Every finding on record at Springtree Rehabilitation & Health Care Center

Based on observations, interviews and record reviews, the facility failed to follow the professional standards of nursing practice, as evidenced by failing to verify physician orders for insulin therapy and blood sugar monitoring; failing to initiate nursing care plans with focus and interventions related to care and management of Diabetes Mellitus for 1 of 1 sampled resident for new admission review, Resident #116; and failure to follow the physician orders for wound care, for 1 of 2 sampled residents reviewed for wound care, Resident # 74. The findings included: Review of the American Diabetes Association (ADA) Standards of Medical Care in Diabetes 2023, included the ADA's current clinical practice recommendations, to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. People with diabetes should be provided with blood glucose monitoring devices as indicated by their circumstances, preferences, and treatment. People using continuous glucose monitoring devices must have access to blood glucose monitoring at all times. People who are on insulin using blood glucose monitoring should be encouraged to check when appropriate based on their insulin regimen.https://diabetes.org/sites/default/files/2023-09/dc22s007.pdf A record review documented Resident #116 was admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes Mellitus, Lumbar Region Radiculopathy and Lumbar Region aftercare following Joint Replacement Surgery. An electronic review of the most recent Minimum Data Set (MDS) dated [DATE], under Section C of the Brief Interview of Mental Status (BIMS), revealed a score of 10 indicating Resident #116 had moderate cognitive impairment. A review of the physician orders dated 08/29/25 did not include physician orders for blood sugar monitoring and insulin therapy. An additional review of nursing care plan with focus on Diabetes Mellitus as one of admitting diagnoses for Resident #116, did not include interventions to monitor blood glucose levels and to administer insulin per physician orders. During an interview conducted with Staff C, Registered Nurse (RN), on 09/23/25 at 3:47 PM, when asked if she had processed the admission of Resident #116 to the facility on [DATE], she responded, No, I did not, but a review of admission documentation submitted by the Director of Nursing, revealed Staff C was the admitting Nurse for Resident #116. In an interview conducted with the Director of Nursing (DON) on 09/23/25 at 3:05 PM, when asked how soon the resident's medications are reconciled after admission from a hospital, she responded, Within the first hour. She added that the Unit Charge Nurse usually reconciles the medications. The staff does this process by getting the medication report from the hospital and confirms the orders with the resident's physician.The DON stated that when a resident has insulin orders, the admitting staff will be able to administer it to the resident per physician order, because the facility has emergency drug kits with different types of insulin. If the type of insulin is not available, then [Name provided] Pharmacy has the capability to deliver any drugs within the first hour of resident's admission.When the DON was asked how soon the Admitting Staff can assess the resident based on Diabetes Mellitus diagnosis, she responded, Within the first hour, and this is going to be coordinated with the hospital records and physician's order.When the DON was asked when the physician order for insulin was ordered for Resident # 116, she responded, It was ordered on 08/31/25. She was reminded that the resident was admitted on [DATE], indicating 2 days had already passed before insulin was ordered. When she was asked why the insulin was not put into Point Click Care (PCP) electronic orders on 8/29/25, she did not respond. A review of August 2025 Medication Administration Record (MAR) revealed the following blood sugar level:On 08/30/25 at 6:30 AM = 194 mg/dl (milligrams per deciliter) - with no insulin coverage per MAR.On 08/30/25 at 6:30 PM = 267 mg/dl - with no insulin coverage per MAR.On 08/31/25 at 6:30 AM = 176 mg/dl - with no insulin coverage per MAR.On 08/31/25 at 6:30 PM = 332 mg/dl - insulin coverage was ordered on 08/31/25 at 8:00 PM. A review of nursing progress notes dated 08/31/25 at 8:00 PM revealed a physician order for Novolog Flex Pen subcutaneous solution pen injector, 100 unit/ml, inject as per sliding scale:If 0 to149=0 unitIf 150 to 200 = 4 unitsIf 201 to 250= 6 unitsIf 251 = 8 units, Call MD if blood sugar is greater than 400.Do not hold coverage. Give subcutaneously one time only for Type 2 Diabetes Mellitus without Complications. An additional review of nursing progress notes on 08/31/25 at 7:12 PM documented that Resident #116 was feeling nauseous, so blood sugar was monitored and found to be over 300. A call was placed to the Advanced Practice Registered Nurse (ARNP) who was covering for resident's physician. A sliding scale for insulin was then ordered by ARNP. An additional review of the progress notes documented that Resident #116's family member complained that her mother was not being cared for and was advising her mother to leave the facility against medical advice (AMA). In an interview conducted with Staff C, RN, on 09/23/25 at 3:52 AM, she was asked the process of admission to the facility from hospital, and responded, Staff must go through History and Physical, check the hospital's discharge records, and call the Physician to verify the orders.When she was asked about the hospital's discharge order of Continue Medications, for Resident #116, she responded that it meant she would call the Physician and inform him/her that the hospital ordered for the resident to continue the medications. She would then enumerate the listed medication, reconcile the medications one by one, and inform the physician about the listed medications' frequency and dosages in case something needs to be changed.Staff C stated that it is very important to discuss the Novolog insulin order for Resident #116 with the physician. She added that she does not know how often the Admitting Nurse would check for blood sugar level but emphasized that it is done when the resident needs it. She also added that she checks the residents' diagnoses to make sure the medications are appropriate with the medical diagnoses. 2. A record review documented Resident #74 was admitted to the facility on [DATE] with diagnoses that included Cerebral Atherosclerosis, Senile Entropion of the Right Lower Eyelid, Hyperlipidemia and Hypertension. An electronic review of recent Minimum Data Set (MDS) assessment dated [DATE], under Section C of the Brief Interview of Mental Status (BIMS), revealed a score of 9 indicating Resident #74 had moderate cognitive impairment.An electronic review of physician orders dated 06/09/25 revealed to cleanse sacrum with normal saline, and apply 1/4 strength Dakins soaked gauze to fill cavity, dry dressing every day shift, for non-pressure wound and as needed. During a wound care observation on 09/24/25 at 10:24 AM with Wound Care (WCN) (RN) and Staff B, Certified Nursing Assistant (CNA), it was observed that the WCN poured Daikins solution onto woven gauze sponges, onto 2 Styrofoam trays. He then stated that the first Styrofoam tray containing Daikin solution-soaked woven sponges which would be used to cleanse around the sacral area, and the second Styrofoam tray of Daikins soaked woven sponges would be used inside the sacral tunnelling. The WCN used the Daikins soaked woven sponges to cleanse around the sacral area, indicating he did not follow the physician order of cleansing the sacrum with normal saline.In an interview conducted with the WCN on 0925/25 at 11:26 AM, when asked why he used Daikins solution in cleansing around the sacrum instead of normal saline solution, he responded, I did not remember the saline order, only the Dakins solution order.In an interview conducted with Staff D, Licensed Practical Nurse (LPN), on 09/25/25 at 1:45 PM, when asked how she would know how to care for the resident's wounds, she responded, I read the physician orders and follow what the orders states.In an interview conducted with Staff F, LPN, on 9/25/25 at 3:05 PM, when asked if nurses verify the physician orders for the solutions to be used for wound care, she responded, Yes, it is very important to verify the physician order and follow them.

Based on review of policy and procedure, observation, record review and interview, the facility failed to implement appropriate interventions to avoid the development of a pressure wound, for 1 of 2 sampled residents, Resident #5, observed for Wound Care and Treatment.The findings included: Based on review of policy and procedure, observation, record review and interview, the facility failed to implement appropriate interventions to avoid the development of a pressure wound, for 1 of 2 sampled residents observed for Wound Care and Treatment, Resident #5.The findings included: Review of the facility policy titled Wound Treatment Management provided by the Director of Nursing (DON) revised 09/2025 documented in the Policy Statement: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Policy Explanation and Compliance Guidelines: 1. Wound treatments will be provided in accordance with physician orders, including cleaning method, type of dressing, and frequency of dressing change.4. Dressings will be applied in accordance with manufacturer recommendations.Resident #5 was re-admitted to the facility on [DATE] with diagnoses which included Non-displaced Fracture of Surgical Neck of Right Humerus in which she was wearing a sling to her right arm, Pressure Ulcer of Right Elbow which originally began as Unstageable and later a Stage IV, Paroxysmal Atrial Fibrillation, Heart Failure, Panic Disorder and Chronic Obstructive Pulmonary Disease. She had a Brief Interview Mental Status (BIM) 15, indicative of----intact cognition.During an initial observational tour conducted on 09/22/25 at 10:41 AM, Resident #5 was observed resting in bed with her right arm sling with swathe on, but it was not noted to be properly positioned in place; the top portion of her sling with swathe was around her neck, but the bottom part of the sling with swathe was not observed with her right elbow located inside to provide support and protection to the arm, at the time. Additionally, there was no other cushion nor elbow protector noted. During a second observation conducted on 09/23/25 at 9:58 AM, Resident #5 was observed resting in bed with her right arm sling with swathe on, but it was still not noted to be properly positioned in place; the top portion of her sling with swathe was around her neck, but the bottom part of the sling with swathe was still not observed with her right elbow located inside to provide support and protection to the arm, at the time.During a third observation conducted on 09/24/25 at 10:01 AM, Resident #5 was observed resting in bed with her right arm sling with swathe on, but again her right sling was swathe was still not noted to be properly positioned in place; the top portion of her sling with swathe was around her neck, but the bottom part of the sling with swathe was still not observed with her right elbow located inside to provide support and protection to the arm, at the time.During an interview conducted with Resident #5 on 09/25/25 at 11:24 AM, she stated that her right arm sling tends to move all around sometimes, making her right elbow a little uncomfortable and feeling un-secured. Resident #5 was unable to recall any information regarding her wound status. On 08/21/25 the Physician's Order documented, Sling and swathe to right arm - may remove for care and skin integrity check every shift. Wound Care Progress Notes revealed the following dates, with measurements, of Resident #5's initial Un-stageable Wound to an ultimate Stage 4 Pressure Wound documented as: initial Un-stageable Right Posterior Elbow full thickness revealed that the wound measurements were: 1.6 x 1.6 x 0.2 cm and the surface area was 2.56 cm^2 on 09/09/25, exudate: Light Serous. Next, the Un-stageable Right Posterior Elbow full thickness wound measurements vs. wound presentation were: 1.3 x 1.2 x 0.2 cm and the surface area was 1.56 cm^2. on: 09/15/25, exudate: Light Serous; with surgical excisional debridement performed. Lastly, the now the Stage IV Right Posterior Elbow full thickness wound measurements vs. wound presentation were: 1.3 x 1.0 x 0.2 cm and the surface area was 1.30 cm^2. on: 09/22/25, exudate: Light Serous; with surgical excisional debridement performed; as noted above there were several documented episodes of drainage noted within the resident's wound.On 09/10/25 the Physician's Order documented, Cleanse right elbow wound with normal saline, pat dry, apply Silver Hydrogel and Dry Dressing, as needed. Computerized record review of the Nursing Weekly Skin Observation Tool dated from 08/20/25 thru 09/16/25, only indicated for Skin Integrity, no new changes to skin integrity noted. However, there was no mention of any intervention being put into place providing additional and appropriate protection for the resident's right elbow area, during that time.Further record review of the Nursing Progress Notes dated from 08/20/2025 until 09/16/25, also did not indicate any current, on-going skin status condition, nor progression of the resident's initial right arm/elbow bruising, in the sling.Moreover, there had been no documented evidence to show, nor to specifically describe Resident #5's skin appearance. During an interview conducted on 09/25/25 at 11:30 AM with the facility's Wound Care Nurse, he stated that he first noted bruising to the resident's right elbow upon both initial admission to the facility on [DATE] and again upon re-admission to the facility on [DATE]. He stated that the nurses are to do weekly skin assessments with the CNAs doing daily skin checks every shift. The Wound Care Nurse stated that he subsequently checks the resident's skin if there are any changes in condition that are communicated to him by nursing staff and then he will refer to the wound care doctor for weekly treatment and evaluation, if needed. The Wound Care Nurse revealed to this Surveyor that one (1) of the resident's assigned CNAs (he could not recall exactly whom) had approached him directly on 09/08/25 in order to inform him to go and check the resident's right elbow because there might have been something, there that presented a concern. And, the Wound Care Nurse went on to say that he checked the resident's skin, took pictures and called the Wound Care Doctor's office, who came in the next day to check it. The Wound Care Nurse acknowledged that prior to first assessing Resident #5's right bruised arm wound area, that there had been no padding inside of the sling in place to protect and cushion the right elbow against the movements. An interview was conducted on 09/25/25 at 1:25 PM with Staff A, Certified Nurse Assistant (CNA) in which she stated that Resident #5 had been wearing a right arm sling that would be removed by nursing staff to provide care, she said that she would look to see if there was any redness or anything that would occur during shift change. During the interview, Staff A also stated that the sling would move all around on the resident's right arm and elbow, sometimes. Staff A also added that on 09/08/25 that she had noticed that there was something that resembled a little small un-usual blister-filled fluid area. Staff A ended by saying that she did tell both the assigned nurse as well as the treatment nurse about what she had seen in order for them to follow-up. During an interview conducted on 09/25/25 at 1:35 PM with Staff D, assigned Licensed Practical Nurse (LPN), she acknowledged that the resident had a sling in place on her right arm and she said that she would loosen it in order to look and check it as well as the resident's skin condition, on a daily basis in order to make sure that the arm was ok, and that there was no irritation on the arm underneath the sling. Staff D also explained how the sling tends to sometimes move all around on the resident's right arm and elbow. Staff D revealed that she does not ordinarily document on the resident's wound, unless she notices some changes and she would document this in the weekly skin assessment or in the progress notes. Otherwise, Staff D said that the Wound Care Nurse would document the resident's skin condition. Staff D indicated that on 09/07/25 that she had only documented in the record that there were, No new changes to skin integrity noted. The assigned nurse ended by saying that she was unable to recall whether or not any type of additional right elbow protection had been in place for the resident; neither had she notified her Supervisor, nor the Physician of such, for the resident.An interview was on 09/25/25 at 3:03 PM with conducted Staff F, LPN, Charge Nurse in which she indicated that she was unable to recall whether or not Resident #5 had any issues or impairments to her right elbow. And, neither was she able to recall whether or not any type of additional right elbow protection had been in place for the resident, at the time. Record review of the Resident #5's Un-stageable Pressure Ulcer Right Elbow Care plan initiated 09/08/25 and revised 09/23/25 indicated Focus: 09/09/25 1.6 cm x 1.6 cm x 0.2 cm, 09/15/25 1.3 cm x 1.2 cm x 0.2 cm, now revealed Stage IV pressure injury.Interventions:.Administer treatments as ordered and monitor for effectiveness.Follow facility policies/protocols for the prevention/treatment of skin breakdown.Goal: Resident #5's pressure ulcer will show signs of healing and remain free from infection by/through review date. Record review of the Resident #5's Skin Impairment Care plan initiated 09/02/25 and revised 09/19/25 indicated Focus: Resident has potential impairment to skin integrity related to requiring assistance with bed mobility, abnormal labs, decline in functional ability, requires protective skin care.09/09/25 - open area to right elbow un-stageable pressure area.09/17/25 Significant change/un-stageable pressure ulcer to right elbow. Interventions:.Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Goal: Resident # 5 will have no complications. There was no order written in the resident's file for a right elbow protector until after surveyor inquisition on 09/23/25. In summary, Resident #5's right elbow wound had been initially recorded as a bruised area, then as an Unstageable (necrotic) wound and finally as a Stage 4 pressure wound (injury), by the Wound Care Doctor. However, there was no evidence reviewed in the Daily CNA Skin Checks, the Weekly Nurse's Skin Assessments, the Medication Administration (MAR), the Treatment Administration Record (TAR), nor in the Nurse's Progress Notes, to reflect that adequate and appropriate assessment, evaluation as well as intervention, had been implemented and put into place, in order to help prevent the development and progression of a pressure wound injury, to the resident's right elbow, in a timely manner. The DON further recognized and acknowledged on 09/25/25 at 3:30 PM that Resident #5 had a right elbow wound which was noted as having had some drainage, and in which appropriate intervention should have been implemented and put in place, in order to adequately protect the resident's right elbow skin area.

