**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 4 residents (Resident #43) reviewed for quality of care. The facility failed to ensure CNA A did not lift Resident #43's urine collection bag above his bladder while she transferred the resident with the use of a mechanical lift. This failure could place residents at risk for catheter associated urinary tract infections (CAUTI). The findings included: Record review of Resident #43's admission record dated 09/17/2024 indicated he was admitted to the facility on [DATE]. Diagnoses included benign prostatic hyperplasia (BPH) (Age-associated prostate gland enlargement that can cause urination difficulty) and diabetes. He was [AGE] years of age. Record review of Resident #43's MDS assessment dated [DATE] indicated Cognitive Skills for Daily Decision Making = Modified independence - some difficulty in new situations only. Bladder and bowel: Appliances = Indwelling catheter (including suprapubic catheter and nephrostomy tube) Record review of Resident #43's care plan dated 08/27/2024 indicated in part: Problem: Resident has a Foley catheter related to dx of BPH. Goal: Resident will be/remain free from catheter-related trauma through review date. Interventions: Monitor/document for pain/discomfort due to catheter. Secure catheter with securement device. During an observation on 09/17/24 at 10:32 AM, CNA A and CNA B transferred Resident #43 from his wheelchair to his bed with the use of the mechanical lift. Resident #43 had an indwelling urinary catheter and CNA A took the catheter drainage bag and hung it on one of the hooks of the mechanical lift. When the CNA's raised Resident #43 with the lift the catheter drainage bag was noted to go up as well approximately 12 inches above the resident's bladder. The urine in the drainage bag was seen flowing back in the direction of Resident #43's penis. During an interview on 09/17/24 at 02:15 PM, CNA A said the urinary catheter bag was supposed to be kept at the height of under the knee. CNA A said the catheter bag was supposed to be kept low so that the urine in the bag would not flow back into the resident's bladder. CNA A was made aware of the observation when she transferred Resident #43, and his catheter bag was about a foot above his waist. CNA A said she had missed that and had not noticed the bag had gone that high during the transfer. CNA A said if the catheter bag was elevated past the resident's waist, that could lead to infections such as UTIs due to the back flow of urine. During an interview on 09/19/24 at 02:20 PM, the DON said it was expected for nursing staff to maintain the height of the catheter bag below the urinary bladder. The DON said if the catheter bag was elevated higher than the resident's bladder that could lead the urine in the bag backing into the resident's bladder. The DON said if the urine in the catheter back flowed into the resident's bladder, it could lead to infections. The DON said they conducted training and in-services on transferring residents and how to maintain the catheter bag below the bladder during resident care. The DON said they monitored nursing staff by conducting proficiency training on an annual basis. During an interview on 09/19/24 at 02:42 PM, the Administrator said he was not a clinician and was not able to explain what the expectations were regarding the catheter bag. The Administrator said he was sure the DON knew the answer to that. Record review of the facility's policy titled Catheter care, urinary dated 09/2014 indicated in part: The purpose of this procedure is to prevent catheter-associated urinary tract infections. Maintaining unobstructed urine flow. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 8 residents (Resident #65, Resident #17) reviewed for care plans. 1. The facility failed to have a care plan addressing Resident #17's Enhanced Barrier Protection with her Pressure Ulcer. 2. The facility failed to have a care plan in place to accurately address Resident #65's behavioral problems. This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs. The findings included: Resident #17 Record review of Resident #17's admission record dated 09/19/2024 indicated she was admitted to the facility on [DATE]. Diagnoses included dementia, and muscle wasting and atrophy. She was [AGE] years of age. Record review of Resident #17's MDS assessment dated [DATE] indicated her BIMS score was a 3 indicating the resident's cognition was severely impairment. In Section M - Skin conditions, Resident had a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device. Record review of Resident #17's care plan dated 07/04/2024 indicated in part: Problem: The resident has actual impairment to skin integrity of the r/t (related to) pressure area noted to coccyx (commonly referred to as the tailbone). Goal: The resident will have no complications through the review date. Interventions: Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Follow facility protocols for treatment of injury. Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal. In an interview on 9/19/24 at 10:26 a.m., the MDS Coordinator stated she was sure Resident #17's Pressure Ulcer needed an intervention or care plan addressing Enhanced Barrier Protection but she needed to learn more about it. In an interview on 9/19/24 at 10:26 p.m., the MDS Coordinator stated her process for identifying what needed to be care planned and not care planned started with printing out the Care Area Assessments from the MDS Assessments and anything she observed in the resident's room. The MDS Coordinator stated the DON reviewed the care plan for accuracy at the time it was written and the regional person also checked but she did not know how often. Resident #65 Observations from 09/17/24 through 09/19/24 of resident in the facility revealed the resident appeared to be upset through the during of the survey. The resident only offered short answers to the surveyor and did not want to have a full interview. Interview with the DON on 09/18/2024 at 12:31 pm revealed the staff were aware of Resident #65's behavioral issues. DON stated that the resident often had emotional outbursts and would yell at staff. DON stated the resident has not ever been aggressive with other residents. Interview with MDS coordinator on 09/19/24 at 1:34 PM revealed she was aware of the behavioral issues the resident had and believed it to be care planned. She stated this is something that needed to be care planned to ensure he is receiving the appropriate interventions. MDS v stated that she had it care planned but for some reason it was resolved when he left for the hospital a few months back. MDS coordinator stated she will reinstate the care plan. Review of the facility's policy and procedure for Comprehensive Person-Centered Care Plans, revised December 2016, revealed: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation The Interdisciplinary Team, in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The comprehensive, person-centered care plan will: incorporate identified problem areas. Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plans. Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process. a. No single discipline can manage an approach in isolation. Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. b. When possible, interventions address the underlying source(s) of the problem area(s), not just the addressing only symptoms or triggers. c. Care planning individual symptoms in isolation may have little, if any benefit for the resident.

