Every finding on record at Warrenton Manor

Based on observation, interview and record review, facility staff failed to ensure three residents (Resident #8, #9, and #10) out of three sampled residents, who are dependent for activities of daily living received the necessary services to maintain personal hygiene. The facility census was 91.1.Review of the policies provided by the facility showed the facility did not provide a shower/bathing policy or grooming/hygiene policy. 2. Review of Resident #8's Significant Change Minimum Data Set (MDS), a federally mandated assessment tool, dated 04/06/26, showed staff assessed the resident as: cognitively intact, does not reject care, and is dependent for showers, toileting, dressing and personal hygiene;Review of the care plan, dated 03/05/26, showed staff assessed the resident is unable to bathe self-related to weakness and poor mobility and wishes two showers a week preferably in the mornings. Review showed the resident required one staff for bathing. At times he/she does not want to get up for showers and will request a bed bath. One person for facial hair, use a razor or tweezers to remove hair.Review of the shower schedule undated showed staff documented all showers to be given as scheduled on Wednesdays and Saturdays.Review of the shower sheets, dated March 2026, showed staff documented the resident received a shower on 03/24/26. The staff did not document a shower or refusal for 03/04/26, 03/07/26, 03/11/26, 03/14/26, 03/18/26, 03/21/26, 03/25/26, or 03/28/26.Review of the shower sheets, dated April 2026, showed staff documented the resident received a shower on 04/15/26. The staff did not document a shower or refusal for a shower for 04/01/26, 04/04/26, 04/08/26, 04/11/26, 04/18/26, 04/22/26, 04/25/26, and 04/29/26.Review of the shower sheets, dated May 2026, did not contain staff documentation resident received or refused a shower.Observation on 05/07/26 at 10:36 A.M., showed the resident in his/her wheelchair in an activity. He/She had long facial hair on his/her chin. Observation on 05/07/26 at 11:54 A.M., showed the resident in the lunchroom. He/She had long facial hair on his/her chin. During an interview on 05/07/26 at 11:54 A.M., the resident said he/she can't remember when he/she received a shower last but knows it's been a little while. He/She said it takes two staff to transfer him/her and sometimes there aren't enough staff. He/She said he/she likes to feel clean.3. Review of Resident #9's annual MDS, dated [DATE], showed staff assessed the resident as cognitively impaired, did not exhibit behaviors or reject care, required substantial to maximal assistance by staff for shower/baths.Review of the care plan, dated 03/07/26, showed staff are directed to offer two showers a week, he/she will decline stating does not want to dry skin or because of behaviors staff attempt but may not be able to complete the shower.Review of the shower schedule, undated, showed the resident scheduled to receive a shower on Tuesday and Fridays.Review of the residents shower sheets, dated March 2026, showed staff documented the resident received a shower on 03/24/26. Review showed the shower sheets did not contain staff documentation resident received or refused a shower the rest of March.Review of the residents shower sheets, dated April 2026, showed staff documented the resident received a shower on 04/14/26 and 04/26/26. Review showed the shower sheets did not contain documentation received or refused a shower the rest of April.Review of the residents shower sheets, dated May 2026, showed the shower sheets did not contain documentation resident received or refused a shower in May.Observation on 05/07/26 at 1:34 P.M., showed the resident with a foul odor and had long fingernails.During an interview CNA said the resident oozes bowel movement and often pushes, pulls and hits at staff during care. Sometimes it takes up to five staff to toilet the resident or give a shower. 4. Review of Resident #10's annual MDS, dated [DATE], showed staff assessed the resident as cognitively intact, did not exhibit behaviors or reject care, and required substantial to maximal assistance from staff for showers.Review of the care plan, dated 05/07/26, showed staff are directed resident resists care to include showers, allow resident to choose options, i.e., Would you like to take a shower in the morning or evening?Review of the shower schedule, undated, showed showers are to be given as scheduled on Tuesdays and Fridays.Review of the shower sheets, dated May 2026, did not contain documentation resident received or refused a shower in May.Observation on 05/07/26 at 1:02 P.M., showed the resident in bed with dry flaky skin on both legs from the knees to the heels and bright red skin under the abdominal folds and both breasts that were covered with a white cakelike substance and foul smell. During an interview on 05/07/26 at 1:02 P.M., the resident said he/she had not received a shower in three weeks. He/She feels dirty and is embarrassed to get out of bed. He/She said he/she has red, itchy skin under his/her skin folds that smell and would feel better if could get a shower. He/She said when he/she asked about it, he/she is told there is not enough staff but does not make since because other residents are receiving a shower. The only reason his/her hair is clean is because it was washed yesterday in the beauty shop or it would be crusty, dry and itchy. 5. During an interview on 05/07/26 at 1:49 A.M., Nurse Aide (NA) J said he/she is responsible for giving showers and documenting them on a shower sheet. If the resident refuses a shower, then the resident is supposed to sign the shower sheet as refused and gets turned into the Director of Nursing (DON). He/She said the DON put the residents name on the shower sheets and gives it to the bath aide every day for completion. He/She said sometimes the bath aide gets pulled to the floor or has to help with care on the floor and could slow down the showers or they may not get done. He/She said he/she does not know where all the shower sheets are for the residents. The NA said he/she isn't always the bath aide but sometimes the aide on the floor. He/She said shave should be given during showers to all residents including the women. He/She is still in training but has been caring for others all his/her life and knows what to do. During an interview on 05/07/26 at 2:14 P.M., the DON said he/she is responsible to oversee the residents receive showers. He/She fills out the shower sheets for the aides and receives them when the showers are completed. Shaves should be completed during showers. He/She expects if a resident refuses care, staff document it and inform the DON so the DON can speak with the resident. He/She was unaware if the showers were completed for the residents or if they were refused. He/She said refusals and completed care should be documented.#3001687

Based on observation, interview and record review, facility staff failed to update the plan of care with changes in care needs for two residents (Resident #1 and Resident #2) out of three sampled residents. The facility census was 91.1. Review of the facility's Care Planning-Interdisciplinary Team policy, undated, showed the facility Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive plan of care for each resident. 2. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 04/08/26, showed staff assessed the resident with moderate cognitive impairment, did not exhibit behaviors and did not reject care.Review of the resident's care plan, dated 03/02/26, showed the care plan did not contain direction for staff when resident rejects care. Review of the residents' progress notes showed staff documented:-On 02/26/2026 the resident refused to allow staff to change his/her clothing;-On 03/24/2026 the resident refused his/her shower;-On 04/06/26, during a care plan meeting, staff discussed resident required assistance with bathing, dressing, and grooming, but he/she often refused showers and may decline care;-04/14/26, resident refused his/her shower.During an interview on 04/17/26 at 10:21 A.M., Licensed Practical Nurse (LPN) C said the resident frequently refused care. He/She said the resident's care plan should have interventions identified to direct staff related to his/her rejection of care, which is updated by the MDS Coordinator. He/She said he/she did not know if the care plan addressed interventions for rejection of care.During an interview on 04/17/26 at 11:14 A.M., Certified Nurse Aide (CNA) B said if a resident rejects care, staff are directed to reapproach again later, and if still refused, report to the charge nurse. He/She said the resident did have a history of rejecting care, to include showers and facial hair shaving. He/She said the resident's care plan should show interventions for his/her behaviors and his/her rejection of care. He/She said the MDS Coordinator would be responsible for updating the resident's plan of care.During an interview on 04/17/26 at 2:29 P.M., the administrator said the resident had a history of rejecting care. He/She said he/she did not know interventions were not listed in the plan of care.3. Review of Resident #2's quarterly MDS, dated [DATE], showed staff assessed the resident with moderate cognitive impairment and did not exhibit behaviors or reject care.Review of the resident's shower sheet, dated 04/08/26, showed the resident refused his/her shower. Review of the resident's plan of care, dated 02/03/26, showed it did not contain direction for staff when resident rejects care. During an interview on 04/17/26 at 10:56 A.M., Certified Medication Technician (CMT) A said the resident has a history of rejecting care depending on his/her mood. He/She said he/she did not know what the interventions were for the resident when he/she rejects care.During an interview on 04/17/26 at 2:29 P.M., the administrator said the resident has a history of rejecting care and there should be documentation in the care plan the resident rejects care. He/She said he/she could not find documentation in the resident's medical record, other than one incident when resident refused a shower. He/She said he/she did not know interventions were not listed in the plan of care for Resident #2.4. During an interview on 04/17/26 at 10:21 A.M., LPN C said rejection of care should be addressed with interventions in the resident's plan of care. During an interview on 04/17/26 at 2:29 P.M., the administrator said if a resident rejected care, it should be addressed in the resident's care plan with an intervention to guide staff on assisting with behaviors. During an interview on 04/17/26 at 2:29 P.M., the Director of Nursing (DON) said if a resident rejects care, it should be addressed in the resident's care plan with an intervention to guide staff when resident exhibit behaviors. The DON did not say why staff did not update the resident's plan of care to include his/her behaviors and the resident rejects care.During an interview on 04/20/26 at 1:47 PM, the MDS Coordinator said he/she was responsible for updating resident plan of care. He/She said if a resident had exhibited behaviors, it was discussed during the morning meeting, or aide report to him/her if a resident rejected care. He/She said he/she did know Resident #1 rejected care and updated the resident's care plan after the surveyor asked about the resident's history of rejecting care and being addressed in the care plan. He/She said he/she was not told Resident #2 rejected care.#2973742

Based on interview and record review, facility staff failed to ensure residents remained free of significant medication errors when staff administered Resident #3's medication Metformin (medication used to treat type two diabetes by lowering blood sugar levels) and Metorprolol Tartrate (a beta-blocker used to treat high blood pressure, chest pain and heart failure) to Resident #1. The facility census was 91.1. Review of the facility's Medication Administration policy, dated 02/07/13, showed medications are given to benefit a resident's health as ordered by the physician. Introduce yourself, call resident by name, and check picture identification in medication book. Review showed the policy did not contain documentation to direct staff on the five rights of medication administration.2. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 04/08/26, showed staff assessed the resident with moderate cognitive impairment. Review of the facility's Medication Error Documentation form, dated 11/02/25, showed Certified Medication Technician (CMT) A gave Resident #3's medication to Resident #1. Review showed staff documented Resident #1 received Metformin and Metoprolol. Review of Resident #1's Physician Order Summary (POS), dated 04/01/26 through 04/20/26, showed it did not contain a physician's order for Metformin or Metoprolol. During an interview on 4/16/26 at 10:21 A.M., Licensed Practical Nurse (LPN) C said CMT A reported to him/her, he/she administered the wrong medication to the wrong resident. He/She said staff are required to verify they are administering the right medication to the right resident by verifying the name tag on the door, ask the resident his/her name or ask another staff member if unsure. During an interview on 04/16/26 at 2:29 P.M., the administrator said staff were directed to verify the picture in the resident's medical record, the name on the door and ask the resident his/her name or another staff member, to verify the identity of the resident before administering medications. During an interview on 04/16/26 at 2:30 P.M., the Director of Nursing (DON) said staff are educated to verify a resident's identity before administering medication by reviewing the picture in the resident's medical record, observing the name on the door and ask the resident his/her name or another staff member.During an interview on 04/17/26 at 10:56 A.M., CMT A said staff are directed to verify the resident by using the picture in the resident medical record or ask other staff if unsure of the resident's name, before administering medications. He/She said he/she mixed up Resident #1 and Resident #3 when he/she administered Resident #3's medication to Resident #1 and did not identify the residents prior to administering the medications #2973742

Based on interview and record review, facility staff failed to maintain professional standards of care when staff left narcotic pain medication unattended at one resident's (Resident #5) bedside and accessible to the resident's roommate. The facility census was 90.1. Review of the facility's Medication Administration policy, dated 02/07/13, showed after staff administer a medication to a resident, staff are to remain in the resident's room while the resident takes the medication. 2. Review of Resident #5's annual Minimal Data Set (MDS), a federally mandated assessment tool, dated 04/11/26, showed the resident's cognition intact, has almost constant pain, and received a scheduled pain medication in the last five days. Review of the resident's care plan, dated 02/28/26, showed the resident resists care which includes taking medications. Review of the resident's physician order sheet, dated January 2026 and March 2026, showed an order for Percocet (A schedule II opioid narcotic prescribed to treat moderate to severe pain) 10-325 milligrams (mg) one tablet every four hours. Review of the resident's medication administration record, dated January 2026 and March 2026, showed the morning dose of Percocet 10-325 mg administered to the resident on 01/06/26 and on 03/21/26. During an interview on 04/29/26 at 12:13 P.M., licensed practical nurse (LPN) C said he/she was the nurse who administered the morning dose of Resident #5's Percocet on 03/21/26. LPN C said he/she went into the resident's room around 7:00 A.M. to administer the Percocet, but the resident was asleep, so he/she left the Percocet on the resident's bedside table. The resident told LPN C he/she woke up and went into the bathroom and when he/she returned, the Percocet was gone. LPN C said he/she knows staff are not supposed to leave medications with residents without watching them take the medication, but they have had issues with the resident become very upset and agitated when staff try to watch him/her take the medications. LPN C said he/she reported the incident to the director of nursing (DON). He/she said the resident does not have orders to leave medications at bedside. During an interview on 04/29/26 at 12:38 P.M., LPN E said he/she was the nurse who administered the morning dose Percocet on 01/06/26. LPN E said he/she went into the resident's room in the morning and left the Percocet with the resident without watching him/her consume the Percocet. The resident told LPN E he/she must have fallen back asleep and when he/she woke up, the Percocet was missing. LPN E said he/she knows staff are not supposed to leave medications with residents without watching them take the medication, and the resident does not have orders to leave medications at bedside, but they have had issues with the resident becoming very agitated when staff tries to watch him/her take the medications and tells staff they are treating him/her like a child. LPN E said he/she reported the incident to the DON. During an interview on 04/29/26 at 12:52 P.M., Registered Nurse (RN) F said he/she was the interim DON in January. RN F said the incident involving the resident Percocet missing on 01/06/26 was reported to him/her. RN F said they have had issues with the resident becoming agitated and yelling at staff when they try to watch him/her take medications, however, staff are expected to stay and watch residents consume the medications and not leave medications with residents. During an interview on 04/29/26 at 1:36 P.M., the interim DON said the incident involving the resident missing Percocet on 03/21/26 was reported to him/her. He/She confirmed the resident has had a pattern of yelling at staff when trying to watch him/her take medications and was aware that LPN C left the Percocet with the resident without watching him/her consume it. He/She said leaving a narcotic medication at bedside is concerning due to him/her having a roommate. The interim DON said he/she always expects staff to stay and watch residents consume their medications and not leave medications with residents. During an interview on 04/29/26 at 1:51 P.M., the administrator said he/she was not aware of the 01/06/26 incident involving the resident missing Percocet and staff leaving it with the resident at bedside, but he/she was aware of the 03/21/26 incident. The administrator said he/she always expects staff to stay and watch residents consume their medications and not leave medications with residents. #2993705

Based on observation, interview, and record review, facility staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when staff failed to apply the appropriate Enhanced Barrier Precautions (EBP) during care for one resident (Resident #3) of three sampled residents with wounds and ensure Personal Protective Equipment (PPE) was in proximity of the resident room for three of three sampled residents with wounds (Resident #3, #2 and #11). The facility census was 91.1. Review of the facility's EBP to Infection Control Guidance, dated March 2024, showed:-EBP should be implemented for the period of the resident's stay or until wounds have resolved or indwelling medical devices have been removed;-EBP should be used with residents with an indwelling medical device including the following: urinary catheter, feeding tube, and tracheostomy (tube inserted into the neck for breathing);-EBP should be used with residents with a wound regardless of their infection status;-EBP should be used when providing high-contact resident care activities such as: bathing/showering, transferring residents from one position to another; providing hygiene, changing bed linens, changing briefs or assisting with toileting, caring for or using an indwelling medical device, performing wound care;-EBP equipment includes a gown and gloves;-Residents placed on EBP should have PPE in proximity outside the door and a trash can in the resident's room for disposal prior to leaving the room.2. Review of Resident #3's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 02/15/26, showed staff assessed the resident as cognitively impaired, dependent on staff for transfers, and with one unhealed Stage III pressure ulcer(deep wound exposing fat).Observation on 02/26/26 at 10:32 A.M., showed Certified Nurse Aide (CNA) A and Certified Medication Technician (CMT) B enter the residents room to transfer the resident from the bed to a shower chair. A sign hung on the door to use EBP for high-contact care to include transfers. The residents' room did not have PPE within close proximity. CNA and CMT applied gloves and rolled the resident to his/her side and placed a mechanical lift sling under the resident. Observation showed a wound to the resident's upper buttocks area. The CNA and CMT transferred the resident to his/her chair. The CNA and CMT did not wear a gown during the transfer or direct resident contact. During an interview on 02/26/27 at 10:45 A.M., CMT B said EBP are used when a resident has a catheter, colostomy or wound. He/She said he/she should have worn a gown and gloves during the residents' transfer and care. He/She said he/she didn't know the resident had a wound and is normally passing medication to residents and not providing direct care. He/She didn't see the sign on the door. During an interview on 02/26/27 at 11:36 A.M., CNA A said staff should wear a gown and gloves if they are told the resident needs them. He/She said Resident #3 did not need EBP since he/she did not have an infection such as Clostridium difficile (c-diff), an infection of the colon, shingles (rash caused by same virus as chickenpox) or Methicillin Resistant Staphylococcus Aureus (MRSA), a resistant bacterium from antibiotic use. He/She said he/she has been employed at the facility for six months and has received EBP training. He/She said the sign on the door is an old sign and didn't apply to the resident. During an interview on 2/26/27 at 11:26 A.M., the Director of Nursing (DON) said he/she was not aware the aides did not apply appropriate PPE during a transfer of a resident with a wound.3. Review of Resident #2's quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact with one unhealed stage III pressure ulcer.Observation on 02/26/26 at 12:01 P.M., showed the door to Resident #2's room contained a sign the resident required EBP for high-contact care. PPE was not observed in proximity of the room. or on a rack on the door inside the room. During an interview on 02/26/26 at 11:42 A.M., the resident said he/she has a wound on his/her bottom. 4. Review of Resident #11's Quarterly MDS, dated [DATE] showed staff assessed the resident as cognitively intact with one unhealed stage III pressure ulcer. Observation on 02/26/26 at 10:06 A.M., showed a sign on the resident's door indicated EBP needed for high-contact resident care. PPE was not observed in proximity of the door or a rack inside the room. During an interview on 02/26/26 at 10:06 A.M., the resident said he/she has wounds on his/her legs and feet.5. During an interview on 02/26/26 at 12:15 P.M., the Director of Nursing (DON) said EBP is used for residents with wounds, catheters, or other indwelling/medical devices. The resident should have a sign on the door alerting staff the need to use EBP and a cart or isolation supplies should be by the resident's door. The DON said it depends on why the resident requires EBP if the staff should use a gown during transfers. The DON said Resident #3 would require EBP since he/she has a wound. He/She said he/she has only been in the DON role for four days and did not know staff were not wearing the appropriate EBP. During an interview on 02/27/26 at 11:26 A.M., the Infection Preventionist (IP) also RN charge nurse said EBP should be followed, to include use of a gown and gloves, for catheter care, wound care, colostomy care and with any direct resident contact with such devices. A sign should be posted on the door to alert staff there is resident in the room that requires the extra PPE. There should also be a rack that hangs on the door with the needed PPE contained inside it to alert staff to apply the necessary equipment for care. Staff should apply antibacterial solution prior to entering the room which is on the walls outside the resident rooms. The IP said if there is no gown or gloves in the resident room, staff are expected to go to the storage closet or linen closet to apply it prior to performing any care. PPE is to be removed and placed in the regular trash prior to leaving the resident room after care is given. The trash is then removed from the room. The IP said the floor charge nurse is expected to ensure compliance with use of EBP. Complaint #2734139

