Every finding on record at West Ridge Care Center

Based on clinical record review, observations, resident, resident family members and staff interviews, and facility policy review, the facility failed to ensure Care Plans were comprehensively reviewed and revised for 1 of 1 residents reviewed for hearing (Resident #19), for 1 of 1 residents reviewed for hypnotic (sleeping pill) medications (Resident #24), and for 1 of 4 residents reviewed for pain (Resident #39). The facility reported a census of 50 residents. Findings Include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #19 revealed diagnoses of vascular dementia, anxiety disorder, and other speech/language deficits following cerebrovascular disease. Section B titled Hearing, Speech, and Vision documented hearing was adequate with a hearing aid. The Comprehensive Care Plan (CCP) printed 11/14/23 with an admitted [DATE] included an intervention dated 11/13/23 that hearing was adequate with bilateral hearing aids. The CCP failed to include a focus area, goal, or additional interventions related to hearing and placing hearing aids. Documents titled Task - Medication Administration Record (MAR), and Treatment Administration Record (TAR) did not include ensuring hearing aid placement. Observation and interview with Resident #19 and a family member on 11/13/23 at 11:42 AM, revealed the resident did not have his hearing aids in. The family member stated staff were supposed to put hearing aids on in the morning and it was not done today. She stated this was not the first time and she was here every day. On 11/15/23 at 10:25 AM, observed documentation on the resident's white board under the miscellaneous section that indicated resident should be provided support with hearing aids and glasses. On 11/15/23 at 1:04 PM, the Director of Nursing (DON) stated the plan for the resident's hearing aids should be on the white board in his room and in his Care Plan. Some plans were included in the TAR and sometimes hearing aids were put in the medication carts as a reminder. On 11/15/23 at 1:38 PM, the Resident Assessment Instrument (RAI) Coordinator confirmed hearing aid placement was not in the Care Plan nor on the MAR or TAR. 2. The MDS assessment dated [DATE] for Resident #39 listed active diagnoses of stroke, anxiety disorder, and spondylosis in the lumbar region. MDS Section C titled Cognitive Patterns documented severely impaired cognitive skills for daily decision making. Section J titled Health Conditions documented a scheduled pain regimen, the presence of pain, and that the resident was unable to answer questions about pain. The CCP printed 11/14/23 with an admitted [DATE] included a diagnosis of pain in thoracic spine. The Care Plan failed to include goals and interventions related to the pain diagnosis. A Progress Note titled Behavior Note 1 dated 10/15/23, documented the resident was tearful, pulling at her G-tube, and putting the call light on frequently. An observation and interview with Resident #39's family member revealed the resident was sad that day. Observed her softly cry out while she leaned sideways in her recliner and fidgeted with her G-tube. The family member requested staff to reposition the resident. On 11/15/23 at 9:48 AM, the DON stated the facility collected information for Care Plans from the history and physical, hospital, admissions nurse, electronic health record triggers, staff, and the physician. On 11/15/23 at 12:58 PM, the Administrator stated he expected the team to maintain documentation that the person has pain, what staff were doing to address the pain, and Physician Orders related to pain. This included Care Plans. On 11/15/23 at 1:38 PM, the RAI Coordinator stated if someone had a diagnosis related to pain she expected documentation in the Care Plan about scheduled and as needed medications, pain evaluations, therapy, and day to day interventions. 34821 3. The MDS for Resident #24 dated 10/30/23, listed diagnoses of pneumonia, chronic pain and depression. The MDS reflected a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating intact cognition for Resident #24. The MDS showed the high risk drugs she took included a hypnotic (sleeping pill). The Care Plan for Resident #24 dated 10/13/23, failed to address the use of the hypnotic medication and failed to direct staff to monitor for adverse effects of the medication. On 11/16/23 at 9:31 AM, the DON reported she expected the Care Plan to identify a residents use of a hypnotic medication. A policy titled Comprehensive Care Plan Policy revised 7/13/23 stated a thorough assessment of the resident's current health status should be conducted and the Care Plan reviewed to determine if revisions were needed. The revised Care Plan should include specific goals and interventions to address the resident's physical, emotional, and social needs. Staff should review and revise the Care Plan at least quarterly.

Based on clinical record review, observation, policy review and staff interviews, facility staff failed to appropriately change gloves between a blood glucose check and sanitizing the blood glucose machine for 1 of 2 residents reviewed for infection control (Resident #38). Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #38 showed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating intact cognition. The MDS Listed a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan revised 3/07/22 identified Resident #38 as a diabetic and directed the nurse to perform the blood glucose checks per the physician orders. An Order Review Report signed by the Provider and noted by a nurse on 10/07/22 showed a Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Inject one lancet subcutaneously four times a day for blood sugar checks. During an observation on 11/16/22 at 8:05 a.m., Staff B, Registered Nurse (RN) performed hand hygiene, gloved, removed a lancet, blood glucose meter, alcohol prep pad and small 2 inch by 2 inch gauze pad from the medication cart and placed on top of her report papers which contained writing on top of the cart. She held the blue barrier sheet (dental drape) in her gloved hands. Staff B approached Resident #38 and laid the blood glucose meter on the table without a clean barrier underneath. She then placed the blue barrier sheet on the table, picked the blood glucose meter up off the table and placed on top of the blue barrier sheet along with the other supplies. Staff B pricked the resident's finger using the lancet, then wiped away the first drop of blood with the gauze pad. She squeezed the resident fingertip again to obtain blood to place on the meter strip. After completing Resident #38's blood sugar she picked up the supplies and returned to the Medication Cart. She disposed of the lancet in the sharps container and disposed of the blood meter strip, gauze pad, alcohol prep pads and barrier sheet. Wearing the same gloves, she removed the green top of the bleach wipes, removed a bleach wipe, wiped down the blood glucose meter. Staff B failed to change her gloves after completing the blood sugar procedure and disposing of the dirty blood glucose equipment before sanitizing the blood glucose meter. During an interview on 11/16/22 at 4:20 p.m., the Infection Preventionist reported the resident's do not have their own blood glucometers. The facility utilizes one blood sugar machine that is used across multiple residents. During an interview on 11/16/22 at 4:30 p.m., the Director of Nursing (DON) reported she would expect the nurse to remove her gloves after the blood sugar procedure is complete. She reported the nurse should not have used the same gloves from the blood sugar procedure to sanitize the blood glucose machine. The Blood Glucose Policy, revised 3/10/22, under Procedure directed the nurse after completing the Resident's blood sugar to do the following: a. Remove the used test strip and lancet by putting into the sharps container. b. Dispose of the dental drape (blue barrier sheet). c. Remove gloves. d. Wash/sanitize hands. e. Disinfect glucometer by wrapping machine with a disinfectant wipe. Sit in a cup and allow for appropriate dry time. f. Do not use a paper towel or Kleenex for a barrier. g. Do not put a glucometer in your pocket nor on any surface without a barrier.

