Every finding on record at Puxico Nursing and Rehabilitation Center

Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. This had the potential to affect all residents. The facility census was 40.Review of the facility's policy titled, Food Preparation and Service, dated November 2022, showed: - Danger zone means temperatures above 41 degrees Fahrenheit ( F) and below 135 F that allow the rapid growth of pathogenic microorganisms that can cause foodborne illness;- The longer potentially hazardous foods (PHF) remain in the danger zone, the greater the risk for growth of harmful pathogens, and must be maintained at or below 41 F or at or above 135 F;- Raw foods cooked in a microwave reach 165 F in all parts of the food, the items are rotated and stirred during the cooking process so that all parts of the food reached 165 F, and allowed to stand covered for at least two minutes after cooking;- Mechanical altered hot foods prepared for a modified consistency diet remain above 135 F during preparation or they are reheated to 165 F for at least 15 seconds if holding for hot service;- The temperatures of foods held in steam tables are monitored throughout the meal service by food and nutrition services staff;- Steam tables are never used to reheat foods.Review of the facility's policy titled, Food Receiving and Storage, dated November 2022, showed: - Foods shall be received and stored in a manner that complies with safe food handling practices;- Dry foods are goods handled and stored in a manner that maintains the integrity of the packaging until they are ready to use;- Dry foods that are stored in bins are removed from original packaging, labeled and dated with a use by date, and such foods are rotated using a first in - first out system.1. Observations on 09/24/25 at 9:15 A.M.,11:32 A.M., and 12:02 P.M., of the kitchen showed:- One 3 quart (qt.) dented can mixed fruit received on 07/31/25;- Five 3 qt. dented cans spaghetti sauce received on 09/18/25;- One 3 qt. dented can short cut green beans received on 09/18/25;- Four unlabeled and undated clear plastic containers of raisin bran, fruit rings, crispy rice, and toasted oat rings cereals; - An approximate 10 gallon (gal.) white plastic container of cornmeal loosely covered, undated, and mislabeled fish;- An approximate 10 gal. white plastic container of sugar loosely covered and undated;- A nonfunctioning plate warmer with a damaged electrical cord;- The ice machine with a white grime build up on the exterior surfaces and interior plastic surface, ventilation louvers with a brown substance, plastic drain line with a black grime build up, and scattered debris on the floor beneath; - The dishwasher with a white grime build up on the exterior surfaces and scattered debris on the floor beneath;- The gas range with an oily grime build up and scattered food debris around each burner and on the floor beneath; - Two 12 inch (in.) diameter ceiling diffusers (one of the few visible parts of an air conditioning system) with dust buildup and a brown substance on the front exterior surface and in between the ventilation louvers;- Commercial style can opener with an oily film build up and a discolored blade with a grime build up;- The 3-compartment sink with hot water faucet at 88 F;- No cleaning log. 2. Observation on 09/24/25 at 11:35 A.M., of the food service steam table showed:- Dietary Aide (DA) F dipped various food items from the steam table trays onto room temperature plates;- Ground roast beef at 115 F in a steam table tray;- [NAME] gravy at 80 F in a steam table tray.3. Observation on 09/24/25 at 12:02 P.M., of the food service test tray showed:- Plate cool to touch; - Sliced ham at 108 F;- Spinach at 110 F;- Diced potatoes at 104 F;- Roast beef at 115 F.During an interview on 09/24/25 at 9:58 A.M., Resident #23 said he/she ate in the dining room and sometimes the food was cold when he/she received it from the kitchen. During an interview on 09/24/25 at 11:51 A.M., DA F said the plate warmer did not work and it had not been used in the four months since he/she began working at the facility. The food should be served warm to the residents.During an interview on 09/26/25 at 3:08 P.M., the Dietary Manager (DM) said the steam table food temperatures should have been around 165 F. The gravy was probably warmed in the microwave and wasn't heated enough. It should have been warmer and at least 135 F. All the foods should have been warmer on the steam table, and it should be turned on earlier in the day so the food would stay warm once it was placed in the bins. There were not dated food labels on the large white food storage bins but there should be. Staff don't label clear dry cereal bins. The plate warmer doesn't work due to a damaged electrical cord that was taped up and it was reported to the Dietician. The ice machine should not have had hardwater build up on the exterior. The drainpipes should be clean below the ice machine, and he/she had not spoken with the Maintenance Director about cleaning the ice machine or the drainpipes. There should be a shelf that was labeled dented cans in the food storage area. The dented cans should have been discarded or placed on the dented can shelf. Sugar was not dated because the bin was refilled every week. The air vents should be kept clean in the kitchen ceiling. The can opener was damaged and had grime on it. Once a month the staff deep cleaned the range, but spills should be cleaned as needed around the burners. There hadn't been any cleaning logs kept for the dietary service staff.During an interview on 09/26/25 at 3:20 P.M., the Administrator and the Director of Nursing (DON) said the kitchen should be ran according to the facility policy and regulations. It should have had more deep cleaning, and hot meals should not be served cool. There were issues they had been aware of in the kitchen that included food storage and equipment problems.

