**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure accuracy of Minimum Data Set (MDS) assessments for 1 (Resident #55) of 4 residents reviewed for discharge assessments. Findings include: Review of Resident #55's admission record documented that Resident #55 was admitted to the facility on [DATE] with diagnoses including: altered mental status, chronic obstructive pulmonary disease (COPD), seizures, cerebral infarction, transient cerebral ischemic attack, anxiety disorder, dysphagia and osteoarthritis. Review of Resident #55's Minimum Data Set (MDS) titled Discharge Return Not Anticipated dated 11/20/2024 showed the resident was discharged to acute hospital on [DATE]. Review of Resident #55's social services notes dated 11/14/2024 at 9:31 AM read, Met with resident and resident stated [Resident #55's Niece's name] came up here and talked to her about transferring and the resident stated she wanted to transfer where she [Social Services Director's name] was working. Referral process initiated. Review of Resident #55's social services note dated 11/15/2024 read, Received a call from [Facility name] who stated they approved the referral and will pick up the resident on 11/20/2024 at 10:00 AM. Review of Resident #55's admission & Discharge summary dated [DATE] read, Resident [Resident #55's name] transferred to SNF [skilled nursing facility]. During an interview on 2/4/2025 at 1:50 PM, the MDS Coordinator confirmed Resident #55 was discharged to another skilled nursing facility and the MDS dated [DATE] was inaccurate. Review of the facility policy and procedure titled Resident Assessment Instruments (RAI) with the last review date of 1/25/2024 read, Policy: It is the policy of the facility to adhere to the following procedures related to the proper documentation and utilization of a resident's Minimum Data Set (MDS) to ensure a comprehensive and accurate assessment of residents will be completed in the format and in accordance with time frames stipulated by Department of Health and Human Services Center for Medicare and Medicaid Services. This assessment system will provide a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacities and assist staff to identify health problems for care plan development. Review of the facility form titled Certifying Accuracy of the Resident Assessment read, 2. Any person who completes any portion of the MDS assessment, tracking form, or correction request form is required to sign the assessment certifying the accuracy of that portion of that assessment . 4. The resident assessment coordinator is responsible for ensuring that an MDS assessment has been completed for each resident.

Based on observation, interview and record review, the facility failed to ensure the drugs and biologicals used in the facility were stored in accordance with currently accepted professional principle in 1 of 4 hallways. Findings include: During an observation on 2/3/2025 at 10:55 AM, Resident #15 was sleeping in bed and there was one bottle of Artificial Tears Ophthalmic Solution (Artificial Tear Solution) on the resident's beside table. Review of Resident #15's physician order dated 1/17/2024 read, Artificial Tears Ophthalmic Solution (Artificial Tear Solution), Instill 1 drop in both eyes four times a day for dry eyes and irritation. During an interview on 2/3/2025 at 10:58 AM, Staff A, Licensed Practical Nurse (LPN), stated Eye drops should not be at the bedside not secured. During an interview on 2/3/2025 at 11:08 AM, the Director of Nursing (DON) stated, Medications need to be secured and there are times when family members bring in eye drops we are not aware of. The medication has been brought to the patient. Review of the facility policy and procedure titled Medication Labeling and Storage with the last review date of 1/7/2025 read, Policy Statement: The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light control.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to inform the resident representative following a change in the resident's condition for 1 of 3 sampled residents, Resident #1. Findings include: Review of Resident #1's admission record revealed the resident was admitted to the facility on [DATE] with diagnoses including acute and chronic respiratory failure with hypercapnia, chronic obstructive pulmonary disease, type 2 diabetes mellitus, acute kidney failure, chronic kidney disease, major depressive disorder, generalized anxiety disorder, and muscle weakness. Review of Resident #1's progress note completed by Staff A, Licensed Practical Nurse (LPN), dated 4/2/2024 at 1:26 PM read, Resident was transferring from bedside commode to wheelchair, and she states her legs gave out and she slide [Sic.] to the floor. CNA [Certified Nursing Assistant] was in the room assisting resident with the transfer and was able to lower resident to the floor. No apparent injury noted at that time no cuts or bruises. [Medical Doctor's name] was notified and family member phone states the number could not be dialed. DON [Director of Nursing] was made aware of incident. Resident denies injury and pain, she said she couldn't breathe rescuer puffer given at that time. During an interview on 5/2/2024 at 12:58 PM, Staff A, LPN, stated, I was assigned to [Resident #1's name] when she fell. I completed an assessment, notified the doctor, and attempted the family but the call would not go through. I don't remember what the message said. I did not inform the resident that I could not get her daughter and did not follow through to obtain a correct number for the records. During an interview on 5/2/2024 at 12:18 PM, the Director of Nursing stated, I was aware that the daughter could not be reached by the phone number recorded, but the resident is responsible for herself, so I did not attempt to get the correct phone number. I didn't ask the resident if she wanted us to call her daughter because I didn't think I had to inform the family since she is responsible for herself. Review of the facility policy and procedures titled Change in a Resident's Condition or Status revised in February 2021 read, Policy Statement: Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and /or status (e.g., changes in level of care, billing/payments, resident rights, etc.) Policy Interpretation and Implementation . 