Based on interviews and record review, facility staff failed to report two separate allegations of resident-to-resident physical abuse involving one resident (Resident #1) to the Department of Health and Senior Services (DHSS) within the two-hour required timeframe. The facility's census was 89.1. Review of the facility's Abuse Prevention Policy, dated 11/28/2016, showed physical abuse includes, but is not limited to, hitting, slapping, punching, biting, and kicking. All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but no later than two hours after the allegation is made, if the events that cause the allegation involve abuse (ALL abuse allegations are to be reported within two hours), or if an event, results in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. 2. Review of Resident #1's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 11/22/25, showed staff assessed the resident with moderate cognitive impairment, diagnoses to include Dementia, Alzheimer's disease, difficulty speaking and understanding others, and independent with ambulation. Review of the resident's progress notes, dated 12/18/25, showed Licensed Practical Nurse (LPN) B documented staff reported Resident #1 was banging on the exit doors of the secured unit, staff redirected Resident #1 away from the door, Resident #1 began to pace the hallway where another resident (Resident #2) was walking towards him/her. Resident #1 grabbed Resident #2 and hit him/her multiple times, which caused Resident #2 to hit Resident #1 in return, staff immediately separated both residents, notified LPN B of the altercation, residents assessed with no injuries, denied pain or discomfort, Resident #1 placed on 15-minute checks, management on call made aware of incident, physician and responsible party notified, Resident #1 sent to the emergency room for evaluation.During an interview on 01/15/26 at 11:24 A.M., the administrator said he/she was not aware of the documented incident on 12/18/25, the incident should have been reported to DHSS within two hours, and he/she does not know why the nurse did not submit an initial report to DHSS.During an interview on 01/15/26 at 12:45 P.M., LPN A said all allegations of abuse or witnessed physical altercations between residents should be reported to DHSS within two hours. LPN A said LPN B notified him/her via phone of the incident, he/she instructed LPN B to start the investigation, fill out an after hours self-report form and submit to DHSS. LPN A said when he/she arrived at facility, LPN B had already left, the self-report form was incomplete, and since it was past the two-hour timeframe, he/she took the completed form to the administrator for guidance, and did not know the administrator did not submit the report to DHSS.During an interview on 01/15/26 at 4:33 P.M., LPN B said all allegations of abuse or witnessed physical altercations between residents should be reported to DHSS within two hours, but he/she did not submit a report to DHSS. LPN B said he/she was told since it was the end of his/her shift, a member of management would take care of it, and LPN A who was the manager on duty, said he/she was on the way to the facility and would complete the report and submit to DHSS. 3. Review of Resident #2's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact, diagnoses to include cognitive deficits following Nontraumatic Intracerebral Hemorrhage (a type of stroke), and independent with ambulation.Review of the facility's investigation, dated 01/07/26, showed staff documented Resident #2 came out of his/her room holding Resident #1's arms and asked staff for help but before staff could intervene, Resident #1 hit Resident #2 on the left side of his/her face and Resident #2 hit Resident #1 by his/her mouth, staff separated/redirected the residents, notified the nurse who assessed both residents, placed the residents on 15 minute checks, notified the DON, ADON, the physician and responsible parties. The report did not contain documentation facility staff reported the allegation to DHSS within the two-hour timeframe. Review of the DHSS complaint/facility self-report database did not contain documentation the facility reported the allegation of physical abuse between the residents. During an interview on 01/15/26 at 1:20 P.M., the administrator said he/she investigated the incident on 01/07/26 but thought it was Resident #1's first physical altercation with another resident, and since there were no injuries to either resident, no suspicion of abuse, and staff immediately placed interventions in place, he/she did not report the incident to DHSS. The administrator said now that he/she is aware of the incident on 12/18/25, he/she should have reported the incident on 01/07/26 to DHSS within two hours.Intake# 2713416

Based on observation, interview, and record review, facility staff failed to complete shiftily controlled drug counts with two staff members per facility policy to prevent misappropriation and assure correct controlled drug counts. The facility census was 92.The administrator was notified on 11/25/25 of past Non-Compliance which occurred on 10/25/25 when the administrator implemented new policies and procedures to ensure Certified Medication Technician (CMT) and nurses counted narcotics at the beginning and end of each shift with two staff members and documented on the Narcotic Count Form. Staff were in-serviced on 10/25/25 regarding counting narcotics at the beginning and end of each shift with two staff members and documented on the Narcotic Count Form.1. Review of the facility's Narcotic Count policy, dated undated, showed staff are directed as follows:-The purpose is to complete a physical inventory of narcotics at each shift change to identify discrepancies. -One Registered Nurse (RN), Licensed Practical Nurse (LPN), or CMT going off duty AND one RN, LPN, or CMT coming on duty must count and justify accuracy of narcotics supply for each individual resident at the change of each shift.-Narcotic records are reconciled by a physical count of the remaining narcotic supply at each shift change by the incoming and outgoing licensed nurse. Records are to be retained for at least one year. -After the supply is counted and justified, the nurse/CMT records the date and his/her signature, verifying that the count Is correct.2. Review of facility's investigation, dated 10/25/25, showed facility staff documentd the narcotic log sheet identified two missing controlled medications. Facility staff found the missing medications to be related to medications not accurately signed out per policy and did not identify misappropriation of any narcotic controlled medications. 3. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 11/02/25, showed staff assessed the resident as:-Moderately cognitively impaired;-Received a pain medication as needed during the seven day look back period;-Used an opioid medication.Review of the resident's progress notes, dated 10/22/25, showed staff documented the resident transferred to the hospital. Review of the resident's progress notes, dated 10/28/25, showed staff documented the resident returned from the hospital.Review of the resident's Physician Order Summary (POS), undated, showed an order for Tramadol (treats pain) 100 milligrams twice a day. Review of the resident's controlled substance log, dated 10/22/25 through 10/25/25, showed controlled substance log did not contain documentation staff counted the resident's Tramadol medication. Review showed the 16 pills remained on 10/22/25 and 14 pills remained on 10/25/25. Review of the facility's Controlled Substance Shift Change Form for upper 100 hall, dated 10/01/25 through 10/31/25, showed:-10/01/25, one staff signature for 7:00 A.M.;-10/02/25, one staff signature for 11:00 P.M.;-10/03/25, one staff signature for 7:00 A.M. and 11:00 P.M.;-10/04/25, one staff signature for 7:00 A.M.;-10/05/25, one staff signature for 11:00 P.M.;-10/06/25, one staff signature for 7:00 A.M. and 11:00 P.M.;-10/07/25, one staff signature for 7:00 A.M.3:00 P.M. and no signatures for 11:00 P.M.;-10/08/25, one staff signature for 7:00 A.M. and 3:00 P.M.;-10/09/25, one staff signature for 3:00 P.M. and 11:00 P.M.;-10/10/25, one staff signature for 7:00 A.M. 3:00 P.M. and no signatures for 11:00 P.M.;-10/11/25, one staff signature for 7:00 A.M. and no signatures for 11:00 P.M;-10/12/25, one staff signature for 7:00 A.M., no signatures for 3:00 P.M. and 11:00 P.M.;-10/13/25, one staff signature for 7:00 A.M. and 3:00 P.M.;-10/14/25, one staff signature for 3:00 P.M. and 11:00 P.M.;-10/15/25, one staff signature for 7:00 A.M., 3:00 P.M., and 11:00 P.M.;-10/16/25, one staff signature for 7:00 A.M., 3:00 P.M. and 11:00 P.M.;-10/17/25, one staff signature for 7:00 A.M., 3:00 P.M. and no signatures for 11:00 P.M;-10/18/25, one staff signature for 7:00 A.M. and 11:00 P.M.;-10/19/25, one staff signature for 7:00 A.M. and 11:00 P.M.;-10/20/25, one staff signature for 7:00 A.M.;-10/21/25, one staff signature for 11:00 P.M.;-10/22/25, one staff signature for 7:00 A.M. and 11P.M.;-10/23/25, one staff signature for 7:00 A.M. and 11:00 P.M.;-10/24/25, one staff signature for 7:00 A.M., 3:00 P.M. and 11:00 P.M.;-10/25/25, one staff signature for 7:00 A.M. and no signatures for 3:00 P.M.;-10/26/25, one staff signature for 3:00 P.M. and no signature for 11:00 P.M;-10/27/25, one staff signature for 7:00 A.M. and 3:00 P.M.;-10/28/25, one staff signature for 3:00 P.M.;-10/30/25, one staff signature for 7:00 A.M. and 11:00 P.M.;-10/31/25, one staff signature for 7:00 A.M. and 11:00 P.M During an interview on 11/24/25 at 12:29 P.M., CMT A said staff are educated to complete a narcotics count at the beginning and end of each shift with two staff members and initial the count as correct on the Controlled Substance Shift Change Form. He/She said if medications were discovered missing, staff should report to the charge nurse. He/She said he/she and CMT B both had the key for his/her medication cart. He/She said it was busy when they came to work, so they did not have an opportunity to count the narcotic medication. He/She said when they did have an opportunity to count the narcotic medication for CMT B's cart, they discovered the missing Tramadol for the resident and reported it to a nurse. He/She said he/she did not take the resident Tramadol medication. During an interview on 11/24/25 at 1:51 P.M., CMT B said staff are directed to count narcotic medications every shift with two people. He/She said he/she worked on 10/23/25 and 10/24/25 and the Tramodol for the resident was correct. He/She said he/she worked with RN C at night, but did not recall if he/she counted the narcotics with him/her. He/She said sometimes the nurse would forget to sign the Controlled Substance Shift Change Form. He/She said he/she was the last person to count before the 7:00 A.M. shift on 10/25/25, but he/she did not take the resident medication. He/She said he/she did receive an in-service making sure the narcotic medication are counted when going off and on shift by two staff and documented on the Controlled Substance Shift Change Form. During an interview on 11/24/25 at 3:06 P.M., RN C said staff are directed to count controlled narcotics at the beginning of each shift with two staff members. He/She said he/she did not complete a narcotic count of the CMT's cart because the staff would leave prior to completing the count. He/She said staff received an in-service on the process for counting narcotics with two people at the beginning and end of each shift and to document on the Controlled Substance Shift Change Form.During an interview on 12/01/25 at 2:46 P.M., the administrator said staff are directed to count the narcotics for all residents at the beginning and end of shift with the ongoing and off going staff. He/She said staff documented their names on the Narcotic Count Sheet. He/She said staff verified the number of pills left in the medication card even if the resident was discharged to the hospital. He/She said the ADON and DON were responsible to audit to make sure the Narcotics were counted each shift. He/She said the DON began his/her position on 11/16/25 after the incident. He/She said the DON will be auditing the forms twice a week. He/She said staff were in-serviced on 10/25/25 on counting with staff members and documenting on the Narcotics Count Sheet. During an interview on 12/01/25 at 2:46 P.M., Director of Nursing (DON) said staff are directed to count the narcotics for all residents at the beginning and end of shift with the ongoing and off going staff. He/She said staff would document the information on the Narcotic Count Sheet. He/She said staff should verify the number of pills left in the medication cards are correct, even when a resident was discharged to the hospital. and document it on the sheet. He/She said the charge nurse was responsible to ensure the medication are counted at each shift and the ADON and DON were responsible to audit to make sure the Narcotics were counted each shift. He/She said he/she was not employed until 11/16/25. He/She said staff were in-serviced on 10/25/25 on counting with staff members and documenting on the Narcotics Count Sheet. He/She said he/she was responsible to audit the forms twice a week.2652477

Based on observation, interview, and record review, facility staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when facility staff failed change and/or store oxygen tubing in a manner to prevent the spread of bacteria for two residents (Resident #14 and #15) out of three sampled residents. Facility staff failed to implement the Enhanced Barrier Precautions (EBP) policy when they did not educate, or alert staff of residents who required EBP, and failed to place appropriate personal protective equipment (PPE) in close proximity for two residents (Resident #26, and #187) of two sampled residents. Facility staff failed to maintain proper infection control practices for two residents (Resident #26 and #187) out of two sampled residents with catheters. Facility staff failed to perform appropriate hand hygiene, and glove changes during wound care for one resident (Resident #26) out of two sampled residents. The facility's census was 83. 1. Review of the facility's Oxygen Equipment policy dated March 2015, showed oxygen tubing, masks, and cannulas used with oxygen therapy should be replaced monthly and marked with the date and initials. All concentrator outside surfaces are to be cleansed weekly by nursing personnel. 2. Review of Resident #14's Quarterly Minimum Data Set (MDS), dated [DATE], showed staff assessed the resident as: -Cognitively impaired; -Did not use oxygen; -Diagnosis of stroke. Review of the resident's Physician Order Sheet (POS), dated March 2025, showed the POS did not contain an order to change the tubing. Review of the Medication Administration Record (MAR,) dated March 2025, showed the MAR did not contain direction to clean the oxygen concentrator filters. Observation on 03/18/25 at 10:50 A.M., showed the resident wore oxygen via cannula. The oxygen concentrator filter covered with white debris on one side of the machine. Observation on 03/18/25 at 1:51 P.M., showed the resident in bed with oxygen on via cannula. The concentrator filter covered with white debris on one side of the machine. Observation on 03/19/25 at 7:57 A.M., showed the resident's oxygen concentrator filter on one side covered with white debris and the tubing. Observation on 03/21/25 at 7:43 A.M., showed the resident's oxygen concentrator filter on one side covered with white debris. 3. Review of Resident #15's Annual MDS, dated [DATE] showed staff assessed the resident as: -Cognitively impaired; -Used oxygen; -Diagnosis of dementia and respiratory failure. Review of the resident's POS, dated March 2025, showed the POS did not contain an order to change the tubing. Observation on 03/18/25 at 11:04 A.M., showed the resident in bed with oxygen on via nasal cannula. Observation on 03/19/25 at 8:13 A.M., showed the resident sat on the side of the bed with oxygen on via nasal cannula. Observation on 03/19/25 at 10:19 A.M., showed the resident in bed on his/her side with oxygen on via nasal cannula. Observation on 03/20/25 at 2:02 P.M., showed the resident sat on the side of his/her bed with oxygen on via nasal cannula. During an interview on 03/21/25 at 08:58 A.M., the MDS Nurse said he/she thinks the nurse aides should change oxygen tubing weekly and clean the oxygen filters. During an interview on 03/21/25 at 10:06 A.M., the Director of Nursing (DON) said he/she oversee's the nursing staff and will do weekly audits. He/She said nursing is to change out oxygen tubing weekly and clean the filters. When oxygen tubing is replaced, it is to be dated. He/She was not aware the filters were dirty. During an interview on 03/21/25 at 11:02 A.M., the administrator said that oxygen tubing should be changed weekly by nursing staff and dated and initialed when changed. The nursing staff should wipe down the concentrator to include the filters weekly. He/She said the DON is responsible for nursing oversight. If the machines are not cleansed, it could case them not to function properly. 4. Review of the Facility's Enhanced Barrier Precautions to Infection Control Guidance, dated March 2024, showed: -To prevent broader transmission of Multidrug-resistance organisms (MDRO) and to help protect patients with chronic wounds and indwelling devices. EBP should be implemented for the period of their stay or until wounds have resolved or indwelling medical devices have been removed; -Who requires EBP: -Residents known to be infected or colonized with MRDO; -Residents with an indwelling medical device including the following: central venous catheter, urinary catheter, feeding tube (PEG tube, G-tube), tracheostomy/ventilator regardless of their MDRO status; -Residents with a wound, regardless of their MRDO status; -When to use EBP: -Bath/showering; -Transferring residents from one position to another; -Providing hygiene; -Caring fir or using an indwelling medical device; -Performing wound care; -Residents that are on EBP should have PPE in close proximity outside the door and a trash can in resident's room for disposal prior to leaving room. 5. Review of Resident #26's Quarterly MDS, dated [DATE] showed staff assessed the resident as: -Cognitively intact; -Substantial maximal assistance with personal hygiene and showers; -Dependent on staff for toilet hygiene; -Indwelling catheter; -Diagnosis of stage 2 (mild damage to your kidney) kidney disease. Review of the resident's POS, dated March 2025, showed the POS did not contain direction for staff on EBP. Review of the resident's care plan, dated 03/06/25, showed the care plan did not contain direction for staff on EBP. Observation on 03/18/25 at 2:15 P.M., showed the resident's room did not contain a sign to alert staff on the use of EBP or PPE in close proximity of the room. Observation on 03/19/25 at 9:06 A.M., showed the resident's room did not contain a sign to alert staff on the use of EBP or PPE in close proximity of the room. Observation on 03/19/25 at 1:36 P.M., showed Registered Nurse (RN) Q provided wound care to the resident and did not wear a gown. Observation on 03/20/25 at 1:59 P.M., showed the resident's room did not contain a sign to alert staff on the use of EBP or PPE in close proximity of the room. Observation on 03/21/25 at 9:15 A.M., showed the resident's room did not contain a sign to alert staff on the use of EBP or PPE in close proximity of the room. During an interview on 03/21/25 at 10:51 A.M., RN Q said he/she should have worn a gown to clean the resident's wound. He/She said there is usually a sign on the door to alert staff or remind them. He/She said the resident had an open wound and is at high risk for infection, and the gown is used to protect them. 6. Review of Resident #187's Admission MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Indwelling catheter; -Ostomy; -Has a stage 4( full thickness tissue loss with exposed bone, tendon, or muscle) unhealed pressure ulcer; -Diagnosis of stroke, dementia, and Hemiplegia (paralysis to one side of the body). Review of the resident's POS, dated March 2025, showed the POS did not contain direction for staff on EBP. Review of the resident's care plan, dated 03/06/25, showed the care plan did not contain direction for staff on EBP. Observation on 03/18/25 at 10:30 A.M., showed the resident's room did not contain a sign to alert staff on the use of EBP or PPE in close proximity of the room. Observation on 03/19/25 at 9:29 A.M., showed the resident's room did not contain a sign to alert staff on the use of EBP or PPE in close proximity of the room. Observation on 03/20/25 at 10:20 A.M., showed the resident's room did not contain a sign to alert staff on the use of EBP or PPE in close proximity of the room. Observation on 03/20/25 at 10:54 A.M., showed Nurse Aide (NA) N and Certifed Medication Technition (CMT) C transferred the resident from his/her bed to his/her wheel chair. The staff touched the resident's catheter bag and NA N emptied the resident's colostomy bag. The NA and CMT did not wear a gown. During an interview on 03/20/25 at 10:01 A.M., the resident said the staff do not wear gowns when handling his catheter, wound or colostomy bag. During an interview on 03/20/25 at 10:17 A.M., the resident's family member said he/she has not seen staff wear gowns when transferring the resident or when doing catheter or colostomy care. He/She said he/she is concerned about the resident's care because he/she has a wound, catheter and colostomy. He/She said the resident now has a UTI that he/she did not have when they were admitted . During an interview on 03/20/25 at 2:12 P.M., NA N said staff are expected to wear gowns when performing catheter care. He/She said they should change gloves and perform hand hygiene between clean and dirty tasks. He/She said gowns are to prevent cross contamination. He/She said he/she knows which residents to use gowns and gloves on by what he/she is told in morning report. He/She said he/she is not sure if gowns are required during transfers or just for when performing catheter care. During an interview on 03/20/25 at 2:22 P.M., CMT C said he/she was taught staff should wear gowns during catheter and ostomy care. He/She was not sure if it needed to also be worn during transfers. He/She said gowns protect residents from infections. He/She said they are made aware of who needs gowns by report. He/She does not know of any other indicators of needing EBP. He/She said PPE is sometimes kept on blue carts in the hallways or staff can get them out of the clean utility room. During an interview on 03/21/25 at 9:13 A.M., the MDS nurse said any resident with a catheter, wound, or colostomy should have EBP in place. He/She said those residents should have a sign on their door to alert staff and staff need to know where the PPE is kept for that resident. He/She said he/she is not sure if there are currently signs up for residents on EBP. During an interview on 03/21/25 at 10:08 A.M., the DON said residents with catheters, colostomies, and wounds should have EBP in place. He/She said it is his/her expectation that staff wear gowns and gloves when caring for those residents on EBP. He/She said if is to protect the residents form cross contamination. He/She said it is his/her responsibility as DON to ensure staff are using the EBP and signs are hung. He/She said when he is not available it is the responsibility of the Assistant Director of Nursing (ADON). He/She said he/she has provided education to the staff on EBP and he is not sure why they are not using gowns and gloves appropriately. During an interview on 03/21/25 at 11:02 A.M., the administrator said residents who have catheters, wounds, ostomies, and colostomies should be on EBP. He/She said residents should have a star placed on their door to alert staff that they are on precautions. He/She said staff should be wearing gowns and gloves when transferring residents on EBP and when providing care. He/She said staff have been educated regarding EBP and the stars. He/She said it is the responsibility of the DON to place the stars the resident's doors and to educate the staff. He/She was not aware that the resident's doors did not contain stars on the doors of the residents who were on EBP. He/She said he/she did not know staff were not wearing PPE while providing care to residents on EBP. 7. Review of the Emptying a Urinary Drainage Bag Catheter policy, dated March 2014, showed staff are directed to keep the drainage bag below the level of the resident's bladder. 8. Review of Resident #26's Quarterly MDS, dated [DATE] showed staff assessed the resident as: -Cognitively intact; -Substantial maximal assistance with personal hygiene and showers; -Dependent on staff for toilet hygiene; -Indwelling catheter -Diagnosis of stage 2 kidney disease. Observation on 03/19/25 at 9:36 A.M., showed Certified Nurse Aide (CNA) O and NA P entered the resident's room to perform perineal and catheter care. NA P placed the catheter bag on the bed. CNA O cleaned the resident's front side and with the sam soiled gloves cleaned the catheter tubin, clean the resident's back side, which had open bleeding wounds. During an interview on 03/19/25 at 9:54 A.M., CNA O said he/she should always perform hand hygiene when he/she changes his/her gloves and gloves should be changed when going from clean to dirty tasks. He/She said he/she doesn't know why he/she did it that way, he/she said he/she was trying to remember the correct steps. He/She said catheter bags should not be placed on the residents bed because of infection control. During an interview on 03/21/25 at 9:13 A.M., the MDS nurse said it is his/her expectation during catheter care, that staff change gloves and perform hand hygiene between clean and dirty tasks. During an interview on 03/21/25 at 10:08 A.M., the DON said it his/her expectation that staff perform hand hygiene and glove changes between clean and dirty tasks. He/She said that applies to catheter care and staff should change gloves when moving from the front side of the resident to cleaning the catheter and then again before moving to the back side of the resident. He/She said this is import for preventing cross contamination. During an interview on 03/21/25 at 11:02 A.M., the Administrator said it is his/her expectations that staff wash their hands when they enter the resident's room, before starting catheter care, when they go from between clean and dirty tasks, any time they change gloves, and before they exit the resident's room. He/She said they should never use the same gloves throughout the whole catheter care process because there is a potential for their gloves to have contaminates on them and they can spread it to other areas. 9. Review of Resident #187's Admission MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Indwelling catheter; -Ostomy; -Has a stage 4 unhealed pressure ulcer; -Diagnosis of stroke, dementia, and Hemiplegia (paralysis to one side of the body). Review of the resident's face sheet, dated 3/17/25, showed the resident had a diagnosis of a urinary tract infection. Review of the resident's care plan, dated 03/06/25, showed the care plan directed staff to keep the catheter bag below the level of the bladder. Observation on 03/20/25 at 10:54 A.M., showed NA N and CMT C entered the resident's room to transfer him/her into his/her wheelchair. CMT C placed the catheter bag on top of the resident's bed, urine in the tube observed flowing toward the resident's body. He/She then picked up the catheter and held it in his/her left hand, holding the bag above the height of the resident's bladder. During an interview on 03/20/25 at 2:12 P.M., NA N said catheters should be kept below the level of the bladder for flow and infection control. 10. During an interview on 03/20/25 at 2:22 P.M., CMT C said catheters should be hung under wheel chairs or on the side of the bed. He/She said they should never be on the floor or placed on the bed for infection control reasons. He/She said it should always be below the resident's waist because it should always drain down. He/She said he/she was trying to think of the right thing to do during the transfer. During an interview on 03/21/25 at 9:13 A.M., the MDS nurse said catheters should be kept below the level of the bladder and should not be placed on beds, to prevent infections. During an interview on 03/21/25 at 10:08 A.M., the DON said catheter bags should be kept below the bladder and should not be placed on beds to prevent back flow and prevent infection/cross contamination. During an interview on 03/21/25 at 11:02 A.M., the administrator said to maintain infectioin control, catheter bags should not be [NAME] above the bladder or placed on resident beds. 11. Review of the Facility's Wound Care and Treatment policy, dated March 2015, showed the record did not contain direction on the care of multiple wounds. Review of the Centers for Diesease Control and Prevention's (CDC) Preventing Transmission of Infectious Agents in Healthcare Settings, dated 11/27/23, showed it directed staff to change gloves during patient care if the hands will move from a contaminated body-site (e.g., perineal area) to a clean body-site (e.g., face). Review of the Facility's Glove policy, dated March 2014, showed: -Gloves must be changed between residents and between contacts with different body sites of the same resident; -Dirty gloves are worse than dirty hands because microorganisms adhere to the surface of a glove easier than to the skin on your hands. 12. Review of Resident #26's Quarterly MDS, dated [DATE] showed staff assessed the resident as: -Cognitively intact; -Substantial maximal assistance with personal hygiene and showers; -Dependent on staff for toilet hygiene; -Risk for skin break down; -Moisture associated skin damage; -Diagnosis of type 2 diabetes mellitus. Review of the wound nurse notes, dated 03/17/25, showed: -Wound one left buttock, superior; -Wound two left buttock, inferior; -Wound three right buttock, superior; -Wound four right buttock, inferior. Observation on 03/19/25 at 1:36 P.M., showed RN Q entered the resident's room to perform wound care. Four open bleeding areas were observed on the resident's buttock and debris from the resident's bed covered the wounds. RN Q cleaned all four areas with the same gauze and gloves. RN Q changed his/her gloves and performed hand hygiene before he/she used the same skin prep pad to wipe round wound 1, 2, 3 and 4, before he/she applied the dressing. During an interview on 03/21/25 at 9:13 A.M., the MDS nurse said he/she expect staff to complete wound care on each wound individually changing gloves and washing hands as they go. He/She said the concern for not doing wounds separately would be the change of cross contaminating the wounds. During an interview on 03/21/25 at 10:08 A.M., the DON said it is his/her expectation that staff clean each would individually to prevent cross contamination. He/She would expect staff to remove the bandage, change gloves and wash hands, clean the wound, remove gloves and wash hands, apply the treatment, remove gloves and wash hands, and then apply the bandage, remove gloves wash hands then move to the next wound. During an interview on 03/21/25 at 11:02 A.M., the Administrator said it is his/her expectation that staff perform hand hygiene any time they remove or replace their gloves, that gloves are changes between clean and dirty tasks and that staff remove gloves and change them between each set of wounds. He/She said staff should never care for multiple wounds with the same gloves, it puts the resident at risk for cross contamination of the wounds. He/She said he/she was not aware staff were caring for the multiple wounds at the same time. During an interview on 03/26/25 at 10:51 A.M., RN Q said he/she individual wounds should be treated separately. He/She said staff should change gloves and perform hand hygiene before moving on to another wound. He/She said he/she did not consider them as separate wounds but as one large wound to the resident's buttock. 47193