Based on observation, interview, and record review, the facility failed to ensure all controlled drugs and biologicals were stored in separately locked and permanently affixed compartments for 2 of 8 medication carts (Med Cart #1, Med Cart #2), reviewed for pharmacy services. The facility failed to ensure Med Cart #1, Med Cart #2 remain locked while unattended. This failure could place residents at risk of and unauthorized access to medications. Findings included: Observation of the facility Med Cart #1 on 09/17/2024 at 09:06 am showed the cart to be unlocked and unattended. Observation of the facility Med Cart #2 on 09/17/2024 at 09:08 am showed the cart to be unlocked and unattended. An interview with CMA C on 09/17/2024 at 11:44 am revealed he had walked away from the cart to administer medication to a resident. CMA C stated that the policy was to lock the cart if they are not getting medication out of it and especially if one walks away. CMA C stated he messed up leaving it unlocked and was just in a hurry. An interview with the DON on 09/19/2023 at 2:30 pm revealed medication carts should be locked when unattended . The DON stated that she educated staff on keeping the carts locked after the initial observation of the medication carts being unlocked and would continue to emphasize the importance. A review of the facility policy titled Medication Administration with a revision date of 12/1/21, provided by the DON, read in part, during administration of mediations, the medication cart is to be kept closed and locked when out of sight of the medication nurse or aid. The cart must be clearly visible to the personnel administering medications, and all outward sides be inaccessible to residents or other passing by.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 4 residents (Residents #17 and #43) reviewed for infection control. The facility failed to ensure CNAs A and B followed EBP procedures by not wearing a gown while transferring Resident #43 with the mechanical lift. (Enhanced Barrier Precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDROs) to residents). The facility failed to ensure the Treatment nurse followed EBP procedures by not wearing a gown while providing wound care for Resident #17. This failure could place residents at risk for cross contamination and infection. Findings: Record review of Resident #43's admission record dated 09/17/2024 indicated he was admitted to the facility on [DATE]. Diagnoses included benign prostatic hyperplasia (BPH) (Age-associated prostate gland enlargement that can cause urination difficulty) and diabetes. He was [AGE] years of age. Record review of Resident #43's MDS assessment dated [DATE] indicated in part: Cognitive Skills for Daily Decision Making = Modified independence - some difficulty in new situations only. Bladder and bowel: Appliances = Indwelling catheter (including suprapubic catheter and nephrostomy tube) Record review of Resident #43's care plan dated 08/27/2024 indicated in part: Problem: Resident has a Foley catheter related to dx of BPH. Goal: Resident will be/remain free from catheter-related trauma through review date. Interventions: Monitor/document for pain/discomfort due to catheter. Secure catheter with securement device. Record review of Resident #43's Order Summary Report dated 09/18/24 revealed in part: Foley catheter care Q shift and PRN. Effective 08/23/2024 Record review of Resident #17's admission record dated 09/19/2024 indicated she was admitted to the facility on [DATE]. Diagnoses included dementia, and muscle wasting and atrophy. She was [AGE] years of age. Record review of Resident #17's MDS dated [DATE] indicated in part: BIMS = 3 indicating resident had severe impairment. Section M - Skin conditions = Resident has a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device. Record review of Resident #17's care plan dated 07/04/2024 indicated in part: Problem: The resident has actual impairment to skin integrity of the r/t pressure area noted to coccyx. Goal: The resident will have no complications through the review date. Interventions: Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Follow facility protocols for treatment of injury. Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal. Record review of Resident #17's Order Summary Report dated 09/19/24 revealed in part: unstageable to sacrum cleanse with dwc (dermal wound cleanser), pat dry. Skin prep around wound, Santyl to wound bed, then calcium alginate and cover with bordered foam. Change daily and prn if dressing come off or becomes soiled. Effective 09/17/2024 During an observation on 09/17/24 at 10:32 AM, CNA A and CNA B transferred Resident #43 from his wheelchair to his bed with the use of the mechanical lift. Resident #43 had a urinary catheter and CNA A took the catheter drainage bag and hung it on one of the hooks of the mechanical lift. Both CNAs assisted with the transfer and neither of them wore PPE during the procedure. There were no EBP sings posted outside the resident's room. During an interview on 09/17/24 at 02:15 PM CNA A was asked if she was aware of what EBP was. CNA A said she had not heard of that nor been told that she had to use PPE when assisting a resident with a catheter. CNA A asked if she was to wear PPE then she would, but again she had not heard about it. During an interview on 09/17/24 at 02:34 PM, CNA B was asked if she was aware of what EBP was. CNA B said she had not heard of that and did not know what EBP stood for. CNA B said they had not received any training about using PPE with residents that had a catheter and of course no training regarding EBP. During an observation on 09/19/24 at 08:38 AM, the treatment nurse performed wound care on Resident #17. The treatment nurse entered Resident #17's room and performed the wound care to the resident's sacrum (coccyx area). During the entire process of the wound care, the treatment nurse did not put on PPE as the resident was on EBP precautions. During an interview on 09/19/24 at 08:50 AM, the treatment nurse said she had forgotten to don PPE during Resident #17's wound care. The treatment nurse said she could not believe she had forgotten as she had thought about making sure she would don PPE when she performed the wound care. The wound care nurse said she was supposed to don PPE to prevent the spread of infections. During an interview on 09/19/24 at 02:24 PM the DON said it was expected for staff to use PPE when assisting a resident on EBP precautions. The DON said if staff did not used PPE, then they could possibly expose residents to infections. The DON said part of the reason the failure occurred was because staff had not gotten used to using EBP procedure. The DON said staff had not placed the PPE and EBP precautions out yet and had not been trained on EBP as they had just recently when surveyor's made them aware of that requirement. During an interview on 09/19/24 at 02:47 PM the Administrator said it was expected for staff to use EBP equipment if they were going to assist a resident on EBP precaution. The Administrator said the reason to use PPE in EBP resident rooms was to prevent the spread of infections. The Administrator said they were in the process of training the staff on the use of EBP. Record review of the facility Enhanced Barrier Precautions policy dated August 2022 revealed in part: Enhanced Barrier Precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. Enhanced Barrier Precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDROs) to residents. EBP's employ targeted gown and glove use during high contact resident care activities and gloves and gown are applied prior to performing the high contact resident care activity. The policy further includes examples of high-contact activities including providing hygiene, transferring, and wound care. Record review of the facility's policy titled Policies and practices - infection control dated October 2018 indicated in part: This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. The objectives of our infection control policies and practices are to: Prevent, detect, investigate and control infections in the facility; Maintain a safe, sanitary and comfortable environment for personnel, residents, visitors and the general public; establish guidelines for implementing isolation precautions, including standard and transmission-based precautions. All personnel will be trained on our infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control. The depth of employee training shall be appropriate to the degree of direct resident contact and job responsibilities.

Based on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed, in that: The facility failed to ensure the Food Supervisor (FS) was wear a mustache guard while there was uncovered food in the kitchen. This deficient practice could place residents who consumed meals and/or snacks from the kitchen at risk for food borne illness. The findings were: During an observation and interview on 09/17/24 at 09:32 AM, the FS was noted to have a mustache and not covered with a hair restraint. The FS was leaning over some uncovered pots that contained food and were on the stove top. The FS was asked about his mustache and if he ever covered it,. The FS asked the surveyor if he was supposed to cover it. The FS said that honestly, he had not thought about covering his mustache and at that time, he took a face mask and put it on. During an interview on 09/19/24 at 02:38 PM, the Administrator was made aware of the observation of the FS not having his mustache covered with a hair restraint. The Administrator said if staff had a beard, then he could see that the policy applied. The Administrator said the policy indicated for staff to use beard coverings and not specifically mustache covering. Record review of the facility's policy titled Employee sanitation and dated 10/01/2018 indicated in part: The nutrition and food service employees of the facility will practice good sanitation practices in accordance with the state and US food codes in order to minimize the risk of infection and food borne illness. Employee cleanliness requirements - Hairnets, headbands, caps, beard coverings or other effective hair restraints must be worn to keep hair from food and food contact surfaces.