Based on observation, interview, and record review, the facility failed to implement proper infection control practices when staff performed incontinent care for three residents (Residents #3, #14, and #35) out of three sampled residents, catheter (a flexible tube inserted into the bladder to drain urine) care for two residents (Residents #3 and #35) out of two sampled residents, wound care for two residents (Residents #3 and #12) out of two sampled residents, and during glucose monitoring and insulin administration for four residents (Residents #5, #26, #28, and #36) out of four sampled residents. The facility also failed to ensure the laundry building remained in good condition to promote infection control. The facility census was 40.Review of the facility's policy titled, Standard Precautions, revised September 2022, showed:- Hand hygiene refers to handwashing with soap (anti-microbial or non-antimicrobial) or the use of alcohol-based hand rub (ABHR), which does not require access to water;- Hand hygiene is performed with ABHR or soap and water before and after contact with the resident, before performing an aseptic task, before moving from work on a soiled body site to a clean body site on the same resident, after contact with items in the resident's room, and after removing gloves;- Gloves (clean, non-sterile) are worn when in direct contact with blood, body fluids, mucous membranes, non-intact skin, and other potentially infected material;- Gloves are worn when handling or touching resident-care equipment that is visibly soiled or potentially contaminated with blood, body fluids, or infectious organisms;- Gloves are changed and hand hygiene performed before moving from a contaminated-body site to a clean-body site during resident care;- Gloves are changed as necessary, during the care of a resident to prevent cross-contamination from one body site to another (when moving from a dirty site to a clean one).- Gloves are removed promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident;- After gloves are removed, hands are washed immediately to avoid transfer of microorganisms to other residents or environments.Review of the facility's policy titled, Urinary Catheter Care, dated August 2022, showed:- Be sure the catheter tubing and drainage bag are kept off the floor;- Keep the drainage bag lower than the bladder at all times to prevent urine from flowing back into the urinary bladder;- Use one area of the washcloth with each stroke.The facility did not provide linen storage and laundry room policies. 1. Observation on 09/24/25 at 10:22 A.M., Resident #14's incontinent care showed:- Nursing Assistant (NA) G and NA H entered the resident's room, did not perform hand hygiene, and put on gloves; - NA G touched the incontinent supplies, the resident's blanket, and the resident's shirt; - NA G and NA H rolled the resident to the left side, lowered the pants, unfastened the brief, rolled the resident to the right side, NA H lowered the back of the brief soiled with fecal material, NA G and NA H did not perform hand hygiene, and did not change gloves; - NA H wiped the right groin area soiled with fecal material with a wipe, wiped the left groin area with a new wipe, wiped the peri area soiled with fecal material, folded the wipe and wiped the right groin area two times with the same area of the wipe, did not check to ensure the right groin and peri areas were clean, changed gloves, and did not perform hand hygiene;- NA G wiped fecal material from the right inner thigh area with a wipe, did not change gloves, did not perform hand hygiene, and touched the resident's upper left arm and shirt; - NA H wiped fecal material from the buttock area, folded the wipe, wiped the buttock area again, wiped the buttock area with a new wipe, folded the wipe, wiped the buttock area three times with the same area of the wipe soiled with fecal material, wiped the buttock area again with a clean wipe, did not perform hand hygiene, and did not change gloves;- NA G handed NA H a clean wipe, NA H wiped the area between the buttocks twice with the same area of the wipe soiled with fecal material, and wiped the anal area with a clean wipe three times with the same area of the wipe;- NA G and NA H did not change gloves, did not perform hand hygiene, NA H retrieved barrier cream from his/her pocket, opened the tube and squeezed the barrier cream onto NA G's glove, NA G applied the barrier cream to the resident's buttocks, and NA H returned the tube of barrier cream to his/her pocket; - NA G and NA H changed gloves, did not perform hand hygiene, rolled the resident to the left side, touched the resident's shirt and clean brief, pulled the resident's pants up into place, and rolled the resident to the right, NA H placed a Hoyer lift (a mechanical lift) pad under the resident, turned the resident to the left side, and NA G unrolled the Hoyer lift pad under the resident;- NA H removed gloves, removed the trash and the soiled linens from the resident's room, did not perform hand hygiene, exited the resident's room, took the trash and the soiled linens to the dirty utility room and placed in the appropriate barrels, and performed hand hygiene;- NA I entered the resident's room, did not perform hand hygiene, did not put on gloves, and assisted NA G to reposition the resident;- NA H did not perform hand hygiene, did not put on gloves, entered the resident's room with a Hoyer lift, and assisted NA G to attach the Hoyer lift pad to the Hoyer lift;- NA G removed gloves, attempted to perform hand hygiene with ABHR but the dispenser in the room was empty, did not perform hand hygiene, exited the room, retrieved clean linen from the hall linen cart, entered the resident's room, did not perform hand hygiene, and assisted NA H to put the clean linen on the resident's bed;- NA I assisted NA H to transfer the resident with the Hoyer lift to the wheelchair;- NA H did not perform hand hygiene touched the resident's hair bows and hat/visor, placed the hat/visor on the resident's head, and touched the blanket;- NA I did not perform hand hygiene, and exited the room;- NA G and NA H did not perform hand hygiene and exited the room.2.Observation on 09/25/25 at 9:08 A.M., of Resident #35's incontinent, catheter, and wound care showed:- Enhanced barrier precautions (EBP) signage outside the resident's door;- Licensed Practical Nurse (LPN) C, Certified Nursing Assistant (CNA) A, and CNA B put on gowns, did not perform hand hygiene, did not put on gloves, and entered the resident's room; - LPN C wiped down the bedside table with a disinfectant wipe, placed a clean towel on the table, and placed the supplies on the clean barrier;- CNA A and CNA B performed hand hygiene and put on gloves;- CNA B performed incontinent care to the resident's peri area, did not change gloves, did not perform hand hygiene, cleaned down the catheter, did not change gloves, did not perform hand hygiene, and rolled the resident to the right side and touched his/her shoulders and hip;- CNA A cleaned the resident's buttocks and an open area multiple times with the same area of the washcloth, did not change gloves, and did not perform hand hygiene;- CNA A and CNA B rolled the resident to his/her back, changed gloves, and did not perform hand hygiene;- LPN C performed the resident's wound care, did not change gloves, did not perform hand hygiene, covered the wound with a bandage, and applied barrier cream to the red area outside of the bandaged area, removed the gloves and performed hand hygiene.3. Observation on 09/25/25 at 11:05 A.M. to 12:45 P.M., of blood glucose monitoring and insulin administration showed:- At 11:05 A.M., LPN E did not perform hand hygiene, put on gloves, performed blood glucose monitoring for Resident #28, did not remove gloves, did not perform hand hygiene, and exited the room; - At 11:11 A.M., LPN E did not perform hand hygiene, entered Resident #36's room, requested the personal glucose monitoring receiver to review the resident's current glucose reading, the resident removed the receiver from top of his/her leg stocking and sat it on the bedside table. LPN E touched the receiver, did not perform hand hygiene, and exited the room;- At 12:27 A.M., LPN E did not perform hand hygiene, drew up insulin with an insulin syringe, put on gloves, entered Resident #28's room, administered the insulin to the resident, removed gloves, did not perform hand hygiene, and exited the room; - At 12:29 P.M., LPN E entered Resident #26's room, performed hand hygiene, put on gloves, administered insulin to the resident, removed gloves, did not perform hand hygiene, and exited the room;- At 12:35 P.M., LPN E did not perform hand hygiene, drew up insulin with an insulin syringe, put on gloves, entered Resident #5's room, administered the insulin to the resident, removed gloves and did not perform hand hygiene; - At 12:45 P.M., LPN E did not perform hand hygiene, drew up insulin with an insulin syringe, put on gloves, entered Resident #36's room, administered the insulin to the resident, removed gloves, did not perform hand hygiene, and exited the room. 4.Observation on 09/25/25 at 1:30 P.M., of Resident #3's catheter care showed:- EPB signage outside the resident's door;- LPN C and LPN E put on gowns, performed hand hygiene, and put on gloves;- LPN C removed the dressing from the suprapubic catheter (a thin, flexible tube inserted directly into the bladder through a small incision in the lower abdomen), did not change gloves, did not perform hand hygiene, performed catheter care, dried the catheter tubing toward instead of away from the insertion site;- LPN E applied gentamicin (an antibiotic medication) ointment to a gloved finger and applied it around the suprapubic catheter site, did not change gloves, did not perform hand hygiene, applied a new dressing to the suprapubic catheter site, did not change gloves, and did not perform hand hygiene; - LPN C changed gloves, didn't perform hand hygiene, and applied nystatin (an antifungal medication) powder to the resident's peri area;- LPN C and LPN E changed gloves and didn't perform hand hygiene;- LPN C removed dressings to the left leg, did not change gloves, and did not perform hand hygiene; - LPN E removed the dressing to the right leg, did not change gloves, didn't perform hand hygiene, performed the treatment to the resident's toes, did not change gloves, and did not perform hand hygiene;- LPN C cleaned the resident's left and right legs, did not perform hand hygiene, and did not change gloves; - LPN C dried the left leg wounds, LPN E dried the right leg wound, and LPN C and LPN E did not change gloves and did not perform hand hygiene;- LPN C lay the jar of Silvadene (an antibiotic cream) on the resident's bed without a clean barrier, applied the Silvadene with his/her gloved fingers to the wounds on both legs, did not change gloves and did not perform hand hygiene between each wound treatment, did not change gloves, did not perform hand hygiene, and put the Silvadene jar back into the resident's wound supply tub;- LPN C did not change gloves, did not perform hand hygiene, calcium alginate (a type of wound treatment) to the wounds on both legs, did not change gloves and did not perform hand hygiene between each wound treatment;- LPN E applied skin prep (a type of wound treatment) to both heels and toes, did not change gloves, didn't perform hand hygiene between each wound treatment, did not perform hand hygiene, did not change gloves;- LPN C applied ABD pads (a large absorbing dressing) to the wounds on the right leg, LPN E ABD pads to the wounds on the left leg, and LPN C and LPN E changed gloves and didn't perform hand hygiene;- LPN C cleaned the wound on the left buttock, changed gloves, didn't perform hand hygiene, applied Medi-honey (a type of wound treatment) to a gloved finger, applied the Medi-honey to the left buttock wound, did not change gloves, did not perform hand hygiene, applied a bordered gauze to the wound, changed gloves, and didn't perform hand hygiene;-LPN C and LPN E put touched the resident's blankets and LPN C handed the resident his/her Bible;- LPN E did not change gloves, did not perform hand hygiene, did not remove the gown, and exited the room to get an incontinent pad;- LPN C emptied the basin of water, did not change gloves, and did not perform hand hygiene;-LPN E did not change gowns, entered the resident's room, did not perform hand hygiene, did not put on gloves, and handed the incontinent pad to LPN C;- LPN C placed the incontinent pad under the resident;- LPN C and LPN E removed the gowns and gloves, performed hand hygiene, and exited the room.During a phone interview on 09/25/25 at 10:53 P.M., NA H said hand hygiene should be completed when going into a resident's room for care and put gloves on. Change gloves and wash hands when gloves were visibly soiled. Change gloves and wash hands when moving from incontinent care to other care. When performing incontinent care, the wipe/washcloth should be folded in half when soiled or throw the wipe away and get a new one, do not wipe with the same soiled area multiple times. Remove gloves and sanitize hands before exiting the room. During an interview on 09/26/25 at 10:05 A.M., with LPN E said during incontinent care, hand hygiene should be completed before and after care. If hands were visibly soiled or other contaminates, use soap and water. Change gloves when going from soiled to clean care and moving from different areas. Incontinent care with wipes, he/she would do one wipe for each swipe. Shouldn't use same side of the cloth and should keep wiping until visually clean and free from odor. Catheter placement hanging on side of bed a few inches off the floor and covered. For catheter care, clean around the site, clean the catheter itself about three inches or so using a different washcloth, wipe from the insertion point down, don't use same area of the washcloth to wipe the catheter. For wound care, perform hand hygiene more frequently between the different sites, don't go from one site to another, and hand hygiene with glove changes, that's why there's hand sanitizer in resident rooms. Place supplies on a clean area, if a hard surface, use a disinfectant wipe. For a medication pass and insulin administration, perform hand hygiene between each resident to prevent infection.During an interview on 09/26/25 at 1:10 P.M., LPN C said when cleaning or drying catheter tubing, it should be done from the insertion point down. During all care, hand hygiene should be done upon entering the room, when going from clean to dirty care, with glove changes, and exiting the room. Q-tips or applicators were preferred to be used when applying ointments or creams to wounds. During an interview on 09/26/25 at 1:20 P.M., the Assistant Director of Nursing (ADON) said when cleaning catheter tubing, it should be done from the insertion point down. With wound care, incontinent care, and catheter care, hand hygiene should be done when starting care, going from dirty to clean care, or changing sites, with glove changes, and exiting the room. During an interview on 09/26/25 at 1:30 P.M., CNA B said when cleaning a catheter, it should be done from the insertion point down. With incontinent care and catheter care, hand hygiene should be done at the start, going from dirty to clean care, with glove changes, and when exiting the room. Glove changes should happen when going from dirty to clean care or changing sites, like cleaning the front verses cleaning the back. During an interview on 09/26/25 at 1:45 P.M., the Director of Nursing (DON) said when cleaning catheter tubing, it should be done from the insertion point down. With wound care, incontinent care, and catheter care, hand hygiene should be done when starting care, going from dirty to clean care, or changing sites, with glove changes, and exiting the room. 5. Observation on 09/26/25 at 10:24 A.M., of the laundry room showed:- An air conditioner (AC) unit with dirty towels placed between the window opening and the AC unit on the left side, the AC unit filter covered with a brown substance hung half off the vent and the unfiltered portion of the vent covered with a brown substance, a brown substance along the wall under the AC unit, and two areas of approximately 8 inches (in.) X 1.5 in of dry wall with boards exposed under the AC unit on the clean laundry side;- A covered linen cart full of clean linen with dust on the cover where the AC unit blew on the clean linen on the clean laundry side;- An uncovered linen cart full of clean linen and pillows to the right of the AC unit and the AC unit blew on the clean linens on the clean laundry side; - A towel draped over the hot water hose attached to the washer, a wet towel lay at the back of the washer due to leaking water in front of the washer, a dirty towel draped over three hoses where they entered the building and water dripped off the hoses continuously, the dry wall around the three leaking hoses with a large hole approximately 8 feet (ft.) by 1 ft. with insulation and daylight showing in several places, a large area approximately 6 ft X 4 ft on the wall above the leaking hoses with a black substance, and one dead mouse beside the washer on a sticky pad on the dirty laundry side. During an interview on 09/26/25 at 10:50 A.M., Housekeeping Staff J said he/she knew of the leak in the laundry room for about five months due to him/her helping with laundry.During an interview on 09/26/25 at 11:05 A.M., the Maintenance Supervisor said he/she knew of the leak in the laundry room for several months and had been told by word of mouth from other employees about the leak. The company had been notified of the leak. During an interview on 09/26/25 at 12:45 A.M., the Regional Consultant said he/she had not been into the laundry building since it was not attached to the facility. The building, pipes, and AC needed repairs to maintain infection control practices. During an interview on 09/26/25 at 2:15 P.M., the Administrator said she would expect staff to follow infection control policies regarding hand hygiene and glove changes. She would expect staff to follow the catheter care policy and procedures as well. She would expect the laundry building to be clean and functional.

