Every finding on record at Windham House of Hattiesburg

Based on observations, interviews, record reviews, and policy reviews, the facility failed to store food and maintain sanitary practices in accordance with professional standards for food safety, including expired foods, exposed foods, overly ripe produce, unsanitary practices by staff, and incomplete temperature logs for resident refrigerators for three (3) of (3) days of survey. Findings included: A review of the facility's policy titled Food Storage Labeling, revised ,d+[DATE], revealed, Policy: The facility will ensure the safety and qualify of food by following good storage and labeling procedures .Procedure: 1. Labeling a. All temperature controlled foods .will be labeled. 3. Rotations b. Foods stored in storage units will be surveyed routinely to identify and discard foods that have passed their manufacturer use-by date or expiration date . A review of the facility's policy titled Employee Work Practices, revised ,d+[DATE], revealed, Food service employees shall follow sanitary practices to prevent the spread of foodborne illness . Wears a . hair restraint (e.g., beard restraint) in the food production area. The restraint must cover all hair and prevent the hair from contacting exposed food . A review of the facility's policy titled Food From Outside Sources, reviewed ,d+[DATE], revealed .Food that is brought to the residents from family, visitors, or volunteers is handled in a safe and sanitary manner. Procedure .4 a. Foods requiring refrigeration may be stored in a resident's personal refrigerator. The refrigerator is equipped with a thermometer .iv. A designated employee is assigned the following tasks: Monitoring refrigerator temperature. If temperature is consistently above 41 F, their immediate supervisor is notified . Kitchen: On [DATE] at 9:07 AM, during an observation and interview with the Dietary Supervisor (DS), it was noted that Refrigerator #1 contained one (1) gallon of 2% milk with a manufacturer's date of [DATE], which the DS confirmed was expired. A 4-ounce carton of cranberry-flavored cocktail fell on to the floor, and the DS placed it back into the box without cleaning it. Refrigerator #2 contained a five (5) pound bag of shredded cheese with no open date, showing a supplier received date of [DATE]. Refrigerator #3 contained a pan of beef stroganoff covered with plastic wrap that had a hole, leaving the food exposed. Freezer #1 contained an opened, exposed bag of chicken nuggets. In the pantry, four (4) onions had white biological growth. On [DATE] at 9:30 AM, during an observation and interview, the Hairdresser (HD) and Business Office Manager (BOM) were in the food preparation area without wearing hair restraints while a kitchen staff member prepared cookie dough. Both the HD and BOM acknowledged they should have been wearing hair restraints. On [DATE] at 10:45 AM, [NAME] #1 was observed preparing raw chicken without a beard net. He moved between tasks, including handling raw chicken, assisting with vegetables, and touching various surfaces, with only glove changes and no handwashing. [NAME] #2 was observed opening an oven with his foot, which the DS later opened by hand. On [DATE] at 11:00 AM, during an interview, [NAME] #1 admitted to not wearing a beard net and failing to use proper hand hygiene. He reported working at the facility for one week. On [DATE] at 1:12 PM, during an interview, [NAME] #2 admitted to using his foot to open the oven and acknowledged it was unsanitary. He stated staff are in-serviced on food safety twice a month. On [DATE] at 1:17 PM, the DS acknowledged outdated foods, exposed foods, overly ripe onions, and unsanitary practices in the kitchen. She stated she conducts in-services twice a month and takes responsibility for ensuring expired and overly ripe foods are discarded. On [DATE] at 8:40 AM, the Administrator confirmed the findings and stated he would assist the DS in conducting more frequent checks for expired foods. He also stated he addressed the issue of non-kitchen staff entering the kitchen without hair restraints. Resident Refrigerator Logs (Resident #17): On [DATE] at 10:05 AM, during an observation, the refrigerator in Resident #17's room was observed with a temperature log that had no recorded temperatures for [DATE]. Items in the refrigerator included water, juice, applesauce, and Jell-O. On [DATE] at 9:10 AM, during an observation and interview with Licensed Practical Nurse (LPN) #1, she confirmed that the refrigerator temperature log was incomplete. She stated temperatures are checked daily by housekeeping. On [DATE] at 9:25 AM, during an interview with Housekeeping #1, she confirmed the logs were to be completed daily but had not been filled out for November. On [DATE] at 1:37 PM, during an interview, the Administrator stated he was unaware that refrigerator temperatures were not being recorded and expects daily monitoring. A record review of the Admission Record revealed the facility admitted Resident #17 on [DATE] with diagnoses including Unspecified Dementia. 48181

Based on interviews, record review, and facility policy review, the facility failed to accurately code a Minimum Data Set (MDS) assessment for a resident receiving dialysis for one (1) of one (1) dialysis residents reviewed. (Resident #10) Findings included: A review of the facility's policy Resident Assessment, revised 09/19, revealed, An assessment will be completed on each resident utilizing the MDS . The completed assessment guide the staff in identifying key information about the resident and serves as a basis for identifying resident-specific issues . The assessment will describe the resident's physical and mental deficits, strengths and the requirements of assistance to meet their needs . A record review of the Order Listing Report revealed Resident #10 had a Physician's Order, dated 7/27/24, for dialysis services at a local clinic every Monday, Wednesday, and Friday. A record review of the Admission Record revealed the facility originally admitted Resident #10 on 4/26/2022 and with diagnoses including End Stage Renal Disease and Dependence on Renal Dialysis. A record review of the Quarterly MDS with an Assessment Reference Date (ARD) of 10/28/2024 revealed Resident #10 had a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated he was cognitively intact. Section O was not coded that Resident #10 received hemodialysis. On 11/12/2024 at 11:25 AM, during an interview, the Director of Nursing (DON) stated that Resident #10 was the only resident in the facility who goes to dialysis. On 11/14/2024 at 9:35 AM, during an interview, Registered Nurse (RN) #2 confirmed that she completed the last Quarterly MDS, and she did not code it in a manner that reflected Resident #10 received dialysis. She explained that during the last visit with Case Mix Management, she was informed that dialysis could only be documented on the MDS if a communication form was completed for each dialysis visit. She stated that previously, one completed communication form was sufficient to document dialysis, but now three forms were required. She acknowledged that the MDS did not accurately reflect the resident's true assessment and confirmed that Resident #10 had consistently received dialysis since admission. On 11/14/2024 at 1:30 PM, during an interview, the DON stated that she was aware there had been problems identified during the Case Mix audit regarding the dialysis communication forms and the MDS coding. On 11/14/2024 at 1:36 PM, during an interview, the Administrator stated that he was not aware the MDS did not document dialysis for a resident who had been receiving dialysis since admission. He expressed his expectation that each resident's MDS be coded accurately.

Based on interviews, record review, plan of correction review, and facility policy review, the facility failed to sustain an effective Quality Assurance and Performance Improvement (QAPI) committee as evidenced by one (1) of (1) re-cited deficiency originally cited in April 2023 on an annual recertification survey. Findings Include: A review of the facility's, QAPI Governance and Leadership Guidelines', revised 08/15, revealed, Oversight of the facilities QAPI program is provided through the Quality Assessment and Assurance (QA Committee) .The QAPI program is developed and led by the QA Committee, but requires input and participation from staff, residents and families .Element 5: Systematic Analysis and Systemic Action .The facility uses a systematic approach to determine when in-depth analysis is needed to fully understand the problem, its causes, and implications of a change. The facility uses a thorough and highly organized/structured approach to determine whether and how identify problems may be caused or exacerbated by the way care and services are organized or delivered .Systemic actions look comprehensively across all involved systems to prevent future events and promote sustained improvement. This element includes a focus on continual learning and continuous improvement. F641: During this recertification survey, 11/12/24 through 11/14/24, the facility failed to ensure a Minimum Data Set (MDS) assessment was accurately coded for a resident receiving dialysis for (1) of (1) resident reviewed for dialysis. During the recertification survey on 4/27/23, the facility failed to accurately code the MDS related to a resident receiving an anticoagulant medication and a resident who had a nephrostomy tube. During an interview on 11/14/24 at 10:00 AM, Registered Nurse (RN) #3 confirmed that she attended QAPI meetings, and the facility had not discussed the MDS inaccuracy regarding Resident #10 receiving dialysis. During an interview with the Director of Nursing (DON) on 11/14/24 at 1:00 PM, she said she had not reviewed the CMS-2567 (a record that identifies the federal regulation in violation and describes the findings of noncompliance and the facility's plan of correction) from the previous annual recertification survey when she came to work at the facility in September 2024. The DON stated she had not attended a QAPI meeting at the facility and was unaware the facility was previously cited for inaccuracy of MDS assessments. During an interview with the Administrator on 11/14/24 at 2:00 PM, he stated he was not aware of the previous MDS assessment citation or the facility's plan of correction because he was not working at the facility at the time of the survey in April of 2023. The Administrator confirmed he had not reviewed the previous 2567 to determine previous citations.

