Every finding on record at St. Mary's Hospital

Based on document review and staff interview, the facility failed to check the nurse-aide registry when ancillary are first hired. This was true for 2 of 2 ancillary staff. Facility census 13.a) On 04/14/2026 at approximately 1:10 p.m., there was no documentation readily available for Maintenance Tech #45 and Housekeeper #46 that the employees were checked on the Nurse Aide registry. b) On 04/14/26 at approximately 1:13 PM, conducted an interview with the HR Generalist and Educator (Employee #44) for the unit. Employee #44 stated that they do not check the Nurse Aide registry with ancillary staff (Maintenance Tech #45 and Housekeeper #46). The deficiency was verified with the HR Generalist and Educator along with unit Clinical Manager. c) On 04/15/26 at approximately 2:30 p.m., the deficiency was acknowledged by the unit's Administrative staff upon the exit interview.

Based upon observation and staff interview, the facility failed to properly store pre-cooked breakfast sausage links by not providing an expiration date after opening and removing the product from its original packaging. This had the potential to affect residents of the facility who might consume this breakfast sausage. Facility census: 12. Findings included: During observation of the kitchen freezers and refrigerators on 02/25/25 around 11:00 AM, a partial bag of opened, pre-cooked breakfast sausage links was found on the top shelf of a cart in one of the walk-in refrigerators. The bag contained no expiration date. When this was pointed out to the Dietary Director, he immediately threw the bag into the trash.

Based on record review, review of skilled nursing unit's NA Role Profile Summary, and staff interview, the facility failed to ensure the staff had the competencies and skill sets necessary to provide nursing and related services to meet the residents' needs. This was true for four (4) of seven (7) nursing staff reviewed for competenencies. Staff Identifiers: NA #12, #45, #2, and #13. Facility census: 12. Findings included: a) NA Role Profile Summary: NA Role Profile Summary dated 01/10/18 revealed HSAF.-16015 Personal Protective Equipment Demonstrates appropriate selection of personal protective equipment (PPE). Identifies and observes the requirement to select, apply and remove the appropriate PPE for personal and patient safety HPSG-16183 Hand Hygiene Complies with current World Health organization (WHO) hand hygiene practices NRSPRO-13769 Urinary Catheter Care Performs perineal and catheter care .HSAF-15943 Infection Control Follows organization's infection control olicies and procedures, including proper hand hygiene. b) NA #12: NA #12 had no competencies for Donning and Doffing of Personal Protective Equipment (PPE), Infection Control, Peri-Care, or Hand Hygiene. c) NA #45: NA #45 had no competencies for Donning and Doffing of Personal Protective Equipment (PPE), Infection Control, Peri-Care, or Hand Hygiene d) NA #2: NA #2 Had no competencies for Donning and Doffing of Personal Protective Equipment (PPE), Infection Control, Peri-Care, or Hand Hygiene e) NA #13: NA #13 had no competencies for Peri-Care, or Hand Hygiene During an interview on 2/26/25 at approximately 2:00 PM with Clinical Manager #6, she acknowledged these should have been done. She did not do any of these in 2024, but had done them in last few years. A review of the competencies from the personnel files revealed these competencies had not been completed since 2019.

Based upon record review and staff interview, the facility failed to provide twelve (12) hours of in-service training for nurse aides to include dementia, or specific care to the unit's resident population This was true for five (5) of five (5) Nurse Aides (NAs) reviewed. Staff identifiers: NA #3, #12, #45, #2, #13. Facility census: 12. Findings included: a) NA #3: Education report showed a total of 5 hours of education for 2024, and did not contain education on dementia care. b) NA #12: Education report showed a total of < 5 hours of education for 2024, and did not contain education on dementia care. c) NA #45 Education report showed a total of < 5 hours of education for 2024, and did not contain education on dementia care. d) NA #2 Education report showed a total of < 5 hours of education for 2024, and did not contain education on dementia care. e) NA #13 Education report showed a total of 10.8 hours of education for 2024, and did not contain education on dementia care. On 02/26/25 at approximately 1:10 PM, an interview was conducted with Clinical Manager #6 regarding education for the NAs. When the Clinical Manager #6 was asked if there were any additional education or in-services provided to the NAs that were not on the education records; she responded, I normally have additional in-services for the staff, but 2024 was crazy for me and I did not get to hold any.

Based on observations and staff interview, the facility failed to provide a clean, comfortable home like environment by having debris in the return vents in Resident's #109 room and Resident's #108 room and bathroom. This was a random opportunity for discovery during the long term care survey process. Resident identifier: #108 and #109. Facility census: 12. Findings included: a) Resident #108 On 02/26/25 at 12:59 PM during the initial tour of the facility, it was observed that Resident #108 bathroom and room had vents full of debris and needed to be cleaned. b) Resident #109 On 02/26/25 at 1:15 PM during the initial tour of the facility, it was observed in Resident # 109 room had vents full of debris and needed to be cleaned. On 02/26/25 at approximately 2:00 PM, during an interview with the Clinical Manager #6, who confirmed the vents needed cleaning, and contacted maintenance.

Based on record review and staff interview, the facility failed to complete the WV Cares report prior to new staff reporting to work. This was found to be true for three (3) of eight (8) staff files reviewed. Staff identifiers: #37, #3, and #12. Facility census: 12. Findings included: a) Dietician #37 Dietitician #37 started to work on 08/12/24. WV Cares investigation was never completed. During an interview with the Clinical Manager #6 on 2/26/25 at approximately 9:35 AM, the Manager stated, I forgot to do the WV Cares upon her transfer from the Dietary Department to the Skilled Nursing Facility (SNF). b) NA #3 NA #3 started to work on 01/22/24. Her clearance letter from WV Cares was dated 01/31/24. c) NA #12 NA #12 started to work on 01/25/21. Her clearance letter from WV Cares was dated 01/28/21. During an interview with the Clinical Manager #6 on 02/26/25 at approximately 9:40 am, when asked why these were not done prior to employment, Clinical Manager #6 did not have an answer. Additionally, the facility's Abuse and Neglect policy requires WV Cares to be complete on prospective staff prior to beginning work.

