some type of bed rail/side rail device attached to the bed. 2. Review of Resident #3's Continuity of Care Document showed his/her diagnoses included dementia, history of falls, altered mental status, need for assistance with personal cares, muscle weakness and abnormalities of mobility. Review of the resident's annual side rails assessment and consent, dated 4/24/23, showed the following: -Reason for side rail use: bed mobility; -Type of rail used: one side; -Used daily Review of the resident's October 2023 physician order sheet (POS) showed an order documenting the resident may use bed rail assist rails for safety (original order date of 12/22/18). Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/7/23, showed the following: -Functional limitations in range of motion (ROM) in upper and lower extremities on both sides of his/her body; -Required substantial to maximal assistance with mobility when rolling left and right, when sitting to lying, and when lying to sitting. Review of the resident's care plan, last revised 10/24/23, showed the following: -Required assistance with turning and repositioning while in bed; -Safe and appropriate with use of bilateral bed assist rails. Observations on 11/13/23 at 11:31 A.M. and 12:15 P.M., showed the resident lay in his/her bed. The resident had 1/8 bed rails (assist rail that does not raise or lower) on both sides of the bed. Observation on 11/15/23, at 5:05 A.M., showed the resident lay in his/her bed. The resident had 1/8 bed rails on both sides of the bed. Review of the resident's medical record showed no evidence staff conducted an inspection of the resident's bed frame, mattress and bed rails to identify areas of possible entrapment. 2. Review of Resident #4's Continuity of Care Document showed his/her diagnoses included multiple sclerosis. Review of the resident's annual side rail assessment and consent, dated 4/24/23, showed the following: -Reason for side rail usage: bed mobility (assist with turning side-to-side); -Types of rails used: two sides; -Frequency of use: daily. Review of the resident's October 2023 POS showed the resident may use two assist devices to bed (original order date of 9/24/20). Review of the resident's quarterly MDS, dated [DATE], showed the resident required substantial to maximal assistance for mobility when rolling left to right. Review of the resident's care plan, last revised 9/5/23, showed the resident had two assistive devices to aid with bed mobility. Review of the resident's medical record showed no evidence staff conducted an inspection of the resident's bed frame, mattress and bed rails to identify areas of possible entrapment. Observations on 11/14/23 at 10:40 A.M., 11/15/23 at 5:05 A.M. and 9:25 A.M. showed the resident lay in bed with 1/8 bed rails on both sides of the bed. Observation on 11/15/23 at 12:05 P.M. showed the resident sat in bed eating lunch with 1/8 bed rails on both sides of the bed. 3. Review of Resident #36's Continuity of Care Document showed his/her diagnoses included history of repeated falls, mild cognitive impairment, bilateral primary optic atrophy (condition that affects the optic nerve, which carries impulses from the eye to the brain, characteristics include deficits in central vision, difficulties distinguishing contrast, and loss of visual acuity), and generalized muscle weakness. Review of the resident's annual side rails assessment and consent, dated 4/24/23, showed the following: -Reason for side rail use: bed mobility; -Type of rail used: two sides; -Used daily. Review of the resident's October 2023 POS showed the resident may use an assistive device on bed for mobility (original order date of 03/30/22). Review of the resident's quarterly MDS, dated [DATE], showed the following: -Functional limitations in range of motion (ROM) in upper and lower extremities on one side of his/her body; -Required supervision or touching assistance when rolling left and right, when sitting to lying and when lying to sitting. Review of the resident's care plan, last revised 11/06/23, showed the following: -He/She had two assistance devices to aide with bed mobility; -He/She was able to turn and reposition himself/herself in bed. Review of the resident's medical record showed no evidence staff conducted an inspection of the resident's bed frame, mattress and bed rails to identify areas of possible entrapment. Observations on 11/15/23, at 5:37 A.M., 5:49 A.M., and 5:57 A.M. showed the resident in his/her bed. The resident had 1/8 bed rails on both sides of the bed. 4. Review of Resident #2's side rails assessment and consent, dated 4/24/23, showed the following: -Medical symptom requiring use of side rails was decreased mobility; -Reason for side rail usage was bed mobility (assist with turning side-to-side); -Rails used on two sides; -Frequency of use was daily. Review of the resident's annual MDS, dated [DATE], showed the resident required moderate assist to roll left and right in bed. Review of the resident's care plan, updated 10/3/23, showed the following: -He/She had assistive device bilaterally to aide with bed mobility; -He/She had impaired mobility related to recent right above knee amputation, history of left below knee amputation, and severe morbid obesity. Observation on 11/14/23 at 9:15 AM, showed the resident lay in bed with bilateral half side rails up. Review of the resident's medical record showed no evidence staff conducted an inspection of the resident's bed frame, mattress and bed rails to identify areas of possible entrapment. 5. Review of Resident #48's side rails assessment and consent, dated 9/1/23, showed the following: -Medical symptom requiring use of side rails was decreased bed mobility; -Reason for side rail usage was bed mobility (assist with turning side-to-side); -Rails used on two sides; -Frequency of use was daily. Review of the resident's admit MDS, dated [DATE], showed the following: -The resident was cognitively intact; -Required moderate assistance with roll left and right in bed and lying to sitting. Review of the resident' care plan, updated 10/18/23, showed the following: -The resident had impaired functional mobility related to unsteady gait and deconditioning; -The resident had two assistive devices to aide with bed mobility. Observation on 11/14/23 at 11:55 AM, showed the resident lay in bed with 1/8 bed rails on both sides of the bed. Review of the resident's medical record showed no evidence staff conducted an inspection of the resident's bed frame, mattress and bed rails to identify areas of possible entrapment. 6. During interviews on 11/15/23 at 10:00 A.M., 11:54 A.M. and 1:48 P.M., and on 11/16/23 at 8:29 A.M., the maintenance supervisor said the following: -He does not do any type of assessments on bedrails; he has only checked them when staff tell him they are loose and they need tightened; -He installed bed rails when nursing staff asked him to do so per residents' physician orders; -He did not conduct bed rail entrapment risk assessments, bed rail inspections, or check compatibility of the bed rails with the bed frames or mattresses; -He was unaware of the manufacturer or model of the bed rails or what the manufacturer's recommendations were for conducting risk assessments or bed frame/mattress compatibility; -He had only worked at the facility four months and could not find any prior bed rail entrapment risk or inspection documentation; -Housekeeping staff conducted monthly inspections of bed rails, frames and mattresses; -The housekeeping supervisor gave him the monthly inspection sheets; he only had September and November 2023 because that's all that he could find. Record review of the September 2023 and November 2023 inspection forms, completed by housekeeping staff, showed the following: -Beds and mattresses: inspect bed rails, bed frames, and bed mattresses; -Beds listed for each room had a pass or fail option; -No measurements or detailed inspection information was listed on the forms; -Staff inspector names for the East Hall inspections conducted on 9/15/23 and 9/16/23 were blank. During an interview on 11/16/23 at 8:29 A.M., the housekeeping supervisor said the following: -Housekeeping staff conducted monthly inspections of resident beds and mattresses to ensure the items were in good working order; -Housekeeping staff did not inspect the bed rails but made sure there were no big gaps between the rail and mattress; -Housekeeping staff did not follow manufacturer's recommendations for assessing if a bed rail was compatible with the bed frame or mattress or for checking for gaps between the bed rail and mattress. During an interview on 11/16/23 at 9:58 A.M., the nurse manager said she could not locate a bed rail maintenance program, policy, or past inspection documentation. She assumed the bed rails were compatible with the bed frames since many were installed years ago. During an interview on 11/15/23 at 9:38 A.M., and 11/16/23 at 9:13 A.M., the director of nursing said she expected maintenance staff to ensure compatibility with bed frames and mattresses, and follow manufacturer's recommendations for installation and maintenance of bed rails.

Based on observation, interview, and record review, the facility failed to ensure meals were served to meet the nutritional needs of the residents. Staff failed to prepare and serve food according to the diet spreadsheet menu. The facility census was 54. Review of the facility's Diet Orders Policy, 2011 Edition, showed the following: -Guideline: Each resident will have a diet order prescribed by the physician and documented in the health record. All physicians will prescribe diets using the terminology of the house diets and/or terminology in the diet manual. Diet orders received from an admission source that do not conform to the standard language of the facility will be converted to an available diet order offered at the facility; -Procedure: Diet orders are clearly communicated, using the designated diet order communication form, to dining services; All diet order communication forms received by dining services are confirmed for accuracy by the dining services manager or designee and noted as received in the resident health record; Consult with the Registered Dietitian for further guidance. 1. Review of the Diet Orders, obtained 11/13/23 and 11/14/23, showed ten residents with a physician-ordered consistent carbohydrate (CCHO) diet. Review of the Diet Spreadsheet, for 11/13/23 (Day 2, Monday) lunch, showed the following: -Staff were to serve one #6 dip (5.33 ounce) serving of apple crisp to residents with a regular diet; -Staff were to serve one #12 dip (2.66 ounce) serving of apple crisp to residents with a CCHO diet. Observation on 11/13/23 at 10:15 A.M., in the walk-in cooler showed a cart containing individual bowls of apple crisp desserts, each of the same portion size serving. Observation on 11/13/23 at 11:00 A.M., showed a cart containing individual bowls of apple crisp desserts, each of the same portion size serving, outside the kitchen entrance door in the dining room. Observations on 11/13/23 from 11:13 A.M. to 12:14 P.M., in the main dining room during the lunch meal service, showed Dietary Aide C served bowls of apple crisp to the residents. All of the bowls contained the same amount of apple crisp. During an interview on 11/13/23 at 4:39 P.M., Dietary Aide C said all residents receive the same serving size of dessert from the dessert cart. Observation of the Special Care Unit on 11/13/23 at 11:40 A.M. showed the following: -Dietary staff delivered a cart with the lunch meal to the special care unit; -Special care unit staff removed items from the cart, including two trays of individually prepared bowls of apple crisp. All of the bowls appeared to contain the same amount of apple crisp. The bowls were not labeled for specific residents. Observation of the lunch meal service on 11/13/23 at 12:25 P.M., in the Special Care Unit, showed staff served residents, including Resident #51 (who was on a physician-ordered CCHO diet), the bowls of apple crisp from the trays. During an interview on 11/13/23 at 12:30 P.M., Licensed Practical Nurse (LPN) A said the following: -Resident #51 was the only diabetic currently on the unit; -All of the desserts were the same; he/she did not know if diabetics were to get something different. During an interview on 11/14/23 at 8:34 A.M., the Dietary Manager said the following: -She did not realize dietary staff served the same portion size of apple crisp to all residents for lunch on 11/13/23; -She expected dietary staff to follow the diet spreadsheet menus when preparing/serving meals to the residents; -The residents on a CCHO diet should have received a #12 serving of apple crisp, not a #6 serving; -She was responsible for making sure staff followed the diet spreadsheet menus. During an interview on 11/17/23 at 12:02 P.M., the Registered Dietitian said dietary staff should be familiar with and follow the diet spreadsheet menu when preparing/serving food items to residents.

Based on observation, interview, and record review, the facility failed to post the total hours nursing staff (registered nurse (RN), certified nurse assistant (CNA), certified medication technician (CMT), and licensed practical nurse (LPN)) worked for each shift. The facility census was 54. Review of the facility's undated policy, Posting Direct Care Daily Staffing Numbers, dated 2001 and last revised 2006, showed the following: -Our facility will post, on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents; -Within two (2) hours of the beginning of each shift, the number of Licensed Nurses (RNs, LPNs, and Licensed Vocational Nurse (LVNs) and the number of unlicensed nursing personnel (CNAs) directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format; -Directly responsible for resident care means that individuals are responsible for residents' total care or some aspect of the residents' care including, but not limited to, assisting with activities of daily living (ADLs), performing gastrointestinal feeds, giving medications, supervising care given by CNAs, and performing nursing assessments to admit residents or notify physicians of changes of condition; -Shift staffing information shall be recorded on the Nursing Staff Directly Responsible for Resident Care form for each shift. The information recorded on the form shall include: a. The name of the facility; b. The date for which the information is posted; c. The resident census at the beginning of the shift for which the information is posted; d. Twenty-four (24)-hour shift schedule operated by the facility; e. The shift for which the information is posted; f. Type (RN, LPN, LVN, or CNA) and category (licensed or non-licensed) of nursing staff working during that shift; g. The actual time worked during that shift for each category and type of nursing staff; h. Total number of licensed and non-licensed nursing staff working for the posted shift; -When computing hours of direct care staff working split shifts, count only the total number of hours the individual is actually scheduled to work for the shift information being posted. (Example: You are posting data for the Day Shift. A CNA reports to work and is scheduled to work four (4) hours on the Day Shift and four (4) hours on the Evening Shift. In computing the number of hours worked for that shift, count only the four (4) hours scheduled for the Day Shift. The remaining four (4) hours would then be counted toward the totals on the Evening Shift); -Within two (2) hours of the beginning of each shift, the shift supervisor shall compute the number of direct care staff and complete the Nursing Staff Directly Responsible for Resident Care form. The shift supervisor shall date the form, record the census and post the staffing information in the location(s) designated by the Administrator; -The form may by typed or handwritten. If completed by typewriter or word processor, the recorded information shall be a minimum font size of 12 points. Should the information be handwritten, it must be legibly printed in black ink and must be written so that staffing data can be easily seen and read by residents, staff, visitors or others who are interested in our facility's daily staffing information. 1. Observation on 11/13/23 at 12:30 P.M., of the facility staffing sheet posted across from the nurses' station showed the following: -The facility census was 54; -Day shift included three LPNs and seven CNA/CMTs for a total of ten staff; -There was no area to document total staff hours. Observation on 11/13/23 at 3:30 P.M., of the facility staffing sheet posted across from the nurses' station showed the following: -The facility census was 54; -Day shift included three LPNs and six CNA/CMTs for a total of nine staff; -There was no area to document total staff hours. Observation on 11/14/23 at 8:21 A.M., of the facility staffing sheet posted across from the nurses' station showed the following: -The facility census was 54; -Day shift included one RN, three LPNs and eight CNA/CMTs for a total of 12 staff; -There was no area to document total staff hours. Observation on 11/14/23 at 2:20 P.M. and 4:16 P.M, of the facility staffing sheet posted across from the nurses' station showed the following: -The facility census was 54; -Evening shift for all disciplines was blank; -There was no area to document total staff hours. Observation on 11/15/23 at 5:02 A.M., of the facility staffing sheet posted across from the nurses' station showed the staffing sheet from 11/14/23 and there was no evening and night shift staff numbers documented. Observation on 11/15/23 at 12:30 P.M., of the facility staffing sheet posted across from the nurses' station showed the following: -The facility census was 54; -Day shift included three LPNs and seven CNA/CMTs for a total of ten staff; -There was no area to document total staff hours. Observation on 11/16/23 at 8:35 A.M., of the facility staffing sheet posted across from the nurses' station showed the following: -The facility census was 51; -Day shift included one RN, two LPNs and six CNA/CMTs for a total of nine staff; -There was no area to document total staff hours. During interview on 11/16/23 at 8:45 A.M., LPN D said the following: -There is no specific person assigned to fill out staffing sheet. It is just whoever remembers first; -The numbers listed per RN/LPN/CNA is the number of staff not the number of hours. During interview on 11/16/23 at 9:38 A.M., the Director of Nurses (DON) said the nurses usually fill out the staffing sheet but there is no one specific assigned. If they forget then she will do fill it out. The numbers listed on the staffing sheet are the number of staff for each discipline, not the number of hours. It had been a while since she had read the regulation but the hours should be listed.