Based on observation, interviews, record review, and facility policy review, the facility failed to protect a resident's right to a dignified existence by posting clinical data on a resident board in open view for one (1) of 15 sampled residents. (Resident #36). Findings included: A review of the facility's Resident Rights Policy, reviewed 12/23, revealed Every resident in the facility has the right to .16. Have their personal and medical records treated as confidential . A review of the facility's policy titled Dignity and Respect, revised 07/22, revealed A facility must treat each resident with respect and dignity .The facility shall protect and promote the rights of the resident . A record review of the Admission Record revealed the facility admitted Resident #36 on 07/19/2022 with diagnoses including Cerebral Infarction. During an observation and interview on 11/12/24 at 10:02 AM, there was identifiable care information visible on a board at the head of the bed in Resident #36's room. The documentation included the resident's name, turn rotation schedule, and care coordination details, such as the requirement for a two-person assist and use of a mechanical lift. Resident #36 stated that the clinical documentation at the head of the bed was intended to assist the Certified Nursing Aides (CNAs) and staff by specifying how to care for her. She mentioned that the documentation included details on when and how to turn her to prevent pressure sores. The resident was unsure how long the information had been displayed. On 11/12/2024 at 10:40 AM, during an interview, Licensed Practical Nurse (LPN) #2 stated that the information on the board in the resident's room was meant to inform staff about providing specific care for the resident. She acknowledged that the documents contained the resident's name and could be considered a dignity issue, adding that the same information was available was available to view in the electronic medical record (EMR). On 11/14/2024 at 1:00 PM, during an interview, the Administrator explained that the information on the board was intended to guide staff in providing care for Resident #36. He admitted that the documents included the resident's name and agreed it could be viewed as a dignity issue, reiterating that the same information was accessible in the resident's EMR.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure the resident's right to a clean, comfortable home-like environment as evidenced by a stained privacy curtain, undusted high-touch areas, scuffed and dirty walls, and an unclean shower in the room of one (1) of 15 sampled residents. (Resident #18) Findings included: A review of the facility's policy Resident Environment, dated 09/15, revealed, It is the policy of this facility to provide a safe, clean, comfortable, homelike environment . On 11/12/2024 at 1:16 PM, during an observation and interview, Resident #18's shower contained a hair wash basin and a dead house plant, with grime and dirt visible on the shower floor. The room had noticeable dust and spider webs above the overhead light, and grime and scuff marks were observed on the wall behind the headboard. The privacy curtain at the sliding glass door displayed oil and dirt stains. Resident #18, the sole occupant of the room, stated that she had never used the shower, noting that it had been grimy for over six (6) months. She mentioned that while staff vacuum, empty the trash, and clean the toilet, they rarely dust certain areas. On 11/13/2024 at 9:12 AM, during an interview, Housekeeping Staff #1 stated that her staff cleans rooms daily, typically including tasks such as vacuuming, dusting, and mopping. However, she noted that privacy curtains are only washed when staff notify her that they need attention. She confirmed Resident #18's room had noticeable dust and spider webs above the overhead light, grime and scuff marks on the wall behind the headboard, and oil and dirt stains on the privacy curtain. She acknowledged that these issues represented lapses in the facility's adherence to cleanliness and maintenance standards. On 11/14/2024 at 11:19 AM, during an interview, the Nursing Home Administrator emphasized that the maintenance and upkeep of residents' rooms are essential to creating a home-like environment. He expressed his expectation that staff adhere strictly to cleanliness and maintenance standards to ensure a comfortable and sanitary setting for all residents. A record review of the Admission Record revealed the facility admitted Resident #18 on 06/19/2017 with diagnoses including Paraplegia. A record review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/03/2024 revealed Resident #18 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact.

Based on observation, staff interview, record review, and facility policy review, the facility failed to implement a resident's comprehensive care plan regarding Enhanced Barrier Precautions (EBP) while providing Percutaneous Endoscopic Gastrostomy (PEG) tube care for one (1) of 15 sampled residents. Resident #19. Findings included: A record review of the facility's policy Care Plan Process, revised 08/17, revealed, . CAA's (Care Area Assessments) assist in guiding to develop an individualized plan of care and should provide structure for the care and services that are needed . When implemented properly, the CAA process should help staff: . address the need and desire for other important considerations . The comprehensive care plan is an interdisciplinary tool . for the care of the resident . A record review of Resident #19's Care Plan revealed Problem/Need: Resident has a feeding tube .Approaches .Enhanced barrier precautions-Gown and gloves to be worn during high contact resident care activities (dressing, bathing, transfers, changing linens, hygiene, and toileting . The intervention was dated 4/23/24. During an observation on 11/13/2024 at 10:25 AM, Registered Nurse (RN) #1 did not wear a gown while providing PEG tube care for Resident #19. After cleaning and drying the site, RN #1 verbalized that she forgot to put on a gown and continued to complete the care without wearing the gown. During an interview on 11/13/2024 at 10:35 AM, RN #1 confirmed she did not use a gown while providing care. She stated that the purpose of the gown was to protect the resident during care and acknowledged that she was expected to wear a gown while providing care and to follow Resident #19's care plan interventions regarding EBP. A record review of the Admission Record revealed that the facility admitted Resident #19 on 02/23/2023 with diagnoses including Encounter for Attention to Gastrostomy and Dysphagia, Unspecified. A record review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/07/2024 revealed Resident #19 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact. A review Section K revealed she had a feeding tube. During an interview on 11/14/2024 at 12:00 PM, RN #2/Care Plan Nurse, confirmed that EBP was required on Resident #19's care plan and stated that she expected all staff to follow the care plan while providing care. During an interview on 11/14/2024 at 1:34 PM, the Director of Nursing (DON) verbalized understanding of Enhanced Barrier Precautions and the importance of following the care plan. She stated that she expected all staff to adhere to Enhanced Barrier Precautions and care plans while providing care.

Based on observation, staff interview, record review and facility policy review the facility failed to implement Enhanced Barrier Precautions (EBP) for one (1) of three (3) residents reviewed as high risk for acquiring multi-drug-resistant organisms (MDROs). (Resident #19) Findings included: A record review of the facility's policy Enhanced Barrier Precautions, revised 03/24, revealed, Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with an MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices) . Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies . On 11/13/2024 at 10:15 AM, during an interview, Registered Nurse (RN) #1 explained that she was aware Resident #19 was on EBP due to having a PEG tube. She stated she had been in-serviced on EBP. On 11/13/2024 at 10:25 AM, during an observation of Percutaneous Endoscopic Gastrostomy (PEG) site care for Resident #19, revealed RN #1 did not wear a gown while providing care. After cleaning and drying the site, RN #1 verbalized that she forgot to put on a gown and continued to complete the care without wearing the gown. On 11/13/2024 at 10:35 AM, during an interview, RN #1 confirmed she did not use a gown while providing care. She stated that the purpose of the gown was to protect the resident during care and acknowledged that she was expected to follow EBP while providing care to Resident #19's PEG site. On 11/14/2024 at 9:40 AM, during an interview, Licensed Practical Nurse (LPN) #1 explained that all staff members had been educated on EBP and that signs were placed on the doors of residents requiring such precautions. She stated she expected all staff to follow EBP to prevent the spread of infections. She confirmed that Resident #19 was on EBP due to having a PEG tube and that a gown and gloves should always be worn when providing high-contact resident care, including PEG site care. On 11/14/2024 at 1:34 PM, during an interview, the Director of Nursing (DON) stated she understood the requirements of EBP and expected all staff to follow them while providing care to prevent the spread of infection. A record review of the Admission Record revealed the facility initially admitted Resident #19 on 11/24/2021 with diagnoses including Encounter for Attention to Gastrostomy and Dysphagia, Unspecified. A record review of the Order Listing Report revealed Resident #19 had a Physician's Order, dated, 9/27/24 to cleanse the PEG site with normal saline, pat dry, and apply new split foam dressing. A record review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/07/2024 revealed Resident #19 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact. A review Section K revealed Resident #19 had a feeding tube.