4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: a. the resident is involved in any accident or incident that results in an injury including injuries of an unknown source; b. there is a significant change in the resident's physical, mental, or psychosocial status; c. there is a need to change the resident's room assignment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the resident assessment accurately reflected the resident's status for 1 of 3 sampled residents, Resident #58. Findings include: Review of the admission record for Resident #58 showed the resident was admitted on [DATE] with the diagnoses including cerebral infection, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, peripheral vascular disease, dysarthria following cerebral infarction, occlusion and stenosis of right carotid artery, other low back pain, paroxysmal atrial fibrillation, transient cerebral ischemic attached, major depressive disorder, gastroesophageal reflux disease, essential (primary) hypertension, dementia, atherosclerotic heart disease of native coronary artery with unspecified angina pectoris, and hyperlipidemia. Review of Resident #58's physician order dated 8/31/2023 reads, May discharged [Sic.] resident to home with [Home Health Agency's name] with SN [skilled nursing], PT [physical therapy], OT [occupational therapy], [Pharmacy's name] for prescriptions and [Home Medical Equipment Provider's name] for DME [Durable Medical Equipment] equipment. Review of Section A (Identification Information) of Resident #58's Discharge Return Not Anticipated Minimum Data Set (MDS) dated [DATE] showed the resident was discharged to acute hospital. During an interview on 10/25/2023 at 2:45 PM, the Director of Nursing (DON) stated that the resident was discharged home and the MDS was inaccurate. During an interview on 10/26/2023 at 11:10 AM, the MDS Coordinator stated that the MDS information needed to be accurate. Review of the facility policy and procedure titled MDS Completion and Submission Timeframes last reviewed on 1/19/2023 reads, Policy Interpretation and Implementation: 1. The Assessment Coordinator or designee shall be responsible for ensuring that resident assessments are submitted to CMS' QIES Assessment Submission and Processing (ASAP) system in accordance with current federal and state guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the residents who were unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for 1 of 3 residents sampled for activities of daily living, Resident #110. Findings include: During an observation on 10/23/2023 at 11:25 AM, Resident #110 was in bed. The resident's fingernails were long and untrimmed with dark substance underneath the nailbeds of both hands. During an observation on 10/24/2023 at 2:07 PM, Resident #110 was in bed. The resident's fingernails were long and untrimmed with dark substance under the nailbeds of both hands. During an observation on 10/25/2023 at 9:28 AM, Resident #110 was in bed with long and untrimmed fingernails and dark substance under the nailbeds of both hands. Review of the admission record for Resident #110 showed the resident was admitted on [DATE] with the diagnose including malignant neoplasm of prostate, urinary tract infection, anemia, acute posthemorrhagic anemia, acute embolism and thrombosis of deep veins of left upper extremity, obstructive and reflux uropathy, hyperlipidemia, hydronephrosis with renal and urethral calculous obstruction, chronic kidney disease, vitamin D deficiency, localized swelling, mass and lump, inflammatory disorders of scrotum, other artificial openings of urinary tract status, intra-abdominal and pelvic swelling, mass and lump, acute kidney failure, hypothyroidism, gastroesophageal reflux disease, and muscle weakness. Review of Resident #110's care plan dated 10/6/2023 reads, Focus: Resident has ADL [Activities of Daily Living] Self-Care Deficit AEB [As Evidenced By]: Resident requires: Assist of one with ADL's . assist with Personal Hygiene At risk of developing complications associated with decreased ADL self-performance r/t [related to] Disease Process/condition . Date Initiated: 10/15/2023. During an observation on 10/25/2023 at 3:37 PM accompanied with the Director of Nursing (DON), Resident #110 had long and untrimmed fingernails with dark substance under the nailbeds. During an interview on 10/25/2023 at 3:37 PM, the DON confirmed the fingernails were long and untrimmed with black substance under nailbeds. The DON stated, I do have a concierge CNA [Certified Nursing Assistant] takes care of it. Review of the facility policy and procedure titled Care of Fingernails last reviewed on 1/19/2023 reads, Purpose: The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections . General Guidelines . 2- Nail care includes cleaning and trimming, weekly and as needed.

Based on observation, record review, and interview, the facility failed to ensure the residents received Midline intravenous catheter site dressing care and services in accordance with professional standards of practice for 1 of 1 resident receiving intravenous therapy, Resident #12 (photographic evidence obtained). Findings include: During an observation on 10/23/2023 at 10:08 AM, Resident #12's transparent dressing covering a midline intravenous catheter located on the right upper arm was dated 9/29/2023. The edges of the top and bottom of the dressing were pulled away from the skin. During an interview on 10/23/2023 at 10:08 AM, Resident #12 stated, The dressing has not been changed in a long time, not weekly and I have not refused to have it changed. The wound care nurse is the only nurse that has changed the dressing for me, and she is gone. During an observation on 10/23/2023 at 3:11 PM, accompanied with the Director of Nursing (DON), Resident #12's transparent dressing covering a midline intravenous catheter located on right upper arm was dated 9/29/2023. During an interview on 10/23/2023 at 3:11 PM, the DON stated, The dressing has