Based on observation, interview, and record review, the facility failed to ensure a urinary indwelling catheter (a tube inserted into the bladder to drain urine) drainage bag was maintained in the proper position for two residents (Residents #3 and #35) out of two sampled residents. The facility census was 40.Review of the facility's policy titled, Urinary Catheter Care, dated August 2022, showed:- Be sure the catheter tubing and drainage bag are kept off the floor;- Keep the drainage bag lower than the bladder at all times to prevent urine from flowing back into the urinary bladder. 1. Review of Resident #3's medical record showed:- admitted on [DATE];- Diagnoses of neuromuscular dysfunction of the bladder (a condition where the nerves or muscles that control the bladder function are impaired which leads to abnormal bladder control), benign prostatic hyperplasia (BPH - a noncancerous enlargement of the prostate), other obstructive and reflux uropathy (the flow of urine is blocked), and retention of urine.Review of the resident's Physician Order Sheet (POS), dated September 2025, showed:- An order to change the 16 French (Fr - size of the catheter) suprapubic (a thin, flexible tube inserted directly into the bladder through a small incision in the lower abdomen) catheter and drainage bag monthly and as needed (PRN) as indicated on the night shift starting on the 4th and ending on the 5th of every month for leakage or obstruction related to neuromuscular dysfunction of the bladder. Hospice (end of life care) will change the 1st Tuesday of the month and PRN for leaks or obstruction, dated 02/28/25. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated process for clinical assessment of all residents in certified nursing homes), dated 06/23/25, showed:- Used an indwelling catheter;- Required assistance for toileting. Review of the resident's Care Plan, dated 04/16/25, showed:- Urinary catheter due to urinary retention due to BPH;- Check for kinks, change monthly, and monitor;- Activities of daily living (ADLs) deficit and dependent for toileting. Observation on 09/24/25 at 10:16 A.M., and 12:15 P.M., and on 09/25/25 at 1:30 P.M., showed:- The resident lay in bed and the catheter drainage bag hung from the bed frame. The catheter drainage bag had a cover that opened at the bottom and the drainage bag touched the floor.2. Review of Resident #35's medical record showed:- admitted on [DATE];- Diagnoses of neuromuscular dysfunction of the bladder, BPH, other obstructive and reflux uropathy, and retention of urine. Review of the resident's POS, dated September 2025, showed:- An order for catheter care every shift, dated 08/21/25;- An order to change the 16 Fr 30 milliliter (ml) bulb urinary catheter and drainage bag once a month on the day shift starting on the 21st and ending on the 22nd and PRN for occlusion or leakage, dated 08/21/25.Review of the resident's admission MDS, dated [DATE], showed:- Used a urinary catheter;- Dependent for toileting. Review of the resident's Care Plan, dated 09/24/25, showed;- Assist with ADLs;- An indwelling Foley (a type of catheter) catheter and to monitor and change monthly. Observation on 09/24/25 at 10:16 A.M., and 12:15 P.M., and 09/25/25 at 1:30 P.M., showed:- The resident lay in bed and the catheter drainage bag hung from the bed frame. The catheter drainage bag had a cover that opened at the bottom and the drainage bag touched the floor.Observation on 09/25/25 at 9:08 A.M., of the resident's catheter care showed: - Licensed Practical Nurse (LPN) C, Certified Nursing Assistant (CNA) A, and CNA B performed catheter care; - LPN C unhooked the catheter from the resident's right side of the bed frame and placed it on the left side of the foot of the bed where it was not below the level of the resident's bladder;- CNA A rolled the resident to his/her left side and the catheter drainage bag fell off the bed and onto the floor at 9:16 A.M. The bottom of the drainage bag and one inch of the catheter tubing touched the floor;- At 9:20 A.M., CNA A rolled the resident to his/her back, picked up the catheter drainage bag off the floor, and hung it on the bed frame;- At 9:25 A.M., LPN C lowered the bed to the low position and the bottom of the catheter drainage bag rested on the floor; - LPN C, CNA A, and CNA B exited the resident's room.During an interview on 09/26/25 at 1:10 P.M., LPN C said a catheter drainage bag or tubing should not touch the floor. During an interview on 09/26/25 at 1:20 P.M., the Assistant Director of Nursing (ADON) said a urinary catheter should always remain below the level of the bladder. The catheter drainage bag and tubing should not touch the floor. During an interview on 09/26/25 at 1:30 P.M., CNA B said a catheter drainage bag or tubing should not touch the floor. The bag should always remain below the level of the bladder.During an interview on 09/26/25 at 1:45 P.M., the Director of Nursing (DON) said a catheter should always remain below the level of the bladder and the drainage bag and tubing should not touch the floor.During an interview on 09/26/25 at 2:45 P.M., the Administrator said a catheter drainage bag should not touch the floor. The catheter tubing should not touch the floor either. It was expected that staff would follow the catheter and infection control policies and procedures.

Based on observation, interview, and record review, the facility failed to ensure two vials of Aplisol (a solution used during a tuberculosis (a serious bacterial infection that mainly affects the lungs) test were dated when opened. This had the potential to affect all residents. The facility's census was 31. Review of the facility's policy titled, Medication Labeling and Storage, revised February 2023, showed multi-dose vials that have been opened or accessed are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. Review of the manufacturer's recommendations for Aplisol, revised November 2013, showed the medication will be discarded 30 days after date opened. Observation on 07/23/24 at 9:10 A.M., of the locked refrigerator in the medication room showed two opened vials of Aplisol solution not dated. During an interview on 07/23/24 at 9:11 A.M., Registered Nurse (RN) A said multi-dose vials should be dated when opened and discarded if not used in 28 days. During an interview on 07/24/24 at 2:10 P.M., the Director of Nursing (DON) said multi-dose vials should be dated when opened and discarded 20 to 30 days after opened.

Based on interview and record review, the facility failed to ensure two nurse aides (NA) completed a nurse aide training program within four months of his/her employment in the facility. This deficient practice had the potential to affect all residents in the facility. The facility census was 31. Review of the facility's policy titled, Nurse Aide Qualification and Training Requirements, revised August 2022, showed: - The facility will employ any individual as a nurse aide for more that four months full-time, temporary, per diem, or otherwise, unless: that individual is competent to provide designated nursing care and nursing related services; and that individual has completed a training program and competency evaluation program, or a competency evaluation program approved by the state; or that individual has been deemed competent as provided in 483.150(a) and (b) of the requirements of participation; - Nursing assistants failing to successfully complete the required training program within the first four months of their date of employment may be terminated from employment or may be reassigned to non-nursing related services. 1. Review of a NA D's Certified Nursing Assistant (CNA) training record showed: - Hire date of 10/26/23; - Classroom and on the job training started on 05/07/24; - The facility failed to ensure the completion of the program within four months of NA D's hire date. 2. Review of the NA E's CNA training record showed: - Hire date of 12/28/23; - Scheduled to start the next class on 8/14/24; - The facility failed to ensure the completion of the program within four months of NA E's hire date. During an interview on 07/24/24 at 12:30 P.M., the Director of Nursing (DON) said she was aware the facility had dropped the ball and she did expect NA's to have completed training within four months of hire. During an interview on 07/24/24 at 2:15 P.M., the Administrator said she expected NA's to have completed training within four months of hire.