Based on record review, staff interview, and facility policy review, the facility failed to ensure a Pre-Admission Screening (PAS) accurately reflected a diagnosis of a major mental illness for one (1) of 16 record reviewed. Resident #6 Findings include: A review of the facility's policy, Pre-Admission Screening PAS/PASRR (MS (Mississippi) Only) revealed, Anyone applying for admission into a nursing facility must be approved prior to the admission .The PAS with level 1 PASRR (Pre-Admission Screening and Resident Review) must be submitted .and approved prior to admission to a nursing facility . A record review of the Face Sheet revealed the facility admitted Resident #6 on 05/06/21 and she had a diagnosis of Schizoaffective Disorder, Bipolar Type. A record review of the Pre-Admission Screening (PAS) Application for Long Term Care, dated 05/06/2021, revealed B Level II Referral was marked to indicate Resident #6 did not have a diagnosis of a major mental illness. A review of the resident's preadmission records provided by the facility revealed Resident #6 was admitted from another long-term care facility and had a diagnosis of Schizoaffective Disorder, Bipolar Type. On 04/26/23 at 10:10 AM, during an interview with the Director of Nursing (DON), she explained the admission staff complete the PAS screening for residents prior to admission. The DON reviewed Resident #6's diagnoses and physician orders and confirmed the resident was admitted with a diagnosis of Schizoaffective Disorder, Bipolar type. She confirmed the PAS should have reflected that a Level II screening was needed because the resident did have a major medical diagnosis prior to admission. She stated she expected the admission staff to complete the PAS accurately. On 06/26/23 at 12:30 PM, during an interview with Certified Nursing Assistant (CNA) #3, who is the Admissions Coordinator, she explained the previous Coordinator completed the PAS dated 05/06/2021 for Resident #6. She confirmed that the PAS should accurately indicate if the resident is taking an antipsychotic medication or has a major mental illness. She reviewed Resident #6's Physician Orders and diagnosis and confirmed she would have indicated this information on the PAS and would have sent for a Level II screening due to the diagnoses of Bipolar.

Based on interviews, record reviews, and facility policy review, the facility failed to ensure Minimum Data Set (MDS) assessments were accurately coded to reflect anticoagulant therapy and a nephrostomy tube for two (2) of 15 sampled residents. Resident #10 and Resident #18 Findings include: A review of the facility's policy Resident Assessment with the latest revision date of 09/19 revealed An Assessment will be completed on each resident utilizing the MDS. The reason for assessment, schedule, and timeframes will be according to the guidance of the Resident Assessment Instrument (RAI) Manual .Any healthcare professional that completes a portion of the assessment must sign and certify the accuracy of the .assessment . Resident #10 On 04/25/23 at 12:12 PM, during an interview with Resident #10, she stated that she is on Pletal (a medication to prevent platelets from sticking together and forming a blood clot). Record review of the Face Sheet revealed Resident #10 was admitted to the facility on [DATE] with diagnoses that included Coronary Artery Disease (CAD). A record review of the Quarterly MDS with an Assessment Reference Date (ARD) of 04/10/2023 revealed Resident #10 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact. A review of Section N of the MDS revealed Resident #10 had received seven (7) days of an anticoagulant medication during the MDS look back period. A record review of the Physician Orders for March and April 2023, for Resident #10, revealed there were no physician orders for an anticoagulant medication. A record review of the MedlinePlus.gov/drug info .revealed, .Cilostazol is in a class of medication called platelet-aggregation inhibitors (antiplatelet medications). Resident #18 On 04/25/25 at 11:50 AM, during an interview with Resident #18, she explained she had a nephrostomy tube for urine on her right side. A record review of the Face Sheet revealed Resident #18 was admitted to the facility 06/27/2019 with diagnoses that included Encounter for Attention to Other Artificial Openings of Urinary Tract. A record review of the Physician Orders for April 2023, revealed Resident #18 had a Physician's Order, dated 2/28/2022, to Change right nephrostomy tube dressing every 7 days. A record review of the Annual MDS with an ARD of 03/07/2023, revealed Resident #18 had a BIMS score of 14, which indicated she was cognitively intact. Review of Section H revealed the MDS was not marked to indicate that Resident #18 had an indwelling catheter (including suprapubic catheter and nephrostomy tube). On 04/27/23 at 11:50 AM, during an interview with RN #1, who is the MDS Care/Plan Nurse, she explained that when Resident #10 was first prescribed Cilostazol, she thought the medication was classified as an anticoagulant. RN #1 then researched the medication and confirmed that Cilostazol was classified as an antiplatelet medication and not an anticoagulant. She confirmed that the assessment was coded in error. RN #1 further explained that Resident #18's MDS was also coded in error and missed because she had a nephrostomy tube. On 04/27/2023 at 1:00 PM, during an interview with the Director of Nursing (DON), she explained that she expected the MDS nurses to code and complete the MDS accurately. The DON reviewed Resident #10's physician orders and confirmed that Resident #10 was not taking any medication classified as an anticoagulant. She also confirmed that Resident #18 has had a nephrostomy tube for a long time and the MDS was coded incorrectly.

Based on observation, staff interview, and facility policy review, the facility failed to provide privacy for Resident #32 during personal care for one (1) of three (3) resident care observations. Findings Include: Review of facility's Confidentiality and Privacy policy, dated 11/2017, revealed it is the policy of this facility that residents are allowed personal privacy and must be allowed privacy when receiving treatment and care for personal needs. During Resident #32's incontinent care observation, on 1/22/2020 at 2:15 PM, performed by Certified Nursing Assistant (CNA) #1 and Certified Nursing Assistant (CNA) #2, it was revealed Resident #32's bed was located next to the glass patio door in her room and the patio door was covered with a set of vertical blinds with three (3) of the 20 total slats missing. The three (3) missing blind slats allowed for a four (4) inch clear opening, which allowed for a clear view from the outside patio area into Resident #32's room. Resident #32 was not provided privacy during the incontinent care due to the openings from the missing slats on the blind. During an interview, on 1/22/2020 at 2:30 PM, CNA #1, stated she didn't know what to do about the missing slats when caring for Resident #32. CNA #1 stated that although she pulled the privacy curtain as far as she could, it did not cover the patio door, and Resident #32 did not have complete privacy during the incontinent care. During an interview, on 1/22/2020 at 2:33 PM with CNA #2, she stated she believed the maintenance man is the one who must fix the blinds. CNA #2 stated Resident #32 did not have privacy during the incontinent care because the blinds were broken. During an interview, on 1/22/2020 at 3:15 PM with Licensed Practical Nurse (LPN) #1/ Staff Development Nurse, she stated it is possible that if someone was outside the patio door, they would be able to see Resident #32 during care through the opening caused by the missing slats on the blind. LPN #1 stated this was a violation of Resident #32's right to privacy. Review of the Face Sheet revealed Resident #32 was admitted to the facility, on 08/27/2019, with [DIAGNOSES REDACTED].