Based on facility clinical record review, resident observation, staff interviews and facility policy review the facility failed to provide professional standards of quality for one of five residents reviewed for Medication Review (Resident #17). The facility provided a census of 45. Findings Include: On 3/22/22 a Comprehensive Care Plan for Resident #17 had identified by documentation resident allergies as [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], and Penicillan. The Care Plan also identified one special instruction which stated, resident swallowed pills whole. The Care Plan had listed resident diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/20/22 a Quarterly Minimum Data Set (MDS) Assessment for Resident #17 had been completed and the resident scored a Brief Interview for Mental Status (BIMS) score of 4 out of 15 indicating the resident had severe cognitive impairment. A review of the October 2022 Electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation on 11/14/22 at 2:00 p.m., showed the resident propelling herself in a wheelchair at moderate speed and redirected easily by staffs when the resident tried locked doors and then tried to enter another resident room. Another resident observation on 11/15/22 again had shown Resident #17 propelling herself in a wheelchair at moderate speed and trying to enter other resident rooms. On 11/15/22 a review of Resident #17's facility Nursing Progress Notes showed on 10/11/22 at 2:17 AM, Staff F, Registered Nurse (RN) documented a Nursing Progress Note titled Behavior Note. The note documented a Certified Nurse Aide (CNA) observed Resident #17 take pills' out of her personal sweater pocket and had been trying to throw the pills in the toilet. Staff F further documented the CNA gave the pills to the nurse. The clinical record lacked further documentation of the quantity of pills, type of pills, notification of facility Administration, notification of the resident provider, notification of family, and there was lack of documentation of a resident physical assessment. On 11/16/22 at 1:16 PM, during an interview, Staff A, RN stated she lacked knowledge of the incident on 10/11/22. The RN had not been given a verbal or documented report of the incident. On 11/16/22 at 2:14 PM, during an interview, Staff D,CNA reported did not recall the incident. Staff D further stated she had worked the shift. An interview on 11/16/22 at 2:20 PM, Staff E, CNA stated she had heard about the resident having pills in her sweater pocket however she had not taken care of the resident on 10/11/22. At 2:30 PM on 11/16/22, during an interview with the facility Director of Nursing (DON). The DON stated there had not been an Incident Report completed on the 10/11/22 incident with Resident #17. When asked what expectations of the Nursing Staff had been, the DON stated she expected the Nursing Staff to have completed an Incident Report, notify Administration, notify the provider, and to have documented a resident physical assessment, the quantity of medication found and to have identified the medication by resourcing the Pharmacy. On 11/17/22 at 8:15 AM, the facility Administrator stated the facility did not have a policy or procedure that included Incident Reports or guidelines to report. The Administrator provided a one page document titled: Documentation/Assessment Guidelines. The document directed Nursing Staff after a medication error identified, the resident should have been assessed for a twenty-four period and documented.

Based on observation, clinical record review, policy review, and staff interview the facility failed to follow the Care Plan as written for 2 of 12 residents (Residents #9 and #45) reviewed. The facility failed to follow Enhanced Barrier Precautions for Resident #45 and failed to measure gastric residual volume prior to a tube feeding for Resident #9. The facility reported a census of 45 residents. Findings Include: 1. Resident #9's Minimum Data Set (MDS) dated [DATE] documented the resident as receiving 51% or more of her total calories and 501 milliliters (ml) or more of fluid daily through her gastric tube. The MDS diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented a Brief Interview for Mental Status (BIMS) of 3 indicating severe cognitive impairment. Resident #9's Care Plan included an intervention initiated on 6/2/20 and last revised on 11/8/22 to monitor Gastric Residual Volume (GRV) prior to every feeding and to reinsert amount if 200 ml for 2 times or 250 ml for 1 time. During an observation on 11/16/22 at 10:53 AM, Staff A, Registered Nurse (RN) entered resident #9's room. She filled the graduate with water from sink and put the syringe in the graduate. Staff A changed her gloves performing hand hygiene between pairs and opened the gastric tube. She administered the water flush with the syringe, without verifying GRV or tube placement. She removed her gloves and performed hand hygiene, then shook, opened and poured the cartons of formula into the gravity setup. The line was primed. Staff A then applied gloves and opened the gastric tube and attached the line. The Facility Policy titled Feeding Tube Placement Check dated 8/4/22 directed staff to measure from insertion site to end of tube. The Facility Policy titled Gastronomy Tube Feeding dated 4/2018 directed staff to check placement with the initial tube feeding for the day for established tubes. During an interview on 11/16/22 at 11:20 AM, Staff A explained she did not check tube placement. She further explained tube placement is verified by 3rd shift prior to the first feeding of the day. During an interview on 11/16/22 at 3:59 PM, the Director of Nursing (DON) explained she expected Care Plans to be up to date, and the Care Plan in Point Click Care (PCC, Electronic Health Record) is the most up to date and current Care Plan, and she expects staff to follow the Care Plan. 2. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #45 showed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating no impairments in cognition. The MDS listed a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented Resident #45 had a recent major orthopedic surgery requiring active skilled nursing therapy services and received intravenous therapy while a resident at the skilled nursing facility. The Care Plan dated 9/27/22 documented Resident #45 admitted to the facility due to a right hip wash out and needed skilled services. The Care Plan directed the Resident had a peripherally inserted central catheter (PICC) line to the right arm and nursing would change the dressing weekly and as needed if soiled as well as keep the line patent per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 11/14/22 at 4:06 p.m., an isolation bin with gowns, gloves and hand sanitizer had been noted in the hallway outside of Resident #45's room. Further observation revealed two infection control bins just inside the doorway of the room for disposal of infectious waste and linens. The room did not have any signage outside of the doorway, on the isolation bin or inside the resident's room to direct staff if any special precautions were required, what precautions to follow, what Personal Protective Equipment (PPE) to wear and when. A random Certified Nurse Aide (CNA) observed in the hallway on 11/14/22 at 4:11 p.m. coming out of Resident # 45's room reported she did not know why Resident #45 had an isolation bin outside his room and did not know why he would need any special precautions. During an interview on 11/15/22 at 7:30 a.m., Resident #45 sat in his room recliner using his reacher to apply protective heel boots to his feet. He reported he is on some type of precautions, but he didn't know what the exact precautions were. He stated the staff wear masks and gloves with his cares, but not gowns. He reported he had a PICC line in his right arm and received antibiotics through the line. During an interview on 11/15/22 at 10:24 a.m. Staff C, Registered Nurse (RN) reported the (isolation) bin was not for Resident #45. She reported they utilized the bin as a supply bin for the entire hallway and Resident #45 did not require any special precautions. Staff C wearing a medical mask and gloves only proceeded to enter Resident #45's room to flush his PICC line and start his IV infusion of [MEDICATION(S)]. Staff C stood in direct contact, less than 1 foot away from Resident #45's PICC line when flushing and setting up the [MEDICATION(S)] IV Infusion. Staff C failed to wear a gown when working directly with the PICC line as directed by the Plan of Care for enhanced barrier precautions. During an observation on 11/15/22 at 3:08 p.m., the Wound Nurse/Infection Preventionist using tape secured a Center for Disease Control and Prevention (CDC) Enhanced Barrier Precaution (EBP) sign to the left side Resident #45's door frame so it could easily been seen when entering the room. The Wound Nurse reported Resident #45 had been on EBP since he admitted to the facility (9/27/22). She reported Resident #45 is to be on EBP and the nurse should have worn a gown in addition to the gloves when flushing the PICC line and setting up for the [MEDICATION(S)] antibiotic treatment earlier in the day. During an interview on 11/16 at 3:13 p.m., the Administrator reported he had checked with the Director of Nursing and the facility did not have a Care Plan policy. He reported they follow the standards of practice.

Based on clinical record review, Resident Assessment Instrument (RAI) Manual review and staff interview, the facility failed to accurately code the use of as needed pain medication on the Minimum Data Set (MDS) Assessment for 1 of 2 residents (Resident #25) sampled for pain. The Facility identified a census of 45 residents. Findings Include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #25 showed a Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicating moderate cognitive loss. The Resident required extensive assistance with bed mobility, transfer, ambulation in the room, dressing and toileting. The MDS listed a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the Resident did not receive scheduled or as needed pain medication in the last 5 days of the assessment period and reported frequent pain of a 7 on a 1-10 scale (10 being the worst possible pain). A Review of the October 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Give one tablet by mouth every 4 hours as needed for pain and revealed the Resident received 10 as needed doses of the Acetaminophen medication for pain levels ranging from 4-10 on a 1-10 pain scale (10 being the worst possible pain). The 10/25/22 MDS failed to accurately document the use of as needed pain medication during the 5 day look back period of the assessment. During an interview on 11/16/22 at 3:13 p.m., the Administrator reported that he had checked with the Director of Nursing and the facility did not have a policy regarding the MDS Assessment. The facility follows the Resident Assessment Instrument Manual standards of practice. During an interview on 11/16/22 at 4:20 p.m., the MDS Coordinator reported she looks at the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . She reported the MDS for Resident #38 had not been completed accurately. During an interview on 11/16/22 at 4:21 p.m., the Director of Nursing (DON) reported she would expect the MDS to be completed accurately. The Center for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.17.1 October 2019, page 1-8 documents an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Those sources must include the resident and direct care staff on all shifts, and should also include the resident's medical record, physician, and family, guardian, or significant other as appropriate or acceptable. It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment, and should be validated for accuracy (what the resident's actual status was during that observation period) by the interdisciplinary team completing the assessment. As such, nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment.