Based on record review and staff interview, the facility failed to develop a care plan for pain for Resident #3. This failed practice was found true for one (1) of eight (8) care plans reviewed during the Long-Term Care Survey Process. Resident Identifier: #3 Facility census:12 Findings included: a) Resident #3 During record review on 02/26/24 of Resident #3's orders revealed the following order; Norco 5/325 one (1) tablet by mouth three (3) times a day PRN (as needed) start date was 02/03/25. Further review of the care plan revealed there was nothing in the care plan regarding pain. On 02/26/25 at 12:41 PM during an interview with the Clinical Manager #6 who stated no its' not in the care plan, but it should be in here. The Clinical Manager #6 confirmed the care plan did not contain anything regarding pain.

Based upon record review, observation, staff interview, and interview with a visitor, the facility failed to ensure daily nurse staffing information was readily available in a format that was clear and readable as found during the staffing review of the long term care survey process. Facility census: 12 Findings included: a) Staffing Reports for 06/30/24 through 07/07/24 It is unclear what the census was for 07/06/24. Nursing hours were not totaled daily. Staffing sheet contained information for the whole month. b) Staffing Reports for 10/27/24 through 11/02/24 Staffing sheet contains information for the whole month. Nursing hours are not totaled daily. c) Staffing Reports for 11/17/24 through 11/23/24: Staffing sheet contains information for the whole month. Nursing hours are not totaled daily. d) Staffing Reports for 12/22/24 through 12/29/24: Staffing sheet contains information for the whole month. Nursing hours are not totaled daily. It was unclear what the census was on 12/24/24, 12/26/24 and 12/28/24. On 02/26/25 at approximately 11:25 AM, conducted an interview with Resident #157's family member (FM). Surveyor showed him a copy of the posted staffing information for the month of December, and asked him the following question, If this piece of paper were posted in the hall near the nursing station, would you know what it was? FM answered, since it says nursing unit staffing, I would guess that it has something to do with the staffing in the unit. Surveyor then asked, Would you know how to interpret the numbers on the sheet? FM answered No, I have no clue what all that means. It sure has alot of numbers on it though. On 02/26/25 at 12:59 PM, held a discussion with Clinical Manager (CM) #6 on the posted staffing information. Surveyor inquired why there are several numbers in some of the same boxes, she explained that census fluctuated and staffing fluctuated. CM acknowledged the staff postings were confusing with all the small numbers. Boxes are so small to write in. CM stated, this form was developed many years ago. I will develop a new one.

Based on observation, record review and staff interview, the facility failed to dispose of expired single-serve condiments stored in the resident refrigerator in the unit pantry. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Facility Census: 9. Findings Included: a) Resident Refrigerator On [DATE] at 11:10 AM, a tour of the unit pantry was completed. The tour found the resident refrigerator containing multiple expired single-serve packets of condiments. The expiration dates found were [DATE] on the salad dressings and [DATE] for the tartar sauces. b) Facility Policy A review of the facility policy entitled Maintaining Kitchenettes dated ,d+[DATE] II D h. states, Do not keep patient silverware or condiments from the trays on the unit. (Typed as written.) During the tour on [DATE] at 11:10 AM, Registered Nurse (RN) #13 was present. Upon discovering the expired condiments, RN #13 stated, let me get rid of all of them. On [DATE] at 11:30 AM, the Clinical Manager (CM) #18 was notified. The CM #18 confirmed the single-serve condiments should not be stored in the resident refrigerator. No further information was obtained during the survey process.

Based on record review and staff interview, the facility failed to obtain proper consent or declination for a COVID-19 booster. This deficient practice had the potential to affect one (1) of five (5) residents reviewed for the care area of immunizations. Resident identifier: #57. Facility census: 9. Findings included: a) Resident #57 The facility's policy and procedure titled, Novel Coronavirus Disease 2019, with formation date January 2021 and last revised January 2024, stated that residents of the Skilled Nursing Unit would be screened and offered COVID-19 immunization while in the skilled nursing unit. Review of Resident #57's medical records showed an undated Skilled Nursing Unit Belongings Sheet that had a written notation that said, Hasn't had last booster of COVID shot. Would like to get it. Further review of Resident #57's medical records showed an Assessment and Consent or Refusal for COVID-19 Vaccination form dated 01/02/24. The consent section of the form was signed by the resident and marked out with the word error written. The refusal section of the form was checked and marked out with the word error written and the signature of Registered Nurse #9. During an interview on 01/17/24 at 11:06 AM, the Director of Nursing (DON) stated Resident #57 had not received a COVID-19 booster vaccination since admission to the facility. The DON confirmed the resident's COVID-19 consent or refusal form had not been completed properly. She stated she would have the consent or refusal form re-done. On 01/17/24 at 10:21 AM, the DON stated Resident #57 had given consent for a COVID-19 booster vaccination and the immunization had been ordered from the pharmacy. No further information was completed through the completion of the survey.

Based on observation and staff interview, the facility failed to maintain appropriate infection control standards for the storage of clean linen. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents at the facility. Facility Census: 9. Findings Included: On 01/15/24 at 1:02 PM, the resident bath/shower room was toured. The tour found folded clean towels uncovered laying on the dirty linen cart lid and on the top of the biohazard box sitting in the floor. On 01/15/24 at 1:04 PM, Registered Nurse (RN) #13 was notified. RN #13 stated, those aren't supposed to be there .I'll take care of it. On 01/15/24 at 1:20 PM, the Clinical Manager (CM) #18 was notified and confirmed the clean linen should not be stored in the resident bath/shower room. No further information was obtained during the survey process.

