Every finding on record at Salem Memorial District Hospital

Based on interview and record review, facility staff failed to provide documentation of monthly drug regimen reviews for five (Residents #1, #2, #4, #13 and #15) of five sampled residents. The facility census was 13.1. Review of the facility's policy titled Long Term Care Drug Regimen Review, dated 06/20/22, showed the drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist. This review must include a review of the resident's medical chart.2. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 09/17/25, showed staff assessed the resident as: -Cognitively intact;-Diagnoses of Diabetes, urinary tract infection (UTI) and paraplegia, paralysis of the legs and lower body;-Received opioids; -Received anticoagulants; -Received antibiotics; -Received anti-anxiety medication;-Received insulin injections seven of the past seven days. Review of the resident's medical record showed the record did not contain documentation the pharmacist conducted a medical record review, at least monthly, that included a review of the resident's medical record and/or documentation the pharmacist reported irregularities, if any, to the attending physician, medical director and the Director of Nursing (DON). 3. Review of Resident #2's Annual MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact;-Diagnoses of diabetes, coronary artery disease, peripheral vascular disease, renal failure, stroke, anxiety and depression;-Received anti-anxiety medication;-Received anti-depression medication;-Received diuretic medication;-Received opioids;-Received anti-platelet medication. Review of the resident's medical record showed the record did not contain documentation the pharmacist conducted a medical record review, at least monthly, that included a review of the resident's medical record and/or documentation the pharmacist reported irregularities, if any, to the attending physician, medical director and the DON. 4. Review of Resident #4's Significant Change in Status (SCSA) MDS dated [DATE], showed staff assessed the resident as: -Cognitively impaired;-Delusional;-Received pain medication as needed;-Received an antipsychotic, antidepressant and antiplatelet medication;-Diagnoses of heart disease, malnutrition, stroke, dementia, depression, arthritis, and hemiplegia (inability to use one side of body). Review of the resident's care plan dated 08/12/25 directed staff to ensure a pharmacy review is completed monthly. Review of the resident's medical record showed the record did not contain documentation the pharmacist conducted a medical record review, at least monthly, that included a review of the resident's medical record and/or documentation the pharmacist reported irregularities, if any, to the attending physician, medical director and the DON. 5. Review of Resident #13's Quarterly MDS dated [DATE], showed staff assessed the resident as: -Cognitively severely impaired;-Diagnoses of non-traumatic brain dysfunction, heart disease, Alzheimer's disease, anxiety and depression;-Received antipsychotic, antidepressant, anti-anxiety medication. Review of the resident's medical record showed the record did not contain documentation the pharmacist conducted a medical record review, at least monthly, that included a review of the resident's medical record and/or documentation the pharmacist reported irregularities, if any, to the attending physician, medical director and the DON. 6. Review of Resident #15's Annual MDS, dated [DATE], showed staff assessed the resident as: -Cognitively severely impaired;-Diagnoses of non-traumatic brain dysfunction, atrial fibrillation, and Alzheimer's disease;-Received antipsychotic medication. Review of the resident's medical record showed the record did not contain documentation the pharmacist conducted a medical record review, at least monthly, that included a review of the resident's medical record and/or documentation the pharmacist reported irregularities, if any, to the attending physician, medical director and the DON. 7. During an interview on 10/16/25 at 10:45 A.M., the facility director said the pharmacist chooses a day each month to go through resident charts to review medications prescribed. If a change is recommended, a sheet is filled out and left in the chart. He/She said they are provided no documentation that the review was completed if a change is not recommended. He/She said staff assume reviews are completed as required.During an interview on 10/16/25 at 11:09 A.M. the Administrator said the documentation provided does not indicate the reviews were completed. Staff are expected to complete the pharmacy reviews as required.

Based on interview and record review, facility staff failed to designate a person to serve as the Director of Food and Nutrition Services with the appropriate qualifications, when the facility did not employ a qualified dietitian or other clinically qualified nutrition professional full-time. This failure has the potential to affect all residents. The facility census was 17.1. Review of the facility's job description titled Food Service Director dated 04/08/21, showed the purpose of the position is to provide supervision over all dietary functions and staff as directed/instructed, which included assisting in planning, organizing, developing, implementing, and directing the dietary services department, as well as its program and activities, in accordance with current rules, regulations, and guidelines that govern the facility. Review of the food service director's personnel records showed a hire date for the food service director's position listed as 01/27/25. Review showed the records did not contain documentation of prior dietary management experience in a nursing facility and certification or other education required for the director of food and nutrition services position. During an interview on 10/14/25 at 11:00 A.M., the food service director said he/she has been the food service director since January 2025, he/she did not have prior experience as a dietary manager in a nursing facility and he/she did not have a degree or certification related to food service management. The food service director said he/she enrolled in an online certified dietary manager's course on 10/13/25, but he/she had not started the course yet. The food service director said the facility's registered dietician only works part-time and the facility did not have any certified or clinically qualified nutritional staff employed full-time. During an interview on 10/15/25 at 1:43 P.M., the Chief Executive Officer (CEO) said the food service director had been the facility's Director of Food and Nutrition Services since January 2025. The CEO said the facility's registered dietician works part-time and the facility did not have any certified or clinically qualified nutritional staff employed full-time. The CEO said he/she knew the food service director did not have the qualifications required for the Director of Food and Nutrition Services position, but he/she thought they had a grace period to get him/her certified and did not know he/she needed to meet the requirements upon hire.

Based on interview and record review, facility staff failed to follow professional standards when physical therapy orders were not initiated for one resident (Resident #1). The facility census was 13.1. Review of the facility's policy titled Medication Management: Ordering and Transcribing, dated 03/01/14, showed all medication and treatment orders shall be written in the medical record or entered in the computerized order entry system of the resident and signed by the ordering licensed independent practitioner. All orders for treatment shall include the type of treatment, specific requirements of the treatment and frequency of the treatment.2. Review of Resident #1's Quarterly Minimum Data Sheet (MDS), a federally mandated assessment tool, dated 09/17/25, showed staff assessed the resident as cognitively intact with a diagnosis of paraplegia, (a severe or complete loss of motor function in the lower extremities and lower portions of the trunk), and generalized muscle weakness.Review of the resident's care plan, dated 09/23/25, showed the resident's goal related to paraplegia and general weakness was to remain as independent as possible. Provide restorative care for passive/active range of motion as ordered.Review of the resident's outpatient discharge records, dated 09/29/25, showed an order for physical therapy at least one hour per day, five days per week, for core and bilateral lower extremity strength, range of motion, transfers, and mobility. Review of the resident's physician order summary (POS), dated 10/15/25, showed the orders did not contain an order for restorative care or physical therapy.3. During an interview on 10/14/25 at 4:13 P.M., the resident said at one time he/she received physical therapy, but he/she had not for about a month and a half. The resident said he/she is supposed to get restorative therapy, and he/she is not. The resident said he/she would like additional exercise, especially for his/her upper body, to maintain strength, and become more independent.During an interview on 10/16/25 at 08:45 A.M., Licensed Practical Nurse (LPN) A said the process for activating written clinic orders is to fax the order to the physician's office, and if the physician approves it, a signed order is sent to the facility or a verbal order is received. The order is transcribed to the medical record by nursing staff. LPN A said he/she thought the physical therapy order had been sent to the physician's office, but he/she did not remember receiving a response. During an interview on 10/16/25 at 8:55 A.M., the facility director said when an order is obtained from an outside source the expectation is to contact the facility physician via fax or phone for approval, and he/she did not know if the physician had been contacted. He/She said typically a nurse from the physician's office calls back with a verbal order, which should be transcribed by the nurse who receives it. The director said it looks like the physical therapy order had not been transcribed. He/She said the risks of resident inactivity include skin breakdown, weakness, blood clots and pneumonia. The facility director said when orders are missed, an incident report is written, and education is provided. During an interview on 10/16/25 at 11:08 A.M., the administrator said when new orders are received, the facility physician reviews the orders and determines if they are necessary, and approved orders are relayed to the nursing staff. The administrator said the nursing staff and facility director are responsible to follow up on all orders. He/She said gaps in service due to missed orders has the potential to lead to decline in the resident's condition.During an interview on 10/16/25 at 11:20 A.M., the physician said he/she has tried to get the resident physical therapy for a long time. The physician said he/she did not recall receiving a faxed order for the resident's physical therapy, but said if he/she had, it would have been approved. The physician said he/she guarantees this resident will experience a decline in physical and mental status without increased physical activity such as that provided by physical therapy.