Based on record review, staff interview, and facility policy review the facility failed to assess, document, notify the provider and family and provide ongoing assessment of a reported wound for one of three residents reviewed (Resident #2). On [DATE] Therapy reported a wound on Resident #2's left elbow to a nurse. The nurse dressed the wound, but failed to assess and document, failed to notify the provider and family, and failed to communicate to the Wound Nurse for ongoing assessment and treatment. On [DATE] the family alerted staff that drainage was leaking out of the dressing that was dated as applied on [DATE]. Resident #2 was transferred to the local emergency room where it was determined that a quarter size hole on her elbow exposed metal hardware from a previous surgery that was contaminated and infected. Resident #2 was treated with IV antibiotics, had surgery to remove the hardware and wash out the wound, and died while at the hospital. The facility reported a census of 50 residents. Findings Include: 1. The Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had short term memory problems. The MDS identified the resident with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident documented with no falls, had a Stage 2 pressure ulcer and identified a risk of developing pressure ulcers. The MDS further documented the resident required extensive assistance of two staff for bed mobility, transfer and toileting. Review of a Facility Assessment for Predicting Pressure Sore Risk dated [DATE] identified Resident #2 at high risk for developing pressure sores. Review of Facility Progress Notes revealed on [DATE] Staff A, Registered Nurse (RN) entered a late entry note for [DATE] that documented Therapy brought Resident #2 to the Nurse's Desk to report a concern. The resident had an open area to the left elbow with blood present. Resident reported unsure how it had happened. Area cleansed with normal saline and a dry dressing applied. Further review of Facility Progress Notes revealed that no entries were made regarding the wound on the left elbow until a note was entered on [DATE] at 3:19 p.m., when Staff A, RN documented Resident #2's son asked her to inspect the resident's left elbow. Noted foul smelling drainage coming from a bandage dated [DATE]. Redness noted around a small 2 millimeter (mm) opening to the elbow. Screw from previous surgery exposed. Provider notified and orders received to transfer to local hospital emergency room (ER). Review of a Facility Skin Sheet dated [DATE] at 2:55 p.m., documented a Re-Admission Skin Assessment which identified a new abrasion on the left elbow, granulation tissue (beefy red) present. Measurements: 2.5 centimeters (cm) in length, 1 cm in width, and 0.1 cm in depth. A wound dressing was applied, the physician and family were notified. Review of a Facility Skin Sheet dated [DATE] at 10:49 a.m., documented the abrasion on the left elbow was healed however noted that the area was scabbed at that time. In an interview on [DATE] at 2:57 p.m., Staff A, RN stated that on [DATE] staff brought Resident #2 to the Nurse's Station and reported blood on her elbow. Staff A confirmed the residents elbow was bleeding and cleaned, dried and put a dressing on the left elbow. Staff A described the wound as a skin tear that had gotten ripped off, and added that the first layer of skin was missing, but deeper in one area. Staff A stated that she had failed to document in the electronic record, failed to notify the provider and family, and had left a sticky note on the Wound Nurse's desk which resulted in the wound not being followed up on. Staff A confirmed that she worked full time, 40 hours a week at the facility, but it had never entered her mind to check how the wound was doing. Staff A admitted that she made the initial error but felt that there were many other opportunities and the expectation for staff to complete Weekly Skin Assessments, provide showers and cares, and apply elbow protectors that should have provided an opportunity for staff to catch that there was a dressing on the left elbow. Staff A, added that the Wound Nurse had healed an area on the left elbow on [DATE] which she thought was the area she had identified. Staff A recalled that she had additionally assessed the area when alerted by the family on [DATE]. She noted a 2 mm hole through which you could visualize hardware that had been placed during a previous surgery, specifically a screw head. Additionally there was pus and serosanguineous fluid (discharge that contains both blood and clear yellow liquid). She stated that it looked like an abscess had formed and burst. She denied that she had noticed any swelling or redness of the arm. In an interview on [DATE] at 10:40 a.m., the Physical Therapist (PT) confirmed that she had noticed an open area on Resident #2's left elbow as she prepared to assist to transfer on [DATE]. Described as a slightly open area that was a little red and stated she alerted Staff A, RN who cleaned and dressed the wound. During an interview on [DATE] at 2:35 p.m., the Director of Nursing, (DON) stated upon readmission to the facility on [DATE], Staff B, RN had completed a full head to toe assessment which she observed. The assessment confirmed that there was a wound/abrasion to the left elbow. This was the area that was healed on [DATE] by the Wound Nurse. The DON responded that she wasn't sure how the Wound Nurse would not have seen the dressing dated [DATE]. The DON confirmed would have expected Staff A to document an assessment on [DATE], also stated that she had not obtained an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, Staff A left a sticky note for the Wound Nurse and this would not be an acceptable way to communicate a new wound. The DON stated would further expect wound to have weekly measurements and assessments, provider updated with changes and treatment as ordered by the provider. In an interview on [DATE] at 3:25 p.m., Staff B, RN confirmed she had completed the Re-Admission Skin Assessment and noted an abrasion on the left elbow. Staff B Documented on the skin sheet, notified the provider and family and informed the Wound Nurse. In an interview on [DATE] at 1:32 p.m., the facility Medical Director (MD) stated that he would have expected staff to notify the provider of a new acute injury on the left elbow for direction on treatment. Additionally, he would have expected daily assessments, and would not have expected the dressing to stay on without being removed from [DATE] to [DATE]. The MD further stated that he would have expected the facility staff to notice the dressing that was clearly dated [DATE]. The MD stated this was just not the care he would have expected from this facility. It was his medical opinion that the infection, coupled with [CONDITION(S)] and immunosuppressive treatment and having tested positive for COVID-19 recently had all contributed to her death. In an interview on [DATE] at 8:33 a.m., the Orthopedic Surgeon stated that during surgery, the plate and screws in Resident #2's left elbow were stable and that the skin had eroded away to expose the hardware. It was the Surgeon's medical opinion that the tissue erosion had not happened overnight, probably over a couple of weeks, and should have been monitored closely and referred to the provider for direction in care. Timely intervention would have impacted the prognosis. The Surgeon stated the wound was the size of a quarter. In an interview on [DATE] at 2:20 p.m., the MDS Coordinator confirmed she was called to assess the wound on Resident #2's left elbow on [DATE] with family present in the room. The MDS Coordinator recalled that she observed a hole on the resident's left elbow and stated that a screw head was visible. The MDS Coordinator confirmed there was no documentation present in the electronic record, and no documentation of provider or family notification. The MDS Coordinator confirmed that it has always been an expectation to assess, measure and document all new skin areas, notify the provider and family, and visualize at least every week and more often with dressing change. Review of an Ambulance Report documented that when they arrived at the facility a wound was noted on the Resident #2's left elbow that appeared to be draining a significant amount of purulent (containing pus) discharge that was yellow and green in color. The bones in the area were visible through the wound and there was redness, warmth, and significant swelling noted throughout the arm from the biceps area down to the wrist. Resident #2 reported the wound was painful. Staff on scene noted that the dressing covering this wound was last changed on [DATE]. Resident was transported to the local hospital for evaluation. Review of an Orthopedic Consult noted dated as completed on [DATE] revealed the left elbow wound was the size of quarter with the hardware from a previous surgery exposed. Elbow hardware was contaminated and/or infected. Review of a hospitalization Summary completed by the Medical Director documented that Resident #2 was admitted for her left elbow wound, Orthopedics was consulted, appeared to have a visible prosthetic joint concerning for infection. She was started on IV antibiotics and went to the operating room on [DATE] for hardware removal. She had significant increase in confusion, tested positive for COVID-19 on [DATE]. She declined in energy and respiratory status. Resident was transitioned to inpatient Hospice on [DATE] and passed away on [DATE]. Review of a facility policy titled Skin Care Policy revealed the facility policy focused on the prevention of pressure ulcers and failed to direct the identification, assessment and care of wounds.