Based on observation, record review and staff interview, the facility failed to provide Peripherally Inserted Central Catheter (PICC line) care in accordance with professional standards of practice. This deficient practice had the potential to affect one (1) of one (1) residents receiving intravenous (IV) antibiotics. Resident identifier: #57. Facility census: 9. Findings included: a) Resident #57 Review of the facility's policy titled, Cental Venous Catheters - Dressing Change, Maintenance, and Removal, with formation date November 1995 and most recent revision date May 2021 gave instructions to aspirate blood for verification of placement prior to infusion of medications. The facility's policy also gave guidelines to scrub the catheter hub with sterile alcohol swab for at least 15 seconds using a twisting motion after removing the end cap of the catheter. Inablility to aspirate blood can indicate catheter malposition. Wiping the catheter hub with an alcohol swab when the cap is removed will prevent potential pathogens from entering the catheter. On 01/17/24 at 1:25 PM, Registered Nurse (RN) #10 was observed administering medications to Resident #10 via PICC line. RN #10 removed the end cap on one lumen of the resident's PICC line and attached a syringe containing saline to flush the catheter. After administering the saline, RN #10 then attached another syringe containing Toradol, a pain medication, and adminstered the medication. RN #10 next attached another syringe containing saline to flush the catheter. After flushing the catheter, RN #10 attached an end cap to the PICC line lumen while she prepared the resident's intravenous antibiotic, Daptomycin, for administration. RN #10 then removed the end cap and attached the resident's antibiotic for infusion over 30 minutes by pump. RN #10 did not aspirate Resident #57's PICC line for blood return to check for placement before administering medications. RN #10 also did not clean the catheter hub with alcohol at any time while administering the IV medications. On 01/17/24 at 2:16 PM, RN #20 was observed disconnecting Resident #57's antibiotic after the infusion was completed. RN #29 wiped the catheter hub after removing the IV tubing before flushing the line with saline and replacing the end cap. On 01/17/24 at 2:25 PM, the Director of Nursing (DON) was informed that RN #10 had not aspirated Resident #57's PICC line to verify placement and had not cleaned the catheter hub with alcohol before use. The DON confirmed the facility's policy for blood aspiration and cleansing of the catheter hubs. The DON was asked where IV flushes were documented. The DON showed computer documentation for IVs and IV site assessment that contained an area to document flushes. The DON confirmed this area had not been completed for Resident #57 and normal saline flushes had not been documented. No further information was provided through the completion of the survey.

Based on observation and staff interview, the facility failed to maintain an infection prevention and control program to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections when they failed to ensure resident hand hygiene was performed prior to meals. This was true for two (2) of the eight (8) Residents on the unit. This had the potential to affect all the residents on the unit. Resident identifiers: #1 and #8. Facility Census: 8 Findings Included: a) Resident #1 and #8 On 7/26/23 at 11:45 AM the surveyor went to the floor in anticipation of the lunch meal trays due to arrive at 12 noon. The surveyor watched one Certified Nurse Aid (CNA) pass ice while two other staff members were sitting at the nurses station. The lunch tray cart was delivered from the kitchen at 12:10 PM. No one performed hand hygiene during the time frame that the surveyor was monitoring the floor from 11:45 AM until 12:10 PM. There were two (2) CNA's and a Registered Nurse (RN) at the meal cart with a large bottle of hand sanitizing gel present. The staff was sanitizing their own hands. After watching them pass three trays without offering residents hand hygiene, I ask, Do you offer residents hand hygiene prior to their meals? RN #19 commented, yes we do and she looked at the CNA #22 and continued don't we? This surveyor commented you have passed three (3) trays and not offered any of them hand hygiene. CNA #22 commented, we wash their hands after we toilet the residents because most of them want to go to the restroom before lunch. This surveyor commented I have been on the floor for twenty five (25) minutes and observed one (1) CNA pass ice while everyone else was at the nurses station and didn't see anyone in residents room during this time. The staff offered no further communication and continued to pass lunch trays to the remaining residents. Resident #2 was not given her tray, it was only placed on her bedside table, as she was in the restroom at this time and the other two (2) residents that were given their tray had not been offered hand hygiene. On 07/26/23 at 12:20 PM it was confirmed with the Clinical Manager #10 that the staff had failed to perform hand hygiene as the lunch meal trays were being delivered.

Based on record review and staff interview, the facility failed to fully screen residents for eligibility to receive pneumococcal vaccination. This deficient practice had the potential to affect three (3) of five (5) residents reviewed for immunizations during the Focused Infection Control Survey (FICS). Resident identifiers: #4, #5, and #8. Facility census: 8. Findings included: a) Resident #4 Review of Resident #4's medical records showed the resident was admitted on [DATE]. The resident's Admission Assessment Report showed the resident reported receiving a pneumococcal vaccine at [AGE] years of age or older, on 10/07/15. The Admission Assessment Report did not document which pneumococcal vaccine the resident had previously received. There was no further documentation in Resident #4's medical records assessing the resident for eligibility to receive further pneumococcal vaccination. b) Resident #5 Review of Resident #5's medical records showed the resident was admitted on [DATE]. The resident's Admission Assessment Report showed the resident reported receiving a pneumococcal vaccine at [AGE] years of age or older, in 2020. The Admission Assessment Report did not document which pneumococcal vaccine the resident had previously received. There was no further documentation in Resident #5's medical records assessing the resident for eligibility to receive further pneumococcal vaccination. c) Resident #8 Review of Resident #8's medical records showed the resident was admitted on [DATE]. The resident's Admission Assessment Report showed the resident reported receiving a pneumococcal vaccine at [AGE] years of age or older, in November 2017. The Admission Assessment Report did not document which pneumococcal vaccine the resident had previously received. There was no further documentation in Resident #8's medical records assessing the resident for eligibility to receive further pneumococcal vaccination. d) Interviews On 07/26/23 at 11:45 PM, the Director of Nursing (DON) and Pharmacist #37 were interviewed. The DON and pharmacist #37 stated admission nursing assessments included a question about whether the resident had received pneumococcal vaccination prior to admission, and if so, when. If the resident had not received pneumococcal vaccination prior to admission, a pneumococcal vaccine order/consent form for residents greater than [AGE] years old was sent to the unit for the nurses to complete with the resident or resident representative. Pharmacist #37 provided a blank pneumococcal vaccine order/consent form. Section one of the form was titled Risk Assessment for Pneumococcal Vaccine for Patient Age Greater than [AGE] years. The risk assessment had the following areas with boxes to be checked: - No or unknown history of prior receipt of pneumococcal vaccine - Administer Prevnar 20 - Received Pneumovax 23 more than 12 months ago and never received Prevnar 13, Prevnar 20, Prevnar 20, or Vaxneuvance - Administer Prevnar 20 - Received Prevnar 13 or Vaxneuvance more than 12 months ago - Administer Pneumovax 23 - Received Prevnar 20 any time in the past - no vaccine indicated - Received any pneumococcal vaccine in the last 12 months - No vaccine indicated; advise patient to follow up with primary care The rest of the form contained an assessment of contraindications to receiving the pneumococcal vaccination, and consent or refusal of Prevnar 20 or Pneumovax 23 vaccination. Pharmacist #37 and the DON stated Residents #4, #5, and #8 did not have a pneumococcal vaccine order/consent completed because the residents' admission assessments indicated the residents had received pneumococcal vaccinations prior to admission. Pharmacist #37 and the DON acknowledged the nursing assessment performed did not assess what pneumococcal vaccinations the residents had previously.