Based on observation and interview the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 kitchen reviewed for physical environment. The facility failed to ensure one of six stove top burners ignited automatically. This failure could place residents at risk of foodborne illnesses and potential for injury to residents and staff. Findings included: During an observation and interview on 09/17/24 at 09:30 AM, the stove in the kitchen was inspected. One of the six burners was noted to turn not turn on when the knob was turned to on by [NAME] D. [NAME] D said she had to use a lighter to turn that burner on as it did not turn on automatically like the other five burners. [NAME] D said she believed the burner had been like that for about two weeks at that time. During an interview on 09/17/24 at 09:32 AM, the FS said the burner on the stove top did not turn on automatically, but that it would turn on with the use of a lighter. During an observation and interview on 09/18/24 10:08 AM, [NAME] D was asked to show the surveyor how she turned on the stove top burner that did not turn on automatically. [NAME] D said they used that burner as well and she would use a lighter to turn it on. [NAME] D went to look for the lighter, but was unable to locate it. The cook asked the FS for the lighter and at this time the FS came with the lighter and turned on the stove top burner. The FS said he was not sure how long the stove top burner had not been working properly. The FS said if the burner was turned on, left on, and it did not light up, it could lead to an explosion. The FS said he had reported it to the maintenance department today and they were going to look at it. During an interview on 09/19/24 at 10:40 AM, the Maintenance Supervisor said he had not been made aware by the kitchen staff that one of the stove top burners was not working properly until after the state surveyors had entered. The Maintenance Supervisor said he had just been made aware yesterday and he had started working on it. During an interview on 09/19/24 at 02:46 PM, the Administrator said they did not have a specific policy regarding the kitchen equipment. The Administrator said it was expected for the kitchen equipment to work properly and if not that it should be reported promptly to be repaired.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of three residents (Resident #2) reviewed for infection control practices. CNA A and CNA B failed to perform hand hygiene and change gloves as appropriate while providing incontinence care for Resident #2. This failure could place residents at risk for cross contamination and the spread of infection. Finding include: Record review of Resident #2's face sheet, dated 03/06/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included constipation, retention of urine, age-related debility (weak state) and Alzheimer's disease (brain disorder). Record review of Resident #2's Minimum Data Set (MDS) quarterly Assessment, dated 12/08/22, reflected Resident #2 required substantial/maximal assistance with most activities of daily living (ADLs) and always incontinent of bowel and bladder. Observation on 03/06/24 at 10:49 a.m. of incontinence care for Resident #2 revealed CNA A and CNA B did not wash their hands before the start of care. Both donned gloves and removed Resident #2 old brief. CNA A wiped from front to back. Resident #2's brief was soiled with urine and fecal matter. CNA A did not change gloves but continued to clean Resident #2. CNA A's gloves were visibly soiled with urine and fecal matter. She did not wash her hands, change gloves or perform hand hygiene before retrieving Resident #2's clean brief and placing it underneath the resident and fastening the brief. CNA B assisted CNA A to provide care. CNA B repositioned the resident and touched the resident's perineal area. She changed gloves and washed hands before helping to fasten Resident #2 clean brief. CNA A and CNA B removed their gloves, picked up the trash and walked out of Resident #2's room, without washing their hands. In an interview on 03/06/24 at 11:12 a.m., CNA A said she had been employed at the facility for about 2-3 weeks and did not receive infection control training during orientation. CNA A stated cross contamination was mixing clean with dirty. CNA A stated she should have washed her hands before she retrieved Resident #2's clean brief and fastened it. She stated Resident #2 could get an infection for not following good infection control practice. During interview on 03/06/22 at 11:16 a.m. with CNA B, she said cross contamination was going from clean to dirty. She stated not changing gloves before she fastened Resident #1's clean brief. CNA B stated she had been employed about 6 weeks and did not receive infection control training during orientation. In an interview on 01/30/23 at 12:21 p.m., the DON stated she was aware of some of the concerns raised about infection control practices. She explained ADON D was responsible for infection control in the facility. She trained and monitored staff with return demonstration. The DON stated aides were expected to follow standard precaution which included washing hands and changing gloves while providing care. Record review of the facility's policy and procedure, revised February 2018, reflected the following: Handwashing /Hand Hygiene Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections. . 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infection to other personnel, residents, and visitors. . 6. Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: a. When hands are visibly soiled; and h. After contact with a resident with infectious diarrhea including, but not limited to infections caused by norovirus, salmonella, shigella and C. difficile. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap ( antimicrobial or non-antimicrobial) and water for the following situations: . b. Before and after direct contact with residents. . f. Before donning sterile gloves. g. Before handling clean or soiled dressings, gauze pads, etc. ii. Before moving from a contaminated body site to a clean body site during resident care . m. After removing gloves

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 3 residents, (Resident #2) reviewed for skin integrity in that: The facility failed to assess Resident #2's heel upon return from the orthopedic doctor for signs of skin breakdown. The facility failed to prevent Resident #2's heel from having further breakdown. LVN A failed to prevent cross contamination during wound care for Resident #2's heel. This failure could place residents at risk for new development or worsening of existing pressure injuries, pain, infection, and decreased quality of life. Findings included: Review of Resident #2's admission Record, dated 7/26/23, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including fracture of the upper and lower end of right fibula for closed fracture with routine healing (broken leg) and age-related osteoporosis (thin, brittle bones). Review of Resident #2's admission MDS Assessment, dated 6/17/23, revealed: Her Mental Status Exam indicated she scored a 12 of 15 (indicating she was moderately impaired) She needed extensive assistance of one of two staff for all ADLs She had range of motion impairment of the lower extremity on one side. Primary reason for admission was fractures and other multiple trauma She received as-needed pain medication, reported she rarely experienced pain and rated it as a 5 of 10. She had a fall with a fracture prior to admission Review of Resident #2's Care Plan, initiated 6/14/23 revealed: Problem: The resident had actual impairment to skin integrity of the right lower extremity related to recent Tibia and Fibula Fracture after fall at home. Goal: The resident will maintain or develop clean and intact skin by the review date. Interventions included: Educate resident/family/caregivers of causative factors and measures to prevent skin injury; Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface; and weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Review of Resident #2's Order Listing Report, dated 7/26/23 revealed orders dated: 6/23/23 Elevate leg with cast when in bed 7/13/23 Ortho boot two times a day for confirmation boot is on right lower leg until healed. 7/24/23 Skin prep right heel, cover with foam dressing until healed, Monday, Wednesday, Friday, 7/26/23 Discontinue boot to right leg. Review of Resident #2's Braden Scale Assessment for Predicting Pressure Sore Risk revealed: 6/14/2023- MODERATE RISK 14.0 7/9/2023 - MODERATE RISK 13.0 7/22/2023- MODERATE RISK 13.0 Review of Resident #2's Nursing Notes, LVN A documented the following notes: 7/17/2023 at 11:05 a.m. Note Text: Skin prepped left heel. Left heel pink, floated heel. Right leg has boot cast and elevated on pillow. Call light in reach. 7/21/2023 at 1:37 p.m. Note Text: Resident's right heel has discolored but not open. New orders to skin prep and cover with foam dressing until healed. Continue to skin prep left heel. 7/26/2023 at 10:06 a.m. Note Text: Sent note to doctor to ask if we can discontinue DC the boot, so the heel pressure can heal. Awaiting response. 7/26/2023 at 9:55 a.m. Note Text: Resident's right heel continue with wound to area. Pink around heel, in center, 2cm X 2cm X < 0.2cm tan/yellow area with scant drainage. Cleaned, applied skin prep, covered with foam dressing, and put boot back on. Will notify doctor of area on heel and ask if we could discontinue the boot, to heal the Right heel. No pain voiced during treatment this morning. Review of Resident #2's Orthopedic Doctor physician note, dated 7/13/23, revealed: Cast discontinued. Ambulatory boot placed. Orders for physical therapy, remaining non weight bearing with initiation of range of motion as tolerated. Erythema (redness of skin): absent Review of Resident #2's therapy notes (PTA D) documented the following notes: 7/20/23 no notes 7/21/23 Therapeutic activities, bed mobility activities to increase functional. PTA observed pressure ulcer on right heel when boot donned (Interview on 07/27/23 at 9:30 AM PTA D stated donned was a typo and it should be doffed). Nursing notified and applied bandage to cover. Comments: Patient reported soreness on right heel. Patient would benefit from continued skilled Physical Therapy services to improve bilateral lower extremity strength, activity tolerance, wheelchair mobility, balance, and all functional mobility. Observation and interview on 07/25/23 at 11:03 AM, revealed Resident #2 in bed with a walking boot on. Her heels were placed on a pillow, so the heel did not touch the bed (the walking boot was on the bed). Resident #2 said she was worried the boot would cause skin breakdown on the right heel since the left heel had already broken down and healed prior to admission. Observation on 07/26/23 at 09:22 AM, revealed LVN A, donned gloves, got some red wipes out of the treatment cart and wiped down Resident #2's bedside table. LVN A then applied wax paper. LVN A returned to the treatment cart, threw out her gloves, sprayed wound cleanser into a cup. LVN returned to Resident #2's room put the wound cleanser down, washed her hands, left the room, grabbed some gloves off the treatment cart, and closed the door. LVN A gloved, picked up Resident #2's left foot and checked the heel to assess for bogginess (squishiness, an indicator that the tissue under the skin may not be