Every finding on record at MRC Creekside

Based on interviews and record reviews, the facility failed to develop a person-centered comprehensive care for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet the resident's needs for 1 of 6 residents (Residents #48) reviewed for comprehensive care plans.The facility failed to ensure Resident #48's comprehensive care plan was revised to reflect the resident requiring a wound vacuum for wound treatments.This failure could place residents at risk of inadequate monitoring of equipment.Findings included:Record review of an admission Record for Resident #48 dated 5/6/2026 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of type 2 diabetes, Parkinson's disease (movement disorder of the nervous system that worsens over time), and neuromuscular dysfunction of bladder (nerve damage or injuries that causes loss of control of the bladder).Record review of active physician orders for Resident #48 dated 5/5/2026 indicated an order for NPWT to sacral wound (wound on the tailbone) at 125 mmhg every day shift for wound care that started on 3/30/2026.Record review of an Annual MDS Assessment for Resident #48 dated 3/6/2026 indicated she did not have any impairment in cognition with a BIMS score of 13. She had an indwelling catheter (tube placed in the bladder to drain the bladder) and an ostomy (an opening in the abdomen that allows waste to exit the body). She had a surgical wound.Record review of a care plan for Resident #48 dated 4/22/2026 indicated she had the potential/actual impairment to skin integrity due to surgical wound to sacrum. There was not a care plan for the wound vac or interventions. During an interview on 5/6/2026 at 9:43 am, an interim MDS Coordinator said she was filling in for the MDS Coordinator at the facility. She said the facility MDS Coordinator was out on leave. She said care plans should be revised and updated with new orders or changes. She said she missed updating the care plan for Resident #48 and the wound vac should have been on her care plan. She said she would update it. She said updating the care plans was to ensure the staff were aware of what was happening with the residents. She said she worked remotely for the facility and was not in attendance at the morning meetings. She said the facility did contact her about 2-3 times a week for updates.Attempted an interview on 5/6/2026 with the DON, but she was out on leave.During an interview on 5/6/2026 at 10:52 am, the Administrator said members of the IDT team were responsible for updating and revising the care plans. He said the care plans should be updated with changes. He said the purpose of the care plans was to keep everyone updated. He said he expected the staff to update the care plans as needed.Record review of a facility policy titled Care Plan, Comprehensive Person-Centered dated 2001 indicated, . A comprehensive, person-centered care plan that includes measurable objective and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 7. The comprehensive, person-centered care plan; b. described the services that are to be furnished to attain or maintain the resident's highest practicable physical, and mental, and psychosocial well-being .

Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 of 3 (treatment cart) carts reviewed.The Treatment Nurse failed to ensure the medication cart for treatments was locked and secured on 5/4/2026.This deficient practice could place residents at risk for adverse reactions to medications and misappropriation of medications.Findings included:During an observation on 5/04/2026 3:04 pm, the Treatment Nurse and MA A were in the room of Resident #48 to provide wound care. The Treatment Nurse sanitized her hands and donned (put on) a gown and cleaned an overbed table and placed wax paper down. The Treatment Nurse placed wound care supplies on an overbed table that was in the doorway of Resident #48's room. The Treatment Nurse entered the room and left the cart in the hallway unlocked with the keys in the lock and closed the door to Resident #48's room. The Treatment Nurse performed wound care on Resident #48 and when the care was completed, she exited the room and said she was not supposed to leave the keys in the cart.During an interview on 5/04/2026 at 3:28 pm, the Treatment Nurse said when she gathered her supplies, she should have taken the keys and locked the cart. She said her cart had different types of dressings and ointments that residents should not have access to. She said the cart should not be left unattended or unlocked unless they were in front of it. She said residents could get in the cart if left unlocked and unattended.Attempted an interview on 5/6/2026 with the DON, but she was out of the facility.During an interview on 5/6/2026 at 9:30 am, the ADON said she had been employed at the facility since December 2025. She said nurse medication/treatment carts should always be locked. She said the person responsible for the cart should have the keys in their possession and never leave the carts unattended. She said residents could get access to all the things in the carts if they were left unlocked and unattended.During an interview on 5/6/2026 at 10:52 am, the Administrator said carts should always be locked and not left unattended due to safety issues. He said he expected the staff to follow policy.Record review of a facility policy titled Medication Labeling and Storage revised February 2023 indicated, .The facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light controls. Only authorized personnel have access to keys .

Based on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 5 staff (Treatment Nurse and LVN B) reviewed for infection control.The facility failed to ensure the Treatment Nurse did not touch clean items with dirty gloves when wound care was provided to Resident #48 on 5/4/2026.The facility failed to ensure LVN B wore a gown during high-contact resident care activities for Resident #48 on 5/5/2026.These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices.Findings included:Record review of an admission Record for Resident #48 dated 5/6/2026 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of type 2 diabetes, Parkinson's disease (movement disorder of the nervous system that worsens over time), and neuromuscular dysfunction of bladder (nerve damage or injuries that causes loss of control of the bladder).Record review of active physician orders for Resident #48 dated 5/5/2026 indicated an order for NPWT to sacral wound (wound on the tailbone) at 125 mmhg every day shift for wound care that started on 3/30/2026.Record review of an Annual MDS Assessment for Resident #48 dated 3/6/2026 indicated she did not have any impairment in cognition with a BIMS score of 13. She had an indwelling catheter (tube placed in the bladder to drain the bladder) and an ostomy (an opening in the abdomen that allows waste to exit the body). She had a surgical wound.Record review of a care plan for Resident #48 dated 4/22/2026 indicated she had the potential/actual impairment to skin integrity due to surgical wound to sacrum. There was not a care plan for the wound vac or interventions. During an observation on 5/4/2026 at 3:04 pm, the Treatment Nurse and MA A were in the room of Resident #48 to provide wound care. The Treatment Nurse sanitized her hands and donned (put on) a gown and cleaned an overbed table and placed wax paper down. The Treatment Nurse placed the wound supplies on the overbed table and entered the room. MA A washed her hands in the room and donned a gown and put on gloves. MA A assisted Resident #48 on her right side. The Treatment Nurse removed the dressing that was noted to Resident #48's sacrum and placed it in the trash with her gloves. The Treatment Nurse sanitized her hands and put on clean gloves. The Treatment Nurse cleaned the wound with normal saline and 4x4 gauze and placed the gauze in the trash. The Treatment Nurse patted the wound dry with 4x4 gauze and removed her gloves and placed them in the trash. The Treatment Nurse washed her hands in the bathroom and put on clean gloves. The Treatment Nurse applied skin prep to peri wound (area around the wound). The Treatment Nurse applied a foam dressing in the wound bed and placed a strip of foam as a bridge to Resident #48's hip area. The Treatment Nurse removed her gloves and placed them in the trash and sanitized her hands. The Treatment Nurse put on clean gloves and placed a dressing on the wound for vacuum suction. The Treatment Nurse removed the brief from underneath Resident #48's buttocks and placed it in the trash. The Treatment Nurse touched a clean brief and placed it underneath Resident #48's buttocks. The Treatment Nurse picked up the wound vac that was in a chair in the room and attached a cannister to the wound vac and turned it on. Resident #48 was repositioned in bed. The Treatment Nurse doffed (took off) her gown and gloves and placed them in the trash and removed the trash from the room. MA A doffed her gown and gloves and washed her hands. The Treatment Nurse exited the room and placed the trash in the soiled linen utility room. The Treatment Nurse reentered Resident #48's room and washed her hands in the bathroom.During an interview on 5/4/2026 at 3:28 pm, the Treatment Nurse said during the wound care that was provided to Resident #48, she should have changed her gloves and sanitized her hands before she touched the wound vac. She said there was a risk of spreading infections if she touched clean items with dirty gloves. She said she should not have touched the clean brief with dirty gloves. During an observation on 5/5/26 at 8:00 am LVN B was observed administering an IV antibiotic, which included flushing a PICC line for Resident #44. An enhanced barrier precautions sign was observed posted inside Resident #44's room. LVN B did not wear a gown for enhanced barrier precautions while flushing the PICC line or connecting the tubing for the IV antibiotic.During an interview on 5/5/26 at 8:20 am LVN B said she forgot to put the gown on. She said she knew the resident was on enhanced barrier precautions because she had a foley catheter, an open wound, and a PICC line. She said it was an infection control issue.During an interview on 5/6/2026 at 9:30 am, the ADON said she had been employed at the facility since December 2025. She said she was the IP for the facility. She said she trained staff monthly on infection control that included hand washing. She said she monitored the staff daily to ensure they were following infection control measures. She said the staff were trained on hire, annually and as needed. She said hand hygiene should be done before and after care, and when hands were visibly soiled. She said staff should never touch clean items with dirty gloves or clean equipment. She said she expected her staff to follow protocols for infection control including enhanced barrier precautions. She said she will be providing more education and in-services going forward to ensure staff were compliant. She said there was a risk for infections.Attempted an interview on 5/6/2026 with the DON, she was out of the facility.During an interview on 5/6/2026 at 10:52 am, the Administrator said staff should perform hand hygiene before and after care. He said he expected his staff to follow proper protocols related to infection control and enhanced barrier precautions. He said he would be providing further education for staff going forward to ensure compliance. He said residents could be at risk of cross contamination and if enhanced barrier precautions were not followed.Record review of a facility policy titled Enhanced Barrier Precautions dated December 2024 read: .Enhanced barrier precautions (EBPs) refer to infection prevention and control interventions designed to reduce the transmission of multi-drug-resistant organisms (MDROs) during high contact resident care activities . and .Enhanced barrier precautions apply when .b. A resident is NOT known to be infected or colonized with any MDRO, has a wound or indwelling medical devices, and does not have secretions or excretions or excretions that are unable to be covered or contained . and .Indwelling medical devices include central lines, urinary catheters, feeding tubes, and tracheostomies. Peripheral IV catheters are not considered an indwelling medical device for purposes of EBPs . and .EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply . and .Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: .i. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.) .Record review of a facility policy titled Handwashing/Hand Hygiene revised October 2023 indicated, .This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Indications for hand hygiene: c. After contact with blood, body fluids, or contamination surfaces; f. before moving from work on a soiled body site to a clean body site on the same resident .

Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for 1 of 1 kitchen reviewed for food service safety. The facility failed to close food product bags in the walk-in freezer, to prevent exposure to air. This failure placed residents who ate food served by the kitchen at risk of cross contamination and food-borne illness. Findings include: During initial observation and interview on 03/03/25 at 08:00 a.m., the walk-in freezer in the kitchen contained the following: *an open original cardboard box dated 02/27/25 containing a clear plastic bag of frozen beef patties that was not properly sealed and exposed to the elements. The Dietitian said it was beef patties. When asked about the frozen beef patties, the Dietitian tied the plastic bag and said it should be sealed. *an open original cardboard box dated 02/27/25 containing a clear plastic bag of fried frozen steak fritter patties that was not properly sealed and exposed to the elements. The Dietitian said it was fried steak fritters. *an open original cardboard box dated 02/27/25 containing a ripped open clear plastic bag of frozen French fries that was not properly sealed and exposed to the elements. The Dietitian said it was French fries. During an interview on 03/03/25 at 08:30 a.m., the Dietitian said her expectations was all products in the kitchen be stored correctly. She said packages of food items should be sealed so not to expose food to the elements. The Dietitian said it was the responsibility of all the dietary staff to ensure products were labeled and stored correctly. She said the EC (executive chef) was to monitor kitchen staff on storage, and preparation of food appropriately. The Dietitian said she did spot checks periodically in kitchen to be sure everything was working in kitchen and completed a walk-through checking for sanitary conditions. The Dietitian said she had not had time to do the walk-through today. During an interview on 03/03/25 at 11:00 a.m., the EC with contracted dietary services, said all products and packages of food should be stored in sealed containers after being opened. The EC said unsealed containers of food could cause food-born illnesses in residents and could affect the taste or quality of the food. He said it was the kitchen staff's responsibility to store, label and date food items taken out of the freezer to use. The EC said he was responsible for monitoring the kitchen staff and ensuring products were stored, labeled, dated and equipment cleaned. He also said he checked the tray line for portion sizes, tray accuracy, monitoring temperatures and staff following facility policy. The EC said some of the kitchen staff were new and he (EC) was trying to educate kitchen staff on storage, labeling, and dating food products. The EC said the kitchen staff had training on these topics, and knew what to do and what not to do in the kitchen. He said the kitchen staff had been changing and there was a new group which could have led to failures of staff may have forgotten their training. He said he felt more education was needed and would conduct a training. During an interview on 03/03/25 at 11:45 a.m., [NAME] D said she did not know who left the bags of foods opened in the freezer, and used bags of food being stored should be sealed or they could cause a person to get sick or food to taste funny. She said she had been trained that after opening a food item, it should be labeled with the opening date and stored in a sealed container. During an interview on 03/04/25 at 4:39 p.m., the Administrator said he expected kitchen staff to follow policies on food storage and preparation. He said the EC was responsible for monitoring kitchen staff and ensuring staff were following the facility's policy. He said not storing and preparing food appropriately could cause freezer burn, affecting the freshness and quality of resident's food. Review of a facility policy, revised January 2025, on Food and Supply Storage indicated Policies: All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain safety and wholesomeness of the food for human consumption . Procedures: Cover, label and date unused portions and open packages .store foods in their original packages. Foods that must be opened must be stored in approved containers that have tight-fitting lids .Store bulk material in approved containers that have tight fitting lids .wrap food tightly to prevent cross contamination .