Based on observation, staff interviews, record review, and facility policy review, the facility failed to clean the dryer lint from the Tumble Dryer Lent Trap for 1 (one) of 3 (three) Laundry Room observations. Findings Include: Review of the facility's policy titled, Laundry Instructions, revised (MONTH) 2013, revealed the facility would remove lint from the dryer Lint Trap regularly, but no less than three (3) times a day. This policy noted the facility should check the top of the dryer and the back of the dryer for lint build-up. Review of the facility's manufacturer's guidelines for the Tumble Dryers Operation/Maintenance, dated (MONTH) 2020, revealed: Warning- the lint compartment must be cleaned daily to avoid the risk of fire. Caution- risk of fire, a clothes dryer produces combustible lint. Exhaust outdoors. Care should be taken to prevent the accumulation of lint around the exhaust opening and in surrounding area. During an observation, in the Laundry Room, with the Maintenance Director, on 01/22/2020 on 9:24 AM, revealed the dryer lint trap filter was covered with lint. The dryer also had large pieces of lint hanging from the filter. The bottom of the dryer case was also covered with lint. In an interview, on 01/22/2020 at 9:29 AM, the Maintenance Director revealed the lint filter was covered with lint, pieces of lint was hanging from the filter and the bottom of the dryer case was covered with lint. The Maintenance Director stated he cleans the lint filter once a month. The Maintenance Director stated the lint filter should be cleaned daily because, this could cause a fire. In an interview, on 01/22/2020 at 9:51 AM, the Laundry Supervisor revealed she has been the supervisor for two (2) months. The supervisor stated the staff are trained to clean the filter every evening before leaving the facility. The supervisor confirmed if the lint filter is not cleaned that it is a fire hazard. During an interview, on 01/22/2020 at 9:59 AM, with the Laundry Worker, she stated she just started back in laundry this week. The Laundry Worker stated she did not check the filter when she came in at 6:00 AM. The Laundry Worker stated she was told the night shift would clean it before they left. On 01/22/2020 at 10:05 AM, the Administrator confirmed the lint trap filter was covered with lint, pieces of lint was hanging from the filter and the bottom of the dryer case was covered with lint. The Administrator stated he was going to have the lint removed immediately because, this could cause a fire. Review the Dryer Log revealed the last time the lint trap filter was checked in the dryer was on (MONTH) 2, 2019. This was confirmed by the Laundry Supervisor and the Administrator.

Based on observation, staff and resident interviews, record review and facility policy review, the facility failed to revise Resident #30's Care Plan to address the resident's call light placement preference, for one of (1) of seventeen care plans reviewed. Findings Include: Review of the facility's policy, Care Plan Process, dated 08/2017, revealed it is the policy of this facility that the key staff or the Interdisciplinary Team (IDT) should subsequently review and revise the current care plan as needed. During a resident care observation, on 1/21/2020 at 11:14 AM, an observation revealed Resident #30's call light was hanging on the call light box located on the wall above the bed. Resident #30 was lying in bed at this time and the call light was not within her reach. During an interview, on 1/22/2020 at 10:20 AM, Licensed Practical Nurse (LPN) #2, confirmed Resident #30's call light was wrapped around the call light box, on the wall, above the bed. LPN #2 confirmed the call light was not in reach, but that Resident #30 doesn't always like it on her bed, and sometimes she puts it on the wall. LPN #2 stated that anyone entering and leaving a resident's room should be making sure the resident's call light is in place unless the resident can tell you they do not want it on the bed. During an interview, on 1/22/2020 at 11:00 AM, Resident #30 confirmed she knew where the call light was, she knew how to use it, and that if she needed someone to help her, she would use it. Resident #30 indicated that she did not have a problem with it hanging on the call light box, and that's what she prefers. During an interview, on 1/23/2020 at 10:00 AM, Registered Nurse (RN) #1/ Care Plan Coordinator confirmed Resident #30's care plan did not, but should have, addressed the resident's call light placement preference of placing the call light above the bed over the call light box. RN #1 stated any preference for any resident should always be addressed on the care plan to paint a more accurate picture of that resident, and to provide the best care possible to meet the resident's needs. RN #1 stated honoring a resident's preferences is respecting their right to make choices involving their care. Review of Resident #30's Comprehensive Care Plan, dated 6/9/2019, revealed the Care Plan had not been revised to reflect Resident #30's call light placement preference. Review of the Face Sheet revealed Resident #30 was admitted to the facility, on 2/19/2019, with [DIAGNOSES REDACTED].

Based on observations, staff interview, record review, and facility policy review, the facility failed to prevent the possible spread of infection as evidenced by being in the hallway with Personal Protective Equipment (PPE) on and not washing their hands after leaving a resident's room that is on isolation precautions, for one (1) of two (2) residents on contact and/or airborne precautions, Resident #49. Findings include: A review of the facility's policy titled, Procedure for Isolation: Isolation Precautions with an original date of (MONTH) 2006, and a latest revision date of (MONTH) 2014, revealed: Handwashing (hand hygiene) is the single most important precaution to prevent the transmission of infection from one person to another. Wash hands with soap and water before and after each resident contact, and after contact with resident belongings and equipment. All PPE (disposable isolation gowns, mask, gloves, etc.) should be used and discarded in either the trash or used linen receptacle before you leave the room. A review of the facility policy titled, Standard Precautions, with an original date of (MONTH) 2006, and a latest revision date of (MONTH) (YEAR), revealed: Handwashing is recognized as the most important way to prevent the transmission of infection. All employees are to wash hands after every unprotected contact with blood or other potentially infectious materials and after removing gloves. On 2/5/19 at 4:45 PM, an observation of Licensed Practical Nurse (LPN) #3, revealed LPN #3 came out of Resident #49's room with gloves on and stated, I used my gloves. An isolation signe was present on Resident #49's door. On 2/5/19 at 5:05 PM, an interview with LPN #3 revealed Registered Nurse (RN) #4 told LPN #3 she should have dressed out to prevent becoming contaminated, because Resident #49 is on airborne precautions. On 2/5/19 at 5:15 PM, an interview with RN #4 revealed she told LPN #3 that she (LPN #3) is supposed to dress out in the full PPE for infection control purposes. RN #4 also stated LPN #3 should remove all of her PPE before leaving the resident's room and wash her hands. On 2/6/19 at 9:15 AM, an interview with Certified Nursing Assistant (CNA) #2 revealed she had never had the Chicken Pox or the [DIAGNOSES REDACTED] before. CNA #2 also stated she was taught to take all of the PPE off in the room and put it in the barrier that is in the room and be sure to wash your hands before you leave out of the room. CNA #2 stated she had not cared for Resident #49. On 2/06/19 at 9:30 AM, an observation of Resident #49's room revealed Resident #49 had two (2) red hampers with lids, one (1) for the soiled linen hamper and one (1) for the trash hamper. The Surveyor also observed the Certified Occupational Therapy Assistant (COTA) therapy staff member remove her PPE and leave Resident #49's room without washing her hands. On 2/6/19 at 9:33 AM, while the Surveyor was in Resident #49's room with the Nurse Practitioner (NP) in the room visiting with Resident #49, the Surveyor observed the NP remove her gloves, open Resident #49's room door, and go out of Resident #49's room into the hallway, with all of her PPE equipment on except her gloves. Then, the NP went to the chart cart that she was using to look at Resident #49's chart. On 2/6/19 at 9:35 AM, an interview with the COTA revealed she should have probably washed her hands before leaving Resident #49's room, because she could have spread germs. The COTA also stated, You should wash your hands before and after providing care to the resident. On 2/6/19 at 9:45 AM, an interview with the NP revealed she thought her cart was closer to Resident #49's door, and she should have taken off all of her PPE to look at the chart. The NP stated, Well she (referring to Resident #49) is on contact precautions and isolation for Chicken Pox-airborne illnesses, so I should have taken that off (referring to her PPE). The NP stated not taking PPE off can spread [MEDICAL CONDITION]. On 2/6/19 at 11:28 AM, an interview with RN #3 revealed the staff should be applying their gown, mask, and gloves when providing care to Resident #49, because Resident #49 is on contact and airborne precautions. RN #3 stated the staff should be washing their hands before leaving Resident #49's room. She also stated the staff should remove all of their PPE before going outside of the room, because it is an infection control issue and the staff have to prevent spreading infection. On 2/6/19 at 11:34 AM, an interview with RN #5 revealed the staff should follow whatever instruction that is on the resident's door, and put on their PPE before entering Resident #49's room. She also stated the staff need to wash their hands before they leave the room, so that they will not spread the infection to themselves, other residents, and employees. RN #5 stated the staff would need to pull off all of their PPE before going outside of the room and wash their hands because they will contaminate the items on the resident's door if they do not wash their hands. She also stated, these measures are to keep the infection confined to one (1) room and not to everyone else, that's why they are on isolation. RN #5 stated the NP and therapy watch videos like all staff for orientation, related to infection control. On 2/6/19 at 11:45 AM, an interview with the Director of Nursing (DON) revealed the staff should wash their hands, observe what type of isolation she (Resident #49) is on, and put on their required PPE. The DON also stated, the staff should pull off the PPE, place it in the dirty barrel, and wash their hands before leaving Resident #49's room. She also stated staff should not leave the resident's room with the PPE on; staff should remove the PPE and wash their hands before leaving the resident's room. The DON also stated this could cause a spread of infection to other residents, visitors, staff, families and whomever else they should come into contact with. The DON stated the facility has not being doing return demonstration, but the facility does at least yearly training on infection control. A review of the facility's Face Sheet revealed the facility admitted Resident #49 on 1/8/19, with a [DIAGNOSES REDACTED].

