Based on observation, interview and record review, the facility failed to ensure two nurse aides (NAs) completed a nurse aide training program within four months of his/her employment at the facility. The facility's census was 62. The facility did not provide a policy related to the NA training program. 1. Review of NA A's personnel file showed: - A hire date of 02/02/24; - NA A currently enrolled in class; - The facility failed to ensure the completion of the program within four months of NA A's hire date. 2. Review of NA E's personnel file showed: - A hire date of 08/15/23; - NA E currently enrolled in class; - The facility failed to ensure the completion of the program within four months of NA E's hire date. Observation on 10/11/24 at 2:15 P.M. showed NA A provided incontinent care for Resident #36. During an interview on 10/11/24 at 11:00 A.M., the Administrator said that two NAs were still working the floor as NAs, and she knew that it would be an issue. During an interview on 10/11/24 at 3:42 P.M., the Administrator said that she would expect NAs to be certified within four months of hire and that there is a plan in place for the two NAs to get certified.

Based on observation, interview, and record review, the facility failed to store food under sanitary conditions, increasing the risk of food-borne illness. This deficient practice had the potential to affect all residents. The facility census was 62. Review of the facility's policy titled, Receiving and Storage of Food, dated May 2015, showed: - The Dining Service Manager (DSM) is responsible for receiving and storing food and non-food items; - Follow the rule of First In, First Out; - Food is stored in designated areas; - Keep all foods in clean, undamaged wrappers or packages; - Reseal open boxes effectively; - Keep storage areas clean and dry. Observation on 10/08/24 at 11:35 A.M. showed: - Four unopened wrinkled boxes of salt that had become solid with a grainy substance on the outside of the boxes; - A potato chip laying on the shelf next to the salt boxes; - A package of opened marshmallows, exposed to air; - One opened gallon of pancake syrup, undated, with about one inch of syrup remaining in the bottom of the container; - One unopened gallon jug of vinegar, with black debris all over the jug; - Two unopened and undated containers of scalloped potatoes; - One unopened and undated gallon jug of lemon juice; - One opened, undated five pound container of peanut butter, with peanut butter on the edge of the lid; - Two unlabeled and undated 35 quart containers of dry cereal; - One 35-quart container, labeled crisp rice cereal, almost empty and dated 7/4; - One 35-quart container, labeled toasted oat cereal, almost full and dated 7/25; - One unopened and undated eight pound container of salsa; - One undated 35-quart tote/container of powdered milk with a golf ball sized amount of water, debris and a black, mold-like substance on the top of the lid. Observation on 10/10/24 at 10:15 A.M. showed: - Four unopened wrinkled boxes of salt that had become solid with a grainy substance on the outside of the boxes; - One opened gallon of pancake syrup, undated, with about one inch of syrup remaining in the bottom of the container; - Two unlabeled and undated 35-quart containers of dry cereal; - One 35-quart container, labeled crisp rice cereal, almost empty and dated 7/4; - One 35-quart container, labeled toasted oat cereal, almost full and dated 7/25; - One undated 35-quart tote/container of powdered milk. During an interview on 10/10/24 at 12:00 P.M., the Dietary Manager said when a shipment is received, it is labeled with the date. If it is something that needs placed in a different container, it is labeled and dated. Refrigerated items are labeled, dated and used within three days. Totes and containers containing food should also be labeled and dated. During an interview on 10/11/24 at 3:43 P.M., the Administrator said she would expect food items to be labeled, dated, and free from debris.

Based on observation, interview, and record review, the facility failed to maintain proper infection control practices during incontinent care for two residents (Resident #8 and #36) outside of the 16 sampled residents. The facility failed to ensure proper Tuberculosis (TB-a communicable disease that affects the lungs, characterized by fever, cough and difficulty breathing) screening of three residents (Resident #19, #38 and #45) out of five sampled residents. The facility's census was 62. Review of the facility's policy titled, Handwashing, undated, showed: - Purpose to reduce transmission of organisms from resident to resident, staff to resident, and resident to staff; - Use of soap, comfortably hot water, and disposable towel; - Soap hands well and briskly rub together, paying attention to areas between fingers; - Rinse hands lowered to allow soiled water to drain into sink; - Do not splash water on clothing and do not touch sink; - Use disposable towel to turn faucet off and dry hands. 1. Observation on 10/11/24 at 1:15 P.M. of incontinent care for Resident #8 showed: - Certified Nurse Assistant (CNA) C and (CNA) D did not wash or sanitize hands prior to beginning care; - CNA C and CNA D donned gloves and assisted the resident out of the wheelchair and into bed; - CNA D obtained peri-wipes from the resident's bedside drawer; - CNA C removed the resident's pants and soiled brief; - CNA C cleaned the resident with a peri-wipe front to back three times, placed soiled wipes in a trash bag, closed the wipe container, then disposed of gloves; - CNA C and CNA D repositioned the resident and covered him/her back up; - CNA C took the trash out of the room and down the hall to the soiled hold room to dispose of before sanitizing hands. During an interview on 10/11/24 at 1:30 P.M., CNA C said he/she would normally wash and or sanitize hands before and after providing peri-care on a resident. 