Based on observations, staff interviews, and facility policy review, the facility failed to conceal the urine collection bag for a resident's indwelling urinary catheter, thus failing to maintain the dignity of a resident, for one (1) of two (2) residents with urinary catheters. (Resident #51). Findings Include: A review of the facility's policy titled Resident Rights revealed, It is the policy of this facility to ensure that the rights of the residents residing at this facility are upheld in the highest regard . 2. Each resident has the right to a dignified existence . During observations on 10/01/24 at 10:50 AM and 1:28 PM, it was noted that Resident #51's door was open, and an indwelling catheter bag was visible hanging on the side of the bed, without a privacy cover. In a follow-up observation and interview on 10/01/24 at 1:29 PM, Registered Nurse (RN) #1 confirmed that the catheter bag had no privacy cover and agreed that it should have been covered to maintain the resident's dignity. During an interview on 10/01/24 at 1:31 PM, the Director of Nursing (DON) verified that Resident #51's catheter bag should have been covered and stated that leaving it uncovered could cause embarrassment for the resident. A record review of the Face Sheet revealed that the facility admitted Resident #51 on 9/11/24 with diagnoses including Neuromuscular dysfunction of bladder.

Based on record review, staff interviews and facility policy review, the facility failed to accurately complete and request a Preadmission Screening and Resident Review (PASARR) for a resident with a history of mental illness for one (1) of 12 residents reviewed. Resident #106 Findings Include: Record review of the facility policy titled, Pre-admission Screening PAS/PASRR with a revision date of 6/13 revealed under, Level II PASRR . When Level 1 screening on the PAS (Preadmission Screening) indicates possible Mental Illness or Intellectual Disability/Developmental Disability and related conditions (RC) the DOM (Division of Medicaid) will notify Proper Name to review the case. Record review of the Level 1 PAS (Pre admission Screening) for Resident #106, with a submission date of 9/30/24, revealed under, Referral Question #28. Does resident have any history of abusing alcohol or drugs? No was marked. #31. Does resident have any history of mental illness? No was marked. #32. Does resident take, or have a history of taking psychotropic medication(s)? No was marked. Record review of the Face Sheet revealed the facility admitted Resident #106 on 9/2/24 with medical diagnoses that included Schizophrenia, Unspecified psychosis, Alcohol use unspecified with intoxication delirium, and Major Depressive Disorder. Record review of the Physician Orders for Resident #106 revealed an order dated, 9/2/24, Cymbalta (antidepressant) 60 MG (milligrams) PO (by mouth) daily. An interview with Social Services (SS) #1 on 10/2/24 at 9:20 AM revealed, she was the person responsible for completing the PAS for residents. She confirmed that she made an error when completing Resident #106's level 1 screening and stated, I did not see that she had a Schizophrenia diagnosis. SS #1 revealed she was aware the resident took an antidepressant medication, but was not aware it was considered a psychotropic medication. She revealed the resident did have a history of alcohol abuse and agreed she did not answer the questions accurately. SS #1 confirmed, if the initial level 1 screen was not completed accurately, Resident #106 might not get the mental health services needed. An interview with the Administrator (ADM) on 10/2/24 at 9:25 AM revealed, it was her expectation for the PASARR's to be completed accurately, so Resident #106 gets any specialized services indicated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews and facility policy review, the facility failed to provide adequate care and treatment to a pressure ulcer to improve healing for Resident #104, for one (1) of 1 resident reviewed for pressure ulcers. Findings Include: Review of the facility policy titled Wound Care with a revision date of 10/2/24 revealed under, Purpose: To provide standardized procedures for the prevention, identification, treatment, and ongoing management of wounds, ensuring the highest quality of care for all residents while maintaining compliance with local, state, and federal regulations . Also revealed under, a. Treatment Plan - A treatment plan will be developed by the wound care team and documented in the resident's medical record. This plan may include: - Cleansing and dressing the wound. - Use of appropriate topical medications or advanced wound care products . An interview with the Director of Nursing (DON) on 