Based on observations, interviews, and record reviews, the facility failed to follow the Center for Disease Control and Prevention (CDC) guidelines for Standard Precautions, for 2 of 2 residents for wound care, (Resident# 74 and Resident #5), and 1 of 1 resident for urinary care (Resident #95). The facility additionally failed to follow the CDC guidelines for Enhanced Barrier Precaution (EBP), for hand hygiene, for 1 of 2 residents reviewed for wound care (Resident #74).The findings included: According to Center for Disease Control (CDC), the following are the guidelines for Standard Precautions: As part of Standard Precautions, which apply to the care of all residents, the use of personal protective equipment (PPE) is based on the anticipated exposure to blood, body fluids, secretions, or excretions. For example, gloves are recommended when contact with blood or other potentially infectious materials, mucous membranes, non-intact skin, or contaminated equipment could occur. A gown is recommended to protect skin and prevent soiling of clothing during procedures and activities that could cause contact with blood, body fluids, secretions, or excretions. https://www.cdc.gov/infection-control/hcp/basics/standard-precautions.html According to CDC, proper PPE removal revealed to grasp the gown in the front and pull away from your body so that the ties break, touching outside of gown only with gloved hands: wash hands or use an alcohol-based hand sanitizer immediately after removing all PPE. INTER-FACILITY INFECTION CONTROL TRANSFER FORM FOR STATES ESTABLISHING HAI PREVENTION COLLABORATIVES Additional guidelines from CDC on when to change gloves and when to clean hands revealed: If moving from work on a soiled body site to a clean body site on the same patient or if a clinical indication for hand hygiene occurs. Clinical Safety: Hand Hygiene for Healthcare Workers | Clean Hands | CDC Additionally, according to CDC, one of few EBP guidelines included that Everyone must clean their hands, including when both entering and leaving the room. https://www.cdc.gov/long-term-care facilities/media/pdfs/ 1. Record review documented Resident #74 was admitted to the facility on [DATE] with diagnoses that included Cerebral Atherosclerosis, Senile Entropion of the Right Lower Eyelid, Hyperlipidemia and Hypertension. Electronic review of the most recent Minimum Data Set (MDS) assessment dated [DATE], under Section C of the Brief Interview of Mental Status (BIMS), revealed a score of 9 indicating moderate cognitive impairment. Electronic review of the physician orders dated 06/09/25 revealed an order: to cleanse sacrum with normal saline, and apply 1/4 strength Dakins soaked gauze to fill cavity, dry dressing every day shift, for non-pressure wound and as needed. During a wound care observation on 09/24/25 at 10:24 AM with Wound Care Nurse (WCN) RN and Staff B, Certified Nursing Assistant (CNA), it was observed that the WCN did not put a protective barrier between the resident's sacral area and resident's bedding which allowed some of the ordered Daikin's solution with sacral secretions to contaminate Resident#74's bedding. After the wound care procedure, the WCN and Staff B did not change the resident's bedding. Following the care provided, it was observed that during personal protective equipment (PPE) gown removal, Staff B, while wearing the same gloves used for Resident #74's wound care, untied the neck and waist ties of her PPE gown, removed her PPE gown, then removed her PPE gloves and left the resident's room without performing hand hygiene. In an interview conducted with Staff D, LPN, on 09/25/25 at 11:30 AM when she was asked how she performs care of residents with fluid drainage or excretions coming from the sacral area, she responded, I protect the bedding of the resident by placing a barrier between the resident and the resident's bedding. She added it is important to prevent the spread of infection. In another staff interview conducted on 09/25/25 at 12:36 PM with Staff I, LPN, when she was asked how she prevents the spread of infection when caring for a possible drainage during wound care, colostomy care and urinary care, she responded, I put a barrier between the resident's skin and their clothes or bed sheets. She added that she would wear PPE like gloves, gown, and mask if she knows secretions might splash into her face. 2. Record review documented Resident #95 was admitted to the facility on [DATE] with diagnoses that included Multiple Sclerosis, Paraplegia and Neuromuscular Dysfunction of the Bladder. Review of the MDS dated [DATE] under Section C, revealed a BIMS score of 15 indicating no cognitive impairment. Section H revealed a yes response to indwelling catheter on 06/27/25. Electronic review of physician orders dated 06/24/25 revealed an order for Enhanced Barrier Precautions (EBP) as indicated for supra pubic catheter. A physician order dated 03/07/25 revealed to check suprapubic catheter for leakage every shift. During a urinary care observation on 09/25/25 at 12:42 PM with Staff E, CNA, who was observed using the same gloves from washing the suprapubic site, and touching the following items: urine bag, resident's left upper thigh, urine bag strap, bed linen, bed control, resident's pants, blouse, and pillow. Staff E did not remove the pair of gloves from the beginning of urinary care until 10 minutes later. She did not perform hand hygiene when the care was moved from the suprapubic catheter site to the resident's leg. In an interview conducted with Staff H, CNA, on 09/25/25 at 1:45 PM, when she was asked how often she changes her gloves when providing urinary care to a resident, she responded, she uses a different set of gloves when cleaning the catheter area, and when she is securing the urinary bag to resident's leg. She added that she would not use the same gloves she used on suprapubic catheter area when she would press the bed control, or when she needs to cover the resident with a blanket. 3. Review of the facility policy titled, Wound Treatment Management, provided by the Director of Nursing (DON) revised 09/2025, documented in the Policy Statement: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Policy Explanation and Compliance Guidelines: 1. Wound treatments will be provided in accordance with physician orders, including cleaning method, type of dressing, and frequency of dressing change.4. Dressings will be applied in accordance with manufacturer recommendations. Record review revealed Resident #5, was readmitted to the facility on [DATE] with diagnoses that included Non-displaced Fracture of Surgical Neck of Right Humerus in which she was wearing a sling to her right arm, Pressure Ulcer of Right Elbow which originally began as unstageable wound and later a Stage IV pressure ulcer, Paroxysmal Atrial Fibrillation, Heart Failure, Panic Disorder and Chronic Obstructive Pulmonary Disease. The record documented a Brief Interview Mental Status (BIMS) score of 15, indicating intact cognition. During a Wound Care (WC) observation, performed by the facility's Registered Wound Care Nurse (WCN), of Resident #5's facility acquired right elbow Stage IV pressure wound, the WCN was observed retrieving a pair of gloves only / Personal Protective Equipment (PPE) from the box located in the resident's room, in order to perform this procedure. The WCN checked the order and verified the resident's identity. The current Physician's WC order dated 09/10/25 was to cleanse the right elbow wound with normal saline, pat dry, apply Silver Hydrogel and dry dressing. Resident #5 provided permission for the surveyor to observe the wound care. The WCN then prepared his supplies and placed them on the cleaned / covered bedside table after sanitizing his hands. The nurse washed his hands appropriately and donned a pair of gloves. The nurse was observed beginning to remove Resident #5's soiled, right elbow dressing containing a small amount of serosanguinous drainage noted atop the resident's contaminated outer clothing. The WCN did not first place a clean barrier underneath and between Resident #5's skin and her dirty / contaminated clothing, until after he had already removed the resident's soiled dressing. During this time, Resident #5's uncovered right elbow had been observed intermittently touching and coming into contact with both her soiled clothing and the side of the inner portion of the resident's wheelchair. During this time, Resident #5 was observed attempting to hold up her own right elbow with her left hand for more than several minutes in an effort to help keep her right elbow elevated, and off her dirty/contaminated clothing throughout the wound care treatment. Review of the WC Doctor's initial documentation revealed the following: on 09/09/25 of the unstageable right posterior elbow full thickness wound revealed the wound was open and had exudate of light serous drainage. On 09/15/25, the documentation included exudate of light serous drainage, and a surgical excisional debridement was performed. On 09/22/25, the documentation included exudate of light serous drainage and was with surgical excisional debridement performed. It was noted there were several documented episodes of drainage within the resident's wound. During an interview conducted on 09/24/25 at 2:19 PM with the facility's WCN, he acknowledged Resident #5 had a wound to her right elbow, which was noted to have some mild serosanguinous drainage at the time. He stated he had not placed a clean barrier underneath Resident #5's right elbow, until after he had already removed the soiled dressing which had allowed Resident #5's uncovered right elbow wound, with mild serosanguinous drainage, to come into contact with both her contaminated clothing and with the right side of her wheelchair throughout the wound care procedure. An interview and side-by-side record review of the WC Doctor's progress notes dated 09/09/25, 09/15/25 and 09/22/25 was conducted on 09/24/25 at 2:31 PM with Staff F Licensed Practical Nurse (LPN)/Charge Nurse, regarding the fact that there was no clean barrier placed down underneath the resident's right elbow. Staff F acknowledged that Resident #5's Stage IV right elbow wound was noted to have some mild serosanguinous drainage, and she also acknowledged that the resident's uncovered right elbow should not have come into contact with her contaminated clothing or with the right side of her wheelchair during the wound care procedure. During an interview conducted on 09/24/25 at 3:32 PM with the Infection Control Licensed Practical Nurse (IC-LPN), regarding the fact that there was no clean barrier placed down underneath the resident's right elbow, the IC-LPN acknowledged Resident #5's Stage IV right elbow wound was noted to have some mild serosanguinous drainage, and the resident's uncovered right elbow should not have been allowed to come into contact with any contaminated surfaces during the wound care treatment. The Director Of Nursing (DON) acknowledged on 09/24/25 at 3:45 PM that Resident #5's right elbow wound was noted to have some mild serosanguinous drainage and the resident's uncovered right elbow should not have been allowed to come into contact with any contaminated surfaces, during the wound care procedure.

Based on observation and interview, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary orderly, and comfortable interior for Unit 1, for 7 of 7 observed resident rooms and the community shower, and Unit 2, for 1 of 1 observed resident rooms. The findings included: During the resident screenings performed by the surveyors on 05/20-21/24 and the Environment observation tour conducted on 05/22/24 at 1:00 PM, accompanied with the Administrator and Corporate Director of Procurement, the following findings were noted: 1. Unit 1: room [ROOM NUMBER]: A - The overbed light cord was too short (cord extension missing), the bathroom door frame & walls were scuffed and in disrepair, and the privacy curtain stained. room [ROOM NUMBER]: The call bell cord was too short; and bathroom ceiling vent-dust laden. room [ROOM NUMBER]: The room walls were in disrepair with scuff marks, the privacy curtain was stained, and the bathroom toilet was running continuously. room [ROOM NUMBER]: The privacy curtain was stained, the bottom of bathroom door corner had loose lower panels, the room walls had numerous large black scuff marks, and the room's privacy curtain (W-bed) was too short to adequately block visual of the resident for privacy. room [ROOM NUMBER]: The A/C-PTAC unit vents (air conditioner) were dirty, the bedside table had broken corners on the surface of the table, the privacy curtain was stained, and the privacy curtain (W-bed) was too short to adequately block visual of the resident for privacy. room [ROOM NUMBER]: The room dresser had missing a drawer knob, and 3 walls were in disrepair. room [ROOM NUMBER]: The furniture dresser had missing drawer pull knobs, the bathroom call bell cord was too short, and the metal plate beneath door knob on the door entry to room was not secure. Community Shower: The Emergency call bell cord located in the toilet room was too short, and the entry door was damaged and in disrepair. 2. Unit 2: room [ROOM NUMBER]: The B-bed fall-floor mat on floor was in poor condition (torn and ripped), and the room entry door had loose lower panels. Following the 05/22/24 environmental tour, the findings were again confirmed with the Administrator. The Administrator was noted to state that the facility has a computerized TELS system for staff to report maintenance and housekeeping issues via the computer. The Administrator further stated that staff is continuously in-serviced on the use of the TELS system, however staff are not utilizing the system.