Based on observation, record review and staff interview, the facility failed to date opened items when placed in the refrigerator and failed to properly label and store dried food items opened. The facility reported a census of 43 residents. Findings Include: During the initial tour of the kitchen on 7/26/21 which began at 9:55 AM with the Administrator revealed: A review of the Maximum refrigerator revealed the following items that had not been dated when opened a. A 2 quart bottle of Ruby [NAME] of grape juice. b. A ½ gallon bottle of Musselmann apple juice which had been approximately ¼ full. c. Two 64 ounce bottles of Ruby [NAME] white cranberry juice 64 oz bottles x 2 opened. d. A 64 ounce bottle of Thickit thickened water. e. A 46 ounce bottle of Thick & Easy thickened kiwi strawberry drink. At the time of the initial tour, the Administrator reported he would have expected the staff to write the date items were opened. A review of the dry storage area with the Dietary Manager revealed the following items that had not been dated when opened nor properly sealed: a. A 1/4 full 2 pound opened bag of Pioneer powdered sugar. b. A 1/4 full 22 oz bag of Trio Country gravy mix. c. A less than 1/4 full 5 lb bag Krusteaz pancake mix. In an interview on 7/28/21 at 10:15 AM, Staff A, Dietary Aide reported the following: a. When she opens a container that is refrigerated, she would need to date it when opened, then after 7 days, would need to dispose of it and open another. b. Staff A reported she opened up the bottles of thickened juices the morning of 7/26/21, but did not get the chance to write the date that she opened the juices that day. c. Foods in the dried food storage area that are opened, should be placed in a Ziploc bag with the date written on it when opened. d. Staff A also stated 3 recently new hires may not have known to write open dates on items after opened.

Based on record review, observation and staff interview, the facility staff failed to check the placement of a gastric tube (G-tube) prior to the administration of medications or tube feeding for one of one residents observed with a G-tube(Resident #15). The facility reported a census of 43 residents. Findings include: The Minimum Data Set, dated dated dated [DATE] identified Resident #15 with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . It also identified the resident with a Brief Interview for Mental Status (BIMS) of 8 which indicated severe cognitive impairment, totally dependent on staff for all activities of daily living and had a feeding tube through which she received 100% of her caloric intake. The Care Plan identified the resident on 6/2/20 with the problem of the potential for fluid deficit as evidenced by tube feeding and the resident can not eat or drink by mouth and on diuretics which can cause fluid issues. Interventions include the following: a. Resident likes staff to give the option to be up out of bed for tube feedings (TF). b. Provide as ordered: TF /water flushes as ordered . c. Monitor signs or symptoms of intolerance, gastrointestinal (GI) conditions, bowel/bladder function. d. Monitor gastric residual volume (GRV) before each feeding and to reinsert amount if 200 milliliters (ml) for 2 times or 250 ml for 1 time. Position upright 45 degrees for 30-60 min after feeding. Monitor tube position if ordered. Monitor oral condition. e. Arrange dentist services as needed. Encourage use of dry mouth spray as needed (PRN). A review of the Physician Orders revealed the following: a. 15 ml of water before, with, and after all medications. b. Elevate Head of Bed (HOB) 30 to 45 degrees at all times during feeding and for at least 30 to 40 minutes after the feeding is stopped every shift. Elevate HOB 30 to 45 degrees at all times during feeding and for at least 30 to 40 minutes after the feeding is stopped every shift for medication flushes. c. Give Fiber Source HN via tube feeding. 500 ml at 6:00 AM, 250 ml at 11:00 AM, 250 ml at 4:00 PM, and 250 ml at 9:00 PM. d. Flush tube with 30 ml water. one time a day for feeding at 6:00 AM give 500 ml and Flush with 30 ml water and one time a day for feeding at 11:00 AM give 250 ml and flush with 30 ml water. And in the evening for feeding at 4:00 PM give 250 ml and flush with 30 ml water. And at bedtime for feeding at 9:00 PM give 250 ml and flush with 30 ml water. During an observation on 7/28/21 at 11:13 AM, Staff C, Licensed Practical Nurse (LPN) drew up 15 mls water in a cath tipped syringe, did not check placement before she flushed the G-tube with the 15 mls of water without resistance. Staff C then connected the tubing from tube feeding bag and unclamped tube to allow the Fibersource tube feeding to run in, removed her gloves and washed her hands. In an interview on 7/28/21 at 12:40 PM, the Assistant Director of Nursing (ADON) reported the facility did not have a policy book, they follow Lippincott guidelines and handed surveyor a book which addressed tube feedings for pediatric patients in the home setting. She also provided a form which she reported she uses when she audits nurses on the process which did not direct staff to check for placement prior to administering medications through GT Procedure: a. Introduce yourself to the resident. b. Explain procedure. c. Provide privacy. d. Wash hands. e. Apply gloves. f. Set up dental drape. g. Apply barrier on resident between tube and clothes. h. Set up medications crushed in own med cup. i. Apply 15 mls of water in each med cup. j. Administer 15 mls of water into tube for flush prior to medication administration. k. Administer medications one at a time with 15 mls flush after each med. l. Ask resident how they are feeling. m. Clean up supplies. n. Check flush orders. Flush orders are resident specific. In an interview on 7/28/21 at 12:49 PM Staff B, RN reported before giving any medications or starting a feeding through a gastric tube (GT) she would check placement of GT prior to administering medications, need to aspirate for contents. In an interview on 7/28/21 at 2:06 PM the Director Of Nursing (DON) reported she expected her nurses to follow the procedure before they administer tube feedings: a. Follow standard of practice as far as hand washing, gloves, crushing the medications, flushing with whatever is ordered to flush with, following the doctor's orders. b. Usually check placement for the first two feedings of the day. She could not recall the current standards of practice are and would have to check our policy book, which is the Lippincott standards of practice. The standards have changed over time. A review of the facility policy titled: Gastrostomy Tube Feeding with the effective April 2018 had documentation of the following procedure: a. Gather equipment and take to bedside b. Explain procedure to resident c. Provide privacy d. Help resident to semi-Fowler position or at least 30 degrees sitting up. e. Check placement if ordered each feeding for a newly placed tube. Established tubes, check placement with the initial tube feeding for the day.

Based on observations, interviews, and record review the facility failed to maintain a clean walk in cooler for 1 out of 1 reviewed. The facility reported a census of 48 residents. Findings included: During the initial kitchen review on 11/3/19 at 10:08 a.m., inside the Kolpack walk in cooler, the blowing 12 inch fan in the back contained 4 inches of light and dark colored furry looking residue around the out side edge of the fan. The silver unit holding the fans bottom right corner contained 25% dark residue, under the fan, and around the fan a dark residue fuzzy looking residue. The ceiling in the Kolpack walk-in cooler contained a gray fuzzy residue over 50% of the ceiling. During the follow up kitchen visit on 11/5/19 at 11:13 a.m., the Kolpack walk-in cooler remained with dark fuzz 4 inches around on on the 12 inch fan and the silver base of the motor of the fan the ceiling constrained 25% fuzzy residue. The Kolpack walk in cooler contained a gray fuzzy residue over 50% of the ceiling. During an interview on 11/5/19 at 11:18 a.m., the Dietary Manager (DM) confirmed the black discoloration on the ceiling of the walk-in cooler, the fuzz around the fan and on the fan. The DM reported the fan, and the ceiling in the walk in cooler not on a cleaning schedule. During an interview on 11/5/19 at 1:36 p.m., the Administrator reported expecting the kitchen walk-in cooler clean and on a cleaning schedule. The Administrator confirmed the dark residue on and around the fan of the walk-in cooler. The facility provided a policy undated, directing staff at point # 1 to clean the refrigerators regularly at least 1 time a week.