10/1/24 at 12:32 PM revealed, she was doing the wound care until the facility hired someone, and explained that Resident #104 came from home with an area like a skin tear on her bottom. She revealed the family told her the resident had the area for a while and thought it was from sitting in a chair for long periods of time. An observation of the sacral area for Resident #104, with the DON, on 10/2/24 at 12:30 PM revealed a broken area of skin that was open, round and located over a bony prominence between the upper aspects of the gluteal fold. The wound bed was 80 percent (%) red granulation tissue and 20 percent (%) white tissue (adherent slough). The wound edges were well-defined and rolled. No redness observed to the peri-wound and no sign of infection was noted. Record review of the Weekly Body Audit for Resident #104 revealed the following documentation: 9/4/24 -Superficial open area measures 1-inch mild redness around area - Lantiseptic applied signed by the DON. 9/11/24 - No redness with no change in open area Lantiseptic applied signed by the DON. 9/16/24 - No change in open area Lantiseptic applied signed by the DON. 9/24/24 - Lantiseptic applied - open area is the same and redness Duoderm ordered per Medical Director signed by the DON. Record review of the Weekly Wound Assessment for Resident #104 revealed the following documentation: Date 9/4/24, Stage 1 & (and) 2, Size .55 inch, Tissue Appearance red, Wound Edge Appearance round intact, Drainage none, Wound Pain Yes sore, Response to Treatment applied Lantiseptic signed by the DON. Date 9/9/24, Stage 1 & (and) 2, Size .55 inch Tissue Appearance red, Wound Edge Appearance round intact, Drainage none, Wound pain sore, Response to Treatment no change signed by the DON. Date 9/24/24, Stage 1 &(and) 2 Size .5-inch x ¾ (three-fourths) inch, Tissue Appearance, red/white, Wound Appearance red and white, Wound Edges intact, Drainage none, Wound Pain sore Response to Treatment Duoderm q (every) 72 hours signed by the DON. Record review of Resident #104's Medication Administration Record (MAR) for September 2024 revealed an order dated 9/9/24, Lantiseptic Skin Protectant PRN (as needed) not initialed as administered for the month of September. Also revealed an order dated 9/24/24, Duoderm CGF (controlled gel formula) 2.5-inch x 2.5-inch dressing change every 72 hours, begin 9/24/24. An interview with the DON on 10/2/24 at 12:38 PM revealed Resident #104 admitted to the facility on [DATE] with the area of broken skin to her sacral area. She revealed that she thought the wound was a skin tear or a shearing and was not pressure related. She revealed she called the Medical Director (MD) the day the resident admitted , and he gave an order for Lantiseptic to be applied as needed. The DON acknowledged, I might not have described the wound correctly. She confirmed they had been applying Lantiseptic (barrier ointment) to the open wound from admit until 9/24/24. The DON explained that the MD assessed the wound on 9/23/24 and changed the order to Duoderm for debridement. She confirmed that Lantiseptic was not an appropriate treatment to assist with healing for an open pressure wound and confirmed this could cause deterioration in the wound. She confirmed that her documentation lacked the total area (length x width x depth) of the wound, which was needed to determine if the wound was healing or getting larger. A telephone interview with the Medical Director (MD) on 10/2/24 at 2:12 PM revealed, the first time he assessed Resident #104's sacral wound was on 9/23/24. He revealed that he did not give the wound a number (stage) and described the wound as, Red and had a white film on it. He revealed that the information that was relayed to him when the resident admitted was the wound was a stage 1 and that was why he ordered Lantiseptic. The MD explained that Lantiseptic was a barrier and reduced friction and would be beneficial for a stage 1 wound. He confirmed, after assessing the wound, he determined the wound was not a stage 1, stopped the Lantiseptic and ordered Duoderm. An interview with the Administrator (ADM) on 10/2/24 at 2:30 PM revealed she was not aware that the resident had a pressure wound. She revealed she was told the resident had something like a bite that was being treated. She confirmed Lantiseptic was not an appropriate treatment to promote healing of a pressure wound. The ADM confirmed the wound needed weekly assessments and measurements to track the status to determine if the wound was responding to the treatment or deteriorating. Record review of the Face Sheet revealed the facility admitted Resident #104 on 9/4/24 with a medical diagnosis that included Unspecified dementia.

