Based on observation, interview, and record review, the facility failed to follow physician's orders by not obtaining the segmental pressures (the measurement of blood pressures at different points along the leg to assess for potential blockages in the arteries) as ordered and for not obtaining the arterial duplex (a non-invasive imaging procedure that uses ultrasound technology to examine the blood flow in the main arteries of both legs) in a timely manner for one resident (Resident #28) out of one sampled resident. The census was 115. The facility did not provide a policy on following physician orders. 1. Review of Resident #28's Physician's Order Sheet (POS), dated 11/14/24, showed: - Diagnosis of hypertension (HTN - high blood pressure); - An order for segmental pressures bilateral (both) lower extremities, dated 11/14/24. Review of the resident's Provider Progress Notes, dated 11/14/24, showed: - Order for arterial duplex bilateral lower extremities. Review of the resident's medical record showed: - No documentation the segmental pressures bilateral lower extremities, ordered on 11/14/24, was completed; - No documentation of a segmental pressures bilateral lower extremities findings report. Review of the resident's Arterial Duplex report, completed on 01/23/23 and dated 01/24/25, showed: - Findings consistent with mild peripheral vascular disease (a circulatory condition that occurs when blood vessels narrow, spasm, or become blocked outside of the heart and brain) without occlusion, right lower extremity; - Findings consistent with moderate peripheral vascular disease without occlusion, left lower extremity; - Moderate stenosis (abnormal narrowing of a passageway in the body, such as a blood vessel, canal, or organ) between the left mid superficial femoral artery (SFA - major artery in the lower extremity) and the distal (far) SFA; - Moderate stenosis (50-75%) of the left mid SFA; - Mild plaque (a buildup of cholesterol, fat, and other substances that can narrow or block arteries) was noted within the visualized arteries, right; - Moderate plaque was noted within visualized arteries, left. Observations on 01/23/25 at 1:36 P.M., showed Resident #28 lay in bed with his/her bilateral legs and feet with no discoloration and dry, flaky skin. The resident complained of pain when LPN E touched his/her feet. He/She said the top and bottom of his/her left toes hurt. The resident had facial grimacing and said the pain was in the bottom of the foot, mostly at the arch. During an interview on 01/23/24 at 11:00 A.M., the Director of Nursing (DON) said the order for the segmental pressure bilateral lower extremities related to discoloring and increased pain was not followed up on, clarified, or completed due to the order not being put in the system. No one followed up on the NP Progress Note, dated 11/14/24, to check for an order which was where the arterial duplex bilateral lower extremities order was located. During an interview on 01/23/25 at 1:36 P.M., CNA C said the resident had been complaining about his/her feet hurting, especially when his/her shoes were put on. CNA C said he/she reported the discoloration, swelling, pain, and if there were any spots on the feet, like pressure spots, to the nurse. During an interview on 01/23/25 at 1:36 P.M., LPN E said Resident #28 had pain in his/her legs and feet, and they were doing the arterial duplex today. The resident had pain when the NP was here on 11/14/24. The left foot was cooler to the touch currently but he/she could feel the pulse on the top of the foot. During an observation and interview on 01/24/25 at 10:40 A.M., Resident #28 said sometimes he/she told the staff his/her feet hurt. The nurse would provide Tylenol, but it didn't always help. The bottom of his/her feet hurt now. The resident sat up in a recliner with the bilateral lower extremities resting on a pillow on the footrest and had non-slip socks on his/her feet. During an interview on 11/24/25 at 12:02 P.M., the DON said If tests or labs were ordered, she usually checked daily for results to let the physician know. She expected physician orders to be followed. She was not aware there was a new order for imaging for Resident #28 on 11/14/24.

Based on interview and record review, the facility failed to ensure an appropriate diagnosis for the use of an antipsychotic (a medication used to treat symptoms of psychosis, such as hallucinations and delusions) medication for one resident (Resident #16) and to limit the use of an as needed (PRN) order for psychotropic (medications that affect how the brain works and causes changes in mood, awareness, thoughts, feelings, or behaviors) medication to 14 days for two residents (Residents #71 and #267) out of six sampled residents. The facility census was 115. The facility did not provide a policy for an appropriate diagnosis for antipsychotic medication and PRN psychotropic medication use. 1. Review of Resident #16's January 2025 Physicians Order Sheet (POS) showed: - Diagnoses of unspecified dementia (a condition characterized by progressive loss of memory and thinking, sometimes resulting in personality change, resulting from disease of the brain), unspecified severity, with other behavior weakness (specific type of dementia is unknown, the severity is not clearly defined, and the patient exhibits behavioral disturbances beyond just memory loss, potentially including things like agitation, mood swings, social disinhibition, or unusual behaviors), anxiety disorder a mental health disorder characterized by feelings of worry, or fear that can be strong enough to interfere with daily activities), and epilepsy (a chronic neurological condition characterized by recurrent seizures, which are brief episodes of abnormal brain activity); - An order for Abilify (an antipsychotic medication) 10 milligram (mg) by mouth every day for unspecified dementia, unspecified severity, with other behavior weakness, dated 10/04/23; - Specific behaviors were not identified or addressed; - The facility failed to provide an appropriate diagnosis for the Abilify medication use. Observations of the resident on 01/21/25, showed: - At 11:18 A.M., the resident sat in a wheelchair at the dining room table waiting for lunch and with nonsensical speech; - At 12:25 P.M., the resident sat quietly in a wheelchair at the dining room table feeding self with assistance of staff; - At 3:15 P.M., the resident sat quietly in a wheelchair at the dining room table holding a doll. Observations of the resident on 01/22/25, showed: - At 9:30 A.M., the resident sat in a wheelchair at the dining room table yelling with nonsensical speech; - At 12:40 P.M., the resident sat in a wheelchair quietly feeding self and consumed 90% of lunch with assistance from staff; - At 2:45 P.M., the resident sat quietly in a wheelchair at the dining room table holding a doll. Observations of the resident on 01/23/25, showed: - At 11:30 A.M., the resident sat in a wheelchair quietly at the dining room table; - At 3:50 A.M., the resident lay quietly in bed. Observations of the resident on 01/24/25, showed: - At 8:38 A.M., the resident sat in a wheelchair at the dining room table holding a doll and laughing; - At 2:45 P.M., the resident sat quietly in a wheelchair at the dining room table during an activity. During an interview on 01/24/25 at 11:35 A.M., Licensed Practical Nurse (LPN) B said Resident #16 did yell out with nonsensical speech at times in the dining room when aggravated. The resident had been taking Abilify 10 mg for at least a year. 2. Review of Resident #71's January 2025 POS showed: - Diagnoses of dementia, anxiety disorder and insomnia (difficulty sleeping); - An order for hydroxyzine (an antianxiety medication) 25 mg three times a day PRN for agitation for anxiety, dated 11/11/24, with no stop date; - The facility failed to provide a 14 day stop date order for the hydroxyzine PRN order. 3. Review of Resident #267's January 2025 POS showed: - Diagnosis of depression (a serious medical illness that negatively affects how you feel, the way you think and how you act); - An order for lorazepam (an antianxiety medication) 2 mg/milliliter (ml) concentrate 0.25 ml to 1 ml sublingual (applied under the tongue) every one hour PRN for anxiety/restlessness, dated 01/15/25, with no stop date; - The facility failed to provide a 14 day stop date order for the lorazepam PRN order. During an interview on 01/22/25 at 1:24 P.M., Registered Nurse (RN) A said he/she was unaware PRN psychotropic medications required a stop date. During an interview on 01/24/25 at 10:52 A.M., the Director of Nursing (DON) said she would expect PRN psychotropic medications to have a 14 day stop date, or the physician would need reevaluate the resident for an extended period stop date. During an interview on 01/24/25 at 10:57 A.M., the Administrator said she would expect PRN psychotropic medications to have a stop date. If not for 14 days, then the order should be written for an extended period with a stop date, and the physician would have to reevaluate the resident before reordering. During an interview on 01/24/25 10:30 A.M., the DON said she would expect all antipsychotic medications to have a proper diagnosis when prescribed and for her staff to be knowledgeable of this. During interview on 01/24/25 10:55 A.M., the Administrator said she would expect a proper diagnosis for antipsychotics to be in place when a physician orders the medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a safe, clean, comfortable, homelike environment. The deficient practice had the potential to affect all residents and staff in the facility. The facility census was 115. The facility did not provide a policy for a homelike environment. 1. Observation on 01/24/25 at 8:05 A.M., of room [ROOM NUMBER] showed: -13 figurines from 1 inch (in.) to 3 in. tall on the light fixture beside the chair. 2. Observation on 01/24/25 at 8:10 A.M., of room [ROOM NUMBER] showed: - Eight figurines from 1 in. to 4 in. tall on the light fixture above the right side of the bed. 3. Observation on 01/24/25 at 8:15 A.M., of room [ROOM NUMBER] showed: - One 8 in. by 10 in. picture frame, one 8 in. by 5 in. picture frame, six stuff animals 4 in. tall, and one 12 in. gnome on the light fixture beside the chair. 4. Observation on 01/24/25 at 8:20 A.M., of room [ROOM NUMBER] showed: - One figurine approximately 5 in. tall and one plaque 8 in. by 5 in. on the light fixture above the bed. 5. Observation on 01/24/25 at 8:35 A.M., of room [ROOM NUMBER] showed: - Two decorative objects approximately 5 in. tall and three 5 in. by 7 in. picture frames on the light fixture above the bed. 6. Observation on 01/24/25 at 8:39 A.M., of room [ROOM NUMBER] showed: - Two angel figurines and a cross figurine from 6 in. to 8 in. tall on the top of the light fixture and one 6 in. snowman stuck to the front of the light fixture beside the bed. 7. Observation on 01/24/25 at 8:43 A.M., of room [ROOM NUMBER] showed: - One ball cap hung on the corner of the light fixture beside the bed. During an interview on 01/24/25 at 8:58 A.M., the Maintenance Supervisor said some residents did have items on their lights. The facility didn't recommend that being done. During an interview on 01/24/25 at 11:50 A.M., the Director of Nursing (DON) said it was not recommended but it happened. The residents usually had to purchase the shelves themselves and then the shelves were put up. During an interview on 01/24/25 at 12:05 P.M., the Administrator said items should not be on top of light fixtures in resident rooms. She would expect staff to inform maintenance and shelves be put up for the residents' belongings.

