Wildewood Downs

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, record review, observations and interviews, the facility failed to ensure proper personal protective equipment (PPE) was used for Resident (R)2 during a dressing change. In addition, the facility failed to follow proper procedures related to dressing changes for 1 of 1 resident reviewed.Findings include:Review of the facility's policy titled, Enhanced Barrier Precautions with a copyright dated 2001 Med-Pass, Inc. states, Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents.Policy Interpretation and Implementation1. Enhanced barrier precautions (EBPs) refer to infection prevention and control interventions designed to reduce the transmission of multi-drug-resistant organism (MDROs) during high contact resident care activities.2. Enhanced barrier precautions apply when:b. A resident is NOT known to be infected or colonized with any MDRO, has a wound or indwelling medical devices, and does not have secretions or excretions that are unable to be covered or contained; and4. Standard precautions apply to the care of all residents regardless of suspected or confirmed infection or colonization status.6. Examples of secretions or excretions include wound drainage, fecal incontinence or diarrhea, or other discharges from the body that cannot be contained and pose an increased potential for extensive environmental contamination and risk of transmission of a pathogen.7. EBPs employ targeted gown and glove use in addition to standard precautions during high-contact resident care activities when contact precautions do not otherwise apply.a. Gloves and gown are applied prior to performing the high-contact resident care activity (as opposed to before entering the room).8. Examples of high-contact resident care activities requiring the use of a gown and gloves for EBPs include:a. dressingj. wound care (any skin opening requiring a dressing).Review of the facility's policy titled, Dressings, Dry/Clean with a copyright dated 2001 Med-Pass, Inc. states, The purpose of this procedure is to provide guidelines for the application of dry, clean dressings.Steps in the Procedure5. Wash and dry your hands thoroughly.6. Put on clean gloves. Loosen tape and remove soiled dressing.7. Pull glove over dressing and discard into plastic or biohazard bag.8. Wash and dry your hands thoroughly.9. Open dry, clean dressing(s) by pulling corners of the exterior wrapping outward, touching only the exterior surface.10. Label tape or dressing with date, time and initials. Place on clean field.11. Using clean technique, open other products (i.d., prescribed dressing; dry, clean gauze).12. Wash and dry your hands thoroughly.13. Put on clean gloves.14. Assess the wound and surrounding skin for edema, redness, drainage, tissue healing progress and wound stage.15. Cleanse the wound with ordered cleanser. If using gauze, use clean gauze for each cleansing stroke. Clean from the least contaminated area to the most contaminated area (usually, from the center outward).16. Use dry gauze to pat the wound dry.19. Remove disposable gloves and discard into designated container. Wash and dry your hands thoroughly.22. Clean the bedside stand.23. Wash and dry your hands thoroughly.Review of R2's Face Sheet revealed R2 was admitted on [DATE] with diagnoses including, but not limited to, muscle weakness (generalized), dysphagia, oral phase, and fusion of spine, lumbar region.Review of R2's Care Plan with a start date of 12/19/25, documented Pressure ulcer-stage II pressure injury to the sacrum. Further review of the care plan revealed the following interventions: Provide skin care per facility's guidelines and prn as needed, monitor ulcer for signs of progression or declination, and educate resident/resident representative (RR) about proper skin care to prevent skin breakdown.During an observation on 01/22/26 at 01:58 PM, Licensed Practical Nurse (LPN)1 entered R2's room without donning [putting on] a gown. The surveyor observed LPN1 washing hands and donning gloves to change R2's sacral dressing. LPN1 cleaned R2's sacral wound with wound cleanser with a 4x4 dressing. LPN1removed the gloves and rewashed hands. LPN1 opened the bordered gauze, placed Medi honey on the gauze, and placed on R2's sacral wound. LPN1 removed the black marker from her pocket and labeled the dressing. LPN1 placed the dressing on R2's sacral area. During an observation on 01/22/26 at 02:05 PM, LPN1 removed R2's sock and donned gloves to remove the bordered gauze. The nurse washed her hands before labeling the gauze. LPN1 cleaned the wound with wound cleanser. LPN1 did not clean off the bedside table or the black marker. During an interview on 01/22/26 at 02:22 PM, LPN1 stated, When asked about the use of PPE, LPN1 stated, I forgot to put it on. I know we need to wear our PPE, I don't know why I forgot it. When asked about training related to PPE requirements, LPN1 stated, We do have in-person in-services and on Relias. Sometimes our training is one-on-one. On the weekend, staff are trained by our weekend nurse managers.During an interview