Based on staff interview, record review, and facility policy review, the facility failed to ensure a resident receiving an as needed (PRN) psychotropic medication had a stop date for one (1) of two (2) medication reviews. Resident #108 Findings Include: Review of the facility policy titled Psychotropic Medications for PRN (as needed) Use and Gradual Dose Reduction (GDR) Reviews undated, revealed under, Policy: . PRN use of psychotropic medications will be strictly regulated and monitored to comply with CMS (Centers for Medicare and Medicaid Services) regulations and ensure resident safety .Time Limitation: PRN orders for psychotropic medications must be limited to 14 days. After 14 days, the attending physician must review the resident's condition before extending the PRN order for continued use. This review must include a clinical evaluation to determine if continued PRN use is necessary. Record review of the September 2024 Medication Administration Record (MAR) for Resident #108, revealed an order dated 9/3/24, Lorazepam 1 MG (milligram) tablet administer 1 mg (milligram) q (every) 12 hours as needed for anxiety or agitation with no stop date. Documentation revealed the resident received doses on 9/5/24, 9/6/24, 9/11/24, and 9/20/24. An interview with the Administrator (ADM) on 10/2/24 at 9:36 AM confirmed, Resident #108's lorazepam order did not have a stop date. She confirmed the medication should have had a stop date after 14 days to ensure the resident got the least amount of medication required to control her symptoms and re-evaluated by the physician to ensure the continued need. Record review of the Face Sheet revealed the facility admitted Resident #108 on 9/2/24 with a medical diagnosis of Hemiplegia following unspecified cerebrovascular disease affecting the right dominant side.

Based on observations, staff interviews, record reviews, and facility policy review, the facility failed to check and record food temperatures before serving all meals for the last 30 of 30 days. Findings Included: A review of the facility's policy titled Monitoring Temperatures of Cooked Foods revealed, Policy: The temperature of potentially hazardous cooked foods will be monitored to ensure that the foods are not in the danger zone (above 41 degrees F (Fahrenheit) and below 135 degrees F) for more than six hours . Cooking, holding, and storage temperatures should be recorded on a Food Temperature Monitoring Log. These logs should be maintained for at least three (3) months. During an observation of the kitchen on 10/2/24 at 11:35 AM, it was noted that kitchen staff were serving lunch to the dining room residents from the steam table. A record review of the meal temperature logbook revealed there was no documentation for breakfast, lunch, or dinner since 9/2/24. In an interview with the Dietary Manager (DM) on 10/2/24 at 11:40 AM, she stated that the kitchen staff had not been checking or recording the meal temperatures because they did not have a logbook. She admitted that she hadn't considered using a piece of paper to log the temperatures and the logbook had just arrived the previous Friday. She stated that she had instructed the kitchen staff to begin recording meal temperatures before serving food and confirmed that no temperatures had been documented. In an interview with the Dietary [NAME] on 10/2/24 at 11:45 AM, she revealed that food temperatures had not been checked because they did not have a thermometer and stated that they had a thermometer the previous day, but it could not be calibrated. She acknowledged that temperatures were not being taken and recognized that this could pose a health risk to the residents. During a follow-up interview with the Dietary Manager on 10/2/24 at 11:52 AM, she confirmed that the thermometer from the previous day was not working and that she needed to purchase a new one. She stated that she had ordered food thermometers for the kitchen, but they had not yet arrived. She admitted that it did not occur to her to obtain a thermometer from another source. She also verified that failing to check food temperatures could result in foodborne illnesses. In an interview with the Administrator (ADM) on 10/2/24 at 11:58 AM, she confirmed that she was unaware the kitchen did not have a food thermometer and did not check food temperatures at each meal. She emphasized that the purpose of checking food temperatures is to prevent burns to the residents and to reduce the risk of foodborne illness if the food is not maintained at a certain temperature.