not been changed since 9/29/2023. Physician orders need to be followed and the dressings are to be changed every 7 days to decrease the risk of infection. When the dressing was changed, the staff will place their initials, the date and time that the dressing was changed on the dressing. I do not know why it is documented on the TAR [Treatment Administration Record] as being completed on October 5th and 19th because the dressing has not been changed since 9/29/2023. During an interview on 10/23/2023 at 3:15 PM, the Physician stated, The dressing should be changed as ordered every 7 days. A midline dressing can go between 15-30 days without being changed without increasing the risk of infection if the dressing is intact and clean. Staff need to document if the patient refuses to have a dressing changed. During an interview on 10/24/2023 at 8:42 AM, the Wound Care License Practical Nurse (LPN) stated, The midline dressing is to be changed every 7 days or when soiled to decrease the risk of infection and the dressing change is documented in the TAR. During an interview on 10/24/2023 at 9:00 AM, the Nurse Manager stated, The wound care nurse normally completes dressing changes for wound or intravenous lines, but nurses can also do the dressing changes. Whoever completes the dressing change will initial, date and time the dressing change and document the dressing change in the TAR. The TAR should be completed when the dressing is changed or refused. The dressing has not been changed since 9/29/2023. During an interview on 10/24/2023 at 3:43 PM, the Infectious Disease Physician stated, The dressing for the midline needs to be changed as ordered and if the patient refuses, the refusal needs to be documented. During an interview on 10/25/2023 at 8:34 AM, Staff C, LPN, stated, I have never changed a midline or PICC [Peripherally Inserted Central Catheter] line dressing. I was told by previous wound care nurse and previous DON that LPNs could not do dressing changes for midlines or PICC catheters. [Resident #12's name] would refuse wound care frequently, but I never attempted to change his midline dressing because I was told that I was not allowed to. I do an assessment of IV [intravenous] line for signs of infection which is redness, drainage, pain and dressing intact. I never pay attention to the date because I don't change the dressing. The documentation of the TAR for 10/5, 10/12 and 10/19 was an error on my part. I must have just been clicking complete on all the task and in error clicked that I changed the dressing on 10/5 and 10/19 and that he refused the dressing change on 10/12. Review of the facility policy and procedure titled Midline Dressing Changes last reviewed on 1/19/2023 reads, Purpose: The purpose of this procedure is to prevent catheter-related infections associated with contaminated, loosened, or soiled catheter-site dressings. General Guidelines: 1. Change midline catheter dressing 24 hours after catheter insertion, every 5-7 days, or if it is wet, dirty, not intact, or compromised in any way.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure the medication error rate was not 5% or greater. The medication error rate was 34.38%. Findings include: During medication administration observation on [DATE] beginning at 9:23 AM, Staff A, License Practical Nurse (LPN), began preparing medications for Resident #110. Staff A administered one Metronidazole tablet 250 mg (milligrams) by mouth for diarrhea. The resident had no current order for Metronidazole tablet 250 mg. The original order was for 7 days, which expired on [DATE]. During medication administration observation on [DATE] beginning at 9:36 AM, Staff A, LPN, began preparing medications for Resident #13. Staff A omitted administering Folic Acid oral tablet 1 mg as ordered for anemia. During medication administration observation on [DATE] beginning at 9:48 AM, Staff A, LPN, began preparing medications for Resident #9. Staff A administered one drop of Brimonidine Tartrate Ophthalmic Solution 0.2% (Brimonidine Tartrate) in each eye related to glaucoma. At 9:48 AM, Staff A administered one drop of Brinzolamide Ophthalmic Suspension 1% (Brinzolamide) in each eye. Staff A did not wait for 5 minutes between eye drop administration for additional eye drops. Staff A did not administer Senokot S oral tablet 8.6-50 mg (Sennosides -Docusate Sodium) for constipation and Polyethylene Glycol 3350 Powder (Polyethylene Glycol 3350 (Bulk) 17 grams by mouth for constipation as ordered. During medication administration observation on [DATE] at 9:11 AM, the Unit Manager, LPN, crushed medications for Resident #215 and administered all at one time, which included Aspirin 81 mg related to cerebrovascular disease, Amlodipine Besylate oral tablet 10 mg related to hypertension, Apixaban oral tablet 5 mg related to cerebrovascular disease, Metoprolol Tartrate oral tablet 25 mg related to hypertension, and Lacosamide oral solution 10 mg/ml [milliliter], 20 ml related to seizures. Review of Resident #110 's physician order dated [DATE] reads, Metronidazole Tablet 250 mg. Give 1 tablet by mouth three times daily for diarrhea for 7 days. Review of Resident #13's physician order dated [DATE] reads, Folic Acid oral Tablet 1 mg (Folic Acid). Give 1 tablet by mouth one time a day related to anemia. Review of Resident #9's physician order dated [DATE] reads, Brinzolamide Ophthalmic Suspension 1% (Brinzolamide). Instill 1 drop in both eyes two times a day related to glaucoma. Review of Resident #9's physician order dated [DATE] reads, Senokot S oral tablet 8.6-50 mg (Sennosides -Docusate Sodium). Give 1 tablet by mouth two times a day for constipation. Review of Resident #9's physician order dated [DATE] reads, Brimonidine Tartrate Ophthalmic Solution 0.2% (Brimonidine Tartrate). Instill 1 drop in both eyes two times a day related to glaucoma. Review of Resident #9's physician order dated [DATE] reads, Polyethylene Glycol 3350 Powder (Polyethylene Glycol 3350 (Bulk). Give 17 grams by mouth two times a day for constipation. Review of Resident #215's physician order dated [DATE] reads, Metoprolol Tartrate Oral Tablet 25 mg. Give 