Every finding on record at Signature Healthcare of Primacy

Based on policy review, medical record review, hospital record review, observation, and interview, the facility failed to ensure residents received treatment and services to promote healing, provide skin assessments, initiate wound treatments, and administer wound treatments for 5 of 96 (Residents #4, #10, #74, #79, and #90) sampled residents for pressure injuries/ulcers. The findings include: 1. Review of the facility policy titled, Skin Integrity, dated 1/2025, revealed .The facility will ensure that based on the comprehensive assessment of a resident.A resident receives care, consistent with professional standards of practice, to prevent avoidable skin integrity issues .unless the individual's clinical condition demonstrates that they were unavoidable.A resident with impaired skin integrity receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent avoidable skin integrity issues from developing.Upon admission, the licensed nurse shall complete the initial skin check and obtain orders from the physician/practitioner for any areas of impaired skin integrity that may not have orders in place when the resident is admitted to the facility from other healthcare settings or home.It is recommended that a nursing leader does a follow-up visualization of skin integrity concerns that were present upon admission.Recommend ongoing observation of skin integrity by licensed nursing staff.The licensed nurse shall initiate applicable Skin Integrity documentation if a new area of impairment is identified.The Nurse Leader/Wound Nurse shall document all impaired skin integrity areas such as.pressure.in the EMR [Electronic Medical Record] on an ongoing basis or until closed or the resident has been discharged .In addition, to ongoing observations of skin integrity impairments mentioned above, nursing stakeholders shall observe the skin for areas of impairment during bathing, dressing, and peri care. Nursing stakeholders will notify the nurse if a new area is identified. 2. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including Rectal Abscess, Rectal Fistula, Urinary Tract Infection, and Chronic Kidney Disease. Review of the undated comprehensive care plan revealed .Start Date .1/12/2026 .Provide me with a weekly skin assessment via [by way of] a licensed nurse . Review of the hospital's After Visit Summary from (Named Hospital) dated 1/22/2026, revealed .The instructions below are accurate as of the time you leave [Named Hospital] .Discharge to Outside Facility Orders .For wound vac [a medical device that uses suction to promote healing in chronic, acute, or deep wounds] .Cleanser .wound cleanser .Periwound [skin area, typically extending up to, immediately surrounding a wound bed] tx [treatment] .skin prep, transparent drape, ostomy ring [moldable, adhesive, hydrocolloid seals used between the stoma and appliance to prevent leakage, protect skin from output, and fill uneven skin contours] at the bottom of the wound near the rectum to aide in seal .Foam/Sponges applied: 2 piece of black foam applied to wound, 1 piece of black foam bridged up left hip .Settings: [named wound vac] @ [at] 125mm/hg [millimeters of mercury a standard pressure setting for a wound vac] with 16ml [milliliter] install and 10 min [minute] soak .Discharge order . Review of the facility's admission Observation dated 1/22/2026 at 11:08 PM, revealed .Skin Impairment upon admission.No. Review of the Daily Skilled Notes revealed .Skin Integrity.N/A [not applicable]. on the following dates: a. 1/24/2026 at 12:55 AM b. 1/27/2026 at 1:08 AM c. 1/28/2026 at 9:16 AM d. 1/29/2026 at 7:57 AM e. 1/29/2026 at 7:39 PM f. 2/1/2026 at 3:57 AM The facility failed to complete an accurate admission assessment, failed to provide a follow up assessment from the Nurse Leader/Wound Nurse (per the facility policy), failed to identify and obtain measurements for a sacral wound, failed to implement the orders for a wound vac, and failed to obtain orders for wound care when Resident #4 was readmitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #4 scored a 14 on the Brief Interview for Mental Status (BIMS) assessment, which indicated she was cognitively intact. Resident #4 had 1 unhealed pressure ulcer that was Unstageable and present upon admission. Review of the Physician Order dated 2/1/2026, revealed .1/28/2026.SACRAL.CLEANSE SACRALWOUND [sacral wound] WITH WOUND CLEANSER, PAT DRY, APPLY MEDIHONEY [medical grade honey for healing], CALCIUM ALGINATE [dressing used for heavily exudating, infected, or bleeding wounds] AND COVER WITH FOAM TUES-THURS-SAT [on Tuesday, Thursday, and Saturday] UNTIL RESOLVED. and .2/17/2026.(sacrum) monitoring every shift. The facility failed to obtain a Physician's Order for wound care to Resident #4's sacral wound from the readmission date of 1/22/2026 until 1/28/2026. Review of the Treatment Administration Record (TAR) dated 1/2026, revealed staff failed to provide wound care to Resident #4's sacral wound from 1/22/2026 to 1/31/2026. Review of the Wound Administration History dated 2/1/2026 through 2/26/2026, revealed there was no documentation wound care was performed to the sacral wound until Sunday 2/1/2026, 10 days after Resident #4 was readmitted to the facility with the wound. Review of the TAR dated 2/2026, revealed staff failed to provide wound care to Resident #4's sacral wound as ordered on 2/3, 2/5, 2/10, 2/14, and 2/17. Review of the Wound Management Detail Report revealed the first documented wound measurements for Resident #4's sacral wound was not obtained until 2/6/2026, 15 days after Resident #4 was readmitted to the facility. The documented measurements were (length- head to toe direction) 14 cm, (width- side to side direction) 15.2 cm, and (depth- deepest part of visible wound) 3 cm. Review of the undated comprehensive care plan revealed .Start Date .2/17/2026.Resident has pressure ulcer(s) r/t [related to] Sacrum .Resident has potential for alterations in skin integrity . The facility failed to include the sacral wound in the comprehensive care plan until 2/17/2026, 26 days after Resident #4 was readmitted to the facility. During an interview on 2/25/2026 at 11:32 AM, Licensed Practical Nurse (LPN) B was asked what her position at the facility was. LPN B stated, Weekend wound care.11 years. LPN B was asked if she recalled Resident #4. LPN B stated, .she wouldn't have been one I treated. LPN B was asked if Resident #4 had any wound orders. LPN B stated, I think she had one when she initially came in. LPN B was asked how she knows what treatments are due on the weekends. LPN B stated, .we have a cheat sheet.that we write on during the week if anyone comes in. LPN B was asked how staff ensures that wound treatments don't get missed. LPN B stated, We've never missed anyone that I can recollect on. LPN B read the order for Resident #4's sacral wound care and was asked if she completed the wound treatment ordered for Saturdays. LPN B stated, No, I did not. During an interview on 2/25/2026 at 4:48 PM, the Director of Nursing (DON) was asked about the process for skin assessments when a resident was newly admitted or returned from the hospital. The DON stated, .the charge nurse or supervisor would do the skin assessment.and then the next day the wound nurse does her assessment, and the wound nurse will put in the orders. The DON was asked who was responsible for making sure staff completed skin assessments. The DON stated, I am. The DON was asked about Resident #4's sacral wound after readmission on [DATE]. The DON stated, .I do not see a wound care leader assessment. The DON was asked what date an assessment was done on Resident #4's sacral wound. I see the 1/10 [1/10/2026] when she was first admitted and I don't see any other assessments for January. The DON was asked if Resident #4 should have been assessed for wounds when she was readmitted to the facility on [DATE]. The DON stated Yes. The DON was asked when Resident #4's sacral wound measurements were recorded. The DON stated, February 6th [2/6/2026]. The DON stated Resident #4's sacral wound was not measured until 2/6/2026. The DON was asked what the order for Resident #4's sacral wound was upon readmission to the facility on 1/22/2026. The DON stated, Looks like her order started on 1/28 [1/28/2026]. The DON was asked if Resident #4 returned the facility on 1/22/2026 and an order was not placed until 1/28/2026. The DON stated, Correct. The DON admitted a wound care order should have been obtained prior to 1/28/2026. The DON was asked while looking at Resident #4's TAR if she could see that Resident #4 received any wound treatments between 1/22/2026 and 1/31/2026. The DON stated, Looking at this screen, I do not. The DON was asked if staff should document Stage 4 pressure ulcers. The DON stated, Of course. The DON was asked how do you know if the wound was improving or declining if no measurements of Resident #4's sacral wounds were obtained until 2/6/2026. The DON stated, I wouldn't know. The DON was asked if wound measurements should have been obtained when Resident #4 returned to the facility on 1/22/2026. The DON stated, Yes. The DON was asked, while looking at the 2/2026 TAR, if wound treatments were provided as ordered by the physician in February. The DON stated, It's not signed off for 3 [2/3/2026], 5 [2/5/2026], 10 [2/10/2026], 17 [2/17/2026]. 3. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including Encephalopathy, Urinary Retention, Cerebral Infarction, Urinary Tract Infection, Hypotension. Review of the quarterly MDS assessment dated [DATE], revealed Resident #10 scored a 3 on the BIMS assessment, which indicated she was moderately cognitively cognitive impaired. Resident #10 had no pressure ulcer, was at risk for developing a pressure ulcer/injury, and required a pressure reducing device for her chair and bed. Observation in Resident #10's room on 2/26/2026 during a skin sweep (facility wide skin assessments) revealed Resident #10 had reddened area to her buttocks and the nurse was unable to stage. The wound nurse was asked to go back and stage the wounds and identified an unstageable wound to the Left buttock. The facility was unable to provide documentation of physician's orders for wound care when the wound was identified on 2/26/2026. Review of the Care Plan dated 2/27/2026, revealed .Pressure Injury(s): STAGE 2-Left Medial Thigh.Notify nurse immediately of any new areas of skin breakdown, redness, blisters, bruises, discoloration noted during cares.Pressure Injury(s): UNSTAGEBLE-RIGHT MEDICAL BUTTOCK. Review of the Progress Notes dated 2/27/2026 at 9:40 PM, revealed .has a new area that has been identified .Wound Care-Physician Assistant has completed a head- to- toe skin assessment (2/27/2026). [Named Resident #10] has an Unstageable to the right medial buttock. The measurements are as follows: 4 x 2.9 x UTD [Unable to determine] cm [centimeters]. [Named Resident #10] has a Stage 2 to the left medial thigh. The measurements are as follows 0.2 x 0.2 x 0.1[cm]. Order decision has been made by Physician Assistant and placed in the system to reflect care . Review of the Physician Orders dated 2/27/2026, revealed .zinc sulfate tablet; 50 mg [milligrams] zinc (220 mg); multivitamin tablet; ascorbic acid (vitamin C) tablet; 500 mg; amt [amount] 1 tablet; oral Twice A Day. During an interview on 2/27/2026 at 10:15 AM, the Regional Nurse Consultant acknowledged there were no orders for wound care to the stage 2 pressure ulcer on Resident #10's left thigh or the unstageable pressure ulcer on her left buttock identified on 2/26/2026. Review of the Physician Orders dated 2/28/2026, revealed .Santyl (collagenase clostridium .) ointment [topical ointment used to remove dead tissue]; 250 unit/gram; amt: Nickel thick; topical Special Instructions: Unstageable (Right Medial Buttock): Cleanse with NS [normal saline], pat dry, apply nickel thick Santyl, cover with dry/foam dressing every 3 days. Review of the Physician Orders dated 2/28/2026, revealed Stage 2 (Left Medial Thigh) Special Instructions: Cleanse with soap and water. Pat dry. Apply skin barrier cream.twice a day until resolved. Twice A Day. 4. Review of the medical record revealed Resident #74 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including Coronary Artery Disease, Dementia, and Pressure Ulcer of Sacral Region. Review of the annual MDS assessment dated [DATE], revealed Resident #74 scored a 3 on the BIMS assessment which indicated she was severely cognitively impaired. Review of the Care Plan for Resident #74 revised on 1/27/2026, revealed .Potential for alteration in skin integrity, breakdown, pressure ulcer r/t [related to] incontinence . Review of the Physician Orders dated 2/16/2026, revealed, Weekly Skin Assessment .Open appropriate event for newly identified skin issues. Once A Day on Tue [Tuesday]. Review of Physician Orders dated 2/17/2026, revealed, Encourage float heels while in bed as resident [Resident #74] allows. Review of Physician Orders dated 2/20/2026, revealed, Pressure Pressure/Relieving/Redistribution mattress. Review of the Wound Management Detail Report dated 2/24/2026, revealed left and right planter 5th metatarsophalangeal (MTP) joint MTP, right heel and left 5th digit dorsal aspect were identified as Deep Tissue Injuries (DTI's). The wounds were discovered on 2/24/2026 but not documented until 2/26/2026. The facility was unable to provide documentation of Physician's orders for wound care when the wounds were identified on 2/24/2026. Review of the (Named Wound Care company) document dated 2/27/2026 at 3:15 PM, revealed the following: a. A Stage 4 sacral Pressure Ulcer that was present on admission. b. A left plantar 5th MTP Deep Tissue Pressure Injury (DTPI) that was present on admission. c. A right plantar 5th MTP DTPI that was present on admission. d. A right heel facility acquired DTI that measured 5 cm x 6 cm x UTD cm that was identified 2/24/2026, during the survey. e. A left 5th digit dorsal aspect facility acquired DTI that measured 1.4 cm x 1 cm x UTD cm that was identified 2/24/2026, during the survey. 5. Review of the medical record revealed Resident #79 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including Encephalopathy, Atrial Fibrillation, Congestive Heart Failure, and Dementia. The quarterly MDS assessment dated [DATE], revealed Resident #79 scored a 00 on the BIMS assessment which indicated she was severely cognitively impaired. Resident #79 had no pressure injuries, was at risk for pressure injuries and had a pressure reducing device for her chair and bed. Review of Progress Note dated 2/24/2026 at 10:11 PM, revealed .quarter sized skin opening on right elbow . Review of Progress Note dated 2/25/2026 at 5:33 AM, revealed .cont [continues] to have skin open but dry without drainage to right elbow .covered with dry drsg [dressing] plan of care ongoing . Observation in Resident #79's room on 2/26/2026 at 11:25 AM, during a skin sweep with LPN F, revealed Resident #79 had an open area to her Right elbow measuring 2.2 cm x 1.3 cm. Review of the Physician orders dated 2/26/2026 at 12:27 PM revealed, apply barrier cream as needed. The facility was unable to provide documentation of physician's orders for wound care when the wound was identified on 2/24/2026. The Wound Nurse provided documentation on 2/27/2026 that Resident #79's wound was a Stage 2 to the right elbow. Review of Progress Note dated 2/27/2026 at 22:56 PM, revealed, .new area that has been identified .Wound Care-Physician Assistant has completed a head- to- toe skin assessment [2/27/2026] .a Stage 2 to right elbow 1 [cm] x 0.9 [cm] x 0.1 [cm]. Order decision has been made by Physician Assistant and placed in the system to reflect care. 6. Review of the medical record revealed Resident #90 was admitted to the facility on [DATE], with diagnoses including Peripheral Vascular Disease, Diabetes, Chronic Kidney Disease, and Dementia. Review of the annual MDS assessment dated [DATE], revealed Resident #90 scored an 8 on the BIMS assessment, which indicated that she was moderately cognitively impaired. Resident #90 was at risk for developing pressure ulcer/injuries, no pressure ulcer/injuries were documented, and she was coded for a pressure relieving device for her bed and chair. Review of the Care Plan dated 2/24/2026, revealed .Skin Integrity Resident has potential for alterations in skin integrity r/t [related to] decreased mobility, episodes of incontinence, non pressure ulcer to left great toe . Review of the Physician Orders dated 2/26/2026, revealed .apply barrier cream as needed . Observation in Resident #90's room during a skin sweep on 2/26/2026 at 9:40 AM, revealed a sacral wound measuring 6.2 cm x 13 cm identified as a Stage 3 pressure ulcer. This wound was not listed on the wound report provided to the surveyors on entrance to the facility. Review of the progress note dated 2/27/2026 at 10:50 PM, revealed, .new area that has been identified .Wound Care-Physician Assistant has completed a head to toe skin assessment (2/27/26) .a stage 2 sacrum 4.2 x 4.0 x 0.2 [cm] .purple area around sacrum .Order decision has been made by Physician Assistant and placed in the system to reflect care . Review of Progress Note dated 3/1/2026 at 3:23 AM, revealed, .Sacral wound noted .Area clean and dried. Barrier cream applied. Dressing applied . Review of the Physician's Orders dated 3/1/2026, revealed .(sacrum) monitoring every shift .Special Instructions: Observe that dressing is dry and intact as applicable, if intact apply dressing, notify Director of Nursing or Wound Care Nurse . Review of the Care Plan dated 3/1/2026, revealed, .Skin Integrity Resident has pressure ulcer(s) STAGE 2-SACRUM . Review of the (Named Wound Care Company) Progress Note dated 3/2/2026 at 12:00 AM, revealed, .seen today for a follow up visit for wound care services .Location: Sacral, Wound Type: Stage 2 Pressure Ulcer, Depth Exposure: partial-thickness, Wound Size: 6 x 7.4 x 0.2 cm , clustered wound . Review of the Physician's Orders dated 3/2/2026, revealed, Sacrum (Stage 2) Special Instructions: Cleanse with wound cleanser. Pat dry. Apply collagen particles to the wound bed, cover with a dry/foam dressing, apply barrier cream to surrounding tissue on M, W, F until resolved. The facility failed to ensure Resident #90's sacral pressure ulcer/injury was accurately staged and assessed. 7. During an interview on 2/26/2026 at 8:37 AM, the DON stated that the facility staff completed skin sweeps of all residents the night of 2/25/2026. The DON was asked if there were any new skin injuries observed during the skin sweep. The DON stated, No. During an interview on 2/27/2026 at 12:33 PM, the DON was asked what date the staff did the skin sweeps on the residents. The DON stated, It was 2/25 and finished the morning of 2/26. She was then asked who participated in the skin sweep. The DON stated, DON, Unit Managers. In your interview yesterday, you stated, Nothing New related to the new skin sweep, the survey team found an additional 8 residents with pressure ulcers. Have you been notified by staff who these additional residents are. The DON stated, I heard partial of it yesterday evening and the remaining of it this morning. Administration generally gets those when discussed in the AM [morning] clinical meetings, but we have not had those [morning clinical meetings] this week. The DON was asked since finding out this new information, what interventions have been put in place, has the medical director been notified. The DON stated, .Orders have been put in, the Dietician and [named Medical Director], Nurse Practitioner, and Responsible Parties were notified. The DON was asked who was responsible for the wound process in the building. The DON stated, Myself, Wound Nurse and [named wound company] Physician Assistant if we need to change a process. During an interview on 2/27/2026 at 12:42 PM, the Administrator was asked if you are aware of the breakdown in the system for pressure ulcers. The Administrator stated, Towards the end of January we were having issues with the wound care nurse and in February the DON and I began digging into it. She was not doing what our expectations were and I suspended her. Then we completed our investigation and terminated her the week of 2/16/2026. The Administrator was asked if they had a Quality Assurance and Performance Improvement (QAPI) meeting about the wounds. The Administrator stated, No, our QAPI was scheduled for Tuesday of this week, but you all came in . No, we did not have one in January, since the ice storm. During a telephone interview on 3/2/2026 at 2:00 PM, the Medical Director was asked do you expect wound treatments to be completed as ordered. He stated, Yes, I ordered them for them to follow .