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, staff interviews, and facility policy review, the facility failed to establish and maintain an infection prevention and control program designed to prevent the transmission of communicable diseases and infections. This failure was evidenced by the facility's failure to administer a second-step tuberculin (TB) skin test to one (1) of 17 residents (Resident #104) and 34 of 37 employees, who had no documentation of a negative TB skin test within the last 12 months. Findings Include: A review of the facility's policy titled TB Testing MS, with a revision date of 4/14, stated: Resident Testing for Tuberculosis .Residents .shall have a baseline Tuberculin Skin Test (TST) performed with the initial step of a two-step Mantoux TST placed within 30 days prior to the day of admission. The second step shall be administered, read, and documented within 10-21 days of the first step . Employee Testing for Tuberculosis .Employees with a negative tuberculin skin test and a negative symptom assessment shall have the second step of the two-step Mantoux tuberculin skin test administered, read, and documented in the employee's personnel record within fourteen (14) days of employment. Resident #104 A record review of Medication Details for Resident #104 revealed that she received a TB skin test prior to being admitted to the facility on [DATE]. This test was read on 8/30/24 and the result was negative. There was no documentation present indicating that Resident #104 received a second-step TB skin test. In an interview with the DON on 10/3/24 at 10:02 AM, she verified that Resident #104 did not have a second-step TB skin test. Record review of the Face Sheet revealed the facility admitted Resident #104 on 9/4/24 with a diagnosis of Essential Hypertension. Employee Testing A review of the facility's TB Skin Test Placement documentation for new hires revealed that 34 of 37 employees had no documentation of a second-step TB skin test or proof of a negative TB skin test within the last 12 months prior to hire. There was no evidence that any of these employees were offered or received a second-step TB skin test. In an interview with the Business Office Manager on 10/3/24 at 9:15 AM, she stated that she was responsible for coordinating and ensuring that new employees receive TB skin tests. She admitted that she was not aware that employees were required to have a two-step TB skin test if they did not have proof of a negative TB skin test within the last 12 months. During an interview with the Administrator (ADM) and Director of Nursing (DON) on 10/3/24 at 10:00 AM, they both stated that they had never heard that a two-step TB skin test was required for staff or residents and confirmed that the facility had always only performed one TB skin test. In an interview with the Social Worker (SW) on 10/3/24 at 10:10 AM, she explained that she is responsible for coordinating admissions and ensuring that residents have the required paperwork before admission. She stated that the first step of the TB skin test is required before admission, and one of the TB Certified Registered Nurses (RN's) is responsible for following up and completing the second-step TB skin test. The SW added that the facility used to perform a two-step TB skin test but had stopped doing so, and she was unsure why. In a follow-up interview with the ADM, on 10/3/24 at 10:15 AM, she agreed that a second-step TB skin test should have been performed on the 34 employees and Resident #104. She acknowledged that not administering a TB skin test to staff or residents could potentially spread TB within the facility.

Based on record review, staff interview, and facility policy review, the facility failed to develop a care plan for anticoagulant medication for two (2) of 12 resident care plans reviewed, Residents #24 and #34. Findings include: Record review of the Care Plan policy, undated, revealed a comprehensive care plan will be developed for each resident, that includes measurable, objective goals, with specific timeframes for meeting those goals. Resident #24 Record review of the comprehensive care plan for Resident #24, revealed no care plan was developed for the anticoagulant, Coumadin, and its possible side effects, which would include bleeding. Record review of Resident #24's December 2019 Physician Orders, revealed an order dated 11/20/19, for Coumadin 3 milligram (mg) daily at bedtime. Resident #34 Record review of the care plan for Resident #34, revealed a care plan for administering an anticoagulant as ordered, however, there was no care plan developed for monitoring possible side effects, which would include bleeding. Record review of Resident #34's December 2019 Physician Orders, revealed an order dated 10/31/19, for Eliquis 5 mg twice daily. Record review of the nurse's notes, dated 10/31/19 at 11:56 AM, revealed the physician visited Resident #34, with new orders noted to send to a local clinic for an ultrasound for deep vein thrombosis to the left leg, discontinue Xarelto, and add Eliquis 5 mg twice daily. On 12/16/19 at 4:20 PM, an interview with Registered Nurse (RN) #2 revealed she is responsible for developing resident care plans. RN #2 confirmed Resident #34 did not have a care plan developed for the Eliquis medication, and Resident #24 did not have a care plan developed for taking the anticoagulant Coumadin, or the monitoring for signs and symptoms related to taking an anticoagulant. On 12/17/19 at 10:00 AM, an interview with the Director of Nursing (DON) confirmed a care plan should be developed for any resident that is taking an anticoagulant, with interventions, which should include: monitor for bruising, bleeding or signs of bleeding, and the staff should be cautious shaving residents on an anticoagulant.