1 tablet via PEG [Percutaneous Endoscopic Gastrostomy] Tube every morning and at bedtime related to hypertension. Review of Resident #215's physician order dated [DATE] reads, Lacosamide oral solution 10 mg/ml. Give 20 ml via PG-Tube every morning and at bedtime related to seizures. Via G Tube. Review of Resident #215's physician order dated [DATE] reads, Aspirin 81 (oral tablet chewable aspirin). Give 1 tablet via PEG (Percutaneous endoscopic gastrostomy) Tube one time a day related to cerebrovascular disease. Via G-tube (Gastric Tube). Review of Resident #215's physician order dated [DATE] reads, Amlodipine Besylate oral tablet 10 mg. Give 1 tablet via PEG tube one time a day related hypertension. Review of Resident #215's physician order dated [DATE] reads, Apixaban oral Tablet 5 mg. Give 1 tablet via PEG-Tube every morning and at bedtime related to cerebrovascular disease. During an interview on [DATE] at 9:55 AM, Staff A, LPN, stated, I do not wait for the suggested 5 minutes between administration of eye drop medication unless it is written as an order. I don't think I have to wait. I do not know what the policy and procedure is here at our facility. During an interview on [DATE] at 12:24 PM, the Director of Nursing stated, Medications are to be administered as ordered and if not given should be documented on the MAR [Medication Administration Record] as not given. During an interview on [DATE] at 10:00 AM, the Unit Manager, LPN, stated, I have always administered the medication via G-tube all at one time. I was not aware that the medications had to be administered one medication at a time with a flush before and after. I am not aware of what our policy and procedure is related to medication administration via G-tubes. During an interview on [DATE] 3:10 PM with the Director of Nursing stated It is the standard and our policy and procedure for a 5-minute delay between administering eye drop medications, All medications via a G-tube are to be give one at a time with flush before and after each medication administered. Review of the facility policy and procedures titled Administering Medications last reviewed on [DATE] reads, Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation . 4. Medications are administered in accordance with prescriber orders including any required timeframe. 5. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: a. Enhancing optimal therapeutic effect of the medication . 21. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose. 22. The individual administering the medication initials the Resident's MAR on the appropriate line after giving each medication and before administering the next ones. Review of the policy and procedure titled Guideline for Administration of Ophthalmics in Long Term Care Facilities reads, 9) Allow 3-5 minutes before administration of another drop of any medication is administered to the same eye. Review of facility policy and procedure titled Administering Medications through an Enteral Tube last reviewed on [DATE] reads, Purpose: The purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube . General Guidelines . 3. Do not mix medications together prior to administering through an enteral tube. Administer each medication separately . Steps in the Procedure . 27. When the last of the medication begins to drain from the tubing, flush the tubing with 15-30 mL of warm sterile water (or prescribed amount).

Based on record review and interview, the facility failed to obtain laboratory service ordered by the physician for 1 of 3 residents reviewed for laboratory services, Resident #2. Findings include: Review of Resident's #2's physician order dated 9/18/2023 showed CBC (Complete Blood Count), BMP (Complete Metabolic Panel), and ProBNP (Pro-brain Natriuretic Peptide) in 1 week. Review of Resident #2's medical records revealed no lab results for CBC, BMP, and ProBMP. During an interview on 10/25/2023 at 12:17 PM, the Director of Nursing stated, The order was written on 9/18/2023 but it was never obtained or completed. Nursing did not complete their 24-hour check and the test was missed. Review of the facility policy and procedure titled Lab and Diagnostic Test results- Clinical Protocol last reviewed on 1/19/2023 reads, Assessment and Recognition: 1. The physician will identify and order diagnostic and lab testing based on diagnostic and monitoring needs. 2. The staff will process test requisitions and arrange for tests. 3. The laboratory, diagnostic radiology provider, or other testing source will report test results to the facility.

Based on record review and interview, the facility failed to ensure resident assessments were transmitted within 14 days of completion for 5 of 6 residents reviewed for resident assessments, Residents #4, #28, #36, #42, and #48. Findings include: Review of Resident #4's MDS (Minimum Data Set) on 10/25/2023 showed the Assessment Reference Date (ARD) of 9/14/2023 and completion due date of 9/28/2023. The transmission was overdue for 28 days. Review of Resident #28's MDS on 10/25/2023 showed the ARD of 9/21/2023 and completion due date of 10/5/2023. The transmission was overdue for 20 days. Review of Resident #36's MDS on 10/25/2023 showed the 3rd quarter ARD of 8/17/2023 and completion due date of 8/31/2023. The transmission was overdue for 56 days. Review of Resident #42's MDS on 10/25/2023 showed the discharge ARD of 8/29/2023 and completion due date of 9/12/2023. The transmission was overdue for 43. Review of Resident #48's MDS on 10/25/2023 showed the discharge ARD of 8/19/2023 and complete due date of 9/2/2023. The transmission was overdue for 53 days. During an interview on 10/25/2023 at 3:15 PM, the Administrator stated, My expectation is that the MDS assessments should be submitted timely. During an interview on 10/26/2023 at 11:10 AM, the MDS Coordinator stated, I am the MDS Coordinator. Once a resident assessment is completed, you have 14 days to submit it. Review of the facility policy and procedure titled MDS Completion and Submission Timeframes last reviewed on 1/19/2023 reads, Policy Statement: Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes.