Based on observation, interview, and record review, the facility failed to ensure the accurate administration of medications to meet the needs of each resident for 1 of 5 residents observed for medication administration. (Resident #19) MA B administered an incorrect dose of felodipine (used to treat high blood pressure) to Resident #19 on 03/04/25 during medication pass. This failure could place residents who received medications administered at risk of not receiving the intended therapeutic benefit of their medications. Findings included: Record review of a face sheet for Resident #19 indicated admitted to facility on 12/27/23 with diagnoses including high blood pressure and chronic kidney disease. Record review of Resident #19's annual MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15 which indicated intact cognition. She required supervision from staff with ADL care. Record review of Resident #19's care plan initiated 01/15/25 indicated a diagnosis of high blood pressure. Interventions included give medicine for high blood pressure and document response to medication and any side effects. Monitor blood pressure. Notify physician of any abnormal readings. Record review of Resident #19's Physician Orders dated March 2025 indicated Resident #19 was to receive Felodipine ER 10 mg. Give with 5 mg to equal 15 mg to treat high blood pressure. Record review of Resident #19's MAR dated March 2025 indicated an order of Felodipine ER 10 mg. Give with 5 mg to equal 15 mg. During an observation of the medication pass on 03/04/25 at 7:45 a.m., MA B prepared and administered a felodipine 10 mg tablet to Resident #19. During an interview on 03/04/25 at 8:15 a.m., MA B acknowledged she had administered an incorrect dose of felodipine to Resident #19 during today's medication pass at 7:45 a.m. She said she gave one 10 mg tablet when she should have also given an additional 5 mg tablet to equal 15 mg, and she did not. During an interview on 03/05/25 at 9:45 a.m., the DON said he expected medications to be available and administered per physician orders. The DON said unstable vital signs could potentially be a negative result of not receiving correct dosage. Record review of the facility's Adverse Consequences and Medication Errors policy dated February 2023 read in part, .A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician orders. Examples of medication errors include wrong dose

Based on observation, interview, and record review, the facility failed to ensure each resident's drug regimen was free of unnecessary medication for 1 of 14 residents reviewed for unnecessary medication (Resident #244) The facility did not monitor Resident #244 for side effects of the anticoagulation medication, Eliquis (a blood thinning medication). This failure could place the residents at risk for adverse consequences of the anticoagulant medication. Findings included: Record review of a face sheet dated 03/03/25 indicated Resident #244 was an [AGE] year-old male admitted [DATE] with a diagnosis of atrial fibrillation (irregular, often rapid heart rate that causes poor blood flow), and stroke (medical emergency that occurs when blood flow to the brain is blocked). Record review of a baseline care plan initiated 02/25/25 indicated Resident #244 was prescribed an anticoagulant medication. Record review of the physician orders dated 03/05/25 indicated Resident #244 was prescribed Eliquis 2.5 mg two times a day for a history of a blood clot with a start date of 02/25/25. The orders did not address monitoring the anticoagulant medication. Record review of a MAR dated 03/05/25 indicated Resident #244 received Eliquis 2.5 mg two times a day for history of a blood clot with a start date of 02/25/25. Record review of the electronic medical record from 02/25/25 to 03/05/25 for Resident #244 did not indicate the nurses' documented monitoring of side effects of the anticoagulant daily with medication administration. During an observation and interview on 03/03/25 at 10:25 a.m., Resident # 244 was up in his wheelchair with no observed bruised areas. He said he received the blood thinner Eliquis. During an interview on 03/05/25 at 9:10 a.m., LVN C said she was providing care for Resident #244 today and he received Eliquis. She said Resident #244 should be monitored for side effects of the anticoagulant medication, but he was not. LVN C said the monitoring was overlooked. She said she was educated to add side effect monitoring for all anticoagulant medication in the computer system. LVN C said the admitting nurse was responsible for adding the monitoring to the computer system and the nurses providing care for Resident #244 were the back up to ensure the monitoring for side effects was added into the computer system for Resident #244's Eliquis. LVN C said the resident's risk of not monitoring anticoagulants for side effects was the monitoring could be overlooked, and the resident could become anemic. During an interview on 03/05/25 at 9:25 a.m., Unit Manager A said she was responsible for adding the monitoring for Resident #244's Eliquis into the computer system. She said Resident #244's Eliquis should have been monitored for side effects, but he was not. Unit Manager A said she admitted the resident and the monitoring was overlooked. She said the DON was the back up to ensure anticoagulant medication monitoring was added into the computer system. She said she was educated to add side effect monitoring to all anticoagulant medication in the computer system. Unit Manager A said the resident risk of anticoagulant medication not monitored was possible bleeding and not being monitored for side effects. During an interview on 03/05/25 at 9:40 a.m., the DON said the admitting nurse was responsible for adding the anticoagulant monitoring into the computer system for all anticoagulants. She said the nurses providing care for the resident and himself were the back up to ensure side effect monitoring was added into the computer system for all anticoagulants. The DON said Resident #244's Eliquis should have been monitored for side effects, but was not. He said the monitoring was overlooked. The DON said all the nurses were educated to add side effect monitoring to all anticoagulant medications in the computer system with the most recent in-service on 12/18/24. He said the resident risk of anticoagulant medication monitoring not added into the computer system was possible bleeding and the staff being unaware to monitor for it. The DON said his expectation was all anticoagulant medication monitored for side effects on entry of the medication order. During an interview on 03/05/25 at 10:05 a.m., the Administrator said the nurses providing care for the resident were responsible for ensuring all anticoagulant medication was monitored for side effects, and the ADON and DON were the back to ensure the side effect monitoring was added into the computer system. He said the monitoring for Resident #244 was overlooked. He said the nursing staff were educated on adding monitoring for anticoagulant medication into the computer system. The Administrator said the resident risk was potential excessive bleeding and his expectation was all anticoagulant medication monitored as required. Record review of a facility policy titled, Anticoagulant - Clinical Protocol revised November 2018, indicated, 1. As part of the initial assessment, the physician and staff will identify individuals who are currently anticoagulated, . a. assess for any signs or symptoms related to adverse drug reactions due to the medication alone or in combination with other medications. a. if an individual on anticoagulation therapy shows signs of excessive bleeding, the nurse will discuss the situation with the physician before giving the next scheduled dose of anticoagulant .

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals used in the facility were labeled and stored in accordance with currently accepted professional principles in 1 of 2 medication carts reviewed. (Hall 200 Nurses medication cart) in that: An insulin pen of Lispro insulin (short acting insulin used to lower blood sugar) labeled for Resident #4 with an open date of [DATE], had been expired for 12 days and not removed from use. An insulin pen of Lispro insulin (used to lower blood sugar) labeled for Resident #31 with an open date of [DATE], had been expired for 29 days and not removed from use. This failure could place residents at risk for accidents, hazards, and not receiving therapeutic effects of medication. The findings included: 1. Record review of Resident #4's face sheet dated [DATE] indicated an [AGE] year-old female readmitted [DATE] with a diagnosis of type 2 diabetes mellitus (trouble controlling blood sugar). Record review of Resident #4's quarterly MDS assessment with an ARD of [DATE] indicated the resident had a BIMS score of 11 indicating the resident was moderately impaired of cognition. The assessment indicated she was diagnosed with diabetes mellitus and received insulin injections 7 of 7 days during the look back period. Record review of Resident #4's care plan updated [DATE] indicated she was diabetic and received diabetic medication as ordered by the physician and to monitor for side effects and effectiveness. Record review of Resident #4's physician order, dated [DATE], indicated she was prescribed Lispro 100 Units/ml Insulin 100 unit/ml inject solution (,d+[DATE] units) subcutaneous before meals. Inject as per sliding scale: if ,d+[DATE] = 2 units, ,d+[DATE] = 3 units, ,d+[DATE] = 4 units, ,d+[DATE] = 6 units, 401- 450 =8 units and if greater than 451 notify physician for type 2 diabetes mellitus. Resident #4 was prescribed Tresiba (long-acting insulin to lower blood sugar) insulin 100 unit/ml solution (10units) subcutaneous in the morning with a start date of [DATE] for type 2 diabetes mellitus. Record review of Resident #4's MAR, dated [DATE], indicated she received Lispro insulin per sliding scale on: *[DATE] at 5:00 p.m., 2 units; *[DATE] at 11:00 a.m., 2 units; *[DATE] at 5:00 p.m., 2 units; *[DATE] at 7:30 a.m., 2 units; *[DATE] at 11:00 a.m., 3 units;and *[DATE] at 5:00 p.m., 3 units. During an observation and interview on [DATE] at 9:45 a.m., Resident #4 was sitting in her wheelchair and said she was treated well and received needed care. Resident #4 said she received insulin daily. 2. Record review of Resident #31's face sheet dated [DATE] indicated an [AGE] year-old female admitted [DATE] with a diagnosis of type 2 diabetes mellitus. Record review of Resident #31's annual MDS assessment with an ARD of [DATE] indicated the resident had a BIMS score of 11 indicating the resident was moderately impaired of cognition. The assessment indicated she was diagnosed with diabetes mellitus and received insulin injections 7 of 7 days during the look back period. Record review of Resident #31's care plan initiated [DATE] indicated she was diabetic and received diabetic medication as order by the physician and to monitor for side effects and effectiveness. Record review of Resident #31's physician order, dated [DATE], indicated she was prescribed Lispro Insulin 100 unit/ml inject solution (,d+[DATE] units) subcutaneous before meal. Inject as per sliding scale: if ,d+[DATE] = 2 units, ,d+[DATE] = 3 units, ,d+[DATE] = 4 units, ,d+[DATE] = 6 units, 401 or greater = 8 units and notify physician for type 2 diabetes mellitus. Resident #24 was prescribed Tresiba Insulin 100 unit/ml solution (25 units) subcutaneous in the morning, hold for blood sugar less than 100, with a start date of [DATE] for type 2 diabetes mellitus. Record review of Resident #31's March MAR, dated [DATE], indicated he received Lispro insulin per sliding scale in March. *[DATE] at 5:00 p.m., 3 units; and *[DATE] at 11:00 a.m., 2 units. During an observation and interview on [DATE] at 9:05 a.m., Resident #31 was lying in bed and said he was treated well and received needed care. Resident #31 said he received insulin sometimes. During an observation and interview on [DATE] at 9:10 a.m., during a review of Hall 200 Nurse's medication cart with LVN C, revealed two insulin pens in use beyond the recommended time frame of use after opened. One Lispro kwick pen 100 U/ ml with 180 units in it, labeled with Resident #4's name with an expiration date of [DATE] and labeled with an open date of [DATE] on the medication cart 12 days after expiration. One Lispro kwick pen 100 U/ ml labeled with Resident #31's name, with an expiration date of [DATE] and labeled with an open date of [DATE] with 180 units on the medication cart 21 days after expiration. LVN C said both Lispro kwick pens should have been removed from the medication cart 28 days from the opening date, but they were overlooked. She said the nurses providing care to the residents were responsible to remove all expired medication. She said the ADON was a backup to ensure all expired medication was removed from the medication carts. LVN C said she was educated on removal of insulin in use beyond the recommended time frame of use after opened. She said she was providing care for Residents #31 and #4 today, and had not given either resident Lispro insulin today. LVN C said the resident risk of insulin, in use beyond the recommended time frame of use after opened, was the medication may not be as effective. During an interview on [DATE] at 09:30 a.m., the ADON, said the Lispro kwick pens expired 28 days after opening and should have been removed. She said the nurses providing care for the residents were responsible for and she was the back up to ensure any insulin, in use beyond the recommended time frame of use after opened, was removed from the nurse's medication cart. The ADON said the insulins, in use beyond the recommended time frame of use after opening, were overlooked. She said she was educated on removal of insulin in use beyond the recommended time frame of use after opened. The ADON said the resident risk of insulin in use beyond the recommended time frame of use after opened was the medication may be not as effective. During an interview on [DATE] at 9:44 a.m., the DON said the nurses were responsible for the removal of Lispro insulin on the nurses' medication cart, 28 days after the open date. He said the ADON was the back up to ensure no insulin, in use beyond the recommended time frame of use after opened, was on the nurse's medication cart and the pharmacy consultant checked random carts monthly for expired medication. He said the nurses were educated on removing expired medication off the nurse's medication cart with [DATE] being the most recent in-service. The DON said Resident #4 and #31's Lispro kwick insulin pens, in use beyond the recommended time frame of use after opened, were overlooked and should have been removed. He said the resident risk of insulin in use beyond the recommended time frame of use after opened was the medication may not be as potent as it should be. The DON said his expectation was all insulin removed at the beyond use date off the nurse's medication cart. During an interview on [DATE] at 10:12 a.m., the Administrator said the nurse administrating a resident's medication was responsible for ensuring insulin was removed after the beyond use date from the nurse medication cart, and the ADON and DON were the back up to double check. He said the nurses were educated to remove expired medication from their medication cart. He said the expired insulins were overlooked. The Administrator said the resident risk of insulin in use beyond the recommended time frame of use after opened was medication may not be as effective. He said his expectation was the nurses monitor the medication cart and remove all expired medication immediately. Record review of a facility policy titled, Medication Labeling and Storage revised February 2023 indicated, 3. If the facility has discontinued, outdated, or deteriorated medication or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. Record review of a facility in-service titled, Pre-Survey Inservice dated [DATE] indicated, . Carts and {Medrooms} . Discontinued and expired meds removed Insulin Storage for Nursing Carts . Insulin type . Humalog, U- 100, U - 200 (Lispro) pens, vials, refillable pens . expiration dated once opened . 28 days . Record review of a web site titled, Humalog, insulin lispro injection 100 units/ ml Accessed on [DATE], https://insulins.lilly.com/ indicated, .used for the control of high blood sugar, . once opened, Humalog vials, prefilled pens, and cartridges should be thrown away after 298 days even if it still contains insulin.