Based on observations, interview, record review, and facility policy review, the facility failed to provide necessary respiratory care and services as evidenced by, failing to ensure oxygen was administered at the correct rate and continuously as ordered for Resident #34, and failing to ensure Continuous Positive Airway Pressure ([MEDICAL CONDITION]) was applied per physician orders, for Resident #106. For two (2) of four (4) residents reviewed. Findings include: A review of the facility's policy titled, Oxygen-Administration, Concentrator, Storage, Assemblage, with a revision date of 10/17, revealed the purpose was to provide adequate tissue oxygenation by providing supplemental oxygen. Staff were to turn the oxygen unit on to the desired flow rate, and assess equipment for proper functioning. A review of the facility's policy titled [MEDICAL CONDITION]-(Bilevel Positive Airway Pressure) [MEDICAL CONDITION] Device, with a revision date of 10/17, revealed the purpose was to provide respiratory support to the resident and was intended for the treatment of [REDACTED]. Resident #34 A review of Resident #34's facility face sheet revealed the facility admitted the resident on 01/24/18, and the resident had current [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. An observation on 02/05/19 at 8:49 AM, revealed Resident #34 seated in a wheelchair in the front day room of the facility. The resident had bi-lateral nasal cannulas and there was a portable oxygen (O2) tank connected to the back of her wheelchair, that was not connected to the tubing. The tank regulator was set on zero (0) liters (L) and the indicator needle was on empty. The tubing was connected to a portable O2 concentrator stored under the resident's wheelchair, however, the concentrator was not on and no O2 was being administered. A review of Resident #34's comprehensive care plan revealed the care plan included a problem with an onset date of 05/14/18, of the resident having a history of a cough. An approach to the problem was added to the care plan on 9/18/18, of O2 at 2L per minute, via nasal cannula, continuous. An observation on 02/05/19 at 03:50 PM, revealed Resident #34 seated in her wheelchair in the day room, with a portable O2 tank connected to the back of the wheelchair. The resident had bi-lateral nasal cannulas and tubing was connected to the portable oxygen tank. The regulator was set on 2L and the indicator needle was on empty. No oxygen was being administered. There was a portable O2 concentrator stored under the resident's wheelchair that was off and not connected to tubing. An observation and interview on 02/05/19 at 4:00 PM, with Registered Nurse (RN) #4, revealed the RN assessed Resident #34's O2. The RN confirmed the portable tank was empty. An interview on 02/05/19 at 4:10 PM, with RN #4, revealed there was no way to know how long Resident #34 did not receive oxygen. An observation and interview on 02/06/19 at 9:26 AM, revealed the resident participating in therapy and was receiving O2 via nasal cannulas connected to the oxygen concentrator, stored under her wheelchair. The concentrator was set at 3L/minute which was confirmed by the Occupational Therapist (OT). The OT stated the battery was getting low on the concentrator. The battery indicator bar had approximately one eighth (1/8) of the bar left before the battery was dead. An observation on 02/06/19 at 9:50 AM, revealed Resident #34 in the activities room participating in church service/hymn singing. The resident's O2 was being administered via nasal cannula connected to the portable concentrator set at 3L. At approximately 9:55 AM, the concentrator screen lit up and beeped. The screen beeped two (2) times, approximately one (1) minute apart, then the screen went black. The concentrator battery was dead and the concentrator was off. An observation on 02/06/19 at 10:09 AM, revealed Resident #34 participating in a group activity of hitting a balloon using a pool noodle. The resident was very involved in the activity. The resident's O2 concentrator screen was black and was not on. An observation on 02/06/19 at 10:36 AM, revealed Resident #34 seated in her wheelchair in the day room with bilateral nasal cannulas. The O2 concentrator was off and not administering oxygen. An interview on 02/06/19 at 2:54 PM, with Licensed Practical Nurse (LPN) #1, revealed he had changed the battery in Resident #34's concentrator twice on this date and the battery was dead on one (1) of those switches. Resident #106 A review of Resident #106's admission history and physical, dated 1/29/19, revealed the resident had a [DIAGNOSES REDACTED]. A review of the facility's face sheet for Resident #106 revealed the resident was admitted by the facility on 02/01/19. A review of the Resident's physician's orders [REDACTED]. An observation on 02/05/19 at 09:26 AM, of Resident # 106's room, revealed a [MEDICAL CONDITION] machine on the floor beside her bed. An observation and interview on 02/05/19 at 12:15 PM, with Resident #106 in the resident's room, revealed a [MEDICAL CONDITION] on floor beside the resident's bed. The resident stated she had not worn the [MEDICAL CONDITION] since being admitted . The resident stated she did not have it set up because she didn't have a table to sit it on and that was why it was on the floor. The resident stated she wore it every night at home for sleep apnea. An observation and interview on 02/06/19 at 8:25 AM, with Resident #106 in the resident's room, revealed a [MEDICAL CONDITION] machine on the floor beside her bed. The resident stated she did not use it the previous night and no nursing staff had asked her about putting it on, taking it off, or whether or not she's used it. The resident stated it had been sitting in the floor, so surely staff knew she hadn't worn it. An interview on 02/06/19 at 2:54 PM, with RN #3, revealed it was the responsibility of the 3:00 PM to 11:00 PM Nurse working the medication cart to make sure the [MEDICAL CONDITION] machine was placed on the resident, and the 11:00 PM to 7:00 AM nurse working the medication cart to make sure it was taken off the resident. RN #3 stated if the resident slept later, the 7 AM-3 PM med cart nurse would be responsible. An interview on 02/06/19 at 3:25 PM, with RN #1/Assessment/Care Plan Nurse, revealed she completed the initial assessment and developed the baseline care plan for Resident #106. RN #1 stated physician's orders [REDACTED]. An interview on 2/6/19 at 2:58 PM, with LPN #1, revealed he worked the medication cart on Resident #106's hall on 02/05/19, and 02/06/19 on the 7:00 AM to 3:00 PM shift. The LPN stated he was unaware the resident had a [MEDICAL CONDITION] machine until today and had not noticed it on the floor in her room. The LPN stated he noticed it for the first time when she moved to her new room this morning. The LPN stated he had not seen it on the resident and had not noticed it on the Medication Administration Record [REDACTED]. An interview on 02/06/19 at 3:41 PM, with LPN #3, revealed she had marked the resident's Medication Administration Record [REDACTED]. The LPN she had not seen the [MEDICAL CONDITION] machine on the resident's floor, had not put the mask on her or taken it off. The LPN stated the resident told her she used the machine independently at home and she assumed she was using the [MEDICAL CONDITION] machine independently in the facility. An interview on 02/07/19 at 1:46 PM, with the Director of Nurses (DON), revealed she was aware the resident had a [MEDICAL CONDITION] machine, but she was not aware the resident had not used the [MEDICAL CONDITION] since admission, until yesterday. She stated she went to speak with the resident about it and the resident stated she preferred to sit the machine on a table her father made her, but had put it on the floor, because she was moving rooms. The DON stated she expected the staff to follow physician's orders [REDACTED]. She stated if the resident refused, or if they did not do it, they would indicate that on the MAR, or write in nursing notes of the resident's refusal. The DON stated she was unable to find any nursing notes of resident refusal or that they did not apply the [MEDICAL CONDITION].