2. Observation on 10/11/24 at 2:15 P.M. of incontinent care for Resident #36 showed: - CNA B and Nursing Assistant (NA) A donned gowns, gloves, and masks upon entry into the room; - CNA B cleaned the resident and the resident's catheter with wipes; - With the same soiled gloves, CNA B and NA A assisted the resident in rolling onto his/her right side; - With the same soiled gloves, CNA B wiped stool from the resident's buttocks and rolled the soiled bed pad underneath the resident; - With the same soiled gloves, CNA B and NA A rolled the resident onto his/her back and removed the soiled bed pad; - With the same soiled gloves, CNA B and NA A repositioned the resident and covered him/her up; - With the same soiled gloves, CNA B and NA A bagged up the trash and soiled linens, removed gowns, gloves, and masks and washed hands before leaving the room. During an interview on 10/11/24 at 2:30 P.M., CNA B said he/she should have changed gloves when he/she changed sides and after cleaning from front to back. Review of the facility's policy titled, Tuberculosis Control, undated, showed: - All residents new to long term care, who do not have documentation of a previous skin test reaction, or a history of adequate treatment of tuberculosis disease, shall have the initial test of Mantoux Purified Protein Derivative (PPD-a diagnostic test used to screen and diagnose TB) two step skin test to rule out tuberculosis within one month prior to or one week after admission; - If initial test result (measured by observing site of test for raised formation) is 0-9 millimeters (mm), the second test, which can be given after admission, should be given at least one week and no more than three weeks after the first test; - Documentation of a chest X-ray, ruling out tuberculosis within one month prior to admission, along with an evaluation to rule out signs and symptoms, may be acceptable on an interim basis until the Mantoux PPD two-step test is completed; - Residents are to be evaluated, at least annually, to assure absence of signs and symptoms for TB. 3. Review of Resident #19's medical record showed: - admission date of 06/14/24; - Screening assessment completed on 10/01/24; - First step TB test not given until 10/04/24 with no read date; - Documented refusal for second step. 4. Review of Resident #38's medical record showed: - admission date of 07/22/24; - First step given on 07/31/24, read on 08/03/24, results of 0 mm; - Second step not completed within recommended time frame; - First step repeated on 10/03/24, read on 10/05, results of 0 mm; - Second step repeated on 10/10/24. 5. Review of Resident 45's medical record showed: - admission date of 08/24/24; - Screening assessment done on 10/01/24; - No documentation of the two step testing. During an interview on 10/11/24 at 1:00 P.M., the Administrator said they waited too long to do the second step for Resident #38 and had to restart the test. During an interview on 10/11/24 at 1:10 P.M., the Quality Assurance (QA) Nurse said they would have to restart the two step for Resident #45, as it had been missed. It may have been initiated, but not completed. A screening was completed for Resident #19 on 10/01/24, due to refusal of the TB test. An audit was done and everyone in the building was screened and the tests were restarted for those that had been missed. Some did not have the proper documentation. During an interview on 10/11/24 at 3:43 P.M., the Administrator said she would expect residents' TB tests to be given and read in the recommended time frame.

Based on interview and record review, the facility failed to have a Quality Assurance and Performance Improvement (QAPI, a program to improve the processes for the delivery of health care and quality of life for the residents) program in place with policies and protocols describing how the facility will identify and correct its own quality deficiencies. This deficient practice had the potential to affect all residents in the facility. The facility's census was 62. The facility did not provide a policy related to the QAPI program. Review of the facility's QAPI binder showed: - The most recent QAPI Plan dated 2019; - A template showing how to create a QAPI plan; - No current QAPI plan that contained the necessary policies and protocols describing how they would identify and correct their quality deficiencies, track and measure performance, and establish goals and thresholds for performance measurement. During an interview on 10/11/24 at 10:41 A.M., the Administrator said she had no QAPI agendas for any meetings. She would expect to have an agenda for each meeting, showing what was discussed and how it's going to be addressed and monitored. She had nothing showing monitoring of any issues and no Performance Improvement Plans (PIPs) in place. She tried to deal with issues that came up in morning meetings. She spoke with another administrator in the company who said they don't have a QAPI policy and that they would just go by the regulations. She would expect the facility to have a QAPI program in place.

Based on interview and record review, the facility failed to ensure the Quality Assessment and Assurance/Quality Assurance Performance Improvement (QAA/QAPI) committee developed and implemented an appropriate plan of action to correct identified quality deficiencies. This had the potential to affect all residents in the facility. The facility census was 62. The facility did not provide a QAPI plan or policy. Review of documentation provided by the Administrator showed: - A template to create a QAPI plan, but no current QAPI plan; - The most current QAPI plan dated 2019. During an interview on 10/10/24 at 3:51 P.M., the Administrator said she does not have any Performance Improvement Projects (PIPs) in place. They do have a morning stand up meeting and try to look into things that come up in those meetings. During an interview on 10/11/24 at 10:41 A.M., the Administrator said she has no QAPI agendas for any meetings, only sign in sheets. She said she should have an agenda for each meeting that has been held, showing what they have discussed and how any issues are addressed and monitored, but she currently has nothing like that in place. She would expect the facility to have a QAPI program in place.