Based on observation, interview, and record review, the facility failed to maintain an error rate of less than five percent (%) when medications were administered. There were 26 opportunities with two errors made, for an error rate of 7.69%. This practice affected two residents (Resident #30 and #23) of five sampled residents. The facility census was 31. Review of the facility's policy titled, Administering Medications, last revised April 2019, showed: - Medications are administered in accordance with prescriber orders; - Medication errors are documented, reported, and reviewed by the Quality Assurance Performance Improvement (QAPI) committee to inform process changes and or the need for additional staff training; - The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time and right method of administration before giving the medication. 1. Review of Resident #23's medical record showed: - Diagnosis of diabetes mellitus (chronic condition that affects the way the body processes blood sugar); - An order on the June 2024 Physician Order Sheet (POS) to discontinue Actos (a medication used to control blood sugar levels), undated; - A progress note, dated 06/25/24, the physician saw resident and wrote an order to discontinue Actos. Observation on 07/23/24 at 8:00 A.M., of the resident's medication administration showed: - Registered Nurse (RN) A administered Actos 15 milligrams (mg) to the resident; - RN A administered a discontinued medication to the resident. During an interview on 07/23/24 at 2:30 P.M., RN A said Actos should have not been given to the resident since there was an order to discontinue it. 2. Review of Resident #30's medical record showed: - Diagnoses of dorsalgia (back pain) and deficiency of other vitamins; - An order for calcium (a mineral used to build and maintain strong bones) 500 mg two times a day. Observation on 07/23/24 at 7:46 A.M., of the resident's medication administration showed: - RN A administered calcium 500 mg with Vitamin D 200 international units (IU) tablet to the resident; - RN A failed to administer the medication as ordered. During an interview on 07/23/24 at 9:05 A.M., RN A said only the calcium tablet should have been given, not the calcium tablet with Vitamin D. During an interview on 07/24/24 at 2:10 P.M., the Director of Nursing (DON) and the Administrator said they would expect to have a medication error rate of less than 5%.

Based on observation, interview, and record review, the facility failed to follow physician's orders for three residents (Resident #21, #23 and #33) out of 12 sampled residents. The facility's census was 31. Review of the facility's policy titled, Administering Medications, revised April 2019, showed: - Medications are administered in a safe and timely manner, and as prescribed; - Medications are administered in accordance with prescriber orders; - Medication errors are documented, reported, and reviewed by the Quality Assurance Performance Improvement (QAPI) committee to inform process changes and or the need for additional staff training. 1. Review of Resident #21's medical record showed: - Diagnoses of type 1 diabetes mellitus (an autoimmune disease that leads to the destruction of insulin-producing pancreatic beta cells); - An order for Humalog (type of insulin) injection per sliding scale subcutaneously (under the skin) before meals and at bedtime for blood sugar of 101-150 = 2 units, 151-200 = 3 units, 201-250 = 4 units, 251-300 = 5 units, 301-350 = 6 units, and a blood sugar greater than 351, give 7 units, dated 06/17/24. - No documentation staff notified the physician of the resident's refusal of the physician ordered Humalog insulin or a different dosage administered per the resident's request . Review of the resident's Medication Administration Record (MAR), dated June 2024, showed: - On 06/04/24 at 7:30 A.M., the resident's blood sugar was 348 and 2 units of Humalog was administered; - On 06/04/24 at 12:00 P.M., the resident's blood sugar was 425 and 4 units of Humalog was administered due to the resident refused the physician ordered dosage and requested 4 units; - On 06/13/24 at 07:30 A.M., the resident's blood sugar was 408 and 4 units of Humalog was administered due to the resident refused the physician ordered dosage and requested 4 units; - On 06/21/24 at 9:00 P.M., the resident's blood sugar was 314, and 2 units of Humalog was administered due to the resident refused the physician ordered dosage and requested 4 units; - On 06/22/24 at 12:00 P.M., the resident's blood sugar was 351 and 6 units of Humalog was administered; - The resident had 28 refusals of the physician ordered insulin injections for elevated blood sugars. Review of the resident's MAR, dated 07/1/24 through 07/23/24, showed the resident had 32 refusals of the physician ordered insulin injections for elevated blood sugars. During an interview on 07/24/24 at 10:00 A.M., the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) said the resident frequently refused his/her Humalog or would request a different dosage than what was ordered. They would expect nurses to administer medications as ordered. 2. Review of Resident #23's medical record showed diagnoses of diabetes mellitus, congestive heart failure (the heart does not pump blood as well as it should), chronic pain, atrial fibrillation (abnormal heart beat), and high blood pressure. Review of the resident's Physician Order Sheet, dated June 2024, showed an order to discontinue Actos (a medication used to control blood sugar levels), undated. Review of the resident's progress note, dated 06/25/24, showed the physician saw the resident and wrote an order to discontinue the Actos. Review of the resident's Medication Administration Record (MAR), dated 06/01/24 - 07/23/24, showed: - On 06/26/24 - 07/23/24, the facility administered Actos to the resident after the order was discontinued; - The resident received 28 doses of Actos after the medication was discontinued by the physician. 3. Review of Resident #33's medical record showed: - Diagnoses of heart failure, diabetes mellitus, traumatic brain injury, and chronic pain; - An order for lab work for hemoglobin A1C (blood test that shows the average level of blood sugar in the bloodstream over time), complete blood count (CBC - a blood test that measures the amount of different cells and substances in the blood), comprehensive metabolic panel (CMP - blood test that measures different substances in the blood), lipid panel (a test that measures cholesterol and other fats in the blood), dated 06/24/24; - No documentation of the hemoglobin A1C, CBC, CMP, and lipid panel blood test results ordered on 06/24/24. During an interview on 07/23/24 at 2:30 P.M., Registered Nurse (RN) A said when orders were written, the nurse receiving the order should process it. During an interview on 07/22/24 at 12:40 P.M., the DON said the orders for Resident #33's lab work were not processed and therefore not completed. During an interview on 07/22/24 at 2:10 P.M., the DON and the Administrator said they expect orders to be followed as written.

Based on interview and record review, the facility failed to provide documentation of ongoing assessment and monitoring for one (Resident #21) out of one sampled resident receiving dialysis (process for removal of waste and excess water from the blood due to kidney failure) after returning from treatments. The facility census was 31. Review of the facility's policy titled, Hemodialysis Catheters-Access and Care of, last revised 2001, showed: Care of arteriovenous fistula (a surgical connection made between an artery and a vein for dialysis access) and arteriovenous graft (a type of access used for hemodialysis): - Check for signs of infection (warmth, redness, tenderness, or edema) at the access site when performing routine care and at regular intervals; -Check the color and temperature of the fingers, and the radial (smaller bone in the forearm) pulse of the access arm when performing routine care and at regular intervals; - Check patency (open/unobstructed) of the site at regular intervals. Palpate the site to feel the thrill (a vibration caused by blood flowing through the fistula), or use a stethoscope to hear the whoosh or bruit (an audible vascular sound associated with turbulent blood flow) of blood flow through the access. - Immediately following dialysis treatment, if the dialysis dressing becomes wet, dirty, or not intact, the dressing shall be changed by a licensed nurse trained in this procedure. Mild bleeding from the site (post dialysis) can be expected. Apply pressure to insertion site and contact the dialysis center for instructions. If there is major bleeding from the site (post dialysis), apply pressure to the insertion site and contact emergency services and the dialysis center. Verify that clamps are closed on the lumens (dialysis tubing). This is a medical emergency. Do not leave the resident alone until emergency services arrive; - The nurse should document in the resident's medical record every shift as follows: Location of catheter; Condition of the dressing (interventions if needed); If dialysis was done during the shift; Any part of the report from the dialysis nurse post dialysis being given; and Observations post dialysis. Review of Resident #21's medical record showed: - admitted on [DATE]; - Diagnoses of anemia (not enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues), type 1 diabetes mellitus (an autoimmune disease that leads to the destruction of insulin-producing pancreatic beta cells), hypercholestremia, (an elevated level of lipids, like cholesterol and triglycerides, in your blood), major depressive disorder (mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy), high blood pressure, systolic congestive heart failure (a specific type of heart failure that occurs in the heart's left ventricle), stage 3 chronic kidney disease (kidneys do not work as well as they should to filter waste and extra fluid out of your blood), end stage renal disease (a person's kidneys cease functioning on a permanent basis), acquired absence of right leg above the knee, and dependence on renal dialysis. Review of the resident's Physician Order Sheet (POS), dated July 2024, showed: - An order to monitor the right arm fistula, site for signs/symptoms of infection every shift. Monitor dialysis graft (an access made by using a piece of soft tube to join an artery and vein in your arm), two times a day, dated 06/07/24; - No documentation of an order to assess and monitor the right arm fistula site for a thrill and bruit; - No current order for hemodialysis three times weekly on Monday, Wednesday, and Friday, last dated order was 03/03/23, from previous admission. - The facility failed to obtain an order for the assessment and monitoring of the right arm fistula site for the thrill and bruit. During interview on 07/24/24 at 10:00 A.M., the Director of Nursing (DON) said that he/she would expect nurses to assess all dialysis residents with fistulas by assessing the site for signs or symptoms of infection, thrill, and bruit every shift. During an interview on 07/24/24 at 10:30 A.M., Licensed Practical Nurse (LPN) F said a resident's dialysis fistula was assessed for signs or symptoms of infection and documented in the Treatment Administration Record (TAR) every shift, but not the thrill and bruit.

