**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of the facility policy, the facility failed to ensure care plans were accurate and current. This affected two residents, (#10 and #20) out of five residents reviewed for care plans. The current census was 53. Findings include: 1. Review of the medical record for Resident #10 revealed the resident was admitted to the facility on [DATE]. Diagnoses included fracture of right humerus, unspecified intellectual disabilities, depression, anxiety, insomnia, and pain. Review of Resident #10's Minimum Data Set (MDS) admission assessment dated [DATE] revealed the resident had impaired cognition. Review of the psychiatric diagnostic evaluation dated 02/17/23 revealed the Psychiatric Licensed Social Worker (PLSW) documented Resident #10 had a history of past trauma involving the murder of her brother, abuse by her parent, and abuse by her partner. Per the evaluation ongoing counseling and evaluation from a psychiatrist for medication management was recommended. Review of Resident #10's care plans dated, 01/13/25, revealed a focus added to the care plans for of history of traumatic experiences. No care plan for trauma was added the the resident's care from 11/29/22 to 01/13/25. Interview on 01/15/24 at 3:33 P.M. with the Administrator and Director of Nursing (DON) revealed Resident #10 had reported her past trauma to the social worker sometime during 12/2024. Per the Administrator upon the report the care plan for trauma was not initiated until 01/13/25. Per the DON, Resident #10 did not report the type of trauma and/or any triggers of trauma to anyone prior to 12/2024 per her knowledge. Interview on 01/16/24 at 8:33 A.M. with Social Worker (SW) #380 revealed on 01/03/25 Resident #10 reported to the social worker she had a past trauma of abuse from her family, including her ex-husband. SW #380 stated she reported the trauma to the Administrator but did not document the report. SW #380 denied knowledge of the psychiatric evaluation dated 02/17/23, and stated she was not made aware of the details regarding the resident's trauma until 01/03/25. 2. Review of the medical record for Resident #20 revealed the resident admitted to the facility on [DATE]. Diagnoses included multiple rib fractures post fall, urinary retention, heart disease, and spinal stenosis. Review of Resident #20's MDS admission assessment dated [DATE] revealed the resident had intact cognition and was admitted to the facility without an indwelling catheter. Review of Resident #20's nursing admission assessment dated [DATE] revealed when the resident re-admitted to the facility on [DATE] he did not have an indwelling urinary catheter. Review of Resident #20's orders revealed the resident was scheduled for an outside appointment with a urologist on 12/23/24. Per the order dated 12/23/24 the resident was ordered to receive indwelling catheter care each shift for the Foley catheter placed. Review of Resident #20's care plans dated from 12/23/24 to 01/13/25 revealed no focus was added to the care plans for the indwelling urinary catheter. On 01/14/25 the staff updated the care plans to add the catheter focus. Interview on 01/16/24 at 10:48 A.M. with Medical Director (MD) 408 revealed when Resident #20 was admitted he was not admitted with an indwelling catheter. Per MD #408, Resident #20 shows signs of urinary retention and was seen by an outside urologist for the issue. MD #408 stated when he returned to the facility from the appointment he had an indwelling catheter placed and the facility staff were caring for the catheter. MD #408 stated the outside urologist is managing the care for the catheter. Interview on 01/16/25 at 11:05 A.M. with Registered Nurse (RN) #350 revealed Resident #20 has had an indwelling catheter for over a month. Interview on 01/16/25 at 11:35 A.M. with the Director of Nursing (DON) verified the care plan was not updated on 12/23/24 when Resident #20 returned to the facility with the indwelling catheter. Per the DON, the care plan was revised after MD #408 had ordered new care orders for the catheter care on 01/14/25. Review of the facility policy titled Comprehensive Care Plans, dated 05/22/18, revealed the facility will ensure all care plans are accurate and current to ensure proper care is provided.

Based on observation, staff interviews and review of facility policy, the facility failed to ensure proper infection control measures wre followed for nephrostomy collection bag. This affected one Resident #144 of two reviewed for urinary catheter care. The facility census was 53. Findings included: Review of medical record for Resident #144 revealed an admission date of 01/10/25. Diagnoses included hydronephrosis with renal and ureteral calculous obstruction with a nephrostomy. Observation on 01/16/25 at 6:57 A.M revealed the resident was lying on his left side with the nephrostomy drainage bags hanging off the left side of the bed touching the ground. Interview with Certified Registered Care Associate (CRCA) # 329 on 01/16/25 at 7:15 A.M. verified the drainage bags were over the left side of the bed and touching the floor. Review of the policy titled Urinary Catheter Care, dated 12/16/24, revealed the urinary drainage bag should be held or positioned lower than the bladder to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. Be sure the catheter tubing and drainage bag are kept off the floor.