Based on interview and record review, the facility failed to maintain quarterly Quality Assessment and Assurance/Quality Assurance Performance Improvement (QAA/QAPI) committee meetings with the required members. The facility's census was 62. The facility did not provide a QAPI policy. Review of the QAPI meeting sign in sheets, provided by the Administrator, showed: - Meetings were held in November 2023, January 2024, and July 2024; - The medical director did not attend any of the meetings. During an interview on 10/10/24 at 3:51 P.M., the Administrator said the medical director is hard to catch when he is in the building. He is so busy that it's difficult for him to come to a 30 minute meeting. She will try to go over things with him, but he doesn't come to quarterly meetings. She would expect meetings to be held quarterly and for the medical director to come to QAPI meetings.

Based on observation, interview, and record review, the facility failed to ensure the dignity of three residents (Resident #4, #37, #39) out of three sampled residents with a properly covered urinary catheter bag (a bag for collecting urine from a tube inserted in the bladder). The facility census was 56. Review of the facility's policy titled, Resident Rights, dated March 2017, showed: - The resident has the right to a dignified existence, self-determination, and communications with and access to persons and services inside and outside the facility; - The resident has a right to confidentiality, privacy and respect. 1. Review of Resident #4's medical record showed: - admission date of 06/27/23; - Diagnoses of congestive heart failure (a condition in which the heart doesn't pump blood adequately) and obstructive and reflux uropathy (when urine cannot drain through the urinary tract); - A physician order, dated 06/27/23, to perform catheter care every shift. Observations on 07/25/23 at 10:12 A.M., and 12:29 P.M., and on 07/26/23 at 9:32 A.M., showed the resident lay in bed with an uncovered and partially full urinary drainage collection bag that hung on the side of the bedframe that faced the open doorway. Review of Resident #37's medical record showed: - admission date of 10/26/22; - Diagnoses of hemiplegia (paralysis of one side of the body and hemiparesis (one-sided muscle weakness) following a cerebral infarction (stroke) affecting the right dominant side and neuromuscular dysfunction of the bladder (nerves and muscles of bladder don't work); - A physician order, dated 04/17/23, to provide Foley catheter (an indwelling catheter) care twice a day. Observations showed: - On 07/24/23 at 8:25 P.M., the resident lay in bed with an uncovered and partially full urinary drainage collection bag that hung on the side of the bedframe that faced the open doorway; - On 07/25/23 2:41 P.M., the resident lay in bed with the uncovered and partially full urinary drainage collection bag that hung on the opposite side of the bedframe visible from the open doorway; - On 07/26/23 3:20 P.M., the resident lay in bed with the uncovered and partially full urinary drainage collection bag that hung on the opposite side of the bedframe visible from the open doorway. Review of Resident #39's medical record showed: - admission date of 11/23/21; - Diagnoses of unspecified injury of urethra (a tube that conveys urine from bladder to outside the body), urinary retention and benign prostatic hyperplasia (enlarged prostate); -A physician order, dated 06/23/23, to perform catheter care every shift and to change catheter on Friday every 3 weeks. Observations showed: - On 07/24/23 at 7:57 P.M., the resident lay in bed with the catheter bag with amber-colored urine in the urinary drainage collection bag visible from the doorway and with the resident's roommate able to visualize the bag; - On 07/25/23 at 2:52 P.M., the resident lay in bed with the urinary drainage collection bag with dark yellow urine visible from the doorway; - On 07/26/23 at 3:00 P.M., the resident lay in bed with the uncovered and partially full urinary drainage collection bag that hung on the side of the bedframe that faced the open doorway; - On 07/27/23 at 9:52 A.M., the resident lay in bed with the uncovered and partially full urinary drainage collection bag that hung on the side of the bedframe that faced the open doorway with the resident's roommate able to visualize the bag. During an interview on 07/27/23 at 11:46 A.M., Licensed Practical Nurse (LPN) B said that a dignity bag should be used to cover a urinary drainage collection bag on a resident's wheelchair and on the bed at all times. During an interview on 07/27/23 at 11:47 A.M., Certified Nurse Aide (CNA) C said that a dignity bag should be used to cover a urinary drainage collection bag on a resident's wheelchair and on the bed. During an interview on 07/27/23 at 12:31 P.M., the Director of Nursing (DON) said that a catheter bag should be placed in a dignity bag when transferred into a wheelchair and when a resident was moved back to their bed, the catheter bag should be placed in the dignity bag on the bed.