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. This had the potential to affect all residents. The facility census was 115. Review of the facility's policy titled, Sanitation, revised April 2014, showed: - The food service area shall be maintained in a clean and sanitary manner; - All kitchens, kitchen areas, and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects; - All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, and cracks, and chipped areas that may affect their use or proper cleaning. Seals, hinges, and fasteners will be kept in good repair; - If a sink is used for washing utensils, cooking equipment, or dishes, and also used to wash produce or thaw food, it will be cleaned between uses with an approved cleaning and sanitizing agent; - Kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime (dirt ingrained on the surface of something); - Food Service staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task before proceeding to the next assignment. 1. Observations on 01/21/25 at 11:12 A.M., and 01/24/25 at 10:13 A.M., of the kitchen showed: - One partially full five-gallon clear plastic storage bin with powdered milk undated and unlabeled near the walk-in freezer; - The floor area behind the tilt skillet fryer with a glue trap, five attached bugs, and an electrical connection box with an oily film build up and brown grime; - Ice machine with white build up on the exterior surfaces; - The commercial style can opener with an oily film and white substance on the blade; - The walk-in refrigerator with scattered food debris and a pooled white liquid on the floor approximately 1 inch (in.) deep, below the left side food shelves with white grime build up; - The floor below the reach-in freezer, reach-in refrigerator, range, deep fryer, and ice machine, with scattered debris and an oily film; - The microwave oven interior with food debris build-up along the top surface; - The dishwasher with white build up on the exterior surfaces; - The floor below the dishwashing area counters with white build up; - A 10 foot (ft.) section of approximately 1 in. deep pooled water in the dishwasher and disposal sink area; - The sink disposal drain area with yellow food debris and white grime build up in the sink basin; - The air curtain (a device used to prevent air, contaminants or flying insects from moving from one space to another) above the back exterior door near the dry food storage room with a brown build up along the ventilation louvers; - The circular fan near the supply closet with a brown build up on the front and back guard; - One 6 ounce (oz.) red plastic drink cup, scattered food debris, and a glue trap with six bugs below a food shelf with drink supplements near the dry food storage room. 2. Observation on 01/21/25 at 11:15 A.M., of the walk-in freezer showed: - The floor near the door with approximately a 3 ft. diameter (dia.) area with ice build up; - Ice build up on most of the food shelving, ventilation louvers, and the ceiling area near the ventilation louvers approximately 1 in. thick; -One 5 pound (lb.) bag of fried okra dated, October 2025, covered with ice build up one-half in. thick; - One 4 lb. bag of mixed vegetables dated, November 2026, covered with ice build up one-half in thick; - Six 3 lb. packages of country ribs dated, October 2025, covered with ice build up one-half in. thick; - One 3 lb. bag of hash brown potatoes undated, covered with ice build up one-half in. thick. 3. Observations on 01/21/25 at 11:22 A.M., and 01/24/25 at 10:23 A.M., of the dry food storage area showed: - Two 6 lb. 12 oz. tapioca pudding cans undated, with a brown substance; - Scattered food debris and three individually wrapped cookies lay in the floor along the walls below the food shelves; - A 55.115 lb. brown sack of dried buttermilk mix lay on the floor beside a large 4 in. metal pipe; - A cardboard box with 72 individual containers of 4 oz applesauce cups lay on the floor beside the metal food racks. During an interview on 01/21/25 at 11:22 A.M., Dietary Aide (DA) F said he/she normally rinsed the food waste down the sink but must have missed a spot this morning. Water splashed out of the sink when rinsing dishes off and created a large pool of water in the floor in front of the dishwashing area and it had to be swept toward the floor drain. During an interview on 01/21/25 at 11:32 A.M., the Dietary Manager (DM) said the order for lime scale remover that removed the white build up from the ice machine had been ordered over a month ago but had been delayed. The air curtain and fan in the dishwashing area should not have dust build up on the louvers and will need to be cleaned by maintenance. An outside service company checked on the freezer about three months ago, but the ice build up occurred since the last service and should not be there. The Maintenance Director had been made aware of the frost build up in the walk-in freezer. The ice was normally scooped out when it was serviced. There were cleaning logs, and it was on the list to clean under the shelving, but those areas would need more work. Food containers should not have been placed on the floor in the dry storage area. 4. Observation on 01/24/25 at 8:12 A.M., of the Whispering Pines kitchen showed: - One 12 in. x 12 in. ceiling diffuser (one of the few visible parts of an air conditioning system) with dust build up and a brown substance on the front exterior surfaces near the food shelves. 5. Observation on 01/24/25 at 8:27 A.M., of the Flowering Dogwood kitchen showed: - The ice machine and refrigerator dispenser with a white substance along the outer surfaces and a brown substance on the ice machine ventilation louvers near the floor. 6. Observation on 01/24/25 at 8:35 A.M., of the Sleepy Oaks kitchen showed: - The dry food storage area floor with food debris below the shelves; - The top refrigerator shelf with a 2 in. dia. area of a red substance and black debris inside the door shelves; - The oven interior with a 1 in. diameter dried yellow substance near the door seal; - 12 recessed lighting canisters with a brown build up along the interior surface. During an interview on 01/24/25 at 8:47 A.M., DA G said the floors were normally swept after breakfast and should not have food debris near the shelves. The oven and refrigerator would have to be cleaned and should not have signs of grime or food debris. During an interview on 01/24/25 at 8:55 A.M., the DM said the recessed lighting housings should be clean and the maintenance department would have to be contacted and asked to clean. The floor should have been cleaned in the dry foods area. The refrigerator shelves with a dried red substance on the shelves and the door shelves should have already been cleaned. The oven should be clean inside and not have any grime build up. During an interview on 01/24/25 at 10:13 A.M., the Administrator said the dishwashing sink sprayer may need to be adjusted or replaced to prevent water from splashing in the floor. The freezer and some food items should not have frost and ice build up and the gasket had been replaced. The freezer would need to be checked to see what caused the issue. The ceiling vents and lighting should be kept clean. Food should not be stored on the floor and should be labeled and dated. Floor areas below the appliances should be clean and the refrigerator spills should not be left to dry. During an interview on 01/24/25 at 12:47 P.M., the Maintenance Director said he/she oversaw the cleaning and servicing for the walk-in freezer. Some of the ice build-up had been removed and it should not be there. The ceiling ventilation louvers and light fixtures in the kitchens with brown build up would need to be cleaned.

Based on interview and record review, the facility failed to implement a baseline care plan (the minimum healthcare information necessary to properly care for a resident) upon admission with specific interventions for one resident (Resident #153) out of one sampled resident. The facility census was 105. Review of the facility's policy titled, Care Plan - Preliminary, dated May 2014, showed: - A preliminary plan of care to meet the resident's immediate needs shall be developed for each resident within 24 hours of admission; - The Interdisciplinary (members from different disciplines working together for a common purpose) Team will review the physicians orders and implement a nursing care plan to meet the resident's immediate care needs; - The preliminary care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary care plan. 1. Review of Resident #153's medical record showed: - An admission date of 10/14/23; - Diagnosis of dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning) and Stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed without slough); - No documentation of a baseline care plan with specific interventions related to dementia care or pressure ulcer treatment. During an interview on 11/03/23 at 12:36 P.M., the Director of Nursing (DON) said nursing staff was responsible for the care plan and she would expect an interim care plan to be completed within 48 hours of the resident's admission, but one for this resident couldn't be found so it must not have been completed. During an interview on 11/03/2023 at 1:52 P.M., Registered Nurse (RN) A said the RN on shift during a resident's admission was responsible for the interim care plan. During an interview on 11/03/2023 at 12:14 P.M., the Administrator said she would expect the baseline care plans to be completed on all new admissions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one resident (Resident #70) out of a sample of two residents had a physician's order to keep nasal spray, prescription cream, and a prescription shampoo at the bedside and to store medications in a safe and effective manner when staff left the medication cart unlocked and unattended, leaving the narcotics behind only one lock. This had the potential to affect all residents. The facility census was 105. Review of the facility's policy titled, Self-Administration of Drugs, dated [DATE], showed: - As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities, to determine whether a resident is capable of self-administering medications; - In addition to general evaluation of decision-making capacity, the staff and practitioner will perform a more specific skill assessment, including (but not limited to) the resident's: Ability to read and understand medication labels; Comprehension of the purpose and proper dosage and administration time for his or her medications; and Ability to recognize risks and major adverse consequences of his/her medications; - The staff and practitioner will document their findings and the choices of residents who are potentially capable of self-administering medications; - For self-administering residents, the nursing staff will determine who will be responsible (the resident or the nursing staff) for documenting that medications were taken; - Self-administered medications must be stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer will be stored on a central medication cart or in the medication room. Nursing will transfer the unopened medication to the resident when the resident requests them; - Staff shall identify and give to the Charge Nurse any medications found at the bedside that are not authorized for bedside storage, for return to the family or responsible party; - The nursing staff will rotate bedside stock and will remove expired, discontinued, or recalled medications; - Nursing staff will review the bedside medication record on each nursing shift, and they will transfer pertinent information to the Medication Administration Record (MAR) kept at the nursing station, appropriately noting that the doses were self-administered; - The staff and practitioner will periodically reevaluate a resident's ability to continue to self-administer medications. 