Reviewed AT Based on observation, interview, and record review, facility staff failed to follow professional standards when staff prepared four medication cups with medications prior to the timed medication pass and left one resident (Resident #10) medication unattended on top of the medication cart. Facility staff failed to notify three resident's (Resident #5, #7, and #13) physician regarding medications not being administered on time. The facility census was 18. 1. Review of the Facility's Administration of Drugs policy, dated 01/24/14, showed medications may not be prepared in advance and must be administered within one hour of preparation. 2. Observation on 09/25/24 at 10:10 A.M., showed the medication cart contained: -One medication cup labeled with a first name contained one pill; -One medication cup labeled with a first name contained eight various pills; -One medication cup labeled with a first name contained two various pills; -One medication cup labeled with a first name contained five various pills. During an interview on 09/25/24 at 10:10 A.M., Licensed Practical Nurse (LPN) A said the medications in the medicine cups were pre-popped for his/her morning medication pass. He/She said the medications are in his/her cart pre-popped while he/she is waiting for staff to get residents out of bed for the day. He/She said he/she cannot pass the medications while they are in bed because they are at risk for choking and he/she does not want to forget to pass them later. He/She said he/she is unsure what the facilities policy is on pre-popping medications. He/she said he/she has seen other staff pre-pop pills, so he/she believes it is okay. During an interview on 09/27/24 at 2:10 P.M., the Chief Nursing Officer (CNO) said the nurses should only be popping pills right before administration to each resident, and he/she expects the nurse to prepare medications for one resident at a time. During an interview on 09/27/24 at 2:26 P.M., the Unit Nurse Manager said he/she does not expect the nurses to practice pre-popping residents' medications. During an interview on 09/27/24 at 3:03 P.M., the Cheif Executive Officer (CEO) said he/she expects staff to prepare a resident's medications immediately before the scheduled time to administer the medication. 3. Review of the Facility's Medication Security policy, dated 03/01/14, showed: -All drugs and biologicals stored in this hospital shall be kept in a secure area, [NAME] when appropriate and accessible only to authorized personnel; -All drugs and biologicals, except those intended for crash carts use, will be stored in lockable containers or areas; -All medications at nurse stations shall be in lockable storage atv all times. Medications are stored either in lockable medicatioin carts/automated disensing machine or the medication room. 4. Review of Resident #10's Minimum Data Set (MDS), a federally mandated assessment tool, dated 07/22/24 showed staff assessed the resident as follows: -Severe cognitive impairment; -Used feeding tube; -Diagnosis of traumatic brain dysfunction. Observation on 09/25/24 at 10:54 A.M., showed LPN A prepared the resident's medication and left the medication cup on top of the medication cart unattended. Observation on 09/25/24 at 11:05 A.M., and 11:19 A.M., showed LPN A left the medication cart unattended and out of sight at the nurse's station as he/she went down the hall to a resident's room. Observation showed multiple residents seated at the nurse's station. During an interview on 09/26/24 at 5:33 P.M., LPN A said he/she placed the resident's medications in the cup of water on top of the cart so they could be dissolved before they were administered to the resident. The LPN said he/she must have stepped away from the cart to answer a call light or something like that, not realizing the medications were left unattended. The LPN said leaving the meds unattended on top of the cart created the risk of someone taking it, and he/she should have probably placed the cup in the top drawer of the cart when he/she stepped away from the cart. During an interview on 09/27/24 at 2:10 P.M., the CNO said it is not okay for staff to leave medications unattended on the cart or anywhere else, as it creates the risk for someone to take it. During an interview on 09/27/24 at 2:26 P.M., the Unit Nurse Manager said it is not okay for the nurse to leave medications unattended on the cart, due to the risk for someone such as a confused resident could get a hold of the medications and potentially take them. During an interview on 09/27/24 at 3:03 P.M., the CEO said staff should not leave medications unattended on the cart because staff could lose track of whose medication it is, someone could take it, or the medications could also be accidentally spilled. 5. Review of the Facility's Medication error policy, dated May 2024, showed when a medication error is made and/or discovered by the nursing staff, the following steps are to be taken: -The patient is to be observed closely for any signs of adverse reaction; -The patient's physician is to be notified of the nature of the error; -An incident report is to be completed immediately by the person discovering the error, completed as thoroughly as possible and submitted to the nursing supervisor; -The error is to be charted in the patient's medical record, stating what was done wrong. 6. Review of Resident #5's annual MDS, dated [DATE], showed staff assessed the resident with severe cognitive impairment and Alzheimer's disease. Review of the resident's Physician Order Sheet (POS), dated September 2024, showed staff is directed to administer the following medications at 8:00 A.M.: -Levothyroxine (treat low thyroid) 100 microgram (mcg); -Tramadol (pain reliever) 50 milligrams (mg); -Aspirin (reduce the risk of heart attack) 81 mg; -Sennoside/docusate (treat constipation) 8.6/50 mg; -Multivitamin. Observation on 09/25/24 at 10:50 A.M., showed LPN A administered levothyroxine, tramadol, aspirin, sennoside/docusate, and a multivitamin to the resident. Review of the resident's medical record did not contain documention staff notified the resident's physician the resident's medication were administered late. 7. Review of Resident #7's admission MDS, dated [DATE] showed staff assessed the resident with mild cognitive impairment and dementia. Review of the resident's POS, dated September 2024, showed staff is directed to administer the following medications at 8:00 A.M.: -Pantoprazole (acid reducer) 40 mg; -Losartan (treat high blood pressure) 50 mg; -Isosorbide mononitrate (prevent chest pain) 30 mg; -Spironolactone (diuretic) 25 mg; -Clonazepam (anti-anxiety) 0.25 mg; -Synthroid (treat low thyroid) 137 mcg at breakfast; -Plavix (blood thinner) 75 mg; -Sertraline (anti-depressant) 100 mg. Observation on 09/25/24 at 10:25 A.M., showed LPN A administered pantoprazole, losartan, isosorbide mononitrate, spironolactone, clonazepam, Synthroid, Plavix, and sertraline to the resident. Review of the resident's medical record did not contain documention staff notified the resident's physician the resident's medication were administered late. 8. Review of Resident #13's annual MDS, dated [DATE] showed staff assessed the resident with severe cognitive impairment and Alzheimer's disease. Review of the resident's POS, dated September 2024, showed staff is directed to administer the following medications at 8:00 A.M: -Furosemide (diuretic) 20 mg; -Florajen (probiotic). Observation on 09/25/24 at 12:00 P.M., showed LPN A administered furosemide and florajen to the resident. Review of the resident's medical record did not contain documention staff notified the resident's physician the resident's medication were administered late. 9. During an interview on 09/26/24 at 2:54 P.M., LPN A said the five rights of medication administration are to ensure the right patient, right medication, right route, right dose, and right time. The LPN said medications ordered to be given at 8 A.M. can be administered between 7 A.M. and 9 A.M., and if administered after 9 A.M., it would be considered a late administration, and maybe a med error. The LPN said if he/she made a med error, he/she thinks there is a form to be filled out, notify the Unit Nurse Manager, and maybe the doctor. The LPN said he/she did not notify the Unit Nurse Manager or the physician about the late medications because he/she just didn't even think about it. During an interview on 09/27/24 at 2:10 P.M., The CNO said he/she expects staff to follow the policy for Medication Administration, and if a nurse administered a medication after the allowed timeframe, that is considered a late administration and a med error. The CNO said if the nurse identified a med error occurred, he/she would expect the nurse to notify the Unit Nurse Manager/CNO, notify the physician of the error and obtain further directions from the physician on whether to administer the medication(s), or not. The CNO said if certain medications are administered late, it could increase the potential for a resident to have a negative outcome. During an interview on 09/27/24 at 2:26 P.M., the Unit Nurse Manager said if the nurse recognizes that medications will be administered late to a resident, or a medication error occurred, he/she would expect the nurse to notify him/her and notify the physician for further directions. During an interview on 09/27/24 at 3:03 P.M., the CEO said he/she expects staff to follow the facility's policies for medication administration, and if a medication is administered past the timeframe, it would be considered late. The CEO said the occurrence of a medication error would depend on the medication and what is stated in the policy. The CEO said if a medication error occurred, he/she would expect the nurse to document the reason for the late administration, alert the physician, CNO, and/or the supervisor at the moment.

Reviewed AT Based on observation, interview, and record review, facility staff failed to obtain informed consent from the resident and/or resident representative for the use of side rails for one resident (Resident #5) and failed to complete an entrapment risk assessment or obtain a physician's order for use of the bed rails for five residents (Resident #5, #8, #11, #12, and #13), out of five sampled residents. The facility census was 18. 1. Review of the facility's policies showed staff did not provide a policy for Entrapment Risk Assessments. Review of the facility's Bed Rails Policy, dated 03/14/2014, showed bed rails are considered a restraint, three rails may be raised at one time to enhance bed mobility of the patient, all four rails may not be raised at the same time. Review of the facility's Consent for Use of Side Rails form, provided to each resident/resident representative at the time of admission, showed staff are directed to obtain a signed consent from the resident/resident representative, and obtain a physician's order including medical symptom/condition/diagnosis for use of the side rail (s). 2. Review of Resident #5's annual Minimum Data Set (MDS), a federally mandated assessment, dated 07/28/24, showed staff assessed the resident as: -Cognition not assessed; -Lower extremity impairment on both sides; -Required maximum assist from staff to roll left and right; -Dependent on staff for lying to sitting on side of bed, sitting to lying in bed. Review of the resident's medical record did not contain a signed consent from the resident and/or resident representative for the use of side rails, an entrapment assessment, or a physician's order for use of side rails. Observation on 09/26/24 at 11:10 A.M., showed the resident in bed on his/her right side with quarter rails on both sides in the upright position. During an interview on 09/27/24 at 10:14 A.M., the Unit Nurse Manager said he/she did not realize the resident's side rail consent form was not filled out or signed. 3. Review of Resident #8's quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -No impairment to upper or lower extremities; -Required substantial/maximum assist from staff to roll left and right, lying to sitting on side of bed, sitting to lying in bed, and transfers from bed to chair. Review of the resident's medical record showed, the record did not contain an entrapment assessment or a physician's order for use of side rails. Observation on 09/26/24 at 11:12 A.M., showed the resident in bed on his/her left side with a quarter rail on the left side in the upright position. 4. Review of Resident #11's annual MDS, dated [DATE], showed staff assessed the resident as: -Cognition not assessed; -No impairment to upper/lower extremities; -Required substantial/maximum assist from staff to roll left and right, sitting to lying in bed, and transfers from bed to chair; -Dependent on staff for lying to sitting on side of bed. Review of the resident's medical record showed, the record did not contain an entrapment assessment or a physician's order for use of side rails. Observation on 09/26/24 at 11:12 A.M., showed the resident in bed on his/her left side with a quarter rail on the left side in the upright position. 5. Review of Resident #12's Admission MDS, dated [DATE], showed the staff assessed the resident as follows: -Moderate cognitive impairment; -Impairment on one side to upper/lower extremities; -Required substantial/maximum assist from staff to roll left and right, sitting to lying in bed, and transfers from bed to chair; -Stroke, Type 2 Diabetes and Hemiplegia (loss of strength to one side of the body) or Hemiparesis (inability to move one side of the body). Review of the resident's medical record showed, the record did not contain an entrapment assessment or a physician's order for the use of side rails. Observation on 09/25/24 at 2:30 P.M., showed the resident in bed with both quarter rails in the upright position. Observation on 09/26/24 at 9:00 A.M., showed the resident in bed with both quarter rails in the upright position. Observation on 09/27/24 at 11:30 A.M. showed the resident in bed with both quarter rails in the upright position. 6. Review of Resident #13's Annual MDS, dated [DATE], showed the staff assessed the resident as follows: -Cognition not assessed; -Required substantial/maximum assist from staff to roll left and right, sitting to lying in bed; -Dependent on staff for transfers from bed to chair and sit to stand; -Non-traumatic brain injury (damage to the brain by internal factors, such as lack of oxygen, exposure to toxins or pressure from a tumor). Review of the resident's medical record showed, the record did not contain an entrapment assessment or a physician's order for the use of side rails. Observation on 09/26/24 at 10:12 A.M., showed the resident in bed with one quarter rail in the upright position on. Observation on 09/27/24 at 9:00 A.M., showed the resident in bed with both quarter rails in the upright position. 7. During an interview on 09/27/24 at 11:35 A.M., the Activities Director (AD) said he/she is responsible to measure bed rails with mattresses quarterly, has been doing them for a few years, documents the measurements by bed serial number, and room number, but does not label the document with a resident's name. The AD said he/she does not do any measurements with a resident in the bed because he/she did not know that was required and was never taught to do that. The AD said he/she does not know anything about an entrapment assessment, he/she just measures the bed, the attached rails, and the mattress. During an interview on 09/27/24 at 2:15 P.M., the Chief Nursing Officer (CNO) said he/she was not familiar with entrapment assessments or consents for the use of bed rails/side rails. During an interview on 09/27/24 at 2:30 P.M., the Unit Nurse Manager said he/she did not know an order was needed for a side rail. The unit manager said he/she was not aware that an entrapment assessment needed to be completed for each resident. During an interview on 09/27/24 at 3:00 P.M., the Chief Executive Officer (CEO) said she was aware side rails typically need orders, but is not familiar with who has rails in the facility and who doesn't, so is not sure who has an order. The CEO said she believes it would be the nurse staff's responsibility to do entrapment assessments, consents and orders for each resident with bed rails/side rails but she does not know why they are not done. 39644

Reviewed AT Based on observation, interview, and record review, facility staff failed to maintain a medication error rate of less than 5% out of 25 opportunities observed, 15 errors occurred, resulting in a 60% error rate, which affected three residents (Resident #5, #7, and #13) out of seven sampled residents. The facility census was 18. 1. Review of the Facility's Medication Administration policy, dated 05/31/20, showed the individual administering a medication will be aware of the following information concerning each medication before administration: Appropriate timing of medication administration. 2. Review of Resident #5's Physician Order Sheet (POS), dated September 2024, showed staff is directed to administer medications at 8:00 A.M.: -Levothyroxine (treat low thyroid) 100 micrograms (mcg) daily on an empty stomach at 8:00 A.M.; -Tramadol (pain reliever) 50 milligrams (mg) twice daily at 8:00 A.M. and 5:00 P.M.; -Aspirin 81 mg daily at 8:00 A.M.; -Sennoside/docusate (treat constipation) 8.6/50 mg twice daily at 8:00 A.M. and 5:00 P.M.; -Multivitamin once daily at 8:00 A.M Observation on 09/25/24 at 10:50 A.M., showed Licensed Practical Nurse (LPN) A administered levothyroxine, tramadol, aspirin, sennoside/docusate, and a multivitamin to the resident (One hour and 50 minutes late). During an interview on 09/25/24 at 10:50 A.M., LPN A said he/she just passed the resident's morning medications because he/she was waiting for staff to get the resident out of bed. 3. Review of Resident #7's POS, dated September 2024, showed staff is directed to administer medications at 8:00 A.M.: -Pantoprazole (acid reducer) 40 mg daily at 8:00 A.M.; -Losartan (treat high blood pressure) 50 mg once daily at 8:00 A.M.; -Isosorbide mononitrate (prevent chest pain) 30 mg once daily at 8:00 A.M.; -Spironolactone (diuretic) 25 mg once dialy at 8:00 A.M.; -Clonazepam (anti-anxiety) 0.25 mg thre times daily at 8:00 A.M., 12:00 P.M., and 5:00 P.M.; -Synthroid (treat low thyroid) 137 mcg daily at breakfast; -Plavix (blood thinner) 75 mg daily at 8:00 A.M.; -Sertraline (anti-depressant) 100 mg twice daily at 8:00 A.M. and 8:00 P.M Observation on 09/25/24 at 10:25 A.M., showed LPN A administered the residents pantoprazole, losartan, isosorbide mononitrate, spironolactone, clonazepam, Synthroid, Plavix, and sertraline (One hour and 25 minutes late). During an interview on 09/25/24 at 10:25 A.M., LPN A said these medications were from the resident's morning medication pass. He/She said he/she was late to pass them because staff had not gotten the resident up out of bed during the morning medication pass. 4. Review of Resident #13's POS, dated September 2024, showed staff is directed to administer medications at 8:00 A.M.: -Furosemide (diuretic) 20 mg once daily at 8:00 A.M.; -Florajen (probiotic) once daily at 8:00 A.M Observation on 09/25/24 at 12:00 P.M., showed LPN A administered the residents furosemide and florajen (Three hours late). During an interview on 09/25/24 at 12:00 P.M., LPN A said the medications he/she has are from the resident's morning medication pass. He/She said he/she had late medications because the resident was not up out of bed during his/her medication pass. 5. During an interview on 09/26/24 at 2:54 P.M., LPN A said the five rights of medication administration are to ensure the right patient, right medication, right route, right dose, and right time. The LPN said medications ordered to be given at 8 A.M. can be administered between 7 A.M. and 9 A.M., and if administered after 9 A.M., it would be considered a late administration, and maybe a med error. The LPN said if he/she made a med error, he/she thinks there is a form to be filled out, notify the Unit Nurse Manager, and maybe the doctor. The LPN said he/she did not notify the Unit Nurse Manager or the physician about the late medications because he/she just didn't even think about it. During an interview on 09/27/24 at 2:10 P.M., the Chief Nursing Officer (CNO) said he/she expects staff to follow the policy for medication administration, and if a nurse administered a medication after the allowed timeframe, that is considered a late administration and a med error. The CNO said if the nurse identified a med error occurred, he/she would expect the nurse to notify the Unit Nurse Manager/CNO, notify the physician of the error and obtain further directions from the physician on whether to administer the medication(s), or not. The CNO said if certain medications are administered late, it could increase the potential for a resident to have a negative outcome. During an interview on 09/27/24 at 2:26 P.M., the Unit Nurse Manager said if the nurse recognizes that medications will be administered late to a resident, or a medication error occurred, he/she would expect the nurse to notify him/her and notify the physician for further directions. During an interview on 09/27/24 at 3:03 P.M., the Chief Executive Officer (CEO) said he/she expects staff to follow the facility's policies for medication administration, and if a medication is administered past the timeframe, it would be considered late. The CEO said the occurrence of a medication error would depend on the medication and what is stated in the policy. The CEO said if a medication error occurred, he/she would expect the nurse to document the reason for the late administration, alert the physician, CNO, and/or the supervisor at the moment.