Based on interview and record review, the facility failed to issue the Skilled Nursing Facility Advanced Beneficiary Notices (SNFABN) when Medicare covered services had ended for two residents (Resident #11 and #44) out of three sampled residents. The facility census was 56. Review of the facility's policy titled, Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNFABN), not dated, showed: - Medicare requires SNF's to issue the SNFABN to Original Medicare, also called fee-for-service (FFS), beneficiaries prior to providing care that Medicare usually covers, but may not pay for in this instance because the care is: not medically reasonable and necessary; or considered custodial. The SNFABN provides information to the beneficiary so that he/she can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility. 1. Review of Resident #11's Notice of Medicare Non-Coverage (NOMNC) showed: - The resident discharged from skilled services on 01/27/23, with skilled Medicare days remaining; - The resident remained in the facility; - The facility failed to provide a SNFABN to the resident. Review of Resident #44's NOMNC showed: - The resident discharged from skilled services on 12/20/22, with skilled Medicare days remaining; - The resident remained in the facility; - The facility failed to provide a SNFABN to the resident. During an interview on 07/27/23 at 9:30 A.M., the Bookkeeper said that he/she was new to his/her position and did not recall seeing the SNFABN form before. He/She did not know to provide the residents with that form. During an interview on 07/27/23 at 1:32 P.M., the Administrator said that she would expect a resident who was discharge from Medicare A, with remaining skilled Medicare days, to be given a SNFABN notice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a comprehensive Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility staff, had been completed in a timely manner, for two residents (Resident #209 and #210) out of 14 sampled residents and two residents (Resident #15 and #21) outside the sample. The facility's census was 56. The facility did not provide a MDS policy. 1. Review of Resident #15's medical record showed: - admitted on [DATE]; - A quarterly MDS, dated [DATE]; - An annual MDS, dated [DATE], 150 days late. Review of Resident #21's medical record showed: - admitted on [DATE]; - A quarterly MDS, dated [DATE]; - An annual MDS, dated [DATE], 156 days late. Review of Resident #209's medical record showed: - admitted on [DATE]; - No documentation of an admission MDS; - The facility failed to complete an admission MDS within 14 days of the resident's admission. Review of Resident #210's medical record showed: - admitted on [DATE]; - No documentation of an admission MDS; - The facility failed to complete an admission MDS within 14 days of the resident's admission. During an interview on 07/27/23 at 9:15 A.M., the MDS Coordinator said the admission MDS assessments should be completed within 14 days of admission. During an interview on 07/27/23 at 9:30 A.M., the MDS Coordinator said she had submitted the MDS's on time. During an interview on 07/27/23 at 1:00 P.M., the MDS Coordinator provided a MDS 3.0 Final Validation Report (a report documenting whether the MDS had been accepted or rejected by Centers for Medicare & Medicaid Services (CMS) showed the MDS's had been submitted on 07/27/23. She thought the MDS's had been uploaded in June 2023, however she had just completed the process and received the validation report at this time. During an interview on 07/27/23 at 1:30 P.M., the Administrator said MDS assessments should be completed within 14 days of admission. The facility did not have an MDS policy, they follow the Resident Assessment Instrument (RAI) manual. During an interview on 07/27/23 at 1:40 P.M.,the Administrator said the MDS Coordinator had informed her of the MDS's not being transmitted correctly. She would expect the MDS's to be done in a timely manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, within the required timeframe for one resident (Resident #8) outside the 14 sampled residents. The facility's census was 56. The facility did not provide a MDS policy. 1. Review of Resident #8's medical record showed: - An admission date of 10/33/16; - A quarterly MDS, dated [DATE]; - The facility did not complete a quarterly MDS for the resident within 92 days of the last MDS. During an interview on 07/27/23 at 9:30 A.M., the MDS Coordinator said she had submitted the MDS on time. During an interview on 07/27/23 at 1:00 P.M., the MDS Coordinator provided a MDS 3.0 Final Validation Report (a report documenting whether the MDS had been accepted or rejected by Centers for Medicare & Medicaid Services (CMS) showed the MDS had been submitted on 07/27/23. She thought the MDS had been uploaded in June 2023, however she had just completed the process and received the validation report at this time. During an interview on 07/27/23 at 1:40 P.M., the Administrator said the MDS Coordinator had informed her of the MDS not being transmitted correctly and uploaded the MDS today. She would expect the MDS's to be done in a timely manner. The facility did not have an MDS policy, the facility follows the Resident Assessment Instrument (RAI) manual.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, for one resident (Resident #7) out of 14 sampled residents. The facility census was 56. The facility did not have a MDS policy, they follow the RAI manual. 1. Review of Resident #7's quarterly MDS, dated [DATE], showed: - The resident received an anticoagulant (a blood thinner or medications that delay blood from clotting). Record review of the resident's July 2023 Physician Order Sheet (POS) showed: - An order for aspirin enteric coated 81 milligram (mg) tablet by mouth daily, dated 2/13/23; - An order for Plavix (an antiplatelet drug used to prevent blood clots) 75 mg tablet by mouth daily, dated 2/13/23; - No order for an anticoagulant medication. During an interview on 07/27/23 at 9:15 A.M., the MDS Coordinator said aspirin and Plavix should not be coded on the MDS as an anticoagulant. Therefore, the MDS was coded incorrectly. During an interview on 07/27/23 at 1:32 P.M., the Administrator said aspirin and Plavix should not be considered an anticoagulant. The MDS was coded incorrectly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to document weekly skin assessments and to document the status of the residents' pressure ulcers weekly for two residents (Resident #4 and #52) out of four sampled residents. The facility census was 56. Review of the facility's policy titled, Wound Care and Treatment, dated 07/2015, showed: - On-going skin assessment with weekly documentation of status. 