intact), then took off her gloves. LVN A took off her gloves and then took off the straps to Resident #2's boot. There was a strip of gauze on the top of Resident #2's foot and a padded dressing to Resident #2's heel. LVN A put on her gloves and pulled off the bandage that had drainage on it. Resident #2 asked if the heel had broken down and LVN A said it had and it had a small amount of drainage. LVN A cleaned Resident #2's foot by wiping over the same area five times with the same area of gauze (this decontaminates the wound). LVN A doffed the gloves, washed her hands, and donned new gloves. LVN A reached into her pocked and pulled out packets of skin prep wipes. LVN A wiped Resident #2's left heel with the front of a skin prep wipe and then flipped it over and wiped with the back side of the same wipe. LVN A picked up Resident #2's right leg and then put it down on the boot. LVN A took off her gloves, stepped out and grabbed more gloves. LVN A donned gloves, picked up Resident #2's heel and then pulled a circular flap that appeared to be dried skin off the wound, opened a package of skin prep wipes and wiped down Resident #2's right heel, turned over the wipe and wiped the heel with the back side of the wipe. LVN A described the wound as a stage II pressure ulcer with moderate drainage that was approximately 2 cm x 2 cm with a tan to yellow center and pink around the edges. LVN A wiped Resident #2's heel with skin prep using both sides of the wipes and then put on the padded dressing. LVN A put the boot back on Resident #2 and checked to make sure it was not too tight. LVN A washed her hands and then threw out the wound care supplies. LVN A said the right heel got too moist and that someone would need to order something more and she was going to call the doctor to get the boot discontinued. Interview on 07/26/23 at 01:44 PM, the ADON stated Resident #2 was [AGE] years old and had a fracture to the right ankle. The ADON stated Resident #2 recently got a cast off and got a walking boot on 7/13/23. The ADON stated the skin assessments documented that Resident #2 was in a cast on 7/11/23 and the next skin assessment was 7/18/23 that showed the right lower extremity was in a cast. The ADON said there was no skin assessment she could find after Resident #2 returned from the orthopedic doctor on 7/13/23. She said an agency nurse documented the skin assessment on 7/18/23 documenting the cast so her guess was as good as the surveyors on if an assessment was even done. The ADON said from the nurse's notes and assessments she was unable to determine when Resident #2 started having problems with her right heel. The ADON guessed 7/24/23 when the order for the padded heel dressing was ordered was when the facility determined there was a problem with Resident #2's heel. The ADON said she was unaware that Resident #2 had skin issues with her heel and was not notified. The ADON said since the DON was out on medical leave, the expectation was she would be notified. The ADON stated the DON usually did the skin assessments on new or worsening pressure ulcers, so she would have the facility RN look at it. Observation and interview on 7/26/23 at 1:56 PM, the ADON did a skin assessment on Resident #2's feet. She stated there was a blister on Resident #2's right great toe. The ADON gloved with no hand hygiene took off Resident #2's boot and dressing. The ADON described Resident #2's heel as approximately 4 cm x 4 cm, had erythema with a soft yellowish center. The ADON said the wound did not go very deep with the yellow/brown part being approximately 2 cm. Interview on 7/26/23 at 02:02 PM, Resident #2 stated after the wound care observation with LVN A, they came back took the dressing off and looked at. Resident #2 said the doctor was going to look at it tonight. Interview on 07/26/23 at 2:03 PM, the ADON stated the expectation for residents with a boot was the nurses were supposed to do a skin assessment every day. The ADON stated the nurses should be taking off the boot looking at the skin daily. The ADON stated if the boot stayed on while the resident was in bed would depend on the order. The ADON stated Resident #2 was in the cast for quite some time and there should have been an order to elevate the foot. The ADON stated there should have been an assessment when Resident #2 returned from the orthopedic doctor; she should have proper nutrition and the nursing staff should remove the walking boot and check the skin routinely. The ADON confirmed the assessment when Resident #2 returned from the orthopedic doctor did not happen. She said if the staff had not been removing the boot and checking the skin it was an avoidable pressure ulcer. She said the necessary services to promote wound healing would be in place by the end of 7/26/23. She said it would take a couple of weeks for a wound to degrade to the condition it was in. She said there was no care plan addressing documenting skin issues. The ADON said there was nothing that was not reviewed. Interview on 7/26/23 at 2:22 PM, the Administrator was informed Resident #2 was found with a pressure ulcer that had degraded. It was explained the ADON had not been informed so the Administrator would not have been informed. She said, we'll have to investigate it. Follow up interview on 07/26/23 at 3:07 PM, the ADON stated the staff RN assessed Resident #2's wound and said it was a stage III. (Per CMS Guidance a stage III is defined as full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and rolled wound edges were often present. Slough (yellow, tan moist tissue) and/or eschar (dead tissue) may be visible but does not obscure the depth of tissue loss. The depth of tissue damage varies by anatomical location.) Interview on 7/26/23 at 3:10 PM, RN C stated he assessed Resident #2's heel. He stated he assessed it as a stage III because subcutaneous tissues were present but he did not see any muscle or tendon. RN C said the only thing that kept it from being an unstageable wound was the depth of the wound and the only way to really determine that would be to take a cotton swab to the yellow tissue, but it was very sensitive. RN C stated he did not know Resident #2's history but Resident #2 said there was a rough area there for a long time and then it was sore. RN C state he could not think of anything to add but he was confident it was stage III until proven otherwise. Interview on 07/26/23 at 4:06 PM, LVN A stated PTA D saw the wound Friday 7/21/23 and it was beginning to turn red. LVN A stated every time the facility had an order to keep the boot on while in bed the resident would get a pressure ulcer and she did not want it breaking down. LVN A stated she checked the heel every day. LVN A stated therapy took the boot off every day because they were working with Resident #2 every day. Interview on 7/27/23 at 8:59 AM, the Administrator stated that it appeared when Resident #2 went to the orthopedic doctor, he put her in the boot and Resident #2 was supposed to wear it like a cast. Interview on 07/27/23 at 9:18 AM, PTA D stated he found a pressure ulcer on Resident #2 at the end of the week (7/21/23) and Resident #2 stated it hurt. PTA D described it as a reddened area. PTA D stated he informed LVN A, who came in and put a foam bandage on it. PTA D stated he believed LVN D wanted to provide some cushioning for the wound because she did not want the skin to break open. PTA D stated he took off the boot to do range of motion exercises with her. He said he saw Resident #2's heel on 7/25/23 and the bandage did not have any drainage leaking through and Resident #2 did not complain of pain. PTA D stated he informed his supervisor about it. He stated he documented it in his notes. PTA D stated on 7/19/23 Resident #2 complained her toenails hurt and he notified nursing, PTA D he did take off Resident #2's boot and did not observe any issues on her foot. PTA D stated the foam dressing would help with pressure to the heel but not significantly. PTA D stated Resident #2 originally had a cast and then was placed in an orthopedic boot. PTA D stated at [AGE] years old Resident #2 did not want to be up for more than 30 minutes. PTA D stated the boot being on while Resident #2 was in bed would depend on the doctor's orders. PTA D looked at Resident #2's order and stated Resident #2 did not have orders to remove the boot while in bed just with range of motion exercises. PTA D stated he thought it would take a couple of days for a wound to get yellow and brown. PTA D stated he worked with Resident #2 prior to this visit in another setting and she had developed something on her left heel then, so they were floating the heels to keep it from breaking open again. PTA D stated the pillow would help with pressure to Resident #2's right foot but not significantly due to the boot. PTA D stated Resident #2's ortho-boot had some thick padding on the heel but over time the heel got irritated. PTA D stated Resident D had no history of non-compliance but had always been thin. PTA D said he thought Resident #2 was not at high risk of developing a pressure ulcer because she moved around the bed independently. cognitively intact and would be able to tell anyone if anything was wrong. PTA D checked his notes for 7/24/23 and stated she did not complain of pain but since they were working on her pushing her wheelchair, he did not take off the boot. Interview and record review on 07/27/23 at 10:10 AM, LVN A stated the wound care was just a blur to her. She stated she saw Resident #2's foot on the weekend and it was just dark, so she put skin prep on it and then she was off for two days. LVN A said Resident #2 always talked to her during wound care and LVN A was distracted by it. LVN A stated she remembered she wiped down the table with wipes put wax paper down and set up the biohazard bag, then she (LVN A) put the things she was going to use including the wound cleaner in the cup and the gauze. LVN A stated she usually set up the skin prep as well, but she had it in her pocket, so she (LVN A) did not put it on the table. LVN A said she then washed her hands, gloved, took off the boot, took off the old dressing and put it in the bag. She said she washed hands and looked at the wound and noticed it was opened. LVN A said she thought she needed to do the treatment, so she reached into her pocket and got the skin prep out. LVN A said she thought she needed to do the treatment the way it was ordered until they got new orders. LVN A stated the orders were clean the wound which she did. LVN A described she put cleanser on gauze went around the wound, folded the gauze, and went outside in and then inside out. LVN A said she reached into her pocket to get the skin prep pad. LVN A said she usually just laid the pad on the wound, patted it on, turned it over and patted it again and then wait for it to dry. LVN A