Based on interview and record review, the facility failed to implement their policy for cardiopulmonary resuscitation (CPR, process of providing rescue ventilation and chest compressions to maintain circulation of blood) and failed to initiate CPR for one resident (Resident #1) of four sampled residents who was identified as having full code status (CPR required in the event of cardiac or respiratory arrest), when staff found the resident unresponsive and without a pulse or respirations. The resident expired at the facility. The facility census was 54. On [DATE], the administrator was notified of a Past Noncompliance Immediate Jeopardy (IJ) which occurred on [DATE]. On [DATE], the facility inserviced staff on the CPR policy and procedure, identified other full code residents in the facility and ensured their code status was accurate and easily identifiable. The facility added lists of full code residents to each medication cart and the nurse's station. Licensed Practical Nurse (LPN) B was educated and would work with another licensed staff member for at least three shifts (more if deemed necessary) before working without supervision again. The IJ was corrected on [DATE]. Review of the facility CPR policy, dated [DATE], showed the following: -Residents at the facility will be designated as full code or do not resuscitate (DNR) as per their request and physician order; -Residents will be identified as a full code by a code status paper in their red folder, full code on their header in the electronic health record and a blue dot on their name tag outside of their room; -When a resident is unresponsive, the CPR certified staff member will check the resident for a pulse. If the resident does not have a pulse the CPR certified staff member will initiate CPR. If the unresponsive resident is found by a non CPR certified staff member they will immediately find help of a certified staff member; -When it is determined CPR should be initiated, the staff member should turn on the call light and yell for help. Once help arrives the charge nurse should take over directing CPR and delegating tasks appropriately; -CPR certified staff will either call 911 or delegate this task to another staff member; -CPR will be continued until emergency services personnel arrive and take over the care of the resident. 1. Review of Resident #1's undated face sheet showed the following: -The resident was admitted to the facility on [DATE]; -The resident had diagnoses that included type 2 diabetes, cerebral infarction (a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), high blood pressure, and paroxysmal atrial fibrillation (a rapid, erratic heart rate begins suddenly and then stops on its own). Review of the resident's physician order sheet showed an order dated [DATE], for the resident to be full code status. Review of the resident's care plan, last reviewed on [DATE], showed no evidence of the resident's preferred code status. Review of the facility's list of CPR certified staff, updated on [DATE], showed the following staff was certified: -LPN B; -Certified Nurse Aide (CNA) G; -Registered Nurse (RN) C. Review of the resident's progress notes, dated [DATE] at 6:23 A.M., showed LPN B charted the following: -At 5:20 A.M. the resident's oxygen concentrator was beeping and LPN B went to the resident's room and adjusted the settings, spoke with the resident, and tested his/her blood sugar. The resident rested with his/her eyes closed when LPN B left the room; -At 5:45 A.M. CNA G alerted LPN B the resident had expired; -LPN B immediately went to the resident's room and found the resident in the same position as when he/she left the resident at 5:20 A.M.; -The resident was unresponsive and cold to touch with very deep blue ears and lips and pallor (paleness); -LPN B removed the roommate from the room; -LPN B called the supervisor and the resident's family; -LPN B called the funeral home as directed by the resident's family. There was no documentation in the resident's record that showed LPN B or CNA G initiated CPR or called 911. During an interview on [DATE] at 10:38 A.M., LPN B said the following: -He/She received training upon hire, but not specifically on the CPR policy; -He/She was not aware which residents were a full code. There was no list of full code residents on the medication carts until after the resident expired; -He/She did not know a resident's code status was listed on the electronic health record; -He/She did not know about red folders with the code status of each resident; -He/She was in the resident's room on [DATE] at 5:20 A.M. to adjust the resident's oxygen level and test the resident's blood sugar. The resident was pleasant and compliant; -At 5:45 A.M. CNA G ran up the hall and told LPN B the resident had expired; -LPN B ran to the resident's room and checked for a pulse at the resident's wrist, foot and neck, and there was no pulse. LPN B also used a stethoscope to check for a heartbeat and there was no heartbeat. The resident's ears were the bluest LPN B had ever seen and the resident's face was completely white; -The resident was in such bad shape LPN B never thought the resident would be a full code; -There was no one at the facility to ask questions and LPN B waited for the day nurse to arrive; -It did not occur to LPN B to look in the resident's chart for his/her code status. During an interview on [DATE] at 6:53 P.M., CNA G said the following: -He/She was CPR certified; -On [DATE] he/she went to check on Resident #1 and the resident was unresponsive; -He/She did a sternal rub and still no response and the resident was foaming from his/her mouth. CNA G checked for a pulse and there was no pulse present; -He/She ran to the nurse's station to get LPN B; -On the way to the nurse's station, CNA G realized the resident was a full code; -He/She started screaming the resident isn't responding, he/she is a full code; -When CNA G got to the nurse's station, LPN B asked are you sure the resident is a full code? CNA G told LPN B he/she was absolutely sure the resident was a full code, but the nurse did not start CPR; -He/She felt LPN B should have started CPR; -CNA G did not start CPR, because he/she did not want to step on the nurse's toes by doing something he/she wouldn't do since he/she was the CNA. During an interview on [DATE] at 11:33, RN C said the following: -He/She arrived to the facility at about 5:50 A.M.; -LPN B said Resident #1 had died ; -LPN B said the resident was okay at 5:20 A.M. when he/she was in the resident's room; -CNA G said during 15 minute checks he/she found the resident unresponsive and ran out of the room shouting He/She is dead. He/She is a full code!; -RN C asked LPN B if he/she coded the resident. LPN B said No, he/she was blue and cold to the touch; -He/She called the administrator and said to have LPN B chart everything and contact the family; -LPN B asked RN C where to find the code status in a resident's electronic health records. During an interview on [DATE] at 12:36 P.M. and [DATE] at 12:13 P.M., the administrator said the following: -She did not think LPN B got information regarding who the full code residents were or how to identify them; -She felt that was an area where the facility had failed; -She would have expected LPN B to have started CPR on the resident until emergency services arrived; -When RN C arrived for day shift, the administrator would have expected RN C to have started CPR on the resident until emergency services arrived; -She would expect any CPR certified staff to start CPR on a resident that was found unresponsive without a pulse that was a full code. MO220884

U4413 Based on record review and interview, the facility failed to provide a quarterly statement, showing all transactions, to the resident and/or guardian for 2 residents (Resident #1 and #3) out of a sample of two. The facility census was 57. 1. Record review of the facility resident trust account for the period 07/01/20 through 07/27/21, showed a quarterly statement was not given to Residents #3 and #1 and/or the guardian. During an interview on 08/10/21 at 9:57 A.M., Resident #3's Financial Power of Attorney said he/she had not received any Resident Trust Quarterly Statements during Resident #3's stay at the facility. During an interview on 08/10/21 at 10:19 A.M., Resident #1's Financial Power of Attorney said he/she had not received any Resident Trust Quarterly Statements during Resident #1's stay at the facility until he/she requested a statement recently. During an interview on 08/10/21 at 12:47 P.M., the Bookkeeper said Resident Trust Quarterly Statements did not go out for the 2nd quarter of 2021 since he/she was out of the office. The Bookkeeper did not know why the residents' financial guardians did not receive any Resident Trust Quarterly Statements.

U4413 Based on record review and interview, the facility failed to use the personal funds of a resident exclusively for the resident and only when authorized in writing by the resident/guardian for three residents (Resident #1, #2 and #3) out of a sample of four. The facility census was 57. 1. Record review of the facility maintained Resident Trust Account Ledger for the period 07/01/20 through 07/27/21, showed Resident #1 had the following withdrawal: Date Amount Description 05/18/21 $1,500.00 [NAME] Funeral Home Record review of the facility maintained Resident Trust Account showed the $1,500.00 withdrawal on 05/18/21 did not have written authorization from Resident #1 and/or the Guardian. During an interview on 07/09/21 at 9:06 A.M., Resident #1's Financial Power of Attorney said the facility sent $1,500.00 to the funeral home without his/her verbal or written authorization. The Power of Attorney also said the facility told him/her the facility could spend Resident #1's Resident Funds as the facility wanted to since the facility was the Representative Payee and the Power of Attorney does not have any input. During an interview on 07/29/21 at 12:47 P.M., the Social Services Staff said the Bookkeeper told him/her the facility was the Representative Payee for Resident #1 and could use Resident #1's money as the facility wanted to for the resident. During an interview on 07/30/21 at 1:19 P.M., the Bookkeeper said the facility has the Representative Payee role but did not realize the facility could not be a designee and decide what to do with Resident #1's money. The Bookkeeper also said all residents for whom the facility was Representative Payee had been handled the same, without getting written authorization from any Resident and/or the Financial Guardian. 2. Record review of the facility maintained Resident Trust Account Ledger for the period 07/01/20 through 07/27/21, showed Resident #2 had the following withdrawals: Date Amount Description 05/11/21 $146.00 Dr. [NAME] 05/11/21 $156.00 [NAME] City Manor 05/26/21 $5.00 M.D. (Beautician) 06/02/21 $15.00 M.D. (Beautician) 06/09/21 $5.00 M.D. (Beautician) Record review of the facility maintained Record of Patient's Personal Allowance Fund showed the facility had the beautician sign Resident #2's Personal Allowance Card for all beautician withdrawals instead of obtaining written authorization from Resident #2 and/or the Guardian. Record review also showed the withdrawals on 05/11/21 did not have written authorization from Resident #2 and/or the Guardian. During an interview on 07/29/21 at 12:47 P.M., the Social Services Staff said the Bookkeeper told him/her the facility was the Representative Payee for Resident #2 and could use Resident #2's money as the facility wanted to for the resident. During an interview on 07/30/21 at 1:19 P.M., the Bookkeeper said the facility had the Representative Payee role but did not realize the facility could not be a designee and decide what to do with Resident #2's money. The Bookkeeper also said that any residents the facility was Representative Payee for had been handled the same, without getting written authorization from any Resident and/or the Financial Guardian. The Bookkeeper also said Resident #2 had insufficient charges on his/her personal checking account and the facility decided to pay the insufficient charges and close the account. The facility asked Resident #2 but did not get any written authorization. During an interview on 08/10/21 at 12:52 P.M., the Bookkeeper also said the facility's process regarding beauty shop services for residents for whom the facility managed funds, was to get the written authorization from the beautician to show the service was received but did not obtain written authorization from the resident and/or guardian. 3. Record review of the facility maintained Resident Trust Account Ledger for the period 07/01/20 through 07/27/21, showed Resident #3 had the following withdrawals: Date Amount Description 04/26/21 $10.00 M.D. (Beautician) 05/05/21 $10.00 M.D. (Beautician) 05/18/21 $3,500.00 [NAME] Funeral Home 06/09/21 $15.00 M.D. (Beautician) Record review of the facility maintained Record of Patient's Personal Allowance Fund showed the facility had the beautician sign Resident #3's Personal Allowance Card for all beautician withdrawals instead of obtaining written authorization from Resident #3 and/or the Guardian. Record review also showed the $3,500.00 withdrawal on 05/18/21 did not have written authorization from Resident #3 and/or the Guardian. During an interview on 08/10/21 at 9:57 A.M., Resident #3's Financial Power of Attorney said the facility set up an account with the funeral home and sent an unknown amount of money without his/her verbal or written authorization. The Power of Attorney also said the facility told him/her the facility could make the decision and spend Resident #3's Resident Funds as they chose since the facility was the Representative Payee and the Power of Attorney does not have any input. During an interview on 07/29/21 at 12:47 P.M., the Social Services Staff said the Bookkeeper told him/her the facility was the Representative Payee for Resident #3 and could use Resident #3's money as the facility wanted to for the resident. During an interview on 07/30/21 at 1:19 P.M., the Bookkeeper said the facility had the Representative Payee role but did not realize the facility could not be a designee and decide what to do with Resident #3's money. The Bookkeeper also said that any residents the facility was Representative Payee for had been handled the same, without getting written authorization from any Resident and/or the Financial Guardian. During an interview on 08/10/21 at 12:52 P.M., the Bookkeeper also said all residents for whom the facility was Representative Payee had been handled the same, without getting written authorization from any Resident and/or the Financial Guardian. MO 027