1. Review of Resident #4's medical record showed: - An admission date of 06/27/23; - No documented skin assessment upon admission. - Diagnoses of abnormal weight loss, cerebral infarction (stroke) and neuropathy (nerve pain); - A Braden scale (a tool that was developed to help health professionals assess a patient's risk of developing a pressure ulcer) with a score of 15 (15-18 at risk), dated 06/27/23; - On 07/19/23, consent provided by the resident for a wound care consultant company; - Documentation of one weekly skin assessment with an intact dark purple area to the left heel, consult wound care for any further treatment, dated 07/12/23; - No documentation of other weekly skin assessments; - No documentation of the status of the wound such as the size, the type, the wound bed, the wound edges, signs of infection, pain, or progression/declination of the wound. Review of the resident's July 2023 Physician Order Sheet (POS) showed: - An order, dated 07/12/23, for skin prep (a protective dressing) twice daily until healed. Review of the resident's July 2023 Treatment Administration Record (TAR) showed: - An order for skin prep applied to the left heel twice a day, dated 07/12/23; - An order for skin prep applied to three areas to the right lateral (side) foot daily, dated 07/20/23. Review of the resident's shower sheets showed: - On 06/29/23, redness to the right shin and the left arm swollen; - On 07/06/23, no skin abnormalities documented; - On 07/11/23, the buttock area with redness with flaked skin and and the heels red with flaked skin. Review of the resident's progress notes showed: - On 07/12/23 at 4:20 P.M., Licensed Practical Nurse (LPN) A documented the resident with an intact dark purple area to the left heel. A new order received to apply skin prep twice a day until healed and to consult a wound care company for any further treatment; - On 07/20/23 at 5:45 P.M., LPN A documented when reviewed the resident's shower sheet, staff said the resident had three areas to the right outer foot. The right lateral foot was assessed and three deep tissue dark purple areas were found on the right foot. Skin prep was applied to the areas. Received a new order for skin prep to these areas daily; -On 07/23/23 at 3:05 P.M., Registered Nurse (RN) D documented he/she was called into the resident's room during peri-care where four open wounds were found to the resident's buttocks. Two wounds were found on the left buttock and two wounds were found on the right buttock. Received a new order to cleanse the open areas on the buttocks, apply calcium alginate (a type of wound dressing) to the wounds, cover with a dry dressing daily until healed. Review of the resident's care plan, revised 07/25/23, showed: - Potential for skin breakdown related to impaired mobility with open areas to the right and left buttocks and three areas to the right lateral foot. During an interview with on 07/27/23 at 11:50 A.M., LPN B said that once he/she was notified of a new wound, he/she took his/her treatment cart to the resident's room in order to measure and then provide treatment. Once measurements were taken, the physician was notified, he/she would chart orders and the wound measurements in the wound documentation, and would make a progress note with the orders and the measurements. Review of the wound care consultant company notes, dated 07/26/23, showed: - The resident was seen today for evaluation and management of multiple wounds; - Wound #1 was on the left buttock and was an acute unstageable pressure injury (obscured full-thickness and tissue loss) pressure ulcer with a status of not healed. The initial wound measurements were 6.5 centimeters (cm) length x 3.5 cm width x 0.2 cm depth. A moderate amount of sero-sanguineous (contains or relates to both blood and the liquid part of blood) drainage noted with a strong odor; - Wound #2 was on the right buttock and was an acute unstageable pressure injury pressure ulcer with a status of not healed. The initial wound measurements were 5 cm x 2.5 cm x 0.2 cm and no tunneling (passageways underneath the surface of the skin) or undermining (a pocket under the wound surface). A moderate amount of sero-sanguineous drainage with a strong odor; - Wound #3 was on the right lateral heel and was an acute full thickness other (damage extending below the all layers of the skin) and with a status of not healed. The initial wound measurements were 3.5 cm x 3 cm x 0.2 cm and with no undermining or tunneling noted. A moderate amount of serous drainage with no odor. Suspected deep tissue injury to the periwound (surrounding area of the wound edge); - Wound #4 was on the right mid-lateral foot and was an acute full thickness other and with a status of not healed. The initial wound measurements were 3 cm x 1.2 cm x 0.2 cm and with no tunneling or undermining. A moderate amount of serous drainage. Suspected deep tissue injury noted to the periwound; -Wound #5 was on the right lateral foot [other distal (furthest away from center of the body)] and was an acute full thickness other and with a status of not healed. The initial wound measurements were 2.1 cm x 2 cm x 0.2 cm and with no undermining or tunneling. A moderate amount of serous drainage. Review of Resident #52's medical record showed: - A re-admission date of 06/01/23; - An admission clinical assessment, dated 06/01/23, showed no skin lesions and the resident to be incontinent; - Diagnosis of unspecified open wound of the buttock; - A Braden scale score of 15 (at risk), dated 06/01/23; - On 07/19/23, phone consent provided by the resident's responsible party was obtained for a wound care consultant company; - Documentation of one weekly skin assessment with a wound to the buttocks, resident seen by consultant wound care, and treatment in place, dated 07/21/23; - No documentation of other weekly skin assessments; - No documentation of the status of the wound such as the size, the type, the wound bed, the wound edges, signs of infection, pain, or progression/declination of the wound. Review of the resident's weekly skin assessments showed: - On 06/15/23, 06/22/23, 06/29/23, and 7/6/23, the resident with 3+ pitting (occurs when excess fluid builds up int the body, causing swelling, pressure of a finger leaves an indentation of five - six millimeters that takes up to 30 seconds to rebound or bounce back in the swollen