Based on observation, interview and record review, facility staff failed to store food in a manner to prevent potential contamination and outdated use. Facility staff failed to reheat pureed food to prevent the growth of food-borne pathogens and potential for food-borne illness. Facility staff failed sanitize kitchen wares in a manner to prevent contamination. Facility staff failed to cover kitchen waste containers when not in actual use to deter the attraction of pests and rodents. These failures have the potential to affect all residents. The census was 18. 1. Review of the facility's Food Storage policy, revised [DATE], showed: -All food will have proper dates, labels and be properly covered when stored; -All prepared, ready-to-eat foods will be marked with a date of preparation and/or expiration date; -All food will be used by the expiration date. Review showed the policy did not address food storage on the freezer floor. 2. Observation on 09/25/24 at 10:41 A.M., showed the walk-in cooler contained opened and undated bags of brussels sprouts, lima beans, cubed potatoes, mixed vegetables, squash, corn nuggets, tater tots, and an unlabeled brown bag. 3. Observation on 09/25/24 at 10:44 A.M., showed the walk-in freezer contained: -A plastic zipper bag labeled pork and dated 7-24, which contained a frost covered substance; -Two plastic zipper bags labeled salmon patties and dated 7-11-24; -Four boxes of frozen foods set on the freezer floor. 4. Observation on 09/25/24 at 10:46 A.M., showed the reach in refrigerator contained a zipper bag of cooked bacon, two bags of shredded cheese and one bag of shredded carrots which were opened and undated. During an interview on 09/25/24 at 12:10 P.M., [NAME] B said the cook was responsible for checking the refrigerator and freezer daily. [NAME] B said all open food items should be labeled and dated. [NAME] B said all opened food items were good for three days after opening or preparation. [NAME] B said food should not be stored on the floor. During an interview on 09/26/24 at 8:00 A.M., the interim Dietary Supervisor (DS) said the cooks were responsible to ensure all food was labeled and dated. The interim DS said opened food items were good for three days. The interim DS said the cooks were responsible to put food deliveries away and food should not be stored on the floor. 5. Review of the facility's Pureed Diets policy, dated [DATE], showed the policy did not address pureed item preparation. Review of the facility's Food Temperatures policy, dated [DATE], showed: -The temperature of food items on trayline shall be taken and recorded before the start of serving; -Hot foods should be above 140 degrees Fahrenheit (F). If they are less than that, they must be returned for heating and reheated to greater than (>) 165 degrees F. 6. Observation on 09/25/24 at 11:22 A.M., showed [NAME] B pureed baked beans and added the beans to a bowl. [NAME] B covered the beans with a plastic lid and placed the bowl on the steam table. [NAME] B did not check the temperature of the beans after they were pureed. Observation on 09/25/24 at 11:30 A.M., showed [NAME] B added four hamburgers, beef broth and thickener to a food processor which was obtained from the drain board. [NAME] B pureed the items and separated the pureed food into four bowls. [NAME] B covered the bowls with plastic lids and placed the bowls on the steam table. [NAME] B did not check the temperature of the pureed hamburgers. Observation on 09/25/24 at 11:40 A.M., showed [NAME] B checked temperatures of steam table items but did not check the temperature of pureed items. Observation on 09/25/24 at 11:50 A.M, showed [NAME] B served residents pureed hamburgers and chicken noodle soup with crackers. Observation showed the temperature of the pureed hamburger was 95 degrees F when checked with a calibrated digital thermometer. Observation showed the temperature of the pureed chicken noodle soup was 125 degrees F. During an interview on 09/25/24 at 12:10 P.M., [NAME] B said he/she pureed items and placed them in covered bowls on the steam table. [NAME] B said he/she was never told to reheat pureed items so he/she never did. [NAME] B said he/she was aware the steam table was not acceptable method of reheating food. During an interview on 09/26/24 at 8:00 A.M., the interim Dietary Supervisor (DS) said hot foods should be held at 140 degrees F and served at 120 degrees F. The interim DS said he/she was not aware of specific requirements to prepare pureed foods. 7. Review of the facility's Nutritional Services Infection Control policy, undated, showed pots, pans, cooking utensils, etc. will be sanitized by an approved chemical per manufacturer's specifications. Review showed the policy did not address thermometer sanitization. Review of the sanitizer solution directions for use showed: -Scrape, flush or presoak articles to remove gross food particles and soil; -Rinse articles thoroughly with potable water; -Sanitize by immersing articles in a 150-400 parts per million solution for at least 60 seconds. 8. Observation on 09/25/24 at 11:25 A.M., showed [NAME] B hand washed the food processor parts, rinsed the items, placed the items in the sanitizer sink, swirled the items around in the sanitizer and did not fully submerge the items for one minute before he/she placed the items on the drain board to dry. Observation on 09/25/24 at 11:40 A.M., showed [NAME] B checked the temperature of the beans on the steam table. [NAME] B wiped the thermometer with an alcohol wipe, then wiped the thermometer with a red cloth which sat on the steam table. [NAME] B checked the temperature of the gravy, wiped the thermometer with an alcohol wipe, then wiped the thermometer with a red cloth which sat on the steam table. [NAME] B used the red cloth to wipe her gloved hands and placed the red cloth back on the steam table. [NAME] B checked the temperature of the hamburgers, wiped the thermometer with an alcohol wipe, then wiped the thermometer with a red cloth which sat on the steam table. [NAME] B used the red cloth to wipe her gloved hands and placed the red cloth back on the steam table. [NAME] B checked the temperature of fish, The cook used the red cloth to wipe her gloved hands and placed the red cloth back on the steam table. During an interview on 09/25/24 at 12:10 P.M., [NAME] B said all item should be completely submerged in the sanitizer solution for one minute. [NAME] B said he/she was nervous and he/she did not fully submerge the food processor. [NAME] B said he/she always used a cloth to wipe the alcohol from the thermometer. [NAME] B said he/she did not want to contaminate the food with alcohol and he/she did not know wiping the thermometer with the cloth was not acceptable. [NAME] B said he/she was nervous and did not realize he/she was using the cloth to wipe his/her gloves. During an interview on 09/26/24 at 8:00 A.M., the interim Dietary Supervisor (DS) said kitchen staff should follow manufacturer's instructions for sanitizer solutions. The interim DS said staff should not wipe a thermometer after it had been cleaned with alcohol. 9. Observation on 09/25/24 at 10:35 A.M. and 11:55 A.M., showed two large plastic trash cans, which contained kitchen wastes, not covered and not in use. Observation showed the area around the trash cans did not contain trash can lids. During an interview on 09/25/24 at 12:10 P.M., [NAME] B said the kitchen trash cans were purchased a couple weeks ago and did not have lids. [NAME] B said he/she was aware the trash cans should be covered when not in use. During an interview on 09/26/24 at 8:00 A.M., the interim Dietary Supervisor (DS) said he/she placed the new trash cans in the kitchen within the past week but they did not come with lids. The interim DS said the trash cans should be covered when not in use. During an interview on 09/26/24 at 8:00 A.M., the interim Dietary Supervisor (DS) said he/she was the hospital infection preventionist and he/she was filling in as DS. The interim DS said the facility had hired two different dietary supervisors in the past couple months, but neither stayed. The interim DS said the facility has a registered dietician who comes in two days per week and the previous dietary supervisor is currently working in another department. During an interview on 09/26/24 at 1:00 P.M., the Chief Executive Officer (CEO) said the facility was struggling to keep qualified staff. The CEO said he/she knew of some of the issues in the kitchen.

reviewed AT Based on interview and record review, the facility staff failed to implement an effective Quality Assurance (QA)/Quality Qssurance Preformance Improvemnt (QAPI) program when staff did not meet and discuss interventions to correct any on-going systemic issues that pertain to the Long Term Care (LTC). The facility census was 18. 1. Review of the facility's LTC QAPI Policy, revised 06/16/22, showed the following: -To identify and correct quality deficits along the areas for improvement within Long Term Care; -The multidisciplinary team will meet monthly to evaluate a current projects and identify areas that need improvement or included. The LTC Medical Director will be made aware of the findings of the LTC QAPI Committee Monthly, LTC Director will report to the Hospital QAPI Committee quarterly. Review of the facility's records, showed staff did not provide documentation of a QAPI/QA program. During an interview on 09/27/24 at 2:16 P.M., the Chief Nursing Officer (CNO) said he/she is familiar with what the QA or QAPI process because the hospital side meets quarterly for this process, LTC is supposed to be included, but there is nothing specific to the LTC discussed. During an interview on 09/27/24 at 3:00 P.M., the Chief Executive Officer (CEO) said the Administrator/Executive Director would be responsible to have a QAPI/QA program implemented. The CEO said if there was a program previously, I do not know so we are starting from scratch.