Based on observation, staff interview, and record review the facility failed to provide appropriate infection prevention measures while handling soiled linens for 1 of 4 residents observed (Resident #188). The facility also failed to provide appropriate catheter cares as allowed the catheter tubing on the floor (Resident #190). The facility identified a census of 48 residents. Findings include: 1. A History and Physical, dated 10/16/19, documented the resident with [DIAGNOSES REDACTED]. The After Visit Summary from the hospital, dated 10/23/19, showed the resident had a [DIAGNOSES REDACTED]. Review of Resident #190's Brief Interview for Mental Status (BIMS), dated 10/23/19, showed the resident with severe cognitive impairment. Review of the Care Plan for Resident #190, dated 10/23/19, showed the resident with a concern for a urinary tract infection and a goal to discharge the resident to the community. An intervention for this concern revealed the resident had a 16 French Foley Catheter due to the [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Review of a urine culture, dated 10/25/19, showed the organism [MEDICATION NAME] Faecium ( a gram positive bacteria found in the gastrointestinal tract of humans and animals). The Nurse Practitioner ordered an antibiotic ([MEDICATION NAME]) twice daily for 5 days. An observation on 11/04/19 8:50 a.m. revealed the resident resting in bed, the Foley Catheter bag rested in a dignity bag and the Foley Catheter tubing lying directly on the carpeted floor. A Progress Note, dated 11/4/19, showed the resident transferred to the hospital. During an interview on 11/5/19 at 1:31 p.m., Staff B, Certified Nursing Assistant (CNA), reported catheter tubing touching the floor not an acceptable practice. During an interview on 11/5/19 at 1:53 p.m., Staff D, CNA, reported it is not acceptable for catheter tubing to be on the floor. During an interview on 11/5/19 at 3:26 p.m., Staff E, Licensed Practical Nurse (LPN), reported catheter tubing should not lay on the floor. During an interview on 11/5/19 at 3:33 p.m., the Director of Nursing (DON), reported the catheter tubing may touch the floor from time to time, but it should be cleansed afterwards if it touched the floor. The DON explained it is not the facility's general practice to have the catheter tubing lying on the floor. During an interview on 11/6/19 at 9:47 a.m., the DON reported the facility utilized the Skills Checklist for Catheter Care and did not have a policy. 2. Resident #188's Minimum Data Set (MDS) assessment, dated 10/23/19, showed the resident with a Brief Interview for Mental Status (BIMS) of 6, indicating severe cognitive impairment. The resident required extensive staff assistance with daily cares. The MDS documented the resident with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. During an observation on 11/5/19 at 10:20 a.m., noted Staff F, Registered Nurse (RN) complete wound cares for the resident. Staff F completed hand hygiene and applied gloves. Staff F then assessed the resident's perineum and the skin under the breasts for skin irritation. Staff F obtained a wet washcloth and dry towel. She cleansed the skin under the breast applied a powder. When Staff F finished cleansing the skin under the breast she dropped the wet washcloth and towel used to cleanse the resident's skin directly on the carpeted floor. After Staff F completed skin treatment under the breast she assisted the resident to remove her pants and incontinent brief. Staff F cleansed the front perineum with a disposable wipe. After cleansing the front perineum Staff F changed her gloves. Staff F assisted the resident to roll to the left side and cleansed the gluteal cleft as the resident had been involuntary of a small amount of stool. Staff F then assisted the resident to put on a clean incontinence brief, pull up the pants and cover the resident with a blanket with the same gloved hands used to cleanse the posterior perineum. During an interview on 11/5/19 at 1:31 p.m. Staff B, CNA, reported she would place all dirty linen in a plastic bag and carry it to a dirty linen basket or a soiled linen room. Staff B reported it is not acceptable to place dirty linen on the floor. During an interview on 11/5/19 at 1:53 p.m., Staff D, CNA, reported soiled linen should be placed in a garbage bag during resident care to keep the soiled linens off of the floor as they should not be on the floor. During an interview on 11/5/19 at 3:26 p.m. Staff E, LPN, reported she would place soiled linen in a bag on the end of the bed while she provided cares for a resident. She reported it is not acceptable to put soiled linen on the floor. During an interview on 11/5/19 at 3:33 p.m. the Director of Nursing reported she expected staff to place soiled linens in a bag and generally staff should have the bag with soiled linens on the bed while providing care for a resident. Record review of the Nurse Aide Skills Checklist for Providing Incontinent Care, revised 8/2012, included the following: a. Wash and rinse abdomen and anterior upper thighs (all areas in contact with urine/feces). For women gently separate the labia and wash down one side then the other (wash from front to back). b. Change cloth or cloth surface with each wipe. c. Place soiled washcloths in appropriate place. d. Turn the resident to the side. Wash buttocks and posterior upper thighs. e. Wash anal area, front to back with warm water or use disposable wipes then discard properly. f. Rinse and dry skin thoroughly. g. Remove towel from under perineum. Put used towels in appropriate place. h. Clean and put equipment away. i. Remove gloves and apply moisture barrier if applicable (following by removing gloves and hand hygiene).

Based on observation, staff interview, and record review the facility failed to provide appropriate perineal cares with catheter care for 1 of 1 residents observed (Resident #190). The facility identified a census of 48 residents. Findings include: 1. A History and Physical, dated 10/16/19, documented the resident with a [DIAGNOSES REDACTED]. The After Visit Summary from the hospital, dated 10/23/19, showed the resident with a [DIAGNOSES REDACTED]. Review of Resident #190's Brief Interview for Mental Status (BIMS), dated 10/23/19, showed the resident with severe cognitive impairment. Review of the Care Plan for Resident #190, dated 10/23/19, documented the resident with a concern for a urinary tract infection and a goal to discharge the resident to the community. An intervention for this concern revealed the resident with a 16 French Foley Catheter due to the [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Review of a urine culture, dated 10/25/19, showed the organism [MEDICATION NAME] Faecium ( a gram positive bacteria found in the gastrointestinal tract of humans and animals). The Nurse Practitioner ordered an antibiotic ([MEDICATION NAME]) twice daily for 5 days. An observation on 11/4/19 at 8:50 a.m., revealed the resident resting in bed with the Foley catheter bag in a dignity bag and the Foley Catheter tubing lying directly on the carpeted floor. An observation on 11/4/19 at 9:21 a.m., showed Staff A, Certified Nurse Assistant (CNA), provide perineal care for the resident. Staff A used a disposable wipe to cleanse the right groin. After cleansing the right groin Staff A used the same disposable wipe to cleanse the front perineum without changing surfaces of the disposable wipe. Staff A wiped the front perineum with several swipes and failed to change surfaces of the disposable wipe with each swipe. Staff A also failed to provide any catheter care. (Standard catheter care requires cleansing of the urethral site and 4 inches down the tubing). A Nurse Progress Note, dated 11/4/19, showed the resident transferred to the hospital. During an interview on 11/5/19 at 1:31 p.m., Staff B, CNA, reported she would wipe front to back while cleansing the perineum with a wash cloth and fold the wash cloth during the perineal care. Staff B remarked she would ensure the resident's skin dried and ensure barrier cream applied. Staff B reported while providing catheter care she would would wipe down the tubing of the catheter. Staff B also reported the extra catheter tubing should be placed in a privacy bag and not acceptable for the catheter tubing to touch the floor. During an interview on 11/5/19 at 1:53 p.m., Staff D, CNA, reported while providing perineal care she would ensure the dirty soiled surfaces are away from the resident, use a disposable wipe to cleanse the perineum first if the area is extremely soiled. Staff D noted cleansing with wash cloths with soap and water or foam cleanser to cleanse the perineal surface. She remarked she would clean the outer surfaces on both sides first then would cleanse the center perineal area. Staff D reported she would use a new wipe with every swipe. Staff D reported to provide catheter care she would cleanse the top of the catheter tubing and move down the tubing, and after finished cleansing the tubing she would use an alcohol wipe on the tubing as well. Staff D stated when handling the catheter tubing she would check the tubing to ensure there are no kinks especially if there is an extension tubing on the catheter, attach the catheter bag to the bottom of the bed and place it in a privacy bag after ensuring the resident is not lying on the tubing. Staff D remarked she also ensure there is a thigh strap on the resident's leg to ensure the tubing did not get pulled on. She reported it is not acceptable for catheter tubing to be on the floor. During an interview on 11/5/19 at 3:26 p.m., Staff E, Licensed Practical Nurse (LPN), reported she would clean the front perineal area, roll the resident onto the side and cleanse the legs and back perineal area. Staff [NAME] explained the need to use a separate wipe with every swipe. She stated when providing cares to a resident with a Foley Catheter, to clean the center perineal area and down the catheter tubing. Staff [NAME] stated the catheter bag should be attached to the bed, below the level of the resident's waist and it is not acceptable to have the catheter tubing on the floor. During an interview on 11/5/19 at 3:33 p.m. the Director of Nursing (DON), reported she expected staff to follow the policy when providing perineal care. She reported the facility routinely had skills fair in the facility one or two times a year. The DON noted the last skills fair was in (MONTH) or (MONTH) of this year. The Restorative CNA also completes random audits on an as needed basis as well. The DON reported she would expect the staff to follow the steps on the Skills Checklist to provide perineal cares. The DON remarked staff should clean the perineum from front to back and change the cloth with each swipe. She expected staff to provide Foley Catheter cares every shift and as needed, the Foley Catheter bag placed below the level of the resident's bladder, attached to an area on the bed, and the catheter tubing may touch the floor from time to time, but it should be cleansed afterwards if it touched the floor. The DON explained it is not the facilities general practice to have the catheter tubing lying on the floor. During an interview on 11/6/19 at 9:47 a.m., the DON reported the facility utilized the Skills Checklist for catheter care and the facility does not have a policy. Record review of the Nurse Aide Skills Checklist to Provide Incontinent Care, revised 8/2012, included the following: a. Wash and rinse abdomen and anterior upper thighs (all areas in contact with urine/feces). For women gently separate labia wash down one side then the other (wash front to back). b. Change cloth or cloth surface with each wipe. Record review of the Nurse Aide Skills Checklist for Catheter care, revised 8/2012, showed the following: a. Gently separate labia on female, wash from front to back. Change cloth surface with each wipe. Pat dry. b. Cleanse area around the meatus, then beginning at the meatus wash the catheter, using soap and water, 4 inches down the tubing.