Based on observation, interview, and record review, the facility failed to ensure the walk-in freezer temperature was maintained at 0 degrees Fahrenheit (F) or below, failed to ensure food items were labeled and dated, failed to ensure a food item was not prepared on the steam table, failed to ensure two ice machines were free of an accumulation of debris, failed to ensure fresh produce was washed prior to preparation, and failed to ensure cookware was free of a buildup of black debris and were easily cleanable. The facility census was 48. Record review of the facility policy, Food Storage (Dry/Refrigerated/Frozen), dated 2011, and showed the following: -Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety; -Frozen storage guidelines to be followed: Keep freezer at a temperature that ensures products will remain frozen (0 degrees F); -Check freezer temperature regularly; -All food items will be labeled. The label must include the name of the food and the day by which it should be sold, consumed or discarded; -Discard food that has passed the expiration date and discard food that has been prepared in the facility after seven days of storing under proper refrigeration; -Leftover contents of cans and prepared food will be stored in covered, labeled and dated containers in refrigerators and/or freezers. Review of the facility policy, Ice Handling and Cleaning, dated 2011 showed the following guideline and procedure: -Ice will be stored and served to residents in a sanitary manner; -Ice will be handled, transported and stored in such a manner as to be protected against contamination; -Ice machine will be emptied quarterly and thoroughly cleaned with an approved sanitizer to remove any settlement or mineral build-up in the ice discharge area and floor of the machine. 1. Review of the walk-in freezer temperature log sheet, dated October 2020, showed the following: -On 10/1/20, the day shift temperature was 9 degrees F, and the night shift temperature was 9 degrees F; -On 10/2/20, the day shift temperature was 8 degrees F, and the night shift temperature was 8 degrees F; -On 10/3/20, the day shift temperature was 7 degrees F, and the night shift temperature was 8 degrees F; -On 10/4/20, the day shift temperature was 8 degrees F, and the night shift temperature was 9 degrees F; -On 10/5/20, the day shift temperature was 10 degrees F, and the night shift temperature was 8 degrees F; -On 10/6/20, the day shift temperature was 9 degrees F, and the night shift temperature was 7 degrees F; -On 10/7/20, the day shift temperature was 7 degrees F, and the night shift temperature was 9 degrees F; -On 10/8/20, the day shift temperature was 7 degrees F, and the night shift temperature was 7 degrees F; -On 10/9/20, the day shift temperature was 7 degrees F, and the night shift temperature was 8 degrees F; -On 10/10/20, the day shift temperature was 8 degrees F, and the night shift temperature was 8 degrees F; -On 10/11/20, the day shift temperature was 9 degrees F, and the night shift temperature was 8 degrees F; -On 10/12/20, the day shift temperature was 7 degrees F, and the night shift temperature was 7 degrees F; -On 10/13/20, the day shift temperature was 7 degrees F, and the night shift temperature was 6 degrees F; -On 10/14/20, the day shift temperature was 10 degrees F, and the night shift temperature was left blank; -On 10/15/20, the night shift temperature was left blank; -On 10/16/20, ,the day shift temperature was 9 degrees F, and the night shift temperature was 9 degrees F; -On 10/17/20, the day shift temperature was 7 degrees F, and the night shift temperature was 8 degrees F; -On 10/18/20, the day shift temperature was 8 degrees F, and the night shift temperature was 9 degrees F; -On 10/19/20, the day shift temperature was 9 degrees F, and the night shift temperature was 9 degrees F; -On 10/20/20, the day shift temperature was 9 degrees F, and the night shift temperature was 9 degrees F; -On 10/21/20, the day shift temperature was 9 degrees F, and the night shift temperature was 8 degrees F; -On 10/22/20, the day shift temperature was 8 degrees F, and the night shift temperature was left blank; -On 10/23/20, the day shift temperature was 10 degrees F, and the night shift temperature was 8 degrees F; -On 10/24/20, the night shift temperature was 8 degrees F; -On 10/25/20, the day shift temperature was 9 degrees F, and the night shift temperature was 8 degrees F; -On 10/26/20, the day shift temperature was 9 degrees F, and the night shift temperature was 8 degrees F; -On 10/27/20, the day shift temperature was 7 degrees F, and the night shift temperature was 7 degrees F; -On 10/28/20, the day shift temperature was 7 degrees F, and the night shift temperature was 7 degrees F; -On 10/29/20, the day shift temperature was 9 degrees F, and the night shift temperature was 8 degrees F; -On 10/30/20, the day shift temperature was left blank, and the night shift temperature was 7 degrees F; -On 10/31/20, the day shift temperature was 7 degrees F, and the night shift temperature was 9 degrees F. Review of the walk-in freezer temperature log sheet, dated November 2020, showed the following: -On 11/1/20, day shift temperature was 7 degrees F, and night shift temperature was 8 degrees F; -On 11/2/20, day shift temperature was 8 degrees F, and night shift temperature was 8 degrees F; -On 11/3/20, day shift temperature was 9 degrees F, and night shift temperature was 9 degrees F; -On 11/4/20, day shift temperature was 8 degrees F, and night shift temperature was 7 degrees F; -On 11/5/20, day shift temperature was 7 degrees F, and night shift temperature was 9 degrees F; -On 11/6/20, day shift temperature was 9 degrees F, and night shift temperature was 10 degrees F; -On 11/7/20, the number documented for day shift was not legible, and night shift temperature was 10 degrees F; -On 11/8/20, day shift temperature was 9 degrees F, and night shift temperature was 10 degrees F; -On 11/9/20, day shift temperature was 7 degrees F. Observation on 11/9/20 at 9:45 A.M. showed the temperature of the walk-in freezer was 10 degrees F. Review of the walk-in freezer temperature log sheet, dated November 2020, showed the following: -On 11/9/20, the night shift temperature was 8 degrees F; -On 11/10/20, the day shift temperature was 7 degrees F. Observation on 11/10/20 at 9:14 A.M. showed the thermometer inside the walk-in freezer measured a temperature of 10 degrees F. Observation on 11/10/20 at 10:38 A.M. of the walk-in freezer showed the thermometer inside the unit measured an internal temperature of 11 degrees F. The digital display outside the freezer showed an internal temperature of 11 degrees F. During an interview on 11/10/20 at 9:14 A.M., the dietary manager said she was not aware the walk-in freezer temperature was measuring above 0 degrees F. During an interview on 11/10/20 at 2:43 P.M., the dietary manager said freezer temperatures should be 0 degrees F or colder. If she found out the freezer temperatures was not measuring 0 degrees F or colder, she would contact maintenance staff. Maintenance staff was then responsible for contacting a repairman if needed. She was not aware the temperature had not been cold enough, as she had been on vacation recently. 2. Observation on 11/9/20 at 9:45 A.M. during the initial tour of the kitchen, showed the following: -In the dry food storage room, a package of tortilla shells was open and not dated; -In the reach-in refrigerator, a container of pimento cheese was open and not dated; -In the reach-in refrigerator, a zippered plastic bag of waffles was not dated; -In the reach-in refrigerator, a zippered plastic bag of donuts were not dated; -In the walk-in freezer, a plastic storage tub held three zippered plastic bags. One bag contained a food item that could not be identified and was not labeled or dated. Two additional bags contained what appeared to be breadsticks and were not labeled or dated. During an interview on 11/10/20 at 2:43 P.M., the dietary manager said staff should label and date food items. Leftovers were good for seven days and then staff should discard them. 3. Observation on 11/10/20 at 10:28 A.M. showed Dietary Staff A poured a 26-ounce package of instant mashed potatoes into a large steam table pan that sat inside the steam table. The pan contained water. He/She stirred the instant potatoes into the water. He/She added approximately half of a second bag of instant mashed potatoes to the pan and stirred the potatoes and water together until they began to thicken and combine. He/She then placed the lid on the steam table pan. During an interview on 11/10/20 at 2:43 P.M., the dietary manager said staff usually prepared mashed potatoes on the steam table. Staff obtained hot water from the coffee maker and added to the steam table pan, added instant potatoes and stirred the mixture together. He/She was not aware food items were not supposed to be prepared on the steam table. 4. Observation on 11/10/20 at 9:00 A.M. showed the ice machine located in the kitchen had a buildup of crusty white-colored debris under the edge of the lid as well as in the area around the hinge located above the accumulated ice cubes below. Observation on 11/11/20 at 10:36 A.M. showed the ice machine located inside a clean utility room on the 200 Hall had an accumulation of crusty white-colored debris around the hinges over the ice and had black-colored debris on the white plastic separator piece above the ice discharge area. During an interview on 11/10/20 at 2:43 P.M., the dietary manager said dietary staff cleaned the ice machine in the kitchen every three months. Staff emptied the unit, melted and drained, then rinsed and refilled. Maintenance staff was responsible for cleaning the ice machine in the utility room. During an interview on 11/11/20 at 10:36 A.M., the maintenance supervisor said maintenance staff was responsible for cleaning the ice machine in the utility room and dietary staff cleaned the ice machine in the kitchen. Maintenance staff cleaned the ice machine in the utility room every three months. 5. Observation on 11/10/20 at 10:36 A.M. showed Dietary Staff B wore gloves, reached into a plastic grocery bag and removed a tomato from the piece of the remaining vine. He/She did not wash the tomato and began slicing the tomato with a knife. He/She placed the slices into a plastic storage container. Observation on 11/10/20 between 11:03 A.M. and 12:29 P.M. during the lunch meal service, showed Dietary Staff A placed slices of tomato from the plastic container onto a resident's tray per the resident's request. During an interview on 11/10/20 at 2:43 P.M., the dietary manager said staff should wash fresh produce prior to food preparation. 6. Observation on 11/10/20 at 10:13 A.M. showed a red skillet hung on a hook from the suspended ceiling storage rack. The skillet had an extremely heavy buildup of black crusty carbon debris that covered approximately 50-75% of the cooking surface on the inside of the skillet. Observation on 11/10/20 at 12:09 P.M. showed a metal wire fryer basket stored below the metal preparation counter. The upper one-third of the basket had a buildup of black carbon-like debris all the way around the basket. The black debris covered the wire basket holes in several areas. During an interview on 11/10/20 at 2:43 P.M., the dietary manager said the red skillet and the wire basket couldn't be cleaned very well and probably needed to be thrown away.

Based on observation, interview and record review, the facility failed to maintain resident restroom and public restroom exhaust fans and dining room ceiling return air vents to be clean and free of a buildup of debris. The facility census was 55. Record review on 3/26/19 of the Work History Report for Exhaust Fans, provided by maintenance, showed the exhaust fans were inspected for proper operation and cleaned if necessary on 5/24/18 and 11/29/18. Observation on 3/25/19 between 9:25 A.M. and 11:50 A.M. during the Life Safety Code tour of the facility showed the following: -The exhaust fan cover in the shared restroom between rooms [ROOM NUMBERS] had a heavy buildup of debris; -The exhaust fan cover in the restroom in room [ROOM NUMBER] had a moderate buildup of debris; -The exhaust fan cover in the restroom in room [ROOM NUMBER] had a heavy buildup of debris; -The exhaust fan cover in the restroom in room [ROOM NUMBER] had a heavy buildup of debris; -The exhaust fan cover in the shared restroom between rooms [ROOM NUMBERS] had a heavy buildup of debris; -The exhaust fan cover in the shared restroom between rooms [ROOM NUMBERS] had a heavy buildup of debris; -The exhaust fan cover in the shared restroom between rooms [ROOM NUMBERS] had a heavy buildup of debris; -The exhaust fan cover in the shared restroom between rooms [ROOM NUMBERS] had a heavy buildup of debris; -The exhaust fan cover in the shared restroom between rooms [ROOM NUMBERS] had a heavy buildup of debris; -The exhaust fan cover in the restroom in the employee lounge had a heavy buildup of debris; -The exhaust fan covers in two public restrooms near the entrance to the 100 Hall had a heavy buildup of debris ; -Two large rectangular ceiling return air vents in the dining room had a heavy buildup of debris. The vents were positioned near the activity office and were located over residents' dining tables. During an interview on 3/25/19 at 9:25 A.M., the maintenance supervisor said staff cleaned the exhaust fans and vents every six months. The fans and vents were due to be cleaned again in May.

Based on observation, interview, and record review, the facility failed to administer insulin according to the manufacturer's recommendations for one resident (Resident #11), in a review of 15 sampled residents. The failure had the potential to result in the resident not receiving the ordered dose of insulin. The facility census was 55. 1. Review of the manufacturer's instructions for use for the Basaglar (insulin) KwikPen (injection cartridge device) showed the following: -Before each injection, small amounts of air may collect in the cartridge during normal use; -It is important to prime your pen before each injection so that it will work correctly; -If you do not prime before each injection, you may get too much or too little insulin; -To prime your pen, turn the dose knob to select two units; -Hold the Basaglar KwikPen with the needle pointing up; -Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge; -Keep the needle pointing upwards and push the dose knob in until it stops, and 0 is seen in the dose window, hold the dose knob in a count to five slowly; -A drop of insulin should appear at the needle tip, if not,repeat the priming procedure no more than four times; -If you do not see a drop of insulin after four times, change the needle and repeat the priming steps; -Turn the dose knob to the number of units of insulin you need to inject; -Insert the needle into the skin and inject the dose by pressing the push button all the in and slowly count to five before removing the needle. 2. Review of Resident #11's Physician order [REDACTED]. Observation on 3/26/19 at 08:14 A.M., showed the following: -Registered Nurse (RN) A opened a new Basaglar KwikPen and put a needle on the pen; -RN A dialed the dose knob of the resident's Basaglar KwikPen to 22 units; -RN A did not prime the pen (as directed by the manufacturer) prior to selecting the desired dose; -RN A administered the Basaglar KwikPen he/she prepared into the resident's right abdomen without priming the insulin pen. Observation on 3/27/19 at 08:12 A.M., showed the following: -RN B dialed the dose knob of the resident's Basaglar KwikPen to 22 units; -RN B did not prime the pen prior to selecting the desired dose; -RN B administered the Basaglar KwikPen he/she prepared into the resident's left abdomen without priming the insulin pen. During an interview on 3/27/19 at 10:12 A.M., RN B said he/she was not aware the insulin pens needed to be primed prior to each use. During an interview on 3/27/19 at 10:37 A.M., the director of nursing (DON) said she expected staff to prime the Basaglar KwikPen with two units of air prior to each use. Not priming the insulin pens with air prior to administration could result in the resident not receiving the ordered dose of insulin.