Based on policy review, medical record review, observation, and interview, the facility failed to ensure the residents' environment was free from accident hazards for 2 of 3 (Resident #1 and #126) residents reviewed for accident hazards. The findings include: 1. Review of the facility policy titled, Oxygen Storage, dated 1/2025, revealed .The facility acknowledges the special hazards associated with the storage and use of compressed oxygen cylinders and the use of cryogenic (low temperature liquid) oxygen and has established procedures for the safe storage, use and transfer of oxygen in the facility.E-tanks [a 3-foot tall aluminum container filled with compressed medical-grade oxygen gas] will be stored in an approved O2 [oxygen] tank holding device or in an approved storage rack at all times. 2. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses including Acute Respiratory Failure, Chronic Obstructive Pulmonary Disease, and Pneumonia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 scored a 14 on the Brief Interview for Mental Status (BIMS) assessment, which indicated he was cognitively intact. Resident #1 received oxygen therapy and experienced shortness of breath with exertion and when lying flat. Review of the Physician's Order dated 2/1/2026, revealed .1/22/2026.Oxygen Therapy: Oxygen via [by way of] (NC) [Nasal Canula] @ [at] 4Liters per minute. 3. Review of the medical record revealed Resident #126 was admitted to the facility on [DATE], with diagnoses including Parkinson's Disease, Dementia, and Hypertension. The admission MDS was not completed at time of survey. Observation in Resident #1 and #126's shared room on 2/23/2026 at 12:48 PM, revealed an E-tank was sitting on the floor in front of Resident #1's bed, unsecured and uncontained, without any a holding device or approved storage rack, approximately 5-6 feet from the room entry way. During an observation and interview in Resident #1 and #126's shared room on 2/23/2026 at 12:56 PM, Registered Nurse (RN) A was asked if the portable oxygen cylinder should be sitting on the floor. RN A stated, No, not like that. During an interview on 2/25/2026 at 4:35 PM, the Director of Nursing (DON) was asked should portable oxygen cylinders be sitting on the floor without a proper tank holding device. The DON stated, .they can't be on the floor.no .

Based on policy review, medical record review, observation, and interview, the facility failed to ensure that medications were properly stored for self- administration when medications were found unsecured in 1 of 55 (Resident #40) resident rooms during initial tour. The findings include: 1. Review of the facility policy titled, Medication Storage Bedside Medication Storage, dated 1/2024, revealed .The manner of storage prevents access by other residents. Lockable drawers or cabinets are required .The nurse will oversee storage security and accountability of bedside medications . Review of the facility policy titled, Medication Storage .of Medication, dated 1/2025, revealed .medication supplies should remain locked when not in use or attended to by persons with authorized access . 2. Review of the medical record revealed, Resident #40 was admitted to the facility on [DATE], with diagnoses including Heart Failure, Atherosclerotic Heart Disease, Essential Hypertension, and Muscle Weakness. Review of the facility document titled, Self-Administration of Medications, dated 4/25/2025, revealed Licensed Practical Nurse (LPN) C completed an assessment for the medication Moxifloxacin (antibiotic) Eye drops.I agree to: Keep them stored in my room in a secure location . Review of the annual Minimum Data set (MDS) assessment dated [DATE], revealed Resident #40 scored a 15 on the Brief Interview Mental Status (BIMS) assessment, which indicated she was cognitively intact and was independent with all Activities of Daily Living skills. Review of the document titled, Self-Administration of Medications, dated 12/16/2025, revealed LPN C completed an assessment for the medication Sucralfate Oral Suspension (used to treat ulcers).I agree to: Keep them stored in my room in a secure location . Observation in Resident #40's room on 2/23/2026 at 10:15 AM, 11:26 AM, and 2:07 PM, revealed Sucralfate Oral Solution on the overbed table and Moxifloxacin drops unsecured on the nightstand. During an interview on 2/23/2026 at 2:10 PM, LPN D was asked, should Resident #40 have medications on the overbed table and nightstand. LPN D Stated, She does self-administer some of her medications. LPN D did not remove the medications from Resident #40's overbed table or nightstand and place them in a secure location at that time. Observation in Resident #40's room on 2/24/2026 at 7:45 AM, 10:20 AM, and 12:36 PM, revealed Sucralfate Oral Solution on the overbed table and Moxifloxacin drops unsecured on the nightstand. During an interview on 2/25/2026 at 10:41 AM, the Director of Nursing (DON) was asked when a resident is screened and approved for self-administration of medications, where would you expect those medications to be stored. The DON stated, They would be stored at [the] residents' preference at [the] bedside or in [the] residents' bedside drawer. The DON was asked if self-administration medications should be kept in a lock box or cabinet. The DON stated, No we do not have lock boxes. The DON was asked where she thinks these medications should be kept. The DON stated, Should be kept in a drawer.

Based on review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, medical record review, and interview, the facility failed to complete discharge assessments, using the Centers for Medicare & Medicaid Services-specific RAI process within the regulatory time frames for 16 of 42 sampled residents (Resident #4, #5, #8, #9, #11, #14, #16, #17, #18, #19, #20, #24, #25, #27, #32, and #73) reviewed for completion of the MDS. The findings include: Review of the MDS 3.0 RAI Manual v (version) 1.17.1 October 2019, page 2-37 revealed .Discharge Assessment .Must be completed when a resident is discharged .Must be completed (item Z0500B) within 14 days after the discharge date . Review of the medical record, revealed Resident #4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #4's discharge MDS with an Assessment Reference Date (ARD) date of 7/24/2021 revealed Item Z0500B was not completed. The discharge MDS should have been completed by 8/7/2021 but had never been completed. Review of the medical record, revealed Resident #5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #5's discharge MDS with an ARD date of 7/23/2021 revealed Item Z0500B was not completed. The discharge MDS should have been completed by 8/6/2021 but had never been completed. Review of the medical record, revealed Resident #8 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #8's discharge MDS with an ARD date 7/24/2021 revealed Item Z0500B was not completed. The discharge MDS should have been completed by 8/7/2021 but had never been completed. Review of the medical record, revealed Resident #9 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #9's discharge MDS with an ARD date of 8/28/2021 revealed Item Z0500B was not completed. The discharge MDS should have been completed by 9/11/2021 but never had been completed. Review of the medical record, revealed Resident #11 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #11's discharge MDS with an ARD date of 8/5/2021 revealed Item Z0500B was not completed. The discharge MDS should have been completed by 8/19/2021 but never had been completed. Review of the medical record, revealed Resident #14 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #14's discharge MDS with an ARD date of 7/23/2021 revealed Item Z0500B was not completed. The discharge MDS should have been completed by 8/6/2021 but never had been completed. Review of the medical record, revealed Resident #16 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #16's discharge MDS with an ARD date of 7/22/2021 revealed Item Z0500B was not completed. The discharge MDS should have been completed by 8/5/2021 but never had been completed. Review of the medical record, revealed Resident #17 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #17's discharge MDS with an ARD date of 8/5/2021 revealed Item Z0500B was not completed. The discharge MDS should have been completed by 8/19/2021 but never had been completed. Review of the medical record, revealed Resident #18 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #18's discharge MDS with an ARD date of 7/24/2021 revealed Item Z0500B was not completed. The discharge MDS should have been completed by 8/7/2021 but never had been completed. Review of the medical record, revealed Resident #19 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #19's discharge MDS with an ARD date of 8/8/2021 revealed Item Z0500B was not completed. The discharge MDS should have been completed by 8/22/2021 but never had been completed. Review of the medical record, revealed Resident #20 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #20's discharge MDS with an ARD date of 11/11/2021 revealed Item Z0500B was not completed. The discharge MDS should have been completed by 11/25/2021 but had never been completed. Review of the medical record, revealed Resident #24 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #24's discharge MDS with an ARD date of 8/7/2021 revealed Item Z0500B was not completed. The discharge MDS should have been completed by 8/21/2021 but had never been completed. Review of the medical record, revealed Resident #25 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #25's discharge MDS with an ARD date of 7/23/2021 revealed Item Z0500B was not completed. The discharge MDS should have been completed by 8/6/2021 but had never been completed. Review of the medical record, revealed Resident #27 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #27's discharge MDS with an ARD date of 7/23/2021 revealed Item Z0500B was not completed. The discharge MDS should have been completed by 8/6/2021 but had never been completed Review of the medical record, revealed Resident #32 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #32's discharge MDS with an ARD date of 9/22/2021 revealed Item Z0500B was not completed. The discharge MDS should have been completed by 10/6/2021 but had never been completed. Review of the medical record, revealed Resident #73 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #73's discharge MDS with an ARD date of 7/22/2021 revealed Item Z0500B was not completed. The discharge MDS should have been completed by 8/5/2021 but had never been completed. During an interview on 12/1/2021 at 8:15 PM, MDS Coordinators #1, #2, and #3 confirmed the discharge assessments for Resident #4, #5, #8, #9, #11, #14, #16, #17, #18, #19, #20, #24, #25, #27, #32, and #73 were not completed timely.