Based on observation, interview and record review, facility staff failed to develop a comprehensive person-centered care plan to meet the resident's medical, nursing, mental and psychosocial needs for five residents (Resident #9, #15, #20, #34 and #53) out of twelve sampled residents. The facility's census was 83. 1. Review of the facility's Care Plan Comprehensive policy dated March, 2015 showed: -The interdisciplinary care plan team (IDT) with input from the resident, family, and/or legal representative will develop and maintain a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain; The comprehensive care plan will be based on a thorough assessment that includes, but is not limited to the Minimum Data Set (MDS), a federally mandated assessment tool; -Assessment of each resident is ongoing and the care plan will be revised as changes occur in the resident's condition. 2. Review of Resident #9's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 12/19/24, showed staff assessed the resident as: -Cognitively intact; -No falls; -Diagnosis of Respiratory failure. Review of the resident's progress note, dated 01/07/2025 at 5:25 P.M., showed the resident has an unwitnessed fall. Review of the resident's progress note, dated 02/05/2025 at 8:32 A.M., showed resident had an unwitnessed fall. Review of the resident's electronic medical record (eMAR), dated 02/05/25, showed an explosive fracture of right hip prothesis. Review of the resident's care plan, dated 03/17/25, showed the care plan did not address falls, contain guidance or interventions after a fall with major injury. 3. Review of Resident #15's Annual MDS, dated [DATE], showed staff assessed the resident as: -Cognitively impaired; -On oxygen; -Diagnosis of respiratory failure. Review of the Physician Order Sheet (POS), dated March 2025, showed the resident to wear oxygen by nasal cannula at 2 liters per minute (L) continuously for pulmonary disease. Review of the care plan dated 02/02/25, showed the care plan did not contain direction or guidance for the use of oxygen, care of the oxygen concentrator, or storage and maintenance of the tubing. Observation on 03/18/25 at 11:04 A.M., showed the resident wore oxygen via nasal cannula at 2L. Observation on 03/19/25 at 08:13 A.M., showed the resident wore oxygen via nasal cannula at 2L. Observation on 03/20/25 at 02:02 P.M., showed the resident wore oxygen via nasal cannula at 2L. 4. Review of Resident #20's Quarterly MDS, dated [DATE] showed staff assessed the resident as: -Cognitively impaired; -Had no weight loss or gain; -Diagnosis of anemia (low iron in the blood), malnutrition and dementia. Review of the resident's Annual MDS, dated [DATE], showed staff assessed the resident as felt it was somewhat important to: -Have books, newspapers or magazines to read; -Listen to music he/she liked; -Do things with groups of people; -Do their favorite activities; -Go outside to get fresh air when the weather is good; -Participate in religious services or practices. Review of the POS, dated March 2025, showed the following physician orders: -Regular diet; -Super cereal (a fortified cereal to provide extra calories, protein and essential nutrients) for breakfast. At risk for malnutrition; -Speech therapy evaluation and treatment related to weight loss; -Very High Caloric drink (VHC) 120 milliliters (ml) three times a day for malnutrition; -Health shakes (drink used to provide extra calories, protein and essential nutrients) three times a day between meals; -Remeron 15 milligrams (mg) daily for malnutrition; -Iron 325 mg twice a day for anemia; -Vitamin B12 1000 mg for anemia. Review of the resident's care plan, dated 03/18/25, showed the care plan did not contain direction or preferences for activities or nutrition needs and/or diet/weight. 5. Review of Resident #34's Annual MDS dated [DATE], showed staff assessed the resident as: -Cognitively impaired; -Feels it is very important to be around animals such as pets and go outside to get fresh air when the weather is good; -Feels it is somewhat important to listen to music, keep up with the news, do things with groups of people, and do their favorite activities; -Diagnosis of dementia. Review of the resident's care plan, dated 03/10/24, showed the care plan did not contain guidance or preferences for activities. 6. Review of Resident #53's Quarterly MDS dated [DATE], showed staff assessed the resident as: -Cognitively impaired; -Required supervision or touch for ambulation and eating; -Required partial to moderate assistance for oral hygiene, upper body dressing, toilet transfers, sitting to lying, and bed to chair to bed transfers; -Required substantial to maximum assistance for lower body dressing, application of shoes, personal hygiene and tub/shower transfers; -Dependent on staff for toilet hygiene and showers/baths; -Diagnosis of dementia. Review of the residents Annual MDS dated [DATE], showed the staff completed the activity preferences for the resident and identified the resident prefers family or significant other involvement in care discussions. No other activity preferences were identified. Review of the resident's care plan, dated 03/15/25, showed the care plan did not contain direction or preferences for activities or activities of daily living (ADL)'s. 7. During an interview on 03/21/25 at 8:13 A.M., Nurse Aide (NA) M said the aides are informed of care needs of residents through word of mouth, through shift change report or care sheets in the closets of each resident room. He/She said he/she did not know why the care sheets were not in the closets for the residents right now but knows they should be there. During an interview on 03/21/25 at 8:58 A.M., the MDS Coordinator said care plans should tell a picture about the resident to include fall risks, wounds, behaviors and be a live document. He/She notifies the staff of changes to the care plans verbally or the aides have access to the care plans through the kiosks. Some rooms have care sheets in the closets and some do not. He/She has been working on the floor as a nurse a lot lately and there has been an increase in new residents so the care sheets is a work in progress. The care sheets should be a snapshot of the residents care needs such as transfers, diet, code status and basic care needs. On the memory care unit, staff will have a binder with the care cards. The MDS Coordinator said he/she is responsible to update the care plans any time there is a change in the resident and is usually done during the daily meetings, but is currently behind. He/She said the Director of Nursing (DON) is responsible to check his/her work. During an interview on 03/21/25 at 10:06 A.M., the DON said care plans should include anything the staff does for the resident or if something else is needed to include showers, refusals of care, how the resident sleeps, out of the ordinary things. The care plans should also include falls, hospice, oxygen and activity preferences. He/She said he/she audits the care plans with falls and discuss resident care needs during morning meetings. During an interview on 03/21/25 at 11:02 A.M., the Administrator said the MDS nurse is responsible for care plans but anyone can update them. Care plans should include resident preferences, behaviors, catheter use, diets, oxygen and everything pertinent to the resident that will paint a picture or story. He/She said care plans should be updated if there are changes in the resident care needs such as falls. He/She said the DON is responsible to ensure the care plans are up to date and accurate. He/She was not aware some of the care plans were missing information. 47193

Based on interview and record review, the facility staff failed to designate one or more individuals with specialized training in Infection Prevention and Control as the Infection Preventionist for the facility's infection prevention and control program. The census was 83. 1. Review of the facility's Infection Preventionist Control policy, undated, showed the IP will complete the Centers for Disease Control (CDC) Long Term Care IP module. Review of the current Infection Preventionist Certificate Of Completion, dated [DATE] showed: -4.0 credit hours; -Web training; -Covered introduction to infection control, transmission, prevention and control, hand hygiene, personal protective equipment, environmental controls, sharps and injection safety, occupational health and safety, and sepsis; -Expiration date of [DATE]. During an interview on [DATE] at 9:20 A.M., the IP said he/she was not aware the certification had expired. He/She is currently the only active IP person at the facility and is always reviewing infection control practices at the facility, completing the antibiotic stewardship tracking and trending and teaching of infection control process's. During an interview on [DATE] at 03:30 P.M., the administrator said he/she was not aware the Infection Preventionist certification expired. He/She said he/she believed the Infection Preventionist had the correct certification. The current Infection Preventionist is the only one acting in that role.

Based on observation, interview, and record review, facility staff failed to post required nurse staffing information to include the facility name, resident census, total number of staff and total actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care, per shift on a daily basis. The facility census was 83. 1. Review of the facility's policies showed staff did not provide a policy for Staffing and Scheduling Postings. 2. Observation on 03/18/25 at 10:49 A.M., showed staff did not post required nurse staffing information to include the total number of staff and the actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care, per shift. 3. Observation on 03/19/25 at 9:40 A.M., showed staff did not post required nurse staffing information to include the total number of staff and the actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care, per shift. 4. Observation on 03/20/25 at 10:23 A.M., showed staff did not post required nurse staffing information to include the total number of staff and the actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care, per shift. 5. Observation on 03/21/25 at 08:15 A.M., showed staff did not post required nurse staffing information to include the total number of staff and the actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care, per shift. 6. During an interview on 03/21/25 at 10:08 A.M., the Director of Nursing (DON) said they do not have it posted anywhere. He/She said he/she is responsible for posting it and he/she knows it is a requirement to be posted but has not been posting it like he/she should. He/She said he/she didn't not have a reason why it was not posted. During an interview on 03/21/25 at 11:02 A.M., the Administrator said he/she is aware that daily staff hours should be posted for direct care staff with the total numbers of actual hours worked. He/She said it is supposed to be posted on the 100 hall by the nurse station where all staff, residents, and visitors can see it. He/she said he/she is not sure why it was not posted.

Based on observation, interview, and record review, facility staff failed to maintain resident dignity by not properly covering urinary catheter bags for two residents ( Resident #55, and Resident #187) out of 2 sampled residents. The facility census was 83. 1. Review of the facility's Resident Rights Policy, dated April 2006, showed: -Residents have a right to dignified existence; -Resients have a right to privacy and Respect. 2. Review of Resident #55's Quarterly Minimum Data Set (MDS), a federally mandated assessment too, dated 02/05/25, showed staff assessed the resident as follows: -Cognitively intact; -Indwelling catheter (tube inserted into the bladder to drain urine). Observation on 03/18/25 at 2:09 P.M., showed the resident in his/her room with the door open. His/Her catheter bag secured to the right leg below the knee containing urine in the a clear plastic bag. No privacy cover was in place for the catheter bag. Observation on 03/19/25 at 8:31 A.M , showed the resident in his/her wheelchair in the hallway outside the residents room. The residents catheter bag full of urine and was not covered by a privacy bag. Observation on 03/20/25 at 2:27 P.M., showed the resident outside the dinning room in the hallway. The residents catheter bag not covered with a privacy bag. During an interview on 03/20/25 at 2:30 P.M., the resident said he/she knows staff should be covering it with a privacy bag. 3. Review of Resident #187's Admission MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Indwelling catheter. Observation on 03/18/25 at 10:30 A.M., showed the resident in his/her room with the door open and his/her catheter bag faced the hallway secured to the bed. The catheter bag did not contain a privacy cover. Observation on 03/19/25 at 9:29 A.M., showed the resident in his/her room with the door open. His/Her catheter bag faced the hallway secured to the bed contained urine. The catheter bag did not contain a privacy cover. Observation on 03/20/25 at 10:20 A.M., showed the resident in his/her room with the door open. His/Her catheter bag faced the hallway secured to the bed contained urine. The catheter bag did not contain a privacy cover. During an interview on 03/20/25 at 10:01 A.M., the resident said he/she had not had a cover over his/her catheter bag since he/she recieved the catheter. He/She said staff had not offered a cover and he/she did not know it was an option. During an interview on 03/20/25 at 10:17 A.M., the resident's family member said he/she had not seen a cover on the resident's catheter bag. He/She said the resident is someone who is concerned with his/her appearance and likes having his/her hair fixed. He/She said he/she has observed issues with staff and keeping the residents modesty. 4. During an interview on 03/21/25 at 8:05 A.M., Certified Nurse Aid (CNA) A said privacy bags should be placed on the cathter bags to protect the residents dignity. During an interview on 03/21/25 at 8:40 A.M. Licensed Practical Nurse (LPN) B said privacy bags are used to cover the resident catheter bags to protect their dignity. During an interview on 03/21/25 at 10:35 A.M., the Director of Nursing (DON) said privacy covers should be placed over catheter bags when they are in view. It is an issue with dignity and privacy. Even if a resident has no concerns with the bag being uncovered they should still be covered. Staff are educated on this as a standard practice. During an interview on 03/21/25 at 11:02 A.M., the administrator said catheters should be placed in dignity bags to prevent them from being exposed for everyone to see. He/She said it is a dignity concern if not placed in a bag. He/She said all catheter bags should be placed in a dignity bag unless a resident does not want it, and in that case would be need be care planned and documented in their record they do not want it.

Based on observation, interview, and record review, facility staff failed to store medication in a safe and effective manor in one medication storage room, and three medication storage carts. The facility census was 83. 1. Review of the facility's Medication, Storage Of policy, dated March 2015, showed: -No discontinued, outdated, or deteriorated drugs or biologicals may be retained for use. All such drugs must be returned to the issuing Pharmacy of destroyed in accordance with established guidelines; -Drugs must be stored in an orderly manner in cabinets, drawers, or carts. 2. Observation on 03/19/25 at 2:47 P.M., showed the 100 hall medication storage room contained: -One intravenous (IV) administration set with an expiration date of 02/19/25; -One bottle Vitamin B-6 100 milligram (mg) with an expiration date of 06/2024. 3. Observation on 03/20/25 at 11:11 A.M., showed the 200 hall medication cart contained one loose red and white oval gel capsule. 4. Observation on 03/20/25 at 11:20 A.M., showed the 100 A hall medication cart contained one loose oval white tablet. 5. Observation on 03/20/25 at 11:25 A.M., showed the 100 B hall medication cart contained one loose round white tablet. 6. During an interview on 03/20/25 at 11:14 A.M., Licensed Practical Nurse (LPN) B said all loose or outdated medication must be destroyed or returned to the Pharmacy. During an interview on 03/21/25 at 8:44 A.M., Certified Medication Technician (CMT) C said staff are to destroy out of date or loose medications found in the cart. During an interview on 03/21/25 at 10:08 A.M., the Director of Nursing (DON) said out of date medications should be destroyed and storage rooms or medication carts are to be monitored for these items. All staff involved are responsible. During an interview on 03/21/25 at 11:03 A.M., the Administrator said there should be no loose or outdated medication kept. Medication technicians are to check the carts and nurses monitor the medication storage rooms. There is no set scheduled to check theses items.