on 01/22/26 at 04:58 PM, the Administrator stated, We will provide additional training on wound dressing changes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy, observations, and interviews, the facility failed to ensure medications and biologicals remained sterile in 1 of 1 treatment carts reviewed.Findings include:Review of the facility's policy titled Medication Labeling and Storage copyrighted 2001 Med-Pass, Inc, revealed The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys.Policy Interpretation and Implementation:2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.During an observation on 01/21/26 at 11:37 AM, the treatment cart on the Rehabilitation Unit revealed the following:Xerofoam Gauze Dressing with 3% Bismuth Tribromophenate and petroleum 4x4 Lot F-20250110 exp 20280109. The DermaRite Sterile packet was cut and packet open. PolyMem, 4x4 non-adhesive pad, reference #5044, expires 2028/07. The pack was marked sterile, however it was observed to have been left open.Medline TheraHoney HD sheet honey impregnated wound dressing 4x5 rectangle, marked as sterile and left open.3M Silvercel, non-Adherent Antimicrobial alginate dressing, marked as sterile and left open. [NAME] Medical Surgical Inc. Lot CZI10-01 MFR#240P Suture Removal Kit metal forceps, open in a sterile container.During an interview on 01/21/26 at 12:00 PM, the Assistant Director of Nursing (ADON) stated, The door is locked behind the nursing station, so the treatment cart can be unlocked. We will do an in-service on infection control of the open sterile dressings.During an interview on 01/22/26 at 5:15 PM, the Administrator stated, The expectation is we will use it or dispose of it. I will look more into this. We initiated education when it was brought to my attention. We will have the Infection Preventionist (IP) Nurse go through the process for Infection Control.

Based on observation, interview, and facility policy the facility failed to ensure that opened food items were properly labeled and stored, 2 of 2 kitchens reviewed.
Findings include:
Review of an undated policy titled, Food Receiving and Storage, revealed Foods shall be received and stored in a manner that complies with safe food handling practices.
Initial tour of the Skilled Nursing Kitchen on 10/08/24 at 10:00 AM revealed the following items opened, but not dated:
In a overhead shelf:
-2 bottles of Steak Sauce
-A bottle of Ketchup
-A bottle of Malt Vinegar
-1 container of house blend coffee
Observation and interview with the Dietary Manager for the Skilled unit on 10/08/24 at 10:05 AM revealed that staff did not update the Food Storage Bin Log to reflect the sugar that was added to the bin on 10/07/24. Review of the Food Storage Bin Log revealed that it was last updated in July 2024.
Observation on 10/08/24 at 10:07 AM of a drying rack revealed several wet cups stacked on top of each other.
An observation on 10/08/24 at 10:10 AM of a storage rack revealed personal items, belonging to some of the kitchen staff and a bin of bananas stored beside each other. During an interview with the Dietary Manager and Kitchen Staff, it was confirmed that personal items are not be stored in the kitchen.
An observation on 10/08/24 at 10:15 AM of a double door refrigerator/cooler revealed the following item not labeled after opening:
-1 gallon of milk
An observation on 10/08/24 at 10:17 AM of the Main Kitchen revealed the following items not labeled after opening:
In the dry storage room:
-1 container of peanut butter
-1 bag of cereal (corn flakes)
In the freezer:
-1 box of biscuit dough
-1 box of stew vegetable mix
-1 freezer bag of salami
-1 freezer bag of cubed cheese
An interview with the Kitchen Manager on 10/08/24 at 10:30 AM revealed that all food items are to be labeled and dated after opening and personal items are not be stored near food items.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy, the facility failed to ensure Resident (R)4 had adequate supervision to prevent a fall. 1 of 3 reviewed for accident/hazards.
Findings include:
Review of facility policy, date unspecified, titled, Falls and Fall Risk, Managing revealed Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. The staff, with input of the attending physician, will implement a resident-centered fall prevention plan the specific risk factor(s) of falls for each resident at risk or with a history of falls. If interventions have been successful in preventing falling, staff will continue the interventions or reconsider whether these measures are still needed if a problem that required the intervention has resolved.
R4 was admitted to the facility on [DATE] with diagnoses including but not limited to fracture of left lower femur, encounter for orthopedic aftercare, and morbid severe obesity due to excess of calories. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date of 08/05/24 revealed that R4 has the Brief Interview of Mental Status (BIMS) score of 15 out of 15, which indicates that she is cognitively intact. Further review of the admission MDS revealed that R4 is dependent on staff for toileting hygiene.