1. Review of Resident #70's Physician Order Sheet (POS), dated [DATE], showed: - Date of admission of [DATE]; - Diagnoses of allergic rhinitis (an allergic response causing itchy, watery eyes, sneezing, and other similar symptoms), actinic keratosis (a rough, scaly patch on the skin that develops from years of sun exposure), hemiplegia (paralysis of one side of the body) following a stroke that affected the left side; major depressive disorder (long-term loss of pleasure or interest in life), anxiety disorder (persistent worry and fear about everyday situations), and congestive heart failure (CHF) (an inability of the heart to pump sufficient blood flow to meet the body's needs); - An order for Flonase (a nasal spray that treats allergy symptoms like sneezing, itching and a runny or stuffy nose) 50 microgram (mcg) nasal spray suspension two sprays each nostril twice a day for allergic rhinitis, dated [DATE]; - An order for Afrin (a topical decongestant medication used to relieve nasal discomfort caused by colds, allergies, and hay fever) 0.05 percent (%) nasal mist two sprays every eight hours for nasal congestion, dated [DATE] and with a stop date of [DATE]; - Ketoconazole 2% topical cream (used to treat infections caused by a fungus or yeast) apply topically three times a day as needed for a rash, dated [DATE]; - Ketoconazole 2% shampoo (used to treat tinea versicolor (a common fungal infection of the skin) apply topically two times per week for actinic keratosis, dated [DATE]; - Visine Dry Eye Relief one drop both eyes four times a day as needed for dry eyes (may keep at bedside), dated [DATE]; - No order for Vicks [NAME] Severe nasal spray (nasal decongestant); - No order to keep Flonase, Afrin, ketoconazole cream and shampoo, and Vicks [NAME] Severe nasal [NAME] medications at the bedside or that the resident could self-administer any of the medications; - No documentation of the evaluation assessment for the resident to self-administer the medications; - No documentation of education provided to the resident regarding medication kept at the bedside. - Review of the resident's Interdisciplinary Notes rounding note, dated [DATE], showed the resident was seen by his/her family nurse practitioner (FNP) for nasal congestion and his/her ears clogged. Discussed ordering Afrin but can only use it for three days due to causing rebound congestion (constant nasal congestion that develops from the overuse of nasal sprays) if used for longer periods of time. New orders include Afrin two sprays each nostril every eight hours for three days. Review of the resident's MAR, dated 10/2023, showed: - Afrin nasal mist self-administered [DATE] at 6:00 A.M., 2:00 P.M., and 10:00 P.M.; - Flonase nasal spray self-administered at 9:00 A.M., 21 out of 31 days and 9:00 P.M., 20 out of 31 days; - No documentation of the ketocanazole 2% topical cream administration. Review of the resident's MAR, dated 11/2023 showed: - Afrin nasal mist self-administered on [DATE] - [DATE] at 6:00 A.M., 2:00 P.M., 10:00 P.M., - Flonase nasal spray self-administered at 9:00 A.M., on [DATE] -[DATE] and at 9:00 P.M., on [DATE] -[DATE]; - No documentation of the ketocanazole 2% topical cream administration, dry eye relief drops Review of the resident's care plan, dated [DATE], showed; - Provide eye medications as ordered; - Eye drops for dry eyes; - Did not address the resident self-administered the medications or kept the medications at his/her bedside. Observations of the resident's room showed: - On [DATE] at 12:15 P.M., and 3:33 P.M., the Flonase, Vicks [NAME] Severe nasal spray, , Afrin nasal decongestant, and dry eye relief lubricant eye drops sat on the table at the foot of the bed; - On [DATE] at 10:15 A.M., and 6:10 P.M., the Flonase, Vicks [NAME] Severe nasal spray, dry eye relief drops, Afrin nasal decongestant, and dry eye relief lubricant eye drops sat on the table at the foot of the bed; - On [DATE] 8:40 A.M., the dry eye relief lubricant eye drops sat on the bedside table next to the resident's recliner. The Flonase, Vicks [NAME] Severe nasal spray, dry eye relief drops, and the Afrin nasal decongestant sat on the table at the foot of the bed; - On [DATE] at 2:20 P.M., the ketoconazole cream sat in the resident's shaving cup in his/her bathroom and the ketoconazole shampoo sat on a shelf in the bathroom. During an interview on [DATE] at 8:40 A.M., Resident #70 said he/she administered the medications his/herself. No staff came into his/her room to administer them. He/She knew when to take the medication and did it. The Afrin was taken every eight hours with one spray up each nostril, but he/she didn't know for how long he/she was supposed to take it. The Afrin didn't have any refills. He/She used the Flonase with one spray per nostril one time a day, same as the Afrin. The physician said not to rely on the Vicks [NAME] nasal spray, but just use it sometimes because it loses its effectiveness. He/She only used the eye drops in the left eye, and knew to use it when the eye started burning, that's he/she knew it wasn't lubricated. He/she probably used it twice a day. During interview on [DATE] at 12:46 P.M., with Director of Nursing (DON) she said Resident #70 had nasal spray in his/her room and self-administered it. She said the physician educated him/her on how to administer it and when to use it. She said no evaluation was done, but the resident was high functioning. During an interview on [DATE] at 2:20 P.M., Resident #70 said he/she used both the ketoconzole shampoo twice a week. The ketoconzole cream he/she put on his/her rash and it did a great job. During interview on [DATE] at 2:55 P.M., the DON said she would expect there to be an order for all medications prescribed and/or over the counter for the residents. She would expect the order to show the resident was allowed to keep the medications at the bedside. She would expect the care plan to address self-administration of medications. She would expect an evaluation of the resident to be completed per the facility's policy and an assessment be completed to ensure the resident was competent and safe. She would expect documentation of medications and treatments to be on the MAR and/or the Treatment Administration Record (TAR). Review of the facility's policy titled, Storage of Medications, undated, showed: - The facility shall store all drugs and biological's in a safe, secure and orderly manner; - The nursing staff shall be responsible for maintaining medication storage; - Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes) containing drugs and biological's shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. 2. Observations during the medication pass on [DATE] of the 400 Hall showed: - At 8:08 A.M., Registered Nurse (RN) A left the unlocked and unattended medication facing the hall and entered room [ROOM NUMBER] to administer medications to the resident; - At 8:16 A.M., RN A left the unlocked and unattended medication facing the hall and entered room [ROOM NUMBER] to administer medications to the resident; - At 8:21 AM, RN A left the unlocked and unattended medication facing the hall and entered room [ROOM NUMBER] to administer medications to the resident; - At 8:24 AM RN A left the unlocked and unattended medication facing the hall and entered room [ROOM NUMBER] to administer medications to the resident; - At 8:26 AM RN A left the unlocked and unattended medication facing the hall and entered room [ROOM NUMBER] to administer medications to the resident; - At 8:35 A.M., RN A returned to the unlocked medication cart. Observation of the medication cart on the 400 hall on [DATE] showed; - At 10:52 A.M., the unlocked and unattended medication cart sat in the hall between rooms [ROOM NUMBERS], facing the hall, with no staff present; - At 10:58 A.M., RN A walked by the unlocked and unattended medication cart that sat in the hall between rooms [ROOM NUMBERS]; - At 11:02 A.M., RN A returned to the unlocked and unattended medication cart; - At 11:06 A.M., RN A walked away from the unlocked medication cart which sat between rooms [ROOM NUMBERS], facing the hall, and entered into room [ROOM NUMBER] which left it unlocked and unattended. During an interview on [DATE] at 11:35 A.M., Certified Medication Technician (CMT) B said both locks should be locked on the medication cart before walking away from it. The keys should never be left in the lock. At times, he/she had left the main lock unlocked if the cart was in the doorway of the resident's room while passing medications in that room and it was in the line of vision. During an interview on [DATE] at 11:49 A.M., RN A said he/she should've locked the medication cart when he/she left it. He/She was busy and just didn't lock it. During an interview on [DATE] at 1:30 P.M., the DON said the medication carts should be locked at all times when left unattended. During an interview on [DATE] at 1:45 P.M., the Administrator said it was expected that the medication cart was locked when left unattended or not in use.

Based on observation and interview, the facility failed to ensure the garbage dumpster and trash receptacles were covered for two of three days of observation. The facility census was 105. Review of the facility's policy titled, Sanitation and Infection Control policy, dated 2000, showed: - All garbage will be disposed of daily; - Prior to disposal, all waste shall be kept in leak-proof, non-absorbent, fireproof containers that are kept covered, - Trash will be deposited into the sealed container outside the premises. Observation of the kitchen on 11/01/23 at 10:20 A.M., showed one 32 gallon uncovered trash receptacle partially full of refuse near the dishwashing sink. Observation of the dumpster area on 11/01/23 at 10:24 A.M., showed one 10 yard (yd.) dumpster partially filled with two plastic lids completely opened. Observation of the dumpster area on 11/03/23 at 9:02 A.M., showed: - One 10 yd. dumpster partially filled with two plastic lids completely opened; - Scattered debris lay on the ground near the dumpster. During an interview on 11/03/23 at 11:00 A.M., the Assistant Maintenance Director said the trash dumpster should be closed after trash was placed inside. Staff had been asked to help with ensuring the dumpster was closed. During an interview on 11/03/23 at 8:45 A.M., the Registered Dietician said facility staff were expected to close the lid when finished loading the dumpster and they should ensure the area around the dumpster was clean. Trash cans inside the kitchen area should be covered with a lid when they were not being used. During an interview on 11/03/23 at 3:35 P.M., the Administrator said the dumpster area should be kept in order and the lid should be closed when it was not being filled. The walking area around the dumpster should be clean.