Based on review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, medical record review, and interview, the facility failed to complete quarterly assessments, using the Centers for Medicare & Medicaid Services-specific RAI process within the regulatory time frames for 5 of 42 sampled residents (Resident #3, #22, #23, #28, and #76) reviewed for completion of the MDS. The findings include: Review of the MDS 3.0 RAI Manual v (version) 1.17.1 October 2019, page 2-33 revealed, .The Quarterly assessment must be completed at least every 92 days following the previous OBRA [Omnibus Budget Reconciliation Act] assessment of any type .The ARD [Assessment Reference Date] (A2300) must be not more than 92 days after the ARD of the most recent OBRA assessment of any type .The MDS completion date (Item Z0500B) must be no later than 14 days after the ARD (ARD + 14 calendar days) . Review of the medical record, revealed Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's quarterly MDS with an ARD dated 9/4/2021 revealed Item Z0500B was completed 11/29/2021. The quarterly MDS should have been completed by 9/18/2021 but was not completed until 11/29/2021. Review of the medical record, revealed Resident #22 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #22's quarterly MDS with an ARD date of 10/18/2021 revealed Item Z0500B was not completed. The quarterly MDS should have been completed by 11/1/2021 but had never been completed. Review of the medical record, revealed Resident #23 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #23's quarterly MDS with an ARD date of 10/26/2021 revealed Item Z0500B was not completed. The quarterly MDS should have been completed by 11/9/2021 but had never been completed. Review of the medical record, revealed Resident #28 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #28's quarterly MDS with an ARD date of 9/21/2021 revealed Item Z0500B was not completed. The quarterly MDS should have been completed by 10/5/2021 but had never been completed. Review of the medical record, revealed Resident #76 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #76's quarterly MDS with an ARD date of 9/10/2021 revealed Item Z0500B was not completed. The quarterly MDS should have been completed by 9/24/2021 but had never been completed. During an interview on 12/1/2021 at 8:15 PM, MDS Coordinators #1, #2, and #3 confirmed the quarterly assessments for Residents #3, #22, #23, #28, and #76 were not completed timely.

Based on medical record review and interview, the facility failed to accurately assess residents for the use of urinary catheters and antipsychotic medications for 2 of 21 sampled residents (Resident #280 and #382) reviewed for accuracy of assessments. The findings include: Review of the medical record, revealed Resident #280 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) dated [DATE] revealed that Resident #280 was not coded for indwelling catheter. Review of the Care Plan dated 1/2/2021, revealed .Resident has a urinary catheter . Observation in the resident's room on 11/29/2021 at 10:10 AM and 4:00 PM, and on 11/30/2021 at 8:23 AM and 4:27 PM, revealed Resident #280 had an indwelling urinary catheter. During an interview on 12/1/2021 at 4:12 PM, MDS Coordinator #1 confirmed the Resident #280 should have been coded for an indwelling catheter. Review of the medical record, revealed Resident #382 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Metabolic [CONDITION(S)], and Depression. Review of the quarterly MDS dated [DATE], revealed Resident #382 was coded as receiving antipsychotic medications on a routine basis. Review of annual MDS dated [DATE], revealed Resident #382 was coded as receiving antipsychotic medications on a routine basis. Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 12/1/2021 at 6:20 PM, MDS Coordinator #2 confirmed Resident #382 was coded incorrectly for receiving antipsychotic medications on the MDS dated [DATE] and 10/23/2021.

Based on policy review, medical record review, observation, and interview, the facility failed to provide care and services to maintain an indwelling urinary catheter for 2 of 2 sampled residents (Resident #52 and #280) reviewed for indwelling urinary catheters. The findings include: Review of the facility's policy titled, Physician Orders, dated 11/6/2019, revealed .Review of new orders in daily clinical meeting .Review Verify Orders page and verify orders, as needed . Review of the facility's policy titled, Catheter Care Procedure, dated 5/23/2018, revealed .Grasp catheter with two fingers to stabilize it .Provide perineal hygiene .Using a clean washcloth, clean catheter. Starting close to the urinary meatus, clean catheter .along its length for about 10 cm [centimeters], moving away from the body .reapply catheter securement device . Review of the medical record, revealed Resident #52 was admitted on [DATE] with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Physician's Orders dated 10/18/2021, revealed .FOLEY CATHETER 16 FRENCH WITH 10 CC [cubic centimeters] .URINARY RETENTION . Observation in the resident's room on 12/1/2021 at 1:28 PM, revealed Certified Nursing Assistant (CNA) #2 washed her hands, donned her gloves, gathered her supplies, removed Resident #52's brief, and cleaned down each side of the labia. CNA #2 removed her gloves, did not perform hand hygiene, donned new gloves, and rinsed and dried the catheter. CNA #2 removed her gloves, did not perform hand hygiene and donned new gloves. CNA #2 positioned the resident on her right side, removed her gloves, did not perform hand hygiene, donned new gloves, and cleaned from front to back. CNA #2 rinsed and dried the resident, removed her gloves, did not perform hand hygiene, donned new gloves, and positioned the resident back in the bed. The resident did not have a catheter securement device. Review of the medical record, revealed Resident #280 was admitted on [DATE] with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Care Plan dated 11/3/2021, revealed that the resident had a urinary catheter. Observation in the resident's room on 11/29/2021 at 10:10 AM and 4:00 PM, on 11/30/2021 at 8:23 AM and 4:27 PM, and on 12/1/2021 at 7:13 AM and 10:14 AM, revealed Resident #280 had an indwelling urinary catheter. Review of the medical record revealed there was no Physician's Order for Resident #280's indwelling catheter. During an interview on 12/1/2021 at 8:51 AM, the Director of Nursing and the Assistant Director of Nursing confirmed that there were no orders for the indwelling urinary catheter for Resident #280. Observation in the resident's room on 12/1/2021 at 10:18 AM, revealed Licensed Practical Nurse (LPN) #1 gathered supplies, donned her gloves, removed Resident #280's brief, cleaned the right perineal area with a soapy wash cloth using a back and forth motion, and the cloth was noted to have a moderate amount of a brown substance. LPN #1 dried the resident with a towel in the same back and forth motion, removed her gloves, and washed her hands. LPN #1 then donned new gloves, and cleaned the left perineal area with a soapy wash cloth, using a back and forth motion, and the cloth was noted to have a moderate amount of a brown substance. LPN #1 dried the left perineal area with a towel using the same back and forth motion. LPN #1 then retrieved a package of wipes from a drawer, and wiped the catheter tubing from the port upward towards the resident. LPN #1 did not clean the catheter from the meatus down and contaminated the area with the brown substance. Resident #280 did not have a catheter securement device. During an interview on 12/1/2021 at 1:56 PM, CNA #2 confirmed that she should wash her hands between glove changes and that the indwelling catheter should be secured. During an interview on 12/1/2021 at 1:58 PM, LPN #1 confirmed that she should not have wiped back and forth during catheter care and that she should have cleaned the catheter from the meatus down. LPN #1 confirmed that the brown substance on the washcloth was feces. LPN #1 stated, .should have cleaned .got all the soap off .rinsed the soap off .pat dry . During an interview on 12/1/2021 at 2:23 PM, the Unit Manager confirmed staff should wash hands between glove changes. The Unit Manager confirmed that Resident #280 should have orders for her indwelling urinary catheter and catheters should be secured. The Unit Manager confirmed staff should discard contaminated wash cloths during perineal care, and should clean the catheter tubing starting at the meatus moving towards the bed side drainage bag.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure 2 of 5 (Registered Nurse (RN) #1 and Licensed Practical Nurse (LPN) #3) nurses administered medications with a medication error rate of less than 5 percent (%). A total of 3 errors were observed out of 26 opportunities, resulting in an error rate of 11.538%. The findings included: 1. The facility's Medication Administration General Guidelines policy dated 05/2016 documented .Medications are administered as prescribed .Prior to administration, review and confirm MEDICATION ORDERS FOR [REDACTED].Verify medication is correct three (3) times before administering the medication. a. When pulling medication package from med cart b. When dose is prepared c. Before dose is administered . 2. Medical record review revealed Resident #73 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].ASPIRIN 81 MG (milligrams) .Give 1 Tablet by mouth 1 time(s) Daily .[MEDICATION NAME] 10 MG TABLET ([MEDICATION NAME] oxalate) Give 1 Tablet by mouth 1 times(s) Daily .[MEDICATION NAME] 10 MG TABLET ([MEDICATION NAME]) Give 0.5 Tablet by mouth 1 time(s) Daily .[MEDICATION NAME] 5 MG TABLET .Give 1 Tablet by mouth 1 time(s) Daily .[MEDICATION NAME] 20 MG TABLET (toresemide) GIVE 2 TABLETS (40 MG) BY MOUTH EVERY OTHER DAY .[MEDICATION NAME] SOD (Sodium) 100 MG SOFTGEL ([MEDICATION NAME] sodium) Give 1 Caplet by mouth 2 time(s) Daily .[MEDICATION NAME] 5 MG TAB (Tablet) ([MEDICATION NAME]) Give 1 Tablet by mouth 2 time(s) Daily . Observations on 12/18/18 beginning at 9:30 AM, at the medication cart at the East Nurses' Station, RN #1 prepared the following medications for Resident #73: [MEDICATION NAME] Sodium 100 MG 1 tablet [MEDICATION NAME] 5 MG 1 tablet Aspirin 81 MG 1 tablet Toresemide 20 MG 1 tablet [MEDICATION NAME] 10 MG 1/2 tablet [MEDICATION NAME] 5 MG 1 tablet [MEDICATION NAME] 10 MG 1 tablet Interview with RN #1 on 12/18/18 at 9:35 AM, at the medication cart at the East Nurses' Station, RN #1 confirmed there were 6 and a half pills in the souffle cup to administer to this resident. There should have been 7 1/2 pills, there was only one toresemide 20 MG tablet in the souffle cup instead of 2. Observations in Resident #73's room on 12/18/18 at 9:45 AM, revealed RN #1 administered these 6 1/2 pills to this resident by mouth. The administration of the toresemide 20 MG instead of 40 MG resulted in medication error #1. 3. Medical record review revealed Resident #197 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's telephone orders dated 12/10/18 documented .(symbol for decrease) Losartan 25 mg po (by mouth) day (daily) . The physician's telephone orders dated 12/16/18 documented, .[MEDICATION NAME] 2 squirts each nostril Q (every) Day . The Medication Administration Record [REDACTED].LOSARTAN POTASSIUM 25 MG .Give 1 Tablet by mouth 1 time(s) Daily . Observations in Resident #197's room on 12/19/18 at 8:05 AM, revealed LPN #3 administered losartan potassium 100 mg to Resident #197 and 1 spray of [MEDICATION NAME] to each nostril. Failure of the nurse to administer the correct dose of losartan potassium and [MEDICATION NAME] resulted in medication error #2 and 3. Interview with LPN #3 on 12/19/18 at 9:45 AM, at the East Nurses' Station, LPN #3 confirmed the medication card contained Losartan Potassium 100 mg and 7 of the 30 tablets were missing from the card. LPN #3 stated, It was discontinued on 12/11/18 and I gave too much. Interview with LPN #3 on 12/19/18 at 10:35 AM, at the East Nurses' Station, LPN #3 confirmed she only gave this resident 1 spray of [MEDICATION NAME] to each nostril. Interview with the Director of Nursing (DON) on 12/19/18 at 11:12 AM, at the East Nurses' Station, the DON was asked how should nurses administer the correct drug and amount. The DON stated, . check Medication Administration Record, [REDACTED].