Based on observation, interview, and record review, facility staff failed to provide services to meet professional standards when staff failed to document and obtain orders for hospice services on two (Resident #53 and #187) of two sampled residents who receive hospice services, to obtain orders for an colostomy for one (Resident #187) out of one sampled residents, failed to document weekly skin assessments for three (Resident #15, #26, and #39) of four sampled residents. Facility failed to follow physician Liodcain Patch orders for one (Resident #11) of one resident. Faciliy failed to administer insulin appropriately for one (Resident #26) of four sampled residents. The facility census was 83. 1. Review of the policies provided by the facility showed the facility did not provide a hospice policy. 2. Review of #53's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 01/10/25, showed staff assessed the resident as: -Severely cognitively impaired; -On hospice; -Diagnosis of dementia. Review of the Physician Order Sheet (POS), dated March 2025, showed the POS did not contain an order for hospice services. Review of the resident's care plan, dated 03/04/25, showed the resident and family have chose hospice. 3. Review of Resident #187's Admission MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -On hospice; -Diagnosis of stroke. Review of the resident's POS, dated 03/2025, showed the POS did not contain an order for hospice care. Review of the resident's care plan, dated 03/06/25, showed the residents was on hospice. During an interview on 03/21/25 at 8:58 A.M., the MDS nurse said residents who recieve hospice services should have a physician order. He/She said it's the nurses responsibility to obtain and transcribe orders. During an interview on 03/21/25 at 10:06 A.M., the Director of Nursing (DON) said nurses are responsible obtain orders for hospice. He/She said it is his/her responsibility to ensure hospice residents have orders but was not aware there were residents without orders. During an interview on 03/21/25 at 11:02 A.M., the Administrator said nursing staff should obtain orders for hospice and document it in the medical record. He/She said the DON is responsible for nurse oversight and was unaware there were residents without hospice orders. 4. Review of the Facility's Physician Orders policy, dated March 2015, showed treatment orders should specify what is to be done, location, and frequency/duration of the treatment. Review of the Facility's Colostomy and Ileostomy Care policy, dated March 2014, showed: -Ostomy seal as ordered by physician; -Apply medication to surrounding skin as ordered by the physician. 5. Review of Resident #187's Admission MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Ostomy; -Has a stage 4 unhealed pressure ulcer; -Diagnosis of stroke, dementia, and Hemiplegia (paralysis to one side of the body). Review of the resident's POS, dated 03/2025, showed the record did not contain an order for ostomy care. During an interview on 03/21/25 at 9:13 A.M., the MDS nurse said he/she expects residents with ostomys to have orders for its care. He/She said the concern with not having orders is that ostomy care may not get done. During an interview on 03/21/25 at 10:08 A.M., the DON said it is his/her expectation that residents have orders for all ostomy care and that staff carry it out as prescribed. During an interview on 03/21/25 at 11:02 A.M., the Administrator said he/she would expect the resident to have an order for ostomy care. He/She said the issue with ostomy care is that the aides provide the care and do not have access to order and are not able to sign off on medication administration record (MAR) for the care. He/She said the concern for not having an order for the care is that it might not be getting done. He/She said aides are made aware of who has ostomy's during report. He/She said it is the DON's responsibility for ensuring the care is completed by the aides. 6. Review of the facility's Wound Care and Treatment policy, dated March 2015 showed the policy did not contain direction when to complete a skin assessment. Review of the facility's General Wound and Skin Care Guidelines, undated showed the guidelines did not contain direction when to complete a skin assessment. 7. Review of #15's Annual MDS, dated [DATE] showed staff assessed the resident as: -Cognitively impaired; -Not a pressure ulcer risk; -Did not have a pressure ulcer; -Diagnosis of diabetes, heart and respiratory failure and dementia. Review of the resident's medical record, showed the record did not contain a documented skin assessment for the weeks of January 19 or 26, February 9, 16, or 23, and March 2, 2025. Observation on 03/19/25 at 8:13 A.M., showed the resident with a wound to his/her left outer lower leg with wound closure strips in place. The skin surrounding the wound red. 8. Review of Resident #26's Quarterly MDS, dated [DATE] showed staff assessed the resident as: -Cognitively intact; -Substantial maximal assistance with personal hygiene and showers; -Dependent on staff for toilet hygiene; -Risk for skin break down; -Moisture associated skin damage; -Diagnosis of type 2 diabetes mellitus. Review of the weekly skin assessment, dated 03/08/25, showed: -Existing non-foot issue; -No documentation/comments in the description box; -Interventions and Treatments marked N/A; -No documentation of measurements. Review of the weekly skin assessment, dated 03/15/25, showed: -Existing non-foot issue; -No documentation/comments in the description box; -Interventions and Treatments marked treatment in place effective; -No documentation of measurements or type of interventions. Review of the resident's electrinic medical record, dated 03/20/2025, showed it did not contain documentation of wound measurements, appearance, or interventions. Observation on 03/19/25 at 1:36 P.M., showed four open bleeding areas were observed on the resident's buttock. During an interview on 03/20/25 at 3:08 P.M., Registered Nurse (RN) R said when you do a skin assessment and click the box that says Existing non-foot skin issue, describe in comment field below and complete interventions the nurse is expected to go to the bottom of the assessment and document the other issues present on that assessment. He/She said then they must click the box for skin issue interventions. He/She said he/she does not know why the resident assessment does not have documented measurements or description noted in the assessment. He/She said this assessment is where they get their wound information from. During an interview on 03/20/25 at 3:26 P.M., the Assistant Director of Nursing (ADON) said he/she is the one who filled out the assessment. He/She said he/she did not do measurements on the wound and did not document the appearance or interventions because he/she has a lot on his/her plate and didn't have time. He/She said if it is not documented on the assessment there is not anywhere else staff can find the information. He/She said he/she is the nurse that follows the wound nurse during rounds, and he/she is the only one with access to the wound nurse's notes. He/She said staff would have to call him/her to get the documentation if he/she was not in the building. During an interview on 03/21/25 at 11:02 A.M., the Administrator said he/she feels like the seasoned aides are good about letting nurses know of wound changes. He/She said it is the nurse's job to do the wound assessments and document measurements. He/She said he/she knows staff are not documenting like they should, but feels they do the work/assessments, but not the documentation. 9. Review of Resident #39's Admission MDS, dated [DATE] showed staff assessed the resident as: -Cognitively impaired; -At risk for developing pressure ulcers; -Did not have a pressure ulcer; -Had an open lesion and a dressing to the foot; -Diagnosis of heart failure, dementia and irregular heartbeat. Review of the resident's medical record, showed the record did not contain documentation of a skin assessment between February 27 and March 9, 2025. Observation on 03/21/25 at 9:22 A.M., showed the resident with gauze rolled bandages on his/her bilateral arms and bilateral heels. During an interview on 03/21/25 at 08:58 A.M., the MDS nurse said skin assessments should be completed weekly and as needed by a licensed nurse. If the resident develops a new wound, the wound should be assessed and documented in the medical record to include, measurements, appearance, pain and areas of concerns. He/She said the DON audits the records to ensure the assessments are completed. During an interview on 03/21/25 at 10:06 A.M., the DON said the skin assessments are completed weekly by the nurse. If the resident has a wound, then the ADON assesses the wounds weekly. He/She said the DON is responsible to ensure the documentation is in the medical record and was not aware any skin assessments were missing. During an interview on 03/21/25 at 11:02 A.M., the Administrator said the DON is responsible to ensure the nursing staff document weekly skin assessments. He/She was not aware there were missing assessments. 11. Review of Resident #11's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Scheduled pain regium for moderate pain; -Diagnosis of Rheumatoid arthritis and polyneuropathy. Review of the resident's care plan, dated 03/20/25, showed the plan directed staff to administer medications as ordered by the physician. Review of the resident's POS, dated 11/27/24, showed an active order to remove Lidoderm patch at bedtime. Observation on 03/20/25 at 8:07 A.M., showed Certified Medication Technition (CMT) C pulled up the resident's shirt, removed a lidocaine patch that was dated 3/19/25, placed it in the trash and applied the new patch dated 3/20/25. 12. Review of the Manufacture's Instructions for Humulin 70/30 KwikPen, revised June 2022, showed: -You can give from one to 60 units in a single injection; -If your dose is more than 60 units, you will need to give more than 1 injection; -Use a new needle for each injection and repeat the priming step. 13. Review of Resident #26's Quarterly MDS, dated [DATE] showed staff assessed the resident as: -Cognitively intact; -Received insulin seven out of seven days; -Diagnosis of type 2 diabetes mellitus. Review of the resident's POS, dated 03/2025, showed an order for 85 units of Humulin 70/30 KwikPen once daily. Observation on 03/21/25 at 8:12 A.M., the ADON gave Humulin KwikPen, 60 units, in the resident's left lower abdomen and kept the needle in place as he/she dialed in 25 more units and then administered the 25 units of insulin in the same location. During an interview on 03/21/25 at 8:15 A.M., the ADON said he/she always gives the residents insulin by administering 60 units, leaving the insulin needle in the abdomen while he/she dials in 25 more units, and then gives that while keeping the needle in the resident's abdomen. He/She said he/she does it that way to keep from sticking the resident twice. During an interview on 03/21/24 at 9:15 A.M., the Administrator said he/she would expect staff to ask the pharmacist if he/she had a question about an order or how to administer an insulin pen. During an interview 03/21/25 at 9:33 A.M., the pharmacist said staff should never leave the insulin needle in the resident while he/she dials in more insulin. He/She said his/her expectation would be that the staff would have administered the 60 units, then removed the needle, discarded the used needle and then they would prep the pen again by cleaning it, primming the pen, dial in 25 more units and then administer that dose into the resident. 47193

Based on observation, interview, and record review facility staff failed to provide assistance to maintain personal hygiene and grooming for eight (Resident #11, #34, #46, #51, #53, #55, #63, and #71) out of nine sampled dependent residents . The facility census was 83. 1. Review of the facility's Bath (Shower) policy, dated March 2015, showed the purpose of bathing was to maintain skin integrity, comfort and cleanliness. Review of the facility's Shaving the Resident policy, dated March 2015, showed the purpose of shaving was to remove facial hair and improve the resident's appearance and morale. Review of the facility's Nails, Care of (Fingers and Toes) policy, dated March 2015, showed the purpose was to provide cleanliness, prevent the spread of infection. 2. Review of Resident #11's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 02/19/25, showed staff assessed the resident as: -Cognitively intact; -Required moderate assistance with showering; -Diagnosis of diabetes mellitus and cellulitis Review of the residents care plan, dated 03/20/25. showed the record did not contain guidance related to the Activities of Daily Living (ADL) for bathing. Review of the resident's shower schedule, undated, showed the resident scheduled for a shower/bath on Monday and Thursday each week. Review of the resident's shower sheets, between 02/01/25 and 03/19/25, showed staff did not document the resident received or refused a shower on 02/06/25, 02/10/25, 02/13/25, 02/17/25, 02/20/25, 02/24/25, 03/03/25, and 03/10/25 Observation on 3/18/25 at 10:30 A.M., showed the resident hair greasy and disheveled appearing hair. A heavy odor of urine was present close to the resident. During an interview on 03/19/25 the resident said he/she may only get a shower once every two weeks and would prefer more. 3. Review of Resident #34's Annual MDS, dated [DATE] showed staff assessed the resident as: -Cognitively impaired; -Required partial to moderate assistance with showers/baths; -No behaviors or rejection of care; -Diagnosis of dementia. Review of the resident's care plan, dated 03/10/25 showed: -He/She is limited in ability to maintain grooming/personal hygiene related to poor balance and mobility; -Offer nail care to hands and feet; -Provide one person assistance for facial hair. Use a razor or electric razor to remove facial hair as needed. Review of the resident's shower schedule, undated showed the resident scheduled for a shower/bath on Tuesday and Friday each week. Review of the resident's shower sheets, between 02/01/25 and 03/19/25, showed staff did not document the resident received or refused a shower on 02/07/25, 02/14/25, 02/18/25, 02/21/25, 03/07/25 or 03/11/25. Observation on 03/18/25 at 3:50 P.M., showed the resident in bed with long fingernails and facial hair. Observation on 03/19/25 at 9:02 A.M., showed the resident with long facial hair and long fingernails. 4. Review of Resident #46's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Behavior does not exist for rejection of care; -Partial/Moderate assistance with showers; Review of the resident's care plan, dated 02/25/25, showed the care plan did not contain direction or preferences for showers or ADL's. Review of the resident's shower sheets, dated 02/01/25 through 03/20/25, showed staff did not document the resident received a shower on 02/05/25, 02/08/25, 02/12/25, 02/15/25, 02/22/25, 03/01/25, 03/08/25, and 03/15/25. Observation on 03/18/25 at 11:54 A.M., showed the resident's hair greasy and disheveled hair. Observation on 03/19/25 at 08:30 A.M., showed the resident's hair greasy and disheveled hair. During an interview on 03/19/25 at 8:53 A.M., the resident said he/she gets showers once a week to once every two weeks. He/She said he/she would like to have a shower at a minimum of once weekly to two times weekly. 5. Review of Resident #51's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Shower substantial assistance; -Diagnosis of diabetes mellitus, and parkinsons disease. Review of the residents care plan, dated 03/17/25 showed the resident has limited ability to maintain grooming/personal hygiene due to weakness and fatigue. Review of the resident's shower schedule, undated, showed the resident scheduled for a shower/bath on Tuesday and Friday each week. Review of the resident's shower sheets, between 02/01/25 and 03/19/25, showed staff did not document the resident received or refused a shower on 02/04/25, 02/07/25, 02/13/25, 02/17/25, 02/20/25, 02/27/25, 03/06/25, 03/11/25, 03/14/25, and 03/18/25. Observation on 03/18/25 at 11:15 A.M., showed the resident hair greasy and disheveled. Observation on 03/19/25 at 11:36 A.M., showed the resident hair greasy and disheveled. During an interview on 03/19/25 at 11:37 A.M., the resident said he/she has been left in urine for hours with no help, and that they may receive only one shower a week. 6. Review of Resident #53's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively impaired; -Dependent on staff for showers/baths; -Required substantial/moderate assistance with personal hygiene; -No behaviors or rejection of care; -Diagnosis of dementia. Review of the resident's care plan, dated 03/15/25 showed: -He/She can become physical during care and during showers/bathing; -Two staff to assist with direct care; -The care plan does not indicate preferences or guidance for nail care or shaves. Review of the shower schedule, undated showed the resident scheduled for a shower/bath on Wednesday and Saturday each week. Review of the resident's shower sheets, dated 02/01/25 through 03/19/25, showed the resident received a shower on March 5, 2025. The staff did not document the resident received or refused a shower on 02/08/25, 02/08/25, 02/12/25, 02/15/25, 02/19/25, 02/22/25, 02/26/25, 03/08/25, 03/12/25 or 03/15/25. Observation on 03/18/25 at 11:08 A.M., showed the resident fingernails long, hair unkempt and long facial hair. Observation on 03/19/25 at 09:18 A.M., showed the resident fingernails long, hair unkempt and long facial hair. Observation on 03/20/25 at 2:00 P.M., showed the resident in the dining room with long fingernails and long facial hair. 7. Review of the Resident #55's Quarterly MDS, dated [DATE], showed staff assessed there resident as: -Cognitively intact; -Showers moderate assistance; -Diagnosis of stroke and respiratory failure. Review of the resident's care plan, dated 03/17/25. showed the care plan did not contain direction or preferences for showers or ADL's. Review of the resident's shower schedule, undated showed the resident scheduled for a shower/bath on Wednesday and Saturday each week. Review of the resident's shower sheets, between 02/01/25 and 03/19/25, showed staff did not document the resident received or refused a shower on 02/02//25, 02/08/25, 02/15/25, 02/19/25, 02/22/25, 03/05/25, 03/08/25, 03/12/25, 03/15/25, and 03/19/25. Observation on 03/18/25 at 2:12 P.M., showed the resident hair greasy. During an interview on 03/19/25 at 2:15 P.M., the resident said staff are very slow to assist him/her and showers are not as often as he/she would prefer. 8. Review of Resident #63's Quarterly MDS, dated [DATE] showed staff assessed the resident as: -Cognitive impairment; -Required moderate assistance with showers; -Diagnosis of schizophrenia and bipolar disease. Review of the resident's care plan, dated 03/20/25. showed the care plan did not contain direction or preferences for showers or ADL's. Review of the resident's shower schedule, undated showed the resident scheduled for a shower/bath on Wednesday and Saturday each week. Review of the resident's shower sheets, between 02/01/25 and 03/19/25, showed staff did not document the resident received or refused a shower on 02/05/25, 02/08/25, 02/19/25, 02/22/25, 02/26/25, 03/01/25, 03/05/25, 03/08/25, 03/12/25, and 03/19/25. Observation on 03/19/25 at 2:00 P.M., showed the residen's hair disheveled hair. 10. Review of Resident #71's Quarterly MDS, dated [DATE] showed staff assessed the residents as: -Cognitively impaired; -Shower set up; -Diagnosis of dementia. Review of the resident's care plan, dated 03/07/25 showed the resident is limited in ability to maintain grooming/personal hygiene due to dementia. Review of the resident's shower schedule, undated showed the resident scheduled for a shower/bath on Tuesday and Friday each week. Review of the resident's shower sheets, between 02/01/25 and 03/19/25, showed staff did not document the resident received or refused a shower on 02/04/25, 02/07/25, 02/11/25, 02/13/25, 02/17/25, 02/20/25, 02/27/25, 03/04/25, 03/06/25, 03/11/25, 03/14/25, and 03/18/25. Observation on 03/19/25 at 11:58 A.M., showed the resident's hair greasy and disheveled. During an interview on 03/19/25 at 12:00 P.M., the resident said he/she had not receive a shower in over a week and he/she feels dirty. He/She when his/her family member visits it makes him/her sad to have not been showered. 11. During an interview on 03/21/25 at 8:04 A.M., Certified Nurse Aid (CNA) A said staff are supposed to do showers daily but if we don't have shower aids scheduled they don't get finished because staff have to stay on the floor for resident care. During an interview on 03/21/25 at 8:38 A.M., Licensed Practical Nurse (LPN) B said showers are to be done twice a week but he/she does not see them always being finished. During an interview on 03/21/25 at 10:38 A.M., the Director of Nursing (DON) said residents are to receive two showers a week but they don't always get finished. He/She said they audit showers every week and aids are to document refusals on the shower sheets. During an interview on 03/21/25 at 11:17 A.M., the administrator said showers should be done twice a week or as needed or requested. He/She said staff are getting about half of the showers done. Not showering is a risk to hygiene and infection. Nail care and shaving are offered on shower days or as needed or requested. 43327 47193

Based on observation, interview and record review, facility staff failed to provide an ongoing program of activities designed to support independence and interaction in the memory care unit. The facility census was 83. 1. Review of the policies provided by the facility showed the facility did not provide a policy for Activities. 2. Observation on 03/18/25 at 9:40 A.M., showed the Activity Calendar, dated March 2025, hung in the hallway of the memory care unit. The calendar showed the following: -03/18/25: 9:00 A.M., Catholic Services, 10:00 A.M., musical bingo and 2:00 P.M., horse racing; -03/19/25: 10:00 A.M., Hair dresser and 2:00 P.M., country store; -03/20/25: 10:00 A.M., Movie and snacks and 1:30 P.M., Bingo; -03/20/25: 9:00 A.M., Communion and 1:30 P.M., Music and groove. Observation on 03/18/25 at 09:30 A.M., showed a religious service held in the entranceway of the facility not located in the memory care unit. Residents from the memory care unit were not present and did not have service on the unit. Observation on 03/18/25 at 2:18 P.M., showed a group of residents in the main sitting area not located in the memory care unit, participated in a group activity. Residents from the secured unit were not present and did not have the scheduled activity on the unit. Observation on 03/19/25 at 10:36 A.M., showed five residents in the memory care unit dining room, three with their eyes closed. Two residents sat in the sitting room on the secured unit and one resident paced the hall of the secured unit. Staff did not offer an activity. Observation on 03/19/25 from 1:41 P.M. to 2:24 P.M, showed the memory care unit residents paced the halls, sat in the dining room/sitting room, or remained in their room. Staff did not offer an activity. Observation on 03/20/25 at 10:00 A.M., showed two resident in the sitting room with their eyes closed, two residents in the dining room with their eyes closed and other residents paced the hall or remained in their room. Staff did not offer a movie or snacks. Observation on 03/20/25 at 2:03 P.M., showed five residents in the memory care dining room. Observation showed two staff interacting with each one another Staff did not offer an activity. During an interview on 03/21/25 at 08:13 A.M., Nurse Aide (NA) M said he/she works on and off of the secured unit. He/She feels there could be more interaction and activities provided to the residents on the memory unit to help with boredom and behaviors. The NA said the residents do not get invited to facility activities because they are escape risks but does not think that should exclude them from group participation. He/She said the residents do get church and/or communion once in a while, and country store, but very rarely. He/She said there are a few things available on the secured unit, but staff that work the unit do not always have the time to do them. During an interview on 03/21/25 at 08:58 A.M., the Minimum Data Set (MDS), a federally mandated assessment, nurse said the memory care unit aides provide the activities on the memory unit with exception of larger group activities where the resident is invited to go out of the unit. Larger groups include guest entertainment, bingo, horseraces, family visits, parties and church. The nurse said it is hit or miss when activities get performed on the memory unit but would give the residents more stimulation than staring at four walls, help with behaviors and keep them active. During an interview on 03/21/25 at 10:06 A.M., the Director of Nursing (DON) said the facility has a good activity director and will go to the memory unit and offer coloring, different games and/or parties. He/She said the Activity Director should be documenting the activity participation in the Electronic Health Record (EHR). Residents are always offered church and the activity director does provide some one-on-ones. During an interview on 03/21/25 at 10:54 A.M., the Activity Director said he/she documents activity participation on a smaller copy of the activity calendar located in each resident room with a highlighter. The letter R indicates a refusal for the activity. He/She said that he/she tries to get the memory unit and/or dependent residents outside when the weather is nice and try to get them off the unit for larger groups. The director does one-on-one activities at least once a week on the memory unit and the unit has self directed activities that the aides have access to on the unit. He/She does not know if the aides document any activities. During an interview on 03/21/25 at 11:02 A.M., the administrator said all residents are offered to go to group activities and staff are to assist with the activities as needed. He/She said the Activity director should be offering one-on-ones if the resident does not attend the group activity and should be documented. He/She said the activity director tries to take residents off the secured unit for larger groups but group activities may not always be done. 47193