Based on observation, interview, and record review, facility staff failed to provide appropriate hair and nail care for three dependent sampled residents (Resident #3, #8, and #10). The facility census was 16. 1. Review of the facility's policy titled, Direct Resident Care, Hygiene and General Care, dated 01/24/23, showed staff were directed to do nail care every week and as needed (PRN). Review of the facility's policy titled, Resident Care Management, Scope of Care, dated 01/24/14, showed staff were directed to ensure each resident receives daily personal hygiene to assure cleanliness, good skin care, good grooming, and oral hygiene taking into account individual preferences. Review of the policies provided showed no policy in regard to facial hair management. 2. Review of Resident #3's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 06/27/23, showed staff assessed the resident as follows: -Cognitively intact; -Independent with personal hygiene; -Did not reject care; -Impairment of upper and lower extremities on one side. Review of resident's care plan, dated 07/11/23, showed staff were directed to cue/assist the resident with personal hygiene. Further review showed no documentation in regard to the resident rejecting care. Review of the activity calendar, dated 08/21/23, showed manicure's at 10:30 A.M. Observation on 08/20/23 at 2:31 P.M., showed the resident with long nasal hair and long nails. Observation on 08/21/23 at 8:55 A.M., showed the resident with long nasal hair and long nails. Observation on 08/21/23 at 1:56 P.M., showed the resident with long nasal hair and long nails. Observation on 08/22/23 at 7:40 A.M., showed the resident with long nasal hair. During an interview on 08/21/23 at 8:55 A.M., the resident said staff does not offer to trim his/her finger nails or toe nails, and it bothers him/her to have long nails. He/She said he/she can not fully unbend his/her fingers, so he/she is not able to trim his/her own nails. 3. Review of Resident #8's Annual MDS, dated [DATE], showed staff assessed the resident as follows: -Moderate cognitive impairment; -Required limited assistance from one staff member with personal hygiene; -Did not reject care; -Impairment of upper and lower extremities on one side. Review of the resident's care plan, dated 05/30/23, showed staff documented the resident requires assistance with personal hygiene. Further review showed no documentation in regard to the resident rejecting care. Review of the activity calendar, dated 08/21/23, showed manicure's at 10:30 A.M. Observation on 08/21/23 at 8:20 A.M., showed the resident with long nasal hair, unkempt facial hair and long nails with debris under the nails. Further observation showed the resident was unable to open his/her left hand. Observation on 08/21/23 at 1:56 P.M., showed the resident with long nasal hair, unkempt facial hair and long nails with debris under the nail. Observation on 08/22/23 at 7:40 A.M., showed the resident with long nasal hair, unkempt facial hair and long nails with debris under the nail. Observation on 08/22/23 at 8:15 A.M., showed the resident with long nasal hair, unkempt facial hair and long nails with debris under the nail. Further observation showed the resident picked up a piece of toast with his/her nails and ate it. 4. Review of Resident #10's Annual MDS, dated [DATE], showed staff assessed the resident as follows: -Moderately impaired cognition; -Required assistance from one staff member for transfers, dressing and toilet use; -Required supervision, cueing, and setup assistance from one staff member for personal hygiene; -Required extensive assistance from one staff member for bathing; -Diagnosis of Dementia. Review of the resident's care plan, dated 07/12/23, showed staff are to assist the resident with setup for personal hygiene. Review of the resident's shower sheets showed the shower aide documented: -07/24/23: Resident needs toenails cut. Further review showed the charge nurse signed the form and did not document he/she provided an intervention for the resident's toenails. The Director of Nursing (DON) did not sign, or date he/she reviewed the shower sheet; -07/26/23: Resident needs toenails cut. Further review showed the charge nurse signed the form and did not document he/she provided an intervention for the resident's toenails. The DON did not sign, or date he/she reviewed the shower sheet; -07/29/23: Resident needs toenails cut. Further review showed the charge nurse signed the form and did not document he/she provided an intervention for the resident's toenails. The DON did not sign, or date he/she reviewed the shower sheet; -08/13/23: Resident needs toenails cut. Further review showed the charge nurse signed the form and did not document he/she provided an intervention for the resident's toenails. The DON did not sign, or date he/she reviewed the shower sheet. During an interview on 08/20/23 at 2:21 P.M., the resident said no one clips his/her toenails, and the facility needs to find someone who can. The resident said he/she asked staff to clip his/her toenails and the staff said the facility did not have clippers for his/her toenails, the facility only has fingernail clippers. Observation on 08/22/23 at 9:23 A.M., showed the Activity Director (AD) removed the resident's socks. Further observation showed the resident's toenails were long and jagged. The resident's toenails appeared to be very thick and full of a built up yellow substance. During an interview on 08/22/23 at 08:10 A.M., the resident said staff still has not provided nail care for his/her toenails. During an interview on 08/22/23 at 8:03 A.M., the AD said Resident #3 and resident #8 require assistance from staff for personal hygiene. He/she said resident #8 will only allow him/her and one other staff member to cut his/her nails. He/She said he/she had not seen resident #8's nails in few days, but he/she had asked the resident if he/she wanted his/her nails cut, but did not document it in the medical record. He/She said he/she had not cut the resident's nails for a while. The AD said Resident #3 and Resident #8 have long nasal hair and the Certified Nurse Aides (CNAs) should be trimming it at least twice a week during their showers. He/She said the facility had a beautician that assisted with facial hair, but they no longer have one. The AD did not feel it was dignified for a resident to have long nails with debris caked under them. He/She said the resident could get sick if the debris was eaten. During an interview on 08/22/23 at 9:47 A.M., CNA A said staff document on the shower sheet if the resident needs their toenails clipped, and then the shower sheet goes to the nurse. The CNA said the resident used to go to a podiatrist, but the facility does not have a podiatrist anymore, so the nurses clip the resident's toenails. The CNA said he/she documented on the shower sheet that the resident needed his/her toenails clipped. The CNA said the DON reviews the shower sheets when the nurse is done. During an interview on 08/22/23 at 9:56 A.M., Registered Nurse (RN) E said the facility does not currently have a podiatrist. The RN said if he/she can not get his/her clippers to go through the nail, he/she does not cut the nails. The RN said if a CNA feels a resident's toenails need to be cut, the CNA documents it on the resident's shower sheet. The shower sheets then goes to the nurse, and if there is an issue the nurse follow up on it. The RN said if a CNA documents the resident needs their toenails cut, the RN will try to get to it within 24 hours, and if he/she can't cut the resident's toenails, he/she will try to make an appointment with a podiatrist. The RN said some nurses will document interventions on the shower sheet and some don't. The RN said once the shower sheet is signed by the nurse, the nurse puts the shower sheet in the DON's basket. The RN said the resident asked to see the podiatrist, and did see one six or seven months ago, but the CNA's told him/her that they could clip the resident's toe nails. Further, the RN said the CNA's should trim nose hair when they provide shaves at least two times per week, or per their preference. The RN said he/she had trimmed Resident #8's nose hair, but it had been a while ago. He/She said the last time he/she had asked Resident #3 or Resident #8 if they wanted their nose hairs trimmed was about five to six weeks ago, and he/she did not know if anyone else had asked them. During an interview 08/22/23 at 11:17 A.M., Long Term Care (LTC) Director said if a CNA documents the resident needs his/her toenails clipped he/she expects the nurse assess the resident's nails and clip them if able. If the nurse can not clip the toenails he/she expects the nurse to notify the doctor and get the resident a podiatry consult. The LTC Director said he/she does not know why the nurse's did not refer the resident to the podiatrist, the nurse should have. He/She said finger nails and nose hairs should be trimmed as needed. 42815

Based on interview and record review, staff failed to provide residents with a written response to grievances. The facility census was 16. 1. Review of the facility's policy titled, Grievances, Investigating and Grievances and Complaints, revised 03/07/17, showed staff were directed to do the following: -It is the policy of this facility to investigate all grievances and complaints filed with the facility; -The Grievance/Complaint Investigation Report must be filed with the administrator within five (5) working days of the receipt of the grievance or complaint form; -The resident, or acting on behalf of the resident, will be informed of the findings of the investigation, as well as any corrective actions recommended, within ten (10) working days of the filing of the grievance or complaint; -A copy of the Grievance/Complaint Investigation Report must be attached to the Grievance and Complaint Report and filed in the Medical Records; -Copies of all reports must be signed and will be made available to the resident or person acting on behalf of the resident. Review of the facility's policy titled, Grievance, Grievance/Complaint Log, revised 03/07/17, showed staff were directed to do the following: -It is the policy of this facility that the disposition of all grievances and/or complaints be recorded on our facility's Grievance and Complaint Log; -The disposition of all written grievances and/or complaints must be recorded on the Grievance and Complaint Log; -The Long Term Care (LTC) Director and/or Social Service Department will be responsible for recording and maintaining the log. During an interview on 08/21/23 at 8:33 A.M., Resident #8 said he/she had Hershey kisses go missing not too long ago. He/She said he/she reported the missing candy to the staff and there was no follow up on his/her concern. During an interview on 08/21/23 at 8:42 A.M., the Administrator/Social Service Director said the resident made several reports of missing candy and the staff reported it. A grievance form was not filled out, and the missing candy was not documented anywhere. They said they have never filled out a grievance form after receiving a reported concern. When asked how staff remembered to follow up on missing items if it's not documented, the they said it's a good question. They said they did not know what the policy said in regard to filling out a grievance form. During an interview on 08/22/23 at 8:03 A.M., the Activity Director said if a resident reports something missing, staff should look for the item and report it to the nurse or supervisor. The AD said he/she reported the resident's missing candy to a nurse, but he/she did not know what happened after that. During an interview on 08/22/23 at 9:57 A.M., Registered Nurse (RN) E said if a resident reports something missing, staff should look for the item and report the concern to the director or Administrator.

Based on interview and record review, the facility failed to submit Payroll Based Journal (PBJ) data (staffing information based on payroll data) for five quarters. The facility census was 16. 1. Review of the policies provided by the facility showed no PBJ policy. Review of the facility's PBJ Quarterly reports showed: -01/01/22 through 03/31/22, showed no data submitted for the quarter; -04/01/22 through 06/30/22, showed no data submitted for the quarter; -07/01/22 through 09/30/22, showed no data submitted for the quarter; -10/01/22 through 12/31/22, showed no data submitted for the quarter; -01/01/23 through 03/31/23, showed no data submitted for the quarter. During an interview on 08/22/23 at 8:31 A.M., the Long Term Care Director said he/she has worked for the facility for a week. He/She said PBJ data was not submitted for the last quarter, and it should be submitted quarterly. The director said he/she does not know why the data was not submitted. During an interview on 08/22/23 at 9:59 A.M., the Chief Nursing Officer (CNO) said the Chief Financial Officer (CFO) is responsible for submitting PBJ data. The CFO started at the facility on 8/21/23. He/she said a management group had managed the facility and the facility is just now resuming in house management. The CNO said the Finance Department is responsible for submitting the data. He/she said he/she knows the data was not submitted but does not know why. The CNO said he/she knows the facility is deficient.

Based on interview and record review, facility staff failed to implement an infection prevention and control program (IPCP) that included an Antibiotic Stewardship Program that addressed antibiotic use protocols and a system to monitor antibiotic use. The facility census was 16. 1. Review of the facility's policy titled, Surveillence, Prevention, and Control of Infection, Renal Dosing of Selected Antimicrobials, dated 02/16/23, showed staff were directed to do the following: -All Medications administered at the facility will be of the appropriate dose, route and frequencey in consideration of the patient's condition, indications, and lab values; -The antimicrobial agents in this policy are considered to be of special interest to the Antimicrobials Stewardship Committee and require precautions and attention to ensure they are dosed appropriately. This policy will authorize dose adjustments to be made dependent upon patient specific factors, according to published guidelines and/or prescribing information. Review of the facility's policy titled, Infection Prevention Program, dated 02/10/21, showed staff were directed to do the following: -An effective infection prevention program is essential for the well-being of patients, resident and the safety of hospital personnel. Measures are develooped to prevent, identify, and control infections aquired in the hospital; -The Infection Prevention Committee (IPC) will establish and execute policies for the surveillance, prevention, and and control of healthcare-associated infections (HAI); -Responsibilities of the Infection Prevention Nurse (IPN) include, but are not limited to perform comprehensive surveillance for healthcare-associated infections and epidemiologically significant organisms and report findings to the IPC and create and maintain appropriate infection prevention policies and procedures; -SMDH participates in surveillance activities to prevent and reduce healthcare-associated infections. Infection surveillance data is used to measure success of infection prevention and control programs, identify areas for improvement, and to meet public reporting mandates and pay for performance goal data is currently reported via National Healthcare Safety Network (NHSN); -The IPN duties related to HAI surveillance includes to identify and investigate clusters or outbreaks of infection. Review of the facility's Infection Control Line Listing form, dated 05/2023, showed Resident #8 and #10 received antibiotcs. Further review showed no documenation that labs were ordered to verify the antibiotics were appropriate for the residents' specific pathogens (bacteria, virus, or other microrganism that can cause disease). Review of the facility's Infection Control Line Listing form, dated 07/2023, showed Resident #2, #6, #12, #13, #14, and #15 received antibiotics. Further review showed no documenation that labs were ordered to verify the antibiotics were appropriate for the residents' specific pathogens. During an interview on 08/21/23 at 3:38 P.M., the Human Resource Director said the Infection Preventionist (IP) was responsible to track antibotic use. During an interview on 08/21/23 at 3:59 P.M., the Administrator said there most likely was not a tracking system for the type of organism because the physician is old school and prescribed antibotics without knowing the specific type of bacteria because he/she prefers to practice medicine the way he/she wants to practice medicine. During an interview on 08/21/23 at 4:30 P.M., the IP said he/she is responsible for tracking antibotic use. He/She said the nursing staff would complete the Infection Control Line Listing form and forwarded the information to him/her. He/She noticed the type of pathogen and the date of the lab was missing for several residents in May and July. He/She said if the staff did not order labs, or document the type of infection the resident had, the prescribed antibiotic may not be appropriate and staff would not know what type of interventions to implement to prevent the spread of the infection. Further, he/she said the tracking log did not include the length of time the resident received the medication.