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. This had the potential to affect all residents. The facility census was 105. Review of the facility's policy titled, Cleaning Instructions, dated 2000, showed: - Can opener will be cleaned after each use, wash in sink filled with soapy water, pay special attention to blade and moving parts; - Kitchen and dining room floors, tables, and chairs will be kept clean and sanitary, kitchen floors will be swept and cleaned after each meal; - Freezers will be defrosted monthly or as needed when frost is one quarter inch (in.) thick, freezer should be defrosted; - The ice machine and equipment (scoops and trays) will be cleaned on a regular basis to maintain a clean, sanitary condition, wash interior thoroughly using detergent solution, rinse and drain with clean hot tap water, clean exterior of machine with detergent solution; - The microwave oven will be kept clean, sanitized and odor free, remove any food particles from interior of oven with a clean wet cloth; - The refrigerators will be washed thoroughly inside and outside with a detergent and followed by a sanitizer at least once every month, or as needed, spills and leaks will be wiped up as they are noticed. Review of the facility's policy titled, Sanitation and Infection Control, dated 2000, showed: - Dry storage areas will be kept in a condition which protects stored foods from infestation; - Floors must be swept clean at all times and mopped at least weekly; - Poisonous and toxic material should be stored outside the food storage and preparation area or in cabinets, which are used for no other purpose; - The floors, walls, shelves and equipment in the storeroom are clean, cleaning products are stored separately from food. Observation on 11/01/23 at 9:50 A.M., of the kitchen showed: - Debris, oily film build-up, and food debris on the floor beneath and behind the range; - Black grime build-up on the pipes behind the range; - The commercial style can opener knife with a worn cutting edge and black grime build-up; - Two ceiling diffusers (one of the few visible parts of an air conditioning system) with brown grime build-up on the front exterior surfaces and between the ventilation louvers; - A wall mounted fan rotated with dust and grime build-up between the ventilation louvers; - Bread and canned food shelving with dust and grime build up below the fan; - Floor with standing water in the dishwashing area. Observation on 11/01/23 at 9:56 A.M., of the dry food storage room showed: - Two cases of bottled water sat on the floor; - Scattered debris below the food storage shelves; - Two undated opened bags of corn chips lay on the food racks; - Bug debris on the floor near a glue trap under the food shelving. Observation on 11/01/23 at 10:00 A.M., of the walk-in refrigerator showed: - Debris on the floor below the food shelves; - Dust and grime build-up between the ventilation louvers; - All metal wire food shelves with a chipped, non-intact surface and a brown substance. Observation on 11/01/23 at 10:01 A.M., of the walk-in freezer showed: - Two 6 in. ice formations hung 12 in. from the area below the ventilation louvers; - A 1 in. ice build-up on ventilation louvers; - A 12 in. diameter by 1 in. thick ice build up on the ceiling above the ventilation louvers; - Two food boxes below the ventilation louvers covered with 1 in. ice build-up; - The floor with 1 in. thick ice formation below the food shelves; - The freezer door separated with seal damage; - Nine clear bags with vegetables partially covered in 1 in. frost build-up; - Metal food shelves covered entirely with 1 in. thick frost build up. Observation on 11/03/23 at 8:50 A.M., of the Activities refrigerator showed: - Lower shelf with four black, gray and white expired tomatoes; - Temperature at 50 degrees Fahrenheit (F.). During an interview on 11/03/23 at 8:50 A.M., Housekeeping Aide C said the activities refrigerator was used to store extra food for the residents. Expired foods should be thrown away and the refrigerator temperature should be checked daily. Observation on 11/03/23 at 9:30 A.M., of the Sleepy Oaks kitchen showed: - Scattered debris and a battery on the floor below the main refrigerator and the food shelves; - Food build-up spilled on the glass turntable and splattered inside the microwave interior; - Ice machine with brown and white grime build-up; - Dust pan with debris and a plant fertilizer container located near the food shelves; - One 12 in. x 12 in. ceiling diffuser with brown grime build-up on the front exterior surfaces and between the ventilation louvers over the pantry refrigerator near the food shelves. During an interview on 11/03/23 at 9:35 A.M., Dietary Aide (DA) D said expectations were to clean up before leaving for the day. The refrigerator, ice machine, microwave, floors and vents should be kept clean but need some work. Food should not be stored near chemicals or cleaning supplies and the items will be moved. Observation on 11/03/23 at 9:50 A.M., of the Whispering Pine kitchen showed: - Pantry refrigerator temperature at 46 degrees (F.). - Broom and dust pan with debris in the pantry area near the food storage shelves; - One 12 in. x 12 in. ceiling diffusers with brown grime build-up on the front exterior surfaces and between the ventilation louvers over the pantry refrigerator near the food shelves; - Scattered debris on the floor below the main refrigerator and the food shelves. During an interview on 11/03/23 at 9:52 A.M., DA E said the temperature should be adjusted on the refrigerator. Expectations were to clean up before leaving for the day. The refrigerator, ice machine, microwave, floors and vents should be kept clean but need some work. Food should not be stored near chemicals or cleaning supplies and the items will be moved. During an interview on 11/03/23 at 8:20 A.M., the Registered Dietician said the dishwasher, appliances and floor surfaces should be clean, and expectations were that staff follow the facility's kitchen policy to keep the kitchen clean. The walk in refrigerator and freezer should be clean and frost free. The food boxes and bags should not have ice build-up. Walls, ceilings and floors in the freezer should be clean and frost free. The door gasket should be fixed by maintenance. Maintenance should clean the ventilation louvers. Rack storage for the canned foods and bread should be kept clean and not have dust build-up. During an interview on 11/03/23 at 8:30 A.M., the Dietary Manager said the kitchen can opener should be cleaned after each use, it should look clean. The walk-in freezer and food boxes should not have ice build-up. It should be working properly but wasn't. The Maintenance Director had been notified about the concern a few days ago. There should not be ice coated on the food boxes or on the floor of the freezer, ice machines and all appliances should be clean. Water always stands in the floor when the dishes were cleaned by staff. During an interview on 11/03/23 at 8:33 A. M., DA F said the freezer should be clean and frost free. The refrigerator shelves should be clean and paint should not be chipped. The maintenance director was supposed to clean the refrigerator and vents. During an interview on 11/03/23 at 8:20 A. M., DA G said expectations were to follow the facility's kitchen policy and keep the kitchen clean. Staff usually swept and mopped after each meal and got as far as possible under counters and appliances. A regular broom was used to get behind appliances and it was limited to how well they could clean behind the appliances. The walk-in freezer had been an issue and had had ice build-up for over two years. The freezer should not have build-up and attempts had been made to knock it loose with a hammer. During an interview on 11/03/23 at 3:27 P.M., the Administrator said the freezer and refrigerators should be clean. The ceiling vents should be clean and not have dust or grime build up. All appliances, counter tops and vents should be clean and work properly. Expectations were to follow the facility's kitchen policy and always keep the kitchen clean.

Based on observation, record review, and interview, the facility failed to adequately assess and monitor one resident (Resident #1) after an accident occurred and failed to assess timely and monitor new bruising. The census was 90. Review of the facility's policy titled, Change in Condition or Status, revised 11/20/14, showed the following: -Our facility shall promptly notify the resident, his/her physician, and representative of changes in the resident's medical mental condition and/or status; -The nurse supervisor/charge nurse will notify the resident's physician or on-call physician when there has been an accident or incident involving a resident, a discovery of injuries of an unknown source, or a significant change in the resident's physical/emotional/ mental condition; -Except in medical emergencies, notifications will be made within twenty-four hours of the change occurring in the resident's medical/mental condition or status; -The nurse supervisor/charge nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition. 1. Review of Resident #1's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission date of 4/07/2015; -Diagnoses included, muscle weakness, hemiplegia following cerebral infarction (paralysis of partial or total body function on one side of the body), pain in right hip, major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily activities), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 2/9/2023, showed the following information: -A BIMS (Brief Interview for Mental Status) score of eight indicated the resident's cognition was mildly impaired; -The resident required extensive assistance for transfers and self-care. Review of the resident's care plan, dated 2/10/2023, showed the following: -Alteration in circulatory status related to Plavix (a blood thinner that's used to prevent heart attack and stroke); -The resident will have no excessive bleeding/bruising related to Plavix; -Protect from injury/falls/ skin tears; -Monitor for bleeding such as black tarry stools, coffee ground emesis, excessive bruising, petechiae (pinpoint, round spots that appear on the skin as a result of bleeding), hematuria (blood in urine), nose bleeds, and frank bleeding; -Monitor for pallor, fatigue, and increased shortness of breath; -Monitor labs; -The resident is at risk for falls due to left hemiplegia, right hip pain, antidepressant medication, periods of increased weakness, usually later in the day when tires and history of syncope (a loss of consciousness for a short period of time); -The resident will remain free from fall related injury through next review, no fracture, abrasion, or bruising; -Monitor for sedation , dizziness, decreased coordination as possible side effects of medications. Review of the resident's interdisciplinary notes showed the following: -On 4/07/23 at 6:34 P.M., Licensed Practical Nurse (LPN) C said he/she entered the room due to the certified nursing assistant (CNA's) report of bleeding from buttocks area. He/she noted three centimeters (cm) long x two cm shearing wound to right buttock, area cleansed with normal saline and applied mepilex (wound dressing). Resident was very weak on the toilet, able to follow directions but was very sluggish, moaning and altered level of consciousness (LOC ). The resident was assisted to stand and assisted to a chair. Once resident was in the chair, the resident began immediately leaning to the right side. Resident's smile was symmetrical, speech clear, PERRL (pupils equal, round, and reactive to light), unable to assess extremities due to previous effects of a cerebrovascular accident (CVA or stroke). Resident's family member is at bedside and is very concerned about change in status. Vital signs, Temperature 99.1, Pulse 61, SPO2 (Oxygen saturation) 98. (Normal Ranges: Pulse: 60 to 100 beats per minute. Temperature: 97.8°Fahrenheit (F) ( to 99.1°F average 98.6° and SPO2 95 to 100) Resident was started on Namenda ( a medication used to treat moderate to severe dementia of the Alzheimer's type) on 4/1/2023 and completed COVID-19 treatment the week prior. Attempted to call on-call physician and unable to reach at this time. Review of the facility's incident report, signed by LPN A on 4/10/2023, at 7:47 A.M. showed the following: -On 4/8/23 at 9:00 A.M., the resident was transferred with the sit to stand lift then slid down in the sit to stand sling causing bruising under the right breast and wrapped around to the right mid back. Above the left breast is a grapefruit size swollen area. The resident's family member and the Physicians Assistant (PA) was notified. Review of the resident's interdisciplinary notes showed the following: -On 4/10/23 at 8:32 A.M., LPN A documented the shower aide and CNA notified this nurse of bruising to right chest and right mid back with grapefruit sized swelling over left breast. Noted resident was transferred with sit to stand causing bruising and swollen area above left breast. Notified the resident's family member and the physician's assistant (PA) of findings. Review of the resident's physician order sheet (POS), dated April 2023, showed the following: -Monitor bruising to right chest around to right mid back. Monitor swollen area to left upper breast every day, dated 4/11/2023 to 4/18/2023. Review of the resident's treatment administration record (TAR), dated April 2023, showed the following: - Monitor bruising to right chest around to right mid back. Monitor swollen area to left upper breast every day, dated 4/11/2023 to 4/18/2023; -Completed as ordered. Review of the resident's skin assessments for 4/12/2023 and 4/15/2023 did not show any bruising. Review of the resident's interdisciplinary notes showed the following: -On 4/16/2023 at 11:47 A.M., LPN D said the resident's family member asked writer, what is being done about the bruising on the resident's abdomen and that big spot on his/her shoulder. Did the physician see him/her following the incident with the sit to stand? He/she explained to the resident's family member that the resident saw the PA on Wednesday, 4/12/2023 and the bruise is being monitored. A call was made on Friday, 4/14/2023 to the physician requesting an x-ray due to the family asking for one. The physician's nurse was notified, and the facility has not heard back from the physician regarding the x-ray. The family said, the facility or provider was being negligent. He/she said all proper steps are being taken to ensure the resident's safety. The resident is being transferred using the Hoyer lift (a mechanical device with a sling attached to a lift and used to transfer a non-ambulatory resident) due to continued decrease in mobility and alertness. Review of the resident's skin assessments for 4/17/2023 did not show any bruising. During an interview on 4/17/23, at 1:35 P.M., the resident representative said the following: -Nurse Aide (NA) A used the sit to stand lift to transfer Resident #1 to the toilet. When he/she was trying to get the resident off the toilet, the resident was too weak to stand and couldn't hold him/herself up; -NA A tried again and then a nurse came in and told him/her not to try again; -The resident ended up having bruising/swelling on his/her left chest and around to his/her back: - On 4/10/2023, LPN A said he/she did not think it needed to be x-rayed and the resident might have a strained muscle; -He/she was concerned that the injury was not properly assessed. Observations on 4/17/2023 at 1:35 P.M., showed the following: -Resident #1 had yellowing bruising under his/her left breast going around to the back of the resident. During an interview on 4/17/2023 at 3:39 P.M., Registered Nurse (RN) E said the following: -Residents should be assessed after incident that could potentially result in an injury; -The incident should be documented in the chart and any injuries or bruising should be documented and monitored. During an interview on 4/20/2023 at 11:38 A.M., LPN A said the following: - A CNA, he/she could not remember who, told him/her that the incident of Resident #1 sliding down in the lift happened sometime over the weekend. On 4/10/2023, he/she documented it occurred on 4/8/2023, because he/she was not sure when it actually happened; -It should have been documented by the nurse that worked over the weekend but it was not; -He/she was not sure if Resident #1 was assessed after the incident but he/she should have been; -He/she was informed by the shower aide that the resident had bruising and he/she assessed the bruising on 4/10/2023. The bruising was on the left breast and went around to the mid back with a grapefruit sized swollen area on the left breast. He/she documented the location incorrectly in the nurses note and is in the left side; -He/she contacted the PA and put the resident on the list to see the physician that week. The PA told him/her to monitor; -The resident only had complaints of mild soreness and he/she did not think the resident required any emergency care; -A new onset of bruising should be monitored daily. He/she added an order to monitor the bruising daily; -The incident should have been investigated to find out exactly when the incident occurred. During an interview on 4/20/2023 at 12:00 P.M., NA A said the following: -On 4/7/2023 in the evening after dinner, he/she transferred the resident with the sit to stand lift to the commode over the toilet. He/she used the lift to help get the resident off the toilet but the resident collapsed, was dead weight and unable to weight bear through his/her legs and was only being held up by the sling/belt under his/her breasts because he/she had slid down in the lift and was slumped over; -The LPN C came in upon his/her second attempt and helped him/her transfer the resident; -He/she told LPN C that the resident had slumped over in the sling. LPN C looked at the resident but he/she is not sure everything that was assessed. The resident also had a new wound that the nurse assessed at that time; -The resident did not appear to be in any pain or distress at that time; -He/she took care of the resident on 4/8/2023 and noticed bruising under his/her breast area. He/she assumed it was from the resident sliding down in the sling the day before; -He/she did not report the new bruising to anyone, however, he/she should have reported it to the resident's nurse who was LPN C. During an interview on 4/20/2023 at 12:22 P.M., LPN C said the following: -He/she was unaware of any accidents, injuries or bruising on Resident #1 on the weekend of 4/7/2023. He/she was not made aware of it until the next weekend; -He/she did not assess or monitor Resident #1 for any possible injuries or bruising because he/she was not aware of what had happened; -On 4/7/2023 in the evening he/she came to Resident #1's room. NA A was starting to lift the resident off of the toilet with the lift and noticed the resident was not able to bear weight and told NA A to lower the resident back to the toilet seat because it was not safe to use with the resident at that time. He/she helped transfer the resident off of the toilet; -NA A did not make him/her aware that the resident had slid down in the lift or that there could be a possible injury; -He/she was told about a wound on the resident's bottom that was unrelated to the incident and he/she assessed that. He/she also assessed the resident due to increased weakness that he/she witnessed. He/she did not assess the resident's chest or back area; -The resident did not appear to be in distress; -He/she would have assessed the resident further if he/she has been aware of the incident that had happened earlier. The incident should have been investigated and the physician should have been called; -If a resident has a new bruise it should be assessed and monitored. He/she was unaware that Resident #1 had any bruising on 4/7/2023 or 4/8/2023. During an interview on 4/20/2023 at 12:40 P.M., CNA F said the following: -He/she was not aware of an incident happening on 4/8/2023 and was not in the room when it happened. He/she was working on that hall with NA B; -He/she was not aware of any bruising on Resident #1; -He/she would inform the nurse of any new bruising on a resident; -He/she would let the nurse know if the resident had any incidents or accidents that could be cause an injury. During an interview on 4/20/2023 at 1:44 P.M. the Director of Nursing (DON) said the following: -Resident #1 was examined yesterday and received an x-ray. There were no injuries; -He/she assumed the incident had happened on 4/8/2023 because that is what LPN A documented. The incident should have been investigated; -He/she expects the aides to report any accidents or incidents that could result in injury to the nurse and then he/she would expect the nurse to assess to the resident as soon as possible. Any injury should be documented and monitored; -CNA's should report any new bruising to the nurse and the nurse should assess and monitor. The assessment and monitoring should be documented; -The physician should be notified of new bruising. During an interview on 4/20/2023 at 2:12 P.M., LPN D said the following: -He/she was not aware of any bruising or incidents for Resident #1 until he/she worked on 4/14/2023. He/she did not have much information about it; -A new bruise should be reported to the nurse and then the nurse should assess it and report to the physician. The bruising should continue to be monitored a lease once a day and it should be documented. New bruising should be investigated if he/she is not sure of the cause of the bruising. During an interview on 4/20/2023 at 3:39 P.M., the Administrator said the following: -NA A should have reported the incident with Resident #1 sliding in the lift to the charge nurse. The nurse should have assessed the resident for injury; -If a resident has new bruising, the resident should be assessed by the nurse and then the bruising should be reported to the physician and monitored; -A new injury or bruising should be investigated and needs to be documented in the notes. During an interview on 4/21/2023 at 8:00 A.M., the PA said the following: -He/she was not aware of the bruising on the resident's chest area until 4/19/2023. He/she saw the resident on 4/12/2023 but did not assesses him/her for the bruising or injury because he/she was not made aware of it; -He/she was contacted on 4/12/2023 but was not informed about the bruising or injury on Resident #1; -He/she did not see any notifications of the bruising being made to the physician either; -He/she should be notified of any new or worsening of bruising or swelling. He/she would have assessed the resident sooner if he/she had known about the injury; -He/she ordered an x-ray of his/her chest but the resident was sent to the hospital per the resident's family request and one was completed there. It was negative for any injury. MO00217073