Based on medical record review and staff interview, the facility failed to ensure pain management was provided to residents consistent with professional standards of practice. Response to PRN (as needed) pain medication was not consistently assessed. This failed practice had the potential to affect three (3) of five (5) reviewed for the care area of unnecessary medications and one (1) of one (1) residents reviewed for the care area of pain management. Resident identifiers: #66, #60, #67, #62. Facility census: 10. Findings included: a) Resident #66 Review of Resident #66's medical records showed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #66's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 05/14/22 at 4:22 PM, Resident #66 received [MEDICATION(S)] for pain in the right foot rated as a 6 on a pain scale from 1-10, with 10 being the worst pain. The records did not contain documentation regarding the effectiveness of this administration of [MEDICATION(S)] in relieving the resident's pain. During an interview on 05/18/22 at 12:20 PM, the Director of Nursing (DON) confirmed Resident #66's response to [MEDICATION(S)] administered on 05/14/22 at 4:22 PM was not documented. No further information was provided through the completion of the survey. b) Resident #60 Review of Resident #60's medical records showed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #60's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 05/16/22 at 6:13 PM, Resident #60 received [MEDICATION(S)] for pain in the right leg rated as a 5 on a pain scale from 1-10, with 10 being the worst pain. The records did not contain documentation regarding the effectiveness of this administration of [MEDICATION(S)] in relieving the resident's pain. During an interview on 05/18/22 at 12:20 PM, the Director of Nursing (DON) confirmed Resident #60's response to [MEDICATION(S)] administered on 05/16/22 at 6:13 PM was not documented. No further information was provided through the completion of the survey. c) Resident #67 Review of Resident #67's medical records showed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #67's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 05/17/22 at 9:56 AM, Resident #67 received [MEDICATION(S)] for pain in the back rated as a 7 on a pain scale from 1-10, with 10 being the worst pain. The records did not contain documentation regarding the effectiveness of this administration of [MEDICATION(S)] in relieving the resident's pain. During an interview on 05/18/22 at 12:20 PM, the Director of Nursing (DON) confirmed Resident #67's response to [MEDICATION(S)] administered on 05/17/22 at 9:56 AM was not documented. No further information was provided through the completion of the survey. d) Resident #62 A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 05/14/22 at 4:59 PM, Resident #62 received [MEDICATION(S)] for pain in left hip and rated as a six (6) on a pain scale from 1-10, with 10 being the worst pain. [MEDICATION(S)] was administered again on 05/17/22 at 8:58 PM for leg pain, rated at four (4). The records did not contain documentation regarding the effectiveness of this administration of [MEDICATION(S)] in relieving the resident's pain. During an interview on 05/18/22 at 12:31 PM, the Director of Nursing (DON) confirmed Resident #62's response to [MEDICATION(S)] administered on 05/14/22 at 4:59 PM and on 05/17/22 at 8:58 PM was not documented.

Based on observation and staff interview, the facility failed to display the most recent State inspection survey in a readily accessible area frequented by residents and visitors. It was discovered the State inspection survey was placed too high for residents to reach. This had the potential to affect a limited number of residents. Facility census: 10 Findings included: a) State inspection survey posting During an observation on 05/17/22 at 9:30 AM, it was discovered the State inspection survey was placed in a wall pocket, located on a hallway frequented by residents and visitors. The survey was placed too high on the wall for a resident in a wheel chair to reach. In an interview on 05/17/22 at 9:45 AM with the Director of Nursing (DON), verified the posting was located too high on the wall. The DON also agreed it would be difficult for a resident in a wheel chair to get the survey out of the wall pocket.

Based on medical record review and staff interview, the facility failed to ensure the baseline care plan was fully developed for three (3) of eight (8) residents reviewed during the long-term care survey process. Resident identifiers: #67, #66, #65. Facility census: 10. Findings included: a) Resident #67 Review of Resident #67's medical records showed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #67's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #67's baseline care plan did not contain a focus related to pain or discomfort. During an interview on 05/18/22 at 12:25 PM, the Director of Nursing (DON) confirmed Resident #67's baseline care plan did not have a focus related to pain or discomfort. No further information was provided through the completion of the survey process. b) Resident #66 Review of Resident #66's medical records showed the resident was prescribed the diuretic medication [MEDICATION(S)], 25 mg, every day, for diastolic heart failure and [CONDITION(S)]. Resident #66's baseline care plan did not have a focus related to diuretic medication nor interventions to assess for possible side-effects or adverse reactions. During an interview on 05/18/22 at 12:25 PM, the Director of Nursing confirmed Resident #66's baseline care plan did not have a focus or interventions related to diuretic medication use. No further information was provided through the completion of the survey. c) Resident #65 A medical record review on 05/18/22, revealed the baseline care plan was not developed in the area of diuretic medication for Resident #65. In an interview with the Director of Nursing (DON) on 05/18/22 at 12:54 PM, verified the baseline care plan was not developed for the use of a diuretic medication for Resident #65.

Based on observation, record review, and staff interview, the facility failed to ensure enteral feeding was utilized in accordance with current professional standards of practice. This deficient practice had the potential to affect one (1) of one (1) residents reviewed for the care area of tube feeding. Resident identifier: #68. Facility census: 10. Findings included: a) Resident #68 Review of Resident #68's medical records showed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During observation on 05/18/22 at 10:30 AM, Resident #68 was noted to have a bottle of Pivot and a bag of water hanging from a pole and infusing by pump into to the J-tube. Neither the Pivot bottle nor water flush bag were dated or timed to show when they were hung. During an interview on 05/18/22 at 10:33 AM, Registered Nurse (RN) #23 stated she had hung the bottle of Pivot and the bag of water earlier that morning. RN #23 stated she would date and time them to show when they had been hung. Additionally, a review of Resident #68's intake and output (I&O) showed the amount of tube feeding and the amount of water flush was not consistently recorded. No enteral intake had been recorded on 05/08/22, 05/09/22, 05/12/22, 05/13/22 or 05/16/22. During an interview on 05/18/22 at 10:48 AM, the Director of Nursing (DON) confirmed Resident #68's enteral intake was not recorded every day. No further information was provided through the completion of the survey.