Based on policy review, observations, and interview, the facility failed to ensure medications were properly and securely stored when medications were unattended in 1 of 62 (room [ROOM NUMBER]B) resident rooms, 1 of 5 (Licensed Practical Nurse (LPN) #2) nurses left medications unattended and out of their sight, and medications were not dated when opened in 2 of 8 (West 2 Medication Cart and West 1 Medication Cart) medication storage areas. The findings included: The facility's BEDSIDE MEDICATION STORAGE policy dated 5/2016 policy documented, .PR[NAME]EDURES .4. Bedside medication .Lockable drawers or cabinets are required . The facility's STORAGE OF MEDICATION policy dated 11/2017 documented, .POLICY Medications and biologicals are stored properly .to maintain their integrity and to support safe effective drug administration. The medication supply shall be accessible only to license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications .PR[NAME]EDURES .3. In order to limit access to prescription medications, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications .are allowed to access medication carts. Medication rooms, cabinets and medication supplies should remain locked when not in use or attended any persons with authorized access .12. Insulin products should be stored in the refrigerator until opened. Note the date on the label for insulin vials and pens when first used . The MEDICATIONS WITH SHORTENED EXPIRATION DATES provided by the American Society of Consultant Pharmacists documented, .[MEDICATION NAME] .Discard when the counter reaches zero or three months after removal from the protective foil package .[MEDICATION NAME] .Vials/Cartridges/[MEDICATION NAME] expire 28 days after or removing from the refrigerator, whichever comes first .[MEDICATION NAME] R (Regular) .Vial: Expires 42 days after opening or removing from refrigerator, whichever comes first . Observations in room [ROOM NUMBER]B on 12/17/18 at 9:30 AM, 12:10 PM, 5:05 PM, and on 12/18/18 at 8:10 AM, revealed a bottle of Dakins solution (1/2 strength sodium hypochlorite 25 percent, a medicated wound irrigation) sitting on top of the nightstand beside the resident's bed. Interview with the Director of Nursing (DON) on 12/18/18 at 8:50 AM, at the West Nurses' Station, the DON was asked if a wound treatment medication should be left at the bedside. The DON stated, No. Observations in Resident #197's room on 12/18/18 at 5:06 PM, revealed LPN #2 placed the resident's medication cups with medications on the over-bed table and went to the bathroom to wash her hands, leaving the medications out of her view. She then left the room to get a syringe, leaving the medications on the over-bed table and out of her view. Interview with the DON on 12/19/18 at 11:10 AM, at the East Nurses' Station, the DON was asked, should medications be left unattended. The DON stated, No. Observations in the West 2 Medication Cart on 12/19/18 at 10:45 AM, revealed 1 open vial of [MEDICATION NAME] R with no open date, 1 open [MEDICATION NAME] Pen with no open date, and 2 open [MEDICATION NAME] inhalers with no open date. Interview with LPN #1 on 12/19/18 at 10:47 AM, at the West 2 Medication Cart, LPN #1 confirmed these medications were not dated when they were opened. Observations in the West 1 Medication Cart on 12/19/18 at 10:55 AM, revealed 1 [MEDICATION NAME] with no open date. Interview with the Director of Nursing (DON) on 12/19/18 at 11:35 AM, in the DON Office, the DON was asked if medications with shortened expiration dates should be dated when opened. The DON stated, Yes.

Based on policy review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were followed when 2 of 5 (Licensed Practical Nurse (LPN) #1 and 3) nurses failed to perform hand hygiene appropriately, use barriers, and clean reusable equipment during medication administration. The findings included: The facility's Handwashing/Hand Hygiene policy documented, Dry hands thoroughly with paper towels and then turn off faucets with a clean, dry paper towel. Discard towels into trash . The facility's Cleaning and Disinfecting Non-Critical Resident-Care Items policy documented, Reusable items are cleaned and disinfected or sterilized between residents ( .stethoscopes, durable medical equipment) . The facility's Clean Glucometer/PT ([MEDICATION NAME]) -INR (International Normalized Ratio) Competency policy documented, .If no visible organic material is present disinfect the exterior surfaces after each use using .facility approved disinfectant with either an EPA (Evironmental Protection Agency) registered detergent/germicide with a turberculocidal or HBV (Hepatis B Virus)/[MEDICAL CONDITION](Human Immunodeficiency Virus) label claim, or a dilute bleach solution of 1:10 to1:100 concentration . Observations in Resident #18's room on 12/18/18 at 9:05 AM, revealed LPN #1 went to the bathroom and placed the medication cups on the sink without a barrier. LPN #1 washed her hands, took the paper towels and dried her hands, then placed the towels on the sink behind the faucet. LPN #1 placed the syringe on the table without a barrier and without cleaning the table. LPN #1 placed the stethoscope on the resident's abdomen, and then put the stethoscope around her neck. LPN #1 did not clean the stethoscope prior to touching the resident's abdomen. After administering the medications, LPN #1 carried the trash and insulin syringe to the bathroom, washed her hands, and then proceeded gather up the trash and took it back to the room, put the syringe in a sharps box and trash in the wastebasket. LPN #1 did not perform hand hygiene after this. Interview with the Director of Nursing (DON) on 12/19/18 at 11:20 AM, at the East Nurses' Station, the DON was asked should the stethoscope be cleaned between residents. The DON stated, Yes, stethoscopes should be wiped down. The DON was asked should a barrier be used. The DON stated, Yes . Observations in Resident #18's room on 12/18/18 at 9:10 AM, revealed LPN #1 did not clean the over bed table before placing items on the table without a barrier. Observations in Resident #445's room on 12/19/18 at 7:30 AM, revealed LPN #3 carried glucometer, a bottle of test strips, lancets, and alcohol pads to the room, placed all the items in her pocket, washed her hands, then took out the items from her pocket. LPN #3 cleaned the glucometer with an alcohol pad. Observations at the East Nurses' Station on 12/19/18 at 8:05 AM, revealed LPN #3 left Resident 197's room after completing his accucheck. LPN #3 then proceeded to clean the glucometer with an alcohol pad and placed the glucometer on the top of the cart without a barrier. Interview with the DON on 12/19/18 at 11:12 AM, at the East Nurses' Station, the DON was asked how should glucometers to be disinfected. The DON stated, .We don't use alcohol wipes, we use germicidal wipes .