said she got the foam dressing and put it on Resident #2's heel. LVN A said she told the ADON and RN C that the wound was open. LVN A said the ADON asked if she (LVN A) could stage it, but RN C staged it and got new wound care orders. LVN A said she got the boot order discontinued. Surveyor and LVN A reviewed the wound care observation. LVN A said she was not supposed to go from one foot to the other and she didn't know what happened and she did not know why she did not fold the gauze she used to clean the wound. LVN A admitted she cross contaminated the gloves when she reached into her pocket. LVN A said, I was just not prepared. LVN A said she thought she was pulling off the old skin prep pad and not a fold of skin. LVN A listened to the wound care observation and stated she needed to wash her hands more. LVN A said she did not get a lot of training on wound care. LVN A stated the facility had a wound care nurse come in and train them about five years ago. LVN A admitted she was not good at wound care. LVN A said she was not sure if she told people she needed more training or not. LVN A stated she was sure the management had checked her off for doing wound care over the years, but it was not recent. LVN A stated she checked Resident #2's foot on 7/23/23 and there was nothing there - it was not red and there was not drainage. LVN A stated she put in the order for the bordered dressing on 7/21/23 - she pulled up the order and showed surveyor. Interview on 07/27/23 at 10:57 AM, the ADON stated the facility's expectation for wound care was for the nurse to wash hands, clean the overbed table, take supplies in and place them on wax paper put the supplies on the over bedside table, don gloves, remove soiled dressing, throw in biohazard bag, doff gloves, sanitize hands, don clean gloves, clean the wound with wound cleanser, remove gloves, sanitize, don gloves, apply treatment, apply clean dressing, date, clean up supplies, wash hands and done. The ADON stated proficiency checks on wound care were done annually by the ADON or DON. The ADON said the last time proficiency checks on wound care was a month or two ago and they got all the nurses that were in the building at that time. The ADON said the last time the staff were in-serviced on wound care was a month or two ago. The ADON stated the facility did the in-service when there was something that triggered the in-service. The ADON said the facility showed what was expected at the time of the in-service, but everyone signed the in-service. The ADON said the DON had nurses watch a video on the expectation of wound care on hire. The ADON added, the facility wound care supply company also sent out literature on how to do wound care. The ADON and surveyor reviewed the wound care observation. The ADON identified the need for hand hygiene prior to beginning the wound care, the need to change gloves between taking off the dressing and blotting the wound. The ADON stated LVN A contaminated her gloves when she went from the left foot to the right foot. The ADON stated the prep pads were not supposed to be flipped because whatever was on one side of the wipe is on the other side of the wipe. The ADON stated the gloves that LVN A put in her pocket were now disgusting with whatever was in the pocket. The ADON stated she understood what the concerns were. Interview on 07/27/23 at 12:56 PM, the Administrator stated the ADON caught her up about the wound care procedure not done appropriately including the reaching into the pocket, not changing gloves, and the wound cleaned improperly. Review of the Treatment Nurse Competency Check Off form for Wound Care, undated revealed: Wash hands Clear overbed table and cleaned with damp paper towel Wash hands Gathered all needed supplies for treatment including piece of wax paper/ barrier for over bed table and set up items maintaining clean field. Wash hands and don gloves Positioned residents Washed hands and donned gloves Cleaned wound with ordered solution using proper technique (inner wound to outer edge) Applied topical medication if ordered If more than one wound, repeat steps. If any area was contaminated, start over. Remove gloves and wash hands. Remove soiled dressings in bag and dispose of in bio-hazard room. Review of the facility's In-Service Training Attendance Roster on Skin and Wounds, dated 5/12/23, revealed: All residents' skin and wounds must be assessed upon admission. The only exception to not changing a dressing to remain in place and this must be documented. Any supplies not available for wound care must be documented and primary care physician to be notified for equivalent dressings. The admission assessment skin assessment must be completed in full with measurements of wounds. If residents does have pressure wounds then a separate wound progress note must be completed Review of the undated Pressure Staging and Recommended Products handout the facility provided in lieu of a policy documented: Category/Stage III: full thickness loss, subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of wound tissue loss. May include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput, and malleolus do not have subcutaneous tissue and these ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage III pressure ulcers. Bone/tendon is not visible or directly palpable. Recommended Guidelines: Eliminate pressure as effectively as possible; clean per facility protocol and apply enzymatic agent (as needed) prior to applying new dressing. Dry to minimal drainage - apply collagen (if >50% necrotic) or calcium alginate (pad or rope), cover with dry protective dressing foams or ABD pads (ABD pads only with copious drainage). Handwritten at the top was multivitamin, vitamin C 500 mg x 30 days, and zinc 220 mg x 14 days. Review of the facility's policy and procedure on Pressure Ulcer/Skin Breakdown - Clinical Protocol, last revised April 2018, revealed: Assessment and Recognition The nursing team member will assess and document an individual significant risk factors for developing pressure ulcers, For example quote, immobility, recent weight loss, and a history of pressure ulcers. 2. In addition, the nurse shall describe and document/report the following: a. full assessment of pressure ulcer including location, stage, length, debt width and depth, pressure of exudates for necrotic tissue. b. Pain assessment. c. Resident's mobility status. d. Current treatments, including support services; And e. all active diagnoses. Treatment/Management 1. The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressing (occlusive, absorptive, etc.) And application of topical agents. 2. The physician will help identify medical interventions related to wound management; for example, treatment treating a soft tissue infection surrounding an ulcer, removing necrotic tissue, addressing comorbid medical conditions, managing pain related to the wound or to whom treatment, etc. 3. The physician will help team member characterize the likelihood of wound healing, based on the review of pertinent factors; For example: a. healing or prevention likely: the resident's underlying physical condition, prognosis, personal goals and wishes, care instructions, and ability to cooperate with the treatment plan make wound healing and subsequent wound prevention realistic. b. Healing or prevention possible: healing may be delayed or may occur only partially; wounds may occur despite appropriate preventative efforts. c. Healing or prevention unlikely: the resident is likely to decline or die because of his/her overall medical instability; wounds reflect the individual's overall medical instability; an existing wound is unlikely to improve significantly; additional wounds are likely to occur despite preventative efforts. Monitoring: 1. During resident visits, the physician will evaluate and document the progress of wound healing - especially for those with complicated, extensive, or poorly-healing wounds. 2. The physician will guide the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions. a. Healing may be delayed or may not occur, or additional ulcers may occur because of other factors which cannot be modified. b. Current approaches should be reviewed for whether they remain pertinent to the resident/patient's medical conditions, are affected by factors influencing wound development or healing, and the impact of specific treatment choices made by the resident/patient or substitute decision-maker.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 1 of 2 meals observed for resident rights. Residents sitting at the same table were not served at the same time. Staff assisting Resident #14 stood while feeding her. This failure could place residents at risk for decreased meal satisfaction. The findings included: Observation on 07/25/23 at 11:59 AM, revealed the first tray in dining room was served to table A, which had three residents at it. Staff continued to serve trays as they came out to different tables. All tables were served randomly. (At 12:04 PM the second tray was served at table A. The third resident at that table began grabbing at any staff that passed her way asking where her food was. At 12:10 PM the third resident was finally served her dinner at Table A but the staff placed it at the table and did not offer to cut up food for her until that resident again had to grab out. Trays continued to be served randomly through the dining room. The last tray was served at 12:20 PM. Review of Resident #14's admission Record, dated 6/27/23, revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease and age-related debility. Review of Resident #14's Annual MDS Assessment, dated 7/13/23 revealed: She had long and short-term memory impairment and severely impaired decision-making skills. She was totally dependent on one or two staff for all ADL care, including one staff for eating. She weighed 91 pounds with no loss or gain indicated but was on a mechanically altered diet. Review of Resident #14's Care Plan, last updated 9/3/21, revealed Problem: The Resident has an ADL self-care performance deficit related to Alzheimer's Dementia, anxiety, depression, difficulty walking, contractures to bilateral lower extremities and history of falling. Goal: The resident will maintain current level of function through the review date. Interventions included: Eating: the resident is totally dependent on staff for eating. Review of Resident #14's Care Plan, last updated 9/14/22, revealed: Problem: The resident has potential nutritional problem related to diet order that includes pureed texture with fortified meal program noted. Observation on 07/25/23 at 12:06 PM, revealed Resident #14 was served dinner. Resident #14 received a pureed diet in a divided plate and her cups had sippy lids on them. The food was placed out of reach of the resident who was not looking at the