Based on record review and staff interview the facility failed to accurately code the nutrition section (section K) of the minimum data set (MDS) assessment for weight change. This deficient practice was found for one (1) of four (4) residents reviewed for the nutrition care area. Resident identifier: #7. Facility census: 13. Findings included: a) Resident #7 A review of Resident #7's minimum data set (MDS) assessment with an assessment reference date (ARD) of 02/12/21 found that Resident #7 had no significant weight loss over either one (1) month or six (6) months based on a weight of 169 pounds measured on 02/12/21. However, a review of Resident #7's weight history during the survey found she did experience a significant weight loss over one (1) month or six (6) months based on the 169 pounds weight measurement. Weight on admission to the facility was 182 pounds (02/03/21) and on 02/09/21 the weight was 169 (Weight used on the MDS with ARD of 02/12/21). This was a 7.14% or 13 pounds weight loss. The facility's Director of Nursing (DON) was asked about this discrepancy on 02/24/21 and stated at 2:09 PM the MDS with ARD of 0212/21 was inaccurrate. No further information was provided prior to exit.

Based on observation, staff interview, and policy review, the facility failed to implement an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections. The facility failed to ensure that contact precautions were followed by a staff member and failed to ensure that an isolation precaution sign was posted on the door of a resident with a transmissible infection. This deficient practice had the potential to affect all residents in the nursing facility. Resident identifier: #113. Facility census: 16. Findings included: a) Resident #113 1. Contact Precautions Not Followed by a Staff Member During the survey, a review of Resident #113's care plan revealed that Resident #113 had a communicable infection. A sign on Resident #113's door instructed visitors to follow contact precautions by donning a gown and gloves upon entering Resident #113's room as well as performing hand hygiene. On 04/15/19 at 1:00 PM, Employee (E) #14 was observed entering Resident #113's room without first putting on a gown. [NAME] #14 then gathered Resident #113's trash and brought it out of the room and into the hallway without performing had hygiene, potentially exposing other residents to the infection. Shortly after exiting Resident #113's room, [NAME] #14 stated that she should have followed the instructions posted on Resident #113's door. A review of the facility's infection control policy during the survey confirmed that for residents under contact precautions, visitors were to wear gloves and a disposable gown and perform hand hygiene prior to exiting the resident's room. Clinical Manager (CM) #5 was informed of the above infection control issue on 04/15/19 at 1:03 PM. No further information was provided prior to the end of the survey. 2. Resident #113 On 04/15/19 at 9:58 AM, Resident #113's room was noted to have personal protective equipment, gloves and gowns, in a container hanging on the door to his room. However, there was not a sign nearby to indicate special precautions needed to be taken by individuals entering his room. During an interview on 04/15/19 at 10:03 AM, Licensed Practical Nurse (LPN) #8 stated Resident #113 was in contact isolation for a [DIAGNOSES REDACTED]icile infection. [DIAGNOSES REDACTED]icile infections can cause severe diarrhea. The infection can be transferred from person-to-person through contact with diarrhea. [DIAGNOSES REDACTED]icile organism can also live on surfaces that have been contaminated with diarrhea. A person can touch the contaminated surface and then carry the organism to another person or surface in the facility. LPN #8 stated Resident #113 was sometimes incontinent of diarrhea. She stated all staff and visitors entering Resident #113's room should wear a gown and gloves. LPN #8 stated the resident should have a sign regarding on his door regarding precautions to be taken upon entering his room. She stated Resident #113 had a contact precautions sign on his door previously, and she was unsure what happened to the sign. LPN #8 placed an orange sign on Resident #113's door on 04/15/19 at 10:05 AM. The sign had a stop sign on it and stated, Extended contact precautions. All persons must do the following: Wash hands or use hand gel upon entering room, wear gown and gloves, before exiting remove and discard gowns and gloves, and wash hands with soap and water. Hand gel is not to be used after patient contact. The sign also stated, Do not remove sign until room has been cleaned by EVS (environmental services).