Based on interview and record review facility staff failed to maintain monthly pharmacist documentation, and ensure the Pharmacist Medication Regimen Review (MRR) was completed for four (Resident #11, #14, #15, and #16) out of eight sampled residents. The facility census was 17. 1. Review of facility records showed the facility did not provide a policy for drug regimen review. 2. Review of Resident #11's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 04/24/22, showed staff assessed the resident as: - Unable to complete Brief Interview for Mental Status (BIMS) as resident is rarely/never understood; - Diagnoses of [CONDITION(S)] [CONDITION(S)] (an injury caused by a complete lack of oxygen to the brain, which results in death of brain cells), [CONDITION(S)] (paralysis of all four limbs), [CONDITION(S)] (a hole that is surgically made through the front of the neck and into the windpipe to allow direct access of a breathing tube), dependent on a ventilator (a machine that mechanically breathes for someone who is unable to breathe independently), and has a gastrostomy (the creation of an artificial external opening into the stomach for nutritional support); - No documentation under section for drug regimen review. Review of the resident's medical record showed the record did not contain the MRR for the months of December 2021 through May 2022. 3. Review of resident #14's Minimum Data Set (MDS), dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -No behaviors; -Diagnosis of Alzheimer's disease, [CONDITION(S)], anxiety, and depression; -Antianxiety and antidepressant medications daily. Review of the resident's medical record showed the record did not contain the MRR for the months of December 2021 through May 2022. 4. Review of Resident #15's annual MDS, dated [DATE], showed staff assessed the resident as: - Severe cognitive impairment; - Diagnoses included Dementia without behaviors, diabetes, [CONDITION(S)], [CONDITION(S)] (fluttering of upper heart chanbers), heart failure and high blood pressure; - Insulin, antibiotics and diuretics daily. Review of the resident's medical record showed the record did not contain the MRR for the months of December 2021 through May 2022. 5. Review of resident #16's Quarterly MDS, dated [DATE], showed staff assessed the resident as: - Cognitively intact; - Verbal behaviors occurred one to three days; - Diagnosis of Non-traumatic brain dysfunction, [CONDITION(S)] or [CONDITION(S)], and manic Depression; - Received an antipsychotic daily for the last seven days; - No Drug Regime Review; - Last GDR attempted 10/30/2019. Review of the resident's medical record showed the record did not contain the MRR for the months of December 2021 through May 2022. 6. During an interview on 5/27/22 at 1:26 P.M., Registered nurse (RN) A said for about a year there was no Pharmacist performing reviews. Facility staff told the physician about medication that needed to be reviewed. During an interview on 5/27/22 at 1:33 P.M., the Director of Nursing (DON) said if the pharmacist review was not in the resident's medical record it was not done due to the lack of pharmacy employees. He/she said pharmacist reviews have not been done since December of 2021.

Based on interview and record review, the facility staff failed to develop a Quality Assurance and Performance Improvement Plan (QAPI) (written plan containing the process that will guide the nursing home's efforts in assuring care and services are maintained at acceptable levels of performance and continually improved). The facility census was 17. 1. Review of the hospital's Quality Assurance and Performance Improvement (QAPI) Plan policy dated 9/02/2021 showed: - Although Long Term Care, [CONDITION(S)], and Salem Memorial District Hospital (SMDH) Family Medicine are separate entities with their own QAPI regulations, they will report data to the Quality Council quarterly or in accordance with their regulations. Review of the facility's records showed the facility did not have a QAPI plan containing the necessary policies and protocols describing how they will identify and correct their quality deficiencies, track and measure performance, and establish goals and thresholds for performance measurements. During an interview on 5/26/2022 at 9:54 A.M., the Administrator said Long Term Care does not have a Quality Assurance (QA) (systematic process of determining whether a service meets specified requirements) program. He/she said Long Term Care is covered under the hospital's QA program. He/she said Long Term Care submits data to the hospital QA program quarterly. During an interview on 5/27/2022 at 1:45 P.M., the Director of Long Term Care said the Long Term Care QA committee does not have a formal schedule or QA plan. During an interview on 5/27/2022 at 2:50 P.M., the Hospital Director of Quality Improvement and Risk Management said he/she was uncertain of the last time Long Term Care submitted data to the facility quality committee. He/she said he/she reviewed records going back to January of 2019 and could find no record of Long Term Care quality data.

Based on observation and interview, facility staff failed to store food in a manner to prevent potential contamination and out-dated use. The facility census was 18. 1. Observation on 11/05/19 at 10:43 [NAME]M., showed an opened and undated box of raisins in the reach-in cooler by the steamtable. Observation of the box showed Best before [DATE] printed on the box. During an interview on 11/05/19 10:44 [NAME]M., the Dietary Manager (DM) said the boxes of raisins are frozen when they come in. The DM said he/she did not know when staff opened the box of raisins and staff should date items when removed from freezer or opened. 2. Observation on 11/05/19 at 10:45 [NAME]M., showed a bag of french fried onions opened to the air and undated on the top shelf in the dry goods storage area located by the walk-in freezer. During an interview on 11/05/19 at 10:45 [NAME]M., Cook A said he/she opened the bag of french fried onions on 11/04/19 for the salad bar and he/she forgot to date the bag. 3. Observation on 11/05/19 at 10:48 [NAME]M., showed the following in the reach-in cooler by cook's station: -the rubber seals torn on the bottom door of first section as well as top and bottom of third section; -two undated and unlabeled plastic containers of an unidentified hardened grease product open to the air; -an undated and unlabeled two quart plastic container of an unidentified liquid egg mixture; -an undated one gallon plastic resealable bag of previously prepared ground sausage; -an undated one gallon plastic resealable bag of previously prepared bacon; -an undated one gallon plastic resealable bag of previously prepared bacon and sausage; -an opened and undated five pound bag of bourbon flavored bacon topping; -an opened and undated five pound container of sour cream. Further observation showed Best if used by 09/30/19 printed on the container; -an opened and undated one pound brick of butter; -an undated one gallon plastic resealable bag of previously prepared chicken tenders; -a one gallon plastic resealable bag of previously prepared hot dogs dated 10/26 open to the air. During an interview on 11/05/19 at 10:52 [NAME]M., Cook A identified the containers of grease as bacon grease from that morning and the container of liquid egg mixture as french toast batter from that morning. The cook also said the bags of bacon and sausage were from that morning. The cook said all opened or previously prepared foods should be in a covered container, labeled and dated before they are stored. The cook said he/she just got in a hurry and forgot to label and date everything. 4. During an interview on 11/05/19 at 11:00 [NAME]M., the DM said staff who work in each station are responsible to monitor the food storage for the refrigerator and freezer units in their stations daily. The DM said all opened or previously prepared foods should be in a covered container, labeled and dated before they are stored and staff are trained on this requirement. 5. Observation on 11/05/19 at 11:03 [NAME]M., showed the following food items stored on the floor in the walk-in freezer: -a case of salted caramel pretzel ice cream snacks; -a case strawberry shortcake ice cream cups; -an opened and undated case of catfish fillets; -an undated case of sugar cookie dough open to the air; -an undated case of strawberry shortcake cookie dough open to the air; -three unlabeled and undated one gallon plastic resealable bags of unidentified meat stored in plastic tub on floor with other packaged meats; -an open and undated bag of green beans; -an undated three pound bag of sliced zucchini open to the air; -an undated one gallon plastic resealable bag of collard greens. 6. Observation on 11/05/19 at 11:28 [NAME]M., showed a 32 ounce bottle of lotion stored on shelf with one gallon jugs of vanilla extract and gravy flavour/colour. 7. Observation on 11/05/19 at 11:41 [NAME]M., showed an open and undated bag of tater tots in the glass front freezer located near the cook's station. 8. Observation on 11/06/19 at 10:00 [NAME]M., showed the following food items stored on the floor in the walk-in freezer: -a case of salted caramel pretzel ice cream snacks; -a case strawberry shortcake ice cream cups; -an opened and undated case of catfish fillets; -an undated case of sugar cookie dough open to the air; -an undated case of strawberry shortcake cookie dough open to the air; -three unlabeled and undated one gallon plastic resealable bags of unidentified meat stored in plastic tub on floor with other packaged meats; During an interview on 11/06/19 at 10:11 [NAME]M., the DM said food should not be stored on the floor, but the kitchen lacked space. 9. Observation on 11/06/19 at 10:14 [NAME]M., showed a 32 ounce bottle of lotion stored on shelf with one gallon jugs of vanilla extract and gravy flavour/colour. 10. Observation on 11/06/19 at 10:17 [NAME]M., showed the following in rear stand-freezer: -an undated and unlabeled bag of dough identified by the DM as pie dough; -an undated and unlabeled bag of white granules identified by DM as grated parmesan cheese; -an undated and unlabeled bag of garlic bread; -two undated plastic containers of cookie dough. During an interview on 11/06/19 at 10:18 [NAME]M., the DM said he/she did not know how old the bags of pie dough, parmesan cheese and garlic bread were and staff should have dated the bags. The DM said staff made the cookie dough 10/31/19 for an event, but staff still should have put a date on the containers.

Based on observation, interview and record review, facility staff failed to maintain professional standards when they failed to follow physician orders [REDACTED].#4) with a gastrostomy tube (tube inserted directly into the stomach to provide nutrition) and a [MEDICAL CONDITION] (a surgical incision in the neck to bypass obstruction of the airway) of eight sampled residents. The facility census was 17. 1. Review of the facility's Gastrostomy Tubes policy, dated 3/3/2014, showed staff are directed to verify placement of the gastrostomy tube by inserting 5-10 milliliters (mls) of air into the tube, and listening for a rush of air, or gurgling in the stomach with a stethoscope. 2. Review of Resident #4's Physician order [REDACTED]. -Prime (insert fluid into) gastrostomy tube with water prior to feedings and medication administration; -Flush gastrostomy tube with 100 to 150 mls of water after medications and feedings; -[MEDICAL CONDITION] care daily prior to administering medications and feedings. Observation on 8/9/17 at 9:34 A.M., showed Licensed Practical Nurse (LPN) A entered the resident's room to provide gastrostomy and [MEDICAL CONDITION] care. Further observation showed LPN A aspirated (pull fluid out of) clear fluid out of the gastrostomy tube, and replaced it. Additionally, LPN A administered medications via gastrostomy tube, followed by 75 ml of water, and 400 mls of nutritional formula, followed by 75 mls of water. Further observation showed LPN A performed [MEDICAL CONDITION] care after he/she completed gastrostomy care. During an interview on 8/10/17 at 11:39 A.M., the Long Term Care Director said he/she expects the staff to use their nursing judgement over the physician's orders [REDACTED]. Furthermore he/she said he/she has previously used his/her judgement and given less than the order directs. Additionally, he/she said he/she is unaware the facility's gastrostomy tube policy directs staff to check placement of the gastrostomy tube by injecting air. Additionally he/she said he/she does not expect staff to perform [MEDICAL CONDITION] care before gastrostomy care, as directed by the physician.