Based on facility policy review, record review, and staff interview, the facility failed to revise the Comprehensive Care Plan related to wound care and treatment for one (1) of three (3) Care Plans reviewed for wound care and treatments, Resident #15. Findings include: Review of the facility policy titled, Care Plan Process, dated 08/2017, revealed it is the policy of this facility that the comprehensive person-centered Care Plan should be reviewed and revised as needed by the Interdisciplinary Team (IDT) or key staff. The facility policy also stated that the Physician Orders, Medication Administration Record [REDACTED]. A review of Resident #15's medical records titled, Care Plan, dated 12/07/2018, revealed a problem/need identified of an un-stageable pressure ulcer to the right lateral foot. The onset date for the problem was 10/02/2018. The last Care Plan review date was noted to be 12/07/2018, with a goal date of 03/07/2019. A review of Resident #15's medical records titled, Physician's Telephone Order, dated 12/17/2018, revealed that the original doctor's order with an onset date of 10/04/2018, for the treatment to the pressure ulcer to resident's right lateral foot, was discontinued (dc'd) on 12/17/2018. A review of Resident #15's medical records titled, Electronic Treatment Administration Record (ETAR), dated (MONTH) (YEAR), revealed the last date wound care treatment was provided was 12/16/2018. During an interview on 02/06/2019 at 3:22 PM, Registered Nurse (RN) #1/ Minimum Data Set (MDS) and Care Plan Coordinator, stated that the Care Plan for Resident #15 had not been revised to reflect that the un-stageable pressure ulcer to the right (R) lateral foot had been resolved. RN #1 stated Care Plans are revised when any new Physician's Orders have been received. RN #1 stated all of the new Physician's Telephone Orders are printed out every Monday through Friday mornings, and the Care Plan for any resident with a new order is revised that day. RN #1 stated on Monday mornings, orders from Friday, Saturday, and Sunday are printed out so the Care Plans can be revised for those days. During an interview on 02/06/19 at 03:47 PM, with RN #2, revealed that the original Physician's Order, dated 10/02/2019, for wound care to the pressure ulcer on Resident #15's right lateral foot had been discontinued on 12/17/2018. RN #2 confirmed that the Care Plan had not been revised regarding the status of the un-stageable pressure ulcer wound to Resident #15's (R) lateral foot. RN #2 confirmed that new orders are printed out daily, and that the Care Plan nurses update the Care Plans to reflect the resident's new status. RN #2 stated that she does not know why Resident #15's Care Plan had not been revised to reflect that the wound care for the right (R) lateral foot had been dc'd. During an interview on 02/06/2019 at 4:25 PM, the Director of Nursing (DON) confirmed that Resident #15's Care Plan had not been revised related to the discontinued treatment to the right (R) lateral foot. The DON confirmed the wound care treatment for the right (R) lateral foot had been resolved, and the order for treatment was discontinued on 12/17/2018. Review of the Face Sheet revealed Resident #15 was admitted by the facility on 09/04/2014, with [DIAGNOSES REDACTED].

Based on observations, interviews, record review, and facility policy review, the facility failed to implement the comprehensive care plan related to respiratory care for two (2) of four (4) resident care plans reviewed for respiratory care. Resident #34 and Resident #106. Findings Include: A review of the facility's policy titled, Care Plan Process, with a revision date of 08/17, revealed facility staff shall follow the care plan. The policy revealed the physician orders, Medication Administration Record, [REDACTED]. Resident #34 A review of Resident #34's facility face sheet revealed the facility admitted the resident on 01/24/18, and the resident had current [DIAGNOSES REDACTED]. A review of Resident #34's comprehensive care plan revealed the care plan included a problem with an onset date of 05/14/18, of the resident having a history of a cough. An approach to the problem was added to the care plan on 9/18/18, of O2 at 2L/min (minute) via NC (nasal cannula) cont. (continuous). An observation on 02/05/19 at 8:49 AM, revealed Resident #34 seated in a wheelchair in the front day room of the facility. The resident had bi-lateral nasal cannulas and there was a portable oxygen (O2) tank connected to the back of her wheelchair that was not connected to the tubing. The tank regulator was set on zero (0) liters (L) and the indicator needle was on empty. The tubing was connected to a portable O2 concentrator stored under the resident's wheelchair, however, the concentrator was not on and no O2 was being administered. A review of the physician's orders [REDACTED]. An observation on 02/05/19 at 03:50 PM, revealed Resident #34 seated in her wheelchair in the day room with a portable O2 tank connected to the back of the wheelchair. The resident had bi-lateral nasal cannulas and tubing was connected to the portable oxygen tank. The regulator was set on 2L and the indicator needle was on empty. No oxygen was being administered. There was a portable O2 concentrator stored under the resident's wheelchair that was off and not connected to tubing. An observation and interview on 02/05/19 at 4:00 PM, with Registered Nurse (RN) #4 revealed the RN assessed Resident #34's O2. The RN confirmed the portable tank was empty. An interview on 02/05/19 at 04:10 PM, with RN #4, revealed there was no way to know how long Resident #34 did not receive oxygen. An observation and interview on 02/06/19 at 09:26 AM, revealed the resident participating in therapy and was receiving O2 via nasal cannulas connected to the oxygen concentrator stored under her wheelchair. The concentrator was set at 3L/minute which was confirmed by the Occupational Therapist (OT). The OT stated the battery was getting low on the concentrator. The battery indicator bar had approximately one eighth (1/8) of the bar left before the battery was dead. An observation on 02/06/19 at 09:50 AM, revealed Resident #34 in the activities room participating in church service/hymn singing. The resident's O2 was administered via nasal cannula connected to the portable concentrator set at 3L. At approximately 9:55 AM, the concentrator screen lit up and beeped. The screen beeped two (2) times approximately one (1) minute apart, then the screen went black. The concentrator battery was dead and the concentrator was off. An observation on 02/06/19 at 10:09 AM, revealed Resident #34 participating in a group activity of hitting a balloon using a pool noodle. The resident was very involved in the activity. The resident's O2 concentrator screen was black and was not on. An interview on 02/06/19 at 02:54 PM, with Licensed Practical Nurse (LPN) #1, revealed he had changed the battery in Resident #34's concentrator twice on this date and the battery was dead on one (1) of those switches. An interview and review of Resident #34's care plan, with RN #2/Care Plan Nurse, on 02/06/19 at 03:18 PM, confirmed Resident #34's comprehensive care plan included a problem with an onset date of 05/14/18, of the resident having a history of a cough and an approach to the problem dated 9/18/18, of O2 at 2L/min via NC cont. The RN stated physician's orders [REDACTED].#34's orders included administer O2 at 2L/min via nasal cannula continuous for shortness of breath. The RN stated that if the resident had an order for [REDACTED]. Resident #106 A review of Resident #106's admission history and physical dated 1/29/19, revealed the resident had a [DIAGNOSES REDACTED]. A review of the facility's face sheet for Resident #106 revealed the resident was admitted by the facility on 02/01/19. An interview on 02/06/19 at 03:25 PM, with RN #1, an Assessment/Care Planning Nurse, revealed she completed the initial assessment and developed the baseline care plan for Resident #106. RN #1 stated physician's orders [REDACTED]. RN #1 confirmed the care plan included use of the Continuous Positive Airway Pressure ([MEDICAL CONDITION]) machine every night. An observation on 02/05/19 at 09:26 AM, of Resident #106's room, revealed a [MEDICAL CONDITION] machine on the floor beside her bed. An observation and interview on 02/05/19 at 12:15 PM, with Resident #106 in the resident's room, revealed a [MEDICAL CONDITION] machine on floor beside the resident's bed. The resident stated she had not worn the [MEDICAL CONDITION] since being admitted . The resident stated she did not have it set up because she didn't have a table to sit it on and that was why it was on the floor. The resident stated she wore it every night at home for sleep apnea. An observation and interview on 02/06/19 at 08:25 AM, with Resident #106, in the resident's room, revealed a [MEDICAL CONDITION] machine on the floor beside her bed. The resident stated she did not use it the previous night and no nursing staff had asked her about putting it on, taking it off, or whether or not she's used it. The resident stated it had been sitting in the floor so surely staff knew she hadn't worn it. An interview on 02/06/19 at 02:54 PM, with RN #3, revealed it was the responsibility of the 3:00 PM to 11:00 PM Nurse working the medication cart to make sure the [MEDICAL CONDITION] machine was placed on the resident and the 11:00 PM to 7:00 AM Nurse working the medication cart to make sure it was taken off the resident. She stated if the resident slept later, the 7:00 AM-3:00 PM med cart nurse would be responsible. An interview on 2/6/19 at 02:58 PM, with LPN #1, revealed he worked the medication cart on Resident #106's hall on 02/05/19 and 02/06/19, on the 7:00 AM to 3:00 PM shift. The LPN stated he was unaware the resident had a [MEDICAL CONDITION] machine until today, and had not noticed it on the floor in her room. The LPN stated he noticed it for the first time when she moved to her new room this morning. The LPN stated he had not seen the [MEDICAL CONDITION], had not noticed the treatment on the Medication Administration Record [REDACTED]. An interview on 02/06/19 at 03:25 PM, with RN #1/Assessment/Care Planning Nurse, revealed if nursing staff did not ensure the resident used the machine per physician's orders [REDACTED].