food. At 12:18 PM revealed staff were standing while feeding Resident #14. The staff fed Resident #14 backhandedly not even facing the resident. All other staff were sitting while feeding the assisted residents. At 12:21 PM revealed the Administrator talking to the aide about standing while feeding. Resident #14 was repositioned. Three staff gathered around Resident #14 about how to reposition her. The aide finally sat down and continued to feed her back handedly while not facing or talking to the resident. Interview on 7/27/23 at 12:56 PM, the Administrator stated her expectation for dining services was the food be served at the same table before staff go to the next table. The Administrator said she expected the staff to set up the resident's tray and ask the resident if they need anything else. The Administrator stated she expected the staff to notice if residents were not eating and offer to get them something else. The administrator said if the resident needed assistance with being fed, she expected the staff to sit next to the resident and encourage the resident to eat. The Administrator said this did not happen on the 7/25/23 lunch meal. The Administrator explained the agency aide set up the meal tickets by who was in the dining room not by where the resident sat. The Administrator said anyone who was waiting for their food to be served would be generally frustrated and antsy. The Administrator agreed one staff did not sit while feeding Resident #14 because she could not reach the resident since the resident was in a bulky chair with a wedge between the resident's legs. The Administrator said the chair had to be repositioned and in the end the staff ended up moving their chair. Administrator said this was only her fourth week at the facility, so she had not had the chance to train the staff on expectations during the meal service. The Administrator stated she had monitored one meal on 7/22/23. The Administrator had no further information. Review of the facility's in-service binder showed meal service was not a covered topic in any in-service for the last year. Review of the facility's policy and procedure on Meal Service, undated, revealed: Policy: The facility believes that all residents should be treated with dignity and respect at all times. A respectful, positive dining experience is essential to the residents' quality of life and help to identify residents' needs and improve their overall nutritional status. Residents will be properly groomed and their needs attended to during the meal service. Residents will be properly positioned in chairs, wheelchairs or geri-chairs at an appropriate distance from the table. Tables will accommodate wheelchairs. Residents will be treated with respect and courtesy. Staff will greet residents by name. Staff will communicate with the residents and not among themselves. All residents at one table will be served at the same time prior to serving residents at other tables. Table service will be rotated so that the same table is not aways served first or last. Residents who require dining assistance will not have their trays delivered until a staff member is available to assist with dining.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services, including procedures that ensure the accurate administering of all drugs to meet the needs of the residents, for 1 of 1 medication rooms, 1 of 2 (wound treatment cart #1), and 1 of 4 (Medication cart #1) reviewed for medication storage. The facility failed to ensure expired medications were removed from the medication room refrigerator the wound care/ treatment cart #2 and medication cart #4. This failure could place residents at risk of receiving medications that were expired and not produce the desired effect. Findings included: During an observation on 07/26/23 at 8:00 AM, the medication room was observed with LVN A present. Inside the refrigerator there were 19 vials of Hepatitis B vaccine with expiration date of 07/03/2023; 25 Bisacodyl suppositories with expiration date of 05/2023; 1 bottle of Calcitonin salmon nasal solution with expiration date of 07/03/2023; 1 glucagon single-dose injector pen with expiration date of 03/2023. During an observation on 07/26/23 at 08:30 AM, the medication cart #4 was observed with ADON present. Inside medication cart #4, there were 3 capsules of diphenhydramine 25mg with expiration date of 05/2023; 1 bottle of eye lubricant drops with expiration date of 04/2023; 2 tuberculin safety syringes with expiration date of 06/30/2022. During an observation on 07/26/23 at 09:00 AM, the wound treatment cart #2 was observed with ADON present. Observation revealed 3 boxes of povidone-iodine prep pads (100 count) with expiration date of 03/2023; 19 petrolatum wound dressings with expiration date of 04/2023; 2 Collagen and silver dressings with expiration date of 10/31/2022; 1 bottle of bio freeze gel with expiration date of 09/2022. Interview with LVN A on 07/26/23 at 08:05 AM, stated that the medication aides check the medication room for expired medications, and they all get thrown into a cardboard box located in the medication room. LVN A stated that expired narcotics remain locked in the medication carts until the DON is in facility, then they go directly to DONs office, where they are stored until medication destruction. Interview with ADON, on 07/26/23 08:20 AM stated that the pharmacist was in the facility yesterday and did an audit of medication room and medication carts and should have disposed of all expired medications found. ADON stated that the pharmacist must have missed the medications found by surveyor. ADON stated that nurses should be checking their own medication carts and wound treatment carts daily. ADON stated that medication aides are responsible for checking medication rooms every Sunday and checking their own carts daily. ADON stated that she is responsible for doing audits and checking for expired medications weekly. ADON stated that she has been too busy and has not had time to perform her usual duties. ADON stated that giving expired medications to residents could make them sick, could result in residents not receiving the desired effect of the medication. ADON stated that using expired wound care supplies while performing wound care is not best practice and could negatively affect the resident and slow the healing process. Record review of the facility's undated policy titled Returns, recalls and medication destruction indicated in part: Discontinued and expired medications should be removed from the resident's medication supply.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 (Resident #2 and #38) of 4 residents reviewed for infection control. LVN A failed to prevent cross contamination during Resident #2's wound care. CNA B failed to wash her hands prior to personal care and change her gloves during incontinent care of Resident #38. This failure could place resident's risk for cross contamination and the spread of infection. Findings included: WOUND CARE. Review of Resident #2's admission Record, dated 7/26/23, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including fracture of the upper and lower end of right fibula for closed fracture with routine healing (broken leg) and age-related osteoporosis (thin, brittle bones). Review of Resident #2's admission MDS Assessment, dated 6/17/23, revealed: Her Mental Status Exam indicated she scored a 12 of 15 (indicating she was moderately impaired) She needed extensive assistance of one of two staff for all ADLs She had range of motion impairment of the lower extremity on one side. Primary reason for admission was fractures and other multiple trauma She received as-needed pain medication, reported she rarely experienced pain and rated it as a 5 of 10. She had a fall with a fracture prior to admission Review of Resident #2's Care Plan, initiated 6/14/23 revealed: Problem: The resident had actual impairment to skin integrity of the right lower extremity related to recent Tibia and Fibula Fracture after fall at home. Goal: The resident will maintain or develop clean and intact skin by the review date. Interventions included: Educate resident/family/caregivers of causative factors and measures to prevent skin injury; Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface; and weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Observation on 07/26/23 at 09:22 AM revealed LVN A, without hand hygiene, donned gloves, got some red wipes out of the treatment cart and wiped down Resident #2's bedside table. LVN A then applied wax paper. LVN A returned to the treatment cart, threw out her gloves, sprayed wound cleanser into a cup. LVN returned to Resident #2's room put the wound cleanser down, washed her hands, left the room, grabbed some gloves off the treatment cart, and closed the door. LVN A gloved, picked up Resident #2's left foot and checked the heel to assess for bogginess (squishiness, an indicator that the tissue under the skin may not be intact), then took off her gloves. LVN then took off the straps to Resident #2's boot. There was a padded dressing to Resident #2's heel. LVN A put on gloves and pulled off the bandage that had drainage on it. Resident #2 asked if the heel had broken down and LVN A said it had and it had a small amount of drainage. LVN A cleaned Resident #2's foot by wiping over the same area five times with the same area of gauze (this contaminates the wound). LVN A doffed the gloves, washed her hands, and donned new gloves. LVN A reached into her pocked (contaminating the gloves) and pulled out packets of skin prep wipes. LVN A wiped Resident #2's left heel with the front of a skin prep wipe and then flipped it over and wiped with the back side of the same wipe. With the same gloves, LVN A picked up Resident #2's right leg and then put it down on the boot. LVN A took off her gloves, stepped out and grabbed more gloves. Without any hand hygiene, LVN A donned gloves, picked up Resident #2's right heel opened a package of skin prep wipes and wiped down Resident #2's right heel, turned over the wipe and wiped the heel with the back side of the wipe and then put on the padded dressing. LVN A put the boot back on Resident #2 and checked to make sure it was not too tight. LVN A took off her gloves, washed her hands and then threw out the dirty wound care supplies with bare hands. Interview on 07/27/23 at 10:10 AM, LVN A stated the wound care was just a blur to her. LVN A said Resident #2 always talked to her during wound care and LVN A was distracted by it. LVN A stated she remembered she wiped down the table with wipes put wax paper down and set up the biohazard bag, then she (LVN A) put the things she was going to use including the wound cleaner in the cup and the gauze. LVN A stated she usually set up the skin prep as well but she had it in her pocket, so she (LVN