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete the required Preadmission Screening and Resident Review (PASARR) (a two level tool used to screen each resident in a nursing facility for a mental disorder or intellectual disability prior to admission) for one resident (Resident #88), prior to or upon admission to the facility, to ensure the resident received appropriate care and services out of a selected sample of 24 residents. The facility census was 119. The facility did not provide a policy for PASARRs. 1. Record review of the Resident #88's admission Minimum Data Sheet (MDS), a federally mandated comprehensive assessment instrument, completed by facility staff, dated 9/15/12, showed the following information: -admitted from the hospital; -Diagnosis included: depression with psychotic symptoms (mental disorder in which a person has depression along with hallucinations or delusions) and anxiety disorder(worry about future events, and fear is a reaction to current events); -Daily use of psychotropic medications (any drug capable of affecting the mind, emotions, and behavior); -Severe cognitive impairment. Record review of the resident's face sheet (a document that gives a resident's information at a quick glance) showed the following information: -admitted to the facility on [DATE]; -re-admitted to the facility from the hospital on [DATE]; -Diagnosis included: recurrent major depressive disorder with psychotic symptoms, obsessive-compulsive disorder (personality disorder characterized by excessive orderliness, perfectionism, attention to details, and a need for control in relating to others); anxiety disorder, post-traumatic stress disorder (PTSD - condition of persistent mental and emotional stress occurring as a result of injury or severe psychological shock, typically involving disturbance of sleep and constant vivid recall of the experience, with dulled responses to others and to the outside world); -No documentation facility staff completed a level 1 or level 2 PASARR. Record review of the resident's care plan, last reviewed on 1/20/20, showed the resident to be at risk for the following: -Altered thought process; -Impaired psychosocial (positive relationships with others, a feeling of purpose and meaning in life) well-being; -Alteration in mood related to depression and PTSD; -Alteration in behavior related to medical status; -Potential drug related complications due to psychotropic drug use daily. During an interview on 2/18/20, at 2:05 P.M., the facility's office staff was not able to locate the DA 124 for a level 1 PASSAR. An interview on 2/18/20, showed the following: -At 3:05 P.M., the administrator said the resident admitted to the facility, from another facility, in 2012. The resident should have a completed DA 124 on file. Staff would contact Central Office Medical Review Unit (COMRU) to see if they had a copy on file. -At 3:45 P.M., the Administrator said COMRU could not locate the resident's DA 124. The staff would submit a new form with the current date. During an interview and record review on 2/24/20, at 2:50 P.M., the office Assistant said staff completed the form and they were waiting on the physician's signature.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of a facility's policy and procedure entitled Personal Protective Equipment - Using Gloves revised April 2014, showed the following: -Objectives included to prevent the spread of infection and to protect wounds from contamination; -Wash hands after removing gloves. Gloves do not replace handwashing. Record review of Resident #40's face sheet showed the following information: -admitted to the facility on [DATE]; -Diagnoses included diabetes, history of severe sepsis with septic shock (a potentially fatal medical condition that occurs when sepsis, which is organ injury or damage in response to infection, leads to dangerously low blood pressure and abnormalities in cellular metabolism), urinary tract infection (UTI) and extended spectrum beta-lactamase resistance (ESBL- an enzyme produced by certain bacteria that has the ability to break down commonly used antibiotics and render them ineffective for treatment) in the urine. Record review of the resident's care plan, showed an area of concern, dated 9/16/19, as followed: -At risk for skin breakdown due to peripheral vascular disease (a blood circulation disorder that causes the blood vessels outside of your heart and brain to narrow, block, or spasm), diabetes, and decline in health status. Per wound care note, dated 12/9/19, the resident bilateral buttocks were dusky purple with areas of excoriated (scraped or abraded) skin, small amount of bleeding with cleansing; -No shoe or soft slipper on the resident's right foot due to pressure sore on his/her right heel; float heels, pressure relief boots when in bed. Monitor for signs/symptoms of infection, worsening of wound, and failure to show progress in healing. Record review of the resident's physician order sheet showed the following: -An order, dated 8/10/19, to cleanse the resident's right heel wound with normal saline, apply triple-antibiotic ointment, cover with a dry dressing, and wrap with gauze, daily and as needed until healed; -An order, dated 2/10/20, an order for Nystatin (antifungal medication)100,000 unit/gram, apply a thin film to the resident's buttocks, two times daily until clear. Observation on 2/21/2020, at 9:00 A.M., showed LPN A and CNA B washed their hands and donned gloves prior to the LPN performing the resident's right heel treatment. CNA B turned the resident onto his/her left side. Using a soapy cloth, LPN A cleaned a small amount of fecal material from the resident's coccyx (tail bone) then cleaned his/her buttocks, using a clean cloth to dry the skin. LPN A changed his/her gloves, without washing or sanitizing his/her hands. LPN A applied Nystatin cream to the resident's right buttock, then used another wash cloth to clean additional stool from the resident's skin. LPN A changed his/her gloves without performing hand hygiene and turned the resident onto his/her right side. CNA B cleaned the resident's coccyx and buttocks of more stool, and LPN A applied Nystatin to the left buttock. CNA B used hand sanitizer and applied new gloves. CNA B held up the resident's right foot, while LPN A cut the old gauze wrap off of the foot. LPN A used spray cleanser and gauze to clean the resident's heel wound. The LPN changed his/her gloves without performing hand hygiene, then applied antibiotic ointment to the heel using a long cotton-tipped swab. He/she covered the wound with a surgical pad and secured it with a gauze wrap. During an interview on 2/24/20, at 11:37 A.M., LPN A said staff should wash their hands in the resident's room prior to providing care. They should prepare supplies and set up the room, then wash their hands and apply gloves. They should clean the wound, change gloves, then apply the ordered treatment and dressing. Staff should wash their hands between dirty and clean steps/body areas of the care, and they should wash their hands with glove changes. The facility did not have hand sanitizer dispensers in the resident rooms. If staff did not carry hand sanitizer, they needed to wash their hands with soap and water before exiting a resident's room. The facility had hand sanitizer dispensers located outside each room. MO00166797 Based on observation, interview, and record review, the facility failed to consistently and accurately assess and document a newly identified pressure ulcer, failed to notify the physician or Nurse Practitioner of a newly identified pressure ulcer, and failed to obtain an order for treatment of the pressure ulcer for one resident (Resident #87) with a history of pressure ulcers. The facility failed to use appropriate hand hygiene practices when performing pressure ulcer treatment for one resident (Resident #40) in a selected sample of 24 residents. The facility census was 119. 1. Record review of the facility's Pressure Ulcer/Skin Breakdown Policy, dated 1/27/15, showed the following: -Full assessment of pressure sore including location; Stage; length, width, and depth; and presence of exudates (any fluid that has been forced out of the tissues or its capillaries because of inflammation or injury) or necrotic tissue (dead tissue); -Pain assessment; -Resident's mobility status; -Current treatment; -All active diagnoses; -Nutritional status. -Staff will examine the skin for new ulcerations or indications of an area not yet ulcerated. -The physician will help clarify relevant medical issues; -Staff will initiate first aid protocol and staff will notify the physician for orders for treatments; -First aid protocol consisted of initiate pressure reduction surfaces, low loss mattress, alternating mattress, heels up, and pressure reduction cushion. The physician will authorize pertinent orders related to wound treatment. Record review of the resident's 5-day Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/10/20, showed the following information: -readmitted to the facility, from a hospital on 1/6/20; -No short or long term memory problems; -Modified independence with cognitive skills for daily decision making; -Required extensive assistance for bed mobility, dressing, eating, and toilet use; -Dependent upon staff for transfers and personal hygiene; -Diagnoses included hemiplegia (paralysis on one side of the body) or hemiparesis (slight paralysis on one side of the body), and multiple sclerosis (a potentially disabling disease of the brain and spinal cord (central nervous system) where the immune system attacks the protective sheath (myelin) that covers nerve fibers and causes communication problems between the brain and the rest of the body); -One or more unhealed pressure ulcer; -One Stage III pressure ulcer (a full thickness loss of skin, where adipose (fat) is visible in the ulcer, and granulation tissue and rolled wound edges are often present. Slough (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like) and eschar (non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture) may be visible, but do not obscure the extent of tissue loss); -Moisture associated skin damage (a general term for inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, sweat, wound drainage, saliva, or mucus); -Had a pressure reducing device for his/her bed; -Turning/repositioning program; -Pressure ulcer care; -Application of nonsurgical dressings other than to feet. Record review of the resident's nurse's note, dated 1/26/20, showed the wound nurse, Licensed Practical Nurse (LPN) A, documented the following: -Left outer hip with a 2 centimeter (cm) dry, non-open area; -Turn and reposition the resident every two hours. Record review of the resident's care plan, dated 1/27/20, showed the following: -The resident had a skin concern on his/her sacrum (triangular bone at the base of the spine) and gluteal fold (bottom of the buttock); -Under care of a wound clinic; -Treat per physician's orders, monitor for infection; -Call physician if wound worsened. Record review of the resident's physician progress notes, dated 1/29/20, showed the physician documented the resident had Stage III sacral ulcers. (The physician did not address the newly identified skin issue on the resident's left hip.) Record review of the resident's nurses' note, dated 2/2/20, showed the following information: -The resident had an open wound on his/her left hip with small amount purulent (consisting of, containing, or discharging pus) drainage; -Wound bed covered with necrotic tissue with flat edges. Record review showed the facility staff could not locate/provide a documented assessment, dated 2/9/20, of the resident's left hip wound. Record review of the resident's skin evaluation form, dated 2/16/20, showed the following: -Origin date of 1/27/20; -Left hip, persistent skin redness, Deep Tissue Injury (DTI - an intact or non-intact skin with localized area of persistent non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle, or other underlying structures are visible, this indicates a full thickness pressure injury (unstageable, Stage III or Stage IV pressure injury)). -Measured 0.5 centimeter (cm) x 2.5 cm; -Tissue type: slough; -Light serous drainage (pale yellow, transparent, thin and watery drainage); -Treatment: cleanse and cover with a dry dressing. Observation and interview on 2/20/20, at 9:00 A.M., showed the following: -LPN J and Certified Nursing Assistance (CNA) K entered the resident's room to provide wound care to the resident's existing pressure ulcers. The nurse completed the wound care per physician's orders. -The resident had an open wound on his/her left hip that measured approximately 0.5 cm x 5 cm. The wound bed was covered with yellow. -LPN J said the resident did not have an order for treatment of the left hip wound. Staff left the wound open to air (without a dressing). Record review of the resident's physician orders showed no order for treatment of the resident's left hip wound. During an interview on 2/21/20, at 11:00 A.M., Registered Nurse (RN) Q said the following: -If staff identified a new wound, they notified the physician; -He/she did not know the resident had a wound on his/her left hip. He/she did not usually work at the building the resident was located in. -Today, he/she called the resident's Nurse Practitioner (NP) I for an order. The NP told him/her (the nurse) to call the wound nurse (LPN A) for treatment orders, which he/she did. Record review of the resident's physician order, dated 2/21/20, showed instructions for staff to clean the resident's left hip wound with normal saline, apply a wound barrier and cover with a dressing, every day. (Staff obtained the order 26 days after the first observation.) Record review of the resident's skin evaluation form, dated 2/23/20, showed the following: -Origin date: 1/27/20; -Left hip, persistent skin redness, DTI; -Staff hand wrote a 1 and a 2, placing () around the 2. -Measured 0.4 cm x 2 cm; -Description: The wound had no drainage, and no foul odor. The wound was covered with a thin layer of slough, improving; -Treatment: Cleanse with normal saline, apply a thin