Based on observation, interview, and record review the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted professional principles for 1 of 2 medication carts (medication aide cart for the second floor) reviewed for pharmacy services. The facility failed to ensure a bottle of morphine sulfate in a medication cart on the second floor was labeled properly in accordance with professional principles for Resident #8 on 1/13/2025. The bottle had a label without any writing on it. This failure could place residents at risk for adverse effects and improper administration of medications. Findings include: Record review of an Admission Record for Resident #8 dated 1/14/2025 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of Alzheimer's Disease, hypertensive heart disease (a condition where high blood pressure makes the heart work harder) and spondylosis (arthritis that affects the neck and low back). Record review of active physician orders for Resident #8 dated 1/14/2025 indicated an order for morphine sulfate oral solution 20 mg/ml give 0.25 ml by mouth every 3 hours as needed for pain that started on 8/28/2024. Record review of a Quarterly MDS Assessment for Resident #8 dated 12/31/2024 indicated she had severe impairment in thinking with a BIMS score of 6. She required substantial/maximal assistance with personal hygiene and showering/bathing. She required set up or clean-up assistance with eating. During the 5 day look back period she did not receive any PRN pain medication. Record review of a care plan for Resident #8 dated 10/7/2022 indicated she was on hospice services related to Alzheimer's. Interventions included to administer pain medication as ordered. During an observation of the medication cart for the second floor on 1/13/2025 at 10:32 AMMA A was present and a narcotic count was conducted with the State Surveyor and MA A. A bottle of morphine sulfate 100 mg/5 ml was in a clear, plastic bag prescribed to Resident #8. The plastic bag was labeled with the resident's name, dosage, date filled, expiration date, pharmacy information, prescribing physician, and quantity of the medication. The medication bottle inside of the plastic bag had a label but the label was blank without any writing on it. During an interview on 1/13/2025 at 10:34 AM, MA A said she had been employed at the facility since September 2024 and worked 6 am - 2 pm. She said medication bottles should have labels on them and the bottle of morphine for Resident #8 did not. She said normally the bottles of morphine were in boxes that were placed inside of a plastic bag and the bag along with the box would be labeled. She said she was not aware the bottle did not have a label. She said during the narcotic counts conducted with other staff, she would ensure the quantity of the medication was correct but never noticed that the label did not have any writing on it. She said she would let LVN B know about the medication. She said she had never given Resident #8 any of the morphine and the only time the medication was administered was during the evening shift. She said if a medication was not labeled properly, the resident could potentially be given the wrong dose or medication. During an interview on 1/13/2025 at 10:38 AM, LVN B said she had been employed at the facility for a year and worked 6 am - 6 pm. She said she was not aware of the morphine for Resident #8 not having a label on the bottle. She said the bottle should have a label that included the prescriber, resident's name, date prescribed, date of birth, route, and directions. She said normally if morphine came from the facility pharmacy, it would be in a box. She said the bottle of morphine for Resident #8 came from the hospice pharmacy. She said the facility would place the box in a zip lock bag as a safety net. She said if the sticker fell off the bottle, staff would not have any idea of what the medication was and could potentially cause a medication error. She said she contacted hospice to notify them as the medication was dispensed through the hospice pharmacy and they would take care of it. During an interview on 1/14/2025 at 12:07 PM, the ADON said the medication aides were responsible for checking the medication carts weekly to ensure medications were properly labeled. She said she was aware of the bottle of morphine for Resident #8 that was found in the medication cart that was not labeled properly. She said Resident #8 received the morphine prn and had not received it since September 2024. She said medications should be labeled with the name of the resident, date it was filled, route to be given, and dosage to confirm how to be given. She said residents could be at risk of a medication error if medications were not labeled properly. During an interview on 1/14/2025 at 12:37 PM, the DON said the medication aides were responsible for checking the medication carts at least weekly. He said medication bottles should have labels that included identifier information for the residents that included date filled, route, dose, and time to be given. He said he was made aware of the bottle of morphine for Resident #8 that was found on yesterday 1/13/2025. He said the facility started an in-service with the nurses and medication aides for proper labeling of medications. He said residents could be at risk for medication errors if medications were not labeled properly. Record review of a facility in-service dated 1/13/2025 titled Medication Aides and Nurses indicated that if medications had missing/incomplete, improper, or incorrect labels they were to immediately contact the pharmacy for instruction. The DON conducted the training. During an interview on 1/14/2025 at 1:36 PM, the Administrator said the medication aides along with the charge nurses were responsible for checking the medication carts at least weekly. He said his expectations were to make sure staff were following the proper policy and procedures. He said if staff were not able to see a label on a prescription, then a resident could be given the wrong medicine. Record review of a facility policy titled Medical Labeling and Storage revised February 2023 indicated, .Medication Labeling, 1. Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. 2. The medication label includes, at a minimum: a. medication name (generic and/or brand); b. prescribed dose; c. strength; d. expiration date, when applicable; e. residents' name; f. route of administration; and g. appropriate instructions and precautions. 8. If medications containers have missing, incomplete, improper, or incorrect labels, contact the dispensing pharmacy for instruction regarding returning or destroying these items. 10. Only the dispensing pharmacy may label or alter the label on a medication container or package .

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen. *An uncovered and unlabeled personal use cup was stored in refrigerator #1. *Food items were not properly labeled with product and expiration date in refrigerator #2. *Food items were uncovered and exposed to air in the walk-in freezer. These failures could place residents who consumed food prepared by staff in the kitchen at risk of cross contamination and food-borne illnesses. Findings included: During the initial tour of the kitchen on [DATE] at 08:25 a.m., the following was observed: *One unlabeled/uncovered personal cup with a straw containing a white slushy substance in refrigerator #1; *One unlabeled single serve container of shredded cheese and one unlabeled single serve container of sour cream in refrigerator #2; *One open plastic bag of link sausages in the walk-in freezer. During an interview on [DATE] at 8:54 a.m., the DM said all foods should be properly labeled and dated and no personal food or drinks should be stored in the kitchen refrigerators. He said not labeling and dating food containers could result in serving expired foods to residents. He said storing an uncovered personal cup in the kitchen refrigerator could cause cross contamination of the other foods. He said all food items in the freezer should be tightly closed to prevent the foods from cross contamination and possible spoiling of the food. He said he was a certified dietary manager and all workers in the kitchen had their food handler's certification. During an interview on [DATE] at 4:26 p.m., the Administrator said he expected all foods stored in the kitchen to be labeled, dated, and stored appropriately according to the facility's Food and Supply policy. He said the DM's direct supervisor was the Dietary Management Supervisor. During a telephone interview on [DATE] at 6:13 p.m., the Dietary Management Supervisor said he was the DM's supervisor. He said he expected all foods stored in the refrigerator to be labeled and dated. He said not labeling and dating foods could result in food being served after the expiration date and could cause food-borne illness. He said no personal items should be stored in the refrigerators. He said all food in the freezer should be tightly closed to avoid freezer burn or changes to the taste and texture of the food. Record review of a Food and Supply Storage policy revised [DATE] indicated All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. The policy further indicated.Cover, label, and date unused portions and open packages. Record review of the 2022 Food Code dated [DATE] indicated ,d+[DATE].17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date. Date marking is the mechanism by which the Food Code requires active managerial control of the temperature and time combinations for cold holding. Industry must implement a system of identifying the date or day by which the food must be consumed, sold, or discarded. Date marking requirements apply to containers of processed food that have been opened and to food prepared by a food establishment, in both cases if held for more than 24 hours, and while the food is under the control of the food establishment. This provision applies to both bulk and display containers. It is not the intent of the Food Code to require date marking on the labels of consumer size packages. A date marking system may be used which places information on the food, such as on an overwrap or on the food container, which identifies the first day of preparation, or alternatively, may identify the last day that the food may be sold or consumed on the premises. A date marking system may use calendar dates, days of the week, color-coded marks, or other effective means, provided the system is disclosed to the Regulatory Authority upon request, during inspections.

Based on interview and record review, the facility failed to ensure that each employee received the required training that at a minimum educated staff on dementia management for 2 of 13 employees (Maintenance Director and Housekeeping Supervisor) reviewed for required annual trainings. The facility did not ensure dementia management training was completed by the Maintenance Director and Housekeeping Supervisor. This failure could place residents with dementia at risk of a poor quality of care by staff with inadequate training when caring for dementia residents. Findings included: Record review of employee file for the Maintenance Director indicated a hire date of 02/21/16. Record review of the training transcript for February 2023 through February 2024 indicated the Maintenance Director had not completed any training for dementia management. Record review of employee file for the Housekeeping Supervisor indicated a hire date of 12/13/94. Record review of the training transcript for February 2023 through February 2024 indicated the Housekeeping Supervisor had not completed any training for dementia management. During an interview on 02/21/24 at 05:30 p.m., the HR staff and Administrator said all staff were to complete required trainings. The HR staff said she tried to keep up with the trainings. They were not able to locate the appropriate training.