Based on observation, interview, and record review, the facility failed to ensure proper food sanitation practices in the kitchen. Facility staff failed to handle foods in a sanitary and safe manner. The facility census was 56. 1. Review of the facility policy Guidelines for Staff Preparing Food: Fundamentals to Prevent Food Borne Illness dated 2011, showed the following: -Dirty hands or gloves spread germs/bacteria; -Gloves are used anytime ready to eat foods must be touched by a hand, and are changed if they come in contact with an unclean surface, door or piece of equipment. A bare hand is never used to touch ready to eat foods. 2. Observation on 5/22/18 at 10:57 A.M. showed the dietary manager opened the chest freezer and removed a plastic bag containing frozen hamburger patties. She placed the plastic bag on the counter, and without washing her hands, removed four frozen hamburger patties from the plastic bag with her bare hands and placed the patties directly on the grill. She closed the plastic bag, opened the lid on the chest freezer and placed the plastic bag into the freezer. Observation on 5/22/18 at 11:10 A.M. showed the dietary manager opened the chest freezer and removed the plastic bag containing frozen hamburger patties. She placed the plastic bag on the counter, and without washing her hands, she removed three frozen hamburger patties from the plastic bag with his/her bare hands, and placed the patties directly on the grill. She closed the plastic bag, opened the lid on the chest freezer and placed the plastic bag into the freezer. Observation on 5/22/18 at 2:11 P.M. showed the dietary manager carried a cardboard box out of the walk in freezer. She opened the cardboard box, and without washing her hands, removed a stack of frozen hamburger patties with her bare hands, and placed the patties directly on the grill. She removed the remaining hamburger patties from the box with her bare hands, opened a plastic bag, placed the hamburger patties in the plastic bag, opened the freezer lid, and placed the bag of patties in the chest freezer. Observation showed two hamburger patties were stuck together on the grill. The dietary manager placed her right hand directly on the top patty and with her left hand used a spatula to pry the two patties apart. The two hamburger patties slid to the front of the grill. The dietary manager moved the patties towards the back of the grill by directly touching the patties with her right bare hand. Observation on 5/22/18 at 2:25 P.M. showed the dietary manager opened a cardboard box, and without washing his/her hands, removed slices of frozen uncooked bacon from the box with her bare hands, and placed the slices on a metal pan. With her bare hands, she showed Cook A how to pull the frozen pieces of bacon apart and placed the slices on the metal pan. Cook A removed the bacon slices from the cardboard box with his/her bare hands, and placed the bacon slices on the metal pan. During interview on 5/22/18 at 2:32 P.M., Cook A said the following: -He/she had worked at the facility for about two weeks; -He/she wears gloves when handling raw foods; -He/she doesn't know if he/she should wear gloves when handling frozen foods. During interview on 5/22/18 at 2:50 P.M., the dietary manager said the following: -She would expect staff to wear gloves when touching raw items (foods that will be eaten raw); -She normally wears gloves when handling raw vegetables or if food is greasy; -She was taught if frozen meat is brought to temperature, it's fine to touch it with bare hands; -She wouldn't think handling frozen meat with bare hands would contaminate it if the food was brought to temperature; -The frozen bacon and hamburger patties were for the residents.

Based on observation, interview, and record review, the facility failed to follow sanitary practices regarding proper handwashing, glove use, and food handling; failed to ensure food items were labeled, dated, covered and discarded when expired; failed to properly store eggs in the walk-in cooler; and failed to ensure HVAC (Heating, ventilation and air conditioning), vents in the kitchen were free of debris. The facility census was 55. 1. Observation on 2/28/17 at 8:47 A.M. showed Dietary Staff X wore gloves and chopped sausage links on a cutting board. He/she removed his/her gloves and sprayed a large roaster pan with cooking spray. Dietary Staff X left the kitchen through a door and touched the door handle with his/her bare hand. He/she touched the door handle to the walk-in cooler, entered the cooler and retrieved a bag of chopped onions and green peppers. He/she closed the cooler door and re-entered the kitchen. He/she did not wash his/her hands upon re-entering the kitchen. Dietary Staff X opened the bag of onions and peppers and poured them into the roaster pan. He/she put on a new pair of gloves and left the kitchen using the door handle. He/she retrieved a box of cooking oil and returned to the kitchen. He/she removed his/her gloves and did not wash his/her hands. Observation on 2/28/17 at 8:57 A.M. showed Dietary Staff X put on a pair of gloves and added oil to the fryer. He/she removed the gloves and did not wash his/her hands. He/she put on another pair of gloves and added the cut up sausage pieces to the roaster pan. He/she picked up the knife and began to chop additional sausage links into pieces on the cutting board. The sausage links were placed in the food processor and ground up for use for the mechanical diet entrée preparation and were then placed in a steam table pan. Dietary Staff X removed some peppers and onions from the roaster pan and added them to the steam table pan of ground sausage. He/she mixed up two boxes of jambalaya rice by adding the rice, seasonings and water to the steam table pan of ground sausage, peppers and onions. He/she left the kitchen wearing gloves and retrieved a large can of diced tomatoes. He/she re-entered the kitchen and did not remove gloves or wash his/her hands. Dietary Staff X used the can opener to open the can of tomatoes and dumped them into a metal pitcher. He/she carried the pitcher over to the roaster pan and poured the tomatoes into the roaster pan. Observation on 2/28/17 at 11:31 A.M. showed Dietary Staff X did not wear gloves and cut sub sandwiches into two pieces. He/she held the sandwich in place with an ungloved hand and used a knife to cut them in half. He/she did not wash his/her hands prior to handling the sandwiches. During an interview on 2/28/17 at 2:40 P.M., the Dietary Manager said staff was responsible for washing their hands upon entering the kitchen, after they sneeze or cough into their hands, or if they handle something dirty, such as the trash. Gloves should be worn if any food contact occurs. Hands should be washed before and after using gloves. Review of the facility policy, Guidelines for Dining Servers, Fundamentals to Prevent Food Borne Illness, dated 2011, showed the following guidelines: -Clean Hands: Dirty hands or gloves spread germs/bacteria. Hands and fingernails should be washed thoroughly using the correct procedure that includes soap and warm water before work, after using the toilet and any time they are soiled, after handling raw foods, between work tasks and any time the employee leaves and re-enters the kitchen. Any cut is covered with a bandage and finger cot and gloves are used at all times during preparation and service and changed in accordance to correct procedure; -Gloves Used Correctly: Gloves are used only one time, are the right size, and are changed anytime they become soiled and between tasks. Gloves are treated like a food contact surface. Gloves are used anytime ready to eat foods must be touched by a hand and are changed if they come in contact with an unclean surface or piece of equipment. A bare hand is never used to touch ready to eat foods. Hands are washed before new gloves are put on. Review of the facility policy, Proper Hand Washing Procedure and Proper Use of Gloves, dated 2011, showed the following procedure: -Turn on water as hot as comfortable; -Wet hands and apply soap; -Scrub 15 to 20 seconds or more: getting under nails, between fingers, and all exposed areas such as back of hands and forearms; -Rinse hands thoroughly; -Dry hands with paper towel or air dryer; -Turn off faucet with paper towel; -All employees will wash hands upon entering the kitchen from any other location, after all breaks (including bathroom and smoking breaks), and between all tasks. Hand washing should occur at minimum of every hour; -Employees will wash hands before and after handling foods, after touching any part of the uniform, face or hair, and before and after working with an individual resident; -Hands are washed before donning gloves and after removing gloves; -Gloves are changed any time hand washing would be required. This includes when leaving the kitchen for a break, or to go to another location in the building; after handling potentially hazardous raw food; or if the gloves become contaminated by touching face, hair, uniform, or other non-food contact surface, such as door handles or equipment; -Staff should be reminded that gloves become contaminated just as hands do, and should be changed often. When in doubt, removed gloves and wash hands again; -When gloves must be changed, they are removed, hand washing procedure is followed, and a new pair of gloves is applied. Gloves are never placed on dirty hands; the procedure is always wash, glove, remove, rewash and re-glove. 2. Observation on 2/28/17 at 8:44 A.M., 11:15 A.M. and 1:40 P.M. showed a white chest freezer located between the stove and a reach-in refrigerator in the kitchen. Frozen hamburger patties were visible inside a plastic bag that was open to the air inside the freezer and were not covered. Observation on 2/28/17 at 2:12 P.M. showed the refrigerator in the Special Care Unit contained the following expired items or items not labeled or dated: -A clear plastic container with a blue lid was labeled honey-thick tea and was dated 2/19; -A small clear plastic container with a red lid was labeled med pudding and was dated 1/21; -A small clear plastic container with a red lid contained a thick pale yellow substance and was not labeled or dated; -A small clear plastic container was partially covered with a red lid and was labeled pimento cheese and was dated 2/15; -A round whipped topping container contained a brown-colored food substance with mold-like areas present on top was not labeled or dated; -A clear container with a red lid contained a yellowish substance and was not labeled or dated. During an interview on 2/28/17 at 2:40 P.M., the Dietary Manager said items in the freezer should be closed or covered. Food items should be discarded after seven days. Items should be labeled and dated when stored in the refrigerator. The items in the Special Care Unit refrigerator were maintained by nursing and nursing staff would be responsible for discarding expired items from the refrigerator and labeling or dating any items that were placed inside. He/she said the honey-thick tea was prepared in the kitchen and should be discarded within seven days. Review of the facility policy, Food Storage (Dry/Refrigerated/Frozen), dated 2011, showed the following guidelines: -General storage-All food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed or discarded; -Discard food that has passed the expiration date, and discard food that has been prepared in the facility after seven days of storing under proper refrigeration; -Leftover contents of cans and prepared food will be stored in covered, labeled and dated containers in refrigerators and/or freezers. Review of the facility policy, Labeling/Dating Foods (Date Marking), dated 2011, showed the following guidelines: -Prepared food or opened food items should be discarded when: the food item does not have a specific manufacturer expiration date and has been refrigerated for 7 days, the food item is leftover for more than 72 hours and the food item is older than the expiration date. 3. Observation on 2/28/17 at 9:30 A.M. and at 1:10 P.M. of the walk-in cooler showed a flat cardboard egg crate contained numerous eggs and sat on top of a cardboard box that contained additional egg crates of eggs. The box sat on the bottom shelf of a storage rack. Three 46-ounce boxes of juice (cranberry, grape and tomato) and a half-gallon carton of fat free vanilla ice cream mix sat next to the box of eggs and below the level of exposed eggs on the rack. During an interview on 2/28/17 at 2:40 P.M., the Dietary Manager said eggs should be stored on the bottom shelf and the exposed eggs should have been placed back inside the box for safety during storage. Review of the facility policy, Food Storage (Dry/Refrigerated/Frozen), dated 2011, showed the following guidelines: -Refrigerated storage-Store raw animal foods such as eggs, meat, poultry, and fish separately from cooked and ready-to-eat food; -Raw animal foods such as eggs, meat, poultry and fish should be stored in drip proof containers. 4. Observation on 2/28/17 at 10:59 A.M. and 1:40 P.M. showed three air vents in the kitchen. One vent was located in the ceiling over the areas of the steam table and the stove. The vent surfaces had an accumulation of brownish-yellow debris. A second vent was located in the ceiling over the metal prep counter where desserts were made and the vent surfaces had an accumulation of brown colored debris. A third vent was located near the Dietary Manager's office. The vent had an accumulation of brown fuzzy debris on the vent surfaces. During an interview on 2/28/17 at 2:40 P.M., the Dietary Manager said Maintenance was responsible for cleaning the air vents in the kitchen on a monthly basis.

Based on observation, interview, and record review, the facility failed to ensure residents with physician orders for a pureed diet were served food at the proper texture. The facility census was 55. Review of the facility's undated diet report, which identified all residents and their corresponding diets, showed five residents had physician orders for a pureed diet. Review of the Diet Spreadsheet for lunch on 2/28/17, showed residents on a pureed diet were to be served a #12 dip of pureed fried okra. Review of the recipe, Pureed Fried Okra, showed the following ingredients and directions to prepare five servings of pureed okra: -Ingredients: Fried Okra, 2 ½ cups; -Water, 1 ½ cups; -Chicken Base, 1 teaspoon; -Margarine, 2 tablespoons; -Directions: Dissolve chicken base and water to make broth. Place prepared vegetables, broth and margarine in a sanitized food processor, blend until smooth. Portion with a #12 scoop; -*Note: Any liquid specified in the recipe is a suggested amount of liquid (if needed). Some recipes items will require no liquid added to achieve the desired consistency; -1. If product needs thinning, gradually add an appropriate amount of liquid (NOT WATER) to achieve a smooth, pudding or soft mashed potato consistency; -2. If the product needs thickening, gradually add a commercial or natural food thickener (ex. Potato flakes or baby rice cereal) to achieve a smooth, pudding or soft mashed potato consistency; -3. Follow any facility policies/procedures, such as the puree volume method procedure, to ensure a correct portion is served; -4. Top pureed foods with appropriate sauces or gravies, as needed, to ensure adequate moisture for safe consumption and enhance flavor. Observation on 2/28/17 at 10:56 A.M. showed Dietary Staff X added frozen breaded okra to the fryer basket and lowered it into the fryer oil. Observation and interview on 2/28/17 at 11:37 A.M. showed Dietary Staff X placed five 4-ounce servings of fried okra in the food processor bowl. He/she prepared 1-½ cups of chicken broth and poured it inside the food processor with the okra. He/She added an unmeasured amount of margarine to the bowl. The food processor was started and ran for approximately two minutes. The pureed mixture appeared thick and sticky with visible lumps of okra and small fibrous pieces. The mixture was thick and sticky on the spatula. Dietary Staff X said the okra was so slimy but he/she thought it was the correct consistency after the puree was completed. He/she covered the pureed okra and placed it on the steam table. Observation on 2/28/17 at 11:45 A.M. showed the Dietary Manager placed a serving of pureed fried okra on three individual residents' trays to be delivered to the Special Care Unit. Three residents had chosen the pureed fried okra for lunch on 2/28/17. Observation on 2/28/17 at 12:23 P.M. showed Dietary Staff X plated a sample pureed test tray from the steam table at the conclusion of the lunch service after the last resident had been served. Observation on 2/28/17 at 12:29 P.M. of the sample pureed test tray showed the pureed fried okra consistency was a thick, sticky and fibrous texture with visible lumps. The puree was extremely difficult to swallow without chewing or taking a drink. Fibers and lumps were visible throughout the pureed item. During an interview on 2/28/17 at 2:40 P.M., the Dietary Manager said pureed items should be prepared according to the recipe. A pureed item should be a smooth, pudding-like consistency. Record review of the facility policy, Pureed Food Preparation, dated 2011, showed the following procedure: -Pureed foods will be prepared using standardized recipes to ensure quality, flavor, palatability and maximum nutritive value; -Pureed foods will be the consistency of applesauce or smooth, mashed potatoes. A food processor is preferred; however, a blender may be used to make pureed foods; -Staff will be in-serviced on proper preparation of pureed foods.