Based on interview and record review, the facility failed to ensure staff reconciled narcotics (a process that allows one staff to reconcile the exact narcotic inventory on hand with another staff) at each shift change for one out of two medication carts. This practice had the potential to affect all residents. The facility census was 31. Review of the facility's policy titled, Controlled Substances, last revised November 2022, showed: - The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications; - Controlled substances inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow up; - The system of reconciling the receipt, dispensing, and disposition of controlled substances includes records of personnel access and usage, medication administration records, declining inventory records, and destruction/waste/return to pharmacy records; - Nursing staff count controlled medication inventory at the end of each shift; - The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the Director of Nursing (DON) services; - The consultant pharmacist or designee routinely monitors controlled substance storage records. Review of the Nurse Medication Cart Eight Hour/Shift Verification of Controlled Substances Count log, dated 06/14/24 - 07/23/24, showed: - No documentation of the narcotic reconciliation completed by staff with 51 out of 79 opportunities missed. During an interview on 07/23/24 at 9:08 A.M., Registered Nurse (RN) A said he/she did count with the off going nurse this morning, but just forgot to sign the log. The nurses compare the quantity on the individual narcotic sheet to the actual quantity of medication. During an interview on 07/23/24 at 9:18 A.M., the DON said she expects the nurses to count and fill out the count verification sheet each shift change. During an interview on 07/23/24 at 9:25 A.M., the Administrator said nurses should count narcotics at each shift change.

Based on observation, interview, and record review, the facility failed to distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These practices had the potential to affect all residents. The facility census was 36. Record review of the facility's Food Preparation and Service policy, dated 11/2022, showed: - Food and nutrition service employees prepare, distribute and serve food in a manner that complies with safe food handling practices; - When meals are assembled in the kitchen and then delivered to residents' rooms or dining areas to be distributed, covering foods is appropriate, either individually or in a mobile food cart; - When actively serving residents in a dining room or outside a resident's room where trained staff are serving food/beverage choices directly from a mobile food cart or steam table, there is no need for food to be covered. However, food should be covered when traveling a distance (i.e., down a hallway, to a different unit or floor); - Identification of potential hazards in the food preparation process and adhering to critical control points can reduce the risk of food contamination and thereby minimize the risk of foodborne illness; - Cross-contamination can occur when harmful substances, i.e., chemical or disease-causing microorganisms are transferred to food by hands (including gloved hands), food contact surfaces, sponges, cloth towel, or utensils that are not adequately cleaned. Cross-contamination can also occur when raw food touches or drips onto cooked or ready-to-eat foods; - All food service equipment and utensils will be sanitized according to current guidelines and manufacturers' recommendations; - Cleaning and sanitizing work surfaces (including cutting boards) and food-contact equipment between uses, following food code guidelines. 1. Observations of the kitchen on 3/28/23 at 11:23 A.M., showed: - A 1 inch (in.) gap along the upper door gasket of the walk-in refrigerator; - Two chest freezers with 1 in. ice build-up along the inside lining; - The gas range with black grime build-up on the back splash and burners; - The floor below the gas range with oily food, dust and trash debris; - One commercial can opener with black grime on the blade and black grime/corrosion on the attached bracket; - One 4 in. (inch) opened drain access under the dishwashing sink with food debris build-up along the inside and the outer surfaces; - One 4 in. covered drain below the dishwashing sink with thick food debris build-up; - The commercial dishwasher with white flake build-up outside of the door and below the dish removal area; - The commercial dishwasher with a damp white grime build up on the top surface; - The ice machine in the dining area with white grime build up on the side, front and behind the machine; - The ice machine in the dining area with no air gap drained into a 4 in. floor drain behind the machine with a dark green grime build-up; - A low shelf section 2 1/2 in. above the floor in the dry food storage with ten pepper shakers and saltine crackers in an open plastic container; - Food shelving and drywall sections with chipped paint in the dry food storage area; - One dented 6 pound (lb.) 9 ounce (oz.) can of pizza sauce, dated 2/1/23; one dented 6 lb. 10 oz. spaghetti sauce, dated 2/8/23; one dented 7 lb. 3 oz. can of ketchup, dated 2/8/23; and one dented 6 lb. 8 oz. fruit cocktail, dated 3/15/23, on the shelving in the dry food storage area; - One ceiling ventilation cover coated with gray dust and grime in the dry food storage area. 2. Observations on 100 and 200 hall showed: - On 3/28/23 at 11:55 A.M., an uncovered resident meal cart on the 100 hall with five uncovered small bowls of chocolate pudding and five uncovered drinks; - On 3/29/23 at 12:15 P.M., an uncovered resident meal cart on the 200 hall with seven uncovered small bowls of peach cobbler and seven uncovered drinks. During an interview on 3/30/23 at 2:20 P.M., Dietary Aide (DA) B said he/she delivered hall trays with the entrees covered, but had never been told to cover the desserts or the drinks on the cart. He/she had never delivered covered drinks or desserts. During an interview on 3/30/23 at 2:31 P.M., the Dietary Manager (DM) said that hall trays should be delivered with all food, drink, and utensils covered. The desserts and drinks should be covered with clear plastic wrap and should not leave the kitchen unless they were covered. 3. Observations of the kitchen on 3/29/23 at 9:22 A.M., showed: - The floor beneath the gas range, freezers, and the food prep counters with brown grime build-up and debris; - The gas range top surface with black grime build-up and flakes around the burners; - One ventilation cover over the dishwashing sink area with brown grime build-up between the louvers; - Eight 12 in. x 18 in. x 1 in. deep baking pans with black grime build-up on the inside corners, on the cooking surface and the outer surfaces; - Two 12 cup muffin baking pans with brown grime build-up on the cooking surface. 4. Observations of the kitchen on 3/30/23 at 9:53 A.M., showed: - The gas range top surface with black grime build-up and flakes around the burners; - One commercial can opener with black grime on the blade and black grime/corrosion on the attached bracket; - Paint and caulk peeled from the wall area surrounding a window air conditioning unit above the sink area; - One 3 ft. x 6 ft. section of unpainted ceiling near the steam table; - The range hood with paint peeled away from the areas with a dark brown substance on the interior; - The steam table with paint peeled away from the front surface near the controls; - The microwave oven with paint peeled away and a dark brown substance on the edge of the interior surface. During an interview on 3/30/23 at 9:53 A.M., DA A said he/she she washed the can opener after every two openings. The base and other surfaces were only cleaned every two months. The blade was chipped and the blade wasn't sharp enough and needed replaced. During an interview on 3/31/23 at 9:46 A.M., the DM said he/she wasn't aware that food shelves should be at least six inches above the floor level. There should be no dented cans in the dry food storage area. The food shelves and walls in the kitchen should be clean and paint should not be chipped. He/she said the appliances and floors should be clean on all surfaces. The ceilings should not have cracks and should be painted. The ceiling and wall ventilation covers should be clean and free of dust and dirt in the kitchen. The walk-in refrigerator door should close completely. He/she said the baking pans and cooking utensils should be clean and shouldn't have carbon build up. The Registered Dietician had recommended replacing the kitchen's microwave. During an interview on 3/31/23 at 9:50 A.M., the Administrator said she wasn't aware that food shelves should be at least six inches above the floor level. There should be no dented cans in the food storage area. The vents should be clean. The food shelves and walls in the kitchen should be clean and painted. She said the appliances and floors should be clean on all surfaces. The ceilings should not have cracks and should be painted. She said the heating ventilation and air conditioning system (HVAC) (the system responsible for heating and cooling a building) vents should be clean and free of dust. The walk-in refrigerator door should close completely. She said no hall trays should be delivered without being covered, which included drinks and desserts. The baking pans and cooking utensils should be clean and not have carbon or grime build up. She said the chest type freezers should not have frost build up.