Based on medical record review and staff interview, the facility failed to ensure a care plan was developed to address resident medical diagnoses. This affected three (Resident #18, #23, and #103) out of 11 residents reviewed for care plans. The facility census was 47. Findings include: 1. Review of the medical record for Resident #18 revealed an admission date of 05/20/22. Diagnoses included congestive heart failure (CHF), atherosclerotic heart disease (ASHD), hypertension, and headache syndrome. Review of Resident #18's admission Minimum Data Set (MDS) assessment, dated 08/17/22, revealed diagnoses of CHF, ASHD, hypertension, and headache syndrome. Review of Resident #18's most recent care plan, last updated 08/22/22, revealed there were no interventions for CHF, ASHD, hypertension, or headache syndrome in the care plan. Interview on 08/24/22 at 1:18 P.M. with Registered Nurse (RN) #139 and RN MDS Support #185 verified Resident #18's diagnoses of CHF, ASHD, hypertension, and headache syndrome were not addressed in the care plan. 2. Review of the medical record for Resident #23 revealed an admission date of 06/16/22. Diagnoses included CHF, osteoarthritis, and diabetes mellitus. Review of the Resident #23's admission MDS assessment, dated 06/20/22, revealed Resident #23 had diagnoses of CHF, osteoarthritis, and diabetes mellitus. Review of Resident #23's care plan, last updated 08/22/22, revealed there were no interventions for CHF, osteoarthritis, or diabetes mellitus in the care plan. Interview on 08/25/22 at 1:33 P.M. with RN #139 verified Resident #23's diagnoses of CHF, osteoarthritis, and diabetes mellitus were not addressed in the care plan. 3. Review of the medical record for Resident #103 revealed an admission date of 07/17/22. Diagnoses include unspecified heart failure and seizures. Review of Resident #103's admission MDS assessment, dated 07/27/22, revealed Resident #103 had diagnoses of unspecified heart failure and seizures. Review of Resident #103's care plan, last updated 07/27/22, revealed there were no interventions for unspecified heart failure or seizures in the care plan. Interview on 08/24/22 at 1:18 P.M. with Registered Nurse (RN) #139 and RN MDS Support #185 verified Resident #103's diagnoses of unspecified heart failure and seizures were not addressed in the care plan.

Based on observation, resident interview, and staff interview, the facility failed to ensure staff trimmed the fingernails of residents who were unable to carry out activities of daily living. This affected one (Resident #22) out of 47 residents reviewed for personal hygiene. The facility census was 47. Findings include: Review of the medical record for Resident #22 revealed an admission date of 06/08/22. Diagnoses included left femur fracture, paranoid schizophrenia, unspecified psychosis, and anxiety. Review of the admission Minimum Data Set assessment, dated 06/13/22, revealed Resident #22 was cognitively intact and required extensive assistance of two staff for personal hygiene. Observations on 08/22/22, 08/23/22, and 08/24/22 revealed Resident #22's fingernails were past the fingertips. Resident #22's nails were clean. Interview on 08/23/22 at 11:00 A.M. with Resident #22 revealed he preferred his nails to be shorter and no one had trimmed them for quite a while. Interview on 08/24/22 at 11:00 A.M. with Director of Health Services and Registered Nurse Clinical Campus Support #184 revealed they were aware Resident #22 stated his fingernails were longer than he preferred. Observation on 08/25/22 at 8:00 A.M. revealed Resident #22's fingernails remained the same length. Interview with Resident #22 at the time of the observation revealed he preferred his nails were cut shorter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident and staff interview, and facility policy review, the facility failed to ensure residents blood sugar levels were checked as ordered. This affected two (Resident #7 and #29) out of five residents reviewed for unnecessary medications. The facility census was 47. Findings