Based on observation, interview, and record review, the facility failed to ensure foods were stored in accordance with professional standards in the kitchen freezer and in 1 of 1 nourishment rooms. Findings include: During an initial tour of the facility kitchen on 10/23/2023 at 9:18 AM with the Kitchen Manager, there was a cake wrapped with no label or date in the kitchen freezer. During an observation of the nourishment room on 10/23/2023 at 9:30 AM with the Kitchen Manager, there was a box of blueberries in the nourishment room refrigerator with no label or date. During an interview on 10/23/2023 at 9:30 AM, the Kitchen Manager confirmed that the observed food items in the kitchen freezer and nourishment room refrigerator were not labeled and dated, and they should have been labeled and dated. Review of the facility policy and procedure titled Food Storage last reviewed on 1/19/2023 reads, Procedures . 5. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure resident records were complete and accurate for 4 of 10 residents reviewed, Residents #12, #17, #24, and #110. Findings include: 1. Review of the admission record for Resident #12 documented the resident was admitted on [DATE] and readmitted on [DATE] with diagnosis that included pressure ulcers. Review of Resident #12's physician order dated 6/21/2023 reads, Wound care: cleans wound to RT [Right] Ischium with NS [Normal Saline]. Apply xeroform and up cover with borderless silicone foam. Change daily. Review of Resident #12's physician order dated 6/30/2023 reads, Wound care: cleans wound to right buttocks with NS. Apply xeroform and up cover with borderless silicone foam. Change daily. Review of Resident #12's physician order dated 8/20/2023 reads, Wound care cleanse Lt. [left] Lateral foot with Dakins. Apply Santyl and calcium alginate. Apply ABD [abdominal] and wrap and kerlix. Change M [Monday]/W [Wednesday]/F [Friday] every day shift Monday, Wednesday, Friday for neuropathic ulcer. Review of Resident #12's physician order dated 8/20/2023 reads, Wound care cleanse Lt. heel with Dakins. Apply Santyl and calcium alginate. Cover with silicone borderless foam. Change M/W/F every day shift Monday, Wednesday, Friday for neuropathic ulcer. Review of Resident #12's physician order dated 8/20/2023 reads, Wound care: cleanse RT [right] heel with Dakins. Apply Santyl and calcium alginate. Apply ABD and wrap and kerlix. Change M/W/F every day shift Monday, Wednesday, Friday for neuropathic ulcer. Review of Resident #12's physician order dated 8/20/2023 reads, Wound care cleanse Lt. plantar (foot) with Dakins. Apply Santyl and calcium alginate. Apply ABD and wrap and kerlix. Change M/W/F every day shift Monday, Wednesday, Friday for neuropathic ulcer. Review of Resident #12's physician order dated 9/8/2023 reads, Wound care: cleanse wound to Lt. Ischium with NS. Apply honey and calcium alginate. Cover with borderless silicone foam. Change daily, every day shift for pressure ulcer. Review of Resident #12's Treatment Administration Records (TARs) for September 2023 and October 2023 revealed no documentation that wound care was provided for the following: 1. Wound care cleanse Lt. Lateral foot with Dakins. Apply Santyl and calcium alginate. Apply ABD and wrap and kerlix. Change M/W/F every day shift Monday, Wednesday, Friday for neuropathic ulcer on 9/8/2023, 9/13/2023, 9/20/2023 or 9/27/2023; 2. Wound care cleanse Lt. heel with Dakins, apply Santyl and calcium alginate. Cover with silicone borderless foam. Change M/W/F every day shift Monday, Wednesday, Friday for neuropathic ulcer on 9/8/2023, 9/13/2023, 9/20/2023 or 9/27/2023; 3. Wound care: cleanse wound to Lt. Ischium with NS. Apply honey and calcium alginate. Cover with borderless silicone foam. Change daily, every day shift for pressure ulcer on 9/9/2023, 9/13/2023, 9/14/2023, 9/16/2023, 9/19/2023, 9/20/2023, 9/21/2023, 9/26/2023 or 9/27/2023; 4. Wound care cleanse Lt. plantar with Dakins. Apply Santyl and calcium alginate. Apply ABD and wrap and kerlix. Change M/W/F every day shift Monday, Wednesday, Friday for neuropathic ulcer on 9/5/2023 and 9/8/2023; 5. Wound care: cleans wound to right buttocks with NS. Apply xeroform and up cover with borderless silicone foam. Change daily on 9/5/2023, 9/8/2023, 9/9/2023, 9/13/2023, 9/14/2023, 9/16/2023, 9/20/2023, 9/21/2023, 9/26/2023,9/27/2023; 6. Wound care: cleanse RT heel with Dakins. Apply Santyl and calcium alginate. Apply ABD and wrap and kerlix. Change M/W/F every day shift Monday, Wednesday, Friday for neuropathic ulcer on 9/8/2023, 9/13/2023, 9/20/2023 or 9/27/2023; 7. Wound care: cleans wound to RT Ischium with NS. Apply xeroform and up cover with borderless silicone foam. Change daily on 9/5/2023 and 9/8/2023. Review of Resident # 12's TAR for October 2023 revealed no documentation for wound care was provided for 1)Wound care cleanse Lt. Lateral foot with Dakins. Apply Santyl and calcium alginate. Apply ABD and wrap and kerlix. Change M/W/F every day shift Monday, Wednesday, Friday for neuropathic ulcer. No documentation on 10/6/2023. 2)Wound care cleanse Lt. heel with Dakins. Apply Santyl and calcium alginate. Cover with silicone borderless foam. Change M/W/F every day shift Monday, Wednesday, Friday for neuropathic ulcer. No documentation on 10/6/2023 and 10/16/2023. 3) Wound care: cleanse wound to Lt. Ischium with NS. Apply honey and calcium alginate. Cover with borderless silicone foam. Change daily, every day shift for pressure ulcer. Wound care cleanse Lt. plantar foot with Dakins. Apply Santyl and calcium alginate. Apply ABD and wrap and kerlix. Change M/W/F every day shift Monday, Wednesday, Friday for neuropathic ulcer. No documentation on 10/6/2023 and 10/16/2023. 4) Wound care: cleans wound to right buttocks with NS. Apply xeroform and up cover with borderless silicone foam. Change daily. Wound care: cleanse RT heel with Dakins. Apply Santyl and calcium alginate. Apply ABD and wrap and kerlix. Change M/W/F every day shift Monday, Wednesday, Friday for neuropathic ulcer. No documentation on 10/6/2023 and 10/16/2023. 