layer of Santyl (a medicated ointment applied to burns and skin ulcers to help remove dead skin tissue and aid in wound healing) and cover with a dry dressing, every day. During an interview on 2/21/20, at 11:40 A.M., Graduate Practical Nurse (GPN) R said if he/she observed a new open area, he/she reported it to the charge nurse who assessed the wound. The charge nurse documented the assessment in the nurses' notes and reported it to the wound nurse (LPN A). During an interview on 2/21/20, at 1:25 P.M., Nurse Practitioner (NP) I said the following: -If the nurses identified a new wound, he/she expected them to report it to him/her as soon as they found it. If the wound was necrotic, the nurses should notify him/her by phone and document the new issue in the NP communication book. The NP reviewed the book on Thursday or Friday, each week, prior to assessing residents. -Staff should report newly identified superficial wounds to LPN A (the wound nurse), but NP I also wanted notification of any skin concern. -The NP did not know the resident had a wound on his/her left hip, until yesterday (2/20/20). Staff should have notified him/her of the new wound; -LPN A did not notify him/her of the resident's skin concern. -He/she instructed RN Q to call the wound nurse for treatments instructions because she needed to assess the wound before she ordered a treatment. During an interview on 2/21/20, at 2:30 P.M., the Director of Nursing (DON) said the following: -If staff identified a new wound, they reported it to the charge nurse. The charge nurse either notified the physician or the wound nurse (LPN A); -Any nurse who identified a new open area, could document it in the computer which created an alert. -The DON found out about new wounds by reviewing the alerts. -The wound nurse assessed all wounds weekly and documented her assessments in the skin evaluation form, and completed dressing changes as needed. -The physician evaluated residents' wounds as needed. -The wound nurse told the charge nurses what treatments needed to use. -The DON did not know the resident had a wound on his/her left hip until 2/19/20. During an interview on 2/21/20, at 3:31 P.M., the DON said the following: -He/she periodically went to the Greenhouses (buildings under the same license, but located separate from the main building) and measured wounds; -There are five charge nurses (for the Greenhouses) who are all responsible for residents' care. When a nurse identified a new wound, he/she should notify the NP and or the physician. During an interview on 2/24/20, at 1:20 P.M., LPN A said the following: -She had worked as the facility's wound and treatment nurse for eight years; -If a nurse identified a new wound, he/she notified the physician for orders. If a nurse identified a problem with an existing wound, he/she notified the NP. -The nurses assessed, monitored, and documented on, residents' wounds weekly. -Every week, she went to the Greenhouses and talked to the nurses about residents' skin issues. -On 1/26/20, when she first identified the skin concern on the resident's left hip, it looked like two small bruises. -The wound nurse told the charge about the bruises. He/she (LPN A) did not notify the NP or physician, because she thought the charge nurse would. She did not know why the charge nurse did not call the physician or at least document it in the NP communication book. -She did not obtain a physician's order for treatment of the resident's left hip wound because the nurses knew the facility had standing treatment orders (first aid protocol) and the resident's hip wound improved. -She should have reported it to the physician or the NP. -She did not report the resident's left hip wound to the DON. -On the nurses' note dated 2/2/20, she used the wrong verbiage when she documented the assessment of the resident's hip wound. She should not have documented the wound had necrotic tissue. During an interview on 2/24/20, at 1:55 P.M., the Medical Director said the following: -If staff identified a new wound, they should report it to him or the NP; -He did not know the resident had a wound on his/her left hip and assessed it today for the first time. -The resident's left hip wound was a Stage II (partial-thickness skin loss with exposed dermis (the inner layer of the two main layers of cells that make up the skin which contains blood vessels, lymph vessels, hair follicles, and glands). The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue (new connective tissue), slough and eschar are not present) fold of skin and superficial. -He observed no necrosis or necrotic skin, so he/she knew the wound nurse documented her assessment wrong. The term necrosis was inappropriate for this wound. -Attention to the wound is the most important to keep the wounds clean and infection free. -We (the medical director and facility staff) were working on communication and documentation, and who reported to who and who monitored wounds.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review of Resident #42's face sheet (basic information sheet) showed the following information: -admitted to the facility on [DATE]; -Diagnoses included: acute cystitis (inflammation of the urinary bladder often caused by an infection and accompanied by frequent painful urination) without hematuria (blood); chronic kidney disease stage 3 (kidneys are damaged and cannot filter blood the way they should); Diffuse large B-cell lymphoma (cancer that starts in white blood cells); type 2 diabetes mellitus (chronic disease associated with abnormally high levels of the sugar glucose in the blood); anxiety; chronic pain. Record review of the resident's annual MDS, dated [DATE], showed the following information: -admitted to the facility 11/22/18; -Required extensive assistance with bed mobility, transfers, toileting, and dressing; -Used a wheelchair for mobility; -Cognitively intact. Record review of the resident's Care Plan, last updated 12/2/19, showed the following information: -Required extensive staff assistance for transfers; -Used ¼ side rails on bed to help with mobility. Record review of the resident's POS, dated 2/24/20, showed no order pertaining to the use of bed rails. Observation and interview on 2/18/20, at 11:57 A.M., showed the resident's bed had half-side rails in place on each side of the bed. The resident said he/she used the bed rails to assist with bed mobility. He/she did not know if staff obtained any measurements on the bed and side rails and did not remember if he/she signed any documents related to risks and benefits of side rail use. Record review of the resident's Side Rail Evaluation, dated 12/2/19, showed the following information: -Resident expressed a desire to have side rails raised when in bed for his/her own safety and/or comfort; used them as an aide with bed mobility; -Resident was not able to get in/out of bed by himself/herself; -Resident had problems with balance and required a mechanical lift or a sit-to-stand lift for transfers; (Staff did not document any risk to the use of side rails). Record review of the resident's EMR showed staff did not document an informed consent for risks and benefits of the bed rails with consent given by the resident or responsible party and there was no documentation of side rail gap measurements. 4. Record review of Resident #88's face sheet showed the following information: -admitted to the facility on [DATE]; -re-admitted to the facility from the hospital on [DATE]; -Diagnosis included: type 2 diabetes mellitus; major depressive disorder with psychotic symptoms (mental disorder in which a person has depression along with loss of touch with reality); dementia with behavior disturbance; chronic pain; right leg below the knee amputation; pressure ulcer (tissue damage, sometimes presenting as an open wound, caused by pressure on a bony prominence) sacrum (a shield-shaped bony structure located at the base of the lower back connected to the pelvis). Record review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/10/20, showed the following information: -Required total assistance for bed mobility, transfers, toileting, and dressing; -Severe cognitive impairment. Record review of the resident's care plan, last updated 1/20/20, showed staff documented the following: -Required extensive and/or total assistance with bed mobility, transfers, dressing, meals, toileting, personal hygiene, and bathing related to dementia and right above the knee amputation; -Transferred with a mechanical lift and 2 staff; -Used a geri-chair (geriatric chair) (a large, padded, comfortable reclining chair with casters designed to allow patients recovering from illness, or the elderly and infirm to get out of a bed and sit comfortably while being fully supported and transported to adjoining areas); -At times used ¼ side rails as aid in bed mobility. Observation and interview on 2/17/20, at 12:01 P.M., showed the resident positioned in bed with raised half-side rails on each side of the bed. Record review of the resident's POS, dated 2/24/20, showed no order related to side rail use. Record review of the resident's Side Rail Evaluation, dated 1/17/20, showed the following information: -Resident expressed a desire to have side rails raised when in bed for their own safety and/or comfort; at times the resident can use to assist in repositioning and turning; -Resident was not able to get in/out of bed by self; -Resident had problems with balance related to being non-ambulatory, had right above knee amputation, required a mechanical lift for transfers, and used a geri-chair; -Staff did not document any risk to the use of side rails. Record review of the resident's EMR showed staff did not document an informed consent for risks and benefits of the bed rails with consent given by the resident or responsible party, and did not document side rail gap measurements. 5. Record review of Resident #102's face sheet showed the following information: -admitted to the facility on [DATE]; -Diagnoses included: weakness, anxiety disorder, fracture thoracic vertebra (small bones forming the backbone) and lumbar vertebra (unstable injury involving bone and/or soft tissue in which a vertebra moves off an adjacent vertebra (displacement)), dorsalgia (pain in the upper back), polyosteoarthritis, depression. Record review of the resident's annual MDS, dated [DATE], showed the following information: -admitted to the facility 10/13/17; -re-admitted from hospital on 1/8/19; -Independent with bed mobility and transfers; -Used a walker for mobility; -Cognitively intact. Record review of the resident's care plan, last updated 1/28/20, showed staff documented the following: -Self care deficit related to chronic back pain and history of vertebral fractures; -Increased pain limited the ability to function; -Uses ¼ side rails on bed as an aid in bed mobility; -Independent with transfers. Observation and interview on 2/17/20, at 12:05 P.M., showed the resident resting in bed with raised side rails on both sides of the bed. The resident said he/she had to stay in bed and keep his/her back straight due to crushed vertebra. He/she used the side rails to help with bed mobility, when needed. Record review of the resident's Side Rail Evaluation, dated 1/28/20, showed the following information: -Resident expressed a desire to have side rails raised when in bed for his/her own safety and/or comfort; stated he/she used them to reposition self; -Resident was able to get in/out of bed by self; -Staff did not document any risk to the use of side rails. Record review of the resident's EMR showed staff did not document an informed consent for risks and benefits of the bed rails with consent given by the resident or responsible party, and did not document side rail gap measurements. 