area) edema with an existing skin issue; - On 07/21/23, the resident with 3+ pitting edema, a wound to buttocks, and the resident being seen by consultant wound company. Review of the resident's July 2023 POS showed: - An order dated, 07/12/23, for Santyl (a wound debridement that removes necrotic (dead) tissue while preserving healthy tissue) ointment applied nickel thick to the open area to the gluteal fold (dead tissue separating from living tissue), applied calcium alginate with a dry dressing every day and as needed. Review of the resident's July 2023 TAR showed: - An order for Santyl, applied nickel thick to the open area to the gluteal fold, applied calcium alginate with dry dressing everyday and as needed, dated 07/12/23. Review of the resident's shower sheets showed: - On 07/3/23, the buttock area red; - On 07/06/23, no skin abnormalities documented; - On 07/10/23, no skin abnormalities documented; - On 07/13/23, an open area to the buttock area. Review of the resident's progress notes showed: - On 07/12/23 at 3:15 P.M., LPN A documented the resident with an open area to the right gluteal fold. The area was assessed and cleaned. Received a new order to clean the open area with wound cleanser and apply Santyl nickel thick, calcium alginate, and dry dressing everyday and as needed until healed; - On 07/26/23 at 6:45 P.M., LPN A documented when performing wound care to the resident's right gluteal fold wound, as compared to 07/12/23, the wound appears stable at this time. The wound was slightly larger than a half dollar with yellow slough (dead tissue separating from living tissue) to the wound bed. No drainage or foul odor noted. The wound assessed today by the outside wound consultant company. Review of the resident's care plan, revised on 07/12/23, showed: - On 07/12/23, an order to consult wound care company; - The treatment, dated 7/12/23 of Santyl nickel thick applied to the open gluteal fold, applied calcium alginate with a dressing every day and as needed. During an interview on 07/26/23 at 3:10 P.M., LPN A said he/she did not know why he/she did not measure the wound on 07/12/23. That was the first time he/she knew Resident #52 had a wound. If he/she had measured it, the measurements would have been documented in the resident's notes. The wound looked about the same today as it did on the 07/12/23. There were not any measurements except what the wound company provided today. During an interview on 07/26/23 at 4:00 P.M., the Director of Nursing (DON) said she did not have an answer why the skin assessments or measurements were not completed. However, she asked LPN A to document today on Resident #52's wound. During a telephone interview on 08/03/23 at 8:00 A.M., the DON said the resident had been a resident here at this facility prior to this admission, and re-admitted on [DATE], with no skin issues. However she said the wound was a re-occuring wound from the previous admission. The care plan had the 07/12/23 date for the wound treatment due to her getting the order for the treatment on the 07/12/23. The resident did not see the wound care company until 07/26/23. Review of the resident's wound care consultant company notes, dated 07/26/23, showed: - The resident was seen today for evaluation and management of a pressure wound; - Unspecified open wound of an unspecified buttock, initial encounter; - Wound #1 to the right buttock was an acute Stage 3 (full thickness tissue loss, subcutaneous fat may be visible, but bone, tendon, or muscle not exposed) pressure injury pressure ulcer with a status of not healed. The initial wound encounter measurements were 5 cm x 4 cm x 0.2 cm with an area of 20 square cm and a volume of 4 cubic cm and with no tunneling or undermining. A moderate amount of sero-sanguineous drainage with no odor. During a telephone interview on 08/03/23 at 10:25 A.M., the Administrator said she would expect skin assessments to be completed within two hours of admission, if a new concern was found, reporting of any change of skin condition, when shower sheets showed anything new, and check to see if there was a treatment already in place. She would expect measurements of a wound to be documented at the time any new area of concern was found, and the nurses should document weekly of any change or the status of the wound.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe environment for the residents and staff by not removing miscellaneous items on top of light fixtures, using wax warmers throughout the facility, and having two broken skylight windows overhead. The deficient practice had the potential to affect all residents and staff in the facility. The facility census was 56. Review of the facility's policy titled, Environmental Safety and Health, dated May 2006, showed: - The Facility Safety and Health Committee with environmental safety in mind will work toward maintaining a safe work environment and control unsafe actions; - Will conduct periodic safety audits of specific areas of the workplace. 1. Observations on 07/24/23 at 8:00 P.M., and 07/25/23 at 10:10 A.M., of room [ROOM NUMBER] showed: - Four medium size dolls and one stuffed animal displayed on top of light fixture above the head of the resident's bed. Observation on 07/24/23 at 8:09 P.M., of room [ROOM NUMBER] showed: - Two small stuffed animals, a small plastic toy animal, and a plastic round plate displayed on top of the light fixture on the wall next to the window, and three fist-sized snowflake stickers adhered to the front of the light cover. Observation on 07/24/23 at 9:29 P.M., of room [ROOM NUMBER] showed: - One 8 inch x 10 inch (in.) glass picture frame, and an 8 in. x 10 in. cloth picture board displayed on top of the light fixture above the head of the resident's bed next to the window; - Two 8 in. x 10 in. glass picture frames, and a small plastic decoration displayed on top of the light fixture above the head of the resident's bed next to the door. Observation on 07/27/23 at 12:07 P.M., of room [ROOM NUMBER] showed: - Two ceramic trinkets displayed on top of the light fixture above the head of the resident's bed next to the window; - One cloth Christmas decoration touched the top of the light fixture above the head of the resident's bed next to the door. 2. Observations on 07/24/23 at 6:45 P.M., 07/25/23 at 9:00 A.M., and 07/26/23 at 10:00 A.M.,showed: - A scented wax warmer on a shelf in the ice cream parlor area with the light on and with liquid melted wax; - A scented wax warmer located behind a picture frame on a table in the front