include: 1. Review of Resident #29's medical record revealed Resident #29 was admitted on [DATE]. Diagnoses included but were not limited to type two diabetes mellitus without complications, acute respiratory failure with hypoxia, and chronic combined systemic and diastolic heart failure. Review of Resident #29's Minimum Data Set (MDS) assessment, dated 07/01/22, revealed the resident was cognitively intact and received insulin. Review of Resident #29's physician order, dated 08/10/22, revealed an order for Novolog (insulin) three milliliter (ML) 100 units/ML per sliding scale based on blood sugar results four times a day. Review of Resident #29's Medication Administration Record (MAR), dated August 2022, revealed on 08/23/22 from 4:00 P.M. to 5:00 P.M., Resident #29 did not have his blood sugar level checked. Review of a note entered on 08/23/22 at 10:17 P.M., revealed Resident #29's blood sugar check was not completed by the previous nurse. Interview on 08/24/22 at 9:29 A.M. with Resident #29 revealed his blood sugar was not checked yesterday (08/23/22) prior to dinner. Interview on 08/24/22 at 10:35 A.M. with Registered Nurse (RN) #131, verified Resident #29's blood sugar was not checked on 08/23/22 prior to the evening meal. RN #131 stated there were two new admissions and she did not have time. 2. Review of Resident #7's medical record revealed Resident #7 was admitted on [DATE]. Diagnoses included but were not limited to type two diabetes mellitus with diabetic chronic kidney disease, end stage renal disease, and heart failure. Review of Resident #7's MDS assessment, dated 08/09/22, revealed Resident #7 was cognitively intact and received insulin. Review of Resident #7's physician order, dated 07/09/22, revealed an order for Novolog Flexpen U-100 Insulin administered per sliding scale based on blood sugar results. Review of Resident #7's MAR, dated August 2022, revealed on 08/23/22 from 4:00 P.M. to 5:00 P.M., Resident #7 did not have his blood sugar level checked. Review of a note entered on 08/23/22 at 10:16 P.M., revealed Resident #7's blood sugar check was not completed by the previous nurse. Interview on 08/24/22 at approximately 4:15 P.M. with Registered Nurse MDS Support #185 verified on 08/23/22, prior to dinner, Resident #7 did not have his blood sugar checked as ordered. Review of the policy titled Glucometer Standard Operating Procedure, reviewed 03/17/22, revealed blood glucose monitoring shall be completed for the resident per the physician order.

Based on medical record review, observation, and staff interview, the facility failed to maintain and store a rigid suction catheter in clean and sanitary manner. This affected one (Resident #20) out of one resident reviewed for respiratory suctioning. The facility census was 47. Findings include: Review of the medical record for Resident #20 revealed an admission date of 03/29/22. Diagnoses included sepsis due to methicillin resistant staphylococcus aureus and pseudomonas, acute respiratory failure, and acquired absence of larynx. Review of the admission Minimum Data Set assessment, dated 06/10/22, revealed Resident #20 was cognitively intact and required extensive assistance of one staff for personal hygiene. The assessment further indicated respiratory suctioning was performed. Observation on 08/22/22 at 10:30 A.M. revealed a rigid suction catheter, attached to a suction hose, was draped over the suction machine in Resident #20's room. The tip of the catheter was exposed to the air and was noted to be crusted with a dark brown substance. Interview with Resident #20 at the time of the observation revealed he used the suction catheter to remove secretions from his tracheostomy stoma and then draped it over the machine. Resident #20 indicated he was only able to see shadows and was unaware of the condition of the catheter. Interview on 08/22/22 at 10:45 A.M. with Registered Nurse Clinical Campus Support #184 verified the tip of Resident #20's rigid suction catheter was crusted with a dark brown substance and was exposed to air.