Based on observation, staff interview, record review, and the facility policy review, the facility failed to administer liquid Potassium per protocol/standards for one (1) of 4 Residents observed during medication administration, Unsampled Resident A. Findings Include: Review of the Nursing Drug Handbook dated 2016, revealed a full glass of water should be given with Potassium to lessen Gastrointestinal (GI)distress. Review of the facility's policy, Administering Medications Through Nasogastric or Gastrostomy Tube with a revision date of 02/16, revealed, 5. Use liquid drug forms whenever possible and dilute them with water as needed. Observation on 10/4/17 at 9:45 AM, during the medication pass, revealed LPN (Licensed Practical Nurse) #2 poured 15 milliliters (ml) of liquid Potassium into a 30 milliliter medicine dose cup and no water was added. LPN #2 poured the undiluted 15 ml of liquid Potassium into the syringe attached to Unsampled Resident A's gastric tube. LPN #2 poured five (5) mls of water into the tube before the Potassium and five (5) mls of water afterwards. Observation of the medication label on the bottle of liquid Potassium revealed to add four (4) ounces of water to the 15 mls of liquid Potassium. Review of the cumulative physician orders for Unsampled Resident A revealed an order for [REDACTED]. Interview with LPN #2 on 10/4/17 at 10:20 AM, revealed he had given Unsampled Resident A five (5) mls of water before and after the Potassium, per tube. LPN #2 further stated he had missed it because he was nervous. LPN #2 stated the effect of giving undiluted Potassium could cause Gastrointestinal distress and, make your stomach hurt real bad. Interview on 10/5/17, with the Pharmacist Consultant at 2:05 PM, revealed it was not an acceptable practice to give Potassium without diluting with water. She stated it had been a while since she had observed the nurses administer tube medications. Record review of the facility training records revealed no training had been documented for the administration of Gastro-tube medications. Review of the facility's face sheet revealed, the facility admitted the resident on 4/19/17. Unsampled Resident A's [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 7/19/17, revealed Unsampled Resident A had a Brief Interview of Mental Status (BIMS) score of 0, which indicated severe cognitive impairment. Section K for Swallowing/Nutritional Status revealed the presence of a feeding tube.

Based on observation, staff interview, and facility policy review, the facility failed to provide a clean and homelike environment for one (1) of 10 resident rooms observed on C-Hall. Resident #5. Findings include: Review of the facility policy titled, Infection Control Housekeeping and Maintenance (Environmental Services) Department Responsibilities, dated 06/14, revealed all carpets are to be cleaned as needed and carpeting is not recommended in areas of heavy soiling or spillage. During initial tour of C-Hall on 10/04/17, from 10:00 AM-11:55 AM, with Registered Nurse (RN) #1, the following housekeeping and sanitary concerns was identified. Observation of Resident #5's room (C-12 A) revealed carpet worn and stained. A foul odor of urine was noted in the room. A phone interview on 10/5/2107 at 4:04 PM, with Resident #5's daughter, revealed when she had visited with her mother a couple of weeks ago the carpet had not been cleaned. She revealed the carpet was stained, worn and a foul odor of urine was present in room. An interview with the Administrator on 10/05/17 at 5:00 PM, revealed the facility are trying to change out the flooring in all rooms. The Administrator stated there was not a scheduled at present time to change carpet out in the resident's rooms. An interview with the Housekeeping Supervisor (HS) on 10/05/17 at 5:10 PM, revealed the carpet is cleaned daily. The HS acknowledged there is no schedule for daily shampooing of carpet. An interview with the Maintenance Supervisor on 10/05/17 at 5:15 PM, revealed carpet is cleaned as needed and the staff tries to clean carpets every day. No scheduled was available or presented for dates or times carpet is cleaned. A review of the facility's Face Sheet revealed the facility admitted Resident #5 on 3/31/16. Resident #5's [DIAGNOSES REDACTED]. A review of Resident #5's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 8/23/17, revealed Resident #5's scored a 10 on the Brief Interview for Mental Status (BIMS), which indicated moderate cognitive impairment.

Based on observation, staff interview, record review, and the facility policy review, the facility failed to follow the care plan for Gastric tube medication administration for one (1) of 15 care plans reviewed, Unsampled Resident A. Findings Include: Review of the facility's policy, Care Plan Process, revised 08/17, revealed, A well developed and executed assessment and care plan provides information regarding how the causes and risks associated with issues and/or conditions can be addressed to provide for a resident's highest practicable level of well-being (care planning). The overall care plan should be oriented towards: 4. Applying current standards of practice in the care planning process. Review of Unsampled A's care plan, initiated 4/19/17, revealed the resident received [MEDICATION NAME] feeding with a [DIAGNOSES REDACTED]. An approach included to give medication as ordered and to observe for effectiveness. Observation on 10/4/17 at 9:45 AM, during the medication pass, revealed LPN (Licensed Practical Nurse) #2 poured 15 milliliters (mls) of liquid Potassium into a 30 ml medicine dose cup. No water was added to the 15 mls of the liquid Potassium. The 15 mls of liquid Potassium was poured into the syringe attached to Unsampled A's Gastric tube. Five (5) mls of water were poured into the tube before the Potassium and five (5) milliliters of water afterwards. Observation of the medication label on the bottle of liquid Potassium revealed to add four (4) ounces of water to the 15 mls of liquid Potassium. Interview with LPN #2 on 10/4/17 at 10:20 AM, revealed he had missed adding the water to Unsampled A's Potassium to dilute the medication, because he was nervous. LPN #2 stated undiluted Potassium could cause Gastrointestinal (GI) distress and, make your stomach hurt real bad. Interview on 10/6/17 at 9:50 AM, with the Assessment Nurse, revealed the care plan had not been followed for Unsampled Resident A, because the Potassium had not been diluted per directions. Review of the facility's face sheet revealed, the facility admitted the resident on 4/19/17. Unsampled Resident A's [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 7/19/17, revealed Unsampled Resident A had a Brief Interview of Mental Status (BIMS) score of 0, which indicated severe cognitive impairment. Section K for Swallowing/Nutritional Status revealed the presence of a feeding tube.

Based on observation, staff interview, record review, and the facility policy review, the facility failed to administer liquid Potassium with the required amount of water for dilution for one (1) of 19 tube medications observed, Unsampled Resident A. Findings Include: Review of the facility's policy, Administering Medications Through Nasogastric or Gastrostomy Tube with a revision date of 02/16, revealed, 5. Use liquid drug forms whenever possible and dilute them with water as needed. Review of the Nursing Drug Handbook 2016, revealed Potassium supplements should be given with a full glass of water to lessen Gastrointestinal upset. Observation during medication pass, on 10/4/17 at 9:50 AM, revealed Licensed Practical Nurse (LPN) #2, prepared 15 milliliters (mls) of liquid Potassium without adding four (4) ounces of water to dilute per label directions for Unsampled Resident #A. LPN #2 administered five (5) milliliters of water to the Gastric tube before and after giving the liquid Potassium. Record review of the cumulative physician orders [REDACTED]. Interview on 10/4/17 at 9:45 AM, with LPN #2, confirmed the medication error of administering the liquid Potassium without dilution with water prior to administration, per label directions. LPN #2 stated he had not diluted the Potassium with four (4) ounces of water, he only administered (5) milliliters of water to the tube before and after the Potassium. LPN #2 stated he had missed it and failure to dilute the Potassium could cause Gastrointestinal distress and make your stomach hurt real bad. Interview on 10/5/17 at 2:05 PM, with the Consultant Pharmacist confirmed the medication error and revealed it was not acceptable to give Potassium without diluting with four (4) ounces of fluid. Interview on 10/5/17 at 2:30 PM, with the Director of Nursing revealed no current training on medications by Gastric tube had been done but was due in November. Review of the facility's face sheet revealed, the facility admitted the resident on 4/19/17. Unsampled Resident A's [DIAGNOSES REDACTED]. Review of the Minimum Data Set with an Assessment Reference Date of 7/19/17, revealed Unsampled Resident A had a Brief Interview of Mental Status (BIMS) score of 0 which indicated severe cognitive impairment.