Based on medical record review, resident interview, staff interview, policy review, and observation, the facility failed to ensure necessary care and services were provided to attain or maintain the highest practicable physical and mental well-being for one (1) of five (5) residents reviewed for the care area of unnecessary medications and two (2) of three (3) residents reviewed for the care area of pain recognition and management. The facility failed to assess, monitor, and administer pain medications to ensure effective pain management for Residents #52 and #48, resulting in actual harm. For Resident #40, the facility failed to administer insulin as prescribed by the physician. Resident identifiers: #52, #48, and #40. Facility census: 15. Findings include: a) Resident #52 Resident #52 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. A resident interview was conducted on the morning of 01/06/15. Resident #52 stated he had chronic back pain from a lower back fusion and had fallen and broken his left hip. He stated, "It hurts." During the interview on 01/06/15, Resident #52 was observed repositioning himself in bed and continued to complain of pain. Review of Resident #52's medical records, on 01/06/15 in the afternoon, revealed physician's orders for [MEDICATION NAME] 50 milligrams (mg) three (3) as needed (prn) and [MEDICATION NAME] 250 mg daily PRN (as needed) for pain. Review of the facility's policy for "Pain Management," on 01/06/15, revealed the facility utilized a 0-10 pain scale. This policy indicated "1-2 = mild pain, 3-5 = moderate pain, and 6-10 indicates severe pain. The patient's response to the medication and differing dosages will be monitored and documented. As part of his/her participation in his own care, the patient will be asked to identify a goal level of pain on the pain scale, and to provide ongoing feedback regarding effectiveness of interventions. Reassessment is essential for optimal pain management. The level of pain will be reassessed at appropriate time intervals depending on the pain management interventions. Nursing staff will contact physician when patient/caregiver's reports of pain indicate that current pain management effort is ineffective." Interview with Employee #1, registered nurse (RN), on 01/06/14 in the afternoon, revealed the resident did not have any pain medications ordered routinely for his chronic pain. She confirmed the resident had [MEDICATION NAME] and [MEDICATION NAME] PRN for pain. Observation, on 01/07/15 at 9:25 a.m., revealed Resident #52 was in bed. When asked if he was having pain, he stated, "Yes, I have chronic back pain and now my hip hurts since I fell ." He further stated, "I have been asking for three (3) days for a list of medications I am on, and (also ask) when I receive them. I took [MEDICATION NAME] home on a routine basis for my chronic back pain." Further observation of Resident #52, on 01/07/15 at 10:50 a.m., found the resident sitting in the therapy room. The resident was observed sitting sideways and leaning to the right. When asked how he was doing, the resident stated, "I am having severe pain in my back and left hip." When asked if he had received pain medication, he stated, "I don't know what medication they give me or when I get it." An interview with Employee #14, registered nurse (RN), on 01/07/15 at 10:55 a.m., revealed the resident had asked for a list of his medication and the times they were scheduled. She said she had been off the last two (2) days so she was not aware of his request before "today." She said the resident's pain medication, [MEDICATION NAME], was changed from PRN to every eight (8) hours on 01/06/15 (after intervention during the survey). The medication was also increased from 50 mg to 100 mg. She also indicated the residents were asked about the effectiveness of the pain medication an hour after it was administered. Review of the medical records, on 01/08/15 at 9:00 a.m., revealed (also after intervention during the survey) the physician added an order for [REDACTED]. The order indicated the [MEDICATION NAME] 100 mg was to be continued every eight (8) hours for pain. Review of the occupational therapy progress notes, on 01/08/15, revealed Resident #52 was evaluated on 01/02/15 for therapy. On 01/03/15, the therapist note was: "Patient refused treatment this date. Benefits of participation and risks of non-participation explained. Offered exercise at edge of bed and in bed exercise, but the patient continues to refuse on the basis of pain. Consulted with the nursing with report they had already gave the patient pain medications. Asked the patient again and he continues to refuse due to pain." Further review of the therapy notes revealed on 01/05/15 and 01/07/15, the resident was unable to do the exercises sitting up due to complaints of pain. On 01/07/15 the therapist noted the resident said the pain was at a level seven (7), which indicated severe pain. The 01/03/15 medication administration record (MAR) was reviewed. It revealed the resident received [MEDICATION NAME] 250 mg by mouth at 9:27 a.m. for pain measured at level six (6), which indicated severe pain. No follow-up regarding the effectiveness of the pain medication could be located. The resident received no other medication for pain until 1:23 p.m. At that time, [MEDICATION NAME] 50 mg was given for pain noted at a level of seven (7). The follow-up of the effectiveness of this medication was "sleeping." Interview with Employee #39, clinical manager, on 01/08/15 at 1:15 p.m., confirmed nursing staff failed to recognize the resident's pain (both chronic and acute), failed to treat and follow-up on the effectiveness of the pain medication, and failed to inform the physician of the resident's unrelieved pain. She further acknowledged the resident's unrelieved pain had interfered with the resident's rehabilitation treatments. . . b) Resident #48 The resident was admitted to the skilled nursing unit on 01/02/15 at 9:08 p.m. The physician's orders revealed the resident was diagnosed with [REDACTED]. Upon admission, the resident was receiving a [MEDICATION NAME] 100 milligrams to be applied every 72 hours for pain and [MEDICATION NAME]/[MEDICATION NAME] 10/325, every six (6) hours as needed (PRN) for pain. Review of the hospital discharge summary, dated 01/02/15, found the following information, "...The patient was admitted to the hospital for pain control...Physical therapy has been working with the patient and she has been doing pretty well. However, she needed further assistance with rehabilitation on discharge...." An admission nursing assessment was completed by the skilled nursing facility at 10:50 p.m. on 01/02/15. The nurse completing the assessment documented the resident rated her pain as, "7-very severe back pain." Further review of the nursing assessment found the resident was alert and oriented. Review of the facility's policy, entitled Pain Management, found the facility used a Numeric Pain Scale for adult patients who are cognitively able to use it. The scale was: 0-1, No pain 2-3, Mild pain 4-5, Moderate pain 6-7, Severe pain 8-9, Very severe 10, Worst possible pain Review of the medication administration record (MAR), on 01/06/15, found the resident was not medicated for pain after she described her pain as a 7, severe, at 10:50 p.m. on 01/02/15. Review of nursing documentation found no evidence her pain was further addressed. According to documentation on the MAR, the resident received her first dose of PRN pain medication, [MEDICATION NAME]/[MEDICATION NAME] 10/325, at 7:30 p.m. on 01/03/14. At that time, the resident rated her pain as a 9, indicating very severe pain. After administration of the medication, at 8:30 p.m. on 01/03/15, the resident rated her pain as an 8, very severe pain. Further review of the MAR, on 01/06/15, found [MEDICATION NAME]/[MEDICATION NAME] 10/325 PRN every six (6) hours was administered at the following times and dates: -- 10:11 p.m. on 01/04/14. At this time the resident rated her pain as a 7, indicating the pain was severe. At 10:51 p.m. her pain had decreased to a 4, indicating her pain was moderate. -- 10:22 a.m. on 01/05/15. The resident rated her pain as a 9, very severe. At 12:28 p.m. her pain was rated as a 7, severe. -- 4:27 p.m. on 01/05/15. The resident rated her pain as 9, very severe. At 5:30 p.m. on 01/05/15, after administering medication, the resident rated her pain as a 4, indicating her pain was moderate. -- 10:22 p.m. on 01/05/15. The resident rated her pain as a 7, severe. At 11:31 p.m., her pain was rated as a 3, indicating the pain was mild.. -- 9:27 a.m. on 01/06/15. The resident rated her pain as an 8,indicating the pain was very severe. At 10:30 a.m., she rated her pain as a 7, indicating the pain was still severe. Review of the medical record found no evidence the facility intervened when the resident's pain was not alleviated after administering the PRN pain medication. There was no evidence the facility implemented non-invasive physical modalities, such as heat packs, deep breathing exercises, etc. On 01/06/15 at 1:35 p.m., the physician discontinued the PRN order of [MEDICATION NAME]/[MEDICATION NAME] 10/325 and wrote a new order for [MEDICATION NAME]/[MEDICATION NAME] 10/325 to be administered every six (6) hours. A nursing note indicated a team meeting was been held, on 01/06/15, to discuss the resident's, "...Severe back pain, limiting..." The pharmacist suggested the pain medication be changed. The physician was contacted and the resident's pain medication was changed. At 3:33 p.m. on 01/06/15, the resident was interviewed. She voiced her pain was somewhere between a 8 and a 9, indicating her pain was very severe. She said she was waiting for her pain medications so she could go to therapy. She activated her call light during the interview and asked for