entrance foyer with the light on and with liquid melted wax; - A scented wax warmer located on a wicker type (flexible dried wood) end table in the 100 hall Wicker Room (commons area) with the light on and with liquid melted wax. Observation on 07/27/23 at 12:20 P.M., showed a scented wax warmer on a table located near the business office window with the light on and with liquid melted wax. 3. Observations on 07/24/23 at 9:53 P.M., and 07/25/23 at 12:36 P.M., showed: - A glass skylight overhead window located in the ceiling of the 100 hall Wicker Room with cracked glass across the bottom right section; - A glass skylight overhead window located in the ceiling of the main dining room and above a table occupied by residents, with cracked glass across the top right section. During an interview on 07/27/23 at 12:00 P.M., Certified Nurse Assistant (CNA) F said he/she was aware that residents cannot have personal decorations on top of the overbed lights and if he/she saw that, he/she would explain to the resident and then remove them. During an interview on 07/27/23 at 12:20 P.M., the Administrator said he/she would expect staff to explain to residents or family members that items cannot be put on the overbed lights for safety reasons and that scented wax warmers were not allowed in the facility also for safety reasons. He/She was not aware of the cracked glass in the skylights and would call the glass company to get those fixed right away. He/She would expect staff to report any broken glass to the maintenance staff so that it could be repaired. During an interview on 07/27/23 at 12:25 P.M., Housekeeper G said he/she was aware that items were not to be placed on top of the overbed light fixtures for safety concerns, and he/she would remove them and explain to the resident or family members that it was a safety concern and they would need to place the items somewhere else in the room. If he/she saw any wax warmers or broken glass in the facility, he/she would report that to his/her supervisor and maintenance. During an interview on 07/27/23 at 12:35 P.M., the Maintenance Supervisor said he was not aware of the broken glass, but would call someone to fix it. There were maintenance repair forms located at the Nurse's Station for staff to fill out if they saw something that needed to be fixed, but he had not received any reports of the cracked glass in the skylights.

Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These deficient practices had the potential to affect all residents. The facility census was 56. Review of the facility's policy titled, Nutrition and Dining Services Manual Guidelines, dated April 2011, showed: - It is the responsibility of the Dining Services Manager to enforce the cleaning schedules and to monitor the completion of assigned cleaning tasks; - Daily, weekly, and monthly cleaning schedules prepared by the Dining Services Manager with all cleaning tasks listed will be posted in the Dietary Department; - The employee will initial in the column under the day the task is completed; - Purpose is to develop detailed cleaning schedules to ensure sanitation is at acceptable standards; - Cleaning schedules should be kept on file for one year; - Wash outside of dishwasher and entire dishwashing area; - Clean top and outside of dish machine; - Areas behind and under equipment must be clean and in good repair; - Pots and pans are to be free of carbon buildup, grease and food particles; - Refrigerator gaskets are to be routinely cleaned and must be free of mold and in good repair. Observations on 07/25/23 at 11:30 A.M., and 07/27/23 at 08:45 A.M., of the kitchen area showed: - A six-burner gas range cook stove with black carbon buildup and brown colored grime on all burners, metal back splash, sides and front; - A gas griddle attached to the cook stove with black carbon and brown colored grime buildup on the cooking surface and all sides, and missing one of three burner control knobs; - Two deep fryer baskets with brown grime buildup on the baskets and the handles; - Two eight inch (in.) skillets with black carbon and brown grime buildup on the inside and outside of the skillets; - Four large skillets with black carbon and brown grime buildup on the outside and the handles; - Two 24-count muffin pans with brown grime buildup inside all the baking cups; - A two-bay plate warmer oven with brown grime on the inside bays and the outside; - An Ice machine with buildup of a white substance on all four outside panels; - A three-bay metal sink with a brown colored spotty substance on the outside of each bay, and a two handle metal faucet with continuous dripping water and covered with a white colored substance; - A dish machine with a white substance buildup and grime on all four outside panels, the top two attached black colored water hoses with brown grime buildup, and two attached copper pipes with grime and a blue colored substance; - A garbage disposal attached to the dish machine with brown grime buildup on the top and sides; - Two 4 in. x 4 in. ceramic tiles pulled away from the wall by the drain pipe of the dish machine; - The wall behind the dish machine covered with brown grime buildup; - The two-bay metal sink with brown grime buildup on the outside of both bays and the attached garbage disposal covered with brown grime; - A small electrical breaker box located on the wall behind the two-bay sink with brown grime buildup on the top and sides; - A five-bay steam table with brown grime buildup on the outside of each end; - A two-door refrigerator with the right side door seal broken and hung from the top of the door, and brown grime buildup on the front and sides; - A single door refrigerator with brown grime buildup on the front and sides; - No documentation of a kitchen cleaning schedule and/or a kitchen cleaning checklist. During an interview on 07/25/23 at 11:31 A.M., the Dietary Manager said he/she knew the kitchen equipment could use a good cleaning and he/she had purchased some heavy duty cleaning supplies to work on that. During an interview on 07/27/23 at 8:45 A.M., [NAME] E said they did not have a cleaning schedule for the kitchen, but that could help keep the kitchen cleaner on a continuous basis. During an interview on 07/27/23 at 9:45 A.M., the Administrator said he/she was aware the kitchen needed a deep cleaning and they had a hard time keeping staff hired for the kitchen. They will get it cleaned and start using a cleaning schedule log sheet so that the staff will know what they were expected to clean each day.