Based on interviews, and record review the facility failed to provide the Baseline Care Plan Summary to the resident and resident representative for 4 out of 5 resident reviewed (Resident # 22, #36, #87 and #190). The facility reported a census of 48 residents. Findings included: 1. Review of the Face Sheet for Resident # 36 listed the admission date of [DATE]. The Face Sheet listed [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], directed extensive assist of 1 staff for toileting, transfers, bed mobility,eating, and personal hygiene. Review of the Progress Notes (PN) for Resident # 36 dated 10/11/19 through 10/13/19, lacks documentation the resident and the resident representative provided the Baseline Care Plan Summary. During an interview on 11/4/19 at 1:31 p.m., Staff C, Minimum Data Set (MDS) Coordinator reported the Baseline Summary Care Plan is provided to the residents and resident's representatives within 48 hours and is documented in the Progress Notes. During an interview on 11/4/19 at 2:23 p.m., Staff C reported the PN lacks the documentation Resident # 36 and the resident representative provided the Baseline Care Plan. Staff C stated the facilities standard is to provide the Baseline Care Plan Summary with in 48 hours. 2. Review of the MDS for Resident # 22 dated 3/22/19, listed [DIAGNOSES REDACTED]. The MDS further identified the resident required extensive assist of 1 staff for bed mobility, transfers, dressing, and personal hygiene. Review of the PN for Resident # 22 dated 3/13/19 through 3/20/19, lack documentation of the Baseline Care Plan Summary provided to resident and the resident's representative. 3. The Face Sheet for Resident # 190 dated 11/6/19, listed [DIAGNOSES REDACTED]. The Care Plan dated 10/23/19, directed the resident required staff assist with transfers, bed mobility, dressing and toileting. Review of the PN for Resident # 190 dated 10/23/19 through 10/30/19, lacked documentation the Baseline Care Plan Summary provided to Resident # 190 and the resident's representative. During an interview on 11/6/19 at 10:13 a.m., the Assistant Director of Nursing (ADON) reported a lack of documentation the Baseline Care Plan Summary provided to Resident # 22 and the resident's representative also a lack of documentation the Baseline Care Plan Summary provided to Resident # 190 and the resident's representative. During an interview on 11/6/19 at 9:46 a.m., the Director of Nursing (DON) reported expecting the Baseline Care Plan Summary provided to the resident and resident's representative within 48 hours of admission. The DON stated expecting documentation in the PN when the Baseline Care Plan Summary is provided and expecting the facility to follow the rules of participation. 4. Review of Resident # 87's Minimum Data Set (MDS) assessment dated [DATE] showed the resident with an intact memory and had [DIAGNOSES REDACTED]. The Care Plan dated 10/10/19 documented the resident sustained [REDACTED]. Record review of the resident's Progress Notes (Nurse's Notes) dated 10/10-14/19 failed to show any documentation of a Baseline Care Plan given to the resident and/or family. During an interview on 11/6/19 at 10:11 a.m., the ADON reported unable to locate any documentation noting the Baseline Care Plan completed and given to the family or resident.

Based on observation, clinical record review and staff interview, the facility failed to ensure staff utilized proper infection control technique during completion of resident cares for one of two residents reviewed. (Resident #26). The facility census was 48 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #26 had [DIAGNOSES REDACTED]. During observation on 8/20/18 at 1:41 p.m., Staff A, licensed practical nurse, LPN used scissors to cut through the dressing to the left foot, removed the kerlix dressing to the left foot and placed it in the trash. Staff A removed the [MEDICATION NAME] dressing from the left heel, removed her gloves, used alcohol hand sanitizer and donned new gloves. Staff A used normal saline soaked gauze dressings to cleanse the wound to the left heel which appeared necrotic. Staff A removed her gloves, used alcohol hand sanitizer and donned new gloves. Staff B, registered nurse, RN lifted the resident's left foot as Staff A measured the area to the heel with a length of 4.3 centimeters (cm) width of 3.3 cm and no depth. Staff A reported an open area at the 1:00 position and with small amount of drainage noted. At 1:48 p.m., Staff A removed gloves, used alcohol hand sanitizer, donned new gloves, removed [MEDICATION NAME] AG from packet and applied it to the wound to the left heel, applied a kerlix dressing to the left foot, but failed to disinfect the scissors before she used it to cut the new kerlix dressing, During interview on 8/22/18 at 8:26 a.m., Staff E, RN reported when removing the dressing to the resident's left heel by cutting the dressing with a scissors that staff should clean them with bleach wipes. During interview on 8/22/18 at 8:37 a.m., Staff C, LPN reported when removing the dressing to the resident's left heel by cutting the dressing with a scissors that staff should clean them with bleach wipes and let it sit in the wipes for two minutes.

Based on observation, staff interview and record review the facility failed to store food products and prepare food in the kitchen in a sanitary method and dispose of gouged cutting boards utilized by dietary staff. The facility reported a census of 52 residents. Findings Include: 1. During the initial Dietary Tour on 5/2/16 at 9:45 a.m. to 10:26 a.m. with the Dietary supervisor noted in the dry storage area, a 30 gallon container with egg noodles approximately 1 1/2 inches deep in the container out of the packaging with another open bag of noodles wrapped in plastic wrap stored on top of the noodles. The Dietary Supervisor reported that was not acceptable and would be disposing of the unpackaged noodles in the container. 2. During the food service serving of the lunch meal on 5/3/16 at 1:15 p.m., noted two 18 x 12 inch cutting boards with numerous cuts and deep gouges to the cutting service, rendering the boards unsanitizable. The Dietary Supervisor concurred with the observation of the cutting boards at that time and stated the boards needed replacing. During an interview on 5/3/16 at 2:59 a.m., the Dietary Supervisor reported checking on a storage policy in regards to the macaroni and the gouged cutting boards, but none found. 3. During the initial Dietary Tour on 5/2/16 at 9:45 a.m. to 10:26 a.m. with the Dietary supervisor noted a section of the textured ceiling between the two ceiling vents at each end of the preparation table approximately 4 feet wide x 22 feet long with dust/darkened areas around the vents. Also dust filaments hanging down approximately 1/4 to 1/2 inch from the ceiling randomly the entire surface area above the preparation table. The Dietary Supervisor identified the ceiling needed to be cleaned. During an interview on 5/3/16 at 2:59 p.m., the Dietary Supervisor reported did not know if a policy for ceiling cleaning, but will check with the Maintenance Supervisor. During an interview on 5/4/16 at 11:55 a.m., the Administrator and Maintenance Supervisor presented the Maintenance Inspection Logs dated April 4, 2016 and May 2, 2016 for different areas of the facility. Under the dietary section the Administrator and Maintenance Supervisor explained, does include cleaning of the ceiling if needed. Both commented that in May added the Task of the kitchen walls painted, paint the ceiling and install new light lens in the kitchen. Both reported not all the tasks completed for the kitchen yet for the month of May.