Based on observation, interview, and record review, facility staff failed to provide safe mechanical transfer for two residents (Resident #30, and #55). Facility staff failed to provided safe wheelchair propulsion for two residents(Resident #13, and #30). Facility staff failed to safely administer medication to one resident (Resident #51). Facility staff failed to lock medication carts when not in use and failed to store hazardous materials in a manner to prevent accidents. The facility census was 83. 1. Review of the facility's mechanical lift policy, dated March 2015, showed staff are directed to follow the manufacturer's instructions when using any type of mechanical lift and does not direct staff on holding onto the resident while suspended in the air. Review of the mechanical lift operating manual, dated 10/18/18, showed: -It is recommended two staff perform mechanical lift transfers; -Staff are to use the straps or handles on the side and the back of the sling to guide the patient's hips as far back as possible into the seat for proper positioning. 2. Review of Resident #30's Significant Change Minimun Data Set, a federally mandated assessment, (MDS), dated [DATE], showed staff assessed the resident as: -Severely impaired cognition; -Dependent on staff for transfers; -Diagnosis of dementia. Observation on 03/18/25 at 10:26 A.M., Certified Nurse Aid (CNA) D and nurse Aid (NA) E transfered the resident from the bed to the wheelchair using a mechanical lift. When clear from the bed, CNA D moved the lift backward, turned toward the wheelchair and pushed the resident over the wheelchair while the resident remained suspended in the air. During an interview on 03/21/25 at 9:56 A.M., CNA D said staff should never leave a resident suspended in the air without a second staff guiding the resident for safety. He/She said the resident could have fallen out or dropped. The CNA said he/she was caught off-guard when asked to be watched and nervous. 3. Review of Resident #55's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Transfer as independent; -Diagnosis of stroke, and acquired absence of left above knee. Observation on 03/18/25 at 10:57 A.M., showed CNA F and CNA G transferred the resident from a bed to a wheelchair. CNA F operated the mechanical lift while CNA G supported the resident. After lifting the resident off the bed and suspending the resident over the wheelchair CNA G walked away from the resident to retrieve and item and left the resident suspended over the wheelchair without assistance. 4. During an interview on 03/21/25 at 10:06 A.M., the Director of Nursing (DON) said two people should perform a mechanical lift transfer, one to guide the machine and one to guide the resident. The resident should not be suspended without staff touching for safety. During an interview on 03/21/25 at 11:02 A.M., the administrator said there should be two people to perform a mechanical lift transfer for safety. One staff member should guide the machine and one staff to guide the resident. 5. Review of the facility's Use of Wheelchair Policy , dated March 2015, showed: -Fold footrest up out of the residents way for safety. Do not remove footrest unless resident uses feet on floor to enable mobility; -Lower footrests and place resident's feet on footrests if used. 6. Review of Resident #13's Quarterly MDS, dated , 02/04/25, showed staff assessed the resident as: -Cognitively impaired; -Independent wheelchair; -Diagnosis of alzheimers. Observation on 03/19/25 at 11:13 A.M., showed the administrator propelled the resident without footrest from the center of 100 hall to the dinning room. The residents feet bounced and glided along the floor. During an interview on 03/19/25 at 11:15 A.M., the administrator said he/she would not normally push a resident without footrests but did not think of it. He/She said doing do could cause injury. 7. Review of Resident #30's Annual MDS, dated [DATE], showed staff assessed the resident as: -Cognitively impaired; -Independent locomotion with a wheelchair; -Diagnosis of dementia. Observation on 03/19/25 at 1:33 P.M., showed Licensed Practical Nurse (LPN) L propelled the resident from the nurse station to the other nurse station in his/her wheelchair. The resident did not have pedals on the wheelchair and his/her feet drug the ground. During an interview on 03/19/25 at 1:41 P.M., LPN L said he/she was busy and in a hurry. Staff should always use pedals if able to keep the residents feet up and safe from getting hurt. 8. During an interview on 03/21/25 at 10:24 A.M., the Director of Nursing (DON) said staff should make sure the footrests are on wheelchairs before pushing a resident because it is not safe and could potentially cause an injury. 9. Review of the Facility's Storage of Medications policy, dated March 2015, showed: -All medications for residents must be stored at or near the nurse's station in a locked cabinet, a locked medicine room, or one or more locked mobile medication carts; -All mobile medication carts must be under visual control of the staff at all times when not stored safely and securely. Carts must be either in a locked room or otherwise made immobile; -All unattended medication carts must remain locked at all times. In the event the nurse is distracted from the task of passing medications by some unforeseen occurrence, the cart must be locked before leaving it, or secured in a locked medication room. 10. Review of Resident #51's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Diagnosis of coronary artery disease, diabetes mellitus, and parkinsons. Observation on 03/19/25 at 11:11 A.M., showed the resident alone in his/her room with multiple medications on the bedside table. Observation showed staff not present in the room. During an interview on 03/19/25 at 11:15 A.M., Certified Medication Technician (CMT) C said he/she got approval from a nurse to leave the medication in the room for the resident to take after staff transferred the resident out of bed into his/her wheelchair. During an interview on 03/19/25 at 11:39 A.M., the Assistant Director of Nursing (ADON) said medication should never be left unattended because staff could not ensure the resident took the medication or not as well as being a safety risk to other residents possibly taking the wrong medication. During an interview on 03/21/25 the DON said medication should not be left unattended with a resident. Staff must see the medication has bee taken and there is a risk to other residents getting the wrong medication During an interview on 01/21/25 at 11:21 A.M., the administrator said medication should not be left in a residents room unsupervised. The resident may not take the medication or the wrong resident could get the medication. 11. Observation on 03/18/25 at 11:20 A.M., showed the nurse treatment cart unlocked and unattended outside of room [ROOM NUMBER], with a basket of lancets and antiseptic wipes. Observation on 03/19/25 at 1:28 P.M., showed the medication cart unlocked and unattended at nurse station with an insulin pen on top of the cart. Three staff, three ambulance crew members, and two residents passed by the cart. Observation on 03/21/25 at 7:25 A.M., showed an unlocked and unattended medication and treatment cart parked near the nurse station. Multiple staff and residents passed by the carts. Observation on 03/21/25 at 7:35 A.M., showed the treatment cart in the hallway with needles and scissors on top of the cart, unattended. Observation on 03/21/25 at 8:05 A.M. and 8:14 A.M., showed the treatment cart in the hallway with needles, scissors, and antiseptic wipes on top of the cart, unattended. Residents passed the cart while it was unattended. Observation on 03/21/25 at 8:14 A.M., showed the treatment cart unlocked and unattended in the hallway, with scissors, needles and antiseptic wipes on top and wipes. Residents passed the cart while it was unattended. During an interview on 03/21/25 at 8:37 A.M., LPN B said the carts should have been locked to keep people out of them, but was in a rush. During an interview on 03/21/25 at 11:02 A.M., the administrator said medication and treatment carts should not be left unattended. He/She expects staff to lock carts and remove items from the top of the carts before they are left unattended because it is a risk for safety to the residents. He/She said he/she was aware that staff were leaving items on top of carts and has educated his/her staff not to do so. 13. Review of the facility policies showed the facility did not provide a policy for chemical and hazard storage. 14. Observation on 03/18/25 at 11:35 A.M., showed the secured units dining room with multiple residents in the dining room. Observation showed the cabinets unlocked and contained: -An aerosol spray labeled air freshener without a cap; -Three open containers of disinfectant wipes; -One container of bleach disinfectant wipes; -A half full bottle of nail polish remover. Observation on 03/19/25 at 8:15 A.M., showed the secured unit dining room contained an aerosol can without a cap in an unlocked cabinet and on top of the refrigerator. Residents wandered the secured unit. Observation on 03/19/25 at 2:11 P.M., showed the secured unit dining room contained an aerosol can without a cap in an unlocked cabinet and on top of the refrigerator. Residents wandered the secured unit. Observation on 03/19/25 during the Life Safety Code tour showed: -The housekeeping closet on the 200-hall was unlocked and contained four containers of cleaning chemicals. Observation showed the containers contained labels indicating hazardous materials; -The cabinet under the sink in the special care unit not locked and contained three containers of cleaning wipes; -The cabinet under the microwave in the special care unit not locked and contained one container of cleaning wipes. Observation showed the product label indicated Flammable. Keep away from heat or flame. During an interview on 03/19/25 at 9:45 A.M., the maintenance director said the housekeeping closet should be locked. The maintenance director said the housekeeper was new and probably forgot to lock the closet door. The maintenance director said he/she assumed nursing staff were responsible for keeping unsafe materials away from residents. The maintenance director said he/she did not look under cabinets unless he/she had to complete work on the cabinets. During an interview on 03/21/25 at 8:31 A.M., NA M said chemicals should be locked up or kept out of reach of the residents, especially on the secured unit or they could eat it or get it on their skin. He/She said the staff sometimes keep air freshener on top of the refrigerator where residents cannot get it. During an interview on 03/21/25 at 11:02 A.M., the administrator said if chemicals are stored in cabinets, the cabinets should be locked. There should not be any chemicals stored on the secured unit without being locked up for safety. He/She said its all staff responsibility to ensure to keep areas safe for residents. 43327 45564

Based on interview and record review, the facility staff failed to ensure four Nurse Aide's ((NA) NA H, NA I, NA J and NA K) out of fourteen sampled staff, completed the nurse aide training program within four months of his/her employment in the facility. The census was 83. 1. Review of the facility's policies showed the facility did not provide a policy for NA qualifications. 2. Review of Newly Hired NA Audit Tool, showed NA H's hire date as 05/06/24. Review showed the NA's file did not contain documentation the NA completed a nurse aide training program. 3. Review of Newly Hired NA Audit Tool, showed NA I's hire date as 10/17/24. Review showed the NA's file did not contain documentation the NA completed a nurse aide training program. 4. Review of Newly Hired NA Audit Tool, showed NA J's hire date as 09/06/24. Review showed the NA's file did not contain documentation the NA completed a nurse aide training program. 5. Review of Newly Hired NA Audit Tool, showed NA K's hire date as 09/06/24. Review showed the NA's file did not contain documentation the NA completed a nurse aide training program. 6. During an interview on 03/20/25 at 3:09 P.M., the Administrator said he/she knows NA's should be certified within 120 days of hire. He/She said the instructors keep track of class progress and notify him/her on where they are in the class, and he/she is responsible for ensuring they are certified within the 120 days. He/She said he/she did not realize there were staff outside of the time frames. He/She said they usually remove staff from the NA position and make them health aides until they pass the classes. Health aides do not provide direct care and usually do things like pass trays and refill ice and water cups.

Based on interview and record review, the facility staff failed to ensure the activities program was directed by a qualified professional. The census was 83. 1. Review of the facility's Role of the Activity Director policy, dated March 2012, showed the policy does not contain direction or guidance for director certification requirements. During an interview on 3/21/25 at 10:54 A.M., the activity director said he/she was not certified and did not know he/she should be certified. He/She has been in the activity director role for a while. During an interview on 3/20/25 at 8:29 A.M., the Administrator said the activity director is not certified but is working on getting him/her scheduled. He/She was not aware until a couple of weeks ago the director was not certified and started working on getting scheduled for the class.