Based on observation, interview, and record review, the facility failed to provide an ongoing program of meaningful activities to meet the interests and the physical, mental, and psychosocial well-being of each resident, based on his/her comprehensive assessment for three residents (Residents #3, #4 and #8) who resided in the Special Care Unit in a review of 12 sampled residents. There were 11 residents on the special care unit. The facility census was 55. 1. Review of the Long-Term Care Facility Resident Assessment Instrument User's Manual dated October 2013, showed: -Most residents capable of communicating can answer questions about what they like; -Obtaining information about preferences directly from the resident, sometimes called hearing the resident's voice, is the most reliable and accurate way of identifying preferences; -If a resident cannot communicate, then family or significant other who knows the resident well may be able to provide useful information about preferences; -Quality of life can be greatly enhanced when care respects a resident's choice regarding anything that is important to the resident; -Interviews allow the resident's voice to be reflected in the care plan; -Activities are a way for individuals to establish meaning in their lives, and the need for enjoyable activities and pastimes does not change on admission to a nursing home; -A lack of opportunity to engage in meaningful and enjoyable activities can result in boredom, depression, and behavior disturbances; -Individuals vary in the activities they prefer, reflecting unique personalities, past interests, perceived environmental constraints, religious and cultural background, and changing physical and mental abilities. 2. Review of the undated facility Statement of Resident's Rights, showed the following: -Activities: we are concerned about your happiness as well as you health and believe that for a person to be happy, they have the opportunity to be involved in social and activity functions; -With this in mind, we maintain a paid staff, joined by volunteers from the community, who provide entertainment, games, parties, picnics, religious services, and many other activities to keep people busy and interested; -You are encouraged to participate in these activities; -Some of activities may be a part of your plan of care to assist in your health and physical improvement; -You have the right to refuse to participate if you feel any of the activities provided may not be to your benefit; -However, in such cases we encourage you to discuss the matter with your physician for his/her advice and guidance. 3. Review of the facility policy Quality of Life-Dignity from the Nursing Services Policy and Procedure Manual for Long-Term Care, revised August, 2009, showed residents shall be assisted in attending the activities of their choice, including activities outside the facility. 4. Review of Today's Activities sheet for Monday, February 27, 2017 showed the following: -9:00 A.M. Daily chronicle (staff review daily activities scheduled for the day, the menu. quote of the day, things that happened on this date, celebrity trivia and a famous birthdays); -10:00 A.M. Music by Connie; -1:30 P.M. Bingo; -2:00 P.M. Retirement party; -3:30 P.M. Smarty Pants card game. Review of Today's Activities sheet for Tuesday, February 28, 2017 showed the following: -9:00 A.M. Daily Chronicle; -9:30 A.M. Catholic Mass; -10:00 A.M. Balloon noodling; -1:30 P.M. Mardi Gras party. Review of Today's Activities sheet for Thursday March 1, 2017 showed the following: -9:00 A.M. Daily Chronicle; -9:30 A.M. Pretty nails/lotion therapy; -10:00 A.M. Music by Pat; -1:30 P.M. Bingo; Review of Today's Activities sheet for Wednesday March 2, 2017 showed the following: -9:00 A.M. Daily Chronicle; -9:30 A.M. Bible study; -1:30 P.M. Big board; -3:30 P.M. Trivia. 5. During interview on 3/1/17 at 4:06 P.M. and on 3/2/17 at 1:35 P.M., the Activity Director said the following: -He/she assesses the residents for their interests and tries to incorporate activities from the assessments; -They used to have music on the special care unit but someone thought it was too loud; -Some of the family members bring their loved ones out of the unit to activities in the lobby or large dining room; -One activity staff is the facility van driver and transportation is his/her priority instead of activities; -Some of the residents will come out of the special care unit at night for a music activity in the main lobby; -The activity assistants do nails on the unit and read the Daily Chronicle to the residents; -The residents don't participate in Bingo, they tried and it didn't work; -They did not have a piano for a person to come back to the unit and play for the residents; -One-on-one activities on the unit have included sensory sand/shells and play dough; -They read to the residents and do the balloon and beach ball toss there; -They have done crafts like the snowflake craft but the residents are limited to what they can do with their hands and then the activity staff do the craft for the residents; -They do not have an activity calendar especially for the residents on the special care unit. During interview on 3/15/17 at 2:30 P.M., the Activity Director said the following: - Music participation for residents on the unit could be a CD player playing music on the unit, music on the television or a radio playing music in the resident's room; -1-1 activities on the unit could be if staff read the daily chronicle to the resident individually or maybe activity staff stopped by to tell a resident good morning or hello. 6. Review of Resident # 3's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/23/16 showed the following: -Short and long term memory problem; -Daily decisions severely impaired; -Staff assessed the resident preferences for customary routine and activities to include snacks between meals, doing things with groups of people and listening to music. Review of the resident's care plan last reviewed on 2/15/17 showed the following: -The resident attends some activities and participates as he/she can during others; -The resident should have the Daily Chronicle read to her; -Monthly activity calendar in room; -The resident should be invited to activities; -The resident should go to each per wheelchair per staff; -Staff should visit with the resident one on one each day and during care to stimulate his/her mind/memory; -The resident watches some television, listens to music, goes to lotion therapy and has occasional visitors; -Staff should assist the resident with mail and read it to him/her. Review of the resident's February, 2017 activity calendar showed the following: -Staff documented the resident participated in staff reading the Daily Chronicle; -TV (Television); -Reading on the 6th; -Music on the 1st, 2nd, 5th, 7th, 8th, 10th, 11th, 12th, 13th, 14th, 19th, 20th, 21st, 22nd, 23rd, 26th, 27th and 28th; -One on one visits on the 1st, 2nd, 3rd, 4th, 5th, 6th, 7th, 8th, 9th, 10th , 11th, 12th, 13th, 14th, 15th, 16th, 17th, 18th, 19th, 20th, 21st, 22nd, 23rd, 24th, 25th and 26th, 27th and 28th; -Games on the 28th. Observation on 2/27/17 from 2:48 P.M., to 4:00 P.M. showed the resident lay in bed with eyes closed and the privacy curtain open. Observation on 2/27/17 at 4:06 P.M. showed the following: -Staff pushed the resident from his/her room to the dining room area and placed the resident at the table after asking another staff member if this was where the resident sat; -The television was on the left side of the resident and it was turned off and no music played. Observation on 2/27/17 at 5:05 P.M., showed the resident sat in the same position with his/her eyes open. On 2/27/17 the resident was not observed off the unit for any of the afternoon activities scheduled off the unit including Bingo, retirement party or scheduled game. Observation on 2/28/17 at 1:30 P.M. showed the resident lay in bed with his/her eyes closed as the scheduled Mardi Gras activity party took place off the unit. Observation on 3/1/17 at 10:30 A.M. showed the following: -The resident sat at a table on the unit with his/her eyes open while a music group activity took place off the unit; -Staff had assessed the resident's interest to include listening to music. Observation on 3/1/17 at 1:00 P.M. showed the resident lay in a bed with his/her eyes open, the television was turned off and no music played. 7. Review of Resident #4's annual MDS dated [DATE], showed the following: -Under activity preferences, it was very important to have books, newspaper, and magazines to read; listen to music he/she liked; be around animals such as pets; keep up with the news; and go outside to get fresh air when the weather was good. Review of the resident's quarterly MDS dated [DATE], showed the resident was cognitively intact. Review of the resident's activity care plan dated 8/15/16 and reviewed 2/1/17, showed the following: -Activity calendar in room. Daily Chronicle; -Check with the resident about anything he/she would like to do for an activity; -Encourage staff to converse with the resident frequently; -Off to assist resident to and from each activity per wheelchair; -The resident likes to watch television, listen to music but participation with outside of the room the activities was poor. Review of the resident's February, 2017 activity calendar showed the following: -Staff documented the resident participated in staff reading the Daily Chronicle; -TV (Television); -One on one visits on the 1st, 2nd, 6th, 9th, 11th, 12th, 15th, 23rd, 24th, and 25th. Observation on 2/27/17 at 2:50 P.M., showed the resident in bed on the special care unit with the room dark. The resident was asleep. (There was a scheduled activity of a retirement party in the main lobby for residents to attend. There was nothing to show on the activity log if staff asked the resident to attend the party or if staff offered to assist the resident to attend). During interview on 3/2/17 at 1:35 P.M., the activity director said the following: -The resident used to be a smoker and became a danger to self and no longer went outside to smoke; -Smoking was a big part of his/her activity at one time; -The resident did play Bingo a little; -The resident had a computer and played the game of Solitaire but the computer was not set up now and he/she was not sure why it was not set up for the resident; -One of the activity aides used to read to the resident which he/she seemed to really like. 8. Review of Resident #8's significant change MDS dated [DATE] showed the following: -Severe cognitive impairment; -While in the facility it was very important to have books, newspapers and magazines to read; -While in the facility it was very important to listen to music; -While in the facility it was very important to keep up with news; -While in the facility it was very important to do things with groups of people; -While in the facility it was very important to do your favorite activities; -While in the facility it was very important to go outside and get fresh air when the weather is got; -While in the facility it was very important to participate in religious practices. Review of the resident's care plan dated 2/7/17 showed the following: -The resident prefers activities that identify with lifestyle; -Inform the resident of upcoming activities by reading the Daily Chronicle to him/her each morning, provide activity calendar in room, verbal reminders, escort, encouragement, etc.; -Interview the resident for daily preferences; -The resident also receives one on one visits and mail; -The resident has outside visitors; -The resident likes to read, do word searches, play ball, watch television; -The resident listens to music, goes to the beauty shop for hair care, does lotion therapy and pretty nails; -The resident uses a wheelchair per staff to and from each activity; -The resident mostly participates in activities in the special care unit but does come to front lobby, dining area for certain activities; -Provide adaptive equipment to facilitate participation in activities; -Provide materials of interest (magazines, needlework); -Report any prolonged (three days) of refusal to attend activities or participate in individual activities. Review of the resident's February, 2017 activity calendar showed the following: -Staff documented the resident participated in staff reading the Daily Chronicle; -TV; -Reading on the 1st through the 17th and the 19th through the 24th; -Mail on the 6th, 8th and 22nd; -Music on the 2nd, 3rd, 6th, 8th, 9th, 12th, 16th, 17th, 19th, 20th, 22nd, 23rd, 24th, 26th, 27th and 28th -1-1 visits were on 2nd, 3rd, 4th, 5th, 6th, 7th, 8th, 9th, 10th , 11th, 12th, 14th, 15th, 16th, 17th, 18th, 20th, 21st, 22nd, 23rd, 26th, 27th and 28th; -Games on the 2nd, 4th, 8th, 22nd , 24th, 26th and 28th; -None of the activities the resident participated in were scheduled activities that took place off the unit. Observation on 2/27/17 at 2:20 P.M. showed the following: -A retirement party took place off the unit for a staff member and many residents attended; -The retirement party was listed on the resident's daily activity sheet; -The resident was not present where the party took place. Observation on 2/27/17 at 3:08 P.M. showed the following: -The resident sat in a recliner chair in the dining room area with eyes open; -The television was off and no music played; -Other residents sat in recliners around the room and no other activities took place. Review of the activity calendar showed that at 3:30 P.M. a game was scheduled off the unit, the resident did not attend. Observation on 2/27/17 at 4:06 P.M. showed the resident remained in the recliner with eyes open and the television was off and no music played or activity took place. Observation on 2/28/17 at 1:32 P.M. showed the following: -The resident lay in bed in his/her room; -A party by activities took place off the unit; -The resident did not attend. Observation on 3/1/17 at 10:15 A.M. showed the following: -The resident sat in a recliner chair on the unit with eyes open while a music activity took place off the unit; -The unit was quiet the television was off and no music played. During interview on 3/1/17 at 1:00 P.M., Certified Medication Technician (CMT) A said the following: -Nothing was set up in the unit for activities; -They want the aides to do activities but they just don't have time. During interview on 3/2/17 at 8:05 A.M., Certified Nurse Aide (CNA) Q said the following: -The CNAs were too busy to really do activities; -Sometimes staff would try to read the chronicle one on one but that did not always get done; -Yesterday morning staff was to do nails for an activity but it did not get done. 9. During interview on 3/2/17 at 3:07 P.M., the Director of Nursing (DON) said the following: -The facility has two full time activity staff and part time staff do activities and van rides; -Auxiliary volunteers come in to do activities for the residents; -Some of the nurse aides and staff do activities like nail care; -Bingo is not always appropriate back on the unit for the residents; -There was a need to have separate calendars for residents in the unit; -She would expect staff to bring the residents out of the unit for activities. During interview on 3/2/17 at 3:20 P.M., the administrator said the following: -She would expect staff to encourage the residents to come off the unit for activities; -If the activities are not an interest to the resident on the unit, staff should provide activities more resident focused; -The facility probably needed activities geared more for the residents on the unit.