Based on observation and interview, the facility failed to store, prepare, distribute, and served food in accordance with professional standards for food services safety. The findings included: 1. During the initial observation tour conducted of the Main Kitchen on 05/20/24 at 9:00 AM and accompanied with the facility cook supervisor (Staff G), the following were noted: (a) A soiled rag was located on the clean food preparation counter next to the commercial toaster. The surveyor informed Staff G that all cleaning cloths must be stored within a chemical sanitizing solution when not in use. (b) The floor area located in front of the commercial toaster and food preparation counter was noted to have numerous missing tiles and holes (3). (c) The ceiling vent located outside of the paper / disposable room was noted to be soiled and dust laden. (d) Observation of the paper / disposable room noted to have freezer jackets that were hanging on shelving and coming into contact with paper / disposable goods. The surveyor informed Staff G that the jackets are soiled and sweaty and are contaminating disposable supplies (cups, bowls napkins, etc.). (e) The ceiling mounted light located in the pantry room was noted to have a broken / cracked cover and could possibly allow pieces of plastic fall into foods stored within the room. (f) The hallway located outside of the walk-in freezer was noted to have cleaning equipment (broom, dust pans, etc.) leaning up against shelving of which potatoes and onions were being stored. The surveyor informed Staff G that soiled cleaning equipment could come into contact with fresh foods. (g) The pot & pan storage racks / shelving were noted to house skillets and pans that were soiled and covered with black carbon. The pans were also noted to have water that was not drained properly after washing. The surveyor requested to Staff G that the food preparation equipment be replaced. (h) Observation of the Artic Aire Reach-in Refrigerator #1 was noted to have 8 internal food storage shelves the were rust laden and had the plastic coating peeling off. The surveyor requested that the shelving be replaced. (i) Observation of the dish machine room noted that soiled water and garbage were backing up and out of the machine into the clean dish run area. The surveyor informed Staff G that the clean dish exiting the machine was becoming contaminated from the waste water from the dish machine. (j) The stainless steel dish runs leading up to the dish machine were noted to have caulking to the walls that had a black mold type matter, The surveyor requested that the molded caulking be removed. (k) Observation of the dish machine room noted to have clean dish racks that were being stored directly on the soiled dish room floor. Further observation noted that the racks were soiled, stained, in disrepair, and in need of replacement. (l) Observation of the commercial meat slicer was noted to have particles of dried food debris around the slicing blade. It was discussed with Staff G that the slicer was not being properly cleaned and sanitized after each use. (m) Observation of the commercial ovens (2) noted that the interior cavity was covered with a black carbon coating. The surveyor informed Staff G that the ovens are not being cleaned and maintained on a regular basis. (n) The kitchen utility cart located in the food preparation area was noted to have metal shelving (3) that was rust laden and in need of replacement. 2. During an observation tour of the facility's pantry kitchens conducted on 05/21/24 at 2:00 PM with the Assistant Director of Nursing (ADON), the following were noted: a. The refrigerator located within the 100 Unit pantry was noted to have torn gaskets on both the freezer and refrigerator doors. b. The refrigerator located in the 200 Unit pantry was noted to have a large tear in the freezer door. It was also noted that the carton of portion control milk (8 ounces) was opened for use and placed back into the refrigerator. It was also noted that a bottle of soda was open, partially empty (drank from) and placed back into the refrigerator.

Based on observations, interviews and record review, the facility failed to implement Enhanced Barrier Precautions (EBP) per Centers for Disease Control (CDC) guidelines and facility policies and procedures for 10 of 10 sampled residents reviewed for Transmission-based precautions, Residents #18, #20, #33, #60, #77, #85, #92, #327, #334, and #371. The census at the time of survey was 108 residents. The findings included: Review of the Center for Disease Control (CDC) guidance for Enhanced Barrier Precautions (EBP), documented, in part, the following: When implementing Contact Precautions or Enhanced Barrier Precautions, it is critical to ensure that staff have awareness of the facility's expectations about hand hygiene and gown/glove use, initial and refresher training, and access to appropriate supplies. To accomplish this: o Make PPE [Personal Protective Equipment], including gowns and gloves, available immediately outside of the resident room. The guidance for the Enhanced Barrier Precautions is located at: CDC_Implementation_Of_Personal_Protective_Equipment_(PPE)_Use_In_Nursing_Homes_To_Prevent_Spread_Of_Multidrug-resistant_Organisims_(MDROs). Review of the facility's policy, titled, Enhanced Barrier Precautions, with a reference date of 04/01/24, documented, in part: Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. 3. Implementation of Enhanced Barrier Precautions: a. Make gowns (may be reusable gowns) and gloves available immediately near or outside of the resident's room. Note: face protection may also be needed if performing activity with risk of splash or spray (i.e. wound irrigation, tracheostomy, etc.). b. PPE (Personal Protective Equipment) for enhanced barrier precautions is only necessary when performing high-contact car activities and may not need to be donned prior to entering the resident's room. 4. High-contact resident are activities include: a. Dressing b. Bathing c. Transferring d. Providing hygiene e. Changing linens f. Changing briefs or assisting with toileting g. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes h. Wound care: any skin opening requiring a dressing. During a unit-by-unit tour of the facility on 05/20/24 at 10:18 AM, it was noted that there was a total of 9 resident rooms that had signage at the entrance to the rooms that informed staff and visitors that the resident / residents in the room were on 'Enhanced Barrier Precautions' (EBP). These rooms were observed to be the resident rooms of Residents #18, #20, #33, #60, #77, #85, #92, #327, #334, and #371. Further observation revealed that there was no personal protective equipment (PPE) at or near the entrance to the rooms. During an interview, on 05/20/24 at 10:20 AM, during the unit-by-unit tour, with Staff D, Licensed Practical Nurse (LPN), when asked about the availability of gowns for the residents on EBP, Staff D replied, they usually bring it out to here (referring to a clean linen cart on the unit). We have masks at the nurse's station and gloves in the residents' rooms. During an interview, on 05/20/24 at 10:30 AM, during the unit by unit tour, with Staff I, Registered Nurse (RN), when asked about the availability of gowns for the residents on EBP, Staff I replied, the gowns are kept on the cart and gloves are on the nurse's carts and in the residents' bathrooms, gowns are on the linen carts (referring to the linen carts that were placed outside in the halls) and by the nurse's station. During the tour, the following observations were made: On the 100 unit: a. The hall that included Rooms #100 to 109, had a linen cart placed outside of room [ROOM NUMBER] that contained no gowns. b. The hall that included Rooms #111 to 119, had a linen cart placed outside of room [ROOM NUMBER] that contained 1 gown. c. The hall that included Rooms #121 to 131, had a linen cart placed outside of room [ROOM NUMBER] that contained no gowns. On the 200 unit d. The hall that included Rooms #201 to 210, had a linen cart placed outside of room [ROOM NUMBER] that contained no gowns. e. The hall that included Rooms #211 to 220, had a linen cart placed outside of room [ROOM NUMBER] that contained no gowns. f. The hall that included Rooms #221 to 230, had a linen cart placed outside of room [ROOM NUMBER] that contained no gowns. During a unit-by-unit tour of the facility, on 05/21/24 at 7:40 AM, the following observations were noted: a. On the 100 unit, the hall that included Rooms 111 to 119, had a linen cart outside of room [ROOM NUMBER] that had one gown. The remaining carts on the other two halls contained no gowns. b. On the 200 unit, the hall that included Rooms #221 to 231, had a linen cart placed outside of room [ROOM NUMBER] that contained an unopened package of ten disposable gowns. The remaining carts on the other two halls contained no gowns. During an interview, on 05/22/24 at 10:36 AM, with Staff J, Certified Nursing Assistant (CNA) when asked about the availability of gowns for residents on EBP, Staff J stated that they were kept at a cart at the nurse's stations. Staff J also stated that there was no other place where the gowns would be stored. During an interview, on 05/22/24 at 12:12 PM, with the Wound Care Nurse, when asked about the facility's policy for PPE, the Wound Care Nurse replied, 'if they have a wound they have EBP, we have to wear a yellow gown, when CNAs are providing care and when I am taking care of the wound and residents with a Foley catheter. If they have an IV (intravenous) or a PICC (peripherally inserted central catheter) line and the nurses are hanging the fluids, they have to wear the yellow gown as well. There is a cart by the desk, they put them [gowns] in there. They have the disposable ones and the ones that get washed. The washable and reusable ones are kept in a cart at the nurse's stations. During an interview, on 05/23/24 at 10:51 AM, with the Infection Preventionist (IP), when asked about the facility's policy for providing PPE for residents on EBP, the IP replied, we started them off in the linen carts, the main ones that are on the floor and moved them from the large carts to the small carts on each unit. Housekeeping said that there was not enough room on the big cart so they brought them straight to the small carts that are on the individual units. At the conclusion of the interview, the IP was made aware of the findings and the carts that had been void of gowns during the three tours of the facility.

Based on record review, interview, and observation, the facility failed to address a urine culture and sensitivity result in a timely manner for 1 of 2 sampled residents reviewed for hospitalization s (Resident #103); and failed to maintain a secure catheter tubing for 1 of 1 sampled resident reviewed for urinary catheters (Resident #92). The findings included: Review of the facility's policy, titled, Laboratory Services and Reporting, dated 2/2023 and revised 2/2024, documented, in part: The facility must provide or obtain laboratory services to meet the needs of its residents. The facility is responsible for the timeliness of the services. Promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside the clinical reference range. 1. Record review documented Resident #103 was admitted to the facility on [DATE]. Review of the comprehensive assessment dated [DATE] documented the resident was cognitively intact and required substantial / maximum assist with activities of daily living (ADLs). Record review revealed a Progress Note dated 04/03/24 at 11:37 AM that documented Resident #103 was not feeling well and appeared weak and listless. The physician was notified, and orders were received for blood labs to be done. Subsequently, on 04/03/24 at 10:47 PM (2247 hours), an order was received for a urinalysis with reflex to culture in AM (04/04/24). A progress note dated 04/04/24 at 6:39 PM documented the results of Resident #103's urinalysis was read to the physician and no new orders were obtained. A progress note dated 04/05/24 at 9:06 AM documented Resident #103's urinalysis on 04/04/24 was indicative of a Urinary Tract Infection (UTI). The progress note further indicated the urine culture and sensitivity was not available, the physician was notified and no new orders were received. A review of Resident #103's Urinalysis result revealed it was received on 04/04/24 at 12:27 PM, and the results were reported on 04/06/24 at 10:09 AM. A progress note dated 04/08/24 at 12:05 PM documented Resident #103's urine tested was positive for a specific organism, with sensitivities to antibiotics. An order for Cipro (an antibiotic) was received from the physician (2 days after the results were received, 5 days after initial symptoms). An interview was conducted with the Infection Control Preventionist (ICP) on 05/22/24 at 12:00 PM. The ICP stated they generally wait until the culture and sensitivity results are received before antibiotics are prescribed to avoid Multiple Resistant Drug Organisms. The ICP acknowledged the results of Resident # 103's culture and sensitivity came back on 04/06/24, the weekend, and it was not addressed until Monday, 04/08/24 (2 days later). Resident #103 was transferred to the hospital on 04/09/24 for diagnosis of Urinary Tract Infection, weakness, and lower extremities edema. 38349 2. Review of the facility policy and procedure on 05/22/24 at 11:50 AM, titled, Catheter Care provided by the Assistant Director of Nursing (ADON) revised 03/2024, documented, in part, in the Policy Statement: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use Policy Explanation: 6. Leg bags will be attached to the resident's thigh or calf making sure to have slack on the tubing to minimize pressure and tension. Ensure straps are snug but not tight as appropriate. 7. Leg bags may be stored in a clean, plastic bag when not in use or as per facility policy. Record review documented Resident #92 was readmitted to the facility on [DATE] with diagnoses that included Obstructive and Reflux Uropathy, Atherosclerotic Heart Disease, Sepsis, Hematuria, Urinary Tract Infection, Anxiety Disorder, Anemia, Acute Respiratory Failure with Hypoxia and Hypertension. The record documented a Brief Interview Mental Status (BIMS) score of 15, indicating cognition was intact. On 02/21/24, the Physician's order documented, Leg strap to anchor indwelling catheter in place. During a Foley catheter / Peri-care observation conducted on 05/22/24 at 10:27 AM with Staff B, Certified Nursing Assistant (CNA), it was observed that Resident # 92's peri-area (penis and scrotum) was clean, but with slight redness noted to his upper thigh and penile area. Resident #92 stated, during the Peri-Foley catheter care session, that it felt a little tender and sore there, and he said that is often that way especially when they put on the leg bag which, as it fills up, it pulls, weighs down, moves all around, and hurts him. The resident further stated he told the nurses, but they just adjust or empty the bag. Resident #92 stated, they should have some type of support strap on, but they don't usually. Photographic Evidence Obtained. On 05/22/24 at 10:41 AM, Staff B acknowledged that they use the strap / anchor sometimes, but she also stated that the dirty strap had been directly placed and not bagged into Resident #92's dresser drawer just across from the resident's bed. There was no accompanying anchor portion in place, none in the resident's room, as ordered, and none on the resident today. The ADON obtained the anchor from the Central Supply room and then applied it following Foley/Peri-care. On 05/22/24 at 11:24 AM, an interview was conducted with Staff C, Registered Nurse (RN), who acknowledged that the Foley catheter strap and anchor were not in place per the physician's orders. Staff C stated, ordinarily the CNAs will take care of this and will tell her if there is a problem. During a side-by-side record review conducted with Staff C, of the Treatment Administration Record (TAR) dated 05/22/24, it was revealed that Staff C had initialed that the Foley strap and anchor for Resident #92's Foley catheter were in place, when in fact, it had not been. Record review of Resident #92' care plan dated 03/11/24 revealed that .Focus: Resident #92 has a Foley Catheter related to Urinary Retention, History of Pyelonephritis, has Benign Prostatic Hypertrophy which may impact, and a diagnosis of Obstructive Uropathy. Interventions included: Position catheter bag and tubing below level of the bladder and away from room door. Check tubing for kinks as needed and every shift, monitor for signs and symptoms of discomfort or urination and frequency. Monitor / document for pain / discomfort due to catheter. Monitor / document / report to Doctor signs and symptoms of Urinary Tract Infection: pain / suprapubic tenderness, burning, blood tinged urine, no output, increased pulse, dysuria, Urinary frequency, Urinary urgency fever or Hypothermia, chills, altered mental status, change in eating patterns or decline in function. Goals: Resident will be/remain free from catheter-related trauma through review date. There was no documentation included in the care plan with regard to the resident's Foley strap or anchor. On 05/22/24 at 11:37 AM, during an interview with the ADON regarding the absence of both the Foley leg strap and anchor for Resident #92, he acknowledged that both should have been in place as ordered. Neither the Foley leg strap nor the accompanying anchor had been applied, until after surveyor inquisition/intervention. On 05/22/24 at 11:40 AM, the Director of Nursing (DON) acknowledged the absence of both the Foley leg strap and anchor for Resident #25, that both should have been in place as ordered and this was not done.