Based on interview and record review the facility failed to provide care in accordance with standards of practice when staff failed to obtain orders for labs related to Coumadin (a blood thinning medication used to treat and prevent blood clots) monitoring for one resident (Resident #17). The facility census was 37. The facility did not provide a policy that addressed Coumadin use or PT/INR monitoring. Record review of Resident #17's Physician Order Sheet (POS), dated 2/1/21 through 2/28/21 showed: - An admission date of 6/29/20; - A diagnosis of coronary artery disease (major blood vessels that supply the heart are damaged or diseased); - An order, dated 6/29/20 for Coumadin 4 milligram (mg) one tablet daily at 3 P.M. - A STAT (immediate) order for PT(clotting of blood)/INR (a laboratory test that measures the time it takes for blood to clot and compares it to an average), dated 2/25/21. Record review of the resident's medical chart showed: - PT 15.5 (normal range 9.6-12.2) and INR 1.4 (normal range 0.9-1.1), dated 2/25/21, with new orders to increase Coumadin 5 mg daily and repeat PT/INR in one week; - The resident remained on the Coumadin 4 mg dose 6/29/20 through 2/25/21 with no PT/INR labs to monitor the coumadin levels. During an interview on 2/24/21 at 11:00 A.M. the Administrator said she would think there would be an order for lab when a resident is taking Coumadin. During an interview on 2/25/21 at 9:15 A.M. the Director of Nursing (DON) said if a resident is taking Coumadin there should be labs to monitor the PT/INR. During an interview on 2/25/21 at 9:50 A.M., Licensed Practical Nurse (LPN A) said PT/INR should be monitored when a resident is on Coumadin, bi-weekly or weekly depending on what they are taking it for and who the doctor is. LPN A said he/she had contacted the physician and received a new order for a STAT PT/INR and will check it weekly from now on.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide adequate incontinent care for one resident (Resident #9) out of two sampled residents, and one resident (Resident #21) outside the sample. The facility census was 37. 1. Record review of Resident #9's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 11/28/20 showed: - Always incontinent of bowel and bladder; - Total dependence on staff for toileting needs. Observation on 2/25/21 at 9:00 A.M., showed; - Certified Nursing Assistant (CNA) E and Licensed Practical Nurse (LPN) C entered Resident #9's room; - CNA E and LPN C put on gloves; - LPN C rolled the resident to his/her right side and removed the urine and stool soiled brief; - CNA E cleaned the residents rectal area, wiping from the rectal area to the front peri area. During an interview on 2/25/21 at 9:11 A.M., CNA E said when doing incontinent care, you should clean from front to back. 2. Record review of Resident #21's quarterly MDS, dated [DATE] showed: - Extensive assist of two staff for toileting; - Frequently incontinent of bowel and bladder. Observation on 2/24/21 at 10:05 A.M., showed: - Resident assisted up from wheel chair; - CNA B lifted resident up and forward from bedside commode; - CNA B removed the residents urine soaked brief; - CNA B and CNA A lowered the resident to sitting position on the toilet; - CNA A assisted the resident to standing position; - CNA B cleaned the residents rectal area, and placed a clean brief on him/her. - CNA A or CNA B did not wash the residents buttocks, hips, thighs or peri area. During an interview on 2/25/21 at 2:29 P.M. CNA A said when doing incontinent care the hips, buttocks, inner thighs and all areas should be washed. During an interview on 2/25/21 at 3:32 P.M. the Director of Nursing (DON) said she would expect staff to clean all areas when providing incontinent care. During an interview on 2/26/21 at 9:26 A.M. CNA B said all soiled areas should be cleaned when providing incontinent care. During an interview on 2/26/21 at 9:54 A.M. the Administrator said she would expect all areas to be cleaned during incontinent care, including the peri area, thighs, buttocks, hips, lower back anywhere that is soiled or contaminated. Review of the facility's Perineal Care Policy dated March 2015, showed: - Purpose was to cleanse the perineum and prevent infection and odor; - Put on disposable gloves; - Wash from front to back; - Rinse and pat dry.

Based on interview and record review, the facility failed to ensure the pharmacy consultant identified and reported the absence of lab work related to Coumadin (a blood thinning medication used to treat and prevent blood clots) use for one resident (Resident #17) out of 12 sampled residents. The facility census was 37. 1. Record review of Resident #17's Physician Order Sheet (POS), dated 2/1/21 through 2/28/21 showed: - A diagnosis of coronary artery disease (major blood vessels that supply the heart are damaged or diseased); - An order, dated 6/29/20 for Coumadin 4 milligram (mg) one tablet daily at 3 P.M. Record review of the resident's Medications Regimen Review (MRR), dated 6/29/20 through 2/26/21 showed no irregularities or recommendations on the reviews. During an interview on 2/25/21 at 1:38 P.M., the Pharmacist Consultant (PC) confirmed no note had been written regarding the lack of lab testing on Resident #17's Coumadin use. The PC said monitoring Coumadin levels are a standard of practice when it comes to Coumadin use and a recommendation for labs should have been made. Record review of the facility's policy on Drug Regimen Review, dated January 2017 showed the pharmacist must report any irregularities to the resident's attending physician and the facility's medical director and the director of nursing.