Based on observation, interview and record review, the facility staff failed to store food in a manner to prevent potential contamination and out-dated use. Facility staff failed to maintain the mechanical dishwasher in good repair to ensure dishes were effectively washed and sanitized to prevent cross-contamination. Facility staff failed to allow cleansed dishes to air-dry prior to stacking in storage to prevent the growth of food-borne pathogens. Facility staff failed to maintain the ice machine in a sanitary manner to prevent cross-contamination. Facility staff failed to maintain the kitchen equipment and surfaces in a sanitary manner to prevent the growth of bacteria and cross-contamination. Facility staff also failed to perform hand hygiene as often as necessary to prevent cross-contamination. These failures have the potential to affect all residents. The facility census was 84. 1. Review of the facility's Receiving and Storage of Food policy, dated April 2011, showed: -The Dining Services Manager is responsible for receiving and storing food and nonfood items; -Follow the rule of First In, First Out (FIFO); -Keep all foods in clean, undamaged wrappers or packages. Reseal open boxes effectively; -Keep storage areas clean and dry. Review of the facility's Storage of Dry Food and Supplies policy, dated April 2011, showed: -The dietary department will store dry food and supplies according to facility guidelines and state regulation; -The storeroom must be neat an d orderly. Shelving is kept clean and free of rust and chipped paint; -Metal or plastic containers with tight fitting covers, labeled top or side, must be used for storing opened products; -Only National Sanitation Foundation (NSF) approved storage containers and food grade vinyl bags are used for food storage; -Open boxes are to be effectively re-sealed. Bulk crackers, cereal, cookies, pasta, et cetera (etc.) are to be stored and properly labeled in sealed containers. Food-grade plastic bags are to be tightly closed after being opened. Observations on 04/15/24 at 10:19 A.M., showed the dry goods storage pantry contained: -An opened and undated 50 pound bag of granulated sugar stored inside an undated plastic barrel. Observation showed the lid to the barrel cracked which exposed the contents to the air and a measured drink pitcher buried in the sugar inside the bag; -Loose oatmeal, removed from its original packaging, stored in side an undated plastic barrel lined with a white plastic bag; -A large undated plastic container labeled pureed bread mix that contained pureed bread mix removed from it's original container; -An opened and undated 50 pound bag of brown sugar stored inside an undated plastic barrel; -An opened and undated 25 pound bag of flour and an opened 25 pound bag of fish breading with a stock date of 04/19 and no opened date; -An opened 10 pound bag of spiral noodles with a stock date of 08/14 and no opened date; -An opened five pound bag of egg noodles with a stock date of 09/20 and no opened date.; -An undated 22 quart plastic container labeled food thickener that contained food thickener removed from its original packaging; -An undated 22 quart container labeled powdered milk that contained powdered milk removed from its original packaging; -A six pound eight ounce can of spaghetti sauce, a 28 ounce can of diced pimentos, and a five pound 13 ounce can of spinach with dents on the seams of the cans stored on the can storage rack. Observation on 04/15/24 at 10:36 A.M., showed two undated metal sheet pans of sausage stored in the walk-in refrigerator. Observation on 04/16/24 at 10:27 A.M., showed the dry goods storage pantry contained: -An opened and undated 50 pound bag of granulated sugar stored inside an undated plastic barrel. Observation showed the lid to the barrel cracked which exposed the contents to the air and a measured drink pitcher buried in the sugar inside the bag; -Loose oatmeal, removed from its original packaging, stored in side an undated plastic barrel lined with a white plastic bag; -A large undated plastic container labeled pureed bread mix that contained pureed bread mix removed from it's original container; -An opened and undated 50 pound bag of brown sugar stored inside an undated plastic barrel; -An opened and undated 25 pound bag of flour and an opened 25 pound bag of fish breading with a stock date of 04/19 and no opened date; -An opened 10 pound bag of spiral noodles with a stock date of 08/14 and no opened date; -An opened five pound bag of egg noodles with a stock date of 09/20 and no opened date.; -An undated factory prepared graham cracker crust stored on the bottom shelf with its cover loosened which exposed the crust to the air; -An opened 24 oz bag of crispy fried onions with a stock date of 08/14 and no opened date; -An opened 25 pound box of parboiled rice with a stock date of 03/21 and no opened date and a second opened 25 pound boxes of perfect parboiled rice opened to the air. Once dated 3/21 and other dated 4/10; -An undated 22 quart plastic container labeled food thickener that contained food thickener removed from its original packaging; -an undated 22 quart container labeled powdered milk that contained powdered milk removed from its original packaging; -A five pound 13 ounce can of spinach with two dents on the seam of the can stored on the can storage rack. Observation showed an accumulation of dust and debris on the rungs of the can storage rack; During an interview on 04/16/24 at 10:38 A.M., Cook F said the white plastic bags used to line the bulk food barrels were regular trash bags. During an interview on 04/16/24 at 12:45 P.M., the Dietary Manager (DM) said the white plastic bags used to line the bulk food barrels were regular trash bags and the bags were not food-grade. The DM said he/she did not know that food products removed from their original packages, like the loose oats, needed to be stored in food-grade bags or containers. The DM also said the bags of food items inside the bulk food item barrels should be rolled shut to keep them fresh and prevent things from getting into them and staff should not leave scoops inside the bulk food items. The DM said staff are trained on these requirements. Observation on 04/16/24 at 12:47 P.M., showed the box of white plastic bags, identified by the DM as the bags used to line the bulk food barrels, did not identify the bags as food-grade or NSF approved for food storage. Observation on 04/16/24 at 1:56 P.M., showed opened and undated plastic bags of diced chicken and pork riblette patties stored in the walk-in freezer. Observation on 04/16/24 at 2:00 P.M., showed an opened and undated five pound container of creamy peanut butter stored on the shelf by the food preparation sink. Observation showed peanut butter residue around the exterior of the container. Observation on 04/17/24 at 9:24 A.M., showed an opened and undated five pound container of creamy peanut butter stored on the shelf by the food preparation sink. Observation showed peanut butter residue around the exterior of the container. Observation on 04/17/24 at 9:43 A.M., showed opened and undated plastic bags of diced chicken and pork riblette patties stored in the walk-in freezer. During an interview 04/17/24 10:25 A.M., the DM said opened food items should be dated when opened so that the food items should have two dates on them; the stock date and the opened date, and staff should use all of one container before they open another so that the oldest food is used first. The DM said dented cans should be stored in his/her office and not with the in-use food supply. The DM said opened food items should also be stored in a way that they are sealed air tight and if a food storage container is damaged staff should throw it away and not use it to store food. The DM said he/she did not know lid to sugar container was cracked. The DM said staff should also clean the outside of containers if they have food on them. The DM said he/she has repeatedly in-serviced the staff on food storage requirements. During an interview 04/17/24 at 11:25 A.M., the administrator said opened food items should be stored dated and sealed in approved containers and if a food storage container is damaged staff should get rid of it and not use it for food storage. The administrator said staff should clean food residue off of the exterior of food containers, scoops should not be left inside containers of food,staff should not use trash bags for food storage and dented cans should be removed from the in-use supply to be sent back to the supplier. The administrator said staff are trained on proper food storage procedures and the DM is responsible to monitor the food storage regularly. 2. Review of the facility's Dishmachine policy, dated April 2011, showed the washing temperature of the dishmachine is to be 150 degrees and the final rinse is to be 180 degrees, except on a low temperature machine in which an adequate temperature is a minimum of 120 degrees, and this should be noted prior to washing the morning dishes and a test strip should be used and noted. Review of the facility's Dishwashing policy, dated April 2011, showed the policy directed staff to: -Fill the dishmachine with water and turn on heaters according to manufacturer instructions; -Check chemical dispensers for proper operation and adequate supply of chemical; -Record temperature of wash and rinse cycle three times daily on heat sanitized machines and one time daily on chemical sanitized machines. Review of the manufacturer's installation records for the facility's low-energy dishmachine, undated, showed: -Water heaters or boilers must provide the minimum temperature required by the type of machine and a minimum recovery rate of 82 gallons per hour. The recommended temperature range for optimal performance is 130 to 140 degrees Fahrenheit (dF). Minimum water temperature is 120 dF; -Set sanitizer concentrations at 50 parts per million (ppm). Warning: Do not exceed 100 PPM's; -Monitor chlorine levels by using chlorine test strips. Observation on 04/15/24 at 9:56 A.M., showed four baking sheets stacked together on the storage rack in the kitchen. Observation showed one of the baking sheets had multiple areas of dried meat product on it and the other three had sticky dried food around their edges. Observation on 04/15/24 at 10:10 A.M., showed dietary staff washed soiled dishes in the mechanical dishwasher. Observation during the second consecutive run of the dishwasher, the gauge on the dishwasher registered the water temperature of the wash cycle at 102 dF and the water temperature of the rinse cycle measured 118 dF. Observation of the manufacturer's instruction label on the dishwasher showed direction for the minimum water temperature to be 120 dF and the sanitizer concentration to be at 50 ppm of available chlorine rinse. During an interview on 04/15/24 at 10:12 A.M. the dietary manager (DM) said the water temperature for the wash and rinse cycles of the dishwasher should be 120 dF. The DM said he/she knew the water in the dishwasher did not get enough and it did not get hot enough because one of the three facility water heaters did not work. The DM said the maintenance director knew about the water temperature problem. Observation on 04/16/24 at 11:03 A.M., showed Dietary Aide (DA) B washed soiled dishes in the mechanical dishwasher. Observation showed a sodium hydrochloride (chlorine) sanitizer used in the dishwasher. Observation showed the concentration of the chlorine sanitizer used in the dishwasher measured 200 ppm when tested with a chlorine sanitizer test kit. Observation also showed the gauge on the dishwasher registered the water temperature of the wash cycle at 108 dF and the water temperature of the rinse cycle at 116 dF. Review of the facility's Dish Machine Temperature Log, dated April 2024, showed staff documented the sanitizer concentration at 200 ppm three times a day for the dates of 04/01/24 through 04/14/24, at breakfast and lunch on 04/15/24 and at breakfast on 04/16/24. Review showed staff did not record the dishwasher's water temperature or sanitizer concentration at dinner on 04/15/24. Review also showed staff documented water temperatures below 120 dF as follows: -04/06/24 Breakfast: Wash 100 dF and Rinse 118 dF; -04/06/24 Lunch: Wash 100 dF and Rinse 118 dF; -04/07/24 Breakfast: Wash 100 dF and Rinse 110 dF; -04/07/24 Lunch: Wash 100 dF and Rinse 100 dF; -04/13/24 Breakfast: Wash 100 dF and Rinse 115 dF; -04/13/24 Lunch: Wash 100 dF and Rinse 100 dF; -04/15/24 Breakfast: Wash 120 dF and Rinse 115 dF; -04/15/24 Lunch: Wash 120 dF and Rinse 113 dF; -04/16/24 Breakfast: Wash 119 dF and Rinse 116 dF. During an interview on 04/16/24 at 11:12 A.M., the DM said he/she knew the water in the dishwasher did not get enough, but it was hotter at breakfast time than rest of day. The DM said they got a booster heater for the dishwasher after the previous survey, but that did not really help and they have continued to have problems with the water not getting hot enough. The DM said he/she most recently told the maintenance director again about the water not getting hot enough about two weeks ago and again on 04/15/24, but he/she did not write the problem in the maintenance log as he/she is supposed to do when something needs repaired. The DM said, while he/she knew the water did not get hot enough, the dishwasher service provider said it was a low-temperature machine and he/she thought water temperatures of 115 to 116 dF were normal. The DM said he/she did not know the water temperature needed to be at least 120 dF. the DM said he/she had not read the manufacturer's instructions for the machine or the manufacturer's label on the dishwasher and thought it was okay for the sanitizer concentration to be 200 ppm okay. The DM said staff should not use dishwasher if it did not working right and it was his/her fault that they still washed dishes in the machine, because he/she did not tell staff not to use it. During an interview on 04/16/24 at 11:18 A.M., the maintenance director said the dietary manager did not report any issues with the dishwasher water temperature to him/her until yesterday. The maintenance director said if something needs repaired, staff are supposed to notify him/her by writing it down in the maintenance log book and the issue had not been documented in the log book. Observation on 04/16/24 at 11:36 A.M., showed when tested with a calibrated metal stem-type thermometer, the water temperature of the dishwasher wash cycle measured 94 dF and the gauge on the dishwasher registered the water temperature at 94 dF. Observation showed when tested with a calibrated metal stem-type thermometer, the water temperature of the subsequent rinse cycle measured 106 dF and the gauge on the dishwasher registered the water temperature at 106 dF. During an interview on 04/17/24 11:33 AM, the administrator said dietary staff are to monitor the dishwasher for proper working condition daily and if it is not working appropriately, then staff should notify maintenance in writing and not use the dishwasher until it is fixed. The administrator said he/she did not know about the issues with the dishwasher. 3. Review of the facility's Dishmachine policy, dated April 2011, showed the policy directed staff to allow dishes to air dry after they are washed and stack in proper area. Review of the facility's Dishwashing policy, dated April 2011, showed the policy directed staff to allow dishes to thoroughly dry before unloading racks or storing items. Observation on 04/15/24 at 9:59 A.M., showed five of eight large white bowls and two of two metal food preparation and service pans stacked together wet on the dish storage racks. Observation on 04/17/24 at 9:16 A.M., showed 15 of 15 large white bowls stacked together wet upside down on storage rack across from steamtable. Observation on 04/17/24 from 9:25 A.M. to 9:27 A.M., showed DA A, a removed a rack of cleansed dishes from the mechanical dishwasher and used a towel to dry the inside of insulated bowls before he/she put them away. Observation showed the DA stacked a large white bowl while wet on top of a stack of large white bowls on the storage shelf by the steamtable. Observation showed the DA also removed a rack of cleansed service trays from the mechanical dishwasher, stacked them together while wet and put them on the storage shelf. During an interview on 04/17/24 at 9:28 A.M., DA A said staff trained him/her to allow dishes to air dry before they are put away and he/she did not have a reason as to why he/she did not let them dry before he/she put them away. Observation on 04/17/24 at 9:39 A.M., showed the DM stacked together multiple cleansed service trays from the clean side of the mechanical dishwashing station while wet and put them on the storage shelf. During an interview on 04/17/24 at 9:42 A.M., the DM said dishes should be air dried before they are put away and he/she did not look at the trays to see if they were dry before he/she put them away. The DM said staff are trained to allow dishes to air dry and they should not use a towel to dry the dishes.Staff should also check to make sure the dishes are clean before they are put away. Staff also trained on this. During an interview on 04/17/24 at 11:33 A.M., the administrator said dietary staff should allow dishes to air dry completely before they are put away, staff should not use a towel to dry dishes and the staff are trained on proper dishwashing and storage requirements. 4. Review of the facility's Cleaning Guidelines-Ice Machine policy, dated March 2015, showed Ice may be come contaminated from use of impure water, contamination form ice-making machines, or from improper storage or handling of ice. Review showed the policy directed staff to clean the ice storage compartment at least monthly and to scrub all surfaces using a clean cloth and fresh detergent/disinfectant solution. Review showed the policy did not contain direction to staff related to maintenance of the ice machine drain and surrounding areas. Review of the facility's Cleaning Schedules policy, dated April 2011, showed daily, weekly, and monthly cleaning schedules prepared by the Dining Services Manager with all cleaning tasks listed will be posted in the dietary department. Review showed the policy directed staff to post the cleaning schedule prior to the beginning of each week and the employee will initial in the column under the day the task is completed. Review of the facility's weekly cleaning schedule, undated, showed the cleaning schedule directed staff to clean the ice machine weekly. Review of the facility's weekly cleaning schedule records posted in the kitchen, dated February 2024 and March 2024, showed staff did not document they cleaned the ice machine. Review of the cleaning schedules posted, showed the records did not contain a weekly cleaning schedule for April 2024. Review of the facility's monthly cleaning schedule, undated, showed the cleaning schedule directed staff to sanitize the ice machine monthly. Review of the facility's monthly cleaning schedule records posted in the kitchen, dated February 2024 and March 2024, showed staff did not document they sanitized the ice machine. Review of the cleaning schedules posted, showed the records did not contain a monthly cleaning schedule for April 2024. Observations on 04/15/24 at 10:40 A.M., showed an accumulation of lime and calcium scale on the exterior of the ice machine in the dining room. Observation also showed an excessive accumulation of dirt and debris behind and beneath the machine and the drain to the ice machine did not contain a visible air gap. Observation on 04/16/24 at 10:00 A.M. showed an accumulation of lime and calcium scale on the exterior of the ice machine and an excessive accumulation of dirt and debris behind and under machine. Observation showed drain to ice machine led into an enclosed space at the bottom of the adjacent cabinet and the end of drain could not been seen. During an interview on 04/16/24 at 12:45 P.M., the maintenance director said he/she did not know where the ice machine drained too and he/she does not clean the ice machine. Observation on 04/16/24 at 3:00 P.M., showed maintenance director broke open the base of the cabinet adjacent to the ice machine. Observation showed the ice machine drain ended beneath the cabinet and drained into a vent covered drain in the floor. Observation showed an excessive accumulation dirt, debris, an unidentifiable black substance and an unidentifiable white fuzzy substance on the ice machine drain, vent cover and surrounding areas. During an interview on 04/17/24 at 10:45 A.M., the DM said he/she thought the ice machine drained under the machine and did not know that the machine drained underneath an enclosed space beneath the cabinet. The DM said the dietary staff are supposed to clean the inside of the ice machine, but he/she did not know they also needed to clean the outside of the machine and surrounding areas, so no one had done so. The DM said he/she just found out that day that it it was his/her responsibility to maintain the whole ice machine. During an interview 04/17/24 at 11:38 A.M., the administrator said the dietary department is responsible to clean the ice machine as needed and at least monthly. The administrator said dietary staff should clean the inside and outside of the machine as well as the surrounding walls and floors. The administrator said he/she did not know that the ice machine drained into an enclosed space beneath the cabinet. 5. Review of the facility's Cleaning Schedules policy, dated April 2011, showed daily, weekly, and monthly cleaning schedules prepared by the Dining Services Manager with all cleaning tasks listed will be posted in the dietary department. Review showed the policy directed staff to post the cleaning schedule prior to the beginning of each week and the employee will initial in the column under the day the task is completed. Review of the facility's daily cleaning schedule, undated, showed the cleaning schedule directed staff to sweep and mop the floors daily. Review of the facility's daily cleaning schedule records posted in the kitchen, dated February 2024 and March 2024, showed staff only documented that they swept and mopped the floors on 02/05/24, 02/06/24, 02/10/24 and on two undated days in March 2024. Review of the cleaning schedules posted, showed the records did not contain a daily cleaning schedule for April 2024. Review of the facility's weekly cleaning schedule, undated, showed the cleaning schedule directed staff to clean the stove, walls and storage room weekly. Review of the facility's weekly cleaning schedule records posted in the kitchen, dated February 2024 and March 2024, showed staff did not document that they cleaned the stove, walls and storage room. Review of the cleaning schedules posted, showed the records did not contain a daily cleaning schedule for April 2024. Review of the facility's monthly cleaning schedule, undated, showed the cleaning schedule directed staff to clean the oven, fryer and baseboards monthly. Review of the facility's monthly cleaning schedule records posted in the kitchen, dated February 2024 and March 2024, showed staff only documented that they cleaned the oven during the second week of March 2024 and the fryer during the first week of February 2024. Review showed staff did not document that they cleaned the baseboards. Review of the cleaning schedules posted, showed the records did not contain a monthly cleaning schedule for April 2024. Observations on 04/15/24 at 10:03 A.M. during the initial kitchen tour, showed: -an accumulation of dried liquid and food debris on the wall in the food service area; -an accumulation of grease deposits and food debris on the exterior top and interior of the convection oven; -the baseboard by the kitchen door pulled away from the wall which exposed the underlying adhesive and an accumulation of debris. Observation on 04/16/24 at 10:27 A.M., showed an accumulation of dust and debris on the rungs of the can storage rack. Observations showed multiple food cans stored on the rack. Observation on 04/17/24 at 9:18 A.M., showed: -an accumulation of grease deposits and food debris inside the convection oven and on the side of range by the fryer; -an excessive accumulation of trash and food debris on floor behind range, fryer and convection oven; -an accumulation of trash and food debris under the steamtable and the microwave counter; -brown splatter stains on the wall between the steamtable and coffee maker. During an interview on 04/17/24 at 10:48 A.M., the DM said he/she had a lot of new staff and he/she instituted the cleaning lists in February 2024. The DM said the staff were trained to do the tasks listed and to sign off on the schedules when done, but he/she had issues with staff doing the cleaning or they clean and do not document that they completed the task. The DM said staff should sweep and mop the floors daily, which included under the counters and equipment and he/she knew there had been a problem with staff not doing that well enough. The DM said the can storage rack and walls should also be cleaned as needed. During an interview on 04/17/24 at 11:45 A.M., the administrator said all kitchen staff are responsible for the cleanliness of the kitchen with oversight from the DM. The administrator said the floors should be swept and mopped daily and staff should sweep and mop under and behind equipment when they clean the floors daily. The administrator said staff should clean the walls and equipment as needed and he/she would expect them to clean spills right away. The administrator said if something needs repaired, staff should document it on the maintenance log so it can be repaired. The administrator said he/she did not know about the issues in the kitchen. 6. Review of the facility's Handwashing policy, dated April 2011, showed the policy did not contain direction to staff on when to perform hand hygiene. Observation on 04/16/24 at 11:57 A.M., showed DA B lifted the trash can lid with his/her bare hands to dispose of trash and then, without performing hand hygiene, donned a pair of gloves and made grilled cheese sandwiches for service to residents at the lunch meal. Observation showed the DA used his/her gloved hand to lift the trash can lid and dispose of trash a second time, removed the soiled glove, and then, without performing hand hygiene, donned a new glove and continued to prepare grilled cheese for service. Observation on 04/17/24 at 9:34 A.M., showed DA C used lifted the trash can lid with his/her bare hand to to dispose of trash and then, without performing hand hygiene, put cleansed dishes away from the clean side of the mechanical dishwashing station. During an interview on 04/17/24 at 9:37 A.M., DA C said he/she had worked at the facility for a month and staff trained him/her on hand hygiene procedures upon hire. The DA said staff should wash their hands after they touch anything dirty. The DA said a trash can lid would be considered dirty and he/she just forgot to wash his/her hands before he/she put the clean dishes away. Observation on 04/17/24 at 9:53 A.M., showed the DM lifted the trash can lid with his/her bare hand to dispose of trash and then, without performing hand hygiene, obtained a dish storage tray bar mat and placed the mat on the dish storage shelf by the steamtable. During an interview on 04/17/24 at 9:53 A.M., the DM said staff should wash their hands after they touch anything dirty and when they change gloves. The DM said a trash can lid would be considered dirty and he/she did not think to wash his/her hands after he/she touched the lid. The DM said all staff are trained on hand hygiene upon hire. During an interview on 04/17/24 at 11:41 A.M., the administrator said staff should wash their hands as needed when soiled, which would include after they touch the trash can and after they remove gloves. The administrator said staff are trained on hand hygiene procedures upon and during random in-services and the DM is responsible to monitor dietary staff hand hygiene practices routinely when on duty. 37131