A) did not put it on the table. LVN A said she then washed her hands, gloved, took off the boot, took off the old dressing and put it in the bag. She said she washed hands and looked at the wound and noticed it was opened. LVN A said she thought she needed to do the treatment, so she reached into her pocket and got the skin prep out. LVN A said she thought she needed to do the treatment the way it was ordered until they got new orders. LVN A stated the orders were clean the wound which she did. LVN A described she put cleanser on gauze went around the wound, folded the gauze and went outside in and then inside out. LVN A said she reached into her pocket to get the skin prep pad. LVN A said she usually just laid the pad on the wound, patted it on, turned it over and patted it again and then wait for it to dry. LVN A said she got the foam dressing and put it on Resident #2's heel. Surveyor and LVN A reviewed the wound care observation. LVN A said she was not supposed to go from one foot to the other and she didn't know what happened and she did not know why she did not fold the gauze she used to clean the wound. LVN A admitted she cross contaminated the gloves when she reached into her pocket. LVN A said, I was just not prepared. LVN A listened to the wound care observation and stated she needed to wash her hands more. LVN A said she did not get a lot of training on wound care. LVN A stated the facility had a wound care nurse come in and train them about five years ago. LVN A admitted she was not good at wound care. LVN A said she was not sure if she told people she needed more training or not. LVN A stated she was sure the management had checked her off for doing wound care over the years, but it was not recent. Interview on 07/27/23 at 10:57 AM, the ADON stated the facility's expectation for wound care was for the nurse to wash hands, clean the overbed table, take supplies in and place them on wax paper put the supplies on the over bedside table, don gloves, remove soiled dressing, throw in biohazard bag, doff gloves, sanitize hands, don clean gloves, clean the wound with wound cleanser, remove gloves, sanitize, don gloves, apply treatment, apply clean dressing, date, clean up supplies, wash hands and done. The ADON stated proficiency checks on wound care were done annually by the ADON or DON. The ADON said the last time proficiency checks on wound care was a month or two ago and they got all the nurses that were in the building at that time. The ADON said the last time the staff were in-serviced on wound care was a month or two ago. The ADON stated the facility did the in-service when there was something that triggered the in-service. The ADON said the facility showed what was expected at the time of the in-service, but everyone signed the in-service. The ADON said the DON had nurses watch a video on the expectation of wound care on hire. The ADON added, the facility wound care supply company also sent out literature on how to do wound care. The ADON and surveyor reviewed the wound care observation. The ADON identified the need for hand hygiene prior to beginning the wound care, the need to change gloves between taking off the dressing and blotting the wound. The ADON stated LVN A contaminated her gloves when she went from the left foot to the right foot. The ADON stated the prep pads were not supposed to be flipped because whatever was on one side of the wipe is on the other side of the wipe. The ADON stated the gloves that LVN A put in her pocket were now disgusting with whatever was in the pocket. The ADON stated she understood what the concerns were. Interview on 07/27/23 at 12:56 PM, the Administrator stated the ADON caught her up about the wound care procedure not done appropriately including the reaching into the pocket, not changing gloves, and the wound cleaned improperly. INCONTINENT CARE. Record review of Resident #38's admission record dated 07/26/23 indicated she was admitted to the facility on [DATE] with diagnoses which included stroke and muscle weakness. She was [AGE] years of age. Record review of Resident #38's MDS dated [DATE] indicated in part: Bladder and Bowel: Urinary Continence =. 3. Always incontinent (no episodes of continent voiding). Bowel Continence = 3. Always incontinent (no episodes of continent bowel movements ). Record review of Resident #38's care plan dated 06/05/2018 indicated in part: Problem: Resident is incontinent of bladder and bowel related to stroke. Goal: Resident will remain clean, dry and odor free with reduced occurrence of skin breakdown x 90 days. Interventions: Monitor resident for incontinence every 2 hours and PRN. Change promptly and apply a protective skin barrier to skin. During an observation on 07/25/2023 at 2:20 PM, CNA B performed incontinent care for Resident #38, the CNA was seen wearing a pair of gloves that she used to get the supplies from a hall cart and then entered the resident's room. CNA B then performed the incontinent care for the resident without first changing her gloves or washing her hands. CNA B then undid the Rresident's brief and wiped the resident's vaginal and then rectal area with some wet wipes. While wearing the same gloves, CNA B took a clean brief and fastened it to the resident and then adjusted the resident's clothing back on her. During an interview on 07/25/23 at 02:50 PM, CNA B said she would usually put on gloves when she was getting the supplies ready in the hall. CNA B said she had forgotten to wash her hands prior to starting the incontinent care. CNA B said she should have changed her gloves after she wiped the resident's personal areas and applied the clean brief. CNA B said she had gotten nervous and forgot to do some of the steps. CNA B said the failure could have led to cross contamination and infections. During an interview on 07/25/23 at 12:12 PM, the ADON said the aides were not supposed to be wearing gloves out in the hallway. The ADON said it was expected for the aides to wash their hands prior to performing incontinent care. The ADON said it was expected for the aides to change their gloves and wash their hands before going from dirty to clean. The ADON said if the aides did not change their gloves or wash their hands then that could lead to infections. The ADON said the failure occurred because the aide probably got nervous and missed some of the steps During an interview on 07/25/23 at 12:40 PM, the Administrator said aides were not supposed to be wearing gloves out in the hallway. The Administrator said aides were supposed to change their gloves and wash or sanitize their hands before applying a new brief on the resident. The Administrator said she believed the failure occurred because the aide got nervous and forgot her steps. Record review of the facility's policy titled handwashing/hand hygiene and dated 08/2019 indicated in part: The facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors. Use an alcohol-based hand rub containing at least 62% alcohol or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations. Before and after direct contact with residents; before handling clean or soiled dressings, gauze pads etc.; before moving from a contaminated body site to a clean body site during resident care; after contact with a resident's intact skin; after contact with blood or bodily fluids; after removing gloves. Hand hygiene is the final step after removing and disposing of personal protective equipment. The use of gloves does not replace hand washing/hand hygiene. Record review of the facility's policy titled Perineal Care and dated 02/2018 indicated in part: The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation and to observe the resident's skin condition. Wash and dry your hands thoroughly. Put on gloves. For a female resident. Ask the resident to turn on her side with her top leg slightly bent if able. Rinse wash cloth and apply soap or skin cleansing agent. Wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks. Rinse and dry thoroughly. Remove gloves and discard into designated container. Wash and dry your hands thoroughly or use hand sanitizer. Put on gloves and apply protective ointment if needed and clean brief. Review of the Treatment Nurse Competency Check Off form for Wound Care, undated revealed: Wash hands Clear overbed table and cleaned with damp paper towel Wash hands Gathered all needed supplies for treatment including piece of wax paper/ barrier for over bed table and set up items maintaining clean field. Wash hands and don gloves Positioned residents Washed hands and donned gloves Cleaned wound with ordered solution using proper technique (inner wound to outer edge) Applied topical medication if ordered If more than one wound, repeat steps. If any area was contaminated, start over. Remove gloves and wash hands. Remove soiled dressings in bag and dispose of in bio-hazard room. Review of the facility's policy and procedure on Standard Precautions, revised September 2022, revealed: Standard precautions are used in the care of all residents regardless of their diagnoses, or suspected or confirmed infection status. Standard precautions presumed that all blood, body fluids, secretions, and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible and infectious agents. Policy Interpretation and Implementation. 1. Standard precautions apply to the care of all residents in all situations regardless of suspected or confirmed presence of infectious diseases. Standard precautions included the following practices: 1. Hand Hygiene a. Hand hygiene refers to hand washing with soap (and try microbial or non antimicrobial) or the use of alcohol fat based hand rub (a BHR), which does not require access to water. b. Hand hygiene is performed with a BHR or soap and water (1) before and after contact with the resident; (2) before performing an aseptic task; (3) before moving from work on a soiled body site to a clean body site on the same resident; and (5) after removing gloves C. Hands are washed with soap and water (1) when visibly soiled with dirt, blood, or body fluids; (2) after contact with blood, body fluids or contaminated surfaces. 2. Gloves a. Gloves (clean, non-sterile) are worn when in direct contact with blood, body fluids, mucus membranes non intact skin, and other potentially infected material b. gloves are worn when in direct contact with a resident who is infected or colonized with organisms that are transmitted by direct contact. d. Gloves are changed in hand hygiene performed before moving from a contaminated body site to a clean body site during resident care. f. Gloves are changed as necessary, during the care of a resident to prevent cross contamination from one body site to another (when moving from an open site to a clean one). j. After gloves are removed, hands are washed immediately to avoid transfer of microorganisms to other residents.

Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure that expired foods were discarded. This failure could affect residents who received meals prepared meals from the kitchen at risk for food borne illness and cross-contamination. The findings included: Observation on 7/25/23 at 10:15 AM, of the kitchen dry storage room revealed: 9, 14-ounce cans of Sweetened Condensed Milk with an expiration date of 8/10/21. In an interview on 07/25/23 at 10:45 AM, the Dietary Manager was advised of the expired food items found during the initial inspection of the kitchen. The Dietary Manager took the items to discard them. The Dietary Manager stated expired items were typically disposed of every six months. During an interview with the Dietary Manager on 07/27/23 at 9:55 AM, when asked if he had a process in place to check for expiration dates on food, he stated this was overlooked because the cans of Condensed Milk were on the top shelf and not seen. The Dietary Manager stated typically every 6 months when he got the new menu, he got the new inventory. He would then get rid of food items not needed or expired. He stated in the future he will make an inventory list so that when food items are received, he will check the expiration dates. If he is not working when food items are received, then another staff will check the food items for expiration dates. When asked if the cook checks the dates on cans or food items before cooking, he stated they should. Review of undated facility policy titled Food Storage, revealed, in part: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HAACP guidelines. Dry storage rooms: - To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be covered and dated. - Use the first-in, first-out (FIFO) rotation method. Date packages and place new items behind existing supplies, so that older items are used first.

Based on observation, interview, and record review, the facility failed to ensure all discontinued controlled drugs and biologicals were securely stored for 1 of 1 medications storage compartment. The facility failed to ensure medication carts were locked when unattended for 2 of 8 medication carts ( C-Hall and D-Hall medication carts) reviewed for drug storage. The discontinued controlled medications and biologicals kept in the DON's were not kept behind 2 separate locks at all times. Medication Carts for Hall C and Hall D were left unlocked and unattended in resident areas. These failures could place the residents at risk of access to medications , accidental ingestion, and drug diversion . Findings Included: During an observation on 5/24/22 at 12:25 PM through 12:49 PM the D-Hall medication cart was seen parked at the nurse's station facing out (drawers toward the hallway). It was facing outwards and unlocked. There was no staff around the cart. Residents were coming and going to /from the dining room passing by the medication cart. During an observation on 05/24/21 at 02:34 PM the DON's office door was open and no staff in the office. The wooden file cabinet drawer had a hasp and lock on it that was locked, there was no second lock observed. During an observation and interview wooden file cabinet for discontinued mediations on 05/25/22 at 11:45 AM. The medications were inspected and the discontinued controlled medications were stored in the DONs office. There were several discontinued medications and were all accounted for when reconciled with their corresponding medication sheets. The medications were located in a wooden file cabinet drawer which only had one lock. The DON said the drawer had only one lock on it and that her office door was considered the second lock. The DON said whenever she stepped out of her office she made sure to close and lock the door behind her. The DON was made aware of her office door observed open with no one in her office and only one lock seen on the wooden file cabinet drawer. The DON said she believed she should have not left the door open and unlocked. During an observation on 5/25/22 at 6:10 PM through 6:25 PM the C-Hall medication cart was observed parked at the wall between the nurse's station and the dining room. It was facing out (drawers toward the hallway), unlocked and unattended. Residents were observed coming to/from the dining room after the supper service. Two residents pointed out three wandering residents passing by. During an observation on 5/25/22 at 6:13 PM , MA A did something on the top of the medication cart and walked away leaving it unlocked. During an interview on 05/26/22 at 11:44 AM the DON said the carts were supposed to be locked if the staff were not attending it. The DON said she conducted monitoring rounds to see that carts were locked if unattended. The DON said the nurses and CMAs were responsible to keep the carts locked if they were stepping away from them. The DON said if the carts were left unlocked then there was a possibility of residents, visitors or unauthorized staff having access to it. The DON said she was not sure how the failure occurred as she did not know the circumstances that led to the staff leaving the cart unlocked. During an interview on 05/26/22 at 12:14 PM the Administrator was made aware of the medication carts observed unlocked, unattended, out of view of staff and the discontinued controlled medications not secured by 2 locks in the DON's office. The Administrator said the discontinued controlled medications were kept in the DON's office and were supposed to be under 2 locks. The Administrator said she had been in the DON's office before, and the DON was good about closing the door behind her to keep the controlled medications behind 2 locks. The Administrator said the failure occurred probably because the DON stepped out and forgot to close the door behind her. The Administrator said the CMAs and nurses were supposed to keep their carts locked if they left them unattended. The Administrator said the failure of the staff leaving the carts unlocked probably occurred because they left and did not lock the cart behind them. The Administrator said the medication carts left unlocked, unattended and the controlled medications not secured could lead to someone taking the medications. Record review of the facility's policy, Storage and expiration of medications, biologicals, syringes and needles and dated 10/31/16 indicated in part: The policy 5.3 sets for the procedures relating to the storage and expiration dates of medications, biologicals, syringes and needles. Facility should ensure that only authorized facility staff as defines by facility should have possession of the keys, access cards, electronic codes or combinations which open medication storage areas. Authorized staff may include nursing supervisors, charge nurses, licensed nurses, and other personnel authorized to administer medications in compliance with applicable law. Facility should store scheduled II controlled substance and other medications deemed by facility to be at risk for abuse or diversion in a separate compartment within the locked medication carts and should have a different key or access device. Facility should ensure that all medications and biologicals including treatment items are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. Facility should ensure that schedule II - V controlled substances are only accessible to licensed nursing, pharmacy and medical personnel designated by facility. After receiving controlled substances and adding to inventory, facility should ensure that schedule II - V controlled substance are immediately placed into a secured storage are (i.e., a safe, self-locked cabinet or locked room in all cases in accordance with applicable law).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to have certified resident rooms equipped for adequate nursing care, comfort and privacy for 3 of 120 certified beds (Rooms #45, #1, and #15) as evidenced by: Hall C, room [ROOM NUMBER], was certified for one Title 19 (Medicare Certified room) resident bed and was not resident ready. It could not easily be transitioned into a resident-ready room. The room was used as a conference room and was filled with office furniture and a large conference table. The call light jack had been converted into a cable line jack. The room had no resident furniture. Hall A, room [ROOM NUMBER] and #15 were used for Therapy Services and were not resident ready. They could not be easily transitioned into resident-ready rooms. The rooms were used as office spaces for therapy and filled with file cabinets and desks. The rooms had no resident furniture. This failure could affect residents by placing them at risk of residing rooms without proper furnishings and privacy. The findings include: Review of the facility-completed Form 3740 Bed Classification completed and signed by the Administrator on 5/25/22 documented the facility identified Rooms #1 and 15 as Title 18 Medicare-Only beds for both the A and B beds. The form also documented the facility identified room [ROOM NUMBER] as Title 18/19 Dually Certified bed for the A and B beds. Observation on 5/26/22 at 12:18 PM showed: room [ROOM NUMBER] was used as a conference room with a long conference table in it. There were no curtain tracks, and the call light [NAME] had been converted into a cable jack. room [ROOM NUMBER] had an electronic combination lock on it. The room had a filing cabinet and therapy equipment in it. room [ROOM NUMBER] was used as a therapy office. It had multiple file cabinets with wooden planks across them to make desks. Interview on 5/26/22 at 4:46 PM the Administrator stated a previous surveyor cited room [ROOM NUMBER] prior due to the amount of file cabinets in the room and the facility found alternative solutions. She stated she was aware there was not a curtain track for room [ROOM NUMBER]. She said she was not aware there was no call light system in the room. She stated Rooms #1 and #15 could be made resident ready quickly. Interview and observation on 5/26/22 at 5:08 PM the Maintenance Assistant looked at Rooms #1 and #15 and stated it would take him a couple of days to get the rooms resident-ready. He stated the call light jack in room [ROOM NUMBER] was now a cable jack and not a resident call light system. He said he did not know how to change that out. Interview on 5/26/22 at 6:00 PM, the Administrator stated if all the staff were working on it they could get Rooms #1 and #15 empty and resident ready . She stated she would have to talk to her corporation about de-certifying room [ROOM NUMBER].