5) Wound care: Cleanse wound to ischium with ½ strength Dakins. Apply moistened ½ strength Dakins and cover with borderless silicone foam. Change daily No documentation on 10/5/2023 , 10/6/2023, 10/16/2023, 10/21/2023. 6) Wound care: cleanse wound to right lateral leg with Dakins. Apply Santyl and Ca Alginate. Cover with silicone borderless foam. Wrap kerlix. Change M/W/F every day shift every Mon, Wed, Fri for wound care. No documentation on 10/16/2023 During an interview on 10/26/2023 at 1:55 PM, the Director of Nursing confirmed all dates that were blank were documentation error and that wound care was provided, and each area should have been signed by the nurse providing the wound care. 2. Review of the admission record for Resident #17 showed the resident was admitted on [DATE] with the diagnoses including peripheral vascular disease, type 2 diabetes mellitus with diabetic neuropathy, non-pressure chronic ulcer of left calf with other specified severity, acute kidney failure, unspecified dementia, neuromuscular dysfunction of bladder, essential (primary) hypertension, major depressive disorder, muscle weakness, benign prostatic hyperplasia without lower urinary tract symptoms, left knee contracture, and repeated falls. Review of Resident #17's TAR for August 2023 revealed no entries documented for head-to-toe skin assessment on Saturdays on Saturday 8/19/2023, no entries for left heel wound care on Monday, Wednesday and Friday on Monday 8/21/2023 and Friday 8/25/2023, no entries for bilateral calf wound care 8/8/2023, 8/21/2023 and 8/25/2023. Review of Resident #17's TAR for September 2023 revealed no entries documented for applying A&D ointment for dry skin on 9/14/2023 and 9/19/2023, no entries for changing catheter drainage bag on 9/19/2023, no entries for head-to-toe skin assessment on Saturdays on Saturday 9/16/2023, no entries for urinary output from foley catheter every shift on 9/25/2023, 9/26/2023, 9/17/2023, and 9/28/2023 at 7:00 PM to 7:00 AM shift, and on 9/26/2023 at 7:00 AM to 7:00 PM shift. Review of Resident #17's TAR for October 2023 revealed no entries documented for applying A&D ointment for dry skin on 10/5/2023, no entries for changing catheter drainage bag on 10/25/2023, no entries for assessment of level of pain on 10/2023 at 7:00 AM to 7:00 PM shift and on 10/15/2023 at 7:00 PM to 7:00 AM shift, no entries for documenting bowel movement on 10/15/2023 at 7:00 PM to 7:0 AM shift, no entries for documenting urinary output on 10/2/2023 and 10/5/2023 at 7:00 AM to 7:00 PM shift and on 10/1/2023, 1015/2023, and 10/20/2023 at 7:00 PM to 7:00 AM shift, AND no entries for catheter care on 105/2023 at 7:00 AM to 7:00 PM shift and on 10/15/2023 at 7:00 PM to 7:00 AM shift. Review of the admission record for Resident #24 showed the resident was admitted on [DATE] with the diagnoses including chronic kidney disease, unspecified atrial fibrillation, peripheral vascular disease, morbid (severe) obesity due to excess calories, end stage renal disease, anemia, atherosclerotic heart disease of native coronary artery without angina pectoris, hypothyroidism, bilateral primary osteoarthritis of knee, unspecified diastolic (congestive) heart failure, need for assistance with personal care, encounter for immunization, muscle weakness (generalized), congenital malformation of ear causing impairment of hearing, essential (primary) hypertension, gastroesophageal reflux disease without esophagitis, difficulty in walking. Review of Resident #24's TAR for September 2023 revealed no entries documented for providing wound care for right hand on Monday, Wednesday and Friday on Monday 9/11/2023, Wednesday 9/13/2023, Monday 9/18/2023, and Wednesday 9/20/2023, no entries for applying Ammonium Lactate external lotion for dry skin every shift on 9/11/2023, 9/14/2023, 9/19/2023, and 9/28/2023 at 7:00 AM to 7:00 PM shift, and on 9/6/2023 and 9/16/2023 at 7:00 PM to 7:00 AM shift, no entries for assessment of level of pain on 9/11/2023, 9/14/2023, 9/19/2023 and 9/26/2023 at 7:00 AM to 7:00 PM shift, and on 9/6/2023 and 9/16/2023 at 7:00 PM to 7:00 AM shift, no entries for monitoring shunt to left upper extremity on 9/11/2023, 9/14/2023, 9/19/2023 and 9/26/2023 at 7:00 AM to 7:00 PM shift, and on 9/6/2023 and 9/16/2023 at 7:00 PM to 7:00 AM shift, and no entries for monitoring dialysis catheter dressing on 9/11/2023, 9/14/2023, 9/19/2023 and 9/26/2023 at 7:00 AM to 7:00 PM shift and on 9/6/2023 and 9/16/2023 at 7:00 PM to 7:00 AM shift. Review of Resident #24's TAR for October 2023 revealed no entries documented for obtaining vital signs every shift on Tuesday, Thursday and Saturday on Thursday 10/19/2023 and Tuesday 10/24/2023, no entries for providing wound care for right hand on Monday, Wednesday and Friday on Monday 10/2/2023, Friday 10/6/2023, and 10/16/2023, no entries for applying Ammonium Lactate external lotion for dry skin every shift on 10/19/2023 at 7:00 AM to 7:00 PM shift, no entries for assessment of level of pan on 10/2/2023 at 7:00 PM to 7:00 AM shift, no entries for assessment of level of pai on 10/5/2023 and 10/19/2023 at 7:00 AM to 7:00 PM shift, no entries for documenting bowel movement on 10/19/2023 at 7:00 AM to 7:00 PM shift, and on 10/15/2023 at 7:00 PM to 7:00 SM shift, no entries for monitoring shunt to left upper extremity on 10/5/2023 and 10/19/2023 at 7:00 AM to 7:00 PM shift, no entries for monitoring dialysis catheter dressing on 10/5/2023 and 10/19/2023 at 7:00 AM to 7:00 PM shift. Review of the admission record for Resident #110 showed the resident was admitted on [DATE] with the diagnoses including malignant neoplasm of prostate, urinary tract infection, anemia, acute posthemorrhagic anemia, acute embolism and thrombosis of deep veins of left upper extremity, obstructive and reflux uropathy, hyperlipidemia, hydronephrosis with renal and urethral calculous obstruction, chronic kidney disease, vitamin D deficiency, localized swelling, mass