Based on observation, record review, staff interview and policy review, the facility failed to provide necessary services to prevent ulcers for one (1) of two (2) residents reviewed for pressure ulcers (Resident #6). Findings include: Resident #6 Observation of Resident #6 on 2/25/13 at 9:50 a.m., revealed that she was lying in bed while facility staff performed wound care to her right heel and left lateral foot. The wound to the right heel was cleaned with wound cleaner, [MEDICATION NAME] was applied over the wound, an abdominal pad was applied over the wound and the wound was wrapped with a Kling dressing. Registered Nurse (RN) #1 performed the wound care. Record review for Resident #6 revealed that she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/6/13, revealed that she scored 0 (zero) of 15 on the Brief Interview for Mental Status (BIMS), which indicated that she had severe cognitive impairment. Further review of the aforementioned MDS revealed that she had 1 (one) unhealed pressure ulcer which was coded as "Unstageable - Deep tissue: Suspected deep tissue injury in evolution". The MDS also included "Most Severe Tissue Type for Any Pressure Ulcer, 2 (two) Granulation tissue - pink or red tissue with shiny, moist, granular appearance". Further record review for Resident # 6 also revealed the following: 1. A Physician's Telephone Order, dated 2/8/13, to "Cleanse right heel (unstageable) with wound cleanser and dry. Apply [MEDICATION NAME] to fit wound. Cover with ABD (abdominal pad) and wrap foot with Kerlix until healed". 2. A physician's orders [REDACTED]. 3. Certified Nursing Assistant Skin Checks from 12/26/12 to 2/28/13 with "Task, Skin Issue; Answer, No skin concern" for every day except 1/10/13 and 2/11/13 which had "Task, Skin Issue; Answer, Skip - Computer not available". 4. A "Skin At Risk Screening", dated 2/6/13, which included "Risk Factors, Current or History of Pressure Ulcer, No". 5. "ETAR (Electronic Treatment Administration Record)", dated 12/12, and 1/13 which had no signatures/entries for "Weekly Body Audit". 6. "Departmental (Nursing) Notes" with 3 (three) entries for 1/14/13: A. "11:13 a.m., Tylenol 325 MG (milligrams) Caplet was Administered c/o (complaint of) pain in feet and legs." This entry was signed by Licensed Practical Nurse (LPN) #1. B. "11:13 a.m., [MEDICATION NAME] 2 MG Capsule was Administered c/o pain in feet and legs." This entry was signed by LPN #1. C. "11:25 a.m., Called (Attending Physician) (Physician # 1) and spoke to (Resident's) son at (phone number) about resient (Resident) not wanting to eat. Also having difficulty swallowing. Resident in the bed at this time c/o heal (heel) pain." This entry was signed by LPN #1. The following Wound Documentation was recorded for the right heel of Resident # 6: 1. "1/21/13, unstageable pressure ulcer, first observed 1/21/13, black/brown (eschar) (soft)." This entry was signed by Registered Nurse (RN) #1. 2. "1/28/13 unstageable deep tissue injury, brown." This entry was signed by RN #1. 3. "2/4/13 unstageable deep tissue injury, brown." This entry was signed by RN #1. 4. "2/11/13 unstageable deep tissue injury, brown." This entry was signed by RN #1. 5. "2/18/13 unstageable deep tissue injury, tan." This entry was signed by the Director of Nursing (DON). 6. "2/21/13 unstageable deep tissue injury." There was no description of the wound color, and this entry was signed by RN #1. The following Wound Documentation for Resident # 6 was recorded for the "L (left) side foot". This wound was marked "Other, Onset Date 1/28/13". 1. "1/28/13, water blister, surround (ing) skin red." This entry was signed by RN #1. 2. "2/4/13, water blister, surround (ing) skin red/normal." This entry was signed by RN #1. 3. "2/11/13, water blister, surround (ing) skin normal." This entry was signed by RN #1. 4. "2/18/13, water blister, dry." This entry was signed by RN #1. 5. "2/21/13, water blister, dry." This entry was signed by RN #1. A "physician progress notes [REDACTED]."DTI (deep tissue injury) to left lateral heel, dark red, dry adherent". This physician progress notes [REDACTED]. Interview with the DON on 2/26/13 at 3:15 p.m., confirmed that the "Skin At Risk Screening", dated 2/6/13, which included "Risk Factors, Current or History of Pressure Ulcer" was marked "no" for Resident #6. The DON also confirmed that there was no documented evidence of "Weekly Body Audit" for the months of 12/12 and 1/13 by the nurses. When the DON was asked if blisters over a bony prominence would be considered pressure ulcers, the RN Nurse Consultant confirmed "All blisters are stage 2 (two) (pressure ulcers)". The DON also confirmed that the Wound Documentation was recorded for the right heel of Resident # 6 had black/brown color. Interview with Nurse Practitioner #1 on 2/27/13 at 10:45 a.m., about the pressure ulcer history for Resident #6 revealed "All I can go with is that today is the first day I saw it (pressure ulcer)". She also stated that she had been coming to the facility "off and on for 3 (three) years" to assess Residents, but that today was the first time she had seen Resident #6 for any reason. Interview with Attending Physician #1 on 2/27/13 at 11:00 a.m., revealed that he did not recall visualization of the pressure ulcer for Resident #6, and that he could not recall her ever having had a previous pressure ulcer. He also added that Resident #6's family requested a change of Physician, and there was a change of Physicians at the end of January 2013. Interview with the Medical Director on 2/27/13 at 11:20 a.m., revealed that Resident #6's care was transferred to his services after the pressure ulcer developed. The Medical Director was informed that the facility had no documented evidence of "Weekly Body Audits" being performed by the nursing staff. He was also informed that Resident #6 had complained of pain on 1/14/13 in her heel, prior to the discovery of the pressure ulcer on 1/21/13, but there was no documentation as to which heel had pain, nor was there any documented evidence of the heels or skin being observed. Interview with the RN Nurse Consultant on 2/27/13 at 2:15 p.m., confirmed that Resident #6's right heel had been wrapped in Kling instead of the Kerlix that was ordered. Interview with LPN #1 on 2/27/13 at 3:15 p.m., revealed that she did not remember which heel that Resident #6 was complaining of pain in. She also added that she did not remember "looking or feeling anything". Review of the facility's "Physician order [REDACTED].#6's right foot, confirmed "The nurse receiving physician orders, whether verbal or in writing, must assure that orders are transcribed properly and implemented." Review of the facility's "Skin Care Policy and Procedure" policy, revised 6/11, confirmed the following: "I. Prevention, Evaluation and Screening, Weekly body audits" "II. Ongoing Surveillance C. 6. Color" "II. Ongoing Surveillance, Definition of a Pressure Ulcer, A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or pressure in combination with shear and/or friction." "II Ongoing Surveillance, Staging of Pressure Ulcers, Stage 2 (two) Partial thickness loss of dermis presenting as a shallow open ulcer with red-pink wound bed, without slough. May also present as an intact or open/ruptured blister." And "Unstageable, Unstageable due to Slough and/or Eschar, Full thickness tissue loss in which to (the) base of the ulcer is covered by clough (slough) (yellow, tan, gray green or brown) and/or eschar (tan, brown or black) in the wound bed". Also included "Unstageable, Unstageable due to suspected deep tissue injury: A purple or maroon area of disclosed intact skin due to damage of underlying soft tissue damage. The area may be preceded by tissue that is painful, firm, mush, boggy, warmer or cooler as compared to adjacent tissue". "IV. Treatment Regimen C. 2. Local care, including cleansing and dressing as ordered."