Based on interview and record review, the facility failed to complete comprehensive Minimum Data Set (MDS) (a federally mandated assessment tool completed by the facility staff) assessments within the required time frames for one resident (Resident #18) out of 12 sampled residents and five residents (Resident #131, #132, #133, #181, and #184) outside of the sample. The facility census was 36. Record review of the facility's Resident Assessments policy, revised March 2022, showed: - The resident assessment coordinator is responsible for ensuring the appropriate resident assessments and reviews are completed; - The Resident Assessment Instrument (RAI) (the manual used to help staff gather definitive information on the resident's strengths and needs which must be addressed in the MDS and care plans) provides detailed information on timing and submission of the assessments. 1. Record review of Resident #18's medical record showed: - An admitted [DATE]; - An annual MDS, dated [DATE]; - No comprehensive MDS assessment completed within 366 calendar days of the last annual MDS assessment. 2. Record review of Resident #131's medical record showed: - An admitted [DATE]; - An annual MDS, dated [DATE]; - No comprehensive MDS assessment completed within 366 calendar days of the last comprehensive MDS assessment. 3. Record review of Resident #132's medical record showed: - An admitted [DATE]; - No comprehensive admission MDS completed within 14 days after admission. 4. Record review of Resident #133's medical record showed: - An admitted [DATE]; - No comprehensive admission MDS completed within 14 days after admission. 5. Record review of Resident #181's medical record showed: - An admitted [DATE]; - An annual MDS, dated [DATE]; - No comprehensive MDS completed within 366 calendar days of the last annual MDS. 6. Record review of Resident #184's medical record showed: - An admitted [DATE]; - An annual MDS, dated [DATE]; - No comprehensive MDS completed within 366 calendar days of the last annual MDS. During an interview on 3/28/23 at 1:30 P.M., the Director of Nursing (DON) said the facility went through multiple MDS Coordinators. They were behind with MDSs from before she started at the end of last year. During an interview on 3/31/23 at 1:30 P.M., the MDS Coordinator said annual MDS assessments should be completed. Admission assessments should be completed within 14 days of admission. During an interview on 3/31/23 at 1:35 P.M., the DON said admission and annual MDS assessments should be completed on each resident. During an interview on 3/31/23 at 1:36 P.M., the Administrator said she would expect all MDS assessments to be completed per the required time frame.

Based on interview and record review, the facility failed to complete a quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, within the required timeframe for two residents (Resident #16 and #23) of 12 sampled residents and 15 residents (Resident #1, #8, #11, #17, #22, #81, #82, #83, #84, #85, #86, #133, #181, #184, and #185 ) outside the sampled residents. The facility's census was 36. Record review of the facility's Resident Assessments policy, Revised March 2022, showed: - The resident assessment coordinator is responsible for ensuring that the appropriate resident assessments and reviews are completed; - The Resident Assessment Instrument (RAI) (the manual used to help staff gather definitive information on the resident's strengths and needs which must be addressed on the MDS and care plans provides detailed information on timing and submission of the MDS assessments. 1. Record review of Resident #1's medical record showed: - An admitted [DATE]; - A quarterly MDS, dated [DATE]; - The facility did not complete a quarterly MDS for the resident within 92 days of the last MDS. 2. Record review of Resident #8's medical record showed: - An admitted [DATE]; - A quarterly MDS, dated [DATE]; - The facility did not complete a quarterly MDS for the resident within 92 days of the last MDS. 3. Record review of Resident #11's medical record showed: - An admitted [DATE]; - An admission MDS, dated [DATE]; - The facility did not complete a quarterly MDS for the resident within 92 days of the last MDS. 4. Record review of Resident #16's medical record showed: - An admitted [DATE]; - No admission MDS completed; - No quarterly MDS completed; - The facility did not complete a quarterly MDS for the resident within 92 days of the last MDS. 5. Record review of Resident #17's medical record showed: - An admitted [DATE]; - A quarterly MDS, dated [DATE]; - The facility did not complete a quarterly MDS for the resident within 92 days of the last MDS. 6. Record review of Resident #22's medical record showed: - An admitted [DATE]; - An admission MDS, dated [DATE]; - The facility did not complete a quarterly MDS for the resident within 92 days of the last MDS. 7. Record review of Resident #23's medical record showed: - An admitted [DATE]; - An admission MDS, dated [DATE]; - The facility did not complete the last two quarterly MDSs for the resident within 92 days of the last MDS. 8. Record review of Resident #81's medical record showed: - An admitted [DATE]; - A quarterly MDS, dated [DATE]; - The facility did not complete the last two quarterly MDSs for the resident within 92 days of the last MDS. 9. Record review of Resident #82's medical record showed: - An admitted [DATE]; - A quarterly MDS, dated [DATE]; - The facility did not complete the last two quarterly MDSs for the resident within 92 days of the last MDS. 10. Record review of Resident #83's medical record showed: - An admitted [DATE]; - A quarterly MDS, dated [DATE]; - The facility did not complete the last two quarterly MDS for the resident within 92 days of the last MDS. 11. Record review of Resident #84's medical record showed: - An admitted [DATE]; - A quarterly MDS, dated [DATE]; - The facility did not complete the last two quarterly MDSs for the resident within 92 days of the last MDS. 12. Record review of Resident #85's medical record showed: - An admitted [DATE]; - A quarterly MDS, dated [DATE]; - The facility did not complete the last two quarterly MDSs for the resident within 92 days of the last MDS. 13. Record review of Resident #86's medical record showed: - An admitted [DATE]; - A quarterly MDS, dated [DATE]; - The facility did not complete the last two quarterly MDSs for the resident within 92 days of the last MDS. 14. Record review of Resident #133's medical record showed: - An admitted [DATE]; - No quarterly MDS; - The facility did not complete a quarterly MDS for the resident within 92 days of the last MDS. 15. Record review of Resident #181's medical record showed: - An admitted [DATE]; - A quarterly MDS, dated [DATE]; - The facility did not complete a quarterly MDS for the resident within 92 days of the last MDS. 16. Record review of Resident #184's medical record showed: - An admitted [DATE]; - A quarterly MDS, dated [DATE]; - The facility did not complete the last two quarterly MDSs for the resident within 92 days of the last MDS. 17. Record review of Resident #185 medical record showed: - An admitted [DATE]; - An admission MDS, dated [DATE]; - The facility did not complete the last two quarterly MDSs for the resident within 92 days of the last MDS. 18. Record review of Resident #186's medical record showed: - An admitted [DATE]; - A quarterly MDS, dated [DATE]; - The facility did not complete the last two quarterly MDSs for the resident within 92 days of the last MDS. During an interview on 3/31/23 at 1:35 P.M., the MDS Coordinator said he/she was responsible for the MDSs, and they should be completed within seven days of an admission, quarterly and with significant changes. During an interview on 3/31/23 at 1:45 P.M., the Administrator said she would expect MD's to be completed in the appropriate timeframe. They were putting the previous MDS Coordinator back in place and hoped to get back on track.

Based on observation, interview, and record review, the facility failed to update and revise care plans with specific interventions tailored to meet individual needs for three residents, (Resident #15, #19, #134) or include the resident and/or the guardian for four residents (Resident #15, #18, #19, and #134) and the interdisciplinary care team (IDT) (a group of health care professionals from diverse fields who work in a coordinated effort toward a common goal for a resident) for two residents (Resident #15 and #134) out of 12 sampled residents. The facility census was 36. Record review of the facility's Care Plans, Comprehensive Person- Centered policy, revised March 2022, showed: - The comprehensive, person-centered care plan is developed within seven days of the completion of the required Minimum Data Set (MDS) (a federally mandated assessment instrument completed by the facility staff) and no more than 21 days after admission; - The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment; - The comprehensive, person-centered care plan should describe services that are to be furnished to attain or maintain the resident's highest practicable well-being; -The IDT reviews and updates the care plan when there is a significant change, desired outcome is not met, when the resident is readmitted to the facility from a hospital stay and at least quarterly in conjunction with quarterly MDS assessments; - The IDT in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan; - The resident is informed of his or her right to participate in his or her treatment, and provided advance notice of care planning conferences. 1. Record review of Resident #15's Physician Order Sheet (POS), dated March 2023, showed no order for an anticoagulant (a blood thinner medication). Record review of the resident's care plan, reviewed on 3/6/23, showed: - The resident received an anticoagulant medication; - The facility did not revise the care plan to discontinue the anticoagulant; - The resident's name and/or the resident representative's name not included for attendance of the care plan conferences; - No documentation of the resident and/or the resident representative nor any of the IDT attended the care plan conference. During an interview on 3/28/23 at 10:05 A.M., Resident #15 said he/she was not invited to his/her care plan meetings. 2. Record review of Resident #18's medical record showed: - An admitted [DATE]; - Diagnosis of Alzheimer's disease (a progressive mental deterioration); Record review of the resident's care plan, revised on 11/9/21, showed: - The care plan dated from a prior admission; - A current admitted [DATE]; - No documentation of the resident and/or the resident representative invited and/or attended the care plan conferences. 3. Record review of Resident #19's POS, dated March 2023, showed: - Diagnosis of Stage 2 (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough (dead tissue)) pressure ulcer (damage to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) to the coccyx (a small triangular bone at the base of the spinal column); - An order dated 2/27/23 to cleanse the Stage 2 pressure ulcer to the coccyx with wound cleanser, pat dry, apply skin prep (a wound treatment) to the peri wound (the area around a wound). Apply triad cream (a wound treatment) to the wound bed and cover with boarder gauze (a type of dressing). Change daily and as needed (PRN). Facility staff to change daily, with hospice to change when present for visit. Observation on 3/29/23 at 1:00 P.M., Registered Nurse (RN) C cleansed two open wounds to the resident's coccyx, applied the skin prep to the peri wound, applied triad cream to the wound bed and covered with a boarder gauze. Record review of the resident's care plan, revised 1/10/23, showed: - The facility did not revise the care plan to reflect the pressure ulcer and the wound care; - No documentation of the resident and/or the resident's guardian invited and/or attended the care plan conferences. 4. Record review of Resident #134's medical record showed: - Diagnosis of Alzheimer's disease; - Impaired cognition; - To have a guardian; - Nurses Note, dated 2/25/23, the resident found sitting on the bathroom floor. Resident said he/she fell when getting on the toilet. Record review of the resident's care plan, revised on 11/10/22, showed: - Did not address the resident's three falls with additional interventions since 9/27/22; - No documentation of the resident and/or the resident representative invited and/or attended the care plan conferences dated 8/12/22 and 11/10/22; - No documentation of the resident and/or the resident representative invited and/or attended nor any of the IDT attended the care plan conference for 2/24/23. During an interview on 3/30/23 at 2:25 P.M., the Corporate Nurse said the system the facility used for care plans pulls over the previous admitted . A book that showed how to correct the date will be provided to the facility. During an interview on 3/31/23 at 1:38 P.M., the MDS Coordinator said he/she and the nursing staff were responsible for the care plans, including but not limited to, care issues, such as hospice, dialysis, wounds, and tube feedings. Care plans should be updated quarterly, and with changes to the resident's status, and new orders. The IDT should be present for care plan meetings to include the resident and/or the family representative. During an interview on 3/31/23 at 1: 48 P.M., the Administrator said she would expect the care plan to be individualized to meet the resident's needs and to be updated in a timely manner. The IDT should be utilized for care plan meetings. The resident and/or the family representative should also be invited and documented if they attend or not. 46521