Based on medical record review, observation, and staff interview, the facility failed to ensure wound measurements were accurately documented on a wound assessment. This affected one (Resident #22) out of two residents reviewed for pressure ulcers. The facility census was 47. Findings include: Review of the medical record for Resident #22 revealed an admission date of 06/08/22. Diagnoses included left femur fracture, unspecified psychosis, paranoid schizophrenia, and anxiety. Review of the Wound Management Detail Report, dated 08/24/22, by Director of Health Services (DHS), revealed Resident #22's wound measured five cm in length, 3.2 cm in width, and 0.2 cm in depth. The wound was documented as unstageable with slough and/or eschar. The tissue type was slough with 25% of wound covered with granulation tissue and 75% of the wound covered with slough tissue. Observation on 08/24/22 at 2:00 P.M. of Resident #22's wound dressing change, performed by DHS, revealed the wound had 75% slough in the wound bed. DHS measured the wound and stated it was five cm in length and 3.2 cm in width. She did not indicate, nor was it observed, a depth measurement. Interview on 08/25/22 at 1:30 P.M. with DHS and Registered Nurse Clinical Campus Support #184 verified Resident #22's wound documentation on 08/24/22 was inaccurate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, resident and staff interview, and review of facility policy, the facility failed to ensure resident smoking supplies were stored in a locked area. This affected one (Resident #7) out of one resident reviewed for smoking and had the potential to affect three additional residents (#4, #9, and #28) who were identified by the facility as being cognitively impaired and independently mobile. The facility census was 47. Findings include: Review of the medical record revealed Resident #29 was admitted on [DATE]. Diagnoses included but were not limited to hypertensive heart disease with heart failure, acute respiratory failure with hypoxia, and type two diabetes mellitus without complications. Review of Resident #29's Minimum Data Set assessment, dated 07/01/22, revealed Resident #29 was cognitively intact. Interview on 08/22/22 at 2:07 P.M. with Resident #29 revealed Resident #29 stored cigarettes and a lighter in his dresser drawer. Observation on 08/24/22 at 8:35 A.M. revealed Resident #29's resident room door was open and State Tested Nursing Assistant (STNA) #182 was observed to open Resident #29's unlocked dresser drawer and hand Resident #29 his cigarettes and lighter. Interview on 08/24/22 at 8:40 A.M. with STNA #182 verified Resident #29's cigarettes and lighter were stored unlocked in the resident's room. Review of the facility policy titled Smoke Free Environment, last reviewed 12/01/21, revealed it is the policy of the facility to provide a Smoke Free Environment for employees, residents, and visitors. The facility and grounds have been designated tobacco free. Smoking and the use of tobacco products is prohibited anywhere on the facility property.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to ensure medications were not left unattended at bedside. This affected one (Resident #34) out of one resident reviewed for self-administration of medication and had the potential to affect three additional residents (#4, #9, and #28) who were identified by the facility as being cognitively impaired and independently mobile. The facility census was 47. Findings include: Review of the medical record revealed Resident #34 was admitted on [DATE]. Diagnoses included polyneuropathy, unspecified protein-calorie malnutrition, hypocalcemia, hypertensive heart disease with heart failure, acute on chronic systolic (congestive) heart failure, hypothyroidism, hyperlipidemia, and major depressive disorder. Review of the admission Minimum Data Set (MDS) assessment, dated 07/06/22, revealed Resident #34 was cognitively intact. Review of Resident #34's physician order, dated 07/28/22, revealed an order for sucralfate one gram four times a day. Additional review of Resident #34's medical record revealed the Resident #34's medical record was silent for a self-medication assessment, physician order for self-administration of medication, and plan of care interventions for self-administration of medication. Observation on 08/22/22 at 1:30 P.M. of Resident #34's room revealed a medication cup on Resident #34's tray table with a single large white pill in the cup. Resident #34 was in bed with bedding over his face and body, and Resident #34 was not responding to questions. Interview on 08/22/22 at 1:37 P.M. with Licensed Practical Nurse (LPN) #103 verified he/she left a sucralfate (antacid medication) pill on Resident #34's bedside table. LPN #103 stated Resident #34 instructed her to leave it and that he would take it later. Review of the policy titled Medication Administration, revised November 2018, revealed residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications. In addition, the resident is always observed after administration to ensure that the dose was completely ingested.