Based on observation, interview and record review the facility failed to maintain the hand rails free of splintering and gouges on 1 of 2 floors (Skilled floor). The facility reported a census of 52 residents. Findings included: Observation during the environmental tour on 5/4/16 at 2-2:40 p.m., revealed : 1. The top corner of the hand rail across from the kitchen door contained a 1 inch by 1 inch area of worn off finish, rough texture. 2. The hand rail between resident room 262-261 contained gouges and rough splintering texturing measuring 1.5 inch long by 1/4 inch wide, 2 inch by 1/4 inch and 1/2 by 1/2 inches. 3. Out side of resident room 253 the top hand rail contained gouges with a rough texture measuring 1 inch by 1/2 inch. 4. The corner of the hand rail next to sitting area across form resident room 250 is rough with sharp edges 1 inch by 1 1/2 inches. 5. The hand rail to the right out side the biohazard door contained a 5 inches by 1/2 inch gouged out. 6. The hand rail between resident room 249-248 contained missing chunks resulting in rough splintering 1 inch by 1/4 inch, 2 inches by 1/4 inch. 7. The bottom of the had rail by room 246-247 contained six garfs approximately 1 inch by 2 inches with rough splintering. 8. The hand rail between resident room 240-239 contained five 1 inch long splintering gouges During an interview on 5/4/16 at 2:40 p.m., the Maintenance Supervisor reported the hand rails could use restained and the gouges are the result of wheel chairs. The Maintenance Supervisor continued to report checking the hand rails is on a monthly schedule. The facility provided an Inspection Log dated, 4/4/16 and 5/2/16 the hand rails are checked off on both of the lists. During an interview on 5/5/16 at 2:00 p.m., the Administrator reported the hand rails are 1/2 way all repaired.

Based on observation, interview and record review the facility failed to hire 1 out of 6 employees within a timely manor after the Single Contact Licence & Background Check(SING). The facility reported a census of 52 residents. Findings included: During the employee record review Staff A Laundry Assistant's SING is dated 7/7/15. The facility provided a list of all new staff with hire dates over the past year. Staff A's date of hire is listed as 8/17/15. The facility provided a time sheet for Staff A listing training on 8/19/15. During an interview on 5/5/16 at 9:03 a.m., the Human Resources (HR) staff reported staff are hired within 30 days of the completion of the SING. The HR staff continued to report if it needs to take longer then 30 days we run another SING check. During an interview on 5/5/16 at 9:40 a.m., the Administrator stated the expectation is to get staff hired within 30 days of the SING check. The facility provided a policy titled Resident Abuse Prevention Plan dated May 2015. The policy lacked direction of any time frame to hire within 30 days of the SING completion.

Based on observation, clinical record review, nurse aide skills checklist review and staff interviews, the facility failed to provide proper catheter care for two of two residents reviewed with indwelling urinary catheters. (Residents #1 & #6) The facility census was 43 residents. Findings include: 1. The Minimum Data Set (MDS) assessment completed 5/22/15, documented Resident #1 had [DIAGNOSES REDACTED]. The MDS assessment documented the resident required extensive staff assistance with most activities of daily living and had an indwelling urinary catheter. The care plan with the target date of 7/7/15, identified the resident with a self-care performance deficit related to chronic intermittent catheter for bladder management and directed staff to assist with toileting/transfer and may use the urinal at night. During observation of catheter care on 6/16/15 at 6:32 a.m. Staff E, certified nurse aide, CNA failed to pull the foreskin back and wash around the meatus (the opening where the tube is inserted) and only washed the top portion of the penis and top of the catheter tubing. During interview on 6/17/15 at 1:38 p.m., Staff C, licensed practical nurse, LPN reported when providing catheter care to male residents, the aides should pull the foreskin back, use a washcloth around the meatus, rinse and dry, then clean the folds, groin area and rinse. During an interview on 6/17/15 at 1:54 p.m., Staff E, CNA reported when providing catheter care to male residents, the aides should pull the foreskin back, clean around catheter insertion site with a soapy wash cloth and clean down the tubing. A review of the nurse aide skills checklist for catheter care and emptying the drainage bag dated as last revised August 2012 directed staff to gently pull back foreskin on a male resident replace after cleansing and rinse and pat dry. It also directed staff to cleanse around the meatus, then beginning at the meatus wash the catheter, using soap and water, 4 inches down the tubing. 2. The MDS assessment dated [DATE], documented Resident #6 had [DIAGNOSES REDACTED]. The MDS assessment identified the resident had severe cognitive impairment, required the extensive assist of 2 staff for most activities of daily living and had an indwelling urinary catheter. The temporary admission care plan dated 6/2/15, identified the resident with a catheter, wore incontinence briefs and required extensive assistance of 2 staff and the use of a Hoyer mechanical lift. Observation of catheter care completed on 6/16/15 at 8:16 a.m., revealed Staff G, CNA failed to cleanse the residents urethral opening or the catheter tube at the insertion site. Upon changing the bag, Staff G failed to cleanse the end of the tube that led from the catheter and connected to the new bag. During interview on 6/16/15 at 8:15 a.m., Staff G, CNA reported after preparation, performing hand hygiene and donning gloves, would thoroughly cleanse the urethral opening, then repeat the sequence by rinsing and drying his/her anatomy. She also reported she would clean the catheter tube leading from the insertion site all the way to the catheter bag and when changing bags, would use alcohol wipes to clean both, the end of the tube leading from the catheter and the end of the tube leading from the bag. During interview on 6/18/15 at 9:30 a.m., the Director of Nursing (DON) reported, after preparation, hand hygiene and gloving, catheter care should be performed by thoroughly cleaning at the insertion site, and cleaning the tube from the urethral opening all the way to the bag. The DON stated to change catheter bags, alcohol wipes should be used to swipe the end of the tube leading from the catheter and the end of the tube leading from the bag and referenced the August 2012 nurse aide skills checklist as the standard for all employees to follow when performing catheter care.

Based on observation, clinical record review, facility policy review and staff interview, the facility failed to provide proper incontinence care for two of six residents observed during personal cares. The facility census was 43 residents. (Residents #2 & #7) Findings include: 1. The Minimum Data Set (MDS) assessment completed 4/21/15, documented Resident #2 had [DIAGNOSES REDACTED]. The MDS assessment documented the resident as incontinent of urine and occasionally incontinent of bowel. The care plan with the target date of 5/11/15, identified the resident with the problem of chronic bowel and bladder incontinence and directed the staff to check and change incontinence every 3 to 4 hours and as needed. During observation of incontinence cares on 6/15/15 at 12:18 p.m., Staff T, certified nurse aide, CNA turned the resident to the right side Staff G, CNA cleansed the resident's left outer hip and rectal crease, removed gloves, washed hands, donned new gloves and placed a new incontinent brief under the resident without cleansing the resident right outer hip. During observation of incontinence cares on 6/16/15 at 8:00 a.m., Staff G cleansed the residents perineal area. Staff E, CNA turned the resident to the right side when the resident had a large bowel movement, Staff G cleansed the residents left outer hip and rectal crease, Staff G removed gloves, washed hands, donned new gloves and placed a new incontinent brief under the resident. Staff E turned the resident to on his/her back and fastened the new brief into place without cleansing the residents right outer hip. A review of the nurse aide skills checklist to provide incontinent care dated as last revised August 2012 directed staff to: a. Wash and rinse abdomen and anterior upper thighs (all areas in contact with urine/feces) for men- cleanse penis by pushing back foreskin, gently wash around penis and scrotum and return foreskin to its natural position b. Change cloth or cloth surface with each wipe c. Turn reside to side wash and posterior upper thighs d. Wash anal area, front to back with warm water or use disposable wipes and then discard properly. 2. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #7 had [DIAGNOSES REDACTED]. and muscle weakness. The MDS indicated the resident required extensive assistance of one staff with most activities of daily living and lacked bladder control. The care plan dated 3/9/15, directed staff to wash, rinse and dry the residents peri area after each incontinence episode. Observation on 6/16/15 at 6:34 a.m., revealed after being incontinent of urine, the resident stood in front of the toilet as Staff G, CNA removed the urine soaked brief. After the resident was toileted, Staff G, failed to wash the residents front perineal area prior to placing a clean disposable brief on the resident. During interview on 6/18/15 at 9:30 a.m., the Director of Nursing reported all staff should wash any body part that came in contact with urine or feces, after preparation, hand hygiene and gloving, peri care should be performed, always wiping front to back when cleansing the genitals and referenced the August 2012 nurse aide skills checklist as the standard for all employees to follow when performing incontinence care.