and lump, inflammatory disorders of scrotum, other artificial openings of urinary tract status, intra-abdominal and pelvic swelling, mass and lump, acute kidney failure, hypothyroidism, gastroesophageal reflux disease, and muscle weakness. Review of Resident #110's TAR for October 2023 revealed no entries documented for changing the dressing to bilateral nephrostomy tube sites every 3 days on 10/15/2023, 10/24/2023, and 10/27/2023, no entries for non-skid footwear on 10/15/2023, no entries for assessment of level of pain on 10/3/2023 at 7:00 AM to 7:00 PM shift, no entries for documenting bowel movement on 10/15/2023 at 7:00 PM to 7:00 AM shift, no entries for emptying bilateral nephrostomy bags on 10/15/2023 and 10/20/2023 at 7:00 PM to 7:00 AM shift and 10/18/2023 at 7:00 AM to 7:00 PM shift, no entries for vital signs on 10/15/2023 at 7:00 AM to 7:00 PM shift and 7:00 PM to 7:00 AM shift, and on 10/18/2023 and 10/19/2023 at 7:00 PM to 7:00 AM shift. During an interview on 10/26/2023 at 1:45 PM, the Director of Nursing (DON) confirmed that the TARs had blanks Residents #17, #24, and #110 and stated that they were documentation issues, and she knew that the care was provided, and the staff did not document them. Review of the facility policy and procedure titled Charting and Documentation last reviewed on 1/19/2023 reads, Policy Statement: All services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. Policy Interpretation and Implementation: 1. All observations, medications administered, services performed, etc., must be documented in the resident's clinical records . 6. Documentation of procedures and treatments shall include care-specific details and shall include at a minimum: 1. The date and time the procedure/treatment was provided; b. the name and title of the individual(s) who provided the care.

Based on observation, interview, and record review, the facility failed to ensure staff followed infection control standards of practice specific to hand hygiene during medication administration and cleansing of automated blood pressure wrist cuff and oxygen saturation probe monitor during direct care. Findings include: During medication administration observation on 10/24/2023 beginning at 9:23 AM, Staff A, License Practical Nurse (LPN), did not complete hand hygiene before preparing Resident #110's medication. Staff A entered Resident #110's room and applied an automated blood pressure wrist cuff on the resident's left wrist to obtain blood pressure and finger probe on the right finger to obtain oxygen saturation. Staff A removed the blood pressure cuff and oxygen saturation probe from the resident and returned to the medication cart. Staff A began preparing medications for Resident #110. Staff A did not clean the blood pressure cuff and the finger probe. Staff A popped one Bicalutamide Oral tablet 50 mg (Bicalutamide), one Tamsulosin HCL Oral Capsule 0.4 mg, and one Metronidazole 250 mg tablet into her non-gloved hand and placed the tablets into the medication cup. Staff A, then, returned to Resident #110 and administered the oral medications. Staff A left Resident #110's room and returned to the medication cart. Staff A collected the blood pressure cuff and oxygen saturation probe and went to Resident #13's room and obtained his blood pressure and oxygen saturation. Staff A returned to the medication cart and began preparing medications for Resident #13. Staff A popped one Amlodipine Besylate 10 mg tablet, one Amiodarone HCL 200 mg tablet, and one Thiamine HCL 100 mg tablet into her non-gloved hand and placed them into the medication cup. Staff A returned to Resident #13's room and administered the medications. Staff A left Resident #13's room and returned to the medication cart. Staff A proceeded to Resident #9's room and applied the automated blood pressure wrist cuff on the resident's wrist and finger probe on his finger and obtained the readings and returned to the medication cart to prepare medications for Resident #9. Staff A began preparing medications for Resident #9. Staff A popped one Ferrous Fumarate 324 mg tablet, one Apixaban tablet, one Glipizide 5 mg tablet, one Losartan 100 mg tablet into her non-gloved hand and then placed the tablets into the medication cup. Staff A proceeded to Resident #9's room and administered Brimonidine Tartrate Ophthalmic solution 0.2% (Brimonidine Tartrate) eyedrop in the resident's both eyes. Staff A administered Brinzolamide Ophthalmic suspension 1% (Brinzolamide) eyedrop in the resident's both eyes and then administered all oral medications prepared. Staff A did not perform hand hygiene. Staff A placed the oxygen saturation probe in her pocket and left the blood pressure cuff on top of the medication cart. During an interview on 10/24/2023 at 9:55 AM, Staff A, LPN, stated, I do not clean the blood pressure cuff or oxygen saturation probe before or after each patient. I clean it at the end of the day. I don't want to use those bleach wipes and I don't know what to clean it with. I do not know what the policy and procedure for the facility is related to cleaning items used between patients such as the blood pressure cuff and oxygen saturation probe. I did hand hygiene earlier before I started medication pass and after I completed several patients. I usually use gel. I miss the cup when I try to pop the medication out of the packet directly into the medication cup, so to save time, I pop the medication in my hand. During an interview on 10/24/2023 at 12:24 PM, the Director of Nursing stated, Hand hygiene is expected before and after each patient contact and before medication preparation and administration. All Resident equipment is cleaned and disinfected after each use. The blood pressure cuff and the oxygen saturation probe are to be cleaned after each patient's use. During an interview on 10/25/2023 at 10:00 AM, the Unit Manager stated, It is my expectation that hand hygiene is used before and after each patient contact and before all medication deliveries. Blood pressure cuffs and oxygen saturation probes are to be cleaned before and after each patient's use. Staff should never be popping medication into their hands and then administering the medication to patients. Review of the facility policy and procedure titled Cleaning and Disinfection of Resident-Care Items and Equipment last reviewed on 1/19/2023 reads, Policy Statement: Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC [Centers for Disease Control and Prevention] recommendations for disinfection and the OSHA [Occupational Safety and Health Administration] Bloodborne Pathogens Standard. Policy Interpretation and Implementation: 1. The following categories are used to distinguish the levels of sterilization/ disinfection necessary for items used in resident care . 4. Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes durable medical equipment). Review of facility policy and procedure titled Handwashing/Hand Hygiene last reviewed on 1/19/2023 reads, Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation . 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . When to Wash Hands. 5. Employees must wash their hands for at least fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions . c. Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice) . i. Upon and after coming in contact with a resident's intact skin. (e.g., when taking a pulse or blood pressure, and lifting a resident) . When to Use Alcohol-Based Hand Rub. 6 In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% ethanol or isopropanol for all the following situations: a. Before and after direct contact with residents . d. Before preparing or handling medications . g. After contact with a resident's intact skin . i. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident.

Based on observation, interview, and record review, the facility failed to ensure nurse staffing information was posted on a daily basis. Findings Include: Observation of the posted nurse staffing information on 4/26/2022 at 9:28 AM revealed the posted nurse staffing information was dated 4/25/2022. During an interview on 4/26/2022 at 9:41 AM, the Administrator stated that he had not realized the posted nurse staffing information was from the previous day and had not been updated. During an interview on 4/29/2022 at 8:36 AM, the Director of Nursing reported nursing shifts were 7:00 AM to 7:00 PM and 7:00 PM to 7:00 AM. Review of the facility policy titled Posting Direct Care Daily Staffing Numbers, last reviewed on 1/22/2022, reads, Policy: Our facility will post, on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents . 1. Within two (2) hours of the beginning of each shift, the number of Licensed Nurses (RNs, LPNs, and LVNs) and the number of unlicensed nursing personnel (CNAs) directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format.

Based on observation, interview, and record review, the facility failed to ensure kitchen equipment were maintained in a sanitary manner. Findings Include: During a tour of the main kitchen on 4/26/2022 beginning at approximately 9:26 AM with the Kitchen Manager, the uncovered deep fryer had oil that was dark brown with debris floating in it and an extensive build-up of dark murky oil. Along the sides of the fryer, there was extensive build-up of a white substance that had dripped down the side of the deep fryer. (photographic evidence obtained). During an interview on 4/26/2022 at approximately 9:30:AM, the Kitchen Manger confirmed the oil is dark brown with floating debris inside and has a build-up of a white substance. Review of the facility policy titled Deep Fryer Cleaning reads, Deep fryer will be cleaned on a regular basis as recommended by the manufacturer. Procedures: 1. Clean element whenever oil filtered or changed. 2. Wipe down the exterior at the ended of day. 3. Clean the fry baskets at the end of the day. 4. Boil out every- 3-6 months. 5. Inspect the fryer annually.

Based on interview and record review, the facility failed to ensure the medical records related to meal intake percentages were complete for 2 of 3 residents reviewed for nutrition, Resident #3, and Resident #20. Findings Include: Review of Resident #3's care plan, initiated on 9/14/2021, revealed the resident had chronic pain related to arthritis and diabetic neuropathy. Resident #3's care plan documented nutritional interventions that included monitor/record/report to nurse loss of appetite, refusal to eat and weight loss. Review of Resident #3's clinical records revealed a Point of Care Response History for Eating Meal Percentage dated 3/30/22- 4/26/22 failed to reveal completed documentation of the amount of the meal Resident #3 had eaten each meal. Documentation of the percentage of the meal Resident #3 had eaten was missing for 3 meals on 5 days, 2 meals on 5 days and 1 meal on 15 days during the period reviewed. Review of Resident #20's clinical record revealed Resident #20 had diagnoses that included mild protein-calorie malnutrition and adult failure to thrive. Review of Resident #20's care plan, initiated on 4/11/2020, revealed the resident was at nutritional risk related to a history of weight loss, refusals of meals and history of leaving more than 25% of most meals uneaten. Resident #20's care plan documented nutritional care interventions that included record intake. Review of Resident #20's clinical record revealed a Point of Care Response History for Eating Meal Percentage dated 4/4/22- 4/26/22 failed to reveal completed documentation of the amount of the meal Resident #20 had eaten each meal. Documentation of the percentage of the meal Resident #3 had eaten was missing for 3 meals on 5 days, 2 meals on 3 days and 1 meal on 14 days during the period reviewed. During an interview on 4/7/2022 at 9:03 AM, the Director of Nursing verified that the amount eaten percentage data had not been entered for Resident #3 and Resident #20. She stated, I don't know if we have a policy, but they are supposed to do it [enter the percentage eaten data].