Based on observation, interview, and record review, facility staff failed to follow infection control measures to prevent or reduce the risk of infection by failing to wash their hands and use gloves appropriately during treatments for two residents (Resident #3 and Resident #4) of eight sampled residents. The facility census was 17. 1. According to Infection Control Guidelines for Long Term Care Facilities (Section 3.0 Body Substance Precautions): *Dirty gloves are worse than dirty hands because micro-organisms adhere to the surface of a glove easier than to the skin of your hands. *Hand washing remains the single most effective means of preventing disease transmission; wash hands whenever they are soiled with body substance and when each resident's care is completed. 2. Review of the facility's Hand Hygiene policy, dated 3/3/14, showed the following: -Staff are directed to wash their hands before performing invasive procedures, before donning (applying) and after removing gloves, when moving from a contaminated body site to a clean body site, after contact with objects in the immediate vicinity of the patients, and when hands are visibly soiled, or contaminated with proteinaceous (drainage from an open site) material. 3. Review of the facility's Tracheostomy Care policy, dated 3/1/14, showed staff are directed to obtain sterile gloves (gloves free from bacteria) to remove and replace the inner cannula (small tube) of the tracheostomy (a surgical opening in the neck to bypass an obstruction of the airway). 4. Observation on 8/9/17 at 9:34 A.M., showed Licensed Practical Nurse (LPN) A entered Resident #4's room to provide tracheostomy and gastrostomy ( a tube placed in the stomach to provide formula feedings) care. Further observation showed LPN A did not wash his/her hands before he/she applied clean gloves. Observation showed LPN A removed a visibly soiled dressing from the gastrostomy site, cleansed the insertion site, and applied a clean dressing to the site with the same gloves on. Further observation showed LPN A removed a visibly soiled dressing from the tracheostomy site, cleansed a visibly soiled tracheostomy oxygen collar, applied cream around the tracheostomy insertion site, removed the tracheostomy inner cannula, inserted a new tracheostomy inner cannula and applied a clean dressing to the tracheostomy site. Further observation showed LPN A did not change his/her gloves or perform hand hygiene between dirty and clean tasks, and did not obtain sterile gloves for the sterile procedure, as directed by facility policy. During an interview on 8/9/17 at 9:45 A.M., LPN A said he/she does not use sterile technique with the resident's tracheostomy because the resident's spouse says it is not needed. LPN A also said he/she does not change his/her gloves from dirty to clean tasks unless they are soiled with stuff all over my gloves. 5. Observation on 8/9/17 at 2:42 P.M., showed LPN A entered Resident #3's room to provide catheter care. Further observation showed LPN A washed his/her hands, removed gloves from his/her pocket, applied the gloves, and cleaned the resident's perineal area. Observation showed LPN A removed his/her gloves, applied a pair of gloves from his/her pocket, and cleansed the resident's catheter tubing. Additional observation showed LPN A removed his/her gloves, applied a pair of gloves from his/her pocket, and applied cream to the resident's buttocks. Additional observation showed the LPN removed his/her gloves, applied a pair of gloves from his/her pocket, and applied a clean brief to the resident with his/her contaminated hands. During an interview on 8/10/17 at 11:39 A.M., the Long Term Care Director said he/she does not expect staff to use sterile gloves when they change the inner cannula of a tracheostomy. Additionally he/she said he/she is unaware the facility's policy directs staff to obtain sterile gloves for the procedure. The Director said he/she expects the staff to follow the spouse's directions over the facility's policy. Additionally he/she said he/she does expect the staff to change their gloves from dirty to clean tasks, and perform hand hygiene. He/She said he/she would not expect the staff to use gloves from their pockets, as staff carry things such as keys in their pockets, and it would not be considered clean. Additionally, he/she said anytime the staff change their gloves, they should perform hand hygiene.

Based on record review and interview, the facility failed to hold the personal funds for six of eight sample residents (Residents #1, #2, #3, #4, #5 and #6) and for 11 additional residents (Residents #9, #10, #11, #12, #13, #14, #15, #16, #17, #18 and #19) in an account separate from the facility operating account. The facility also failed to allocate interest earned by the account to each of the 17 residents. The facility census was 18. 1. Review of the facility maintained resident trust funds account records, dated 08/01/15 through 08/10/16, showed the facility managed the personal funds of 17 residents during the year and 15 residents (Residents #1, #2, #3, #4, #5, #6, #9, #10, #11, #12, #13, #14, #15, #18 and #19) with current balances which totaled $543. Review of each resident ' s trust funds account ledger, showed the account for maintaining the personal funds listed as an AR account. Further review showed the residents ' ledgers did not include any interest payments. Review of a bank statement, provided by the Chief Financial Officer (CFO) and dated 07/29/16, showed the account in the name of the facility and $393.02 in interest earned for the month. During an interview on 08/10/16 at 3:00 P.M., the CFO said the residents ' personal funds are held in the facility operating bank account and the bookkeeping is managed under a subaccount of accounts receivable. The CFO said withdrawals from the resident trust funds account are done by a check written from the facility operating account or taken from the facility petty cash if the resident requests cash. The CFO said the facility operating account does earn interest, but no interest is allocated to the residents whose funds are managed by the facility. The CFO said he/she did not know the residents ' personal funds could not be a part of the facility operating account or that interest should be allocated to the residents.

Based on observation, interview and record review, the facility failed to reheat pureed food items served at the noon meal to 165 degrees Fahrenheit (°F) to prevent the growth of food-borne pathogens. The facility failed to ensure food held on the steamtable maintained an internal temperature of at least 135° F during the noon meal service. The facility failed to allow sanitized kitchenware to air dry prior to stacking in storage. The facility also failed to store frozen foods in a manner which protected it from physical contamination. The facility census was 17. 1. Observation on 09/03/15 at 11:37 A.M. showed the menu consultant portioned four ounces of prepared broccoli and cauliflower into a blender, added water from the faucet and blended. Observation showed, after processing, the menu consultant poured the pureed vegetables into a bowl and placed the bowl on the steamtable. Observation showed the internal temperature of the pureed vegetables measured 120° F when placed on the steamtable. Review of the recipe for pureed frozen vegetables showed instruction to reheat the pureed product to an internal temperature of 180° F after processing. Observation on 09/03/15 at 11:55 A.M., showed Cook A removed the pureed vegetables from the steamtable and poured them from the bowl onto a plate for service at the noon meal. Observation showed the internal temperature of the pureed vegetables at this time measured 110° F. 2. Observation on 09/03/15 at 11:50 A.M., showed the Dietary Director pureed four ounces of prepared noodles with six ounces of prepared beef stroganoff. Observation showed the director handed the blender jar to Cook A to portion onto a plate for service at the noon meal. Observation showed the internal temperature of the pureed beef stroganoff at this time measured 130° F. Review of the recipe for pureed beef stroganoff showed instruction to reheat to the pureed product to an internal temperature of 180° F after processing. Observation on 09/03/15 at 11:55 A.M., showed Cook A portioned the pureed stroganoff onto a plate for service at the noon meal. Observation showed the internal temperature of the pureed stroganoff at this time measured 135° F. During an interview on 09/03/15 at 12:50 P.M., the Dietary Director said pureed food items should be reheated after processing to a temperature of at least 140° F. 3. Observation on 09/03/15 at 11:55 A.M., showed the internal temperature of the broccoli and cauliflower held on the steamtable and served to residents at the noon meal measured 120° F. Further observation showed the internal temperature of the mashed potatoes held on the steamtable and served to the residents at the noon meal measured 125° F. During an interview on 09/03/15 at 12:50 P.M., the Dietary Director said the temperature of foods held on the steamtable should be at least 140° F. 4. Observation on 09/03/15 at 12:30 P.M., showed Cook B removed wet kitchenware from the draining area of the three-sink dishwashing station and put the kitchenware away on shelves and in cabinets in a manner which did not promote air drying. Observation on 09/03/15 at 12:35 P.M., showed seven food preparation/service pans stacked wet in the cabinet beside the steamtable. During an interview on 09/03/15 at 12:38 P.M., the Dietary Director said staff should allow dishes to air dry prior to storage and all staff had been trained on this requirement. The director said the wet pans were a result of staff being in too big of a hurry. 5. Observation on 09/03/15 at 12:40 P.M., showed one case of biscuits, one case of sausage patties, once case of veal luncheon steaks and one case of tilapia fillets open with the contents exposed the air inside the walk-in freezer. During an interview on 09/03/15 at 12:42 P.M., the Dietary Director said staff should reseal food items after opening and all staff had been trained on this requirement. After viewing the open cases of food, the director said he/she would not consider the storage to be safe or appropriate.

Based on record review and interview, the facility failed to obtain written authorization to hold and manage money for 22 of 22 residents (Residents #1, #2, #3, #4, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23) whose funds were held in trust by the facility from January 2014 through September 2014. The facility also failed to deposit funds in excess of $50 into an interest bearing bank account for seven of 22 residents (Residents #1, #6, #7, #8, #9, #10 and #11 ) for the period of January 2014 through September 2014. The facility census was 18. 1. Review of the facility maintained resident trust fund records dated January 2014 through September 2014 showed deposits and withdrawals made on the trust accounts for Residents ##1, #2, #3, #4, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23. Further review showed the records did not contain written documentation from each of the residents or their responsible parties authorizing the facility to hold and manage their personal funds. During an interview on 10/01/14 at 3:15 P.M., the Business Office Controller said the facility did not have written authorizations from the residents or their responsible parties to hold and manage their personal funds. 2. Review of Resident #1's trust fund statement dated 01/08/14 through 09/30/14, showed the resident with deposits made to his/her personal funds which allowed balances in excess of $50 as follows: -$85 on 02/24/14 ($35 over the maximum cash amount allowed on hand); -$55 on 06/09/14 ($5 over the maximum cash amount allowed on hand); -$55 on 09/22/14 ($5 over the maximum cash amount allowed on hand). Review of Resident #6's trust fund statement dated 02/17/14 through 09/30/14, showed the resident with deposits made to his/her personal funds which allowed balances in excess of $50 as follows: -$60 on 05/08/14 ($10 over the maximum cash amount allowed on hand); -$70 on 06/03/14 ($20 over the maximum cash amount allowed on hand); -$60 on 07/01/14 ($10 over the maximum cash amount allowed on hand); -$130 on 07/30/14 ($80 over the maximum cash amount allowed on hand). Review of Resident #7's trust fund statement dated 01/08/14 through 09/30/14, showed the resident with deposits made to his/her personal funds which allowed balances in excess of $50 as follows: -$65 on 02/11/14 ($15 over the maximum cash amount allowed on hand); -$85 on 03/10/14 ($35 over the maximum cash amount allowed on hand); -$85 on 04/23/14 ($35 over the maximum cash amount allowed on hand); -$80 on 05/19/14 ($30 over the maximum cash amount allowed on hand). Review of Resident #8's trust fund statement dated 03/13/14 through 09/09/14, showed the resident with a balance of $20 on 08/11/14. Further review showed a deposit of $40 made to the resident's funds on 08/13/14 which left a balance of $60 ($10 over the maximum cash amount allowed on hand). Review showed the resident's funds remained in excess of $50 until 09/09/14. Review of Resident #9's trust fund statement dated 01/08/14 though 08/08/14, showed the resident with a balance of $20 on 02/03/14. Further review showed a deposit of $100 made to the resident's funds on 02/06/14, which left a balance of $120 ($70 over the maximum cash amount allowed on hand). Review showed the resident's funds remained in excess of $50 until 03/10/14. Review of Resident #10's trust fund statement dated 01/08/14 through 09/09/14, showed the resident with deposits made to his/her personal funds which allowed balances in excess of $50 as follows: -$70 on 01/14/14 ($20 over the maximum cash amount allowed on hand); -$85 on 02/10/14 ($35 over the maximum cash amount allowed on hand); -$60 on 03/13/14 ($10 over the maximum cash amount allowed on hand); -$70 on 04/07/14 ($20 over the maximum cash amount allowed on hand). Review of Resident #11's trust fund statement dated 01/07/14 through 09/30/14, showed the resident with deposits made to his/her personal funds which allowed balances in excess of $50 as follows: -$60 on 01/07/14 ($10 over the maximum cash amount allowed on hand); -$60 on 02/24/14 ($10 over the maximum cash amount allowed on hand); -$70 on 03/24/14 ($20 over the maximum cash amount allowed on hand); -$55 on 04/30/14 ($20 over the maximum cash amount allowed on hand); -$75 on 05/27/14 ($25 over the maximum cash amount allowed on hand); -$60 on 08/08/14 ($10 over the maximum cash amount allowed on hand); -$65 on 09/04/14 ($15 over the maximum cash amount allowed on hand). During an interview on 10/01/14 at 3:15 P.M., the Business Office Controller said the resident trust fund is handled only in cash. The Business Office Controller said the facility set the maximum amount of cash maintained for each resident at $50. The Business Office Controller said sometimes families bring in more money which will put the resident over the $50 and the facility allows it. The Business Office Controller said he/she did not know the facility could not maintain more than $50 in cash for each resident.