Record review of R4's Nurses Notes dated 08/05/24 revealed At approximately 7:45 PM Certified Nursing Assistant (CNA) approached nurse in hallway and requested help. Nurse entered room and bed was in highest position, resident was on floor lying on her left side. CNA stated that she was providing incontinent care without a second person. Nurses assessed resident for injury, resident stated repeatedly that she was okay. Nurse and CNA used Hoyer lift to assist resident back to her bed. Resident did not lose consciousness during this episode. She remained alert. Nurse assessed resident again when she was back in bed, and noted swelling and bruising to her left forearm, and a swollen spot to her head. Resident stated that she was in pain to her arm and head and needed pain medication. As needed pain medication administered to resident notified R4's resident representative informing her of incident. Nurse suggested to resident that she go to the hospital for evaluation, resident refused. Nurse re-emphasized the importance of going considering she hit her head, and her injured leg. She then agreed to go hospital. Resident left facility via stretcher to hospital. Director of Nursing (DON) and Resident Care Coordinator (RCC) notified of transfer and incident.
Record review of R4's Nurses Notes dated 10/07/24 revealed At around 3:00 pm reported by another nurse, patient noted sitting in front of her wheelchair. Per Therapy during her sliding board transfer training, patient begin to scoot off board interiorly and unable to scoot back in bed, patient requires maximum assist to slowly lower to ground with slide onto buttocks. Then other nurse and Therapy get patient up from floor using Hoyer lift to put back in the wheelchair. Assessment done no noted any injury and no verbalizes complaint of pain. Patient placed on monitoring; patient informed us to place a call to daughter at around 5-6 pm after her work from school.
Review of R4's Care Plan dated 07/30/24 - present revealed R4 is at risk for falls related to overall weakness, history of fall resulting in left hip fracture. Interventions include resident requires two-person assist for all bed mobility and Activities of Daily Living (ADL)s. Re-educated therapy staff and nursing staff on safety precautions and ADLs. Footwear will fit properly and have non-skid soles. Keep areas free of obstructions to reduce the risk of falls or injury. Place call light within easy reach.
An interview on 10/09/24 at 12:30 PM with R4 revealed that back in August (08/05/24), a CNA was providing incontinence care to them without a second person, and they rolled off the bed. R4 stated that she went to the hospital and had some bruising after the fall but did not have any injury. R4 continued to talk about having a second incident with therapy staff where she had to be lowered to the ground due to weakness. R4 stated that normally there are always two people with me, but the therapy staff member was working alone as well.
A phone interview on 10/10/24 at 10:13 AM with R4's Resident Representative (RR) revealed that R4 had a fall due to the facility not having adequate staffing and not providing the resident with two-person assistance. R4's RR stated that she was told by staff that the CNA that assisted R4 with ADL care did not want the resident sitting in her waste for a long period of time and knew that the other CNAs were busy at the moment and that it would be a while before another person could assist the resident. When the CNA provided care, R4 accidently rolled off the bed. R4's RR was upset during the interview due to a second incident with therapy staff (10/07/24) having to lower R4 to the floor because they were also working alone.
An interview on 10/10/24 at 2:11 PM with CNA5 revealed that the resident has had 2 falls at the facility due to staff not following the resident's care plan for two- person assist. CNA5 stated that the first fall occurred due to CNA attempting to provide ADL care for R4 without another CNA in the room and the second fall occurred because therapy staff did not have a 2nd person, and the resident had to be lowered to the floor.
An interview with 10/10/24 at 3:46 PM with Physical Therapy Assistant (PTA) revealed they were working with the resident attempting to stand her up from a chair without assistance. PTA stated that resident should have been two-person assist and was re-educated related the incident. PTA confirmed that they were aware the resident had a fall with a CNA in August where they were also working alone as well.
An interview on 10/10/24 with the Administrator and Director of Nursing (DON) revealed that the resident is a two-person assist and staff (therapy and nursing) have been re-educated on the importance of having adequate assistance when providing ADL care with R4.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review, and policy review, the facility failed to provide respiratory care in accordance with professional standards. The facility failed to clarify one of one sampled resident (Resident (R1) physician's orders regarding the correct CPAP Support Therapy mode and settings.