Based on observation, staff interview, and facility policy review, the facility failed to prevent the likelihood of infection, during medication administration, for one (1) of three (3) of six (6) residents observed for medication administration. Findings include: Review of the Infection Control - Standard and Transmission-based Precautions, policy, undated, revealed: It is the policy of the facility to ensure that appropriate infection prevention and control measures are taken to prevent the spread of communicable disease and infections in accordance with State and Federal Regulation, and national guidelines. Procedure: Standard Precautions, 1. All staff are to adhere to standard precautions. a. Personal protective equipment is to be worn to protect health care workers (i.e. have a barrier) from contact with body fluids. b. Personal protective equipment includes gloves, gowns, masks, goggles and or face shield. c. The personal protective equipment worn will vary by task being performed and likelihood of exposure to body fluid. 2. Standard precautions apply to all residents. Review of the Hand Hygiene, policy, with an effective date of 12/31/17, revealed: It is the policy of this facility to conduct proper hand hygiene consistent with accepted standards of practice Staff must perform hand hygiene (even if gloves are used): .7. Before and after contact with the resident .9. After contact with blood, body fluids, visibly contaminated surfaces or after contact with objects in the resident's room. On 12/16/19 at 09:12 AM, observation of Medication (MED) Pass, with Licensed Practical Nurse (LPN) #1, revealed LPN#1 did not wear gloves while administering medications to Resident #44. LPN #1 returned to the medication cart and did not wash her hands, or use hand sanitizer, before preparing medications for Resident #20. LPN #1 donned one (1) glove on her right hand and walked to Resident #20, who was sitting in an upright Gerichair in the lobby, and placed the bottle of Artificial Tears on the resident's lap tray, without a barrier. She administered the medications by mouth, and opened the Artificial Tears, and placed the lid of the dropper bottle on top of the lap tray. LPN #1 touched Resident #20's face, by pulling the lower lid down, to instill eye drops to both eyes, with her ungloved hand. LPN #1 wiped the resident's face with the blanket, used to cover the resident's head. She then replaced the lid on the Artificial Tears, put the bottle in the carton, and placed it inside the top drawer of the medication cart . LPN #1 then prepared medications for Resident #45, without performing hand hygiene. On 12/16/19 at 8:54 AM, an interview with LPN #1 confirmed she had not used proper hand hygiene between residents, during medication pass. LPN #1 stated it would be an infection control problem and could potentially spread germs from one patient to another. She stated having placed the Artificial Tears on the resident's lap tray, without a barrier, and then back into the cart, would contaminate the medication cart. On 12/17/19 at 9:36 AM, during an interview, LPN #2/ Staff Coordinator stated by not washing hands, or using hand sanitizer between residents, there was a risk of cross contamination, which is an infection control issue. LPN #2 stated when Resident #20's bodily fluids (tears) came into contact with LPN #1's ungloved hand, potential infection could spread, and with flu season, it could be an epidemic quickly. Record review of the Infection Control Orientation Checklist, signed by LPN #1 and verified by LPN #2/Staff Coordinator, on 9/24/19, revealed she had been trained on the explanation of infection process, Occupational Safety and Health Administration (OSHA) standards for blood borne diseases, epidemiology, and transmission/prevention of infection. LPN #1 also signed she understand the importance of hand washing in preventing infections and had been given an explanation of Standard precaution (Universal Precautions) and transmission based precautions, how, and when to use them. Record review of In-Service Training, presented by the Administrator, on 11/19/19 and 11/21/19, revealed LPN #1 had signed she attended. Content of the in-service included Standard Precautions.