Based on observation, interview, and record review, the facility failed to maintain clinical records on each resident in accordance with accepted professional standards and practices that were complete and accurately documented for 2 of 17 residents (Residents #7 and #28) reviewed for accuracy of clinical records. The facility did not ensure the wound assessments for Residents #7 and #28 were completely and accurately documented. This failure could place residents at risk of not receiving care and services to meet their needs. Findings included: 1. Record review of physician orders dated February 2024 indicated Resident #7 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included dementia (a loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), pulmonary fibrosis (a lung disease that occurs when lung tissue becomes damaged or scarred), and deep tissue injuries (DTI) (pressure ulcer defined as purple or maroon localized area of discolored intact skin or a blood-filled blister due to damage of underlying soft tissue from pressure and/or sheer) to bilateral heels. Orders indicated to paint bilateral heels with betadine daily and leave open to air. Record review of a significant change MDS assessment dated [DATE] indicated Resident #7 had moderate cognitive impairment, required substantial/maximal assistance with ADLs, was at risk for developing pressure injuries, and had been admitted to hospice services. Record review of a care plan dated 12/27/23 indicated Resident #7 had a DTI to her left heel. The care plan was revised on 02/20/24 to indicate the wound was classified as unstageable (a full-thickness pressure injury in which the base is obscured by slough and/or eschar [tissue that is typically dead, dry, black, & firm]). Record review of a wound evaluation dated 02/15/24 indicated Resident #7 had a DTI to her left heel. The picture of the left heel showed an area of blackened tissue. The wound evaluation was revised on 02/20/24 to indicate an unstageable pressure injury to the left heel due to covering of eschar. During an observation and interview on 02/20/24 at 1:43 p.m., the Treatment Nurse painted Resident #7's left heel with betadine and left it open to air to dry. She said she thought the blackened area was eschar tissue, but the ADON assessed and staged wounds. She said she was currently attending training for wound care certification and had been the Treatment Nurse at the facility for 2 months. During an interview on 02/21/24 at 2:29 p.m., the ADON said the Treatment Nurse had notified her of a change to Resident #7's wound on 02/20/24. She said she then assessed the wound, notified the physician of the change, wrote a nurse's note indicating the wound status change, and revised the wound evaluation dated 2/15/24 changing the wound stage from DTI to unstageable. She said she should have written a new wound evaluation dated 02/20/24 instead of revising the evaluation dated 02/15/24 because that note should reflect the assessment of the wound on 02/15/24. She said she was certified in wound care since 2022. She said she assessed wounds weekly and audited wound evaluations weekly for accuracy after assessments. She said inaccurate wound documentation could result in wound deterioration. 2. Record review of a face sheet indicated Resident #28 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included congestive heart failure (a condition in which the heart's main pumping chamber is weak, becomes stiff, and is unable to fill properly). Record review of the care plan dated 08/14/23 indicated Resident #28 had a Stage 2 pressure injury to the intergluteal cleft (deep [NAME] or groove that lies between the two gluteal regions (commonly known as the buttocks)). Record review of the care plan dated 10/17/23 indicated Resident #28 had a Stage 2 shearing (two surfaces move in the opposite direction) pressure injury to the left gluteal cheek (buttock). Record review of Progress Notes Skin Only Evaluation entries for Resident #28 indicated Skin Issue #001: * on 12/22/23 had no change and she had a stage 2 pressure ulcer/injury to the right buttock; * on 12/29/23 had no change and she had a stage 2 pressure ulcer/injury to the right buttock; * on 01/05/24 had no change and she had a stage 2 pressure ulcer/injury to the right buttock; * on 01/12/24 had no change and she had a stage 2 pressure ulcer/injury to the right buttock; * on 01/19/24 had no change and she had a stage 2 pressure ulcer/injury to the right buttock; * on 01/26/24 had no change and she had a stage 2 pressure ulcer/injury to the right buttock; * on 02/02/21 had no change and she had a stage 2 pressure ulcer/injury to the right buttock; and * on 02/09/24 had no change and she had a stage 2 pressure ulcer/injury to the right buttock. Record review of Progress Notes with a Wound entry note dated 02/15/24 indicated Resident #28 had a wound to the sacrum, 3.3 cm length by 4.4 cm width by 0.1 cm depth, unstageable, and beefy red color covered with slough. Record review of physician orders as of 02/20/23 indicated Resident #28 had an order dated 02/15/24 to clean left sacral/coccyx wound. Record review of a Skin and Wound Evaluation form dated 02/15/24 indicated Resident #28: * had an unstageable (wound with slough (white/yellow stringy or thick substance)/eschar (tan, brown, or black dead tissue) obstructing the wound bed) pressure ulcer; * it was located on the left gluteus (muscle that makes up the buttocks) * with 20% granulation (pink/red, moist, shiny tissue that glistens and is composed of new blood vessels, connective tissue, fibroblasts, and inflammatory cells that fills an open wound when it begins to heal) * with 80% slough, and * had no eschar. Record review of a Wound Evaluation dated 02/15/24 indicated Resident #28: * had an unstageable pressure ulcer; * was located on the left gluteus; and * with the wound bed having 20% granulation and 80% slough. Record review of a Skin Only Evaluation form dated 02/16/24 indicated Resident #28 on the right buttock. Record review of Progress Notes a Skin Only Evaluation entry for Resident #28 indicated on 02/16/24 Skin Issue #001 had no change and she had a stage 2 pressure ulcer/injury to the right buttock. During an observation and interview on 02/20/24 at 11:45 a.m. the Treatment Nurse provided wound care to Resident #28. The resident only had one wound and it was located on the left upper buttock near the sacral area. When the resident skin was pulled to expose the wound better, it appeared to be on the sacral area. The wound base was partially covered with dull yellow colored stringy tissue but there was a small portion of red beefy looking tissue. There was no presence of eschar. The wound had a small amount of blood coming from it. The Treatment Nurse said with the way Resident #28's skin would move it was not easy to determine the exact location of the wound. During an interview on 02/21/24 at 2:26 p.m., the DON said the wound evaluation dated 02/15/24 should not have been altered and a new wound evaluation should have been completed. He said all wound care notes were audited weekly by he and the ADON. He said the ADON did all wound evaluations because she was wound care certified. He said possible negative outcome of wound stage or status being documented incorrectly could be wound deterioration. Record review of the facility policy titled Charting and Documentation last revised July 2017, indicated All services provided to the resident, progress toward care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. According to the National Pressure Ulcer Advisory Panel's Clinical Practice Guideline dated April 2016 accessed at https://npiap.com/page/2019Guideline: Classification of Pressure Injuries: .Pressure injury classification is based on the visual and palpatory identification of tissues including skin, subcutaneous fat, bone, muscle, tendon, and ligament. Necrotic tissue (slough and eschar) appears in full-thickness pressure injuries. Granulation tissue becomes present as a full-thickness pressure injury heals. In contrast, Category/Stage II pressure injuries do not have necrotic tissue and heal with epithelialization rather than granulation tissue. Healing tissues include scar, granulation tissue, and epithelium The description of a pressure injury should be supplemented with other findings. Indicating the exact anatomical location of the pressure injury is important, including clearly identifying location over a bony prominence as applicable NPUAP Classification System (April 2016): Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss: Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration: Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions 36214

Based on interview and record review, the facility failed to ensure preadmission screening for individuals identified with MI, DD, or ID were evaluated for services for 1 of 17 residents reviewed for PASRR (Residents #17). The facility did not have an accurate PASRR level 1 screening for Residents #17 upon admission therefore a PASRR Evaluation was not conducted. This failure could place residents who have a diagnosis of mental disorder, developmental disability, or intellectual disability at risk for a diminished quality of life and not receiving necessary care and services in accordance with individually assessed needs. Findings included: Record review of a face sheet dated 02/20/24 indicated Resident #17 was an [AGE] year-old female admitted [DATE], and readmitted [DATE], with diagnoses of major depressive disorder (mental disorder characterized by persistent hopelessness, disinterest in and lack of enjoyment of normal activities, and prolonged sadness that affects people on a daily basis and can be recurring) as of 07/03/23, cerebral infarct (stroke/ disruption of blood flow to the brain), dementia (loss of cognitive function) and anxiety (a feeling of fear, dread, and uneasiness). Record review of PASRR level 1 screening completed by the transferring facility dated 07/06/23 indicated Resident #17 was negative for mental illness, intellectual disability, and developmental disability. No PASRR Level II Screening or Form 1012 (Mental Illness/Dementia Resident Review) was found in the clinical record from 07/06/23 through 02/19/24. Record review of an admission MDS dated [DATE] indicated Resident #17 had a BIMS score of 15 indicating cognitively intact, was negative for PASRR, and had a diagnosis of depression and received medication for depression during the look back period. Record review of a care plan revised 01/26/24 indicated Resident #17 was currently taking psychotropic medication including an antidepressant medication and required monitoring for side effects and effectiveness. Record Review of physician's orders dated 02/19/24 indicated Resident #17 was prescribed Remeron (an antidepressant medication) 15 mg daily for major depressive disorder with a start date of 1/18/24. During an interview on 02/19/24 at 4:00 p.m. the MDS nurse said she was responsible for completing all PASRR forms including the PL1. She said she had worked at the facility for 8 years. She said she did not have a backup with the PASRR process. She said she had been educated on the PASRR process and had been updated at times. The MDS nurse said the DON and the ADON look at the resident diagnoses on admission for PASRR positive diagnoses. She said she was unaware that the diagnosis of major depressive disorder should have been a positive MI diagnosis for PASRR. During an interview on 02/20/24 at 3:30 p.m. the MDS nurse said Resident #17's PL1 was incorrect. She had completed a 1012 form after the state surveyor intervention on 02/20/24 and was waiting for the physician signature, but she should have completed one sooner. The MDS nurse said the risk of an incorrect PL1 was not a risk to the resident. She said the risk was having an incorrect form, she said she rarely saw residents receive services regardless of diagnosis. During an interview on 02/20/24 at 4:50 p.m., the ADON said she had received no education on PASRR forms. She said the MDS nurse was responsible for PASRR forms. The ADON said her expectation was for all PASRR forms to be completed accurately and timely. During an interview 02/20/24 at 4:53p.m., the Administrator said his expectation was for all PASRR forms to be completed accurately and timely. He said the MDS nurse was responsible for PASRR forms, and the DON and Corporate Clinical Reimbursement Nurse were the back up. During an interview on 02/21/24 at 2:30 p.m., the DON said his expectation was all PASRR forms to be completed accurately and timely. He said the MDS nurse was responsible for PASRR forms, and the Corporate Clinical Reimbursement Nurse was the backup. He said Resident #17's PASRR form should have been completed accurately and timely or a resident may miss out on services. During an interview on 02/21/24 at 3:27 p.m., the Corporate Clinical Reimbursement Nurse said she could be the backup if the facility needed help, but she had never had to do it. She said she did biweekly Medicaid triple checks on MDS, she looks at LTCMI, and PASRR but she did not double check the MDS nurse's work. She said she did train on PASRR as needed. The Corporate Clinical Reimbursement Nurse said major depressive disorder diagnosis was a diagnosis positive for PASRR and she would do training with her other buildings to make sure they were all aware of it. Record review of a facility policy, revised March 2019, titled, Admission Criteria indicated, .9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-Admission Screening and Resident Review (PASRR) process. b. If the level 1 screen indicated that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASRR represented for the Level II (evaluation and determination screening process. (1) The admitting nurse notifies the social services department when a resident is identified as having a possible (or evident) MD, ID, or RD. Record review of the October 2023 Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual titled, A1500: Preadmission Screening and Resident Review (PASRR) Item Rationale Health-related Quality of Life indicated . o All individuals who are admitted to a Medicaid certified nursing facility, regardless of the individual's payment source, must have a Level I PASRR completed to screen for possible mental illness (MI), intellectual disability (ID), developmental disability (DD), or related conditions o Individuals who have or are suspected to have MI or ID/DD or related conditions may not be admitted to a Medicaid-certified nursing facility unless approved through Level II PASRR determination. Those residents covered by Level II PASRR process may require certain care and services provided by the nursing home, and/or specialized services provided by the State.

Based on observation, interview, and record review, the facility failed to ensure that the residents' environment remained as free of accident hazards as was possible for 1 of 17 (Resident #12) residents reviewed for hazards. The facility failed to ensure an oxygen cylinder (a tank that contains oxygen) in Resident #12's room was properly stored. This failure could place the residents at risk of accidents or injury. The findings included: Record review of an admission sheet dated 02/19/24 indicated Resident #12 was admitted on [DATE], was [AGE] years old with diagnoses of chronic obstructive pulmonary disease (COPD -a lung disease) and dementia. Record review of the annual MDS assessment dated [DATE] indicated Resident #12 had severely impaired cognition and required assistance of 1 staff for bed mobility and transfer. She received oxygen therapy while at this facility and during the last 14 days. Record review of care plan dated 01/28/23 indicated Resident #12 had COPD interventions included 02 via nasal cannula as needed. Record review of physician orders dated February 2024 indicated Resident #12 orders included an order for 02 at 2 LPM, 3LPM, 4 LPM or 5LPM as needed for shortness of breath. During an observation on 02/19/24 at 10:00 a.m., Resident #12's room had an 02 cylinder under the bed. The 02 cylinder was between the wheels of the bed and the wall, positioned horizontally. The 02 cylinder was not in a cart or secured. The cylinder was about 4 inches by about 30 inches. During an observation on 02/20/24 at 11:25 a.m., Resident #12 was in bed with 02 in progress per the concentrator. The portable 02 cylinder was still on the floor, under Resident #12's bed, between the wall and the wheels of the bed. During an observation and interview on 02/20/24 at 11:27 a.m., Unit Manager B said all tanks/cylinders should be secured and not on the floor as she removed the O2 cylinder from Resident #12's room. She stated, all of the staff were responsible to remove any hazardous items from the resident's room. The Unit Manager said the nurse was responsible for ensuring the 02 cylinder, when brought to the room on a cart, or in a bag on the wheelchair. She said all nurses are trained on hire about oxygen. During an interview on 02/20/24 at 11:30 a.m., the ADON said all the nurses were trained on hire to secure 02 on wheelchair carts or in the 02 closet in the rack. She said the cylinder could be damaged by the wheels of the bed and for fire safety 02 cylinder must be stored properly. During an interview on 02/20/24 at 11:45 a.m., LVN C said she was unaware the 02 cylinder was under Resident #12's bed and should have been in the 02 closet when not in use. During an interview on 02/21/24 at 10:30 a.m., the DON said the 02 cylinder should not be under the beds in the residents' rooms and he said his expectation was for the 02 cylinders to be stored in the 02 closet. Record review of the policy titled Fire Safety and Prevention dated May 2011 indicated All personnel must learn methods of fire prevention and must report condition (s) that could result in a potential fire hazard. Oxygen Safety: . f. Store oxygen cylinders in racks with chains. Sturdy carts or approved stands. Do not store oxygen cylinders in any resident room or living area.