Based on medical record review, observation staff interview, and review of manufacturer guidelines, the facility failed to ensure a resident's insulin was administered according to manufacturer guidelines, resulting in a significant medication error. This affected one Resident (#5) of two residents observed for insulin administration. The facility identified three residents receiving insulin. The facility census was 44. Findings include: Review of Resident #5's medical record revealed an admission date of 07/26/18. Medical diagnoses included chronic kidney disease, diabetes mellitus, major depressive disorder, hypertension, malignant neoplasm of colon, and anxiety disorder. Review of the resident's physician's orders revealed an order dated 08/23/19 for Lantus insulin (long acting insulin) pen 33 units subcutaneous once daily. Observation of medication administration on 08/28/19 at 8:06 A.M. with Registered Nurse (RN) #200 revealed she prepared Resident #5's Lantus pen by turning the dial to 33 units. She then administered Lantus 33 units subcutaneous without priming the Lantus insulin pen. Interview with RN #200 on 08/28/19 at 8:10 A.M. verified she did not prime the resident's Lantus insulin pen prior to administration. Interview with Regional Nurse #210 on 08/28/19 at 9:19 A.M. revealed the facility did not have a policy regarding insulin administration. She stated the facility staff were to follow manufacturer guidelines. Review of Lantus Solostar Pen manufacturer guidelines dated 2017 revealed steps for injection included performing a safety test. Dial a test dose of two units. Hold pen with the needle pointing up and lightly tap the insulin reservoir so the air bubbles rise to the top of the needle. This will help you get the most accurate dose. Press the injection button all the way in and check to see that insulin comes out of the needle. The dial will automatically go back to zero after you perform the test. If no insulin comes out, repeat the test two more times. Always perform the safety test before each injection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview and facility policy review the facility failed to implement appropriate hand hygiene during a dressing change. This effected one Resident (#5) of two observed for dressing changes. The facility census was 44. Findings include: Review of the medical record of Resident #15 revealed an admission date of 07/27/12. Diagnoses included cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery, chronic kidney disease, major depressive disorder, generalized anxiety disorder, hypertension, anemia, deficiency of other specified B group vitamins, unspecified mononeuropathy of left lower limb, and hyperlipidemia. Review of the annual Minimum Data Set, dated [DATE] revealed Resident #15 had severe cognitive deficit and did not have a pressure ulcer at the time of the assessment. Review of the care plan last revised 08/06/19 revealed Resident #15 has a pressure ulcer and treatment was to be administered as per physician order. Review of the physician orders dated 08/12/19 revealed treatment to the coccyx and right sacrum: cleanse wound with sterile water, pat dry and apply acticoat (antimicrobial dressing) to wound beds, apply skin prep, and cover with foam (gentle or life) dressing change three days. Observation on 08/27/19 at 10:55 A.M. of the dressing change completed to the coccyx and sacral area revealed Registered Nurse (RN) #200 washed her hands and donned gloves. She then removed the old foam bordered dressing and noted no drainage. The wound was irregular in shape extending from the rectum to the sacral area. The proximal end had discoloration from the antimicrobial dressing. No necrotic tissue was visualized. The wound base, at the proximal end, was gray in color. The distal wound base was dark pink. RN #200 removed the soiled gloves, washed her hands and donned new gloves. RN #200 cleansed the wound beds with four by four gauze and sterile water, patted the area dry and applied skin prep to the surrounding tissue. RN #200 then cut the antimicrobial barrier dressing into pieces, approximately the size of the wounds, and placed them into the wound bed. She then applied a foam dressing to the entire area. RN #200 had not changed gloves and washed her hands after cleansing the area and before applying the new dressing. Interview on 08/27/19 at 11:56 A.M. with RN #200 provided verification of her not changing gloves and washing her hands after cleansing the wound and before applying the new dressing. Review of the facility policy titled Guideline for Handwashing/Hand Hygiene dated 02/09/17 revealed hands should be washed after removing gloves and after contact with secretions of excretions.

Based on observation, staff interview and facility policy review the facility failed to maintain the kitchen in a clean manner, failed to store foods as per guidelines and failed to ensure proper sanitation of utensils, pots and pans while using the sink. This had the potential to effect all 44 residents residing in the facility. Findings include: Observation on 08/26/19 at 8:30 A.M., during the tour of the kitchen, revealed two dust pans heavily coated with old food and paper products. The outer surfaces of the lids of the dried food storage bins were soiled with dust and loose food. The surface of the shelf, used to store spices, had a thick coat of grease and dust. The floors, in areas under tables and counters, were soiled with a dried brown substance. Loose plastic items were under the refrigerator. The convection oven was heavily splattered on the inside of the door and the oven floor. The walk-in freezer contained a three tier rolling cart that held nine small dishes of ice cream, uncovered and undated. The sanitizer sink had already been used by the kitchen staff, earlier in the morning, Director of Dining Services (DDS) #230 tested the water, which was negative for any sanitizing solution. DDS #230 emptied the sink and refilled it with the hose attached to the sanitizing solution. DDS #230 re-tested the water and again the test resulted in a negative reading. DDS #230 investigated and discovered the sanitizing solution was not being siphoned out of the bottle. Interview on 08/26/19 at 8:45 A.M. with DDS #230 provided verification of the cleanliness, food storage and sanitizing concerns. Review of the facility policy titled Food Labeling and Dating Policy dated 03/18/19 revealed any food product removed from its original container must have a label. The label shall contain; the item name, date and time food was labeled, the use by date. The policy further indicated the food shall be securely covered.