Findings Include:
A review of the facility policy titled CPAP/ BiPAP Support, with a complete revision date of March 2015 states - Preparation 3. Review the physician's order to determine the oxygen concentration and flow, and the PEEP pressure (CPAP, IPAP, and EPAP) for the machine. 4. Review and follow the manufacturer's instructions for CPAP machine setup and oxygen delivery. Steps in the procedure 8. Set mode, CPAP, IPAP, and EPAP settings on the machine, as prescribed. Documentation- Document the following in the resident's medical record: 3. Mode and settings for the CPAP/IPAP/EPAP.
A review of R1's Face Sheet revealed that R1 was admitted to the facility on [DATE] at 2:15 PM with diagnoses that included Pneumonia, Sleep Apnea, Parkinsonism, and Hypertension.
A Review of R1's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 08/22/24 revealed a Brief Interview for Mental Status (BIMS) score of 07 out of 15, indicating R1 was severely, cognitively impaired.
A Review of R1's Physician Orders revealed Orders: Hour of Sleep Continuous Positive Pressure (CPAP) AC
Start Date: 08/18/2024
Start Time: 12:00 am
Scheduled
First scheduled time is 8/18/2024 on the Hour of sleep time period.
Instructions:
Use with home settings already set.
Observation and interview with R1 on 10/08/24 at 12:18 PM revealed R1 in her room, sitting in a non-mechanical wheelchair with CPAP noted at the bedside, R1 stated that staff will put on a CPAP machine at night, R1 also stated she was unsure of the settings on the machine.
An interview with a Licensed Practical Nurse, (LPN)1 on 10/09/24 at 11:42 AM revealed LPN1 confirmed he knew R1 and had provided care to her prior. LPN1 stated the doctor's order has the right pressure for the CPAP in it. LPN1 stated that distilled water, not regular water goes in the machine. When the machine comes in, it's the nurse's responsibility to ensure that the machine is set to the correct mode and settings per physician orders.
A phone interview with the facility's Nurse practitioner, (NP) on 10/10/24 at 1:31 PM revealed the following, NP confirmed she was familiar with the resident. NP stated typically when a resident brings a CPAP from home, the settings are just monitored. NP stated if the staff does not know the settings, oxygen is used until the staff finds out what the settings are on a resident's CPAP machine. NP stated if something occurs with the CPAP machine, the nursing staff is to call her. She then stated at that point she would then write an order for oxygen. She stated if the machine was in the incorrect setting, the CPAP machine will alarm, and that's how staff will know if something is wrong with that machine. NP stated there is no standard setting for the CPAP machine. The settings are determined by the sleep study. NP stated that R1's CPAP equipment was present upon admission. NP stated she was not aware that the mode and settings needed to be included in the CPAP order. NP verbalized the nursing staff can look at the display screen located on the CPAP to determine the mode and settings. NP thanked the surveyor for the information related to the CPAP policy.
An interview with Registered Nurse (RN)3 on 10/10/24 at 3:05 PM revealed RN3 confirmed she was familiar with R1. RN3 stated when R1 was admitted she did not have a CPAP machine upon admission, however, she received one a few days after. RN3 stated R1 is required to wear a CPAP at night. RN3 verified R1's order and stated she was unsure of what the resident's home settings were. RN3 stated that nursing staff can call the resident's family to obtain more information in regard to the CPAP machine mode and settings. RN3 stated she would usually expect to see the mode and settings clarified in the physician orders in the case something happens to the machine such as if the CPAP machine falls or if the resident touches or changes the setting.
An interview with the Director of Nursing (DON) on 10/10/24 at 3:16 PM revealed the DON confirmed she was familiar with the resident. DON stated R1's CPAP machine settings should be between 5-12. DON stated, R1's order needs to be more specific and confirmed the CPAP settings should have been included in the physician's order. DON stated moving forward, her expectation are for the nurses to be aware of the importance of the order to include CPAP mode and settings. DON stated if mode and settings are not included in the order, it would be the nurse's responsibility to clarify the physician's orders.

Based on observations, interviews, and facility policy review, the facility failed to ensure food
was stored and labeled properly in the dry goods storage, walk-in fridge, and walk- in freezer to
prevent the spread of foodborne illnesses. The facility also failed to ensure the ice machine was properly
sanitized and/or cleaned.
Findings include:
1. A review of the facility's policy titled, Food Receiving and Storage, revised 07/2014,
revealed, . 8. All foods stored in the refrigerator or freezer will be covered, labeled and dated
('use by' date).