Based on policy review, medical record review, observation, and interview, 2 of 5 (Licensed Practical Nurse (LPN) #1 and Registered Nurse (RN) #1) nurses failed to follow the facility policy for administration of medications through an enteral tube and administration of eye drops. The findings included: 1. The facility's Medication Administration Enteral Tubes policy documented, .The powder from each medication is mixed with water before administration. The souffle cup is rinsed with water to get all of the medication contained within the cup to facilitate the ordered dose .Enteral tubes are flushed with at least 15 ml (milliliters) of water before administering any medications and after all medications have been administered .PR[NAME]EDURES .Crush each immediate-release tablets, one at a time, into a fine powder, and dissolve in water .Dilute each liquid medication with water .Administer liquid medications first .Clean feeding syringe and return to bedside stand . Medical record review revealed Resident #18 was admitted to the facillity on 7/31/18 with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].Give 1 Tablet .1 time Daily .[MEDICATION NAME] 10 MG . GIVE 1 TABLET .ONCE DAILY .[MEDICATION NAME] .150 MG .TWICE DAILY .[MEDICATION NAME] ([MEDICATION NAME]) 5MG/ML .5 ML .EVERY 12 HOURS .FLUSH TUBE WITH 30ML H2O (water) BEFORE AND AFTER MEDICATION . Observations in Resident #18's room on 12/18/18 at 9:10 AM, revealed LPN #1 administered an unmeasured amount of water, then poured in dry crushed [MEDICATION NAME], poured in an unmeasured amount of water, added dry crushed aspirin, added an unmeasured amount of water, added [MEDICATION NAME] solution without diluting, added an unmeasured amount of water, then added [MEDICATION NAME] liquid without diluting and followed with an unmeasured amount of water. LPN #1 did not measure the water and only poured a small amount of water following each medication. LPN #1 did not mix these medications with water prior to administering them through the enteral tube. Interview with the Director of Nursing (DON) on 12/19/18 at 12:00 PM, outside the Chapel, the DON was asked should enteral medications be diluted prior to administering in the enteral tube. The DON stated, Yes, they should . 2. The facility's Medication Administration Eye Drops policy documented, .With a gloved finger, gently pull down lower eyelid to form a pouch, while instructing resident to look up .Hold inverted medication bottle between the thumb and index finger, and press gently to instill prescribed number of drops into pouch near outer corner of eye . Medical record review revealed Resident #73 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].REFRESH TEARS 0.5% (percent) EYE DROPS .Give 1 Each in both eyes. As Needed .DRY EYES . Observations in Resident #73's room on 12/18/18 at 9:40 AM, revealed RN #1 administered eye drops without forming a pouch and held the bottle of medications above the eye and administered one drop over the center of the eye. Interview with the DON on 12/19/18 at 11:07 AM, at the East Nurses' Station, the DON was asked how should eye drops be administered. The DON stated, .form a pouch .

Based on medical record review, observation, and interview, the facility failed to follow physician orders [REDACTED].#47) sampled residents reviewed with pressure ulcers. The findings included: Medical record review revealed Resident #47 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The significant change Minimum Data Set ((MDS) dated [DATE] revealed a stage 2 pressure ulcer, stage 3 pressure ulcer and 1 suspected deep tissue injury (sDTI). The physician's orders [REDACTED].Order Date .9/11/2018 .BILATERAL HEEL BOOTS (Prevalon heel boots for prevention and treatment of [REDACTED]. The Pressure Ulcer Record dated 12/6/18 documented, .Date of Origin 09/10/2018 .Left heel stage 2 ruptured blister .Facility acquired .Length .0.3 .Width .0.3 .Depth .0.0 . SPECIALTY INTERVENTIONS .bilateral heel boots . The Pressure Ulcer Record dated 12/6/18 documented, .Date of Origin 09/10/2018 .Right heel sDTI .Facility acquired .Length .0.0 .Width .0.0 .Depth .0.0 . SPECIALTY INTERVENTIONS .bilateral heel boots .Sdtl .right heel has resolved .Prevalon boot remains in place for protection . Observations at the West Nurses' Station on 12/17/18 at 4:10 PM, revealed Resident #47 was sitting in a wheelchair only wearing one heel boot on her left foot. Wound care observations in Resident #47's room on 12/18/18 at 10:20 AM, revealed Resident #47 was in the bed lying on a special air mattress. Licensed Practical Nurse (LPN) #2 removed a non-skid sock from Resident #47's left foot. The wound area had a small scab with no drainage. A heel boot was on the resident's right foot, the wound area was dry and intact. Observations on 12/19/18 at 8:33 AM, revealed Resident #47 was dressed, sitting in her wheelchair by the bed, only wearing non-skid socks on both feet. Resident #47 was not wearing bilateral heel boots. Interview with LPN #4 on 12/19/18 at 9:38 AM, in Resident #47's room, LPN #4 was asked what Resident #47 was wearing on her feet. LPN #4 stated, Non-skid socks . LPN #4 was shown Resident #47's physician order [REDACTED].#4 then placed the heel boot on the resident's left foot and was unable to find the heel boot for Resident #47's right foot. Interview with the Director of Nursing (DON) on 12/19/18 at 9:00 AM, in the DON office, the DON was asked if staff should follow physician orders [REDACTED]. The DON stated, Absolutely .

Based on policy review, medical record review, observation, and interview, the facility failed to ensure residents were free of significant medication errors when 1 of 5 (Licensed Practical Nurse (LPN) #3) nurses did not administer significant medications at the correct dosage. The findings include: 1. The facility's Medication Administration General Guidelines policy dated 5/2016 documented .Medications are administered as prescribed .Prior to administration, review and confirm MEDICATION ORDERS FOR [REDACTED].Verify medication is correct three (3) times before administering the medication. a. When pulling medication package from med cart b. When dose is prepared c. Before dose is administered . 2. Medical record review revealed Resident #197 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].(symbol for decrease) Losartan (a blood pressure medication) 25 mg (milligrams) po (by mouth) day (daily) . The Medication Administration Record [REDACTED].LOSARTAN POTASSIUM 25 MG .Give 1 Tablet by mouth 1 time (s) Daily . Observations in Resident #197's room on 12/19/18 at 8:05 AM, revealed LPN #3 administered losartan potassium 100 mg to Resident #197. The failure of the nurse to administer the correct dose of losartan potassium resulted in a significant medication error. Interview with LPN #3 on 12/19/18 at 9:45 AM, at the East Nurses' Station, LPN #3 confirmed the medication card contained Losartan Potassium 100 MG and 7 of the 30 tablets were missing from the card. LPN #3 stated, It was discontinued on 12/11/18 and I gave too much. Interview with the Director of Nursing (DON) on 12/19/18 at 11:12 AM, at the East Nurses' Station, the DON was asked how should nurses administer the correct drug and amount. The DON stated, .check Medication Administration Record, [REDACTED].

Based on policy review, resident rights review, job description review, medical record review, and interview, the facility failed to ensure that licensed nurses did not borrow medications prescribed to one resident and administer those medications to another resident for 1 of 3 (Resident #1) sampled residents reviewed for medication administration. The findings included: 1. The facility's Medication Administration . policy documented, .Medications supplied for one resident are never administered to another resident . 2. The JOB DESCRIPTION .Charge Nurse (LPN or RN) (Licensed Practical Nurse or Registered Nurse) documented, .Essential Duties & Responsibilities .Prepare and administer medication as ordered by the physician .Verify that prescribed medication for one resident is not administered to another . 3. Medical record review revealed Resident #1 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #1 did not have a comprehensive assessment completed because he was only in the facility for approximately 31 hours before leaving against medical advice. The physician admission orders [REDACTED]. The pharmacy's Shipping Manifest Pharmaceuticals dated 4/21/18 at 12:36 PM, revealed [MEDICATION NAME], and Duloxetine were delivered to the facility for Resident #1. The pharmacy's Shipping Manifest Pharmaceuticals dated 4/21/18 at 5:17 PM, revealed [MEDICATION NAME] was delivered to the facility for Resident #1. The (MONTH) Medication Administration Record [REDACTED]. No [MEDICATION NAME] was delivered from the pharmacy due to no written prescription was available and sent to the pharmacy. Interview with the Director of Nursing (DON) on 5/9/18 beginning at 9:35 AM, in the conference room, the DON provided a narcotic sign out sheet for a random resident that revealed 1 [MEDICATION NAME] was signed out on 4/21/18 at 12:00 AM. The DON reviewed the MAR for the same resident and revealed documentation that 1 [MEDICATION NAME] was administered to that resident. Review of Resident #1's MAR indicated [REDACTED]. The DON was asked about Resident #1's MAR indicated [REDACTED]. The DON stated that even though other resident medications should not be borrowed, she confirmed the nurses did borrow medications from other residents and documented they were administered on Resident #1's MAR. The DON stated that the nurses should not borrow medications. The (MONTH) MAR indicated [REDACTED]. Telephone interview with LPN #1 on 5/9/18 at 10:00 AM, in the conference room, LPN #1 confirmed that she signed the [MEDICATION NAME] as given on the random resident's MAR indicated [REDACTED]. LPN #1 confirmed she administered the borrowed [MEDICATION NAME] it to Resident #1. Telephone interview with LPN #1 on 5/17/18 at 8:04 AM, LPN #1 was asked if she administered [MEDICATION NAME] to Resident #1. LPN #1 stated that she did give him a [MEDICATION NAME] sometime during that first night and she confirmed that he did take the medication. LPN #1 confirmed that she did borrow medications from other residents.