Based on observation, interview, and record review, the facility failed to administer pain medicine as ordered for 1 of 4 sampled residents reviewed for pain (Resident #85). The findings included: Record review revealed Resident #85 was admitted to the facility on [DATE]. Review of the comprehensive assessment dated [DATE] documented the resident was cognitively intact and required partial / moderate assistance with activities of daily living (ADLs). Record review documented Resident #85 was care planned for pain and had interventions in place to assess and document pain and monitor effectiveness of interventions. An interview was conducted with Resident #85 on 05/21/24 at 12:00 PM. The resident stated he was only getting Tylenol for pain, and it was not effective. Record review revealed an order of 05/03/24 for Oxycodone 5 milligrams (mg) every 4 hours as needed for acute pain on a scale of 5-10 out of 10. Further review of the resident's orders revealed an order for Extra Strength Tylenol 500 mg every 6 hours as needle for pain level 3-10. A secondary interview was conducted with Resident #85 on 05/22/24 at 12:30 PM. Resident #85 acknowledged he had pain medicine Oxycodone ordered for pain, but stated the medication had not been available for some time. Resident #85 stated the pain medication had to be reordered and had not come from pharmacy. A review of Resident #85's Medication Administration Record (MAR) revealed the last time the resident was medicated with Oxycodone was on 05/17/24. Further review of the MAR revealed the resident was medicated with Tylenol Extra Strength on 05/17/24, 05/18/24, 05/19/24, 05/20/24, and 05/21/24. Prior to 05/17/24, the resident had not received Tylenol Extra Strength. A review of Resident #85's Medication Monitoring / Control Record revealed the resident ran out of Oxycodone medication on 05/17/24. An interview was conducted with Staff Z, Licensed Practical Nurse / LPN, on 05/22/24 at 12:50 PM. Staff Z stated she realized Resident #85 was out of his pain medication Oxycodone on 05/21/24, and had gotten a prescription and was awaiting the medication to be delivered from pharmacy. Staff Z did not have an explanation as to why the resident was without the pain medication since 05/17/24.

Based on review of policy and procedure, observation, interview and record review, the facility failed to ensure it secured and locked two (2) over-the-counter (OTC) medications and one (1) prescription medication for 3 of 3 sampled residents observed, Resident #63, Resident #79 and Resident #73; and failed to promptly discard one (1) expired OTC medication and one (1) prescription medication for 2 of 3 sampled residents, Resident #63 and Resident #79. The findings included: Review of the facility policy and procedure on 05/23/24 at 11:23 AM, titled, Storage of Medications, provided by the Assistant Director of Nursing (ADON), reviewed May 2022, documented, in part, in the Policy Statement: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications .Procedures: .B. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) are permitted to access medications. Medication rooms, carts and medication supplies are locked when not attended by persons with authorized access .All expired medications will be removed from active supply and destroyed in the facility, regardless of amount remaining. The medication will be destroyed in the usual manner. 1. Record review revealed Resident # 79 was admitted to the facility on [DATE] with diagnoses that included Syncope and Collapse, Cerebrovascular Disease, Urinary Tract Infection, Hypertension, Gastroesophageal Reflux Disease and Epilepsy. The record documented a Brief Interview Mental Status (BIMS) score of 13, indicating cognition was intact. During an initial observational tour conducted on 05/20/24 at 9:57 AM, Resident # 79's room was noted to have a used expired bottle of prescription 10 ml Bausch & Lomb Neomycin Polymyxin B Sulfate and Hydrocortisone Otic Suspension drops with an expiration date of 04/16, located atop the resident's bedside dresser tabletop. It was visible, unsecured and accessible to other residents, staff members and visitors. During a brief interview conducted on 05/20/24 at 9:59 AM with Resident #79 regarding the Otic drops, she stated that she brought the Otic drops from home. She also stated that she uses them every day, if needed. Photographic Evidence Obtained. On 05/20/24 at 3:11 PM, Resident # 79's room was still noted to have the used expired bottle of prescription 10 ml Bausch & Lomb Neomycin Polymyxin B Sulfate and Hydrocortisone Otic Suspension drops located atop the resident's bedside dresser tabletop. An interview was conducted on 05/22/24 at 12:04 PM with Resident #79's nurse, Staff D, Licensed Practical Nurse (LPN), regarding the prescription Otic drop medication bottle observed on Resident #79's bedside table. Staff D acknowledged the medication Otic drop bottle should not have been there. Staff D added this resident does not self-administer any of her own medications and was not assessed to be able to do so. A side-by-side record review was conducted with Staff D, in which it was noted that neither Resident #79's hard copy chart nor her computerized Point-Click-Care (PCC) medical record indicated that the resident had any self-assessment completed in order for her to be able to administer her own medications. On 05/22/24 at 10:06 AM an interview was conducted with Staff D, in which she stated there are only two (2) individual packet types of House stock barrier cream (Periguard Ointment Skin Protectant with Vitamins A, D, E, Aloe Vera and Zinc) or Derma - Fungal Antifungal Cream with 2% Miconazole Nitrate, that the facility utilizes. Staff D added they are kept in the locked Treatment cart and it is distributed to the Certified Nursing Assistants (CNAs) to apply to the residents who have orders for it. Staff D further stated any unused packets of either barrier cream type would be discarded. There was no order on Resident #79's Medication Administration Record (MAR) or Treatment Administration Record (TAR) for this prescription Otic drop medication to be administered to this resident. 2. Record review revealed Resident # 63 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease, Dementia, Malignant Neoplasm of Brain, Nondisplaced Intertrochanteric Fracture of Right Femur and Hypertension. The record documented a Brief Interview Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. During a subsequent observational tour conducted on 05/20/24 at 11:08 AM, Resident # 63's room was noted to have a used expired bottle of OTC Tums with an expiration date of March 2024 located in the second drawer of a small portable rolling cart in her room just across from her bed. It was visible, un-secured and accessible to other residents, staff members and visitors. Photographic Evidence Obtained. On 05/20/24 at 3:29 PM, Resident #63's room was still noted to have the used expired bottle of OTC Tums located in the second drawer of a small portable rolling cart in her room just across from her bed. On 05/21/24 at 11:58 AM, Resident #63's room was still noted to have the used expired bottle of OTC Tums located in the second drawer of a small portable rolling cart in her room just across from her bed. On 05/21/24 at 4:07 PM, Resident #63's room was still noted to have the used expired bottle of OTC Tums located in the second drawer of a small portable rolling cart in her room just across from her bed. During a brief interview conducted on 05/21/24 at 4:15 PM with Resident #63, regarding the Antacid tablets, she stated that she brought the Antacids from home, and she uses them all the time, every day, if needed. On 05/22/24 at 9:50 AM, Resident #63's room still noted to have the used expired bottle of OTC Tums located in the second drawer of a small portable rolling cart in her room just across from her bed. An interview was conducted on 05/22/24 at 12:17 PM with Resident # 63's nurse, Staff D, regarding the expired bottle of OTC Tums medication bottle observed on Resident #63's bedside table. Staff D acknowledged the medication bottle should not have been there. During an interview conducted on 05/22/24 at 12:20 PM with Staff D, for the 1st Unit, she indicated that this resident does not self-administer any of her own medications and was not assessed to be able to do so. A side-by-side record review conducted with Staff D indicated that neither Resident #63's hard copy chart nor her computerized Point-Click-Care (PCC) medical record indicated that the resident had any self-assessment completed in order for her to be able to administer her own medications. There was no order on Resident #63's MAR or TAR for this OTC medication to be administered to this resident. 3. Record review revealed Resident #73 was admitted to the facility on [DATE] with diagnoses that included Cerebral Atherosclerosis, Seizures, Atrial Fibrillation, Dementia, Cerebral Infarction, Malignant Neoplasm of Prostate, Anxiety Disorder and Hypertension. The record documented a Brief Interview Mental Status (BIMS) score of 14, indicating cognition is intact. During a Medication Administration Observation conducted on 05/21/24 at 10:03 AM with Staff D for Resident #73, it was observed that there was a used unsecured jar of House stock OTC Zinc Oxide 20% medicated cream ointment located on the bedside dresser. During a brief interview conducted on 05/21/24 at 10:08 AM with Resident #73, he stated that his sister brought the jar of butt cream in from home. The resident added that the nurses apply this to his skin as he needs it. An interview was conducted on 05/21/24 at 10:18 AM with Resident #73's nurse, Staff E, regarding the House stock OTC Zinc Oxide 20% medicated cream ointment jar observed on Resident #73's bedside table. Staff E acknowledged that it was an OTC medication, and this medicated cream ointment jar should not have been there. On 05/22/24 at 9:28 AM, an interview was conducted with the facility's Lead Pharmacist. She indicated that Zinc Oxide 20% medicated cream ointment is considered to be an OTC medication. During an interview conducted on 05/22/24 at 2:17 PM with Staff F, Registered Nurse / Unit Manager (RN/UM), for the 2nd Unit, he indicated this resident did not self-administer any of his own medications and was not assessed to be able to do so. A side-by-side record review conducted with Staff F indicated that neither Resident #73's hard copy chart nor his computerized Point-Click-Care (PCC) medical record indicated the resident had any self-assessment completed in order for him to be able to administer his own medications. An interview was conducted on 05/22/24 at 12:25 PM with the ADON (Assistant Director of Nursing) , regarding both the OTC and prescription medications observed on Resident #79's bedside table. He acknowledged the OTC and prescription medications should not have been there. The jar of House stock OTC medicated cream ointment was not removed from this resident's bedside until after surveyor intervention. On 05/22/24 at 2:28 PM, the Director of Nursing (DON) further acknowledged and recognized that the OTC and prescription medications should not have been left at either of the resident's bedsides. The DON indicated that all expired medications are to be promptly discarded. She further indicated that the medications should be kept locked at all times. This was not done.