a, "pain pill." Review of the MAR found the medication [MEDICATION NAME]/[MEDICATION NAME] 10/325 was administered at 3:53 p.m. on 01/06/15. The resident rated her pain as a 9, indicating very severe pain. At 4:53 p.m. the resident rated her pain as a 6, indicating the pain was severe. There was no evidence the facility continued to address the resident's pain. Continued review of the facility's policy for Pain Management found the general principles of pain management included but were not limited to: "For continuous pain, physician to consider regularly scheduled pain medication....Non-invasive physical and psychological modalities are to be considered by a multidisciplinary approach. i.e. superficial heat, cold. massage, deep breathing exercises, range of motion, pastoral care, support groups, counseling, etc...." At 4:00 p.m. on 01/06/15, the physical therapist, Employee #5, was interviewed. The therapist stated the resident had a lot of chronic back pain. She stated the resident liked to do her therapy after she received medication. The therapist stated, "She definitely has a lot of pain." Employee #5 stated she had to do the resident's therapy while she was in bed lying down "yesterday," (01/05/15)because the resident had so much pain. The therapist stated, "The pain medication was not effective for her to sit up and participate, she couldn't tolerate sitting up to participate." Employee #5 stated, "We wanted to try heat packs but we couldn't because of the pain patch." The physical therapist later confirmed the resident told her heat packs could not be used with a pain patch. The physical therapist said she did not consult nursing or the physician to verify if the resident could not have heat packs. Review of the resident's interim care plan, with a start date of 01/02/15, found the facility addressed the resident's pain with the following: -- Problem: The resident has a history of a pelvic fracture / rib pain (no fracture). -- Goal: Comfort will be maintained; pain controlled. Will be able to participate in activities of daily living and activities. -- Interventions: -Offer to assist patient with position changes for comfort every 2 hours; -Assess pain before and after pain medications given; -Offer pain medications 30 minutes prior to activity; -Offer/provide diversion activities (list). The facility listed only skilled nursing unit recreational activities. The care plan did not include what the resident considered to be comfortable and pain controlled; therefore, the goal was not measurable. The care plan addressed a "history" of pelvic fracture, although the [DIAGNOSES REDACTED].e. superficial heat, cold. massage, deep breathing exercises, range of motion, pastoral care, support groups, counseling, etc. The care plan listed only one (1) divisional activity and did not include attempting to use any of the non-invasive interventions suggested by the policy. The care plan failed to address the resident's strengths and her individual needs. Employee #40, a licensed practical nurse, was interviewed at 4:30 p.m. on 01/06/15. She verified an interim care plan should outline the care and assistance a resident required. She also stated that anything new would be discussed in a meeting at the change of shifts. At 4:30 p.m. on 01/06/15, Employee #39, the registered nurse clinical manager, was interviewed. The following information was discussed with Employee #39: -- Did the facility intervene when the resident rated her pain as a 7 upon admission? Employee #39 was unable to find evidence of any interventions. -- What did the facility do when the resident continued to experience pain after administration of the PRN medication [MEDICATION NAME]/[MEDICATION NAME] on 01/03/15, 01/04/15, 01/05/15 and 01/06/15. Employee #39 stated that normally the facility does not address single incidents of pain unless the pain continues on a daily basis. -- What non-invasive interventions were provided, such as repositioning, heat packs, etc. when the resident experienced pain? No information was provided by Employee #39 to address this question. The care plan was also discussed with Employee #39, as the care plan coordinator was not in the facility. She confirmed the care plan should have been more specific to the resident's needs. Employee #39 was asked if she considered the resident's pain to be managed on 01/03/15 when the resident rated her pain as a 9, indicating severe pain and one (1) hour later the resident rated her pain as an 8, indicating the pain was still severe. Employee #39 stated it would not have been addressed unless this practice continued on a daily basis. Employee #39 also stated, "We might want to look at tweaking the medication again. Normally, if nursing or therapy sees an issue with pain, they let the doctor know." Employee #39 stated the resident had chronic pain. When asked if the facility had assessed the resident's acceptable level of pain, she stated, "That question used to be on the assessment, but it got removed." At the close of the survey on 01/09/15, no further information had been provided. . . c) Resident #40 A review of Resident #40's medical record, at 10:00 a.m. on 01/07/15, revealed the resident's insulin was not administered in accordance with physician's orders: 1. Physicians order: [MEDICATION NAME]. The dosage was to be determined by using a formula: blood sugar - (minus) 100/ (divided by) 20 = (equals) number of units to administer. This medication was to be administered at 7:30 a.m., 11:30 a.m., 4:30 p.m., and 10:00 p.m. The order had a start date of 01/03/15 and was discontinued on 01/05/15. Review of Resident #40's medication administration record (MAR), from 1/03/15 until 01/05/15, found the resident received her insulin outside of the scheduled timeframe and/or received the wrong dose of insulin as follows: -- 01/04/15 at 11:30 a.m., Resident #40 was given zero (0) units of insulin when her blood sugar was 219. According to the formula: blood sugar (219) minus 100 divided by 20 = 5.95, the resident should have received six (6) units of insulin for a blood sugar of 219. -- 01/04/15, the 4:30 p.m. dose was not given until 6:05 p.m. This was one (1) hour and thirty-five (35) minutes after the scheduled time of 4:30 p.m. 2. A physician's order, with a start date of 01/03/05, and was current at the time of the review on 01/07/15, was: [MEDICATION NAME], give zero (0) units if (the resident) eats zero (0) percent of meal, give two (2) units if eats less than fifty (50) percent of meal, give four (4) units if eats greater than fifty (50) percent of the meal. The scheduled administration times were 9:00 a.m., 1:00 p.m., and 6:00 p.m.. The facility meal times were 8:00 a.m., 12:00 p.m., and 5:00 p.m. Review of the MAR, from 01/03/15 until 01/07/15, found the resident received the insulin outside the scheduled time frame and/or received the wrong dose as follows: -- 01/04/15 at 6:05 p.m., the resident was given two (2) units of insulin when she had consumed more than fifty (50) percent of her dinner meal. According to the physician's order, she should have received four (4) units of insulin. -- 01/04/15 1:00 p.m., the insulin was administered at 2:29 p.m. This was one (1) hour and twenty-nine (29) minutes after the scheduled time of 1:00 p.m. 3. The resident also had a physician's order for [MEDICATION NAME] on a sliding scale had a start date of 01/05/15. It was current at the time of the review on 01/07/15. The scale was 151-200 one (1) unit, 201-250 two (2) units, 251- 300 three (3) units, 301- 350 four (4) units, 351- 1000 five (5) units. The physician was to be notified if the blood sugar was less than 70 or greater than 350. The insulin was scheduled for administration at 7:30 a.m., 11:30 a.m., 4:30 p.m., and 10:00 p.m. Review of the MAR from 01/05/15 until 01/07/15 found the resident received the insulin outside the scheduled time frames as follows: . -- On 01/05/15, the 11:30 a.m. dose was administered at 1:06 p.m., one (1) hour and thirty-six (36) minutes after the scheduled time. -- On 01/05/15, the 4:30 p.m. dose was administered at 6:30 p.m., two (2) hours after the scheduled time. -- On 01/06/15, the 11:30 a.m. dose was administered at 1:15 p.m., one (1) hour and forty-five (45) minutes after the scheduled time. -- On 01/06/15, the 4:30 p.m. dose was administered at 5:50 p.m., one (1) hour and twenty (20) minutes after the scheduled time. -- On 01/07/15, the 7:30 a.m. dose was administered at 9:58 a.m., two (2) hours and twenty-eight (28) minutes after the scheduled time. An interview with Licensed Practical Nurse (LPN) #29, at 8:56 a.m. on 01/07/14, revealed the time documented on the MAR was the time the medication was actually given. She stated they scan the resident's bracelet and the medication prior to administration; therefore, the time documented on the MAR was the time of administration. The LPN stated Resident #40's family preferred the resident's before meal insulin be given with her after meal insulin so the resident only got one (1) shot. She stated because of this request, the medication was sometimes given outside of the one (1) hour time frame allotted from the scheduled time. The LPN said they did the finger stick and obtained the blood sugar before the resident ate, then held her before meal insulin until after she ate. She confirmed the physician's order did not not allow for this. When interviewed at 11:36 a.m. on 01/07/15, Registered Nurse Clinical Manager #39 acknowledged the discrepancies in the insulin doses and the insulin administered outside the scheduled time frames. She confirmed it was the family's preference for Resident #40 to receive only one (1) shot. She said they had not obtained a physician's order to administer the before meal insulin after meals instead. She indicated that was something they needed to address. .