Based on observation, interview, and record review, facility staff failed to provide appropriate care and services to prevent and treat pressure ulcers when identified on admission as well as for facility acquired pressure ulcers for four residents (Residents #1, #2, #3, and #4), out of five sampled residents assessed for pressure ulcers. The facility census was 77. 1. Review of the facility's Wound/Skin Champion Program Guidelines, dated 11/2010, showed the guidelines included the following instructions: -Staff are expected to complete a thorough head to toe assessment within four hours of admission; -Complete Braden scale (prediction of pressure ulcer risk) on admission. When completing a Braden score, when in question between to scores, lean to the lower score. Scores below 16 are to start pressure ulcer prevention methods; mattress, wheelchair cushion, heel lift boots, and lay down and pressure relief schedule; -Obtain treatment orders for wounds on admission if none are listed in transfer information; -Any resident that is admitted with or develops a stage III (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed) or stage IV pressure ulcer (Full thickness tissue loss with exposed bone, tendon or muscle) shall be referred to specialized wound care management or outside wound clinic. This does not waive the facility's responsibility to that wound and close monitoring per the guidelines must be carried out by the facility; -The Wound Champion/Assistant Director of Nursing(ADON) will collaborate with licensed nurses and the Director of Nursing (DON) on each and every wound/pressure sore. The Wound Champion will monitor the progress of each wound weekly and recommend treatment and treatment changes when applicable. Having a Wound Champion does not waive the licensed nurses and the DON of the responsibility of monitoring wounds, this must be done daily while administering treatments; -To treat and prevent further breakdown of pressure ulcers the nurse is responsible for carrying out treatment as ordered by the attending physician and for implementing measures to prevent pressure ulcers. 2. Review of Resident #1's Physician order [REDACTED]. Review of the resident's admission Nursing Evaluation/Data Collection sheet dated 2/2/15 at 8:00 P.M. showed staff documented to refer to nursing notes for skin condition. Review of Nurses notes dated 2/2/15 at 8:10 P.M. showed staff documented the resident was continent of bowel and bladder, right lower leg calf has brown scaling with open areas in several areas with a yellow-white appearance to wound bed. The left lower leg had an open area, beefy red wound bed. Review of interim care plan dated 2/2/15 showed staff documented the resident was totally dependent on staff for mobility, toileting, personal hygiene, and incontinent of bowel and bladder. Staff documented open areas were unstageable (full thickness tissue loss in which wound bed is not visible) to right outer foot and proximal/distal right lower extremity. Review of the resident's POS, dated 2/3/15, showed the physician ordered an Ace wrap to left leg, wound consult, and to cleanse wound to right outer shin with wound cleanser , apply Santyl (a [MEDICATION NAME] agent to treat pressure ulcers) and [MEDICATION NAME](antibiotic) and a dry dressing. Change daily. Review of The resident's Braden scale (prediction of pressure ulcer risk) dated 2/3/15, showed facility staff assessed the resident at a score of 17, with scores of 15-18 considered mild risk. Further review showed facility staff assessed the resident as occasionally moist, occasionally walked, with slightly limited mobility. Review of the resident's Treatment Administration Record (TAR) dated 2/3-2/5/15 showed: - Physician ordered treatment to cleanse wound to the outer right calf with wound cleanser. Apply Santyl and [MEDICATION NAME] ointment (pressure ulcer treatment) and dry dressing. Change daily. Further review showed staff did not document they completed the treatment on 2/4/15 (one of three days); -Staff did not document they completed the physician ordered ace wrap to left leg. Review of a Interdisciplinary team (IDT) note dated 2/4/15 (no time) showed staff documented the resident was unable to stand due to non-weight bearing to right lower extremity and [DEVICE] (a vacuum dressing to promote healing in acute or chronic wounds) to right foot. Staff documented the resident required maximum assistance of two staff for transfers, bed mobility, toileting, and dressing. Review of the resident's TAR, dated 2/2 through 2/22/15 showed staff first documented an assessment of the resident's pressure ulcers. Staff documented the following: -Stage II pressure ulcer (wound nurse reported she obtained stage from hospital discharge report), (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough (necrotic/avascular tissue in the process of separating from the viable portions of the body and is usually light colored, soft, moist, & stringy at times)) to the right lower extremity (calf area), irregular shaped, measuring 5.8 cm x 2.2 cm with yellow/black wound bed (stage II pressure ulcers do not have slough or eschar); -an unstageable irregular shaped pressure ulcer to the proximal right lower extremity measuring 1.1 cm x 1 cm x 0.1 cm with yellow wound bed present; - stage III pressure ulcer (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed) to right outer foot measuring 2.7 cm x 7 cm x 1 cm with a red color wound bed. During an interview with the Assistant Director of Nursing (ADON) on 3/18/15 at 1:20 P.M. she said the resident was admitted with mushy heels but that she did not document her assessment of the resident's heel condition. Review of the resident's POS dated 2/6/15 showed the wound care physician ordered the following treatment: -Discontinue [DEVICE] to right outer foot and current treatment to right lower distal foot; -Cleanse right outer foot with wound cleanser, apply Santyl, cover with 4 x 4 dressing dampened with ¼ strength Dankin's (used to kill germs and prevent germ growth in wounds) solution, cover with abdominal pad, wrap with Kerlix (roll type dressing) dressing. Change daily; -Cleanse proximal and distal right lower leg with wound cleanser, apply Santyl, cover with 4 x 4 dressing dampened with Dankin's, cover with abdominal pad and wrap with Kerlix dressing. Change daily. Review of the resident's Minimum Data Set (MDS), a federally mandated assessment instrument, dated 2/9/15, showed staff assessed the resident as follows: -Cognitive problems; -Able to make self understood and understood others; -Did not refuse care; -Required extensive, two or more person assistance for bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing; -Required extensive one person assistance for locomotion; -Non-ambulatory; -Occasionally incontinent of bladder; -Continent of bowel; -At risk for a pressure ulcer; -Two stage II pressure ulcers on admission; -One stage III pressure ulcer on admission. Review of the resident's TAR dated 2/6- 2/21/15 showed direction for staff to cleanse the resident's proximal right lower extremity with wound cleanser apply Santyl, cover with dressing dampened with Dankin's solution, cover with abdominal pad and wrap with Kerlix. Change daily. Further review showed staff did not document they completed the treatment until 2/10/15. Review of the resident's POS dated 1/22 - 2/21/15 showed the physician did not order staff to to treat the resident's heels with Sure Prep daily from 2/2/15 - 2/13/15. Review of the resident's TAR dated 2/6 - 2/16/15 showed direction for staff to apply Sure Prep (skin protectorate) daily to right and left heels. Further review showed staff did not document they completed the treatment on 2/10 and 2/12/15. - Review showed staff did not document further assessment of the resident's right and left heel condition they ADON said were mushy on admission but started treatment on 2/7/15 of Sure Prep (skin protection for damaged or delicate skin) to heels daily. Review of a nursing head to toe assessment, dated 2/6/14, showed staff documented the resident's right leg calf brown and scaly with open areas in several areas, and the resident's lower left leg had open areas staff described as beefy red. Staff documented they discontinued the [DEVICE] that day. Review of an IDT note dated 2/11/15 (no time) showed staff documented the resident could not stand due to non-weight bearing to right lower extremity and [DEVICE] to right foot. The resident required maximum assistance of two staff for transfers, bed mobility, toileting, and dressing. Review of an at risk note, dated 2/11/15 (no time) showed staff documented the Wound Care Specialist saw the resident on 2/6/15 related to pressure areas to right outer foot and right proximal and distal lower leg. The specialist discontinued the [DEVICE] and ordered Santyl and Dankin's solution to all areas, and directed staff to float the resident's heels while in bed to reduce pressure. The specialist educated the resident on the importance of good nutritional intake to promote wound healing and would continue to monitor for new, or worsening skin concerns. Review of nurses' note dated 2/12/15 (no time) showed the Assistant Director of Nursing (ADON)/wound care nurse documented Physical Therapy (PT)/Occupational Therapy (OT) reported to large areas of excoriation/open areas to the resident's bilateral buttocks. Staff cleansed the areas with wound cleaner, applied [MEDICATION NAME] cream (used to prevent and treat wound infections) and a dry dressing. Review of POS dated 2/12/15 showed the physician directed staff to cleanse areas to bilateral buttock with wound cleanser, apply [MEDICATION NAME], cover with abdominal pad and secure. Change twice daily and as needed. Review of the resident's plan of care, showed on 2/12/15 staff added the resident had open areas to bilateral buttocks. Staff did not document any further wound description (size, depth, appearance) and did not add additional interventions to instruct staff in the care for the newly identified pressure ulcers. Review of a nursing head to toe assessment, dated 2/13/15 showed staff documented the resident had right lower leg open areas, and left lower leg open areas. Staff did not document any open areas to coccyx (upper buttock)/bilateral buttocks to show on-going monitoring for improvement of decline. Review of weekly wound assessment and measurements document on back of resident TAR dated 2/2 - 2/22/15 showed on 2/13/15 staff documented wound assessments. Staff documented the following: -New unstageable pressure ulcer to the left heel measuring 5.6 cm x 10.7 cm black color of wound bed; -Right outer foot measuring 2.7 x 6.3 cm x 1 cm stage IV (Full thickness tissue loss with exposed bone, tendon or muscle), irregular shaped with yellow and pink color noted to the wound bed; -Distal right lower extremity unstageable pressure ulcer measuring 4.7 cm x 1.5 cm irregular shaped with yellow/black wound bed; -Review showed staff did not document condition of right heel receiving treatment until 2/16/15. Review of POS/wound care specialist orders dated 2/13/15 showed direction for staff to provide the following: -Discontinue treatment to proximal right lower extremity (healed), to distal right lower extremity, and right outer foot; -Cleanse right outer foot with wound cleanser, apply Santyl and hydrogel(pressure ulcer treatment), cover with abdominal pad and wrap with Kerlix. Change daily; -Apply skin prep to left heel three times a day and float heels while in bed; -Cleanse distal right lower extremity with wound cleanser, apply [MEDICATION NAME] (pressure ulcer treatment) cut to wound size, cover with abdominal pad and wrap with Kerlix. Change daily; -Review showed the POS did not direct staff to discontinue Sure Prep (as provided on TAR) to right heel or indicate alternative treatment. Review of the resident's care plan, dated 2/13/15, showed staff assessed/planned the following interventions: -Resident has incontinent episodes. Goal is for resident to not have difficulties related to incontinence; -Resident has a pressure ulcer noted to the right proximal lower right leg and to the distal right lower leg. Resident admitted with pressure ulcer to right outer foot. Other problems identified are deep tissue injury noted on left heel on 2/12/15 (facility acquired), Moisture associated areas to bilateral buttocks identified on 2/12/15 (facility acquired), moisture associated area to coccyx area identified on 2/12/15 (facility acquired), and deep tissue injury to the right heel identified on 3/5/15 (facility acquired). Goals include resident ulcer will heal without complications. Resident seen by wound care specialist. Interventions included: -Assess and record the condition of the skin surrounding the pressure ulcer; -Assess Pressure ulcer for location, stage, size, wound bed condition; -Avoid friction and shearing; -Conduct a systematic skin inspection weekly, report any further skin breakdown; -Keep skin as dry as possible. Minimize skin exposure to moisture; -Keep heels floated/elevated and turn/reposition throughout the day, as resident can tolerate. -Resident is limited in ability to transfer related to weakness, fatigue and non-weight bearing status to right leg. Goal is to transfer with two person assist. -Resident noted with skin breakdown to buttocks and heels, refuses to elevate (float) heels or use pressure reducing devices, resident also declines to turn and reposition to relieve pressure from buttocks. When staff attempts to reposition resident he/she resists and attempts to push away. Interventions included: -educate resident of need for pressure relief for wound healing, seen by wound care specialist weekly, offer turning/repositioning/heel elevation frequently throughout the day. Review of the resident TAR dated 2/12- 2/21/15 showed direction for staff to cleanse the resident's buttocks with wound cleanser, apply [MEDICATION NAME] cream, cover with abdominal pad, and secure twice daily, and as needed. Further review showed staff did not document they completed the treatment on the 6:00 A.M. -2:00 P.M. shift on 2/20 and on the 10:00 P.M. - 6:00 A.M. shift on 2/12, 2/14, 2/16, 2/17, 2/18, 2/19, 2/21/15 as directed. Review of back of TAR showed staff did not document assessment of wound area as directed to the buttocks area treated. Review of a sticky note provided by the ADON/wound care nurse (due to lack of documentation on TAR) showed the following measurement are said to have been obtained from the ADON's own personal records and unavailable in the resident's medical record, which showed wound measurement of the buttocks on 2/13/15 as follows: - Right buttock measured 6 cm x 3.7 cm x no depth or other wound description documented; - Left buttocks measured 1.9 cm x 2.3 cm x no depth or other wound description documented. Review of the resident's POS dated 2/16/15 showed direction for staff to complete the following: -Discontinue treatment to left heel; -Cleanse left heel with wound cleanser, apply Silvagel (provides moisture to treat and protect wounds), cover with abdominal pad and wrap with Kerlix. Change daily; -Ankle elevators on bilateral feet while in bed. Review of a progress note dated 2/18/15 (no time) by IDT showed the resident required maximum assistance of two for transfers and bed mobility with little progress due to wounds, could stand with maximum assistance in parallel bars, required maximum assistance of two for toileting and dressing, required daily wound care and was seen by wound specialist weekly. Review of a progress note dated 2/18/15(no time) showed an at risk note: Seen by wound care specialist related to multiple wounds to bilateral lower extremities, bilateral heels, and bilateral buttocks. Skin very fragile and opens easily. Treatment orders to continue. Education done with staff on the importance of good peri-care and frequent positioning to decrease pressure compromise skin integrity. Review of the resident's POS dated 2/20/15 showed direction for staff to complete the following: -Discontinue current treatment to distal right lower extremity, right outer foot and left heel; -Cleanse distal right lower extremity with wound cleanser, apply Santyl, cover with abdominal pad and wrap with Kerlix. Change daily; -Cleanse right outer foot with wound cleanser, apply Santyl, cover with abdominal pad and wrap with Kerlix. Change daily. -Cleanse left heel with wound cleanser, apply skin prep and cover with abdominal pad, and wrap with Kerlix dressing. Change daily. Review of the resident's TAR, showed staff did not document any assessment of the resident's pressure ulcers for the week of 2/15-2/21/15. During an interview on 3/18/15 the ADON said she kept sticky notes with wound measurements from her own personal records. Review of a sticky note provided by the ADON/wound care nurse (due to lack of documentation on TAR) showed the following measurement not available in the resident's medical record. The ADON documented wound measurement of the buttocks on 2/20/15 as follows: -Distal right lower extremity measured 4.9 cm x 1.7 cm with no wound depth or other wound description documented; -Right outer foot measured 2.1 cm x 7.5 cm x 1 cm with no other wound description documented; -Left heel measured 6.5 cm x 8 cm with no depth or other wound description documented; -right buttock measured 4.1 cm x 2 cm with no depth or other wound description documented; -left buttock measured 1.7 cm x 2.3 cm with no depth or other wound description documented. Review of a nursing head to toe assessment, dated 2/20/15 showed staff documented right leg wound, right foot wound, bilateral buttocks wound, small wound to genital area. Review of a nursing head to toe assessment, dated 2/21/15 showed staff reassessed and no new open areas of concern noted. Genital area red, but skin is intact, barrier cream applied. Review of the resident TAR dated 2/22- 3/10 (when discharge to hospital) showed staff are directed to cleanse the bilateral buttocks with wound cleanser, apply [MEDICATION NAME] cream, cover with abdominal pad, and secure twice daily and as needed. Further review showed staff did not document they completed the treatment on the 6:00 A.M. - 2:00 P.M. shift on 2/25/15 and on the 2:00 P.M. - 10:00 P.M. shift on 2/22, 2/23, 3/6, and 3/7. Review of back of TAR showed staff documented the first complete assessment of open areas identified on 2/12/15 on 2/27/15. The review showed staff assessed a 7 cm x 8 cm x 0.1 cm irregular shaped open area to the buttocks, no specific area identified (circled entire buttocks area) with red appearance and minimal drainage. Further review of TAR showed staff did not complete any further assessment of wound to buttocks through discharge on 3/10/15. Review of the resident's TAR dated 2/22 - 2/27/15 showed direction for staff to cleanse the right lower extremity with wound cleanser, apply Santyl, cover with an abdominal pad, and wrap with Kerlix. The review showed staff did not document they completed the treatment as ordered daily on 2/24 and 2/26. Review of an At risk note dated 2/26/15 (no Time ) showed staff documented they wound care specialist saw the resident on 2/20/15 related to multiple skin concerns. Areas to bilateral buttocks healing well and treatment to continue as ordered. Pressure ulcer to distal right lower extremity and right outer foot continue healing with moderate drainage noted. treatment for [REDACTED]. Skin prep to left heel. Ankle elevators to bilateral heels to reduce pressure. Staff educated on importance of proper peri-care and positioning to preserve skin integrity. Will continue to monitor for new or worsening skin concerns. Review of POS dated 2/27/15 showed the wound care specialist directed the following: -Discontinue current treatment to right outer foot and distal right lower extremity; -Cleanse right outer foot and distal right lower extremity with Dankin's solution, apply Santyl and pack with gauze dampened with Dankin's, cover with an abdominal pad and wrap with Kerlix dressing. Change daily; -Cleanse right medial right lower extremity with wound cleanser, apply [MEDICATION NAME], cover with an abdominal pad and wrap with Kerlix. Change daily. Review of TAR dated 2/22- 3/10/15 (discharge) showed staff documented the following wound conditions on back of TAR: -Distal right lower extremity, stage III, measuring 3 cm x 1.7 cm x 0.2 cm irregular shaped and wound bed yellow in color; -Right outer foot pressure ulcer stage IV, measuring 2.7 x 7.6 x 1 cm irregular shaped with pink and yellow wound bed. Review of POS dated 2/28/15 showed the physician ordered a catheter placed due to [MEDICAL CONDITION], and lower extremity swelling. Review of an at risk note, dated 3/4/15 (no time) showed: resident seen by wound care specialist on 2/27/15 related to multiple wounds to right lower extremity, bilateral buttocks, and left heel. All treatment to continue as ordered, bilateral buttocks remains excoriated and open. treatment for [REDACTED]. Review of the resident's POS dated 3/6/15 showed the wound care specialist ordered treatment to cleanse right heel and right great toe with wound cleanser, apply skin prep, cover with abdominal pad and wrap with Kerlix. Change daily. Review of TAR dated 2/22 - 3/10/15 (discharge) showed staff documented the following pressure ulcer wound conditions on 3/6/15: -Right great toe pressure ulcer measured 1.2 cm x 1.5 cm irregular shaped with black wound bed; - right heel unstageable measuring 7.5 cm x 4.4 cm with black wound color; - left heel unstageable measured 10.3 cm x 6 cm with black wound color; -right outer foot pressure ulcer, stage IV, measuring 2.7 cm x 7.5 cm x 1 cm with red/ yellow wound color; -distal right lower extremity, stage III measuring 2.5 cm x 1.5 cm x 0.2 cm with yellow would color. Review of a sticky note provided by the ADON/wound care nurse (due to lack of documentation on TAR) showed the following measurement are said to have been obtained from the ADON's own personal records and unavailable in the resident's medical record, showed wound measurement of the buttocks on 3/6/15 as follows: -Left heel measured 9 cm x 9 cm with no depth or other wound description documented; -Right buttock measured 1.5 cm x 0.7 cm x 0.1 cm with no other wound description documented; -Left buttock measured 1.7 cm x 1.7 cm x 0.1 cm no other wound description documented. Review of a nurses note dated 3/10/15 at 3:45 P.M. showed staff documented they sent the resident to the emergency room per resident and family request and physician approval due to shortness of breath. During an interview on 3/18/15 at 1:20 P.M. the ADON/wound care nurse said nursing staff should document ulcer wound measurements and description on the back of TARs weekly to monitor wound healing and acknowledge they did not get recorded as expected. She said the resident was admitted with mushy heels but that she did not document heel conditions. The ADON said she did not assess the resident's heels herself, but said the nurse came to her and reported heel condition and reported they were not blackened per nurses' report to her, and she implemented heel elevators on either 2/3 or 2/4/15. She said the resident would refuse to use elevated heels. She said the resident's buttocks wounds were moisture associated as the resident would not let staff know when he/she was incontinent. During an interview on 3/19/15 at 4:35 P.M. the administrator and DON said that they would expect the resident's Braden scale to accurately reflect residents current conditions and that the resident should be reassessed for increased risk as changes in conditions indicate. They said that they would expect complete pressure ulcer wound conditions to be recorded on the resident TAR weekly or as conditions change. They said that they expect staff to provide and document all treatments as ordered and directed on the TAR. 3. Review of Resident #2's Treatment Administration Record (TAR) dated 12/22 -1/21/15 showed staff document weekly wound assessments on the back of the TAR. Review showed staff documented the resident had the following pressure ulcers: -On 12/26/14 a pressure ulcer to the right upper buttocks measuring 0.6 cm x 1.2 cm x 0.1 cm; - On 1/2/15 a pressure ulcer to the right upper buttocks measuring 0.6 cm x 1 cm x 0.1 cm; -On 1/9/15 a pressure ulcer to the right upper buttocks measuring 0.3 cm x 0.5 cm x 0.1 cm; -1/15/15 staff document pressure ulcer to right upper buttocks is healed Review of the resident's Physician order [REDACTED]. -Apply [MEDICATION NAME] to affected area twice daily; -Cleanse right upper buttock with wound cleanser, apply polymem (wound dressing to protect the wound and facilitate the natural healing process) 4 x 4 cut in half, and secure with tape. Change every 3-7 days. Review of the resident's Physician order [REDACTED]. heel once per shift daily to blister. Review of the resident's POS dated 1/13/15 showed the physician directed staff to cleanse the resident's left hip with wound cleanser apply [MEDICATION NAME] gel (Antimicrobial Wound Gel) and cover with an abdominal pad. Change daily and as needed until healed. Review of the resident's Treatment Administration Record (TAR) dated 12/22/14 - 1/21/15 showed the following: -Direction to cleanse right upper buttock with wound cleanser, apply polymem (pressure ulcer treatment for [REDACTED]. Change every 3-7 days. Staff documented the resident's wound healed on 1/15/15. -Direction to apply [MEDICATION NAME] to affected area twice daily. Further review showed staff did not document they completed the treatment on the 7:00 A.M. to 3:00 P.M. shift on 12/23, 12/25/15, and 1/4/15, and on the 3:00 P.M. - 11:00 P.M. shift on 12/23-12/26/14, 1/1/15, 1/3, 1/4, 1/10, 1/11, 1/17, 1/18/15. -Direction to apply skin prep to right heel (blister) once per shift daily. Further review showed treatment started on 12/31/14 and staff did not document they completed the treatment during the 7:00 A.M. - 3:00 P.M. shift on 1/4 and 1/18/15, during the 3:00 P.M. - 11:00 P.M. shift on 1/1, 1/3, 1/4, 1/6, 1/10, 1/11, 1/17, an 1/18/15, and during the 11:00 P.M. - 7:00 A.M. shift on 12/31/14, 1/1/15, 1/5, 1/20, and 1/21/15. -Review of back of TAR showed no assessment of right heel condition during treatment period (12/22/14 - 1/21/15). -Direction for staff to cleanse the open area on the left hip with wound cleanser, apply [MEDICATION NAME] Gel, cover with abdominal pad. Change daily and as needed. Further review showed staff did not document they completed the treatment on 1/17 and 1/18/15. -Review of the back of the TAR showed staff did not document a wound assessment of the left hip from start date of 1/13 through 2/21/15. -Direction for staff starting 1/16/15 to apply ankle elevators to right leg at all times every shift. Heel protector to be worn on left foot every shift. Review showed staff did not document elevator/heel protector in place on 7-3 shift on 1/18, 3-11 shift on 1/17, 1/18, and 11- 7 shift on 1/16, 1/20, and 1/21/15. Review of the resident's POS dated 1/22 - 2/21/15 showed the physician directed staff to complete the following: -Apply [MEDICATION NAME] to affected area twice daily; -Cleanse left hip with wound cleanser apply [MEDICATION NAME] gel (wound treatment) cover with abdominal pad. Change daily and as needed until healed. Review showed no discontinuation of treatment on 1/22 or orders to restart treatment on 2/27/15 as documented on the TAR; -Apply skin prep to right heel once per shift daily to blister; -Directed on 2/16/15 to begin treatment to the resident's coccyx area. Clean with wound cleanser, apply silva gel, cover with abdominal pad and secure with medfix (dressing). Change daily. Review of the resident's TAR dated 1/22-2/21/15 showed directed to complete the following treatments: -Apply [MEDICATION NAME] to affected area twice daily. Further review showed staff did not document they completed the treatment on the 7:00 A.M. - 3:00 P.M. shift on 1/29, 2/1, and on the 3:00 P.M.- 11:00 P.M. shift on 1/25, 1/26 -2/2, 2/4, 2/9, 2/10, 2/12, 2/13, and 2/18; -Cleanse the open area on the left hip with wound cleanser, apply [MEDICATION NAME] Gel, cover with abdominal pad. Change daily and as needed. Further review showed staff did not documented they completed the treatment on 1/22-1/26, and documented Healed across dates. Further review showed three lines drawn through healed and treatment resumed on 1/27/14. The review showed staff did not document they completed the treatment on 1/29 and 2/1/15. -Apply skin prep to right heel once per shift daily. Further review showed staff did not document they completed the treatment on 7:00 A.M. to 3:00 P.M. shift on 2/1, 2/3 and 2/12/15, during the 3:00 P.M. - 11:00 P.M. shift on 1/25, 1/28 -2/2, 2/4, 2/9, 2/10, 2/12, 2/13, an 2/18/15, during the 11:00 P.M.-7:00 A.M. shift on 1/23, 1/24, 1/29, 1/31, 2/32/14-2/16, 2/18, and 2/19/15; -Cleanse coccyx with wound cleanser, apply Silvagel, cover with abdominal pad and secure. Change daily. Further review of back of TAR showed on 2/16/15 staff identified a new pressure ulcer on the resident's coccyx, stage II, measuring 1 cm x 1. 6 cm x 0.1 cm irregular shaped with red wound bed. Review of the resident's care plan, showed staff assessed the resident at risk for pressure ulcers related to poor mobility and incontinence. They listed the goal was for the resident's skin to remain intact. On the following dates, staff documented the resident had the following pressure ulcers: -1/27/15 Left hip stage III (Wound/Skin Care Guidelines direct staff to refer to the wound care specialist when identified). Further review of the resident's plan of care showed staff did not consult the wound care specialist until 2/24/15; -2/10/15 coccyx stage II; -2/21/15 right hip stage II. Further review of the resident's plan of care showed staff documented the following interventions: -Avoid shearing during positioning, transfers, and turning; -Conduct skin assessments weekly; -Keep clean and dry; -use moisture barrier cream to perineal area. Review of the resident's POS dated 2/22 - 3/21/15 showed the physician directed staff to provide the following treatments: -Apply [MEDICATION NAME] to affected area twice daily; -On 2/27/15 the physician changed the treatment for [REDACTED]. Change twice a day; -Apply skin prep to right heel once per shift daily to blister. Review of the resident's TAR dated 2/22-3/21/15 showed direction for staff to provide the following treatments; -Apply [MEDICATION NAME] to affected area twice daily. Further review showed staff did not document they completed the treatment on the 3:00 P.M. - 11:00 P.M. shift on 2/22, 2/24 - 2/28, 3/2 - 3/6, 3/8, 3/9,3/13, 3/17, and 3/18; -Cleanse coccyx wound with wound cleanser, apply [MEDICATION NAME], cover with abdominal pad and secure. Change twice a day. Further review showed staff did not document they completed the treatment on the 10:00 P.M. - 6:00 A.M. shift on 2/27, 3/1-3/3, 3/5, 3/6, and 3/11/15 ; -Apply skin prep to right heel once per shift daily. Further review showed staff did not document they applied the treatment during the 3:00 P.M. - 11:00 P.M. shift on 2/22