Based on observation, interview, and record review, the facility failed to prepare food in a pureed form designed to meet the needs of 2 of 4 sampled residents of 7 residents with physician ordered pureed diets, Residents #40 and #58, and that included sampled residents, Residents #20, and #373, who were on pureed diets. The census at the time of survey was 108 residents. The findings included: During the review of the facility's Level 4 Pureed Diet, the following were noted: a. Grains - Recommend Pureed soft-cooked hot cereals smooth with no lumps. Served without excess liquid. Do not serve any cooked cereal that is not pureed and has no lumps. b. Pasta - Recommend Pureed moist pasta without lumps. Liquids / sauces do not separate from food. Do not serve and cooked pasta that is not pureed and has no lumps. 1. During the observation of the lunch meal in the main dining room on 05/20/24 at 12:30 PM, it was noted that Resident #40 was served a Pureed Diet. Further observation noted that the pureed Spaghetti was not smooth in texture and there were visible lumps. At the request of the surveyor, a test tray of the pureed lunch meal was requested. The surveyor requested the facility administrator to taste test the pureed meal. The test revealed that the pureed Spaghetti was not smooth in texture and contained numerous lumps and was validated by the Administrator. It was noted that the Administrator went into the kitchen and requested that the pureed spaghetti be prepared to the proper smooth consistency without lumps. 2. During the observation of the breakfast meal on 05/22/24 at 8:15 AM, it was noted that the food tray was served to the room of Resident #58. Observation of the pureed tray noted that the Oatmeal was not smooth in consistency and lumps could be observed. At the request of the surveyor, he met the administrator in the main kitchen to taste test the cooked Oatmeal. The tasting was confirmed, by the surveyor and Administrator, that the cooked Oatmeal was not smooth in consistency and lumps could be tasted in the pureed mixture. The Administrator stated to the surveyor the issues would be corrected immediately. During the review of the facility's Diet Census for 05/20/24, it was noted that there were currently 7 facility residents with physician ordered Pureed Diet which included sampled Resident's #20, #40, #58, and #373. 50895

Based on observation, interview and record review, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior that included 2 of 2 residential areas (Unit 1 and Unit 2) and the facility's laundry department. The findings included: 1. During the initial resident screening conducted on 06/05/23 and the Environment Tour conducted on 06/07/23 at 12:30 PM, accompanied with the facility's Assistant Administrator, and corporate Housekeeping Director, the following were noted the following: (a.) 100 Unit: room [ROOM NUMBER]: The room walls were noted to be damaged and in disrepair and required repainting, an approximate 2 feet of floor damage next to the A-bed, and the exterior of the bathroom entry door was damaged and in a state of disrepair. room [ROOM NUMBER]: The room walls were noted to be damaged and in disrepair, and the exterior of the bathroom entry door was damaged and was in a state of disrepair. room [ROOM NUMBER]: The room walls were noted to be damaged and in disrepair, and the exterior of the bathroom entry door was damaged and was in a state of disrepair. room [ROOM NUMBER]: The exterior of the metal bed frame (B-bed) was noted to be rust laden and areas of peeling paint, large hole in room wall, exterior of the bathroom entry door was damaged and was in a state of disrepair, and bathroom toilet required re-caulking to the floor. room [ROOM NUMBER]: The room walls were noted to be damaged and in disrepair, and the exterior of the bathroom entry door was damaged and was in a state of disrepair, room wall electric light switches (2) were noted to be broken, and dresser drawer (A-bed) was broken and would not shut properly. Room # 108: The room walls were noted to be damaged and in disrepair, and the exterior of the bathroom entry door was damaged and was in a state of disrepair, room wall electric light switches (2) were noted to be broken, and bathroom walls were in disrepair and required re-painting. room [ROOM NUMBER]: The room walls were noted to be damaged and in disrepair, and the exterior of the bathroom entry door was damaged and was in a state of disrepair, room wall electric light switches (2) were noted to be broken, and over-bed light pull cord was missing from A-bed. room [ROOM NUMBER]: The room walls were noted to be damaged and in disrepair, and bathroom toilet was soiled and stained. room [ROOM NUMBER]: The bathroom floor was heavily stained in black color, and room wall electric light switches (2) were noted to be broken. room [ROOM NUMBER]: The room walls were noted to be damaged and in disrepair, and the exterior of the bathroom entry door was damaged and was in a state of disrepair, metal bed frame (B-bed) was stained and rust laden, and over-bed light pull cord was missing from A-bed. Room# 119: The bathroom walls were noted to be damaged and in disrepair, the floor area at the entry to the bathroom was in disrepair and was a fall hazard. room [ROOM NUMBER]: The dresser (B-bed) was soiled with an unidentified white matter. room [ROOM NUMBER]: The floor area at the entry to the bathroom was in disrepair and was a fall hazard. room [ROOM NUMBER]: The bathroom entry door was damaged and was in a state of disrepair. room [ROOM NUMBER]: The bathroom entry door was damaged and was in a state of disrepair, and over-bed light pull cord was missing from B-bed. room [ROOM NUMBER]: The metal bed frame (B-bed) was noted to be rust laden and areas of peeling paint, The bathroom entry door was damaged and was in a state of disrepair, and landing/fall mat (B-bed) was noted to have a large tear and in need of replacement. (b) 200 Unit: room [ROOM NUMBER]: The room electric wall light switches (2) were broken and in need of replacement. room [ROOM NUMBER]: The room electric wall light switches (2) were broken and in need of replacement. room [ROOM NUMBER]: The room electric wall light switches (2) were broken and in need of replacement. room [ROOM NUMBER]: The room electric wall light switches (2) were broken and in need of replacement and exterior of bathroom entry door was in a state of disrepair. room [ROOM NUMBER]: The room electric wall light switches (2) were broken and in need of replacement and exterior of bathroom entry door was in a state of disrepair. room [ROOM NUMBER]: The room entry door was in disrepair. room [ROOM NUMBER]: The room electric wall light switches (2) were broken and in need of replacement, IV Pole (B-bed) was soiled and stained, portable commode seat was rust laden, and the bathroom toilet requires re-caulking to the floor, room [ROOM NUMBER]: The room electric wall light switches (2) were broken and in need of replacement. (c). Main Hallway: The handrail located outside of the entry room to the rehab department was broken and noted to have exposed sharp plastic edges. Following the Environment Tour conducted on 06/06/23, the findings were again confirmed with the administrative staff and were discussed with the facility's Administrator. 45951 2. A tour was conducted of the facility's laundry area with the District Manager over Environmental Services on 06/07/23 at 2:20 PM. Staff F, Laundry Services, was present during this tour as well. There were two washing machines present, both in working order. The District Manager stated the laundry machines are rented and the maintenance is done regularly by the rental company. There were two dryers also present. Both dryers had gaskets which were torn and not in proper working condition Photographic Evidence Obtained. Both dryers had lint traps which were full of lint, despite the documentation that they had been cleaned at 2:00 PM. Photographic Evidence Obtained. After showing the District Manager and Staff F the lint concern, Staff F used a broom and swept the lint trap areas clean. After the tour, the facility's Assistant Administrator brought the surveyor an invoice which stated two dryer gaskets were ordered for the dryers on 06/05/23. The Assistant Administrator did not know when the gaskets would be delivered or installed.

Based on observations, record review and interviews, the facility failed to provide foot care to 4 of 4 sampled residents reviewed for foot care, Residents #7, #28, #54, and #65. The findings included: Review of the facility's policy, titled, Skin Integrity- Foot Care, implemented on 01/2023, documented, in part, .comprehensive assessment will include an assessment of the feet for disorders which may require treatment .nail disorders. Nursing assistants will inspect skin during bath and will report any concerns to the resident's nurse immediately after the task .the attending physician will assume responsibility for the overall care and treatment of the resident's medical conditions . 1. Review of Resident #7's, clinical record documented an admission to the facility on [DATE] with no readmissions documented. The resident's diagnoses included Ataxic (awkward, uncoordinated walking) Gait, Unspecified Mood, Anxiety Disorder and Hereditary and Idiopathic Neuropathy (an illness where sensory and motor nerves of the peripheral nervous system are affected) and Muscle Weakness. Review of Resident #7's Minimum Data Set (MDS) quarterly assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 6 indicating that the resident had severe cognition impairment. The assessment documented under Functional Status that the resident needed extensive assistance from the staff to complete her activities of daily living (ADL's). Review of Resident #7's care plan, titled, [resident's name] presents with a decline in functional mobility and ADL task performance related to generalized weakness . The care plan did not document that the resident refuse toenail care. Review of Resident #7's electronic clinical record under the Miscellaneous section revealed the lack evidence of any uploaded files related to a podiatrist consultation visit. On 06/05/23 at 9:37 AM, an interview was conducted with Resident #7 who stated she has not been seen by a foot doctor. The resident was accompanied by a female and a male who she stated they were her children. The resident allowed for the surveyor to check her feet. Observation revealed elongated toenails with fungus like nails. On 06/06/23 at 2:05 PM, a side-by-side observation and review of Resident #7's toe nails was conducted with Staff A, Licensed Practical Nurse (LPN). Staff A stated definitely the resident needed toenail care. During the review, Resident #7 stated I really do appreciate it, I'm tired at looking at my ugly nails. On 06/06/23 at 2:25 PM, a side-by-side review of Resident #7's uploaded files was conducted with Staff A who stated there was not a podiatrist consult uploaded. On 06/06/23 at 2:45 PM, an interview was conducted with Staff B, Certified Nursing Assistant (CNA), who stated she saw Resident #7's long toenails and did not tell the nurse because the podiatrist comes automatically every two months and sees them. A joint interview was conducted with Staff A, LPN, and Staff B, CNA. Staff A educated Staff B to tell her when the residents' toenails are long so she can tell the podiatrist. On 06/06/23 at 3:42 PM, during an interview, the Assistant Director of Nursing (ADON) stated that as far as she knew, Resident #7 had not been seen by a podiatrist but that she would be contacting the Managed Care insurance's podiatrist to check and see if he had seen her. On 06/07/23 at 8:35 AM, the ADON submitted Resident #7's podiatrist note dated 12/29/22. The note documented .a mechanical and surgical debridement of all nails was accomplished (acc). Provider to return (ptr) in two months. The ADON confirmed that Resident #7 had not been seen since 12/29/22. On 06/07/23 at 8:45 AM, an interview was conducted with the Director of Nursing (DON) who stated that she saw the podiatrist documentation and the unapproved abbreviations. The DON was asked what the facility's protocol was related to foot care. The DON replied there was not a protocol and added that the residents are seen as needed. 2. Review of Resident #28's clinical record documented an admission on 10/25/15 and a readmission on 05/15/17. The resident diagnoses included COPD (Chronic Obstructive Pulmonary Disease), Polymyalgia (muscle pain and stiffness) and Anxiety. Review of Resident #28's MDS's quarterly assessment dated [DATE] documented a BIMS score of 6, indicating the resident had severe cognition impairment. The assessment documented under Functional Status that the resident needed extensive to total assistance from the staff to complete her activities of daily living. Review of Resident #'s care plan, titled, Resident presents with a decline in functional mobility and ADL task performance . initiated on 08/26/19 and revised on 03/17/2, documented an intervention that read .provide daily bed bath . The care plan did not document the resident refused toenail care. On 06/05/23 at 12:02 PM, observation revealed Resident #28 sitting up in a wheelchair in her room. An attempted to interview the resident was made and she was not answering the questions asked. Further observation revealed the resident was using open-toed sandals. The observation revealed Resident #28's feet skin was very dry and scaly with jagged and elongated toenails. On 06/06/23 at 10:34 AM, a telephone interview was conducted with Resident #28's responsible representative who stated the facility was supposed to cut the resident's toenails. On 06/06/23 at 2:01 PM, a side-by-side review and observation of Resident #28's toenails was conducted with Staff A, LPN. Staff A confirmed the resident's toenails were jagged and needed to be trimmed. Staff A stated the resident had very dry skin and needed a good moisturizing lotion. Staff A stated she would check with someone about who would come to do the resident's toenails. On 06/06/23 at 2:13 PM, a side-by-side review of Resident #28's clinical record was conducted with Staff A, who stated the dermatologist saw the resident on 05/09/23 and ordered Triamcinolone for three (3) weeks for a body rash, but no treatment for the resident's scaly/crusted skin of the feet. Continued review revealed a podiatrist consult report, dated 10/06/22. Staff A stated she did not see any other podiatrist's note for Resident #28. On 06/07/23 at 8:38 AM, during an interview, the ADON stated Resident #28 was seen by the Podiatrist on 04/25/23 and that he did not see her on 06/06/23 because it was less than two months. The ADON was apprised of the resident's long and jagged toenails and her toenails should have been done on 06/06/23 when the Podiatrist was in the facility. On 06/07/23 at 8:45 AM, an interview was conducted with the DON who was asked what the facility's protocol was related to foot care and hospice care. The DON replied there was not a protocol. The DON added the residents are seen by the Podiatrist regardless of been on hospice and they are seen as needed even if the insurance did not pay for it, the facility would. The DON was apprised of Resident #28's toenails long and jagged and was not seen on 06/06/23. The DON added this is their home, so the facility would pay for podiatry care if needed. 3. Review of Resident #54's clinical record documented an admission on 11/22/19 and a readmission on 12/03/22. The resident diagnoses included Cerebral Infarction, Type 2 Diabetes Mellitus, Anemia, Depressive Episodes, Gout and Malignant Neoplasm of Prostate. Review of Resident #54's MDS quarterly assessment dated [DATE] documented a BIMS score of 12 indicating that the resident had moderate cognition impairment. The assessment documented under Functional Status that the resident needed extensive to total assistance from the staff to complete his ADLs. Review of Resident #54's care plan, titled, Resident presents with a decline in functional mobility and ADL task performance .initiated on 02/14/22 and revised on 05/11/23, documented an intervention that read .provide daily bed bath . The care plan did not document that the resident refused toenail care. On 06/05/23 at 11:56 AM, observation revealed Resident #54 lying in bed with eyes open. During an interview, the resident was not able to tell if his toenails had been trimmed or not. Resident #54 agreed to have the surveyor look at his toenails. Observation revealed elongated toenails. On 06/06/23 at 1:55 PM, a side-by-side review and observation of Resident #54's toenails was conducted with Staff A, who confirmed the resident had elongated toenails. Staff A stated definitely, his toenails need trimming. Staff A stated the facility had two podiatrists coming to see the residents. On 06/06/23 at 2:25 PM, a side-by-side review of Resident #54's clinical record was conducted with Staff A who stated there was not a podiatrist consult in the resident's record. On 06/06/23 at 2:41 PM, an interview was conducted with Staff C, CNA, who stated that she washed Resident #54 today, and noticed his toenails were long. Staff C stated she was supposed to tell the nurse but had not done so at the time of the interview. On 06/06/23 at 3:42 PM during an interview, the ADON stated that as far as she knew the resident had not been seen by a podiatrist, but she would be contacting the HMO podiatrist to check and see if he had seen the resident. On 06/07/23 at 8:39 AM, the ADON submitted Resident #54's last Podiatrist note which was dated 09/27/22. The note documented patient is type 2 diabetic with severe onychauxis (an overgrowth or thickening of the nail) all nails . mechanical and surgical debridement of all nails was accomplished (acc). Provider to return (ptr) in two months. The ADON confirmed that Resident #7 had not being seen since 09/27/22. 4. Review of Resident #65's clinical record documented an admission on 02/08/23 with no readmissions. The resident's diagnoses included Heart Failure, Anxiety Disorder, Chronic Pulmonary Edema, Dyspnea and Atrial Fibrillation. Review of Resident #65's MDS quarterly assessment dated [DATE] documented a BIMS score of 14 indicating that the resident had no cognition impairment. The assessment documented under Functional Status that the resident needed extensive to total assistance from the staff to complete his ADLs. Review of Resident #65's care plan, titled, Resident's name has an ADL self-care performance deficit related to weakness, poor endurance .on hospice care .initiated on 02/15/23 and revised on 02/23/23, documented an intervention that read .check nail length .on bath days and as necessary. Report any changes to the nurse. The care plan did not document that the resident refused toenail care. On 06/05/23 at 10:10 AM, an interview was conducted with Resident #65 who stated he had not been seen by the foot doctor. Observation revealed elongated toenails. During the resident's interview, a hospice aide came into the room and stated the resident was on hospice and that she has seen the resident 3 times a week to do personal care. On 06/06/23 at 1:45 PM, an interview was conducted with Staff D, CNA, who stated a foot doctor comes to see Resident #65. Staff D was asked if she had seen the resident's toenails and stated she had not seen his toenails in a longtime. On 06/06/23 at 1:54 PM, a side-by-side review and observation of Resident #65's toenails was conducted with Staff A, LPN. Staff A confirmed the resident's toenail were elongated and stated the resident's left foot toenail needed trimming. Staff A added the right foot toenails were up to the flesh. On 06/06/23 at 2:25 PM, a side-by-side review of Resident #65's clinical record was conducted with Staff A who stated there was not a podiatrist consult in the resident's record. On 06/07/23 at 8:35 AM during an interview, the ADON stated Resident #65 was seen by the Podiatrist for the first time on 06/06/23. On 06/07/23 at 10:34 AM, an interview was conducted with Resident #65 who stated the doctor came in on yesterday and cut his toenails.