This deficiency is uncorrected. For previous examples please see the Statement of Deficiencies dated 11/20/12. Based on observation, interview and record review, facility staff failed to provide appropriate care and services to treat and prevent the development of one unidentified facility acquired unstageable pressure ulcer and failed to inform the physician and obtain a treatment for [REDACTED]. The facility census was 16. 1. Review of the facility's "Decubitus" (Pressure Ulcer) Policy, dated 7/19/07, showed staff were directed to provide the following for prevention and treatment of [REDACTED]. - Closely observe the condition of the skin, especially over bony prominences and between two opposing skin surfaces; - Massage any reddened areas or the intact skin around a pressure ulcer to promote better circulation, lotion may be used; - Change the position of the resident frequently. However, pressure on an existing decubiti must be prevented or kept to a minimum; - Keep the resident's skin clean and dry; - Foam heel and elbow protectors; - Chart a weekly wound assessment of a pressure ulcer including length, width, depth, dimension, coloration, condition of surrounding skin, presence or absence of drainage, and stage of pressure ulcer. 2. Review of Resident #4's Minimum Data Set (MDS), a federally mandated assessment, dated 10/12/12, showed staff assessed the resident as follows: - Severely cognitively impaired; - Did not reject care; - Required extensive assistance from staff for toilet use, personal hygiene, dressing, and walking; - Required limited assistance from staff for bed mobility, transfers, and eating; - Used a walker and wheelchair; - Frequently incontinent of bladder; - Occasionally incontinent of bowel; - At risk for pressure ulcers; - Had one Stage II pressure ulcer; - Most severe type of tissue for any pressure ulcer was granulation tissue; - Worsening in a Stage II pressure ulcer since prior MDS assessment; - No venous or arterial ulcers present. Review of the resident's active comprehensive care plan, dated 10/12/12, showed staff identified the resident required assistance with ADLs due to [MEDICAL CONDITION] and stroke and had a pressure ulcer on his/her heel. Review showed the care plan directed staff to provide the following interventions for the resident: - Provide assistance with mobility, transfers, ambulation, locomotion, dressing, and hygiene as needed; - Treatments as ordered; - Monitor skin for redness, open areas, and excoriation; - Weekly skin assessment; - Turn and reposition every two hours when in bed; - Pressure ulcer risk assessment quarterly; - Rotating air mattress. Review of the resident's "Decubitus Report", dated 12/19/12, showed staff documented the resident had a "hard callous" to the "right" without drainage. Review showed staff failed to document the length, width, depth, coloration, condition of surrounding skin, and stage of pressure ulcer. Further, review showed staff failed to document the location of the "hard callous". Review of the facility's Plan of Correction received on 12/31/12 showed the staff said wound assessment sheets would be completed when appropriate for the resident by the charge nurse per the facility's policy. Review of the resident's physician's orders [REDACTED]. Review of the resident's Weekly Skin Assessment, dated 1/2/13, showed staff documented the resident's right heel had a callus area that was being treated with [MEDICATION NAME] daily. Review of the resident's "Shower Skin Assessment", dated 1/7/13, completed by the Certified Nurse Assistant (CNA) showed staff recorded the following: - Staff checked "yes" to the question "Any open [MEDICAL CONDITION], cuts, lacerations or skin tears?"; - Staff checked "yes" to the question "Any open ulcers?"; - Staff recorded the resident had a "scratch" to his/her left upper buttock - Further review of the Shower Skin Assessment showed the nurse recorded he/she applied Zinc (topical medication) to the resident's "scratch". Review showed the nurse signed off on the "Shower Skin Assessment" but did not record anything about the resident's "open ulcer" identified by the CNA . Review of the resident's nurses' notes of 1/7/13 showed nursing staff failed to record an assessment of the "open ulcer" as directed by the facility's Decubitus Policy. Review of the resident's POS, and Treatment Administration Record (TAR), dated January 2013, did not show an order for [REDACTED]. Review of the resident's TAR dated January 2013, showed the following: - Apply [MEDICATION NAME] wipe to right heel daily; - Review showed the resident's TAR did not include any information to show staff administered the resident's [MEDICATION NAME] wipe as directed on four of four days between 1/4/13 through 1/7/13 to promote healing and prevent further decline in the resident's skin condition. Observation on 1/8/13 at 10:30 A.M., showed the resident sat in the dining room in his/her wheelchair. The resident wore socks but did not wear heel protectors. The resident's heels rested directly on the metal foot pedals of the wheelchair. Observation on 1/8/13 at 11:30 A.M., showed the resident sat in the dining room in a wheelchair. Observation showed the resident wore socks but did not wear his/her heel protectors as directed by the facility's Decubitus Policy. The resident's heels rested directly on the metal foot pedals. Observation on 1/8/13 at 1:10 P.M., showed the following: - The resident lay in bed. CNA C and Licensed Practical Nurse (LPN) H assisted the resident to turn to his/her left side. During an interview and observation on 1/8/13 at 1:25 P.M., CNA C said staff told him/her on Monday morning in report that the resident scratched him/herself on Sunday night. - LPN H said staff reported the resident scratched his/her left upper buttock which resulted in the wound. - Observation showed a 1.3 centimeter (cm) circular, open, red and ulcerated area on the resident's left upper buttock. - LPN H said this is the first time he/she saw this open area and he/she was going to get an order for [REDACTED]. - CNA C then removed the resident's right heel protector. A dark circular area was noted on the resident's right heel The center of the area was open and had dry black tissue. Surrounding the open area was a black blistered area. The black blistered area measured 3.0 cm long by 2.5 cm wide. A nonblanchable purple area surrounded the black area. The entire area, including the nonblanchable purple area, measured 4.5 cm by 4.0 cm; - CNA C said he/she saw the resident's right heel last week and it "did not look like that"; - LPN H said "it wasn't like that the last time he/she saw it, I'll get a wound consult for that heel"; - LPN H said the heel was being treated with a [MEDICATION NAME] wipe; Observation and interview on 1/8/13 at 1:50 P.M., showed the following: - The Certified Wound Specialist (CWS) looked at the wound on the resident's right heel; - LPN H said "we keep these heel protectors on him/her all the time"; - The CWS said the area on the resident's right heel was an unstageable pressure ulcer and pressure needed to be off of the resident's heel. During an interview on 1/8/13 at 2:00 P.M., LPN H said the following: - He/she initialed the treatment for [REDACTED]. - If a treatment is done, it should be documented; - The last day he/she saw the resident's right heel was on 1/3/12, the last day he/she worked, and the right heel had a white calloused area; - He/she did not know why staff did not document the application of the resident's right heel treatment for [REDACTED]. - If the treatment is not done for any reason, staff should circle the treatment box for that day and write on the bottom section of the TAR why the treatment was not done. Review of the resident's nurses notes dated 1/6/13 through 1/8/13 did not show staff documented any information related to the "scratch" on the resident's left upper buttock. Further review showed staff failed to document they notified the resident's physician of the area to obtain a treatment to ensure healing and prevent infection. During an interview on 1/8/13 at 2:30 P.M., the Long Term Care Director (LTCD) said the resident had a rotating air mattress as indicated on his/her care plan. Observation and interview on 1/8/13 at 2:32 P.M., showed the following: - The LTCD went into the resident's room and assessed the resident's bed; - The LTCD said the resident was not on a rotating air mattress, she thought he/she use to be but she didn't know when the mattress was changed. - Observation showed the resident was not on a rotating air mattress as directed by the care plan. During an interview and observation on 1/8/12 at 2:40 P.M., the LTCD said the following: - She looked at the resident's heel and "it looks like a blood blister next to a scabbed over area, it looks necrotic under there"; - The resident had a callous on that heel and the ordered treatment was for [MEDICATION NAME] wipe once daily; - If staff do not apply a treatment, they are supposed to circle the treatment date and time and write on the bottom section of the TAR why the treatment was not applied; - One of the nurses told her on Monday the resident had a scratch on his/her buttock but she did not look at the wound. - If a resident scratches themselves and causes an open area or wound, staff should document that in the nurses notes; - Staff are supposed to put heel protectors on the resident when he/she is in bed; Review of the facility's Plan of Correction received on 12/31/12 showed the staff said wound assessment sheets would be completed by the charge nurse per LTC policy. Staff said they would document the width, depth, dimension, coloration, condition of surrounding skin, presence or absence of drainage, and stage of a pressure ulcer.