Based on observation, interview, and record review the facility failed to provide care in a manner that enhanced resident dignity and ensured full recognition of individuality for three residents (Resident #1, #3 and #5), in a review of 12 sampled residents. Facility staff failed to cover Resident #1 and #5's urinary catheter (tube leading from the urinary bladder to the outside to drain urine) drainage bags with a dignity bag (cover for the urine collection bag) and staff failed to provide assistance to Resident #3 in a dignified manner during the meal service. The facility census was 55. 1. Review of the undated, facility Statement of Resident Rights showed the following: -We believe the maintenance of human dignity is vital to good health care. Resident, like all people, is entitled to exercise their rights and privileges to fullest extent possible unless otherwise medically indicated; -The management and staff will make every effort to assist you in exercising you resident rights; -Federal regulations require that those healthcare facilities such as this one, set forth a statement outlining the rights and privileges of residents entrusted in their care; -Privacy: we want to do all we can to make your stay here as pleasant as possible; -With this in mind, we provide you with privacy so you may maintain dignity and individuality; -Privacy is also maintained during toileting, bathing and other activities of personal hygiene, except when assistance is needed for you safety and well-being; -Care with dignity: it is the policy of the facility to provide care with dignity, which includes food and hydration. 2. Review of the facility policy Quality of Life-Dignity from the Nursing Services Policy and Procedure Manual for Long -Term Care revised August 2009, showed the following: -Residents shall be treated with dignity and respect at all times; -Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth; -Demeaning practices and standards of care that compromise dignity are prohibed. Staff shall promote dignity and assist residents as needed by helping the resident to keep urinary catheter bags covered; -Staff shall treat cognitively impaired residents with dignity and sensitivity. 3. Review of Resident #3's physician order sheets (POS) dated 2/1/17 to 2/28/17 showed [DIAGNOSES REDACTED]. Review the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 2/7/17 showed the following: -Short-term and long-term memory problem; -Daily decision making severely impaired; -Total assistance of two or more with transfers; -Total assistance of one with locomotion on and off unit, dressing, eating, personal hygiene and bathing. Review of the resident's care plan last reviewed 2/15/17 showed the following: -Address by name at all times; -Allow extra time for the resident to process and understand information being given; -Allow the resident extra time to complete tasks as needed; -Always explain what you are going to do when performing care; -Ask only yes or no questions; -The resident should always be approached in a calm friendly manner as he/she gets anxious and doesn't like to be bossed around; -The resident is on a pureed diet and requires staff assistance with eating and drinking. Observation on 2/27/17 at 5:10 P.M. in the facility dining room showed the following: -The resident sat at a dining table in a high back wheel chair, semi reclined, the resident's tray sat on the table in front of him/her, partially covered; -Two other residents ate their lunch at the same table; -At 5:28 P.M., after the resident's tray sat in front of him/her for at least eighteen minutes, Certified Medication Technician (CMT) A, without interacting with the resident or explaining what he/she was going to do, placed a clothing protector around the resident's neck, pulled the resident's head forward, placed a wedge pillow behind the resident's head and brought the wheelchair to an upright position in an abrupt manner; -CMT A sat down in a chair next to the resident on his/her left side; -The resident's food (pureed) sat in front of the resident; -CMT A fed the resident without engaging the resident in conversation and did not tell the resident what foods he/she was feeding the resident; -CMT A touched the resident's lip with the spoon and food until the resident opened his/her mouth; -Food ran out of the resident's mouth down his/her chin and the resident coughed; -CMT A touched the cup to the resident's lips until the resident opened his/her mouth; -CMT A failed to interact with the resident throughout the entire meal or tell the resident what food or drink he/she was offering the resident. During interview on 3/2/17 at 2:00 P.M., CMT A said the following: -The resident normally did not interact so he/she just took care of the resident; -Feeding the resident was more like a task and he/she didn't really interact with the resident when she/she fed him/her; -Sometimes he/she would talk to the resident and the resident may laugh but normally the resident did not respond; -He/she didn't explain what he/she was doing when he/she fed the resident because the resident could see what he/she was doing and if he/she was going to get a bite or not. 4. Review of Resident #'1's quarterly MDS, dated [DATE] showed the following: -Short-term and long-term memory problem; -Daily decision making severely impaired; -Total assistance of two or more with bed mobility, transfers, toileting and bathing; -Total assistance of one with locomotion on and off unit, dressing and personal hygiene; -Indwelling catheter. Review of the resident's care plan last reviewed 12/7/16 showed the following: -The resident is dependent on staff for activities of daily living and transfers; -The resident has an indwelling catheter in place; -Needs assist of one to two staff for dressing, bathing, turning and repositioning; -The resident uses a Broda (tilt and recline positioning chairs (wheelchairs) for long term care) chair for primary mode of locomotion; -Provide peri care and catheter care every shift. Review of the resident's POS dated 2/1/17 to 2/28/17 showed the following: -[DIAGNOSES REDACTED]. -Urinary catheter. Observation on 2/27/17 at 4:55 P.M., showed the following: -The resident in his/her room, seated in the Broda chair; -CNA F placed the resident's catheter drainage bag containing urine under the Broda chair without placing it in a dignity bag; -CNA F pushed the resident from his/her room to the dining room in the Broda chair with the uncovered catheter bag hanging from the chair frame. Observation on 2/28/17 at 7:35 A.M. in the resident's room, showed the following: -CNA G placed the resident's catheter drainage bag which contained urine under the front of the Broda chair without a dignity bag; -CNA H pushed the resident through the halls to the dining room in his/her Broda chair, with the uncovered catheter bag hanging from the chair frame. Observation on 2/28/17 at 11:35 A.M. in the resident's room, showed the following: -CNA I removed the uncovered catheter drainage bag from the side of the bed and placed it on the bed; -CNA I and CNA H provided peri care for the resident; -CNA H placed the catheter drainage bag containing urine under the front of the Broda chair without placing it in a dignity bag; -CNA I pushed the resident from his/her room to the dining room with the uncovered catheter bag hanging from the Broda chair, frame. Observation on 2/28/17 at 2:40 P.M., showed the resident lay in bed with eyes closed and the catheter drainage bag, containing urine hanging uncovered on side of the bed frame. The uncovered drainage bag was visible from the hallway outside the resident's room. 5. Review of Resident #5's POS dated 1/27/17 to 2/27/17 showed the following: -admitted [DATE]; -[DIAGNOSES REDACTED]. -Urinary catheter to gravity. Review of the resident's temporary care plan dated 2/21/17, showed the following: -The resident has an actual risk for incontinence. Complete toileting diary, per protocol. Offer toileting assistance promptly, when requested. Toilet per protocol and as needed; -Extensive assist with transfers, mobility, grooming/dressing/hygiene, toileting and oral care. Observation on 2/27/17 at 3:15 P.M., showed the resident sat in a recliner in the commons area of the special care unit with his/her feet elevated. The resident's catheter drainage bag containing urine hung on the wheelchair in front of him/her and was not covered with a dignity bag. Other residents also sat in the commons area and a visitor spoke to the resident as he/she sat in the recliner. Observation on 2/28/17 at 5:00 A.M., showed the resident sat in a recliner in the front commons area at the front entrance by the nurse's station, with feet elevated. His/her catheter bag, containing urine lay on the floor without a dignity bag. Observation on 2/28/17 from 5:20 A.M. to 6:05 A.M., showed the resident continued to recline in a recliner in the front commons area at the front entrance by the nurses' station with his/her catheter bag on the floor and not covered with a dignity bag. Four staff members were present in the commons area assisting another resident. One staff member straightened a blanket on the resident's lap and left the catheter drainage bag on the floor without a dignity bag. Observation on 2/28/17 at 2:40 P.M., showed the resident in his/her bed with eyes closed and the resident's catheter drainage bag rested on the floor with no dignity bag covering the bag. The catheter drainage bag contained urine and was visible from the hallway. 6. During interview on 3/2/17 at 3:00 P.M., the Director of Nursing (DON) said the following: -He/she would expect staff to let a resident know what they are going to do before they do it; -Staff should let a resident know prior to bringing their chair upright or placing a clothing protector into place; -Staff should not place a tray in front of a resident until they plan on serving the resident; -If a tray sat for a long period staff should warm it up for the resident; -He/she would expect a catheter bag to always be placed in a privacy/dignity bag.

Based on observation, interview, and record review, the facility staff failed to provide care and services to prevent urinary tract infections (UTIs) for three residents (Residents #1, #5, and #8), who had urinary catheters (small tubular structure that drains urine from the bladder to the outside of the body) in a review of 12 sampled residents. The facility census was 55. 1. Review of the facility policy Catheter Care, Urinary dated October 2010 showed the following: -The purpose of this procedure is to prevent catheter-associated urinary tract infections; -The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder; -Be sure the catheter tubing and drainage bag are kept off the floor. 2. Review of the 2001 revision of the Nurse Assistant in a Long Term Care Facility manual, showed: -The bladder is considered sterile, the catheter, drainage tubing and bag are a sterile system; -Drainage tubing/bags must not touch the floor, always hook to unmovable part of the bed frame or chair; -When transferring residents from bed to chair, always move the drainage bag over to the chair before moving the resident; -The drainage bag should always be below the level of the bladder; -If moved above, urine could flow back into the bladder. 3. Review of Resident #8's significant change Minimum Date Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/31/17 showed the following: -Severely impaired cognition; -Extensive assist of two or more with transfers and toilet use; -Indwelling catheter. Review of the resident's physician order sheet (POS) dated 2/1/17 to 2/28/17 showed [DIAGNOSES REDACTED]. Review of the resident's care plan dated 2/7/17 showed the following: -Required an indwelling urinary catheter related to [MEDICAL CONDITION]; -The resident will have catheter care managed appropriately as evidenced by not exhibiting signs of urinary tract infection; -Do not allow tubing or any part of the drainage system to touch the floor; -Position bag below level of bladder at all times. Observation on 2/28/17 from 5:10 A.M. to 7:45 A.M., showed the following: -The resident lay on his/her back in bed and the bed was in a low position; -The resident's catheter bag was attached to the bed frame and the catheter bag lay directly on the floor. Observation on 2/28/17 at 7:45 A.M., showed the following: -The resident lay in a low bed with the catheter drainage bag attached to the bed frame; -The drainage bag lay directly on the floor -Certified Nurse Aide (CNA) B and CNA C entered the room washed their hands and put on gloves; -CNA B removed the drainage bag from the bed frame; -There was approximately 100 milliliters (ml) of cloudy, dark yellow colored urine in the drainage bag; -CNA B held the resident's drainage bag in his/her hand above the level of the resident's bladder and dark, cloudy, yellow urine ran back down the tubing toward the resident; -CNA C dressed the resident and CNA B continued to hold the drainage bag above the level of the resident's bladder; -CNA B placed the catheter bag on the bed beside the resident as CNA C continued to dress the resident; -CNA B picked up the catheter bag from the bed and walked around the bed with the drainage bag in his/her hands above the level of the resident's bladder, urine ran down the tubing toward the resident; -CNA B continued to hold the catheter bag above the level of the resident's bladder as CNA B placed a gait belt around the resident's waist. During interview on 3/10/17 at 8:20 A.M., CNA B said the following: -The catheter bag was to be kept below the bladder; -The catheter bag should not be on the floor because it could cause contamination. 4. Review of Resident #1's quarterly MDS, dated [DATE] showed the following: -Short-term and long-term memory problem; -Daily decision making severely impaired; -Total assistance of two or more with toileting; -Total assistance of one with personal hygiene; -Indwelling catheter; -Frequently incontinent of bowel. Review of the resident's care plan last reviewed 12/7/16 showed the following: -The resident is dependent on staff for activities of daily living and transfers; -The resident has indwelling catheter in place; -Goal is to maintain patency and prevent acute urinary tract infection [MEDICAL CONDITION] symptoms through next review; -Monitor for increased confusion, temperature, dark foul smelling urine, or increased communication problems as he/she has frequent UTIs that are no longer treatable; -Per physician orders, no further UAs; -Keep catheter below the level of resident's bladder at all times. Review of the resident's POS dated 2/1/17 to 2/28/17 showed the following: -[DIAGNOSES REDACTED]. -Urinary catheter. Observation on 2/27/17 at 4:55 P.M., in the resident's room showed the following: -The resident lay in bed on his/her back; -The resident's catheter bag was attached to the bed frame; -CNA F placed the catheter drainage bag which contained urine on the bed beside the resident, at the level of the resident's bladder; -CNA F and CNA P provided peri care for the resident and placed the Hoyer (mechanical lift) lift pad under the resident; -CNA F raised the catheter bag, above level of the resident's bladder and placed it at the resident's side in the Hoyer lift sling; -CNA P operated the lift controls and raised the resident off the bed and lowered him/her into the Broda chair; -CNA F moved the catheter bag from beside the resident, raising it above the level of the resident's bladder and placed it under the Broda chair. Urine flowed back toward the resident. During interview on 2/27/17 at 5:00 P.M., CNA F said the following: -The catheter bag should be placed low enough for the urine to flow into the bag; -During Hoyer transfers, the drainage bag is placed beside the resident's leg; -The catheter should not be raised above the bladder. Observation on 2/28/17 at 11:35 A.M., in the resident's room showed the following: -The resident lay on his/her right side in bed; -CNA I placed the catheter drainage bag which contained urine on the bed beside the resident; at the level of the resident's bladder; -CNA I and CNA H completed peri care for the resident and placed the lift sling under the resident; -The resident lay on his/her back; -CNA I held the catheter drainage bag above the level of the resident's bladder and urine flowed back toward the resident. He/She placed the catheter bag on the resident's knees; -CNA H picked the catheter bag up from the resident's knees and held it above the resident's bladder level with urine flowing back toward the resident; -Using the Hoyer lift CNA H lifted the resident up from the bed and lowered him/her into the Broda chair. During interview on 2/28/17 at 11:54 A.M., CNA H said the catheter bag should be held below the bladder and he/she tried to but there was a few times that he/she didn't because he/she was trying to hold the resident's legs. 4. Review of Resident #5's POS dated 1/27/17 to 2/27/17 showed the following: -admitted [DATE]; -[DIAGNOSES REDACTED]. -Urinary catheter to gravity. Review of the resident's temporary care plan dated 2/21/17, showed the following: -The resident has an actual risk for incontinence. Complete toileting diary, per protocol. Offer toileting assistance promptly, when requested. Toilet per protocol and as needed; -Extensive assist with transfers, mobility, grooming/dressing/hygiene, toileting and oral care. Observation on 2/28/17 at 5:00 A.M., showed the resident sat in a recliner in the commons area at the front entrance by the nurse's station. His/her catheter bag contained urine and lay directly on the floor. Observation on 2/28/17 from 5:20 A.M. to 6:05 A.M., showed the resident continued to recline in a recliner in the commons area with his/her catheter bag resting directly on the floor. Four staff members were present in the commons area assisting another resident. One staff member straightened a blanket on the resident's lap and left the catheter drainage bag on the floor. Observation on 2/28/17 at 6:50 A.M., showed the following: -The resident sat in a recliner in the front commons area; -CNA I placed the catheter bag on the resident's abdomen, put the leg rest down on the recliner and assisted the resident to sit up in the recliner; -CNA H and CNA I transferred the resident from the recliner to his/her wheelchair; -During the transfer, CNA I placed the catheter bag on his/her arm and held it above the resident's bladder with urine flowing back toward the resident; -CNA I pushed the resident to the shower room in the wheelchair; -CNA H and CNA I transferred the resident to the toilet; -CNA I placed the catheter bag on the floor; -CNA I picked the catheter bag up off the floor and hung it from the toilet paper dispenser (level with the resident's bladder); -CNA I sat on the floor and fed the catheter tubing and bag through the resident's incontinence brief and placed it back on the floor; -CNA I fed the catheter tubing and bag through the resident's long pants and placed the catheter bag back on the floor. Observation on 2/28/17 at 2:40 P.M., showed the resident in his/her bed with eyes closed and catheter drainage bag lay on the floor. Observation on 3/1/17 at 9:35 A.M., in the resident's room, showed the following: -CNA M and CNA U transferred the resident from his/her wheelchair to the bed; -CNA U held the catheter bag containing urine above the resident's bladder during the transfer and urine flowed back toward the resident; -CNA M took the catheter bag from CNA U, placed it on the floor and drug it across the floor as he/she assisted the resident to get his/her feet in the bed; -CNA M and CNA U removed the resident's brief and fed the catheter tubing and bag through the long pants and held the bag above the resident's bladder; -CNA U provided peri care to the resident; -CNA M held the catheter bag above the resident's bladder level during the peri care with urine flowing back in the tubing toward the resident. During interview on 3/1/17 at 10:00 A.M., CNA U said the following: -Catheters should be in the lowest position; -Catheters should be kept below the bladder. During interview on 3/1/17 at 10:05 A.M., CNA M said that the catheter should not be on the floor and it should be kept below the bladder. During interview on 3/15/17 at 8:05 A.M., CNA I said the following about catheters: -Catheters should be lower than the bladder level; -Catheters should not be on the floor; -Catheters should not be on a resident's abdomen; -Catheters should not be placed on the bed. 5. During interview on 3/2/17 at 3:00 P.M., the Director of Nursing (DON) said the following: -He/she would expect the catheter bag to always be positioned below the level of the bladder; -The catheter bag should never be placed on the resident or on the floor; -If the resident is in a low bed the catheter bag should always be in a dignity bag and not touch the floor.