Based on observations, interviews, and record review, the facility failed to ensure medications were not stored at residents' bedsides for 4 sampled residents, Residents #240, 44, 45, 255; failed to ensure proper medication disposal; failed to maintain medication carts in proper order for 1 of 3 medication carts reviewed for medication storage; and failed to ensure expired medications were properly disposed of in 1 of 1 treatment carts reviewed for medication storage. The findings included: Review of the facility policy, titled, Medication Storage in the Facility, last revised January 2018 revealed the following, in part: Medications and biologicals are stored safely, securely, and properly following manufacturers recommendations. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Outdated medications are immediately removed from inventory, disposed of according to procedures for medication disposal, and reordered from the pharmacy. All expired medications will be removed from the active supply and destroyed in the facility. Review of the facility policy, titled, Disposal of Medications and Medication-Related Supplies, last revised January 2018 revealed the following: Unused, unwanted, and non-returnable medications should be removed from their storage area and secured until destroyed. Mix drugs with an undesirable substance. Put the mixture into a disposable container with a lid. 1. Resident #240's Admission Minimum Data Set (MDS) was In Progress at the time of the survey; and there was no Brief Interview of Mental Status (BIMS) score documented. An Admission Summary Note written on 06/01/23 at 12:28 PM documented Resident #240 was alert and oriented x 3. An observation was conducted on 06/05/23 at 7:59 AM during a medication administration observation for Resident #240 which revealed Resident #240 had a container of Tums on his nightstand. A secondary observation was conducted on 06/07/23 at 3:44 PM of Resident #240 which revealed the Tums bottle was still present on his nightstand. Record review revealed Resident #240 did not have an active order for Tums. No documentation was found of a Medication Self-Administration Assessment in Resident #240's chart. No care plan was found regarding self-administration of medication. A Health Status Note written on 06/07/23 at 9:02 PM documented, Dr. [name documented] on call physician for Dr. {name provided] made aware of resident request to have tums as needed in his profile for potential heartburn/indigestion, see new order. Further record review revealed an order was written on 06/07/23 for Tums. 2. An observation conducted on 06/05/23 at 8:43 AM during the initial tour of the facility revealed Resident #44 had a bottle of Biofreeze muscle relaxer cream on her bedside table and a tube of Hemorrhoid cream next to the toilet in her bathroom. A secondary observation was conducted on 06/07/23 at 3:38 PM of Resident #44 and the muscle relaxer cream was still present on her bedside table and the hemorrhoid cream was still present in her bathroom. Record Review revealed Resident #44 did not have an active order for Biofreeze or Hemorrhoid cream. No documentation was found of a Medication Self-Administration Assessment in Resident #44's chart. No care plan was found regarding Medication Self-Administration. A quarterly MDS was documented on 05/04/23. This MDS documented Resident #44 had a BIMS score of 15, which indicated she was cognitively intact. A Health Status Note written on 06/07/23 at 11:22 PM stated, RESIDENT ROOM CHECKED AND SOME OVER THE COUNTER MEDICATIONS FOUND. RESIDENT MADE AWARE THE FACILITY NOT ALLOW MEDICATION IN THE ROOM AND AGREE TO THE REMOVAL OF ALL OTC MEDICATIONS. Further record review revealed an order was written on 06/07/23 for Hemorrhoid cream and Biofreeze muscle relaxer cream. 3. An observation was conducted on 06/07/23 at 4:06 PM during a medication administration observation which revealed Resident #45 had a tube of medicated skin cream on her bedside table. The name of the cream was written in Spanish, so it was not clear what the cream was for. Record review revealed Resident #45 did not have an active order for medicated skin cream. No documentation was found of a Medication Self-Administration Assessment in Resident #45's chart. No care plan was found regarding Self-Administration of medication. An Admission MDS was documented on 05/25/23. This MDS documented Resident #45 had a BIMS score of 14, which indicated she was cognitively intact. Further record review revealed Resident #45 was going to be discharged home on 06/08/23. 4. An observation was conducted on 06/07/23 at 4:06 PM during a medication administration observation for Resident #255 which revealed Resident #255 had a bottle of Refresh eye drops on her bedside table. Record review revealed Resident #255 did not have an active order for eye drops. No documentation was found of a Medication Self-Administration Assessment in Resident #255's chart. No care plan was found regarding Medication Self-Administration. An Admission MDS was In Progress at the time of this survey; there was no Brief Interview of Mental Status (BIMS) score documented. An Admission Summary Note written on 05/30/23 at 12:56 PM documented Resident #255 was alert and oriented x3. A Health Status Note written on 06/07/23 at 9:03 PM stated, Dr. [name provided] on call physician for Dr. [name provided] made aware of resident request for refresh eye drops three times daily for dry eye syndrome, see new order. Further record review revealed an order was written on 06/08/23 for Refresh Eye Drops. 5. A medication administration opportunity was conducted on 06/05/23 7:46 AM with Staff G, Licensed Practical Nurse (LPN), for Resident #240. While Staff G was preparing Resident #240's medications, one medication capsule fell on to the top of the medication cart. Staff G picked up the capsule and placed it into the garbage on the side of the medication cart. An interview was conducted with Staff G after the medication administration was complete. The surveyor asked Staff G what the proper protocol for disposal of medications was. She stated she would normally crush a tablet and then put it into the garbage can, but since this was a capsule, she just threw it away. When the surveyor asked her about a drug disposal chemical such as Drug Buster, she stated she was unaware of what Drug Buster was. The surveyor then asked the facility's Consultant Nurse if a Drug Buster is kept in each medication cart or in the medication rooms. The Consultant Nurse stated the Drug Buster is kept in each cart; she then looked in Staff G's medication cart and found the Drug Buster container in the bottom drawer of the medication cart. The Consultant Nurse then explained the use of this chemical to Staff G. Staff G donned gloves and retrieved the medication capsule from the medication cart garbage and placed it into the Drug Buster. Interviews were conducted with the facility's Director of Nursing, Administrator, and Assistant Administrator on 06/07/23 at 5:10 PM regarding these observations. They stated they would have staff check each room and remove any found medications. They also stated continuing education would be conducted regarding proper medication disposal. 36057 6. On 06/07/23 at 9:34 AM, a side-by-side review of the facility's unit treatment cart #1 was conducted with the Wound Care Nurse (WCN). The review revealed one Arnica (pain relief gel) tube with an expiration date of 05/2023 for Resident #2. The WCN stated the floor nurses are responsible to check the tube expiration date. 7. On 06/07/23 at 1:17 PM, a side-by-side review of the facility unit two's medication cart #2 was conducted with Staff E, LPN. The medication cart review revealed one loose blue in color capsule, one opened / undated bottle of sterile water, and one unwrapped normal saline syringe of 10 cc with 7 cc left in the syringe. During an interview, Staff E stated she did not use the sterile water or the normal saline. Staff E stated the saline or sterile water are not supposed to be left in the cart once they are opened. On 06/07/23 at 3:45 PM, during an interview, the DON was apprised of the treatment and medication cart findings.

Based on observation, interview, and record review, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety that included; failure to hold hot foods at regulatory temperatures at 135 degrees or greater. This potentially effected 28 facility residents that included sampled Residents #5, #7, #38, #59. and #184. The findings included; During the second Kitchen/Food service observation tour conducted on 02/08/22 at 9:30 AM, it noted that numerous containers of foods were noted to be located on a utility cart near the oven area. Further observation noted that the pans contained : Ground Cooked Beef - 10 portions prepared on 02/07/22. Pureed Chicken - 10 Portions prepared on 02/07/22. Baked Fish - 6 portions prepared on 02/07/22. Baked Potatoes - 8 portions prepared on 02/07/22. At the request of the surveyor the temperatures of these foods were taken by the Corporate Food Service Manager with the use of the facility's calibrated digital thermometer and were recorded as follows; Ground Cooked Beef = 60 degrees F Pureed Chicken = 56 degrees F Baked Fish = 53 degrees F Baked Potatoes = 60 degrees F Interview with the cook at the time of the observation noted that the foods were prepared on 02/07/22 and were going to be reheated and served as menu alternates, mechanical soft, and pureed foods for the lunch meal of 02/08/22. The cook stated that the foods were taken out of the refrigerator and were waiting to reheated for the lunch meal. It was also discussed that potentially hazardous foods are to be held at regulatory temperatures of below 41 degrees F or above 135 degrees F . It was also discussed that foods (Chicken, fish, beef should be prepared daily and not ahead of time and served as left overs. A review of the facility's Diet Census for 02/08/22 noted that there were 21 residents with physician ordered mechanical Soft Diet that included; Residents #5, #59, and #184, and 7 residents with physician ordered pureed diets that included: Residents #7, and #38).

Based on observation and interview, it was determined that the facility failed to dispose of garbage and refuse in a safe and sanitary manor. The findings included: During the observation of the dumpster/refuse area accompanied with the Corporate Food Service Manager on 02/08/22 at 9:30 AM, the following were noted: 1) Upon exit of the rear door of the facility in route to the dumpster area, it was noted that there was an open trash barrel next to the exit door. Further observation noted that the open barrel was full of staff discarded Personal Protection Equipment (PPE) that included masks, gloves, and gowns. The Corporate Director stated that it was not the facility's procedure for disposing of infectious PPE's. The surveyor requested that the barrel contents be safely discarded as soon as possible and educate staff on proper disposal of PPE's. 2) Observation of the dumpster noted that 1 of 2 garbage dumpsters was noted to have a large hole in the bottom right corner. It was also noted that a rag had been placed in the hole. It was discussed with the Corporate Director that the hole was large enough for the entrance of vermin or potential leakage out of the dumpster of garbage/trash. The surveyor requested that the Dumpster Company be contacted immediately for a replacement dumpster. 3) Observation of the dumpsters (2) noted that there was thick build-up of black mold matter between the 2 dumpsters. The surveyor discussed with the Corporate Director that the area is not being being cleaned and sanitized on regular basis. 4) Observation noted that the walk way from the facility exit door to the dumpster (approximately 25 feet) was stained and covered with a thick black mold type matter. It was discussed with the Corporate Director that each time staff walk through the area that mold type matter is transferred into the facility. * Photographic evidence obtained.