Based on observation, interview, and facility policy review, the facility failed to label and date food stored in the refrigerator and freezer for one (1) of two (2) kitchen tours. Findings include: Record review of the Storage of Frozen Food policy, undated, revealed the facility ensures the quality and safety of frozen food through accepted storage practices. Frozen foods are dated when received. The first in, first out method is used: products with the earliest date are stored in front of products with a later date. Frozen food is stored in the original package. Record review of the Storage of Refrigerated Food policy, undated, revealed the facility ensures the quality and safety and sanitation of refrigerated foods through accepted storage practices. All opened foods are labeled with common name of food, date stored, and use-by-date. On 12/15/19 at 10:51 AM, observation in the kitchen, revealed a zip-lock plastic bag of squash, in the freezer, without a date or label, a plastic bag of cut broccoli, without a date or label, and eight (8) cups of pudding on a metal pan, covered with plastic wrap, were in the cooler, without a date or label. On 12/15/19 at 10:57 AM, an interview with Dietary Staff (DS) #1, confirmed the squash and broccoli were in plastic bags, without a date or label. DS #1 revealed she did not know when they were put in the freezer, she thought it might have been last week. DS #1 confirmed the pudding did not have a date, and she thought it was from 12/14/19. DS #1 revealed whoever places the food in the freezer, or cooler, is responsible for labeling it with the date. On 12/15/19 at 11:57 AM, an interview with the Dietary Manager (DM), revealed the DS called her and told her about the pudding, squash, and broccoli, not labeled or dated. The DM revealed staff knew if they find anything without a label or date, they should throw it away, no matter what it is.

Based on observation, staff interview, and facility policy review, the facility failed to administer eye drops as ordered by the physician for one (1) of 32 medication administration opportunities; Resident #17. Findings include: Review of the facility's Drug Administration policy, dated 06/94, revealed the complete act of medication administration entailed removing an individual dose from a previously dispensed, properly labeled container (including a unit dose container), verifying it with the physician's orders, giving the individual dose to the proper resident, and promptly recording the time and dose given. An observation during medication administration on 10/10/2018 at 8:22 AM revealed Licensed Practical Nurse (LPN) #1 administered Ketorolac 0.5% ophthalmic (opth) solution one (1) drop into Resident #17's left eye. Review of the cumulative October 2018 Physician Orders for Resident #17, revealed an order dated 09/06/18 for Ketorolac 0.5% opth solution one (1) drop in right eye four times a day. An interview, with LPN #1, on 10/10/2018 at 8:38 AM, confirmed Ketorolac 0.5% opth solution one(1) drop was administered in Resident #17's left eye. LPN #1 stated she was nervous and administered eye drop in the wrong eye. Review of the Licensed Nurses Orientation Checklist for LPN #1, revealed, LPN #1 received training from LPN #2, on 09/06/2018, which included Medication Administration. An interview, with LPN #2, on 10/10/2018 at 8:40 AM, revealed, all nurses had completed a skills check off on medication administration. An interview, with the Administrator, on 10/10/2018 at 10:55 AM, revealed the Director of Nursing (DON) and the Staff Development Nurse are responsible for monitoring appropriate medication pass technique and accuracy. An interview, with the DON, on 10/11/2018 at 10:10 AM, revealed that it was the responsibility of the Nurse Trainer to make sure all new nurses are trained on proper medication pass procedure, and that medication administration should be monitored by the Nurse Trainer and the Staff Development Nurse. The DON confirmed that the administration of the eye drop in the wrong eye was a medication error. Review of the Face Sheet revealed, the facility admitted Resident #17 on 02/06/2017, with diagnoses which included Unspecified Dementia and Type II Diabetes Mellitus. Review of the Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 07/31/2018, revealed Resident #17 scored 15 on the Brief Interview for Mental Status (BIMS) which indicated cognitively intact.