Based on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs when used without adequate monitoring for 1 of 17 residents (Resident #256) reviewed for unnecessary medication. The facility failed to monitor Resident #256 for side effects from 02/05/24 to 02/20/24 of the anticoagulant medication Eliquis (a blood thinning medication). This failure could place residents at risk for adverse consequences such as bleeding, bruising, and black colored stools related to the use of the anticoagulant medication. Findings included: Record review of Resident #256's face sheet, dated 02/20/24, indicated an [AGE] year-old female who was admitted to the facility on [DATE] with a diagnosis which included an intertrochanteric fracture of left femur (left sided hip fracture). Record review of an admission MDS assessment, dated 02/09/24, indicated Resident #256 had a BIMS score of 12, which indicated moderately impaired cognition. Resident #256 had a diagnosis of hip fracture and received an anticoagulant medication during the look back period. Record review of a care plan, initiated 02/16/24, indicated Resident #256 received an anticoagulant medication, with interventions which included medications administered as ordered and monitored for side effects and effectiveness. Record review of physician orders dated February 2024, indicated Resident #256 was prescribed Eliquis 2.5 mg two times a day for deep vein thrombosis prophylaxis (blood clot in a deep vein usually legs preventive) with a start date of 02/05/24. The orders did not address monitoring the anticoagulant medication. Record review of a MAR, dated 02/1/23, indicated Resident #256 received Eliquis 2.5 mg two times a day from 02/05/24 to 02/20/24 with a start date of 02/05/24. Record review of the electronic record for Resident #256 from 02/02/24 to 02/20/24 indicated the nurses did not document monitoring of side effects of the anticoagulant medication daily with medication administration. During an interview and observation on 02/19/24 at 11:00 a.m., Resident #256 said she gets a blood thinner, Eliquis, but had no bleeding or bruising issues. During an interview on 02/21/24 at 11:10 a.m., LVN A said she was assigned to provide care for Resident #256. She said Resident #256 was on an anticoagulant and should be monitored but was not. She said the admission nurse was responsible for ensuring the monitoring was added into the computer system. She said it was overlooked. LVN A said the ADON, and the DON were the backup to double check physician orders for monitoring and accuracy. She said she was educated on monitoring of anticoagulants. LVN A said the risk of not monitoring an anticoagulant was potential bleeding or too much coagulant. During an interview on 2/21/23 at 11:18 a.m., Unit Manager B said the admission nurse was responsible to input monitoring for the anticoagulant medication into the computer system. She said herself, the ADON, and the DON were responsible to double check orders to ensure accuracy. She said Resident #256 should have been monitored for anticoagulant medication and was not. She said the staff were educated on monitoring anticoagulant medication and putting it into the computer system. She said it was overlooked. Unit Manager B said the risk of not monitoring anticoagulant medication was the risk of bleeding. During an interview on 2/21/24 at 11:50 a.m., the ADON said the admitting nurse was responsible to input the monitoring for anticoagulant medication into the computer system. She stated her and the DON were responsible for double checking the orders for accuracy and ensuring anticoagulants were monitored. She said she put Resident #256's anticoagulant order in the computer system and overlooked the monitoring. She said the staff were educated on ensuring anticoagulants were monitored. The ADON said the risk of not monitoring anticoagulants was increased bleeding, black tarry stools, and complications of bleeding with falls. During an interview on 2/21/24 at 2:11 p.m., the DON said his expectation was monitoring to be put in the system when the order was placed into the system. He said they had standing orders for monitoring. The DON said the admission nurse was responsible to input monitoring for anticoagulant medication into the system. He stated that himself and the ADON were responsible for double checking to ensure monitoring was put into the system. He said the ADON had overlooked putting the monitoring in for Resident #256. The DON said the risk of not monitoring anticoagulants was bleeding, complications, scrapes, and bruises. During an interview on 2/21/24 at 2:18 p.m., the Administrator said his expectation was for any medication that required monitoring to be monitored. He said the charge nurse was responsible for monitoring and the DON was ultimately responsible. Record review of a policy revised November 2018, titled, Anticoagulation- Clinical Protocol indicated, .Monitoring and follow up . 5. The staff and physician will monitor for possible complications in individuals who are being anticoagulated and will manage related problems. a. If an individual on anticoagulant therapy shows signs of excessive bruising, . or other evidence of bleeding, the nurse will discuss the situation with the physician before giving the next scheduled dose . Record review of the Reference obtained from the internet on 10/12/23 from, How Rx ELIQUIS(R) (apixaban) Can Help | Safety Info (bmscustomerconnect.com) indicated, . ELIQUIS can cause bleeding, which can be serious, and rarely may lead to death. This is because ELIQUIS is a blood thinner medicine that reduces blood clotting. While taking ELIQUIS, you may bruise more easily, and it may take longer than usual for any bleeding to stop. Call your doctor or get medical help right away if you have any of these signs or symptoms of bleeding when taking ELIQUIS: *unexpected bleeding or bleeding that lasts a long time, such as unusual bleeding from the gums, nosebleeds that happen often, or menstrual or vaginal bleeding that is heavier than normal *bleeding that is severe or you cannot control *red, pink, or brown urine; red or black stools (looks like tar) *coughing up or vomiting blood or vomit that looks like coffee grounds *unexpected pain, swelling, or joint pain *headaches, or feeling dizzy or weak

Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and distributed under sanitary conditions in 1of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure the dish machine tested at the required 50-100 PPM and the water temperature reached the required 120 degrees Fahrenheit required for proper sanitation in a low temperature, chemical sanitizer dish machine. These failures could place the residents at risk of foodborne illnesses. Findings include: During an observation and interview on 01/09/23 at 10:13 A.M., the DA, ran the dish machine to get the water temperature to the required 120 degrees F for proper sanitation in a low temperature, chemical sanitizer dish machine. The water temperature was 114 degrees F. She then took a chemical sanitizing test strip and dipped it into the water of the dish machine. The test strip indicated 10 ppm. The DA had been washing the breakfast dishes and the calendar on the wall indicated she had tested the dish machine at the start of her shift on 01/09/23 and the water temperature was 113 degrees F, and the chemical sanitation level was at 50 ppm. The Dining Service Director made three additional attempts to test the machine, and recalibrated the machine, getting air bubbles out of the liquid sanitizer line. The sanitizer tested at 50 PPM, but the water temperature was still low at 114 degrees F. A calendar dated January of 2023 indicated: Water Temperature in degrees F: Breakfast: Lunch: Dinner: 1st-120 118 100 2nd-113 118 115 3rd-112 116 118 4th-116 118 118 5th-113 118 0 6th-115 116 118 7th-113 118 116 8th-115 117 118 9th-113 120 121 10th-122 During an interview on 01/09/23 at 10:20 AM, the DA said she had worked at the facility for 3 years and was trained by a Chef, who was no longer at the facility. The DA said she told the Dining Service Director that the machine was not getting the water hot and the technician came and looked at it about a week and a half ago but did not fix it. The DA said the residents could get sick if the dish machine was not sanitizing the dishes properly. During a record review on 01/09/23 at 10:30 PM of the January calendar the lowest temperature recorded was 112 degrees F. and the highest was 116 degrees F. which did not meet the required water temperature of 120 degrees F. for a low temperature machine. During an interview on 01/09/23 at 11:00 AM the Dining Service Director said it was his responsibility to train his staff to test the dish machine correctly and notify him, or maintenance when the water temperature does not meet the required 120 degrees F and the sanitizer does not reach 50-100 PPM. During an interview on 01/11/23 at 2:02 PM, the ADM said going forward, he expected the staff to check the machine every shift and notify the Dining Service Director if the machine does not reach the required water temperature of 120 degrees F and sanitation level of 50-100 PPM. He said there would be additional training for the staff on testing the machine. A POLICY # F019: Sanitation and Infection Prevention/Control Subject: Dishwashing Temperatures Revised January 2022 indicated: LOW TEMPERATURE DISHWASHER (Chemical Sanitation): *Wash 120 F; and * Final Rinse 50 ppm (parts per million) hypochlorite (chlorine) on dish surface in final rinse. The chemical solution must be maintained at the correct concentration, based on periodic testing, at least once per shift, and for the effective contact time according to manufacturer's guidelines. The wash period shall be at least 40 seconds with a temperature of 120 degrees F in dish machine. The sanitizing rinse period shall be at least 20 seconds with minimum temperature of 120 degrees. h. Facilities shall use an approved test kit to measure the parts per million (ppm) of the chemical solutions in the low temperature dish machine daily. Any abnormal test results shall be reported to the CMD. A ppm of 50 will be attained prior to dishes being washed.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 5 residents reviewed for infection control. (Resident #9, Resident #23, and Resident #56) 1. CNA A did not wash or sanitize her hand when changing gloves while performing incontinent care for Resident #9. 2. CNA B and LVN E did not wash or sanitize their hands when changing gloves while performing incontinent care for Resident #56. 3. CNA C and CNA D did not wash or sanitize their hands when changing gloves while performing incontinent care for Resident #23. These failures could place residents at risk of exposure to communicable diseases and infections. Findings included: 1. Record review of a Face Sheet dated 01/10/2023 for Resident #56 indicated he admitted to the facility on [DATE] and was [AGE] years old. His diagnoses included cerebral infarction (a lack of adequate blood supply to the brain), dysphasia (unable to swallow food or liquids), metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), urinary tract infection, moderate protein-calorie malnutrition (means you are not receiving enough protein or calories), cognitive communication deficit (difficulty with thinking and how someone uses language) and gastrostomy status (feeding tube in the stomach), benign prostatic hyperplasia (prostate gland enlargement that can cause urination difficulty). Record review of a care plan, dated 9/30/2022 for Resident #56, indicated he had urinary incontinence with an approach to provide extensive to total assistance by 1 staff for incontinent care. Record review of a Quarterly MDS assessment dated [DATE] for Resident #56 indicated he was interviewable with a BIMS score of 12. He required total dependence with one-person physical assist with bed mobility, transfer, dressing, toilet use and personal hygiene. He was always incontinent of bowel. Bladder was not rated due to having suprapubic catheter in place. During an observation on 1/10/2023 at 10:10am in Resident #56 room revealed, CNA B and LVN E were present to provide incontinent care. Both staff washed their hands in the bathroom in Resident #56's room and applied gloves. CNA B and LVN E positioned Resident #56 in supine position then turned him on his left side to perform his incontinent care. LVN E removed the Velcro fastener on the right side of residents brief and rolled the brief to the residents left back side. LVN E removed a wipe from a container and cleaned his rectal area wiping from front to back, LVN E repeated this step 6 times until residents' rectal area did not have and visible bowel movement. LVN E placed the wipes in the trash bag leaving soiled brief in place and LVN E unrolled a clean brief and placed at residents' buttocks area. LVN E then performed wound care to wounds on sacrum. After completing wound care without changing gloves, sanitizing, or washing hands LVN E repositioned clean brief to buttocks area and pushed the soiled brief under residents left hip and placed her hands on residents' right hip to guide resident to roll onto clean brief. CNA B reached under resident to remove soiled brief and wrapped soiled brief and attached Velcro fasteners around brief to secure it and placed it in the trash bag, without changing gloves, sanitizing, or washing hands CNA B applied Velcro strips on clean brief on residents left side to secure brief around resident. LVN E and CNA B then adjusted residents clothing, bed linens and pulled resident up in bed without changing gloves, sanitizing, or washing hands. LVN E and CNA B then doffed their gloves and washed their hands in resident's bathroom before exiting resident's room. During an interview on 1/10/23 at 11:11 AM, LVN E said she had been employed at the facility for about 2 years as ADON and treatment nurse. When she was asked if she would have done anything differently with the incontinent care provided to Resident #56, she said she should not have touched dirty and clean briefs with the same gloves. She says she should have changed gloves and washed hands after performing incontinent care. She stated she received multiple in-services and trainings related to handwashing, PPE, and brief sizing. She said residents could be at risk of an infection if they did not wash or sanitize their hands when changing their gloves. During an interview on 1/10/23 at 11:11 AM, CNA B said she had been employed at the facility as the restorative CNA. When asked if she would have done anything differently with the incontinent care provided to Resident #56, she said she would admit that she messed up and she should not have touched dirty and clean briefs with the same gloves. She says she should have changed gloves and washed hands after performing incontinent care. She stated she received multiple in-services and trainings related to handwashing, PPE, and brief sizing. She said residents could be at risk of an infection if they did not wash or sanitize their hands when changing their gloves During an interview on 01/10/2023 at 10:23 AM, DON said he expected hand washing to be done between anything soiled. DON said he expected to increase his in-services on hand washing, setting up cart for wound care, not transferring infection from area to the next, and clean versus dirty. She said a resident could be at risk for infections, if staff did not wash or sanitize their hands between gloves changes. 2. Record review of a Face Sheet dated 01/11/2023 for Resident #23 indicated he admitted to the facility on [DATE] and was [AGE] years old. Her diagnoses included Alzheimer's disease (disease that destroys memory and other mental functions), dementia (destroys 2 brain functions), chronic kidney disease Stage 3 (as kidneys fail waste builds up), overactive bladder, chronic Embolism, and thrombosis of unspecified popliteal vein (blood clot in the vein), Obesity (excessive body fat). Record review of a care plan dated 9/28/2022 for Resident #23 indicated he had bowel and bladder incontinence with an approach to provide incontinent care every 2 hours and as needed. Record review of a Quarterly MDS dated [DATE] for Resident #23 indicated she has severe impaired cognition with a BIMS score of 02. She required extensive to total dependence with one-person physical assist with bed mobility, transfer, dressing, toilet use and personal hygiene. During an observation on 1/11/2023 at 10:02am of Resident #23 's room revealed CNA C and CNA D were present to provide incontinent care. Both staff washed their hands in the bathroom in Resident #23's room and applied gloves. CNA C and CNA D positioned Resident #23 in supine position to perform his incontinent care. CNA C removed the Velcro fastener on the sides of residents brief and rolled the brief toward the residents back. CNA C removed a wipe from a container and cleaned her peri area wiping from front to back, CNA C repeated this step 3 times. CNA C and CNA D doffed gloves and placed them in the trash can and doffed new gloves without sanitizing or washing hands. CNA C rolled Resident #23 to her left side with the assistance of CNA D, CNA C removed the soiled brief and handed it to CNA D and CNA D placed soiled brief in trash can. CNA C placed the wipes in the trash. CNA C and CNA D doffed gloves and placed them in the trash can and doffed new gloves without sanitizing or washing hands. CNA C unrolled a clean brief and placed at residents' buttocks area. CNA C attached Velcro fasteners around brief to secure it, without changing gloves, sanitizing, or washing hands. CNA C and CNA D then adjusted residents clothing, bed linens and pulled resident up in bed without changing gloves, sanitizing, or washing hands. CNA C and then doffed her gloves and washed her hands in resident's bathroom before exiting resident's room. CNA D doffed gloves and did not was or sanitize hands before leaving resident's room. During an interview on 1/11/2023 at 10:25 AM, CNA C said, when asked what she would do differently, she said that she would have hand sanitizer with her. She said she would have washed her hands more and, would have had the table closer to her. When asked about infection control CNA C stated that she would have brought hand sanitizer and washed her hands more. During an interview on 1/11/2023 at 10:29 am, CNA D said, when asked if she would do anything differently, no, and that it had been too long since she has done incontinent care for state, then stated that she would have positioned the resident differently. When asked about infection control CNA D stated she would not have done anything differently. 3. Record review of an Admission Record for Resident #9 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of hemiplegia (weakness on one side), hydronephrosis with renal and ureteral calculous (backup of urine in the kidneys), and major depressive disorder (feeling of sadness or loss of interest constantly). Record review of a Quarterly MDS Assessment for Resident #9, dated 12/16/2022, indicated she did not have any impairments in thinking with a BIMS score of 15. She required extensive assistance with 1 person assist in bed mobility, dressing, and personal hygiene. She was totally dependent with toilet use and always incontinent of bowel and bladder. Record review of a care plan for Resident #9, dated 2/9/2019, with a revision on 3/1/2021 indicated a focus that she required assistance with ADL's and transfers. Interventions and tasks included to encourage and assist resident in turning/repositioning/incontinent care every 2 hours and PRN. She had a focus of bowel and bladder incontinence dated 3/31/2019 with a revision on 3/1/2021 with interventions/tasks to check every 2 hours and as required for incontinence. During an observation on 1/10/2023 at 11:10 AM in Resident #9's room with CNA A present. CNA A washed her hands in Resident #9's bathroom and applied gloves to her left hand and 1 glove to her right hand. CNA A pulled the linens back and Resident #9's brief down between her legs. CNA A removed wipes three times from the container and wiped Resident #9's vaginal area on both sides of her inner thighs and down the middle of her vagina. CNA A removed the glove from her right hand and placed it in the trash and placed another glove on her right hand. CNA A rolled Resident #9 to her left side and removed a wipe from the container 5 times and wiped stool front Resident #9's rectum front to back, back to front and on both sides. CNA A rolled brief and placed an under pad under Resident #9's buttocks. CNA A removed gloves from both hands and placed them in the trash. She applied gloves to both hands and placed a clean brief under Resident #9's buttocks. Resident #9 was rolled to her right side and dirty brief and under pad was removed. CNA A rolled the clean under pad, and brief under Resident #9's buttocks. CNA A removed the gloves from both hands and placed them in the trash. CNA A applied gloves to both hands and removed linens from the room and placed them in the dirty linen closet. CNA A washed her hands in the dirty linen closet. During an interview on 1/10/2023 at 11:25 AM, CNA A said she had been employed at the facility for over a year, but only worked prn at the facility. When asked if there was anything she would have done differently with incontinent care, she said would have only wiped from front to back and not in both directions. She said she had received trainings on patient care, incontinent care, and every month the staff at the facility were assigned different topics to complete online. She said she should have washed or sanitized her hands with each glove change. She said a resident could get an infection if staff didn't wash hands with glove changes and wiping a female resident from back to front. During an interview on 1/11/2023 at 11:35 AM, the DON said he had been employed at the facility since July 2022. He said he expected hand washing to be done between anything soiled. DON said he expected to increase his in-services on hand washing, setting up cart for wound care, not transferring infection from area to the next, and clean versus dirty. He said a female resident should be wiped from front to back and that the staff knew that. He said a resident could be at risk for infections if staff did not wash or sanitize their hands between gloves changes. Record review of a facility policy titled Handwashing/Hand Hygiene with a revised date of August 2019 indicated, .1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: m. after removing gloves . Record review of a facility policy titled Perineal Care with a revised date of February 2018 indicated, .The purpose of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritations, and to observe the resident's skin condition. For a female resident: b. Wash perineal area, wiping from front to back. e. Wash the rectal area thoroughly, wiping form the base of the labia towards and extending over the buttocks . 47339

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions in the kitchen. There were two open cartons of chocolate Blue Bell Ice Cream with no label or date. There was a one five-pound carton of sour cream with no label or date. Cook C did not use the three-compartment sink per manufactures recommendations. These failures could place the residents who ate meals prepared in the kitchen at risk for food borne illness. Findings included: During an observation on 11/08/21 at 10:15 a.m., there were two cartons of chocolate Blue Bell Ice Cream, in the ice cream freezer, with no label or date. During an observation on 11/08/21 at 10:20 a.m., there was a five-pound carton of sour cream in the walk-in refrigerator with no label or date. During an observation on 11/09/21 at 11:30 a.m., Cook C was washing dishes in the three-compartment sink. She washed the dishes, rinsed them, and dipped them in the Quaternary Ammonium Compound solution to sanitize, and placed them on the counter to dry. She did not leave the dishes in the Quaternary Ammonium Compound solution for the manufacture's recommended time of one minute. The instructions for the three compartment sink were on the wall over the sink. During an interview on 11/09/2 at 11:35 a.m., with Cook C, she said she had worked at the facility for 3 or 4 months, and she had not been instructed on how to use the three-compartment sink. During an interview on 11/10/21 at 11:27 a.m., a.m., the Dining Service Director said it wasn't one person's job to label and date the food it was everybody's. He said it was his and the Chef's responsibility to teach staff the staff how to use the three-compartment sink, and to label and date the food. He said it was his responsibility to teach them compliance with the rules and regulations. During an interview on 11/10/21 at 11:45 a.m., with the Administrator, he said he expects the dietary staff to follow the Texas Food Establishment Rules and regulations and the Dining Service Director would be in-servicing staff today. Record review of the policy titled, Storage of Food and Supplies, dated December 15, 2020 indicates that open, unused portions and opened packages of food should be covered, labeled, and dated. Complete all sections on date label. Products are good through the close of business on the date noted on the label. There was no policy for three compartment sinks. TFERFieldInspectionManual 015.pdf (texas.gov) accessed 11/17/2021, states After being cleaned, equipment food-contact surfaces and utensils shall be sanitized in: (3) chemical manual or mechanical operations, including the application of sanitizing chemicals by immersion, manual swabbing, brushing, or pressure spraying methods, using a solution as specified under §228.111(n) of this title by providing: 113 §228.118 (3)(a) §228.121 (b) (A) except as specified under paragraph (B) of this subsection, an exposure time of at least 10 seconds for a chlorine solution specified under §228.111(n)(1) of this title; P [10] (B) a contact time of at least 7 seconds for a chlorine solution of 50 mg/L that has a pH of 10 or less and a temperature of at least 38 degrees Celsius (100 degrees Fahrenheit) or a pH of 8 or less and a temperature of at least 24 degrees Celsius (75 degrees Fahrenheit); P [10] (C) a contact of at least 30 seconds for other chemical sanitizing solutions; P [10] or (D) An exposure time used in relationship with a combination of temperature, concentration, and pH that, when evaluated for efficacy, yields sanitization as defined in §228.2(125) of this title (relating to Definitions). P [10]