Based on observation, interview, and record review, the facility failed to ensure two residents at risk for pressure ulcers (Resident #1 and Resident #5) of 21 residents sampled, did not develop pressure ulcers and received the necessary treatment and services to promote healing and prevent new ulcers from developing. The facility placed Resident #1 on an air mattress to prevent pressure ulcers, but discontinued it because the resident had fallen out of bed. Approximately two months later, the resident developed a pressure ulcer on his/her left foot. The physician ordered heel protectors at all times. The facility failed to follow the physician's orders [REDACTED]. The facility failed to follow the resident's care plan directing staff to ensure the resident wore heel protectors at all times and utilized a pressure relieving cushion when the resident was up in a chair. The resident's foot wound worsened and the resident developed another pressure ulcer on his/her buttocks. The facility failed to follow their policy regarding selection of therapeutic surfaces following the development of the pressure ulcers. Both pressures ulcers extended to the bone. The resident was placed on hospice due to the pressure ulcer on his/her buttock and the resident died eleven days later with a decubitus ulcer of the left hip being one of the causes leading to his/her death. Facility staff failed to change Resident #5's position frequently to prevent unnecessary pressure to any bony prominences. The facility census was 48. 1. Review of the facility's skin risk assessment (not dated) showed information that included the following: -Immobility can occur in residents with neurological disease, fracture, pain, contractures, and use of restraints; -Immobility not only impairs a resident's ability to relieve pressure, it also predisposes the resident to insult by shearing and friction; -Sensory impairment results in reduced sensation and insensitivity to painful stimulus to relieve pressure; -Impaired sensory awareness occurs in residents with reduced level of consciousness, reduced level of awareness, and/or sensory [MEDICAL CONDITION]; -Advanced age-with normal aging, skin changes occur; -Regeneration of the epidermis is delayed, the dermis thins, blood supply is reduced, collagen production is decreased, and there are decreased subcutaneous tissue and nerve endings; -Decreased nerve endings results in the elderly resident not sensing the need to shift weight leading to skin breakdown; -Poor blood supply lowers capillary pressure and [MEDICAL CONDITION] of the tissues; -Severe chronic/terminal illnesses or multiorgan failure, poor perfusion, and immobility; -Incontinence can lead to excessive moisture or skin irritation from acidic urine or stool; -History of pressure sores (ulcers); -When a pressure ulcer closes, the edges taper and the wound bed becomes shallower; -However, it is not replaced with new muscle, subcutaneous fat or dermis; -The ulcer is filled with granulation (scar) tissue composed primarily of endothelial cells, fibroblasts, collagen, an extracellular matrix; -Because this tissue does not possess the strength of the lost tissue, the affected area will always be prone to subsequent breakdown; -Hard surface equipment can cause skin to break down in residents with impaired mobility and/or sensory impairment; -Skin should be inspected routinely for pressure/irritation caused by external positioning devices; -When possible, devices should be removed with skin cleaned, and pressure removed for defined periods of time; -Bed positioning-suspend heels on a pillow; -Use positioning devices such as bolsters or pillows to maintain bed position; -Adequate staff to meet the resident's needs; -Education/training-identification of risk factors; -Pathophysiology of pressure ulcer development; -Skin inspection; -Incontinence and skin care; -Selection of pressure prevention devices; -Techniques to minimize pressure, shear, and friction; -Information sources-direct observation and communication with the resident; -Medical record-history/physical, medical plan of care, resident care plan, transfer information, and documentation of service; -Discussion with resident's family members/significant others; -Discussion of resident's status with other appropriate licensed health professionals who have observed, evaluated, or treated the resident. Review of the facility's policy/procedure for selection of therapeutic surfaces (not dated) showed information that included the following: -An appropriate therapeutic surface should be provided when determined to be medically necessary by the interdisciplinary team and/or the physician for prevention and healing of skin impairment; -Prevention of Stage I or II wounds-Overlays-air (powered and non powered), foam, gel, water; -Pressure relief-therapeutic, multiple Stage II's, III, and IV-Low air loss, alternating pressure; air fluidized; -Seated dependent residents should be evaluated for appropriate pressure relief products for their wheelchair, gerichair, etc; -Use pillows to suspend the heels off the bed surface; -A resident with severe flexion contractures also may require special attention to effectively reduce pressure on bony prominences or prevent breakdown from skin to skin contact. Review of Resident #1's history and physical from an area hospital dated [DATE] showed the resident had [DIAGNOSES REDACTED]. Review of the resident's nurse's notes dated [DATE] through [DATE] showed the following: -On [DATE] (no time documented), the facility discontinued the resident's side rails and placed the resident on a scoop mattress; -On [DATE] at 12:45 P.M., after placing the resident in bed, staff found the resident laying on the floor (next to his/her bed); -The resident was transferred to an area hospital for evaluation/treatment of [REDACTED]. -On [DATE] (no time documented), staff placed the resident in a high/low bed with mats on the floor and discontinued the resident's alternating air mattress. During interview on [DATE] at 2:20 P.M. and [DATE] at 9:50 A.M., the administrator said the following: -The resident's air mattress was discontinued because the resident fell out of bed; -The scoop mattress placed on the resident's bed was more of a mattress cover; -The facility placed it over the air mattress, and the resident still fell out of bed, so the scoop mattress was removed. During interview on [DATE] at 9:20 A.M. and [DATE] at 1:15 P.M., the Director of Nurses (DON) said the following: -The resident was placed on an air mattress in the first place due to risk of skin breakdown, immobility, and dementia; -The air mattress was removed because the resident fell out of bed. Review of the resident's Braden Scale for predicting pressure sore risk showed the following: -On [DATE], staff scored the resident 14 (total score of ,[DATE] equals moderate risk); -On [DATE], staff scored the resident 13/moderate risk. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated instrument required to be completed by staff dated [DATE] showed the resident had a Stage II pressure ulcer, (A partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed without slough. May also present as an intact or open/ruptured blister). Review of the resident's nurse's notes dated [DATE] through [DATE] showed the following: -On [DATE] (no time documented), staff observed the resident had swelling in his/her left foot; -The physician directed staff to obtain a venous ultrasound to rule out a blood clot; -On [DATE] at 10:45 A.M., a certified nurse aide reported the resident had blood on his/her foot; -Staff observed the resident had swelling of the foot/ankle; -The resident's foot was red and warm to touch; -Staff observed a open area on the resident's foot that had a small amount of bleeding; -Staff applied Vaseline gauze to the open area and covered it with Kling; -The physician directed staff to obtain a wound culture, and prescribed an antibiotic for the resident; -On [DATE] at 6:00 P.M. (late entry), the physician ordered a wound nurse consult to evaluate the resident's left foot wound; -On [DATE] at 11:30 A.M., the wound nurse ordered an antibiotic ointment to treat the left foot area. Review of the resident's wound/ostomy care report dated [DATE],showed the wound nurse said the following: -The resident had an open area on his/her left foot; -It was about 0.4 centimeters in diameter by 0.3 centimeters deep; -It appeared to be an area that may have had a callous and the callous came off; -It had a small open area and it had been noted to [MEDICAL CONDITION] ([MEDICAL CONDITION] resistant staph aureus) positive growing in it; -The resident's foot was very swollen, up to about mid calf; -There was a medication technician in the room with the wound nurse; -The medication technician said the resident's foot was always swollen; -Staff did have a pressure relieving appliance on the resident's foot, and it was up on one pillow, but not enough to help with any sort of decrease in [MEDICAL CONDITION]; -The wound bed was very pink, and did not show any signs of trying to heal; -Staff had an order for [REDACTED]. -Staff also needed to keep the foot up as much as they could, propped up even on a wedge, or a couple of pillows to help with [MEDICAL CONDITION]. Review of the resident's occupational therapy postural seating evaluation and plan of care dated [DATE] showed the following: -The resident was referred to therapy secondary to sliding down in his/her wheelchair with pain and severe lower extremity contractures; -The resident was at risk for falls secondary to lower extremity, spinal, and pelvic deformities causing leaning/sliding in the wheelchair; -The resident was at risk for skin break down secondary to inability to reposition self for pressure relief. Review of the resident's nurse's notes dated [DATE] at 2:30 P.M. showed staff notified the physician the area on the resident's left foot was healed. Review of the resident's podiatry note dated [DATE] showed the following: -Family brought the resident in for a left foot ulcer; -Family said in July (2010), the foot looked red/swollen; -The facility said it was probably a pressure ulcer; -Staff started dressing the foot; -The foot seemed to get a little better; -A wound nurse looked at it; -It continued to get better; -The facility said it was almost completely resolved; -Family noticed blood on the resident's sock; -Family removed the sock and noticed further breakdown of the area; -Physician observed a two centimeter by two centimeter ulceration of the left foot down to the subcutaneous tissue, (nurse's note for [DATE] showed the area on the left foot to be healed); -There was fibrotic tissue noted as well with a surrounding rim of [DIAGNOSES REDACTED] (thickening of the skin); -The physician debrided the area and dressed it with [MEDICATION NAME] (antibiotic ointment)/guaze bandage; -The physician directed staff to discontinue the [MEDICATION NAME] and start using Santyl (for debridement) to the left foot ulcer one time a day; -The physician directed staff to use the resident's heel protectors or foot protectors at all times to try to prevent further pressure to the area; -The physician also ordered x-rays of the left foot to rule out osteo[DIAGNOSES REDACTED] (infection of the bone-can begin in the bone itself or when bone is exposed to germs); -The physician started the resident on Bactrim DS (an antibiotic) two times a day, and planned to see the resident the next week. Review of the resident's podiatry progress note dated [DATE] showed the resident had a grade III (Stage III) pressure ulcer of the left foot, (Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling); -The facility's policy/procedure for selection of therapeutic surfaces directed a low air loss, alternating pressure, or air fluidized surface (mattress) for pressure relief of multiple Stage II's, Stage III, and IV (Full thickness tissue loss with exposed bone, tendon, and muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) pressure sores. During interview on [DATE] at 9:50 A.M., the administrator said the resident's mattress was a spring unit urethane foam mattress, (this mattress was not identified as a low air loss, alternating pressure, or air fluidized surface for pressure relief). Review of the resident's podiatry note dated [DATE] showed the following: -The resident was seen for a follow up of an ulceration on the left foot; -Nursing staff said the resident was seen by a physician for another problem; -The physician also looked at the resident's foot; -Apparently, the physician was supposed to do this on a couple of other visits, but the family never had the physician do this (look at the resident's foot); -Examination showed the ulceration on the left foot was about 1.5 centimeters by 1.5 centimeters; -Still down to the subcutaneous tissue, but less fibrotic tissue; -X-rays negative for osteo[DIAGNOSES REDACTED]; -The ulcer was debrided to the subcutaneous tissue and dressed with Santyl; -Nursing staff to see if family wants podiatrist to see the resident or to have a follow up with the other physician instead; -The podiatrist planned to see the resident again the next week for further evaluation/treatment or otherwise just as needed. Review of the resident's nurse's notes dated [DATE] showed the podiatrist directed staff to continue current treatment (to the resident's foot). Review of the resident's podiatry note dated [DATE] showed the following: -There was still a little bit of fibrotic tissue noted to the ulceration; -The ulcer was about 1.5 centimeters by 1.5 centimeters; -Ulcer to full thickness left foot; -The ulcer was debrided and dressed with Santyl; -The podiatrist prescribed Santyl once a day followed by a gauze dressing; -The podiatrist directed staff to continue with heel protectors. Review of the resident's podiatry noted dated [DATE] showed the following: -Staff had been placing Santyl on the wound daily; -Ulceration about one centimeter by one centimeter; -There was a small area of hyperkeratotic rim; -There was minimal fibrotic tissue which was debrided; -Ulceration to full thickness. Review of the resident's podiatry note dated [DATE] showed the following: -Ulcer had not made much progress; -Ulcer still about one centimeter by one centimeter; -It was still full thickness; -There was less fibrotic tissue with a rim of [DIAGNOSES REDACTED] surrounding the area; -To continue with Santyl to the ulceration once a day. Review of the resident's podiatry note dated [DATE] showed the following: -Apparently, the resident's primary physician saw the resident today and wanted a culture done of the resident's left foot ulceration; -The primary physician started the resident on an antibiotic; -Nursing staff said they had been doing the dressing changes with Santyl as instructed, however, the resident's cushioned boot that he/she wore to offload the left foot had not always been on his/her foot (the resident's physician's orders [REDACTED]. -The left foot was much more [MEDICAL CONDITION] than the podiatrist had ever seen it; -The resident also had some [MEDICAL CONDITION] in the left leg as well; -There was some redness/[MEDICAL CONDITION] also on the foot and ulceration; -The ulceration looked much larger; -Ulceration about two centimeters by two centimeters and down to the subcutaneous tissue; -The area was full thickness; -There was some