During the initial tour of the main kitchen with the Executive Chef (EC) on 05/16/2023 at 10:43 AM, revealed the following:
In the dry goods storage:
- One package of tortillas in a plastic bag. The original package had been opened and the current
package was sealed but there was no opened date or end date. The EC stated she did not know
the open date and the package should be dated.
- One package of breadcrumbs in a plastic bag. The original package had been opened and the
current package was sealed but there was no opened date or end date. The EC stated she did not
know the open date and the package should be dated.
In the walk-in freezer:
- One box of frozen premade hamburger patties. The package inside of the box contained seven
frozen hamburgers. The package was open, exposing the frozen hamburgers. The EC stated the
kitchen staff must have come into the freezer and got some of the hamburger patties out of the
package to prepare for the next meal and they did not close the packaging.
- One brown paper package of Arancini (small balls of rice stuffed with a savory filling, coated
in breadcrumbs, and fried) was opened, not sealed, and was undated. The EC picked up the
package and three Arancini balls fell out of package and fell to the floor due to it not being
sealed. The EC stated she did not know the date the package was originally opened and the
package should be dated and sealed.
- Two brown paper packages of French fries were stacked on top of each other. The bottom
package had a visible cut in the package, exposing a French fry. The EC picked up the top
package of French fries, which exposed a cut on the right side of the package. When the EC
picked up the package, the packed burst open, making the French fries fall to the floor. The EC
stated the packages should have been sealed.
In the walk-in fridge:
- One metal cart with shelves containing eight baking trays. Each tray had raw bacon and raw
sausage patties that were covered with wax paper. The bacon was draped over the lip of the tray
and was uncovered. None of the trays were sealed and only had wax paper not fully covering the
raw meat. The EC stated she was told on a previous inspection that it was okay to store the raw
meat with only wax/parchment paper as a covering. The EC stated by not having the meat
properly sealed, cross contamination could occur.
During an interview on 05/18/2023 at 9:43 AM, the EC stated all food located in the dry goods
storage, walk-in fridge, and walk-in freezer should be wrapped and/or sealed, labeled, and have
an opened and end date.
During an interview on 05/18/2023 at 3:37 PM, the Director of Nursing (DON) stated food
located in the dry goods storage, walk-in fridge, and walk-in freezer should be labeled and sealed
if the product had been opened.
During an interview on 05/18/2023 at 4:00 PM, the Administrator stated there should be no open
containers of food located in the dry good storage, walk-in fridge, and walk-in freezer and all
items should be dated and labeled. The Administrator stated meat should be in a sealed package.
2. A review of the facility's undated policy titled, Ice Machines and Ice Storage Chests,
revealed, Ice machines and ice storage/distribution containers will be used and maintained to
assure a safe and sanitary supply of ice. 1. Ice-making machines, ice storage chests/containers,
and ice can all become contaminated by .b. Waterborne microorganisms naturally occurring in
the water source; c. Colonization by microorganisms . f. Clean and sanitize the tray and ice
scoop daily . j. Flush and clean the ice machine and dispense after lengthy water disruptions .
During the initial tour of the main kitchen on 05/16/2023 at 10:43 AM, the EC
opened the lid of the commercial ice machine and used a clean paper towel and wiped the
backside of the gray baffle (diverter that directs ice to the back of the machine) and the paper
towel came up clean. There were 7 white plastic pieces that extended out from the back of the
baffle. On each plastic piece, there was a pink/brown residue. The EC wiped one of the plastic
pieces with a paper towel and stated there was a pinkish brown residue on the paper towel. The
EC then looked inside the ice machine and stated she was able to see the pinkish brown residue
on the plastic pieces. The EC stated the facility has a company that comes out once a month to
service the machine. The EC stated the residue should not be present.
During an interview on 05/18/2023 at 9:43 AM, the EC stated the ice machine should be cleaned
once a week by kitchen staff and she had been doing it until there was a change in management
and she had stopped cleaning it weekly.
During an interview on 05/18/2023 at 3:37 PM, the Director of Nursing (DON) stated she was
not sure how often the ice machines were cleaned and the kitchen staff were responsible for
maintaining a clean ice machine. The DON stated the pink/brown residue indicated the machine
was not clean.
During an interview on 05/18/2023 at 4:00 PM, the Administrator stated the kitchen staff should
follow the facility policy regarding the cleaning schedule of the ice machine, however, she was
unsure of what the policy was. The Administrator stated if there was pink/brown residue inside
the ice machine, she expected the kitchen staff to clean the machine.