6. During an interview on 2/21/20 at 11:52 A.M., the Director of Nursing (DON) said staff completed a risk evaluation prior to the use of side rails (which have to be requested by the resident), but did not discuss risks of use with the resident/family or obtain written/verbal consent. They did not obtain gap measurements between the mattress and side rails. During an interview on 2/24/20, at 3:05 P.M., the maintenance supervisor said maintenance staff only applied side rails to a resident's bed after they received orders from the nursing staff. Maintenance staff did not complete any measurements on the bed rails. The rails are in a fixed position on the beds and are not adjustable. Some of the larger beds have adjustable width rails but they are still fixed to the bed frame. Based on observation, record review, and interview, the facility failed to complete a side rail risk/benefit review with the resident and/or responsible party and obtain informed consent for the use of side rails, and failed to complete the bed rail safety measurements for five residents (Residents #15, #87, #42. #88, #102) in a selected sample of 24 residents. The facility census was 119. The facility did not provide a copy of a policy related to the use of side rails. 1. Record review of Resident #15's face sheet (gives basic profile and health information) showed the following information: -admitted to the facility on [DATE]; -Diagnoses included congestive heart failure (CHF), fibromyalgia (widespread muscle pain and tenderness), polyosteoarthritis (pain and inflammation in multiple joints), high blood pressure, and palliative care. Observation on 2/18/2020 at 1:46 P.M., showed half-side rails raised on both sides of the resident's bed. During the observation, the resident said he/she used the rails to reposition himself/herself and to keep from rolling out of bed. Record review of the resident's Side Rail Evaluation, dated 5/1/19, showed the following information: -Resident expressed a desire to have side rails raised when in bed for his/her own safety and/or comfort; stated he/she used them to help reposition himself/herself; -Resident was unable to get in/out of bed; -History of falls; -Side rail helped the resident rise from a supine (lying face upward) position to a sitting/standing position; -No risk that resident would climb over the side rails; -Staff did not document any risk to the use of side rails. Record review of the resident's electronic medical record (EMR) did not show documentation regarding either a risk/benefit review with or consent given by the resident/responsible party for bed rail use in spite of risks. Record review of the resident's physician order sheet (POS), current as of 2/24/2020, showed no order pertaining to the use of bed rails. Record review of the resident's care plan showed on start date of 11/14/19, the resident requested the side rails be left on his/her bed to assist with bed mobility. 2. Record review of Resident #87's face sheet showed the following information: -admitted to the facility on [DATE]; -Diagnoses included generalized anxiety disorder, multiple sclerosis, morbid obesity, high blood pressure, acute and chronic respiratory failure, gastro-esophageal reflux disease (GERD), and restless leg syndrome. Observation on 2/21/20 at 3:40 P.M., showed half side rails raised on both sides of the resident's bed. Record review of the resident's Side Rail Evaluation, dated 3/21/16, showed the following information: -Resident expressed a desire to have side rails raised when in bed for his/her own safety and/or comfort; stated he/she used them to help with bed mobility; -Experienced periods of delusions and hallucinations; -Resident was unable to get in/out of bed; -No risk that resident would climb over the side rails; -Staff did not document any risk to the use of side rails. Record review of the resident's EMR did not show documentation regarding either a risk/benefit review with or consent given by, the resident/responsible party for bed rail use in spite of risks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to use appropriate infection control procedures to prevent or reduce the risk of spreading bacteria or other infectious causing contaminants when staff did not use appropriate hand hygiene during incontinence care for two residents (Resident #42 and Resident #88) out of a selected sample of 24. The facility census was 119. Record review of a facility's policy entitled Handwashing/Hand Hygiene dated April 22, 2014, showed the following information: -Hand hygiene products and supplies shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies; -Employees must wash their hands with soap and water under the following conditions: Before and after direct contact with residents; after contact with blood, body fluids, secretions, or non-contact skin; after removing gloves; after handling items potentially contaminated with blood, body fluids, or secretions; and when hands are visibly dirty or soiled with blood or other body fluids. Record review of the Using Gloves portion of the facility's Infection Control Policy and Procedure Manual, dated April 2014, showed the following information: -Use non-sterile gloves primarily to prevent the contamination of the employee's hands when providing treatment or services to the patient and when cleaning contaminated surfaces; -Wash hands after removing gloves (Note: Gloves do not replace handwashing). 1. Record review of Resident #42's face sheet (basic information sheet) showed the following information: -admitted to the facility on [DATE]; -Diagnoses included: acute cystitis (inflammation of the urinary bladder often caused by infection and usually accompanied by frequent painful urination) without hematuria (blood); chronic kidney disease stage 3 (kidneys are damaged and cannot filter blood the way they should); Diffuse large B-cell lymphoma (cancer that starts in white blood cells); type 2 diabetes mellitus (chronic disease associated with abnormally high levels of the sugar glucose in the blood); anxiety; and chronic pain. Record review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 11/29/19, showed the following information: -Required extensive assistance with bed mobility, transfers, toileting, and dressing; -Always incontinent; -Used a wheelchair for mobility. Record review of the resident's care plan, last updated 12/2/19, showed staff documented the following: -Incontinence related to taking two daily diuretics (medications designed to increase the amount of water and salt expelled from the body as urine); -Offer assistance with toileting on the bed pan every morning, before and after meals, at bedtime, at night when awake, and as needed; -Monitor for incontinence with care and every 2 hour repositioning, provide perineal care, keep skin clean and dry; -Monitor for skin redness or breakdown to perineal area, notify charge nurse if noted. An observation on 2/25/20, at 1:15 P.M., showed Certified Nurse Aide (CNA) C and CNA D entered the resident's bathroom. CNA D washed his/her hands and applied gloves, CNA C applied gloves but did not wash his/her hands. CNA D assisted the resident into a standing position using the sit-to-stand lift. CNA C pulled down the resident's pants and assisted him/her into bed. CNA C unhooked the resident's wet brief and cleaned the resident's inner thighs and peri-area with a wet, soapy washcloth. CNA C removed his/her gloves then applied new gloves without washing his/her hands or using hand sanitizer. CNA C used a wet cloth to wipe off the soap residue, then used a dry cloth to dry area. The CNAs assisted the resident onto his/her right side and CNA C cleaned the resident's buttocks region with wet, soapy washcloth. He/she removed his/her gloves and applied new gloves, without washing his/her hands or using hand sanitizer, then rinsed the resident's buttock region with a wet cloth and dried it with a dry cloth. CNA C fastened the resident new incontinent brief and adjusted the resident's gown. He/she removed his/her gloves and without washing hands or using hand sanitizer, repositioned the resident's pillow, adjusted the bed covers, and handed the resident the oxygen tubing. CNA D and CNA C washed their hands before leaving the room. 2. Record review of Resident #88's face sheet showed the following information: -admitted to the facility on [DATE]; -re-admitted to the facility from the hospital on [DATE]; -Diagnoses included: diabetes, depression with psychotic symptoms, dementia with behavior disturbance, chronic pain, right leg below the knee amputation and sacral pressure ulcer. Record review of the resident's annual MDS, dated [DATE], showed the following information: -Required total assistance of two staff for bed mobility, transfers, toileting, and dressing; -Always incontinent. Record review of the resident's care plan, last updated 1/20/20, showed the following: -Incontinent of bowel and bladder; -Check for incontinence every 2 hours and as needed; -He/she wore attends all the time; -Observe for signs and symptoms of urinary tract infection (UTI); -Monitor for redness, irritation to perineal area and report to nurse if noted. An observation on 2/21/20, at 9:05 A.M., showed CNA D and CNA E entered the resident's room to provide incontinence care to the resident. The CNAs washed their hands and applied gloves. CNA E unfastened the resident's brief; the resident was incontinent of liquid stool that extended down the resident's thigh and part way up his/her back. CNA E cleaned the resident's inner thigh with a wet, soapy cloth, discarded the cloth, then wiped the resident's opposite inner thigh with wet, soapy cloth and discarded the cloth. The aide removed his/her gloves and applied new gloves, without washing his/her hands or using hand sanitizer. CNA D rolled the resident onto his/her right side and CNA E cleaned the resident's left thigh and buttock area with a wet cloth. CNA E removed his/her gloves, applied new gloves, without washing his/her hands or using hand sanitizer then removed the resident's gown. He/she changed his/her gloves but did not wash his/her hands or use hand sanitizer before applying the new gloves. CNA D removed his/her gloves, picked up the trash and dirty laundry, and opened the door. He/she said he/she would wash his/her hands out there and left the room. CNA E removed his/her gloves and washed his/her hands. 3. During interviews on 2/24/20, at 1:00 P.M., CNA F and CNA G said staff should wash their hands before care and after care. Staff should not leave the resident's room without washing their hands and they should not touch resident's personal items without washing their hands. During an interview on 2/24/20, at 1:05 P.M., Registered Nurse (RN) H said staff should wash their hands before and after any cares. When staff remove their dirty gloves, they should wash their hands before applying new gloves or before touching anything clean. Staff should not leave any resident room without washing their hands. During an interview on 2/25/20, at 4:02 P.M., the Director of Nursing (DON) said she expected staff wash their hands before cares, during cares, in between glove changes, and any time hands or gloves were soiled. Staff should not touch clean items in the resident's room with dirty gloves, without washing their hands first. It was not acceptable for staff to leave the room, without washing their hands, after providing resident cares.

Based on observation, interview, and record review, the facility failed to protect food from possible contamination when staff failed to ensure the air gap, for two ice machines, had the required two-inch gap between the drain in the floor and the tubing from the ice machine. The facility had a census of 119 residents. Review of the 2017 Food Code, issued by the Food and Drug Administration, showed the an air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or non-food equipment shall be at least twice the diameter of the water supply inlet and may not be less than 1 inch. 1. Observation on 2/18/20, at 4:15 P.M., showed three ice machines in the main building of the facility. Two were located in a closed area off the staff lounge. The ice machines had PVC type pipe of about 1 inch diameter going directly into a larger PVC pipe drain of about 2-3 inches diameter. There was no air gap. During an interview on 2/21/20, at 12:20 P.M., the Dietary Manager said the maintenance department cleaned the ice machines frequently. When she first started at the facility, about 5 years ago, the ice machines drained to the floor drain. Maintenance department changed them at some point and the two machines now drain into the pipe in the wall; she did not know when the piping changed. During an interview and observation on 2/24/20, at 3:05 P.M., the Maintenance Supervisor said the ice machines always drained into the PVC pipe; the pipe went directly into the sanitary drain. He did not know about the 2 inch air gap requirement.