Based on policy review, resident rights review, medical record review, and interview, the facility failed to manage or prevent pain to help residents attain or maintain the highest practicable level of well-being for 1 of 3 (Resident #1) sampled residents reviewed for pain. The findings included: 1. The facility's Pain Management policy documented, .The purpose of this policy is to outline guidelines that will promote effective pain management, including .timely response to complaints of pain .Our facility is committed to help each resident attain or maintain their highest reasonable level of well-being and to prevent or manage pain to the extent possible. Our pain management policy includes recognizing when the resident experiences pain .and management or prevention of pain consistent with professional standards of care and in accordance with the plan of care .MANAGEMENT .When treating pain, start with drugs appropriate to the resident's current level of pain and progress by increasing the dose of that drug until maximum benefit is obtained . 2. The Residents Rights documented, .Nursing home residents have the right .to reside and receive services with reasonable accommodation .to voice grievances about care or treatment they do or do not receive .and to receive prompt response from the facility . 3. Medical record review revealed Resident #1 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #1 did not have a comprehensive assessment completed because he was only in the facility for approximately 32 hours. The Baseline Admission Care Plan documented, .Problem .Resident has pain .Related to .Diabetic [MEDICAL CONDITION] .Approach .Administer pain medications per physicians orders . The hospital physician admission orders [REDACTED]. The original handwritten prescriptions signed by the physician for these medications were not found when Resident #1 arrived to the facility via ambulance. Medical record review revealed Resident #1 did not receive [MEDICATION NAME] for pain, [MEDICATION NAME] for anxiety, or [MEDICATION NAME] for [MEDICAL CONDITION] during his stay at the facility. Review of the hospital medication reconciliation discharge paperwork dated 4/20/18 revealed Resident #1 had last received [MEDICATION NAME] on 4/15/18 at 3:14 AM, [MEDICATION NAME] on 4/19/18 at 9:50 PM, [MEDICATION NAME] on 4/20/18 at 11:22 AM, and [MEDICATION NAME] on 1/16/18 at 12:00 AM, while a patient in the hospital. The nurse's notes dated 4/21/18 at 2:57 AM, Licensed Practical Nurse (LPN) #1 documented, .CONCERNED WITH MEDS (Medications) NOT BEING HERE .RESIDENT NOT PLEASED .ASKING TO GO BACK TO HOSPITAL .NOW AT DESK REQUESTING PAIN PILL. MEDS STILL NOT AVAILABLE FROM PHARMACY .4:12 AM .AT DESK AT THIS TIME TALKING AGGRESSIVELY TO NURSE ABOUT HIS MEDS. WILL NOT ALLOW NURSE TO EXPLAIN MED SITUATION TO HIM. KEEPS OVERTALKING NURSE AND YELLING ABOUT THIS IS NOT RIGHT. REQUESTING THAT I CALL AMBULANCE FOR HIM TO GO BACK TO HOSPITAL. ADVISED THAT HE (Resident #1) MAY DO SO BUT IT WOULD NOT BE AN EMERGENCY TRANSFER FROM FACILITY .(RESIDENT #1) STATING .NURSE TOLD HIM THAT MEDS WERE ON THE WAY .I CANNOT GIVE HIM MEDS THAT I DO NOT HAVE . The (MONTH) MAR indicated [REDACTED]. Resident #1 was not administered any [MEDICATION NAME] from 4/20/18 at 11:22 AM (at the hospital) until 4/21/18 at 4:33 AM (at the nursing home facility). Resident #1 did not have any pain medication for a total of 17 hours and 11 minutes. Resident #1 did not receive any additional pain medication for an additional 21 hours and 17 minutes during his stay at this facility and he left against medical advice on 4/22/18 at 1:50 AM. On 4/21/18 at 5:43 AM, LPN #2 documented, .Writer then Called NP (Nurse Practitioner) on call .and explained the issue, she was given his dx (diagnosis) with chronic pain she ordered to give Tylenol 650mg every 4 hours as needed for pain. he refused to receive it saying it upsets his stomach. DON (Director of Nursing) then notified about issue. (Named Medical Director) was called but could not be reached at the time .DON was notified of unresolved issue, she ordered to transfer resident to hospital for uncontrolled pain .he refused and stated that [MEDICATION NAME] would be fine at the moment . The nurse's note dated 4/22/18 at 4:02 AM, documented, REPORTED PER VS (VITAL SIGNS) THAT BP (BLOOD PRESSURE) IS 176/99. PRN (AS NEEDED) [MEDICATION NAME] OFFERED WITH TYLENOL FOR C/O (COMPLAINT OF) PAIN. DECLINED TYLENOL. STATED IT CAUSES GI (GASTROINTESTINAL) UPSET. RESIDENT OBSERVED PACKING BELONGINGS AND STATED THAT HE WILL BE LEAVING TONIGHT .SAID HE WOULD CALL 911 OR AMBULANCE SERVICE. ADVISED TO ALLOW NURSE TO GIVEN HIM PRN FOR BP. STATED THAT HE COULD NOT TAKE IF HE DIDN'T HAVE HIS PAIN MED (MEDICATION) ALSO. INFORMED THAT NO PAIN MED AT THIS TIME EXCEPT TYLENOL AVAILABLE. (RESIDENT #1) REMAINED DETERMINED TO LEAVE. FINISHED PACKING ALL BELONGINGS AND AT DESK ASKING WHAT PAPER TO SIGN TO GET OUT OF HERE. PRESENTED WITH AMA (AGAINST MEDICAL ADVICE) PAPERS. READ OVER PAPERS AND SIGNED .OBSEVRED EXTING (OBSERVED EXITING) UNIT WITH PERSONAL BELONGS TOWARD FRONT DOOR OF FACILITY. ALARM SOUNDED OF EXIT AT 0150 AM .6:23 AM FACILITY ADMINISTRATOR AND DON MADE AWARE OF AMA OF RESIDENT. The pharmacy's Shipping Manifest Pharmaceuticals dated 4/21/18 at 12:36 PM, revealed the following medications were delivered to the facility for Resident #1. [MEDICATION NAME] 30 tablets, Atorvastatin 30 tablets, [MEDICATION NAME] 30 tablets and Duloxetine 60 tablets. The pharmacy's Shipping Manifest Pharmaceuticals dated 4/21/18 at 5:17 PM, revealed the following medications were delivered to the facility for Resident #1. Losartan 60 tablets, [MEDICATION NAME] 30 tablets, [MEDICATION NAME] 30 tablets and [MEDICATION NAME] 7 tablets. The DON provided a narcotic sign out sheet for a random resident that revealed 1 [MEDICATION NAME] was signed out on 4/21/18 at 12:00 AM. Review of Resident #1's (MONTH) MAR indicated [REDACTED]. Interview with Resident #1 on 5/8/18 beginning at 2:14 PM, in the conference room, he was asked about his stay at this facility in April. Resident #1 confirmed he was admitted to the facility at approximately 5:50 PM on 4/20/18 and the hospital sent written prescriptions with him in an envelope. He stated they lost the prescriptions and he did not get any pain medicine when he was there. He stated that he had [MEDICAL CONDITION] pain and anxiety. Interview with the DON on 5/9/18 beginning at 9:35 AM, in the conference room, she was asked about the facility's process if narcotic prescriptions are lost when residents are admitted to the facility. The DON stated that they cannot get narcotics if there is no written prescription. The DON stated that the facility was looking into the incident and would be doing a process improvement plan. The DON confirmed that Resident #1 should not have gone so long without pain medication. The DON was asked about Resident #1's continued requests for medication. The DON confirmed that Resident #1 was hard to manage and he was not truthful. She stated that they offered to send him to the ER but he refused. Telephone interview with Resident #1 on 5/9/18 at 2:10 PM, revealed he was upset with how he was treated. He stated that he felt they didn't care about him and he told them if he couldn't get his medicine and he was hurting that he was going to leave. He stated that he asked the supervisor to call an ambulance so he could go to the hospital and that she told him you have a phone, you can call and get over there yourself and it wasn't an emergency. He stated that they didn't want to do anything to help him. He continued to say he did not get his medications especially his pain medication. During a telephone interview with the Nurse Practitioner on 5/9/18 at 2:40 PM, the Nurse Practitioner was asked about Resident #1 and did she receive a call from the nursing staff that he needed pain medication. The Nurse Practitioner stated, I don't have my computer up and I don't have my notes but they called me about a patient and it was a while back, but when they call about a patient, the hospital is supposed to send their scripts (handwritten prescriptions) with them, with the amount of issues with controlled substances of that nature, we don't write narcotics until you actually see that patient, so if they call and say we don't have the script, then the patient typically gets Tylenol until either I will tell them to call the hospital and ask them where's the script at, find the script so you guys can go pick it up and do it that way, but in the meantime there is a Tylenol ordered to give them a chance to maintain them until then. Telephone interview with LPN #1 on 5/17/18 at 8:04 AM, LPN #1 was asked if she administered (Named Narcotic) to Resident #1. LPN #1 stated that she did give him a [MEDICATION NAME] sometime during that first night, because he was acting out. She was asked if she administered any other medications to him during his stay. She stated that she gave him one other medicine that morning at about 6:00 AM. LPN #1 was asked if she administered any other medications to Resident #1. She stated that she did not give him anything else because his medications had not come from the pharmacy yet. LPN #1 confirmed that she did borrow those 2 medications from other residents.