Based on interview and record review, the facility failed to provide documentation of ongoing assessments, monitoring, and communication between the facility and the dialysis (a process for removing waste and excess water from the blood) center for one resident (Resident #15) out of one sampled resident. The facility's census was 36. Record review of the facility's End-Stage Renal Disease (ESRD), Care of a Resident With policy, revised September 2010, showed: - Staff caring for residents with ESRD, including residents receiving dialysis care outside the facility, shall be trained in the care of these resident; - Education and training of staff includes the type of assessment data that is to be gathered about the resident's condition; - Agreements between the facility and the contracted ESRD facility include all aspects of how the resident's care will be managed, including how information will be exchanged between the facilities; - The resident's comprehensive care plan will reflect the resident's needs related to ESRD/dialysis care. 1. Record review of Resident #15's medical record showed: - Diagnosis of chronic kidney disease (longstanding disease of the kidneys leading to renal failure); - Started dialysis on 2/16/23; - Attended dialysis treatments three times a week; - No physician's order for the dialysis treatments; - The dialysis communication record with no communication between the facility and the dialysis staff from 2/20/23 through 3/8/23; - The dialysis communication record with the resident's shunt site not addressed on 3/13/23; - The dialysis communication record with three undated communications with the shunt site and returning weight not addressed. During an interview on 3/30/23 at 2:58 P.M., the Director of Nursing (DON) said she did not know there needed to be a physician's order for dialysis, but she would obtain one. During an interview on 3/28/23 at 3:43 P.M., Resident #15 said staff do not look or touch his/her port before or after dialysis. He/she went to dialysis three times a week and had never missed an appointment. During an interview on 3/28/23 at 3:53 P.M., the DON said the resident started dialysis in the hospital and came back to the facility with dialysis three times a week. The communication between the facility and the dialysis center just started in March 2023, but the documentation needs to be improved. During an interview on 3/31/23 at 1:30 P.M., the Administrator said she expected orders to be obtained for treatments and special services. She also expected communication to be completed between the facility and the dialysis center.

Based on interview and record review, the facility failed to complete a significant change Minimum Data Set (MDS) (a federally mandated assessment tool completed by the facility), assessment for three residents (Resident #18, #19, and #23) out of 12 sampled residents. The facility's census was 36. Record review of the facility's Resident Assessments policy, Revised March 2022, showed: - The resident assessment coordinator is responsible for ensuring that the appropriate resident assessments and reviews are completed; - The Resident Assessment Instrument (RAI) (the manual used to help staff gather definitive information on the resident's strengths and needs which must be addressed on the MDS and care plans) provides detailed information on timing and submission of the MDS assessments. 1. Record review of the Resident #18's medical record showed: - An admitted [DATE]; - admitted to hospice (health care focused on the quality of life of a terminally ill person) care on 2/15/23; - The facility did not complete a significant change MDS within 14 days after the election of the resident's hospice benefit. 2. Record review of Resident #19's medical record showed: - An admitted [DATE]; - admitted to hospice care on 1/10/23; - The facility did not complete a significant change MDS within 14 days after the election of the resident's hospice benefit. 3. Record review of Resident #23's medical record showed: - An admitted [DATE]; - admitted to hospice care on 2/28/23; - The facility did not complete a significant change MDS within 14 days after election of the resident's hospice benefit. During an interview on 3/28/23 at 1:30 P.M., the Director of Nursing (DON) said the facility went through multiple MDS Coordinators. They were behind from before she started at the end of last year. During an interview on 3/31/23 at 1:30 P.M., the MDS Coordinator said a significant change MDS should be completed when a resident experienced a significant change in condition, such as being admitted to hospice services. During an interview on 3/31/23 at 1:35 P.M., the DON said a significant change MDS should be completed within 14 days after a significant change in the resident's condition, such as being admitted to hospice services. During an interview on 3/31/23 at 1:36 P.M., the Administrator said she would expect a significant change MDS to be completed during the appropriate timeframe. 46521

Based on observation, interview and record review, the facility failed to maintain a safe, clean, comfortable, and homelike environment. The facility's census was 36. Record review of the facility's Maintenance Service policy, revised December 2009, showed: - Maintenance service shall be provided to all areas of the building, grounds, and equipment; - The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times; - Functions of maintenance personnel include, but are not limited to: maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines; maintaining the building in good repair and free from hazards; maintaining the fire alarm system and emergency generator system in good working order; maintaining the heat/cooling system, plumbing fixtures, wiring, etc., in good working order; maintaining lighting levels that are comfortable, and assuring that exit lights are in good working order; establishing priorities in providing repair service; maintaining the paging system in good working order; maintaining the grounds, sidewalks, parking lots, etc., in good order; providing routinely scheduled maintenance service to all areas; and others that may become necessary or appropriate; - The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner; - Maintenance personnel shall follow the manufacturer's recommended maintenance schedule; - Maintenance personnel shall follow established infection control precautions in the performance of their daily work assignments; - The Maintenance Director is responsible for maintaining the following records/ reports: inspection of the building, work order requests, maintenance schedules, authorized vendor listing, and warranties and guarantees; - Records shall be maintained in the Maintenance Director's office; - Maintenance personnel shall follow established safety regulations to ensure the safety and well-being of all concerned. Observations of the north hallway shower room on 3/31/23 at 12:22 P.M., showed: - A musty odor; - A shower head with a brown substance; - The shower floor with 1 inch (in.) x 1 in. ceramic tiles with black grime along the grout cracks near the front entrance to the shower; - The perimeter of the shower floor with brown and black grime build up along the caulk; - Three lower shower stall wall sections with a black build up; - A towel rack with a brown substance; - A section of peeled paint and a brown substance on the shower ceiling; - A section of white ceramic tiles outside of the shower stall with black grime along the edges. Observation of room [ROOM NUMBER]'s bathroom on 3/31/23 at 12:22 P.M., showed: - Black grime build-up around the base of the toilet; - One section of caulk around the sink edge with 1/2 in. gap between the sink and the wall; - The wall under the hand sanitizer dispenser stained with hand sanitizer. Observation of the room [ROOM NUMBER]'s bathroom on 3/31/23 at 12:32 P.M., showed: - One section of caulk around the sink edge with 1/2 in. gap between the sink and the wall; - The toilet with brown grime on the floor below the front edge; - One wall section to the right of the toilet near the floor with a 3 foot (ft.) diameter (diam.) brown patch; - One vanity mirror with no reflective coating on 1 in. of the bottom right edge. Observation of the north hallway on 3/31/23 at 1:01 P.M., showed: - One attic stairway with a 1 in. gap between the ceiling and the staircase cover. Observation of the dining room on 3/31/23 at 12:30 P.M., showed: - One 6 ft. wall section behind the ice machine with no baseboard; - A wall section behind the ice machine with a 1 ft. x 1 ft. area with a 1 in. area of pipe exposed; - One 1 ft. x 1 ft. floor tile with white scratch marks in front of the kitchen door; - The floor near the dining tables with 20 - 6 in. black scratches. Record Review of the facility's maintenance log, dated February 2023 and March 2023 showed: - Facility lighting repairs; - Items listed were initialed by the Maintenance Director as resolved; - The issues noted in the observations were not on the list. During an interview on 3/31/23 at 12:16 P.M., Certified Nursing Assistant (CNA) E said if there were issues found with the environment, he/she would write it in the maintenance log. During an interview on 3/31/23 at 12:30 P.M., Housekeeping Aide D said they used disinfectant and an antimicrobial cleaner for hard stains or such. He/she said the Maintenance Director caulked around the shower not too long ago. The shower room was sprayed and cleaned daily, but it didn't ever look that clean. During an interview on 3/31/23 at 1:30 P.M., the Maintenance Director said he/she checked the maintenance log each morning that was kept by the facility. He/she also did daily walk throughs to see if anything needed fixed. If staff found something on the floor, it was placed in the log. He/she placed new caulking in the shower room once and housekeeping had scraped a lot of it away. The facility rooms should be clean and in good condition. During an interview on 3/31/23 at 1:33 P.M., the Administrator said the shower room and the facility should be kept clean and in good condition. During an interview on 3/31/23 at 1:36 P.M., the Director of Nursing said the shower room and the facility should be kept in good condition and be clean.