Based on observation, interview and record review, facility staff failed to provide appropriate care and services to treat and prevent the development of eight facility acquired pressure ulcers, seven of which were unidentified and one of which was a stage three pressure ulcer (full thickness tissue loss; subcutaneous fat may be visible but bone, tendon or muscle is not exposed; slough may be present but does not obscure the depth of tissue loss; may include undermining and tunneling) for one resident (Resident #1). Staff failed to update the care plan for one resident (Resident #1) to include the development of the pressure ulcer. Staff failed to document weekly wound assessments of pressure ulcers as directed by facility policy for two residents (Resident # 1 and # 4). The facility census was 18. 1. Review of the facility's "Decubitus" (Pressure Ulcer) Policy, dated 7/19/07, showed staff were directed to provide the following for prevention and treatment of [REDACTED]. - Closely observe the condition of the skin, especially over bony prominences and between two opposing skin surfaces; - Massage any reddened areas or the intact skin around a pressure ulcer to promote better circulation, lotion may be used; - Change the position of the resident frequently. However, pressure on an existing decubiti must be prevented or kept to a minimum; - Keep the resident's skin clean and dry; - Foam heel and elbow protectors; - Chart a weekly wound assessment of a pressure ulcer including width, depth, dimension, coloration, condition of surrounding skin, presence or absence of drainage, and stage of pressure ulcer. 2. Review of Resident # 1's Admission Minimum Data Set (MDS), a federally mandated assessment instrument, dated 8/30/12, showed staff assessed the resident as follows: - Moderately cognitively impaired; - Did not reject care; - Independent for bed mobility, transfers, walking, eating, and personal hygiene; - Required limited assistance from staff for dressing and toilet use; - Used a walker and wheelchair; - Occasionally incontinent of bladder; - Always continent of bowel; - diagnosed with [REDACTED]. - At risk for pressure ulcers; - Had no pressure ulcers. Review of the resident's Admission Skin Assessment, dated 8/16/12, showed staff documented "bottom is reddened" but did not identify any open areas. Review of the resident's Braden scale (instrument used to predict a person's risk of developing a pressure ulcer), dated 8/16/12, showed staff documented the resident scored 18 (at low risk for developing pressure ulcers). Review of the resident's comprehensive care plan, dated 9/6/12, showed staff identified the resident required assistance with activities of daily living (ADLs) due to generalized weakness and liver disease and that the resident was at risk for skin breakdown related to incontinence and directed staff to provide the following interventions for the resident: - Assistance with mobility, transfers, ambulation, locomotion, dressing, and hygiene as needed; - Shower twice weekly; - Toilet every two hours and as needed; - Prompt perineal care after each incontinent episode; - Monitor skin for redness, open areas, rash and excoriation; - Weekly skin assessment. Further, review showed the resident's care plan did not contain any information to indicate the resident had skin breakdown or pressure ulcers. Review of the resident's Braden scale, dated 9/21/12, showed staff documented the resident scored 17 (at low risk for developing pressure ulcers). Review of the resident's Treatment Administration Record (TAR), dated September 2012, showed a physician's orders [REDACTED]. Further, review showed staff did not documented any zinc application to any reddened areas on the resident. Review of the resident's skin assessments from 9/5/12, 9/12/12, 9/19/12 and 9/26/12 showed staff did not identify any reddened areas, open areas, or pressure ulcers on the resident's skin. Review of the resident's TAR, dated October 2012, showed a physician's orders [REDACTED]. Review showed staff documented zinc application to reddened areas on 10/20/12, 10/27/12, 10/28/12, and 10/29/12. Review of the resident's skin assessments from 10/3/12, 10/10/12, 10/17/12, 10/24/12 and 10/31/12 showed staff did not identify any reddened areas, open areas, or pressure ulcers in the resident's skin. Review of the resident's TAR on 11/19/12, dated November 2012, showed a physician's orders [REDACTED]. Review showed staff documented zinc application to reddened areas at least once a day from 11/1/12 through 11/19/12 (every day of the month up to the current date). Review of the resident's skin assessment, dated 11/2/12, showed staff documented the "resident has a open area on the right buttock cheek. Zinc applied". Review showed staff failed to document the width, depth, dimension, coloration, condition of surrounding skin, presence or absence of drainage, and stage of pressure ulcer as directed by facility policy. Review of the resident's skin assessment, dated 11/7/12, showed staff documented the resident had an "open area on the right buttock cheek" and "treatment in place". Review showed staff failed to document the width, depth, dimension, coloration, condition of surrounding skin, presence or absence of drainage, and stage of pressure ulcer as directed by facility policy. Review of the resident's skin assessment, dated 11/14/12, showed staff documented the resident had an "open area on the right buttock cheek and zinc applied". Review showed staff failed to document the width, depth, dimension, coloration, condition of surrounding skin, presence or absence of drainage, and stage of pressure ulcer as directed by facility policy. During an interview on 11/19/12 at 11:45 A.M., Registered Nurse (RN) F said the resident had one stage II pressure ulcer on his/her bottom and that staff were treating this area with zinc oxide. Review of the resident's Shower Skin Assessment, dated 11/19/12 at 1:45 P.M., read the assessment was to be completed after every shower by a CNA and if any areas of concern were identified, the "Charge Nurse will verify and complete an assessment". Review showed the following: - A Certified Nurses Aid (CNA) identified the resident had an open ulcer; - An RN signed off on the shower sheet and documented "coccyx area red" and "zinc applied"; - Staff failed to document the width, depth, dimension, coloration, condition of surrounding skin, presence or absence of drainage, and stage of pressure ulcer as directed by facility policy. Observation on 11/19/12 at 4:10 P.M., showed the resident sat in a wheelchair in the dining room. Observation on 11/19/12 at 5:15 P.M., showed the resident continued to sit in a wheelchair in the dining room. Observation on 11/19/12 at 5:35 P.M., showed the resident continued to sit in a wheelchair in the dining room. Observation on 11/19/12 at 5:45 P.M., showed the resident continued to sit in a wheelchair in the dining room. Observation showed staff placed the resident's supper tray in front of him/her at this time. Observation on 11/19/12 at 5:50 P.M., showed the resident continued to sit in a wheelchair in the dining room eating supper. Observation on 11/19/12 at 6:15 P.M., showed the resident continued to sit in a wheelchair in the dining room. Observation on 11/19/12 at 6:30 P.M., showed the resident continued to sit in a wheelchair in the dining room. Staff did not remind or assist the resident to change position, as directed by the facility's Decubitus Care Policy, between at least as early as 4:10 P.M. until at least as late as 6:30 P.M.. Staff did not toilet the resident every two hours as directed by the resident's plan of care to prevent further skin breakdown. Observation on 11/20/12 at 5:40 A.M., showed staff woke the resident and assisted him/her to the bedside commode. Observation showed the resident had multiple open areas on his/her bottom. During an interview on 11/20/12 at 6:20 A.M., Licensed Practical Nurse (LPN) B said the resident had a small open area on the right side of his/her bottom that was a stage II pressure ulcer that staff treated with zinc cream. Further, LPN B said that was the only pressure ulcer the resident had. Review of the resident's active care plan on 11/20/12, last evaluated 11/13/12, showed staff failed to document the "open area"/pressure ulcer to the resident's right buttock first identified on 11/2/12. Observation on 11/20/12 at 5:50 A.M., showed staff assisted the resident to a wheelchair. Observation on 11/20/12 at 6:20 A.M., showed the resident continued to sit in a wheelchair in the hallway. Observation on 11/20/12 at 7:15 A.M., showed the resident continued to sit in a wheelchair in the dining room at a table. Observation on 11/20/12 at 7:30 A.M., showed the resident continued to sit in a wheelchair in the dining room at a table. Observation on 11/20/12 at 8:00 A.M., showed the resident continued to sit in a wheelchair in the dining room at a table while he/she ate breakfast. Observation on 11/20/12 at 8:30 A.M., showed the resident continued to sit in a wheelchair in his/her room. Observation on 11/20/12 at 9:00 A.M., showed the resident continued to sit in a wheelchair in his/her room. Staff did not remind or assist the resident to change position, as directed by the facility's Decubitus Care Policy, between 5:50 A.M. until 9:10 A.M.. Staff did not toilet the resident every two hours as directed by the resident's plan of care to prevent further skin breakdown. Observation on 11/20/12 at 9:10 A.M., showed CNA D assisted the resident from the wheelchair to the toilet. Further, observation showed the following: - The resident had four superficial, open and ulcerated areas on his/her right buttock inside a reddened area that measured 3.0 centimeters (cm) long and 2.0 cm wide; - The resident's left buttock had a dry, red open area that was superficial and measured 0.5 cm; - The resident's left buttock also had a reddened area that measured 1.0 cm with an open area in the center that tunneled. The depth of the pressure ulcer was not noted. - As CNA D removed the resident's sock from his/her left foot, the resident said "ouch" as the sock moved over his/her heel observation showed a 2.0 cm reddish/purple area that did not blanch on the resident's left heel; - The resident's right heel had a 1.0 cm long by 2.0 cm wide dark purple/black area that was not open, but had peeled skin around it; - CNA D said that was the first he/she knew of the areas on the resident's heels. During an interview on 11/20/12 at 9:25 A.M., LPN E said the following: - The resident did not have any open areas on his/her bottom; - The resident had a history of [REDACTED]. - He/she would not put zinc cream on any open areas on the resident, that the zinc cream was just ordered for reddened areas. - The resident did not have any skin abnormalities on his/her heels. During an interview on 11/20/12 at 9:30 A.M., the Long Term Care Director (LTCD) said the following: - The resident recently had a stage I pressure ulcer on his/her bottom and staff were treating it with zinc, but the resident had no pressure ulcers on his/her heels; - The CNAs fill out the shower sheets for residents and the nurse has to sign off on each shower sheet; - Nurses are supposed to document an assessment on the shower sheet of any areas of concern the CNAs identify; - If the resident had a pressure ulcer greater than a Stage I, staff should have notified the resident's physician of the change in the resident's condition and also see what treatment the physician wanted staff to use on the resident's pressure ulcer. Observation on 11/20/12 at 11:20 A.M., showed LPN E and the LTCD assessed the resident's pressure ulcers. Observation showed the following: - The resident had four superficial, open and ulcerated areas on his/her right buttock inside a reddened area that measured 3.0 centimeters (cm) long and 2.0 cm wide. The four open/ulcerated areas measured 0.5 cm, 1.0 cm, 1.0 cm, and 0.75 cm. The LTCD said the four open areas were all stage II pressure ulcers; - The resident's left buttock had a dry, red open area that was superficial and measured 0.5 cm; - The resident's left buttock also had a reddened area that measured 1.0 cm with a 0.5 cm open area that tunneled. The depth of this pressure ulcer was unable to be seen. The LTCD measured the depth with a Q-tip to be 1.0 cm deep. The LTCD said she would probably stage this as a Stage III pressure ulcer; - The resident's left heel had a 2.0 cm area that was reddish/purple, did not blanch, and was mushy. The LTCD said she would stage this as a stage I pressure ulcer, that she did not think this area was a suspected deep tissue injury (purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue); - The resident's right heel had a 1.0 cm long by 2.0 cm wide dark purple/black area that was not open but had peeled skin around it. The area was not a scab. The LTCD said she thought this area looked like an abrasion or a pressure ulcer that had healed. The LTCD said she did not think this area was a suspected deep tissue injury. During an interview on 11/20/12 at 8:15 P.M., the LTCD said every residents' care plan gets reviewed by a nurse weekly for accurateness and updated at that time and as needed. During an interview on 11/20/12 at 1:20 P.M., LPN E said the following: - If a CNA identifies new open areas or pressure ulcers on a resident, he/she should tell the charge nurse; - If a nurse knows of a new open area or pressure ulcer on a resident, he/she should update the resident's care plan, notify the LTCD, and pass on the information in report to the next shift's nurse; - The LTCD assigns nurses to review resident care plans and each resident's care plan gets reviewed and updated weekly and as needed and the LTCD should be notified of any changes needed to the care plan. During an interview on 11/20/12 at 2:08 P.M., the LTCD said the nurse that documented an open area to the resident's buttock on 11/2/12 should have updated the resident's care plan to include the pressure ulcer and should have communicated to her and the other nurses that the resident had a pressure ulcer. During an interview on 11/27/12 at 11:15 A.M., the LTCD said the following: - She expected staff to reposition the resident every two hours to prevent skin breakdown; - Staff were supposed to toilet the resident at least every two hours to get the resident out of the wheelchair for a little bit. 3. Review of Resident # 4's MDS, dated [DATE], showed staff assessed the resident as follows: - Severely cognitively impaired; - Did not reject care; - Required extensive assistance from staff for toilet use, personal hygiene, dressing, and walking; - Required limited assistance from staff for bed mobility, transfers, and eating; - Used a walker and wheelchair; - Frequently incontinent of bladder; - Occasionally incontinent of bowel; - At risk for pressure ulcers; - Had one Stage II pressure ulcer; - Most severe type of tissue for any pressure ulcer was granulation tissue; - Worsening in a Stage II pressure ulcer since prior MDS assessment; - No venous or arterial ulcers present; - Not having a pressure reducing bed. Review of the resident's active comprehensive care plan, dated 10/12/12, showed staff identified the resident required assistance with ADLs due to [MEDICAL CONDITION], stroke, and a pressure ulcer on his/her heel. Review showed the care plan directed staff to provide the following interventions for the resident: - Provide assistance with mobility, transfers, ambulation, locomotion, dressing, and hygiene as needed; - Monitor skin for redness, open areas, rash and excoriation; - Weekly skin assessment; - Turn and reposition every two hours when in bed; - Pressure ulcer risk assessment quarterly; - Rotating air mattress. Review of the resident's skin assessments from September showed staff documented the following: - 9/5/12 "Right heel with dark black center, treatment in place"; - 9/12/12 "Right heel with dark black center, treatment in place"; - 9/19/12 "Right heel with dark black center, treatment in place"; - 9/26/12 "Right heel with dark black center, treatment in place"; Further, review showed staff failed to document the width, depth, dimension, coloration, condition of surrounding skin, presence or absence of drainage, and stage of pressure ulcer as directed by facility policy. Review of the resident's skin assessments from October showed staff documented the following: - 10/3/12 "right heel has blackened area on it, using [MEDICATION NAME]" (topical medication used to prevent infections); - 10/10/12 "right heel has blackened area on it, using [MEDICATION NAME]"; - 10/17/12 "right heel has blackened area on it using [MEDICATION NAME]"; - 10/24/12 "decubitus on right heel, foot doctor debrided (removed dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue) it on last visit"; - 10/31/12 "decubitus on right heel"; Further, review showed staff failed to document the width, depth, dimension, condition of surrounding skin, presence or absence of drainage, and stage of pressure ulcer for these assessments as directed by facility policy. Review of the resident's skin assessments from November showed staff documented the following: - 11/8/12 "Right heel has callous on it, [MEDICATION NAME]"; - 11/14/12 "Right heel has a callous that has a black center, treatment in place"; Further, review showed staff failed to document the width, depth, dimension, condition of surrounding skin, presence or absence of drainage, and stage of pressure ulcer as directed by facility policy. Observation on 11/19/12 at 1:20 showed the following: - CNA G removed the residents socks; - The resident's right heel had a 2.5 cm calloused area with peeled skin and a 1.5 cm brown center. 4. During an interview on 11/19/12 at 6:10 P.M., the LTCD said the residents' skin and wound assessments are documented weekly on Wednesday evening by the night nurse. 5. During an interview on 11/20/12 at 2:50 P.M., the LTCD said the following: - The nurse that does the weekly skin and/or decubitus assessment is supposed to document the measurements and stage of each pressure ulcer; - When doing the weekly skin assessment, staff should include all the information indicated to be included per the Decubitus Care Policy.