Based on policy review, observation, and interview, the facility failed to ensure the Registered Dietician (RD) provided oversight of the kitchen when food was not prepared and served under sanitary conditions as evidenced by inappropriate tray line serving temperatures. The facility had a census of 82, with 78 of those residents receiving a meal tray from the kitchen. The findings included: The facility's Dietician policy documented, .Specific Responsibilities .7. Through observation and evaluation, promote food production and service procedures that conserve nutritive value, flavor, appearance, and quality, and are attractively served at the proper temperature .9. Develop and conduct person-centered Inservice training for dietary personnel and, as needed, for other healthcare community personnel . Observations in the kitchen on 2/12/18 at 5:00 PM, revealed Dietary Cook #1 took temperatures on the serving line. The pork loins temperature was 137 degrees Fahrenheit (F) and the corned beef temperature was of 89 degrees F. The first cart with 16 meals trays had left the kitchen to be served. Observations in the kitchen on 2/12/18 at 5:10 PM, revealed Dietary Cook #1 continued to serve the dinner trays and a plate of pork loin was requested and served. Interview with the Registered Dietician (RD) on 2/12/18 at 5:12 PM, in the Kitchen Manager office, the RD was asked should meat that didn't reach the appropriate temperature be served. The RD stated, .it should have been reheated . The RD was asked what the reheated temperature of the meat should be. The RD stated, 165. Interview with the Kitchen Manager on 2/12/18 at 5:15 PM, in the Kitchen Manager office, the Kitchen Manager was asked if she was going to let her dietary staff serve meat that didn't reach a safe temperature. The Kitchen Manager stated, No! and hurriedly stopped the cook from serving any more meals. The Kitchen Manager was asked what the reheated meat temperature should be. The Kitchen Manager stated, .Hold on a second .I'm not sure . Interview with the RD on 2/12/18 at 5:18 PM, in the Kitchen Manager office, the RD was asked what the reheated meat temperature should be. The RD stated, .It should get back up to 165. The RD was asked whose responsibility it was for the kitchen staff to know what the food temperatures should be. The RD stated, .The Kitchen Manager and if she doesn't know, she can ask her assistant. Interview with the Administrator on 2/13/18 at 9:05 AM, in the dining room, the Administrator stated, .Yes .her (the RD) lack of leadership was my concern .not taking ownership of the situation with the food temperatures yesterday .

Based on policy review, observation, and interview, 1 of 15 (Certified Nursing Assistant (CNA) #1) staff members failed to distribute and serve food and beverages in a sanitary manner during dining and the facility failed to ensure food was prepared and served under sanitary conditions as evidenced by inappropriate tray line serving temperatures. The facility had a census of 82, with 78 of those residents receiving a meal tray from the kitchen. The findings included: 1. The facility's Handwashing/Hand Hygiene policy documented, .Policy Statement .The facility considers hand hygiene the primary means to prevent the spread of infections .Policy Interpretation and Implementation .7. Use an alcohol-based hand rub containing at least 62% (percent) alcohol, or, alternatively, soap .and water for the following situations .b. Before and after direct contact with residents .o. Before and after handling food . Observations in the 200 hall on 2/11/18 beginning at 12:16 PM, revealed CNA #1 assisted to position Resident #35 in bed, touched the resident and the bed. CNA #1 did not perform hand hygiene, continued to set up the resident's meal tray and touched the bread on his tray. CNA #1 repositioned Resident #56 in the bed and adjusted his bed, then continued to set up his meal tray, and touched the bread, without performing hand hygiene. CNA #1 asked the resident if he wanted butter on the bread, he stated no, and CNA #1 placed the bread back into the packet, and touched the bread again. CNA #1 adjusted Resident #59's bed, moved a wheelchair, and continued to set up the resident's meal tray, without performing hand hygiene. Observations in Resident #129's room on 2/11/18 at 12:45 PM, revealed CNA #1 repositioned the resident in bed with gloves on, then continued to set up the resident's meal tray with gloves on and did not perform hand hygiene. Interview with the Director of Nursing (DON) on 2/13/18 at 3:23 PM, in front of the Admission office, the DON was asked what should be done after assisting residents, touching objects and prior to setting up a meal tray or touching food. The DON stated, wash hands . 2. The facility's Dietician policy documented, .Specific Responsibilities .7. Through observation and evaluation, promote food production and service procedures that conserve nutritive value, flavor, appearance, and quality, and are attractively served at the proper temperature .9. Develop and conduct person-centered Inservice training for dietary personnel and, as needed, for other healthcare community personnel . Observations in the kitchen on 2/12/18 at 5:00 PM, revealed Dietary Cook #1 took temperatures on the serving line. The pork loins temperature was 137 degrees Fahrenheit (F) and the corned beef temperature was of 89 degrees F. The first cart with 16 meals trays had left the kitchen to be served. Observations in the kitchen on 2/12/18 at 5:10 PM, revealed Dietary Cook #1 continued to serve the dinner trays and a plate of pork loin was requested and served. Interview with the Registered Dietician (RD) on 2/12/18 at 5:12 PM, in the Kitchen Manager office, the RD was asked should meat that didn't reach the appropriate temperature be served. The RD stated, .it should have been reheated . The RD was asked what the reheated temperature of the meat should be. The RD stated, 165. Interview with the Kitchen Manager on 2/12/18 at 5:15 PM, in the Kitchen Manager office, the Kitchen Manager was asked if she was going to let her dietary staff serve meat that didn't reach a safe temperature. The Kitchen Manager stated, No! and hurriedly stopped the cook from serving any more meals. The Kitchen Manager was asked what the reheated meat temperature should be. The Kitchen Manager stated, .Hold on a second .I'm not sure . Interview with the RD on 2/12/18 at 5:18 PM, in the Kitchen Manager office, the RD was asked what the reheated meat temperature should be. The RD stated, .It should get back up to 165. The RD was asked whose responsibility it was for the kitchen staff to know what the food temperatures should be. The RD stated, .The Kitchen Manager and if she doesn't know, she can ask her assistant.

Based on review of the Federal Resident / Patient Rights, observation, and interview, the facility failed to maintain or enhance resident dignity and respect when 3 of 15 (Certified Nurse Assistant (CNA) #2 and 3, and Dietary Cook #1) staff members failed to knock before entering a room. The findings included: 1. The Federal Resident/Patient Rights documented, Every facility resident has a right to a dignified existence . Observations on the west hall on 2/11/18 at 11:53 AM, revealed CNA #2 delivered meal trays to rooms 107, 110 and 115. CNA #2 failed to knock on the door or announce herself prior to entering the rooms. Observations on the west hall on 2/11/18 at 12:31 PM, revealed Dietary Cook #1 delivered a sandwich to room [ROOM NUMBER] and failed to knock on the door or announce herself prior to entering the room. Observations on the west hall on 2/12/18 at 5:06 PM, revealed CNA #2 delivered a meal tray to room [ROOM NUMBER], placed the tray on the over bed table and exited the room and then returned. CNA #2 failed to knock or announce herself prior to entering the room. Observations on the west hall on 2/12/18 at 5:06 PM, revealed CNA #3 delivered meal trays to room [ROOM NUMBER] and 117. CNA #3 failed to knock or announce herself prior to entering the rooms. Interview with the Director of Nursing (DON) on 2/13/18 at 2:57 PM, in the human resource conference room, the DON was asked what should staff to do before entering a room. The DON stated, I expect them to knock and announce themselves . The DON was then asked what should staff to do when their arms are full. The DON stated, If they have their hands full I still expect them to announce themselves.

Based on policy review, medical record review, observation, and interview, the facility failed to provide appropriate oxygen therapy for 1 of 6 (Resident #74) sampled residents reviewed for oxygen therapy. The findings included: The facility's Departmental (Respiratory Therapy) - Prevention of Infection policy documented, .The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment .Infection Control Considerations Related to Oxygen Administration .7. Change the oxygen cannulae (cannula) and tubing every seven (7) days, or as needed . Medical record review revealed Resident #74 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. O2 (oxygen) @ (at) 2L (liters) BNC (binasal cannula) . The care plan dated 2/7/18 documented, .Problem .Resident has [MEDICAL CONDITION] condition/Dx (diagnosis) of [MEDICAL CONDITIONS] exacerbation, resp (respiratory)failure .Approach .Change O2 tubing once a week . Observations in Resident #74's room on 2/11/18 at 10:06 AM, 2:57 PM, 5:00 PM, and on 2/12/18 at 7:41 AM, and 2:03 PM revealed the oxygen tubing was dated, but the date was illegible, and the filter on the concentrator was dirty. Interview with Registered Nurse (RN) #1 on 2/13/18 at 10:20 AM, in Resident #74's room, she was asked when this O2 tubing was changed. RN #1 confirmed the date could not be read and stated, I will change it, can not tell when was changed. RN #1 confirmed the filter was dirty and stated, will need to change. RN #1 was asked if they document when the tubing or the filter would be changed. RN #1 stated, No, just date the tubing. Interview with the Director of Nursing (DON) on 2/13/18 at 10:33 AM, in the Admission office, the DON was asked how often O2 tubing and the filter should be changed. The DON stated, every week

Based on medical record review, observation, and interview, the facility failed to follow physician's orders for a tube feeding for 1 of 2 (Resident #230) sampled residents reviewed with a tube feeding. The findings included: Medical record review revealed Resident #230 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 1/29/18 revealed Resident #230 was at nutrition and/or hydration risk with approaches to provide Percutaneous Endoscopic Gastrostomy (PEG) feeding as ordered. The physician's orders dated 2/2/18 documented, .[MEDICATION NAME] 1.5 cal (calorie) per peg tube at 50 cc (cubic centimeters)/hr (hour) for 22 hours, on at 8am, off at 6am . Observations in Resident #230's room on 2/11/18 at 2:44 PM and 4:57 PM, revealed Resident #230 was in the bed, [MEDICATION NAME] 1.5 was infusing at 55 ml/hr. Interview with Registered Nurse (RN) #1 on 2/12/18 at 2:20 PM, at the 200 hall medication cart, RN #1 was asked what Resident #230's feeding rate should be. RN #1 stated, 55 .oh no .50 . RN #1 confirmed Resident #230's feeding rate was infusing at 55 cc/hr. Interview with the Director of Nursing (DON) on 2/13/18 at 10:26 AM, in the Admissions office, the DON was asked if she expected her staff to follow the physician's orders. The DON stated, Yes. The DON was asked if an order for [REDACTED].