fibrotic tissue noted with some drainage; -The ulcer was debrided and dressed with Santyl; -The podiatrist stressed the importance in the orders of keeping the heel protectors on the resident's feet to try and offload the area; -Ordered x-rays of the left foot to see if the resident potentially had osteo[DIAGNOSES REDACTED]. Review of the resident's nurse's notes dated [DATE] (no time documented) showed a culture of the resident's foot showed the wound [MEDICAL CONDITION] ([MEDICAL CONDITION] resistant staph aureus) positive. Review of the resident's Braden Scale skin assessment dated [DATE] showed staff assessed the resident 13/moderate risk even though the resident had a Stage II pressure sore. Review of the resident's annual MDS dated [DATE] showed staff assessed the following: -The resident was always incontinent of bowel and bladder; -The resident was totally dependent on staff for hygiene; -The resident was totally dependent on two staff for bed mobility; -The resident had impaired range of motion on both upper extremities (shoulder, elbow, wrist, and hand) and both lower extremities (hip, knee, ankle, and foot); -The resident was at risk for pressure ulcers; -The resident had a Stage II pressure ulcer; -Skin and ulcer treatments noted as pressure reducing device for chair, turning repositioning program, ulcer care, nutrition/hydration intervention, and applications of dressings; -The MDS did not show a pressure reducing device for the resident's bed (resident already had a Stage II pressure ulcer and determined to be at risk for pressure ulcers). Review of the resident's Care Area Assessments (CAA's) dated [DATE] showed the following: -The resident was being treated for [REDACTED]. -The resident was on a pressure reduction mattress; -Heel protectors were to be used; -The resident had severe contractures of the lower extremities. Review of the resident's podiatry note dated [DATE] showed the following: -The resident was to be seen last week in the office, but was not brought in for the appointment by the facility; -The resident's primary physician saw the resident in interim and placed the resident on an antibiotic [MEDICAL CONDITION] of the left foot wound; -The primary physician started the resident on [MEDICATION NAME] on the ulceration and dressing changes; -There was some swelling to the left lower extremity, but not as swollen as previously; -The ulceration was about two centimeters by two centimeters and still full thickness, but did look slightly improved; -The ulcer was debrided and dressed with [MEDICATION NAME] followed by a guaze dressing; -The podiatrist wrote orders to continue the [MEDICATION NAME] as ordered by the primary physician; -Continue the off-loading boots as well. Review of the resident's physician's orders [REDACTED]. Review of the resident's care plan dated [DATE] showed the following regarding pressure ulcers: -The resident was diabetic and at risk for open areas on his/her lower extremities and feet; -The resident currently had a Stage II on his/her foot; -Heel protectors on at all times; -Pressure relieving cushion in the chair; -Resident dependent on staff for most activities of daily living; -Turn resident on back/right side; -Resident did not like to be on left side. Review of the resident's podiatry note dated [DATE] showed the following: -The ulcer was still about 2 centimeters by 1.5 centimeters; -Full thickness, but did look improved; -The ulcer was debrided and dressed with [MEDICATION NAME]; -Nursing staff going to continue with current dressing changes; -As of note, when the podiatrist saw the resident, the resident did not have his/her boots on to offload the ulceration, so these were put on the resident's feet (the resident's physician's orders [REDACTED]. -Staff needed to continue with the boots at all times. Review of the resident's podiatry note dated [DATE] showed the following: -Ulcer about 1.5 centimeters by 1.5 centimeters; -Full thickness; -Appeared to be filling in; -There was a little bit of fibrotic tissue that was debrided; -Ulcer dressed with [MEDICATION NAME] ointment. Review of the facility's weekly wound report completed by the DON on [DATE] and [DATE] showed the resident had a Stage II pressure ulcer on the left foot. Review of the resident's podiatry note dated [DATE] showed the following: -The left foot ulcer looked a little bit larger from two weeks ago; -Area about 2 centimeters by 1.5 centimeters; -Area of old coagulated drainage and [DIAGNOSES REDACTED] was debrided; -Ulcer was still full thickness; -Ulcer dressed with [MEDICATION NAME]. Review of the facility's weekly wound report completed by the DON on [DATE] showed the resident had a Stage II pressure sore on the left foot. Review of the resident's podiatry note dated [DATE] showed the following: -Recent cultures showed [MEDICAL CONDITION] of the ulceration; -Ulceration about 1 centimeter by 1.5 centimeter; -Old coagulated drainage and a rim of [DIAGNOSES REDACTED] surrounding the ulcer; -The ulcer was still full thickness on debridement; -Wrote orders to discontinue the [MEDICATION NAME] and begin using Allevyn (moist wound healing dressing) once a day to the left foot ulcer. Review of the facility's weekly wound report completed by the DON on [DATE] and [DATE] showed the resident had a Stage II pressure sore on the left foot. Review of the resident's podiatry note dated [DATE] showed the following: -The ulcer was still full thickness and about 0.75 centimeters by 1 centimeter; -There was a rim of [DIAGNOSES REDACTED] and a little bit of coagulated drainage. During interview on [DATE] at 9:15 A.M., the podiatrist said the following: -There were a couple of times when he/she arrived at the facility to see the resident, the resident did not have his/her off-loading boots on to relieve pressure (on feet); -Sometimes, the boots would be in bed with the resident, but not on the resident (the resident's physician's orders [REDACTED]. Review of the resident's nurse's notes dated [DATE] showed the following: -At 4:30 A.M., a certified nurse aide reported the resident had an open area on the left buttock; -Staff observed a Stage II, dime sized area; -Staff applied Sensicare (topical moisture barrier) and faxed the physician. Review of the facility's weekly wound report completed by the DON on [DATE] and [DATE] showed the resident continued with a Stage II pressure ulcer on the left foot and had a Stage II pressure ulcer on the left buttock; -The facility did not place the resident on a different type of mattress (the facility's policy/procedure for therapeutic surfaces directs a low air loss, alternating pressure, or air fluidized surface (mattress) for pressure relief of multiple Stage II's, III, and IV pressure ulcers). Review of the resident's nurse's notes dated [DATE] (no time documented), showed the wound nurse evaluated the area, and ordered Santyl ([MEDICATION NAME] ointment) two times a day. Review of the resident's wound/ostomy care report dated [DATE] showed the wound nurse said the following: -The resident had a large unstageable pressure ulcer on the left buttock; -The area had eschar over 50% of the wound; -The area was approximately two centimeters in diameter and depth could not be appreciated due to the necrotic tissue; -The resident was to be kept off the area as much as possible; -Santyl to be applied to the wound and dressing changed two times a day; -Clean in between the dressing changes; -This would help debride the necrotic slough; -One of the nurses went with the wound nurse, and not only were the orders written, but they were also given verbally for understanding. Review of the resident's [DATE] quarterly MDS showed the following: -The resident was always incontinent of bowel and bladder; -The resident was totally dependent on staff for hygiene; -The resident was totally dependent on two staff for bed mobility; -The resident's range of motion was impaired on both upper extremities (shoulder, elbow, wrist and hand), and both lower extremities (hip, knee, ankle, and foot); -The resident was at risk for pressure ulcers; -The resident had a Stage II pressure ulcer (the resident developed a second Stage II pressure ulcer on the buttocks that staff observed on [DATE] that had not been identified on this MDS); -Skin and ulcer treatments included pressure reducing device for chair, turning repositioning program, nutrition/hydration intervention, ulcer care, and application of dressings; -The MDS did not show a pressure reducing device for the resident's bed even though the resident already had a Stage II pressure ulcers on the foot and an unstageable pressure ulcer on the buttock). -Review of the resident's Braden Scale dated [DATE], showed staff scored the resident 13/moderate risk even though the resident had a Stage II pressure ulcer on the foot and an unstageable pressure ulcer on the buttocks. Review of the resident's podiatry note dated [DATE] showed the following: -The ulcer (foot) was about 0.75 centimeters by 0.5 centimeters. Review of the resident's nurse's notes dated [DATE] through [DATE] showed the following: -On [DATE] at 8:30 P.M., staff observed the area on the resident's left buttock was bright red and warm to touch; -Staff notified the physician by fax; -On [DATE] at 2:00 P.M., the wound nurse evaluated the area. Review of the facility's weekly wound report completed by the DON on [DATE] showed the resident continued with a Stage II pressure sore on the left foot, and but the pressure sore on the resident's left hip had become non-stageable; -The facility did not place the resident on a different type of mattress (the facility's policy/procedure for therapeutic surfaces directs a low air loss, alternating pressure, or air fluidized surface (mattress) for pressure relief of multiple Stage II's, II, and IV pressure sores). Review of the resident's wound/ostomy care report dated [DATE] showed the wound nurse said the following: -The wound nurse had seen the resident on [DATE] for the same open area on the left buttock; -We had been putting Santyl on the area and covering it with a 4 x 4 (changing two times a day); -The DON contacted the wound nurse and said he/she noticed the necrosis had kind of toughened up, so the Santyl had quit doing it's job; -The DON requested the wound nurse come and see the resident again; -When the wound nurse entered the resident's room, staff were just putting the resident back to bed from his/her wheelchair; -The aide asked "If the cushion in the wheelchair had been changed to a different kind of cushion, could that have caused part of the problem?"; -The aide said someone had taken the Roho cushion out of the wheelchair and placed just a regular hard cushion in the wheelchair (the facility's skin risk assessment policy/procedure showed hard surface equipment could cause skin to break down in resident's with impaired mobility and/or sensory impairment) (the resident's care plan directed staff to use a pressure relieving cushion in the resident's chair); -The aide said he/she had just noticed it when staff was putting the resident to bed; -This could be a possibility because the regular cushion (that was in the wheelchair) was not a pressure relieving cushion; -So, that was rectified; -The Roho cushion was a pressure relieving cushion (the resident's care plan directed the use of a pressure relieving device in the resident's wheelchair and the facility's policy/procedure for therapeutic services directed seated dependent residents should be evaluated for appropriate relief products for wheelchairs/gerichairs); -The wound was completely covered with a soft, black eschar; -Taking some forceps, the wound nurse was able to gently remove a lot of the eschar; -In gently [MEDICATION NAME] the wound open, it had a very foul smelling liquid brown drainage coming from the entire area; -When the wound was completely opened, there was a lot of slough in the wound; -The wound had tunneled some at about the nine o'clock position, and a little bit of undermining around the edges; -There was a purplish hue around the wound of a suspected deep tissue injury which could also be what has started some of this breakdown; -Applied saline soaked open 4 x 4's ' into the wound, and covered with dry 4 x 4' s'; -The resident was to stay off that side; -The resident was to sit on a Roho cushion; -Staff to do wet-to-dry dressing changes every six hours until Monday; -The resident's nutrition was not the best, but according to an aide, the resident's nutrition was adequate. During interview on [DATE] at 1:15 P.M., the wound nurse from an area hospital said the following: -In February, a nurse aide (name unknown) came in the resident's room and said the resident had a good (Roho) cushion (for his/her chair), but now it was gone; -The aide found a good cushion and put it in the resident's chair (tilting wheelchair); -The wound nurse talked to the DON about an air mattress for the resident; -The DON said the resident had one at one time, but the resident kept falling out of bed. During interview on [DATE] at 9:20 A.M., the DON said the following: -The resident had a Roho cushion in his/her chair; -The cushion stayed in the chair unless it was soiled, and had to be cleaned; -The cushions were usually cleaned one time a week; -After cleaning the cushions, the cushions were dried and placed back in the chairs. Review of the resident's wound/ostomy report dated [DATE] showed the wound nurse said the following: -When he/she saw the resident on [DATE], we (the wound nurse and facility staff) had agreed to do wet to dry dressing changes to finish cleaning out the wound; -Today, the wound nurse returned to see how well the wound was doing; -There was still some extra slough in the wound; -The odor was much less, but when talking with the DON, the DON said staff had been putting the dressings in the wound soaking wet, and the dressing had been removed moist; -The DON did talk to staff a couple of days ago when the DON found out that was what was going on as that would not help debride the wound; -Taking some forceps, the wound nurse cleaned out a little more of the necrosis; -Since the wound still had some odor and there was about four small dots of granulation, the wound nurse suggested trying ,[DATE] strength Dakin's solution two times a day to help clean out the wound and also to control the odor; -The resident's nutrition was very poor. Review of the facility's weekly wound report completed by the DON on [DATE] showed the resident continued with a Stage II pressure ulcer to the left foot, and the left buttock pressure ulcer remained non-stageable. Review of the facility's weekly wound report completed by the DON on [DATE] showed the resident continued with a Stage II pressure sore on the left foot and the pressure sore on the left buttock had developed into a Stage IV. Review of the resident's nurse's notes dated [DATE] (no time documented) showed the physician evaluated the resident and ordered an alternating air mattress and changes in the resident's pain medication. Review of the resident's physician progress/visit note dated [DATE] showed the following: -The resident had a large tunneling decubitus (pressure) ulcer on the left buttock; -The resident had a surgical consult pending; -Ulcer treatment left foot per podiatrist; -The resident awakes, moaning in pain; -Large decubitus ulcer left buttock measuring 3XXX