Based on medical record review, review of the facility's skin care protocol, and staff interview, the facility failed to ensure one (1) of three (3) residents reviewed for pressure ulcers, in the Stage 2 sample of nine (9), received the care and services necessary to promote wound healing. Resident #68 had a Stage I pressure ulcer to the sacrum which later increased to a Stage II area. The facility did not initiate their skin protocol, or establish a care plan, when the area was a Stage I, therefore, the resident's skin breakdown could not be determined to have been unavoidable. Resident identifier: #68. Facility census: 13. Findings include: a) Resident #68 On 08/13/12 at 4:00 p.m., a review of Resident #68's closed medical record revealed this [AGE] year old female was admitted to the facility on [DATE]. On 04/13/13, the wound assessment form identified the resident had a pink area that looked like an old scar on the sacrum. (Old scar tissue is not as strong as normal skin - typically only about 80% as strong as it once was, in addition to the normal loss of elasticity and fragility associated with advanced age. These factors would predispose the resident to skin breakdown.) The admission minimum data set (MDS) assessment, with an assessment reference date (ARD) of 04/20/13, indicated the resident required extensive assistance for bed mobility and transfers. The resident was coded as being at risk of developing pressure ulcers. The assessment also indicated the resident had two (2) Stage I pressure ulcers. On 04/21/13, the wound assessment identified the resident had redness/excoriation on the sacrum. The area was described as intact with redness that was not resolved within 30 minutes of pressure relief. (This indicated the circulation was compromised in this area, putting the resident at higher risk for skin breakdown.) On 04/23/13, the wound assessment noted the resident had an open area to the sacrum/ left buttock (measurement 1.1 cm wide x 3.8 cm long). The facility began using a [MEDICATION NAME] dressing at that time. On 04/18/13, the dietitian had noted the resident's [MEDICATION NAME] was low, but noted that was not necessarily the best indicator of nutritional status. According to the resident's medical record, there was no evidence the dietitian was made aware of the resident's skin breakdown until 04/30/13. Employee #2 (a registered nurse & minimum data set assessment coordinator) provided a copy of the facility's skin care protocol (revised 09/12) on 08/13/13 at 5:00 p.m. She said the facility had not initiated this protocol for Resident #68 when they should have. She said they should have initiated this protocol when the resident had a red/excoriated area noted on 04/21/13. She indicated the facility should have treated this area as incontinence associated [MEDICAL CONDITION] and begun applying Magic Butt paste TID (three times a day) and prn (as needed) for seven (7) days. On 08/15/13 at 9:00 a.m., the resident's admission minimum data set (MDS) assessment, assessment reference date (ARD) 04/20/13, was discussed with Employee #2, the MDS Coordinator. Employee #2 confirmed again the facility had not initiated their skin care protocol for this resident when the resident developed a red/excoriated Stage I area to the sacrum. This Stage I pressure area became a Stage II on 04/23/13 when the wound opened. .