Based on observation, interview and review of policy and procedure, it was determined that the facility failed to ensure that it secured medications for Resident #37, during a Medication Pass Observation and properly disposed of over-the-counter (OTC) medication for Resident #13, during an observational room tour. The findings included: 1) On 02/07/22 at 9:50 AM during a Medication Administration Observation, it was noted that there were three (3) unidentified, loose pills---one (1) orange and two (2) pink on Resident #37's floor, one (1) near the doorway and two (2), near her bedside table, unsecured and accessible to other residents, staff and visitors. Resident #37 was originally admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She had a Brief Interview Mental Status (BIM) score of 6 (severely impaired). Photographic evidence obtained of the three (3) loose, unidentified pills located on the floor in Resident #37's room. On 02/07/22 at 9:52 AM an interview was conducted with Staff A, a Registered Nurse (RN), in which she acknowledged that the pills should not have been there and should have been discarded. 2) During an observational room tour conducted on 02/07/22 at 11:15 AM of Resident #13's room, it was noted that there was a container of (OTC) vaporizing Chest rub sitting on Resident #13's bedside table; the container had no expiration date on it. And, in Resident #13's bathroom located on the over-sink shelf, it was noted that there was a one-half (1/2) used bottle of (OTC) Sore Throat Spray with an expiration date of 07/23, also unsecured and accessible to other residents, staff and visitors. Resident #13 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #13 is currently out of the facility since 02/02/22 after transfer to Hospital with a determined diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She had a Brief Interview Mental Status (BIM) score of 13 (cognitively intact). Photographic evidence obtained of the container of (OTC) Chest rub on the resident's bedside table and (OTC) Sore Throat Spray in the resident's bathroom. On 02/07/22 at 12:47 PM it was still noted that there was a container of vaporizing Chest rub sitting on Resident #13's bedside table and it was also still noted on the over-sink shelf, that there was a one-half (1/2) used bottle of Sore Throat Spray. On 02/07/22 04:08 PM it was still noted that there was a container of vaporizing Chest rub sitting on Resident #13's bedside table and it was also still noted on the over-sink shelf, that there was a one-half used bottle of Sore Throat Spray. On 02/08/22 at 10:30 AM An interview was conducted with Staff B, a Licensed Practical Nurse (LPN), in which she acknowledged that neither the chest rub medication nor the sore throat spray bottle, should have been there and should have been properly stored/secured. 3) On 02/07/22 at 3:56 PM during an evening observational tour, it was noted that there was a single, loose, unidentified green pill located on the floor of unit two (2) in the 100's unit hallway leading down to the resident rooms. The pill was unsecured and accessible to residents, staff members and visitors. Photographic evidence obtained of the loose, unidentified green pill on the 100-unit hallway. During an interview conducted on 02/07/22 at 4:06 PM with Staff C, an (LPN) she indicated that the pill looks like a green iron tablet and she acknowledged that the pill should not have been there and should have been properly discarded. On 02/08/22 at 12:02 PM an interview was conducted with the Director of Nursing (DON) and she further acknowledged that the loose pills should have been discarded and that the chest rub medication and the sore throat spray bottle, should not have been there and should have been properly stored/secured. Review of facility policy and procedure for Medication Storage in the Facility---Storage of Medications, provided by the Director of Nursing (DON), dated April 2018 Policy: Medications and biologicals are stored safely, securely and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.

Based on observation, interviews and record review, the facility failed to identify unkempt fingernails for 1 of 1 sampled resident reviewed for Activities of Daily Living, (Resident #42), as evidenced by failing to address Resident #42's long fingernails; and failed to timely assist Resident #42 during dining observations. The findings included: 1. Record review of Resident #42 showed that he was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Care Plan, dated 02/21/20, showed that Resident #42 has Activities of Daily Living (ADL) self-care performance deficit related to Disease Process ([DIAGNOSES REDACTED]. It further showed that Resident #42 needs to be assist with all ADL tasks: toileting, dressing, and bathing. In an observation conducted on 02/08/21 at 9:40 AM, Resident #42 was noted in bed resting comfortably. Closer observation showed long unkempt fingernails with unidentified matter underneath the fingernails. The fingernails were observed to be digging into the palm of the resident's left hand. In this observation, Resident #42 stated that his fingernails were too long, and he wanted them trimmed and cleaned. When asked if he told staff that he wanted his nails trimmed he said yes. In an observation conducted on 02/09/21 at 11:00 AM, Resident #42 was noted in bed resting comfortably. Closer observation showed long unkempt fingernails with unidentified matter underneath the fingernails. In an observation conducted on 02/10/21 at 11:00 AM, Resident #42 was noted in bed resting comfortably. Closer observation showed long unkempt fingernails with unidentified matter underneath the fingernails. Record review of the personal hygiene self-performance, done under tasks showed that Resident's #42 received grooming from 01/27/21 to 02/09/21 with total dependence on staff. Closer review showed that the task for grooming does not have a specific section for fingernails grooming. In an interview conducted on 02/11/21 at 9:45 AM, with Staff E, Certified Nurse Assistance, reported that she will cut and trim residents' fingernails when needed. She further stated that she will clean underneath the nails and will let the nurse know so she can document in her notes. When asked if Resident #42 needed his nails trimmed, she was not sure. In this interview, Staff E was asked to accompany surveyor into Resident #42's room. Resident #42 was observed sitting in his wheelchair comfortably. Closer observation showed that his fingernails were cut and trimmed. Resident #42 reported that his nails were cut and trimmed last night. In an interview conducted on 02/11/21 at 1:00 PM, with the facility's Administrator, she was told of the findings. 2. Review of the Resident #42's Minimum Data Set (MDS) annual assessment, dated 12/18/20, Section C showed that Resident #42 has a Brief Interview of Mental Status (BIMS) score of 15, indicating the resident is cognitively intact; and Section G for eating showed that Resident #42 can eat independently with set up only. Further review of the Quarterly MDS, dated [DATE], showed that for Section G, eating, Resident #42 needs extensive assist with one-person assist. In an observation conduced on 02/08/21 at 11:46 AM, Resident #42 received his lunch tray. Staff A, Certified Nurse Assistant (CNA) set up his tray and left the room. Resident #42 was observed trying to eat on his own and at times having difficulties grabbing the food with his adaptive devices. During this observation, Resident #42 asked for assistance with his lunch tray from the surveyor while in the room. He stated that he needs help with his tray. In a continued observation at 12:20 PM, Resident #42 was attempting to eat his lunch meal with no assistance from staff. Closer observation of the tray showed that he ate only 10% of his lunch meal. At 12:33 PM, Staff A was observed in the room helping the resident with his lunch meal, soda and ensure (nutritional supplement). Resident #42 then ate another 30% of his meal, did not touch his magic cup ice cream and drank some of his ensure supplements. In an interview conducted on 02/08/21 at 12:35 PM, with Staff A, CNA, she reported that Resident #42 can eat on his own, but he needs help with his meals from time to time. She further stated that she usually helps other residents with their meal trays one at a time, and when she is done, she will check on Resident #42 to see if he needs assistance and encouragement with his meals. She further stated that he will eat more of his meals when helped by staff. In an observation conducted on 02/09/21 at 9:10 AM, in Resident #42's room, Staff B, Certified Nurse Assistant (CNA) was observed in the room assisting Resident #42 with his breakfast meal while standing over the side table. Further observation showed that his breakfast tray consisted of eggs, croissant, and bacon. Staff B was adding and guiding the adaptive devices towards Resident #42's mouth. She was often observed queuing and encouraging Resident #42 with his breakfast meal. In this observation, Staff B reported that she has worked in the past with Resident #42 in the other Wing, and that he needed help with his meals. She further stated that currently Resident #42 needs extensive assistance with all his meals. Staff B reported that he will eat most of his meals when he is helped by staff. In an interview conducted on 02/10/21 at 12:30 PM, Staff E, Minimum Data Set (MDS) Coordinator, was asked as to what the expectations for a resident who is coded independent for eating and extensive assistance for eating. She reported that only set up is needed with a resident who is independent, and they are left alone with their meals. For a resident who needs extensive assistance with eating, a staff member needs to be in the room at all time to guide the spoon or help bring the utensils towards the mouth. According to her, some residents may get tired halfway or may not be able to eat independently for the entire meal. When asked as to why Resident #42 is coded as independent for eating, she stated that he may have gotten worse and may needed to be reassessed.

Based on observation, Interviews and record review, the facility failed to ensure that 1 of 1 sampled resident reviewed for hearing (Resident #15) received the timely treatment and assistive devices to maintain hearing and prevent decline in a timely manner as necessary. The findings included: Resident #15 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), Annual, dated 11/03/20 for Section C, documented a Brief Interview of Mental Status (BIMS) score of 15, indicating the resident is cognitively intact. In this MDS, the Section B for hearing showed that Resident #15 has moderate hearing loss with no hearing aids in place. Review of the Care Plan, dated 02/04/21, documented that Resident #15 has potential for communication / comprehension problem related Hearing deficit, tone of voice needs to be adjusted depending on environment; Has tendency for increased cerumen build up and an audiology consult was done on 10/29/20 for hearing aids. It further documented that a hearing aid evaluation was also done on 02/04/21. In an interview conducted on 02/08/21 at 9:40 AM, with Resident #15, she reported that she cannot hear anything in her right ear. When asked by surveyor about her left ear, she reported that it is not as good either. She further reported that she told the facility around October 2020 that she has had severe hearing loss and was seen by a doctor but did not hear anything from the facility. She also stated that she was seen by another doctor a few days ago, but nothing has been done so far. Resident #15 stated I want to be able to hear already to surveyor in the room. During this interview the surveyor had to alternate between writing the question on a piece of paper and speaking out loud for the resident to be able to answer some of the questions. Progress notes, dated 11/02/20, showed that Resident #15 was seen by an Audiology Physician 10/29/20. The documentation included: 'Cerumen was removed in both ears without incident. Audiometric testing revealed moderate sensorineural hearing loss in both ears. Re-evaluate hearing as needed. Discussed results and recommendations with patient/staff. Per report resident is a candidate for hearing aid per approval by (company name).' Review of progress note by the facility's Social Worker (SW), dated 01/14/21, showed that the Social Worker was informed by the same Audiology Physician that Resident #15 was unable to proceed with hearing aids because she was not an Optum provider. The Resident's son was contacted regarding his mother going to another Audiology consultant, but he has declined an outpatient audiology visit at this time. In this note, the Social Worker was going to follow up with another company. Review of progress notes, dated 02/04/21, by the Social Worker showed that Resident #15 was evaluated for hearing aids by the 3rd company that was contacted. It further showed that the delivery date for hearing aids could be between 1-3 months contingent upon Medicaid's processing time. The SW was going to follow up as needed. Further record review of the MDS Quarterly, dated 02/17/20, showed that for Section B for hearing, Resident #15 is with minimal difficulties. In an interview conducted on 02/10/21 at 7:50 AM, with Resident #15 she reported that she was not told by the Social Worker regarding the progress of the hearing aids. The surveyor attempted to yell the questions but Resident #15 became frustrated and said, I cannot hear anything you are saying The surveyor wrote the questions on a piece of paper. When asked how you communicate with staff in the facility, she stated that they get angry with her when she cannot hear some of the things they may say. When asked if the facility tried to provide her with other ways to communicate, she said no. Resident #15 further reported that this has been going on for some time and nothing has been done. In an interview conducted on 02/10/21 at 8:00 AM, with Staff C, Registered Nurse, she reported that she has been working in the facility for a long time and is familiar with Resident #15. When asked if Resident #15 has hearing problems, she said that she does not and that she can hear everything well. In an interview conducted on 02/10/21 at 8:07 AM, with Staff D, Certified Nurse Assistant, she reported that Resident #15 can hear very well and that she is not aware of any hearing issues. Staff D also reported that Resident #15 told her that she had an assessment for her hearing, but she could not recall what she told her. In an interview conducted on 02/10/21 at 8:13 AM with the Director of Social Services, she reported that when residents complain of hearing issues, she will make an appointment for an audiology evaluation. After they get assessed by the audiology/doctor, she will find out almost immediately if the resident will benefit from a hearing aids and if the resident's insurance will pay for the hearing aids. If the hearing aids are not covered, she will use other companies, such as the 2 additional companies notified above. She further stated that other hearing options may be offered to residents while waiting for hearing aids such as communication board, and an amplifier. When asked if Resident #15 was offered any of the above options she said 'yes'. She said she told Resident #15 and her son that they are waiting on the hearing aids and it may take 1-3 months. The Social Worker stated that since the pandemic they were not allowing some consultants into the facility. When asked as to why it took from October of 2020 to January 2021 to find out the Resident #15's insurance will not cover for the hearing aids provided from the 1st Audiology Physician, she reported that since the pandemic things have been running slower than usual. Once she found out by the company that the hearing aids were not going to be covered by her insurance, she tried looking for other options. In a phone interview conducted on 02/10/21 at 8:00 PM, with Resident #15's son, he reported that the facility's Social Worker (SW) called him weeks ago to let him know that his mom's insurance will not cover the hearing aids. He further stated that the SW told him that the only option left for him was to take his mom to see an Audiologist privately. According to the son, the SW never told him of other options that can be done so his mom can better communicate with staff. Resident #15's son stated that the SW worker told him that would update him, when she is able to find another company that will cover the cost of the hearing aids. She never contacted him with the updates, and he had to call the social worker multiple times for the updates. In an interview conducted on 02/11/21 at 9:25 AM, with Staff E, Minimum Data Set (MDS) Coordinator, she reported that the care plan for communication was not updated until 11/17/20 which was a little later according to her. This change was not reflected on the care plan until 02/04/21. In an interview conducted on 02/11/21 at 10:19 AM, with the facility's Speech Language Pathologist (SPL), she reported that she could provide Resident #15 with an amplifier so she can use it until her hearing aids arrived. In an interview conducted on 02/11/21 at 1:00 PM, with the Administrator she was told of the findings.