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 3 residents reviewed for infection control. (Residents # 13, 27, and 38) CNA-E and CNA-F did not wash or sanitize their hands when changing gloves while providing incontinent care for Resident #38. CNA-E touched clean items with contaminated gloves. CNA-G did not wash or sanitize hands when changing gloves while providing incontinent care for Resident #13. Wound care nurse did not wash or sanitize her hands when changing gloves while performing wound care to Resident #27. These failures could place residents at risk of exposure to communicable diseases and infections. Findings included: Record review of the face sheet dated 11/9/2021 for Resident #27 revealed he admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of an Order Summary Report (physician orders) dated 11/9/2021 for Resident #27 indicated a wound care order to cleanse his left second toe with normal saline/wound cleanser, paint heavy with [MEDICATION(S)], cover with [MEDICATION(S)] soaked gauze and wrap in [MEDICATION(S)] every shift. Record review of the Significant Change MDS assessment for Resident #27 dated 9/27/2021 indicated the resident had moderate impairment with cognition and was totally dependent with all activities of daily living and had 2 unhealed stage 4 (full thickness tissue loss) pressure ulcers. He also had 1 venous and arterial ulcers (caused by decreased blood circulation) along with an infection of the foot. Record review of a Care Plan for Resident #27 dated 9/15/2021 indicated he had gangrene to his left second toe related to peripheral arterial disease, vascular insufficiency with an intervention for wound/dressing to observe dressing every shift. Change dressing and record observations of site as ordered. 1. During an observation and interview on 11/9/2021 at 10:10 AM, wound care nurse was observed at the doorway of Resident #27's room prior to performing wound care treatment. She applied gloves and cleaned the over bed table with a Sanidex wipe. She removed the gloves and placed them in the trash and did not wash or sanitize her hands after removing them. She applied gloves, went into the treatment cart, placed a piece of wax paper on the over bed table and placed wound supplies on top of the wax paper. She then removed her gloves and placed them in the trash and went to the restroom of Resident #27's room and washed her hands. She put on gloves before starting wound care on Resident #27's left second toe. She was being assisted by CNA B who was holding Resident's #27's left foot with gloved hands. Wound care nurse cleaned his left second toe with saline soaked gauze, removed gloves and placed in the trash. She did not wash or sanitize her hands before applying another pair of gloves and applied a gauze with [MEDICATION(S)] to Residents #27's left middle toe, removed gloves and placed them in the trash. She did not wash or sanitize her hands before applying another pair of gloves and covered Resident #27's left second toe with a bandage dated 11/9/21, removed gloves and placed them in the trash. She did not wash or sanitize her hands before applying another pair of gloves and went to the treatment cart in the hallway and used a Sanidex wipe to clean the over bed table. She removed the gloves and placed them in the trash and went into the restroom of Resident #28's room and washed her hands. She said she has been the wound care nurse at the facility for about a year. She said she would not have done anything differently with her wound care treatment initially when asked. When asked about the procedure for putting on and taking off gloves, she said she was supposed to wash or sanitize her hands before putting on gloves and after removing them. She said she thinks it was about two times that she forgot to sanitize or wash her hands during the wound care treatment observation. During an interview on 11/9/2021 at 4:15 PM, DON said the wound care nurse has completed training with the contracted nurse who came to the facility to monitor and assess the wounds along with the wound care physician. She said the treatment nurse had been certified to perform wound care this past year. She said the felt like the treatment nurse needs to be observed several times to ensure no break in infection control during treatments. She said the wound care nurse was nervous during the observation. She said they have had multiple in-services in the past 3-4 months on infection control and they are usually conducted by the Infection Preventionist. She said her expectations was for staff to maintain infection control while performing wound care treatments and to perform handwashing or use of a hand sanitizer before and after applying gloves to prevent the spread of infections. 2. Record review of the face sheet dated 11/10/21 indicated Resident #38 was a [AGE] year-old female admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Minimum Data Set (MDS) dated [DATE] indicated Resident #38 was cognitively severely impaired and was totally dependent on staff assistance for all ADLs. Record review of an undated care plan indicated Resident #38 required assistance with ADLs and transfers. Staff was to provide incontinent care every 2 hours and reposition every 2 hours. She required 2-person Hoyer lift for transfer into her specialized wheelchair. During an observation of incontinent care on Resident #38 on 11/10/21 at 8:40 AM, CNA-E's gloves became soiled with BM. CNA-F used a wipe to remove the BM from CNA-E's glove. CNA-F then donned clean gloves without sanitizing or washing hands. After cleaning Resident #38 and removing the soiled pads and brief, CNA-F again donned clean gloves, without sanitizing or washing hands, and placed a clean pad and brief under the Resident. CNA-F then rolled the Resident so that CNA-E could unroll the clean pad and brief underneath the Resident's other side. CNA-E completed this task without donning clean gloves or washing/sanitizing hands. CNA-E then pulled up the Resident's blanket, placed her call light within reach, and pulled the bedside table back in place wearing the same dirty gloves. CNA-E then doffed the dirty gloves and washed hands. CNA-F took the soiled pads/linens to the soiled linen room and disposed of both appropriately, then washed hands. During an interview on 11/10/21 at 9:05 AM, CNA-E said they should have had more supplies on hand prior to providing incontinent care (during care, CNA-F had to leave the room to get additional wipes). CNA-F said they should have brought alcohol-based hand sanitizer with them and sanitized their hands when changing gloves. CNA-E agreed. Both CNAs said they had forgotten to sanitize their hands during the care provided. They said they had been in-serviced on proper hand hygiene to prevent the spread of infection. Resident #38's room had a bathroom with sink. 3. Record review of the face sheet dated 11/10/21 indicated Resident #13 was a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the minimum Data Set (MDS) dated [DATE] indicated Resident #13 was cognitively intact with a BIMS (Brief Interview for Mental Status) score of 15. She was totally dependent on staff for all ADLs. Staff was to provide incontinent care every 2 hours and reposition every 2 hours During an observation of incontinent care provided for Resident #13 on 11/10/21 at 9:12 AM revealed, CNA-G did not sanitize hands when changing gloves during the process of incontinent care. CNA-G washed her hands in Resident #13's bathroom, donned gloves and removed the Resident's soiled brief. CNA-G then doffed the gloves and donned clean ones without sanitizing her hands. She then cleaned the Resident's front peri area, doffed the gloves and donned clean ones without sanitizing hands. She then assisted the Resident into a side-lying position and cleaned her inner buttocks, doffed the gloves and donned clean ones without sanitizing hands. CNA-G then cleaned the Resident's outer buttocks, doffed the gloves and donned clean ones without sanitizing her hands. She applied a clean undersheet, pad and brief to the Resident. She then doffed her gloves and applied clean ones without sanitizing and placed the bed back into a low position and the call light in reach. The CNA then doffed her gloves and discarded the soiled trash/linens appropriately and washed her hands. During an interview on 11/10/21 at 9:34 AM, CNA-G said she did not think there was anything missing in the incontinent care process provided for Resident #13. When informed that hand sanitizing had not been done with the glove changes, CNA-G said she was not aware she was expected to sanitize with every glove change and would be sure to do so in the future and carry hand sanitizer with her. She said she been in-serviced on infection control but did not recall that hands were to be sanitized with every glove change. During an interview on 11/10/21 at 9:45AM, the DON said a skills check-off was completed with every new hire and infection control teaching was the responsibility of the Infection Preventionist. CNA skills were checked off by the lead CNA on each floor. The DON's expectation was for CNAs to sanitize their hands with every glove change. At the beginning and end of incontinent care and any time there was visible soiling they were to wash their hands with soap and water. She said CNAs should carry hand sanitizer with them at all times. Record review of the facility policy on handwashing/hand hygiene with a revision date of August 2019 indicated, .2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors .7 Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively soap (antimicrobial or non-antimicrobial) and water for the following situations: g. before handling clean or soiled dressings, gauze pads, etc.; 7 m. after removing gloves; 8. Hand hygiene is the final step after removing and disposing of personal protective equipment .

Based on interview and record review, the facility failed to employ staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service for 1 of 15 dietary staff (Cook D) reviewed for food handler certification. The facility did not ensure Cook D had a current food handler certification. This failure could place all residents who consumed food prepared from the kitchen at risk of food-borne illness. Findings included: Review of the personnel file for Cook D indicated she was hired on 5/06/21 and she had not acquired her food handler's certificate within the required 60 days. Cook D said she had just forgot to do it. During an interview on 11/10/21 at 11:50 a.m., the Dining Service Director said it was his responsibility to ensure all kitchen staff have a current food handler certification. He said he had left for eight months and had recently returned to the facility; he was still trying get things in order. During an interview on 11/10/21 at 12:00 p.m., with the Administrator he said he expected the dietary staff to have updated food handler certificates, and to follow the rules of the TFER, (Texas Food Establishment Rules, dated October 2015). During an interview on 11/10/21 at 12:15 p.m. the Dining Service Director was asked for a policy addressing food handlers certificates and he said he did not have a policy for food handler's certification. On exit 11/10/21 at 1:00 p.m., the facility was asked for any additional information they would like to present to survey team and they declined. Record review of the Texas Food Establishment Rules (TFER), accessed 11/10/21 at https://dshs.texas.gov/foodestablishments/pdf/Laws/228TFER 015/ dated October 2015, stated, (d) Except in a temporary food establishment and the certified food manager, all food employees shall successfully complete an accredited food handler training course, within 60 days of employment.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food under sanitary conditions in the kitchen. The facility failed to ensure that staff wore beard protectors while in the kitchen. This failure could place residents who received their meals from the kitchen at risk for food-borne illness and food contamination. Findings included: During an observation of the kitchen on 02/09/20 the following was observed: At 10:15 a.m., the Kitchen Supervisor did not have a beard or mustache protector covering his facial hair. During an interview on 02/10/20 at 10:30 a.m., the Kitchen Supervisor said he was normally clean shaven. During an interview on 2/11/20 at 2:15 p.m., the FSS said she expected all employees to wear hair covers and those with facial hair to wear beard covers. A HACCP/Food Safety Program Policy revised 1/08/20 indicated: . Facial hair longer than ¼ will require beard restraints to effectively keep facial hair from contacting exposed food, clean equipment, utensils, linens and unwrapped single service and single use articles as well as to minimize hand contact with facial hair. During an interview on 02/11/20 at 4:00 p.m., the facility was asked for additional information for kitchen sanitization. No additional information was provided.