Based on observation, interview, and record review, facility staff failed to provide appropriate care and services to identify, assess and treat facility acquired pressure ulcers for one of 16 sampled residents (Resident # 9). The facility staff failed to provide weekly skin assessments, and assess the skin in a timely manner for resident # 9 to help prevent the development of a stage III pressure ulcer located on the sacrum area (a wound that presents with full thickness tissue loss without ligament of bone tissue present, with or without slough-dead skin tissue). The facility also failed to accurately assess and treat a stage II pressure ulcer (a wound that presents with partial thickness loss of dermis (skin) presenting as a shallow open ulcer with a red-pink wound bed. May also present as an intact or open/ruptured blister) in the resident's front perineal area. The facility census was 76. Review of the facility's Wound and Skin Care Guidelines dated 2009, showed the following: -Establish a turning/positioning schedule. Usual schedules are at least every 2 hours while in bed and at least hourly in a chair. Use positioning products and draw sheets as indicated. - Evaluate the need for a pressure reduction surface for bed and or chair, as well as the need for heel and /elbow protectors or specialized protection. -Evaluate nutritional /hydration status and make appropriate interventions. Encourage fluids and determined unless contraindicated. -All chronic wounds are contaminated. Chronic wounds should be dressed using a clean technique unless physicians orders state otherwise. -Thoroughly document all wound information such as type, location, stage(if applicable), length, width, depth, drainage, notation of tunneling or undermining, description of tissue(necrotic, granulating, etc), state of periwound area, treatment of [REDACTED]. -Notify appropriate personnel of all new pressure ulcers, or if you have any questions. 1. Review of Resident # 9's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, dated 8/1/13, showed staff assessed the resident as follows: - Moderate cognitive impairment; - Required total assistance from staff for bed mobility and transfers; - Required extensive assistance from staff for dressing and personal hygiene; - Did not walk; - Used a wheelchair; - Limited range of motion is impaired on both sides of lower extremities; - At risk for pressure ulcers. Review of the resident's Braden Scale (assessment used to predict a person's risk of developing a pressure ulcer), dated 11/1//13, showed staff assessed the resident scored a 15 (at low risk of developing a pressure ulcer). Review of the resident's care plan, updated on 11/1/13, showed staff documented: Resident experiences bladder incontinence: -Apply moisture barrier; -Provide incontinence care after each episode; -Report any signs of skin breakdown (sore, tender, red, or broken areas). Resident is at risk for skin breakdown related to poor mobility: -Assess resident for presence of risk factors. Treat, reduce, eliminate risk factors to extent possible; -Conduct a systematic skin inspection weekly. Pay particular attention to the bony prominences; -Keep clean and dry as possible. Minimize skin exposure to moisture; -Turn and reposition every 2 hours; -Use cushion for pressure reduction when resident is in chair. Review of the resident's Nurses' Notes dated 11/1/13, showed staff documented a bruised area was noted in the perineal area, resident denies pain, and staff will continue to monitor. Further review showed staff failed to provide follow up documentation regarding the blistered area. During tour of the facility on 11/12/13 at 11:15 A.M., the Director of Nurses (DON) said the resident had no known skin issues. Observation on 11/12/13 at 2:30 P.M., showed the resident lay in bed on his/her back Observation on 11/12/13 at 3:30 P.M., showed the resident lay in bed on his/her back. Certified Nurses Aide (CNA) Q and CNA R provided peri care to the resident. Observation showed the resident had a open area approximately the size of a pencil eraser located on the sacrum (tailbone). The wound was surrounded by a pink area approximately the size of a dime. CNA Q and CNA R said it has been there for about 2 weeks and the nurses knew about it. There were no treatment orders the staff knew of except for barrier cream to be applied. Observation showed CNA R applied a thick layer of Inzo barrier (Dimethicone) cream, (a cream used to protect skin from moisture) on and around the wound and perineal area. CNA R also applied a barrier cream to the resident's genital area and stated the resident also had a blister there. Review of the resident's medical record showed staff failed to document information related to any skin issues, assessments or treatment of [REDACTED]. Review of the resident's weekly head to toe skin assessments dated Oct and [DATE] showed blank, undocumented forms. Record review on 11/12/13, of the resident's Physician order [REDACTED]. Record review on 11/12/13, of the resident's Treatment Administration Record (TAR) dated 10/22/13 to 11/21/13, showed no wound care treatment orders. Additionally the skin assessment section of the TAR showed no documentation. Observation on 11/12/13 at 6:45 P.M., showed the resident lay in bed on his/her back. Observation on 11/13/13 at 9:30 A.M., showed the resident lay in bed on his/her back. Observation on 11/13/13 at 2:00 P.M., showed the resident lay in bed on his/her back. During an interview on 11/13/13 at 4:00 P.M., CNA O said the area on the resident's wound developed about two weeks ago and the blister on the perineal area has been there even longer. The nurses are aware of both areas. CNA O personally told Registered Nurse (RN) D approximately 2 weeks ago. CNA O said a nurse at one time put a dressing on the sacrum wound. There were no treatment orders that she/he knew of. CNA O was not aware of any changes made to the resident's care since the pressure sore developed. CNA O said the resident had a decline in condition and doesn't want to get up out of bed as often. Observation on 11/14/2013 at 09:05 A.M., showed CNA P and CNA R transferred the resident to bed from his/her wheelchair by using the mechanical lift. CNA P and CNA R provided pericare and assisted the resident to his/her right side. Observation of the resident's skin showed a dime size reddened area with three open stage III (full thickness tissue loss)on his/her sacrum pressure ulcers. Using a clock, 12 o'clock for the position of the resident's head and 6 o'clock for the position of the resident's feet, 10 o'clock is the largest of the three pressure ulcers appearing to be about the size of a #2 pencil eraser. The second and third pressure ulcers are at 2 o'clock and 6 o'clock positions. The 2 o'clock and 6 o'clock pressure ulcers were both oval in shape and about one half the size of a #2 pencil eraser. The wound bed of the pressure ulcers showed red granulation tissue. The wound edges and skin between the three ulcers showed to be macerated (white in color and moist) and indurated (raised and firm). The dime size area of surrounding skin on the outside of the pressure ulcers showed to be red and non-blanchable. Observation of the frontal perineal area showed a stage II ( partial thickness loss of the dermis) pressure ulcer. The wound bed had light red/pink granulation tissue present with slightly raised wound edges. The surrounding skin was pink and blanchable. CNA P applied barrier cream (Dimethicone cream) to the resident's sacrum and frontal perineal area. During an interview on 11/14/13 at 9:20 A.M., CNA P said she/he was aware of the open area on the residents sacrum. CNA P first noticed the area on the resident's sacrum a couple of weeks ago. CNA P told RN D about the skin issue when she/he first discovered it. During an interview on 11/14/13 at 11:00 the Director of Nurses (DON) said she/he was not aware of any skin issues that the resident was experiencing. If staff did informed a nurse regarding a change in a resident's skin condition, the nurse is expected to assess and document the skin issue and follow the skin care guidelines. 2. Observation on 11/14/2013 at 01:06 P.M., showed that Licensed Practical Nurse (LPN) B used a paper measuring tool and measured the length and width of the dime size reddened area that surrounded all three open pressure ulcers on the resident's sacrum. LPN B did not measure the three open areas on the sacrum individually. When LPN B measured the depth of the pressure ulcer on the sacrum, he/she placed the paper measuring tool down toward the wound bed and measured the macerated raised skin that divided the three pressure ulcers. LPN B said the measurements were 2 centimeters (cm) in length x 1 cm in width x 0.5 cm in depth for the sacrum pressure ulcer(s). LPN B then measured the length, width and depth of the frontal perineal area pressure ulcer of resident #9, with the same paper measuring device used on the sacrum pressure ulcers. LPN L said the length was 3.5 cm x 1.5 cm in width x 0 cm in depth. LPN B washed and gloved her hands, and applied barrier cream to the resident's sacrum and frontal perineal pressure ulcers. During an interview on 11/14/13 at 1:45 P.M., License Practical Nurse (LPN )B said she/he was just made aware of the resident's skin issues today. LPN B said it is protocol to put barrier cream on Stage II wounds and blisters. Treatment was started today of applying barrier cream every shift until healed. Both skin areas on the resident are from pressure. LPN B is not sure if the physician has been notified. During an interview on 11/14/13 at 2:00 P.M., CNA Q said she/he was aware of the open area on the resident's sacrum and the pressure sore has been open for a couple weeks. CNA Q said RN D was informed about it. During an interview on 11/15/13 at 11:00 A.M., RN D said she/he was not aware of any skin issues for the resident until today (11/15/13). RN D said nothing was reported to her/him within the last couple weeks that she/he could remember. RN D said if a staff person reports a skin issue, she/he would look at the resident's skin, document it in the nurses notes and notify the physician if needed. During an interview on 11/15/2013 at 2:28 P.M., LPN E said Resident #9 has had reoccurring redness to his/her buttock, but not aware of any open areas on the resident.

Based on observation and interview the facility staff failed to ensure safety of a resident at risk of elopement (Resident #18) who was found outside the facility on the ground. The following day the resident's right eye was noted to be very swollen and purple. Staff transferred the resident to a local hospital. Review of the hospital discharge record showed the resident sustained [REDACTED]. Additionally staff failed to develop meaningful interventions in response to repeated falls for the resident. Facility staff also failed to ensure medication was not left unattended and accessible to the residents. Five Spiriva Handihaler capsules (a medication used in an inhaler taken once a day for Chronic Obstructive Pulmonary Disease) were left unattended on top of the medication cart. Facility census was 76. 1. Record review of Resident #18's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 8/14/13, showed the following: -Short and Long-term memory problems; -Wandering occurred four to six days during the past seven days; -Resident requires oversight, encouragement, and/or cueing while moving in his/her wheelchair; -Dependent on staff for extensive assistance to ambulate, toilet, and transfer (how the resident moves between surfaces, bed to wheelchair); -Dependent on staff to assist with balance while moving from a seated to standing position, walking, turning around, and moving on and off the toilet; -Using a wheelchair as an assistive device; -diagnosed with [REDACTED]. Review of the resident's wandering assessment, dated 8/5/13, showed staff assessed the resident as a " wander/elopement " risk. Review of the resident's fall risk assessment, dated 8/5/13, showed staff marked seven out of ten categories showing a risk for falls. Record review of the resident's plan of care, dated 8/20/13, showed a problem as of 8/25/13: " Resident has made attempts to go out emergency doors. He/she said, "I have to go home." Resident has confusion, poor memory recall & poor safety awareness. " Review of the resident's nursing note, dated 8/27/13, showed the resident continues wandering in the hallway looking for his/her spouse and child. Review of the resident's nursing note, dated 9/3/13, showed the resident made comments about looking for a way home. Review of the resident's nursing note, dated 9/5/13, showed during an interdisciplinary team meeting, a resident's family member expressed concern regarding possible elopement by the resident. Review of the resident's nursing note, dated 9/10/13, showed staff wrote " At risk note: Continues to wander in the hallway. " Review of the resident's nursing note, dated 10/25/13 at 3:30 P.M., showed the Assistant Director of Nurses (ADON) brought the resident to the nurse's station. Staff found the resident lying on the ground outside the northeast door. Review of the resident's nursing note, dated 10/26:13 at 6:10 A.M., showed staff observed the resident's right eye as very swollen and purple. Review of the hospital discharge record, dated 10/26/13, showed the resident sustained [REDACTED]. Observation of the resident on 11/7/13 at 9:40 A.M., showed a small, red bruise under his/her right eye and redness in the white of the right eye. Observation on 11/7/13 at 10:45 A.M. of the northeast exit door showed the door contained a red alarm box with an on/off key setting. During an interview on 11/7/13 at 2:49 P.M., the Activity Director (AD) said upon returning to the facility from a recent activity in the van at approximately 3:30 P.M., he/she observed the resident lying on the grass outside the northeast exit door. Observation of the location pointed out by the AD showed he/she found the resident approximately 20 feet from the door adjacent to a concrete sidewalk. The AD said he/she found the resident on the grass on his/her right side facing his/her wheelchair. The AD said the resident had not eloped previously, but would frequently say he/she " was going home " . During an interview on 11/7/13 at 10:46 A.M., the maintenance employee said medical deliveries come through northeast exit door. He/she said staff unlocked this door when medical deliveries came through. He/she said a medical delivery occurred a day prior to the elopement of the resident, but he locked the door after this delivery. During an interview on 11/7/13 at 1:06 P.M., the maintenance employee said he, the charge nurses, the administrator, and the housekeeping supervisor all have keys to turn off the alarms on the exit doors, including the northeast exit door. During an interview on 11/12/13 at 11:31 P.M., CNA S said while the ADON brought the resident in after his/her elopement he/she checked the northeast exit door, because he/she did not hear any alarm sound. CNA S said when he/she looked at the alarm on the northeast exit door, he/she noticed the key lock in the off position. He/she did not know how this alarm got in the off position. During an interview on 11/12/13 at 12:21 P.M., the ADON said the resident had attempted to elope from an exit door used by employees previous to the elopement on 10/25/13. The ADON said he/she did not recall details about the incident. During an interview on 11/13/13 at 1:24 P.M., the administrator said medical supplies come through the northeast exit door twice a month. She did not know how the northeast exit door alarm got turned off (prior to the elopement). Record review of the resident's plan of care, dated 5/20/13 and updated 8/20/13, showed direction for staff to do the following fall prevention interventions: -Encourage the resident to assume a standing position slowly; -Give the resident verbal reminders not to ambulate/transfer without assistance; -Keep call light in reach at all times; -Keep personal items and frequently used items within reach; -Observe frequently and place in a supervised area when out of bed; -Occupy the resident with meaningful distractions; -Provide proper, well-maintained footwear; -Provide the resident an environment free of clutter; -Provide toileting assistance every two hours and as requested by the resident; -Teach the resident safety measures. Further review of the resident's care plan, dated 5/20/13 and updated 8/20/13, showed staff documented the resident's fall history and interventions in response to the falls as follows: -On 6/26/13, staff " observed on floor of room in front of wheelchair. Attempted to transfer self to restroom. " In response staff wrote " frequent monitoring when up in wheelchair. Is currently working with therapy, will notify of fall. " (Intervention developed 5/20/13 stated " Observe frequently " ). -On 7/7/13, " CNA observed resident attempting to transfer unassisted; could not get to before fell on floor. " In response, staff wrote " toilet every two hours. Therapy educate to use call light for assistance and to ask staff for assist with transfers. Continue with PT (physical therapy) and OT (occupational therapy). " (Interventions developed 5/20/13 stated " Teach the resident safety measures " and " Provide toileting assistance every two hours " ). -On 7/17/13, " resident observed on floor of room in front of wheelchair " ; in response staff wrote " Placed on falling star program. Due to elevated blood pressure 1 time dose of Norvasc (blood pressure medication) 5 MG (milligram) given & continue to monitor blood pressure. " -On 7/25/13, " resident observed by therapy attempting to ambulate unassisted. Therapy startled (him/her) and (he/she) lost balance falling onto buttock. In response staff wrote " Continue all current interventions " . -On 8/30/13, " observed on floor of room in front of closet. " In response staff wrote " Continue all current interventions and obtain UA (urinalysis). " -On 10/18/13, " observed on floor beside wheelchair; stated (he/she) slid out of wheelchair. " In response staff wrote " Continue all current interventions at this time. " Review of the resident's post fall reports showed the following: -On 6/26/13 (no time given), staff documented that the resident went to the bathroom unassisted and sat down on the floor. No injury noted. -On 7/7/13 at 3:15 P.M., staff documented a nurse aide observed the resident going to the bathroom unassisted and sitting down on the floor in his/her bedroom. No injury noted. Review of the resident's nursing notes regarding falls showed the following: -On 7/17/13 at 3:30 P.M., staff observed the resident sitting on the floor of his/her bedroom next to his/her wheelchair. Upon assessment, staff noted redness to right side of the resident's abdomen. -On 7/25/13 at 3:15 P.M., the therapist observed the resident transferring/ambulating unassisted. The therapist startled the resident when he/she entered the resident's room causing the resident to lose his/her balance and fall to his/her buttocks. No injuries noted. -On 8/30/13 at 9:30 A.M., staff observed the resident sitting on the floor in his/her bedroom in front of his/her closet. No apparent injuries noted. -On 10/18/13 at 12:00 A.M., staff observed the resident on the floor. The resident said he/she slid out of his/her chair. No injuries noted. Review of the resident's physician's orders [REDACTED]. During an interview on 11/12/13 at 2:51 P.M., LPN E said the falling star program involves staff monitoring residents at risk of falling more closely and toileting more frequently. During an interview on 11/12/13 at 2:59 P.M., the MDS Coordinator said in regards to the resident's care plan fall intervention in response to a fall on 7/7/13, she meant to write that staff educated the resident on the use of call lights (instead of therapy) and staff remind the resident not to transfer without assistance. She said in regards to the fall on 6/26/13, the resident had already been receiving therapy when the fall occurred. She said the falling star program identifies residents at high risk of falls to staff so they can monitor them more carefully. During an interview on 11/13/13 at 11:07 P.M., the MDS Coordinator (after he/she had reviewed the resident's care plan) said he/she did not know of any other fall prevention interventions put in the place for the resident other than two added after the elopement (on 10/25/13). During an interview on 11/13/13 at 11:34 P.M., the Director of Nursing (DON) (after review of the resident's care plan) said she did not know of any other fall prevention interventions put in the place for the resident other than two added after the elopement (on 10/25/13). During an interview on 11/13/13 at 1:23 P.M., the DON said she did not know why the resident's fall prevention interventions of a fall mat and low bed (put in place 10/25/13) were not put in place earlier. 2. Observation on 11/15/2013 from 10:00 A.M. until 11:50 A.M., showed the medication cart unattended with five Spirivia HandiHaler capsules in a package on top of the cart by the medication administration book. Further observation showed residents wheeled past the cart multiple times. During an interview on 11/15/2013 at 11:50 A.M., RN D said that Spirivia Handihaler capsules should never be left unattended on a medication cart. During an interview on 11/15/2013 at 11:52 A.M., the Minimum Data Set (MDS) Coordinator said Spirivia Handihaler capsules are never to be left unattended on a medication cart. During an interview on 1/15/2013 at 2:28 P.M., LPN E said that Spirivia Handihaler capsules should at no time be left unattended on a medication cart. During an interview on 1/15/2013 at 2:57 P.M., the Director of Nursing (DON) said that Spirivia Handihaler capsules should never be left unattended on top of a medication cart. MO 219 & MO 227