Based on observations, interviews and record review, the facility failed to ensure that 3 of 3 sampled residents reviewed for positioning and mobility with contractures, were consistnetly provided with splints to prevent decline in range of motions for (Resident #42, Resident #63 and Resident #37). The findings included: 1. Record review of Resident #42 documented that he was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review conducted on 02/08/21 at 1:30 PM, showed that Resident #42 had a Physician's order for 'Left-hand roll at all time except for Activities of Daily Living (ADL) activities'. On 02/09/21 at 9:00 AM, review of Physician's Orders showed an another order for Adaptive Equipment bilateral hand-roll on at bedtime and off in AM, dated 01/16/20. In an observation conducted on 02/08/21 at 9:45 AM, Resident #42 was noted resting in bed. Further observation showed a left-hand splint device on the side table near Resident #42. In an observation conducted on 02/08/21 at 11:46 AM, Resident #42 was observed sitting in his wheelchair with the lunch tray in front of him. Closer observation showed a left-hand splint device on his left hand. In an observation conducted on 02/08/21 at 3:15 PM, Resident #42 was observed resting comfortably in bed. Closer observation showed a left-hand splint device on his left hand. Review of the Minimum Data Set annually12/18/20 section C showed that Resident #42 has a Brief Interview of Mental Status (BIMS) score of 15 which is cognitively intact. Record review of the care plan, dated 12/21/20, documented that Resident #42 wass to have adaptive equipment of a left-hand ulnar deviation splint on during daytime and removed in the evening. It further showed that Resident #42 has altered ADL (activity of daily living) mobilities and functions. Review of the Certified Nurse Assistant (CNA) task for adaptive equipment showed that between 01/27/21 to 02/09/21, Resident #42 was provided with bilateral hand roll on at bedtime and off in AM. In an interview conducted on 02/10/21 at 9:30 AM, Staff A, Certified Nurse Assistance, she reported that Resident #42 needed to wear his splint on during the day. She waits until she is done with morning care to place the device on his hand. In an interview conducted on 02/10/21 at 1:35 PM, Staff E, Occupation Therapist, she reported that Resident #42 has a hand roll splints for both hands at bedtime and non in the daytime. She further stated that the splints are used to prevent further skin breakdown, proper alignment, and further contractures. Record review of the therapy screen completed by Staff E, showed that it was recommended to discontinued left ulnar deviation splint and Resident #42 was instructed to use bilateral hand rolls at night. In an interview conducted on 02/10/21 at 2:00 PM with Resident #42, he reported that he must wear the left-hand splint during the day. In this interview, the surveyor noted the left-hand splint was on the side table. Resident #42 stated that he just took it off and will wear it again as it needs to be on all day. 2. Resident #63 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. In an observation conducted on 02/08/21 at 1:40 PM, Resident #63 was observed asleep in bed with no staff in the room. Further observation showed a left-hand roll device on the side table near Resident #63. Review of the Physician's order dated 01/21/21 showed an order for [REDACTED]. Review of the annual Minimum Data Set (MDS) of 01/04/21, Section C showed that Resident #63 has a Brief Interview of Mental Status (BIMS) score of 05, which is severe cognitive impairment. In an observation conducted on 02/08/21 at 3:25 PM, Resident #63 was observed asleep in bed. Further observation showed the left-hand roll at the side table. No staff were observed in the room. Review of the care plan, dated 01/11/21. documented that Resident #63 has a decline in functional mobility and activity of daily livings task performance, and she required extensive to total assistance, related to major [MEDICAL CONDITION], medical history of [REDACTED]. In this care plan, it was noted that on 01/09/20, Resident #63 was holding her left hand closed and did not want to open it. An Occupational (OT) screenimg was done for limited range of motions and a left-hand resting and splint with hand roll was provided for contractures and to decrease [MEDICAL CONDITION]. In an interview conducted on 02/10/21 at 9:30 AM, Staff A, Certified Nurse Assistance, reported that Resident #63 needs to wear her left-hand splint on during the day. She waits until she is done with morning care to place the device on her hand. In an interview conducted on 02/10/21 at 1:35 PM, Staff E, Occupation Therapist, reported that Resident #63 has a left handroll device that is used at all time except during hygiene and bathing time. She further reported that Resident #63's hand is tight and non-functional, and the splint is used to prevent skin breakdown. 3. Resident #37, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During an observational tour on 02/08/21 at 10:19 AM, Resident #37 was observed with a right-hand contracture (limited range of motion) and no splint in place. The resident's right-hand splint was noted sitting on the resident's bedside dresser top. The right-hand splint was observed on the dresser for approximately 20 minutes and not applied/put in position for the resident. The resident was not currently receiving Activities of Daily Living (ADL) / personal care by staff and he was not being actively bathed, at this time. There was there not any other type of device or appliance put in place as a substitute for the resident's right-hand splint. (Photographic evidence obtained of: Resident#37's right-hand splint sitting on his nearby dresser top). An interview was conducted with Staff K, a certified nursing assistant (CNA), on 02/08/21 at 11 AM, regarding the timing of Resident#37's (ADL) care and she acknowledged that the resident's shower days and times are Monday and Thursday on the 3 PM-11 PM, evening shift; with bed baths during the day on the five (5) other days of the week. An observation was conducted on 02/09/21 at 9:38 AM of Resident #37, who was observed sitting up in bed with the head of bed elevated, but again it was noted with his right hand splint was sitting on his bedside table. The right-hand splint was again observed on the bedside table for a minimum of 20 minutes, and not applied/put in position for the resident. The resident was not currently receiving (ADL) / personal care by staff and he was not being actively bathed at this time. There was no other type of device or appliance put in place as a substitute for the resident's right-hand splint. During an interview conducted on 02/09/21 at 11 AM, with Staff K, a CNA, regarding when she had provided (ADL) personal care to Resident #37, she replied that she had just provided personal AM care to this resident. She acknowledged that the resident's right-hand splint should be worn, at all times, except when personal (ADL) care is being provided to the resident. A computerized record review was conducted of Resident#37's physician order dated 01/21/21 for: Adaptive equipment: rolled up wash cloth or hand roll to right hand per resident's preference, on at all times, remove for (ADL) s and bathing. A computerized record review conducted of Resident #37's CNA tasks and showers listed the following tasks as being checked/signed off as: yes, for completed for 'Adaptive equipment: rolled up wash cloth to right hand per resident's preference, on at all times, remove for ADL's and bathing, revised 11/18/20'. The resident's showers were scheduled (Monday/Thursday 3PM-11PM). During a computerized record review conducted of Resident#37's care plan, dated 12/03/20 and revised 01/21/21, for Right hand contracture indicated Adaptive equipment: rolled up wash cloth to right hand per resident's preference, on at all times, remove for ADL's and bathing. On 02/11/21 at 10:48 AM, an interview was conducted with the Director of Rehabilitation Services Occupational Therapist (OT), in which she stated that Resident #37 had been receiving Occupational Therapy (OT) 11/17/20 - 11/18/20 and 11/23/20 - 11/28/20; three (3) times per week; and Speech Therapy (ST) 05/29/20 - 06/04/20; three (3) times per week. She said that the resident had been re-evaluated for (OT) in order to assess a right contracture following a Cerebral Infarction on 09/16/16. Throughout the therapy, the Director said that they addressed his right hand splint device, which was ordered to be worn at all times and to remove for hygiene. She said the goal was met of tolerating the splint for this amount of time during the day. The Director stated that upon discharge from (OT) on 11/28/20, a summary was generated for Resident #37 which indicated that he was referred to the Restorative nursing program for hygiene hand care and contracture management. The Director added that the right-hand splint application was to be done at all times by both restorative and nursing. The Director acknowledged the location of Resident#37's splint, both days, on the bedside dresser table and not on the resident's person/hand, based upon photographic evidence viewed/presented to her. She emphasized that it is imperative that this right-hand splint remain in place at all times during the day when not receiving personal care to avoid any type of skin breakdown. During an interview conducted on 02/11/21 at 11:40 AM, with Staff K, a CNA, regarding when she had provided (ADL) personal care to Resident #37, and she replied that she had just provided personal AM care to this resident and she acknowledged the location of the Resident#37's splint, both days, being on the bedside dresser table and not on the resident's person, based upon photographic evidence viewed/presented to her. She acknowledged that the resident's right-hand splint should be worn at all times, except when personal (ADL) care is being provided to the resident. An interview was conducted with Staff M, a Licensed Practical Nurse, (LPN), on 02/11/21 at 11:50 AM regarding Resident #37's right-hand splint orders. She acknowledged the location of Resident #37's splint, both days, being on the bedside dresser table and not on the resident's person, based upon photographic evidence viewed/presented to her. She also acknowledged that the resident's right-hand splint should be in position and in place at all times, except when personal (ADL) care is being provided to the resident. On 02/11/21 at 12:07 PM, an interview was conducted with both the Assistant Director of Nursing (ADON), Unit Manager for the 100-hallway, and with the Director of Nursing (DON). They both acknowledged the location of Resident #37's splint, both days, being on the bedside dresser table and not on the resident's person, based upon photographic evidence viewed/presented to them. They further acknowledged that Resident #37's right hand-splint should have been applied at all times, according to the physician's order and the facility's care plan. This was not done. Review of the facility policy and procedure on 02/11/21 at 12:30 PM for Range of Motion (ROM) Splints, Braces, Orthotics provided by the DON indicated that Residents identified as a risk for contractures will have a ROM program. The ROM includes the programs provided to prevent contractures and keep joints as limber as possible .Splints, braces and orthotics will be applied according to manufacturer instructions and/or instructions from physical and occupational therapy. Purpose: to maintain a resident's ability to move a joint through its normal range of movement and perform activities of daily living (ADL). To prevent pain, discomfort, swelling and stiffness when joint movement is limited or contracted Splint/Braces Orthotics .Follow the device schedule according to therapy instructions .Document according to facility protocol. Follow applications of splints, braces, orthotics according to manufacturer's Physical and Occupational Therapy instructions.

Based on observation, interview and record review, the facility failed to provide catheter care in a manner to prevent urinary tract infections for 1 of 1 sampled resident reviewed for Urinary Catheter/UTI (urinary tract infection), Resident # 473, as evidenced by failing to follow the facility Catheter Care Policy. The findings included: Review of the facility's Catheter Care Policy, date implemented 09/2019, on page 1 of 2, documented the following: under Policy: It is the policy of the facility to provide catheter care to all Residents that have an indwelling catheter to reduce bladder and kidney infection. Female: 10. Gently separate the labia to expose the urinary meatus. 11. Wipe from front to back with a clean cloth moistened with water and perianal cleaner (soap). 12. Use a new part of the cloth or a different cloth for each side. 13. With a new moistened cloth, starting at the urinary meatus moving out, wipe the catheter making sure to hold the catheter in place to not pull on the catheter. 14. Dry area with towel. Review of the clinical record for Resident # 473 revealed the resident was readmitted to the facility on [DATE] with pertinent [DIAGNOSES REDACTED]. Review of a care plan, dated 02/8/21, documented the following: Focus: Resident # 473 has, and Indwelling Catheter related to [MEDICAL CONDITION] Goals: The resident will be/remain free from catheter-related trauma through review date. The resident will show no sign and or symptoms of Urinary infection through review date Interventions: Change Indwelling catheter as needed for leakage or blockage The resident has a 16FR/10CC Indwelling Catheter. Position catheter bag and tubing below the level of the bladder and away from entrance room door. Monitor/document for pain/discomfort due to catheter. Monitor/record/report to Medical Doctor (MD) for signs and or symptoms urinary tract infection [MEDICAL CONDITION]: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Clinical record review of Resident # 473 revealed a physician order, dated 02/05/21, that documented: Indwelling Urinary Catheter care every shift, discontinued 02/10/21. Another physician order, dated 02/10/21, documented: urine for urine analysis (UA) and culture and sensitivity (C&S) in the AM. During an observation on 02/08/21 at 11:58 AM, Resident #473 was sitting in her wheelchair in her room with her indwelling catheter with the bedside drainage bag hanging on the right side of her wheelchair below the resident's bladder. The indwelling catheter was draining clear yellow urine. During an observation on 02/09/21 at 1:12 PM, Resident #473 was lying in her bed with her indwelling catheter and the bedside drainage bag was clipped on the side of bed below the resident's bladder. The indwelling catheter was draining clear yellow urine. During an observation on 02/10/21 at 9:06 AM, Resident #473 was lying in her bed with the indwelling catheter and the bedside drainage bag was clipped to the side of the bed below the resident's bladder. The indwelling catheter tubing was observed to have sediment in it. During an observation on 02/10/21 at 2:24 PM of Staff N (certified nursing assistant/CNA) performing catheter care on Resident #473 revealed the following: Staff N was wearing personal protective equipment that included a gown, a face shield, a surgical mask, and gloves. She gathered the following supplies: warm soapy water, Procare large adult washcloths and a 1 bath towel. Staff N asked permission of the resident to clean her catheter and peri area, to which the resident agreed. Staff N then removed the blankets from the resident and covered her with a bath towel, partially removing the adult brief. Staff N used one Procare large adult washcloth, without putting it in the soapy water and wiped the catheter starting about 6 inches from the resident wiping toward the resident's peri area. Once Staff N got to the resident's peri area, she continued with the same washcloth, without folding it or using another part of the washcloth, and cleaned both sides of her peri area in an up and down motion, starting from the back of the peri area to front of the peri area. She then dried the area with the bath towel. Staff N then finished removing the adult brief, removed gloves excused herself to retrieve an adult brief, washed her hands, and put gloves on. Upon returning to the resident, she asked the Resident if she was ok. Staff N then put the clean adult brief on the resident and covered her with blankets. Next Staff N emptied the indwelling bedside drainage bag, while placing the bag above the resident's bladder. Staff N removed her gloves and washed her hands. On 02/10/21 at 2:48 PM, during an interview with Staff N, she was asked if there were any concerns with the resident's urine. Staff N replied 'no, there is nothing wrong with her urine, it isn't cloudy or anything'. The surveyor pointed out that there was sediment in the tubing of the indwelling catheter. Staff N looked at the tubing and agreed there was sediment in the tubing and stated she would notify the nurse. Staff N stated this is how she does the catheter care. On 02/11/21 at 9:40 AM, during an interview with Staff O, a CNA, she stated that she has been employed with facility for [AGE] years and she was in-serviced on catheter care when she first came here and every so often but doesn't know the dates or exactly how often. The facility also provides in-services on catheter care if anything changes. She stated she wipes the catheter tubing away from the resident and the drainage bag should never be above the Resident's bladder. On 02/11/21 at 10:04 AM during an interview with the Director of Nursing (DON), the DON stated Certified Nursing Assistants (CNAs) get in-serviced on catheter care when they first get hired and they get in-serviced on catheter care usually annually after that.