Based on clinical record review, the facility failed follow physician orders [REDACTED].>directed for one of thirteen resident reviewed. The facility census was 43 residents. (Resident #1) Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #1 had [DIAGNOSES REDACTED]. The MDS assessment documented the resident required extensive staff assistance with most activities of daily living. A review of the March 2015 medication administration records (MAR) revealed an order for [REDACTED]. A review of the April 2015 MAR indicated [REDACTED] On April 27 the residents BP was 109/78 and no documentation to show the dose was held for the morning dose No documentation to show the evening dose had been held for the following BPs on the following dates: April 15 BP 92/51 April 16 BP 104/65 April 17 BP 107/71 April 21 BP 104/59 A review of the May 2015 MAR indicated [REDACTED]. A review of the June 2015 MAR indicated [REDACTED]. A review of the June 2015 physician order [REDACTED]. Based on record review and staff interview, the facility failed to document blood pressure and pulse rates for [MEDICATION NAME] ordered with parameters and failed to document if dose had been held for blood pressures and pulse rates below the parameters for Resident #1, failed to follow physician orders [REDACTED].#5 and failed to ensure physician orders [REDACTED].#12 for a total of 3 of 13 residents reviewed in the standard sample. Findings include: 1. Resident #1's Minimum Data Set 60 day assessment completed 5/22/15 had documentation of the following Diagnoses: [REDACTED]. It also identified the resident required extensive staff assistance with most activities of daily living. The care plan with the target date of 7/7/15 did not identify the resident with the problem of high blood pressure and the need to check blood pressure and pulse prior to the administration of [MEDICATION NAME] ordered. A review of the March 2015 medication administration records (MARs) revealed an order for [REDACTED]. A review of the April 2015 MAR indicated [REDACTED] April 4 and 5 no documentation of the pulse rate for the morning dose April 5 no documentation of a BP for the morning dose April 27 BP of 109/78 and no documentation to show the dose had been held for the morning dose No documentation to show the evening dose had been held for the following BPs on the following dates: April 15 BP 92/51 April 16 BP 104/65 April 17 BP 107/71 April 21 BP 104/59 A review of the May 2015 MARs revealed the same order with a BP of 108/72 on May 25 without documentation to show the morning dose had been held. A review of the June 2015 MARs revealed the same order and on 6/5/15 the morning dose had been signed out as given when the blood pressure had been documented as 104/53. A review of the June 2015 physician order [REDACTED]. A review of the undated policy titled: administration of oral medications directed staff to: observe the resident for any unusual conditions which should be reported prior to medication administration, record the medication administered and observe and chart and/or report the results. A review of the undated policy titled: physician orders [REDACTED]. a. All orders for treatment shall be faxed or written by the physician, dentist, APN (Advanced Practice Nurse) or PA (Physician Assistant) with the exception of situations that may require the provider to issue an order verbally or by telephone so that the patient treatment can begin immediately. b. Standing orders may be used on a limited basis in situations where treatment initiatives are an essential part of effective medical management. In an interview on 6/17/15 at 1:38 p.m., Staff C, LPN reported when nurses receive a new order, notification of the family should be documented on the order sheet there is a place where we could check it or in the progress notes. If a nurse receives an order for [REDACTED]. 2. Resident # 5's Minimum Data Set ((MDS) dated [DATE], identified [DIAGNOSES REDACTED]. The MDS further identified the Resident's Brief Interview for Mental States (BIMS) of 7 showing cognitive impairment. The MDS continued to report Resident # 5 required extensive assist of 2 staff for bed mobility, transfers, dressing and toileting. The Care Plan imitated on 3/24/15, directed staff to monitor/document signs and symptoms of UTI: pain, burning, blood tinged urine, cloudiness, no out put, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, change in behavior and change in eating pattern. The Care Plan continued to direct staff to report any abnormalities to the charge nurse and physician promptly. Review of the Medication Administration Record [REDACTED]. Review of a fax dated 4/29/15, directed staff to administer Keflex 250 mg by mouth 4 times a day for 7 days and recheck a urine culture after the treatment. Review of the MAR indicated [REDACTED]. A physician's orders [REDACTED]. During an interview on 6/17/15 at 5:24 p.m., the Director of Nursing(DON) revealed the facility does not have a protocol that another urinalysis is needed to recheck after a UTI has been treated with antibiotics unless the resident displayed symptoms of UTI. During an interview on 6/18/15 at 4:00 p.m., Staff F Registered Nurse (RN) reported not finding the repeat urine culture in the resident record and not knowing why it was not obtained. Staff F continued unable find an order to discontinue the recheck of the urine order. During an interview on 6/18/15 at 10:17 a.m., the DON reported expecting 24 staff to collect a follow up urinalysis hours after the last antibiotic was given, unless otherwise ordered. If the doctor did not want the follow up UA, would need to write it as an order The facility provided steps in the nursing process from the North American Nursing [DIAGNOSES REDACTED]. 3. Resident # 12's Minimum Data Set ((MDS) dated [DATE], identified [DIAGNOSES REDACTED]. The MDS further identified the Resident's Brief Interview for Mental States (BIMS) of 4 showing cognitive impairment. The MDS continued to report Resident # 12 required limited assist of 1 staff for bed mobility, dressing and personal hygiene. The Care Plan with a revision date of 2/5/15, directed staff to administer medications as ordered. Review of a fax order dated 4/8/15, directed staff to administer [MEDICATION NAME] 12.5 micrograms topically change every 3 days. The progress notes for Resident # 12 dated 4/8/15 at 3:00 p.m., documented fax back from Physician ok to start Fentyl 12.5 micrograms toppically change every 3 days, order transcribed and noted by Staff S Registered Nurse (RN). Review of the employee record for Staff S revealed a written offense form date 4/9/15, indicating Staff S falsified an order on 4/7/15. The counseling form stated Staff S marked yes when the Physician circled no to the request for a Fentanly patch. Staff A processed the order and administered the medication. The counseling form continued to state the Physician was upset about the order being changed. Education provided to the nurse about not making that kind of determination to order medications and clarifying orders. During an interview on 6/17/15 at 4:05 p.m. the Interim Director Of Nursing reported Staff S stated not seeing that the Physician circled no. The Interim DON reported the facility ended the employment of Staff S on 5/1/15. The facility provided a policy titled physician's orders [REDACTED].

Based on observation, record review and interviews the facility failed to assess for 1 out 7 residents reviewed (Resident # 5). The facility reported a census of 43 residents. Findings included: Resident # 5's Minimum Data Set ((MDS) dated [DATE], identified [DIAGNOSES REDACTED]. The MDS further identified the Resident's Brief Interview for Mental States (BIMS) of 7 showing cognitive impairment. The MDS continued to report Resident # 5 required extensive assist of 2 staff for bed mobility, transfers, dressing and toileting. The Care Plan imitated on 3/24/15, directed staff to monitor/document signs and symptoms of UTI: pain, burning, blood tinged urine, cloudiness, no out put, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, change in behavior and change in eating pattern. The Care Plan continued to direct staff to report any abnormalities to the charge nurse and physician promptly. Review of the Progress Notes dated 4/20/15 through 4/25/15 , revealed no assessment or documented reason for why the staff obtained a urine specimen on 4/25/15. Review of the Medication Administration Record [REDACTED]. Review of the MAR indicated [REDACTED]. Review of the MAR indicated [REDACTED] During an interview on 6/18/15 at 3:50 p.m., Staff F Registered Nurse (RN) reported thinking the staff obtained the order to collect a urine sample related to the resident's mental status changes and foul smelling urine. The facility provided steps in the nursing process from the North American Nursing [DIAGNOSES REDACTED].