Based on observation, interview, and record review, the facility failed to ensure proper transfer technique for four residents (Resident #1, #12, #13, and #20) out of 4 sampled residents and one additional resident (Resident #9) outside the sample. The facility census was 27. 1. Record review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, completed 10/3/20 showed: - Extensive two person assist for transfers. Observation on 10/16/20 at 11:20 A.M., showed: - The resident lay in his/her bed; - CNA B assisted the resident to the sitting position; - CNA B placed his/her bilateral arms under the residents bilateral arms; - CNA B lifted the resident to the standing position; turned the resident and lowered the resident to the wheelchair; - The resident's feet did not touch the floor during transfer; - CNA B did not place a gait belt on resident for the transfer. During an interview on 10/16/20 at 11:03 A.M., CNA B said the resident did not bear any weight when assisted to the standing position. 2. Record review of Resident #9's quarterly MDS, dated [DATE] showed: - Extensive one person assist for transfers. Observation on 10/15/20 at 11:10 A.M., showed: - The resident sat in his/her wheelchair; - CNA B placed his/her left hand under the residents left arm; - The resident held the grab bar with his/her right hand, stood and pivoted to sit on the toilet; - CNA B did not place a gait belt on the resident. 3. Record review of Resident #12's quarterly MDS, completed 9/15/20 showed: - Extensive two person assist for transfers. Observation on 10/16/20 at 11:00 A.M., showed: - The resident lay in his/her bed; - CNA B assisted the resident to sitting position; - CNA B placed his/her bilateral arms under the residents bilateral arms; - CNA B assisted the resident to the standing position; - CNA B pivoted the resident and lowered him/her to the wheelchair; - CNA B did not place a gait belt on the resident. During an interview on 10/19/20 at 10:49 A.M., CNA B said sometimes the residents require one person assist sometimes they require two person assist, depending on how they are that day. A gait belt should be used with transfers and they should not be transferred by placing your arms/hands under their arms. 4. Observation on 10/16/20 at 10:50 A.M., of Resident #13 showed: - The resident sat in his/her wheelchair; - CNA A and CNA B placed their arms under the resident's arms, stood the resident up, and pivoted the resident to sit on the bed; - CNA A and CNA B did not place gait belt on the resident. During an interview on 10/16/20 at 2:05 P.M., CNA B said the resident should be a two person transfer. He/She forgot to get the gait belt out of the breakroom. CNA A said staff should not place their arms under the arms to transfer a resident. During an interview on 10/16/20 at 2:15 P.M., CNA A said the resident should be a two person assist with transfers. CNA A said he/she did not have gait belt and thought the other CNA had one. During an interview on 10/19/20 at 12:40 P.M. the Director of Nursing (DON) said Resident #13 should be a two person gait belt transfer. Staff should always use a gait belt when transferring the residents. 5. Record review of Resident #20's quarterly MDS, dated [DATE] showed: - Extensive two person assist for transfers. Observation of Resident #20 on 10/16/20 at 8:47 A.M., showed: - Resident seated on bedside commode; - CNA B bent over and wrapped his/her arms around resident's waist; - CNA B lifted resident up and forward from bedside commode; - CNA B pivoted and sat resident on side of bed; - CNA B did not place a gait belt on resident for the transfer. During an interview on 10/19/20 at 10:50 P.M., CNA B said she did not know that a gait belt was required to transfer Resident #20. Record review of the facility's Resident Handling Policy, dated 5/2000, showed: - The policy exists to ensure a safe working environment for resident handlers. This policy is to be reviewed and signed by all staff who perform or may perform resident handling. - Initial screening will be performed on all residents assess transfer and ambulation status. - Mandatory gait belts (an assistive device which can be used to help safely transfer a resident) for all resident handling with the exception of bed mobility and medical contraindications. - This policy is to be followed at all times.

Based on interview and record review, the facility failed to notify the resident and/or responsible party in writing of a facility-initiated transfer for three residents (Resident #4, #24, and #26) out of three sampled residents. The facility census was 27. Record review of the facility's policy on Transfer or Discharge Notice, dated December 2016 showed: - The resident and/or representative (sponsor) will be notified in writing of the following information: - The reason for the transfer or discharge; - The effective date of the transfer or discharge; - The location to which the resident is being transferred or discharged ; - A copy of this notice will be sent to the Office of the State Long-Term Care Ombudsman. 1. Record review of Resident #4's medical record showed: - Resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. - Did not contain documentation of a letter which notified the resident and/or the resident's representative of the transfer to the hospital. 2. Record review of Resident #24's medical record showed: - Resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. - Did not contain documentation of a letter which notified the resident and/or the resident's representative of the transfer to the hospital. 3. Record review of Resident #26's closed medical record showed: - Resident transferred to the hospital on [DATE] and did not return to the facility; - Did not contain documentation of a letter which notified the resident and/or the resident's representative of the transfer to the hospital. During an interview on 10/19/20 at 12:45 P.M., the Director of Nursing (DON) said she did not realize the transfer/discharge notice had to be done, she thought the facility was doing what needed to be done, by giving the resident or representative the bed hold policy. During an interview on 10/19/20 at 12:50 P.M., the Corporate Nurse said the corporation had a form and this facility would use it.

Based on interview and record review, the facility failed to ensure the status of the advance directives (a written instruction, such as a living will or durable power of attorney for health care, recognized under State law relating to the provision of health care when the individual is incapacitated) regarding the resuscitation status for one resident (Resident #25) outside the sample. The facility census was 27. Record review of the facility's Advance Directives policy, dated December 2016, showed: - Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so; - If the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident's legal representative; - Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. 1. Record review of Resident #25's medical record showed: - admitted to facility on 9/25/20; - Advance Directives explained section of the Interim Care Plan, dated 9/25/20, not completed; - physician's orders [REDACTED]. - Face Sheet located in front of medical chart, did not show a code status for the resident; - No Advance Directives or code status located in Resident's medical chart. During an interview on 10/19/20 at 10:05 A.M., the Social Services Director said the Resident is a Full Code (will allow all interventions needed to restart heart), and the code status should be listed on the Resident's POS. During and interview on 10/19/20 at 10:15 A.M., LPN C, said if a purple colored Do Not Resuscitate (DNR) paper is not in the Advanced Directive section at the front of the resident's chart, then they are to be treated as a Full Code, and their code status should be listed on the current POS.

Based on interview, and record review, the facility failed to accurately code the Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, for two residents (Resident #19 and #20) out of 12 sampled residents, and one resident (Resident #25) outside the sample. The facility census was 27. 1. Record review of Resident #19's Quarterly MDS, dated [DATE] showed: - A [DIAGNOSES REDACTED]. - The N410E area marked for an anticoagulant (medication that slows down the process of making clots). Record review of the resident's September 2020 physician's orders [REDACTED]. - A [DIAGNOSES REDACTED].>- No order for an anticoagulant. Record review of the resident's October 2020 POS showed: - A [DIAGNOSES REDACTED].>- No order for an anticoagulant. 2. Record review of Resident #20's Quarterly MDS, dated [DATE] showed: - A [DIAGNOSES REDACTED]. - The N410E area marked for an anticoagulant. Record review of the resident's September 2020 POS showed: - A [DIAGNOSES REDACTED].>- No order for an anticoagulant. Record review of the resident's October 2020 POS showed: - A [DIAGNOSES REDACTED].>- No order for an anticoagulant. 3. Record review of Resident #25's Admission MDS, dated [DATE] showed: - A [DIAGNOSES REDACTED].>- The N410E area marked for an anticoagulant. Record review of the resident's October 2020 POS showed: - No order for an anticoagulant. During an interview on 10/19/20 at 12:10 P.M., the MDS coordinator said she always marks [MEDICATION NAME] as an anticoagulant on the MDS and did not know it was one of the medications that was not supposed to be marked. During an interview on 10/19/20 at 12:40 P.M., the Director of Nursing (DON) said she was not aware the MDS had been marked incorrectly.