Based on interview and record review, the facility failed to provide adequate supervision and assistance devices to prevent accidents for 1 of 5 residents reviewed for accidents. (Resident #1) The facility did not revise and/or implement interventions to prevent falls for Resident #1. Resident #1 had a history of [REDACTED].#1 fell and sustained a [MEDICAL CONDITION]. This failure contributed to Resident #1's fall and [MEDICAL CONDITION]. This failure could place 18 residents with a history of falls at risk of injuries and neglect. Findings included: Physician orders [REDACTED].#1 was an [AGE] year old male, admitted [DATE], with [DIAGNOSES REDACTED]. An admitting nursing note dated 05/04/18 indicated Resident #1 arrived in a wheelchair, transferred to his bed by two people and had a [DIAGNOSES REDACTED]. A care plan dated 05/04/18 indicated Resident #1 was at risk for falls related to weakness and unsteady balance. Interventions listed for Resident #1 were mats beside bed, keep bed in the lowest position and obtain therapy for strengthening. An initial social service assessment dated [DATE] at 2:47 p.m., indicated Resident #1 was oriented to himself only and admitted for skilled therapy following a hospitalization for a fall. This assessment indicated Resident #1's cognitive/decision making skills were poor due to the level of confusion, he was very hard of hearing and his mood was irritable. The most recent MDS dated [DATE] indicated Resident #1 had clear speech, was usually understood by others, usually understands others. Resident #1 was severely cognitively impaired and required extensive two person physical assistance with bed mobility and transfers. The assessment indicated locomotion on and off the unit did not occur and Resident #1 was only able to stabilize with staff assistance. An event report dated 05/07/18 at 2:31 a.m., indicated Resident #1 was found on the floor at the foot of his bed. This was an unwitnessed fall in his bedroom with no injuries noted. This event report indicated Resident #1 was assisted back to bed with the bed in the lowest position, call button within reach. The report did not have revised interventions to prevent falls. A nursing note dated 05/10/18 at 12:35 a.m., indicated Resident #1 was noted to be on the floor on his fall mat laying supine with his feet under the bedside table. There were no new injuries noted. The following event reports for Resident #1 indicated falls with no new interventions implemented: 05/12/18 at 7:15 a.m., indicated Resident #1 was found kneeling on the floor next to his bed with his head on the bed. This was an unwitnessed fall in his bedroom with no injuries noted. This event report indicated Resident #1 had a recent decline in ADL abilities, which may have been a contributing factor. Resident #1 was assisted to a standing position with two staff members. The report did not have revised interventions to prevent falls and noted the care plan was not reviewed. 05/13/18 at 6:55 p.m., indicated Resident #1 was found on the floor with his back to the seat of the wheelchair. This was an unwitnessed fall in his bedroom. Resident #1 sustained an abrasion. This report indicated Resident #1 was unable to complete range of motion. The report did not have revised interventions to prevent falls and noted the care plan was not reviewed. A care plan dated 05/14/18 indicated Resident #1 was admitted on a short-term basis for rehabilitation therapy and was to discharge back home upon completion. A handwritten note at the bottom of the care plan dated 05/14/18 indicated Resident #1 was moved to the room nearest the nursing station. A care plan with the onset date of 05/15/18 indicated Resident #1 required one person to assist with bed mobility, transfers and toileting. The following event reports for Resident #1 indicated a fall and no new interventions were implemented: 05/20/18 at 9:56 p.m., indicated Resident #1 was found on one knee with both hands holding to the wheelchair at the end of his bed. This was an unwitnessed fall in his bedroom. Resident #1 sustained bruising and an abrasion on his upper right thigh and required first aid. The report did not have revised interventions to prevent falls and noted the care plan was not reviewed. 05/22/18 at 3:54 p.m., indicated Resident #1 was found on his knees on the floor mat. This was an unwitnessed fall in his bedroom. Resident #1 sustained an abrasion. This report indicated in the Orders section to document if interventions currently in place were effective. The report did not have revised interventions to prevent falls and noted the care plan was not reviewed. 05/24/18 at 7:14 p.m. and a nursing note at 7:12 p.m., indicated Resident #1 was found on his knees on the floor. This was an unwitnessed fall in his bedroom. Resident #1 sustained an abrasion to his right knee. The event report did not have revised interventions to prevent falls and noted the care plan was not reviewed. A nursing note dated 05/27/18 at 1:31 p.m., indicated Resident #1 was found on the mat in his room and assisted back to bed. There was not an event report for this fall. A nursing noted dated 05/27/18 at 2:10 p.m. indicated Resident #1 was found face down on the floor stating he hit his head. Resident #1 complained of neck and back pain, 911 was called and he was transferred to the emergency room for evaluation and treatment. There were no additional entries. An event report dated 5/27/18 at 2:10 p.m., indicated Resident #1 was found on the floor. This was an unwitnessed fall in his bedroom. Resident #1 complained of pain and hitting his head. The event report did not have revised interventions to prevent falls and noted the care plan was not reviewed. A provider investigation report for Resident #1 dated 05/27/18 indicated the resident fell this same date at 2:10 p.m. Resident #1's reported to the state agency 05/27/18 at 6:10 p.m. This report indicated Resident #1 was heard yelling and found lying face down on the side of the bed. Resident #1's fall mat was out of place and his bed was not in the lowest position. Resident #1 complained of pain, was sent out to the hospital per 911 where it was determined Resident #1 sustained a [MEDICAL CONDITION]. The hospital records dated 5/27/18 indicated Resident #1 had fractures of his left hip and left femur. Resident #1 was transferred to an out of town hospital for orthopedic surgery. During an interview on 06/05/18 at 8:40 a.m., the DON said Resident #1 remained in the hospital at this time. The DON said Resident #1 sustained a [MEDICAL CONDITION], which was surgically repaired and was transferred to a long term acute care facility. During an interview on 06/05/18 at 10:00 a.m., CNA S said she assisted Resident #1 to bed 45 minutes prior to the unwitnessed fall with serious injury on 05/27/18. She said Resident #1 attempted to transfer himself in the dining room earlier that day, was up out of his chair walking around. She said other residents would yell to staff to help Resident #1 sit down so he would not fall. CNA S said she assisted Resident #1 to bed. She said she lowered the bed as far as it would go but it would not go to the lowest position. CNA S said she placed a fall mat on either side of Resident #1's bed and left the room. CNA S said Resident #1 frequently transferred himself from the bed to wheelchair or vice versa. She said Resident #1 was very busy and it was hard to keep up with him. CNA S said Resident #1's fall precautions were the bed in the lowest position and a fall mat on the sides of his bed. She said Resident #1's interventions did not change after each fall. The only other fall precaution attempted was moving Resident #1 from the end of the hall closest to the nursing station approximately two weeks prior to the fall on 05/27/18. During an interview on 06/05/18 at 8:30 a.m., the administrator and DON said Resident #1 had a history of [REDACTED]. They said the facility implemented the following fall precautions: a fall mat on each side of the bed, the bed to remain in the lowest position, therapy and moved him nearest the nursing station. The DON said on 05/27/18, CNA S could not get the bed to go all the way to the floor, so it was not in the lowest position as care planned. She said it was approximately an inch from the lowest position at the time of the fall with serious injury. During an interview on 06/05/18 at 9:13 a.m., human resources said Resident #1 had fallen several times. She said they tried to get the family to provide sitters to no avail but there were precautions in place, the low bed and fall mats. During an interview on 06/05/18 at 10:14 a.m., LVN G said Resident #1 was aggressive and noncompliant with care and therapy. LVN G said Resident #1 was very confused and would stand and walk unassisted. She said he had a history of [REDACTED].#1 was found on the floor. LVN G said the only precautions implemented for Resident #1 were the bed was to be in the lowest position, a fall mat on either side of the bed, call light in reach and to make regular two hour rounds to monitor him. LVN G said Resident #1 was moved closer to the nurses' station approximately two weeks prior to falling and fracturing his hip. During an interview on 06/05/18 at 10:37 a.m., CNA V said she provided care for Resident #1. She said Resident #1 always attempted get out of his wheelchair and/or bed. CNA V said Resident #1 was admitted with his bed to be in the lowest position and fall mats on both sides. She said Resident #1 refused therapy at times. CNA V said she was at work when he fell on [DATE] and Resident #1 immediately complained of pain. She said they placed a pillow under his head and did not move him until the ambulance drivers moved him. CNA V said Resident #1 required a lot of attention and needed one to one supervision for safety. During an interview on 06/05/18 at 11:10 a.m., CNA E said Resident #1 was always all over the place and everywhere. CNA E said if staff took their eyes off of him for five seconds he (Resident #1) would be gone. She said Resident #1 attempted to transfer himself in the dining room earlier that day (5/27/18) and CNA S assisted him back to his wheelchair and to his room. She said Resident #1 was very confused and unsafe with transfers due to history of falling so he was moved to the room nearest the nurses' station. CNA E said Resident #1 needed constant supervision and attention 24/7. He really needed a sitter to be right there to redirect him, so he would not try to get up and fall. During an interview on 06/05/18 at 11:39 a.m., the DON said the facility met with the family to try to convince them to hire a sitter or see if they could sit with Resident #1. The DON said Resident #1's family provided a sitter to watch him while he was in therapy to ensure Resident #1 was participating, but no other time. She said Resident #1 did need more attention than the other residents and acknowledged new interventions were not attempted after each fall. The DON said they moved Resident #1 nearest the nurses' station, but their company was not allowed to use fall alarms. She said Resident #1 was moved to room by the nursing station on 05/14/18 and suffered five falls after the room change without any new interventions or safety precautions being attempted. The DON agreed there should have been more interventions attempted. The facility 802 dated 06/05/18 indicated there were 18 residents with falls including falls with major injury.

Based on observation, interview, and record review, the facility failed to provide necessary treatment and services, based on the comprehensive assessment and consistent with professional standards of practice, to promote healing and prevent new pressure injuries from developing for 2 of 3 residents reviewed for pressure injuries. (Resident #s 40 and 1) 1. The facility did not ensure accurate assessment, obtain treatment orders, or communicate with other professional staff when Resident #40 developed a right hip pressure injury. The pressure injury progressed to unstageable in one week. 2. The facility did not ensure Resident #1's wheelchair foot pedal did not cause pressure to her right 5th toe and she develped a unstageable pressure injury. This failure could place the 4 residents with pressure injuries at risk for development of new pressure injuries and the decline in existing pressure injuries. Findings included: 1. Physician orders [REDACTED].#40, admitted [DATE], was [AGE] years old, with [DIAGNOSES REDACTED]. The Weekly Skin Assessments for Resident #40 dated from 08/04/17 until 08/25/17 indicated treatment to a pressure ulcer on his left hip. The Weekly Skin Assessment for Resident #40 indicated on 09/01/17 .treatment plan in place to right and left hip . The completed date and the date recorded fo this assessment was 09/08/17. There was no assessment including measurements of the new wound on his right hip noted when it was observed on 09/01/17. The nursing notes dated 09/08/17 for Resident #40 indicated .Noted new open area to right hip, area is unstageable with wound bed covered in slough/necrosis, surrounding skin is red. Measures 3cm x 5.5cm . A physician's orders [REDACTED]. he began going to the wound care center on 09/25/17 and at that time Santyl ointment was ordered. A statement dated 09/12/17 by LVN E who did the assessment on 09/01/17, said she saw the areas on both hips and created a treatment plan for what she thought was a new skin tear on the right hip. The assessment dated [DATE] had no measurements, only that dressings were in place. The nursing notes dated 09/01/17 - 09/08/17 did not address the new pressure ulcer identified on 09/01/17. The care plan for Resident #40 was updated on 09/18/17 to include the left hip decubitis had healed and the right hip has a skin breakdown unstageable to (R) hip. The most recent MDS dated [DATE] indicated Resident #40 had severely impaired cognition. The MDS indicated Resident #40 required extensive assistance of one person to physically assist with dressing, toilet use, eating and personal hygiene. He required total dependence and two person to physically assist with transfers. The MDS indicated Resident #40 was at risk for pressure ulcer and had one unstageable pressure ulcer present. The most recent Braden Scale dated 12/13/17 indicated Resident #40 was a moderate risk for the development of pressure injuries. An observation on 01/29/18 at 3:00 p.m. revealed Resident #40 was in his bed. turned to his left side. There was a bandage covering the right hip. When the dressing was removed, there was an open Stage IV wound that had just been debrided by the wound care doctor. The wound had slight bloody drainage and edges were defined and clean. The left hip had no open areas. A care plan reviewed/revised on 12/29/17 and again on 01/11/18 for Resident #40 indicated he was at risk for pressure ulcers related to impaired mobility and incontinence. An approach noted to .conduct a systematic skin inspection weekly . A treatment order from the wound care physician dated 01/29/18 noted to clean the wound on the right hip, apply Calcium alginate, Santyl ointment, and a dry dressing every day. During an interview on 01/31/18 at 2:00 p.m., the DON said Resident #40 had a wound on his left hip that was being treated and healing and has since healed. She said a nurse found the one on the right hip and revised the physician's orders [REDACTED]. The DON said the nurse did not tell anyone, just put a dressing on it. She said the routine weekly skin assessment for Resident #40 was done on 09/08/17 and the new pressure injury on his right hip was seen and unstageable. A progress note for Resident #40 by the wound care physician dated 01/29/18 indicated (right hip) .Surgical excisional debridement of necrotic tissue. Measures 3.5cm x 5.5cm x 1cm . 2. Physician orders [REDACTED].#1 admitted [DATE], was [AGE] years old, with [DIAGNOSES REDACTED]. The weekly Braden scale done 08/22/17 indicated Resident #1 at risk. The most recent Braden Scale dated 01/06/18 indicated Resident #1 was at moderate risk for the development of pressure injuries. The most recent MDS dated [DATE] indicated Resident #1 was cognitively intact. The MDS indicated Resident #1 required total dependence of one person to physically assist with dressing, toilet use, and personal hygiene. She required total dependence and two person to physically assist with transfers. The MDS indicated Resident #1 was at risk for pressure injuries. A care plan initiated 08/06/16 and revised 01/21/18 for Resident #1 indicated she was at risk for alteration in skin integrity. An approach noted for .weekly body audit by nurse .and conduct a skin inspection during peri care . A nursing progress note dated 12/25/17 for Resident #1 indicated .resident noted with wound to lateral aspect of right foot. 3.5 cm x 2.8 cm in area. tissue to wound bed dark and with scant bloody drainage. edges are macerated. resident complains of some tenderness to area. also slightly reddened to medial posterior foot . Skin prep was applied to the area. An order dated 12/29/17 indicated Medi-honey was to be used and covered every day. Resident # 1 began going to the wound care center and on 01/08/18, began a treatment of [REDACTED]. A nursing progress notes dated 12/26/17 for Resident #1 indicated .dressing placed to right outer aspect of foot. appears that foot peddles that are meant to keep right foot straight are pressing against foot . A progress noted for Resident #1 by the wound care physician dated 01/29/18 indicated .Surgically excise 2.0 cm of devitalized tissue and necrotic subcutaneous fat. The wound size measures 2cm x 2cm x 0.2cm . The Weekly Skin assessment dated [DATE] for Resident #1 indicated .Treatments in place for Sacral wound and wound to right foot. No other skin problems noted . During an interview and observation on 01/30/18 at 9:15 a.m., the treatment nurse said Resident #1 received a new custom wheelchair on 10/24/2017 and after a while, it was discovered the pedals were pressing against the resident's foot. She said due to Resident #1's disease, the resident did not realize the pedal was pressing against her foot and she could not move her foot. The right foot had a dressing on it dated 01/29/18 and when the dressing was removed, the side of the right foot had an open area that clearly had been debrided. The open area was pink with no odor and small amount bloody drainage. On 12/27/17 Resident #1 was noted to have an unstageable pressure area to her right 5th metatarsal head. (lateral pinky toe) The wheelchair vendor immediately came out and adjusted the metal pieces on the pedal. She said she had not been notified before 12/25/17 that there was an open area to the resident's foot. She also said there was a time when the charged nurses were doing their own treatments and there was no documentation of an open area anywhere on the right foot during that time. An undated Skin Assessment policy noted, .Risk Assessment and Plan of Care: .It is important to identify and promptly institute risk reduction strategies .communicate changes in the resident's skin condition. The Charge Nurse will assess any skin breakdown found during assessment. A. Charge Nurse will document findings . B. Charge Nurse will notify DON or designee of new pressure areas. C. Charge Nurse will contact physician for treatment orders . The National Pressure Ulcer Advisory Panel accessed on 01/25/18 at http://www.npuap.org/wp-content/uploads/2014/09/NPUAP-Staging-Poster.pdf indicated .UNSTAGEABLE PRESSURE INJURY - Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough 6or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed . During an interview on 01/30/18 at 10:00 a.m., the treatment nurse said there were currently 4 residents with pressure ulcers. The other residents with wounds were identified as venous or diabetic.