Based on review of facility policy, interview and record review, the facility failed to track and trend antibiotic usage, infections and perform infection surveillance for six of the twelve months reviewed. This failure placed all residents at risk for potential transmission of infections and communicable diseases. The facility census was 16.
Findings include:
Review of facility's policy titled Antibiotic Stewardship revised in December 2016 revealed, Antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. The purpose of our antibiotic stewardship program is to monitor the use of antibiotics in our residents. Orientation, training and education of staff will emphasize the importance of antibiotic stewardship and will include how inappropriate use of antibiotics affects individual residents and the overall community.
Review of the facility's monthly line/log listing of infections and antibiotics prescribed, revealed that for six out of twelve months, no documentation identifying the type of infection, the type of antibiotic prescribed for treatment, or the resident's room number had been completed. Review of the facility's Antibiotic Stewardship monthly line/log book revealed tracking and trending completed from May 2022 thru January 2023.
An interview with the Infection Control Coordinator on 5/18/23 at 12:10 PM revealed, she would have to ask the Director of Nursing (DON) about previous months not included in the Antibiotic Stewardship Program log/book. She stated when she started this job, she began the Antibiotic Stewardship log/book and monitorization. She stated the DON and her are completing this task together now, but the DON was completing this prior to her starting the job.
In an interview on 5/18/2023 at 12:21 PM, the DON revealed, she could not find her December 2022 - May 2023 infection control log/antibiotic stewardship book.
In an interview on 5/18/2023 at 2:42 PM, the Administrator revealed her expectations of her staff in regard to antibiotic stewardship is for staff to follow policy and procedures. She stated the responsible person for this task is the DON. She stated the DON monitors, but if it is passed, it is passed to the Assisstant DON. She stated she was not aware of any outbreaks during the timeframe of 2022, when the antibiotic stewardship log cannot be located.

Based on interviews, record review, and facility policy review, the facility failed to review and revise a comprehensive person-centered care plan for 1 (Resident (R)17) of 10 residents whose comprehensive care plans were reviewed. Specifically, the facility failed to revise the comprehensive care plan for R17 after a pressure ulcer was identified.
Findings include:
The facility's policy titled, Goals and Objectives, Care Plans, revised 04/2009 indicated, Care plan goals and objectives are defined as the desired outcome for a specific resident problem. The policy further indicated, Care plan goals and objectives are derived from information contained in the resident's comprehensive assessment and are resident oriented.
A review of R17's Face Sheet revealed the facility admitted the resident with diagnoses which include; type 2 diabetes mellitus, end stage renal disease, stage three pressure ulcer of unspecified site, muscle weakness, dependence of renal dialysis, presence of a cardiac pacemaker, and acute on chronic combined heart failure.
A review of an admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/18/2023, revealed R17 had a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. Per the MDS, R17 had a stage three pressure ulcer during the time of the assessment.
A review of R17's Care Plan, initiated on 04/06/2023, revealed the resident did not have a care plan for pressure ulcers. Further review of the care plan revealed the care plan indicated the resident was only at risk for alteration in skin integrity related to decreased mobility and did not indicate the resident had actual skin impairment.
A review of a progress note on 04/18/2023 at 11:50 AM, LPN2 indicated, Resident c/o [complained of] pain to sacrum. Upon assessment, nurse observed resident to have open area to sacrum. Area cleansed with wound cleanser, pat dry, Medi-honey ointment applied, covered with 2x2 gauze, and secured with tape. Resident stated felt better. Provider notified of new treatment order.
A review of 24 Hour Report/Change of Condition Report indicated on 04/18/2023, R17 had an open area to the sacrum, treatment was initiated, and the resident was placed on a list for the provider to evaluate.
A review of April 2023 Physician Order Sheet indicated on 04/19/2023 a treatment order was created to, Cleanse open area to sacrum with wound cleanser, pat dry, apply medi-honey ointment, over with 2x2 gauze, and secure with tape, daily and as needed until healed.
A review of Skin Observation Form dated 04/20/2023 was not completed and had been locked by the Director of Nursing (DON).
During an interview on 05/18/2023 at 08:39 AM, MDS Coordinator stated that if there was a wound coded on the MDS, there should have been a care plan developed and implemented for the wound. She was unsure why there was not a care plan for the pressure ulcer or why R17 had a care plan for being at risk for alteration in skin integrity if the resident was admitted with a wound. The MDS Coordinator confirmed she is responsible for updating the care plan along with the staff nurses. The nurses will alert the MDS Coordinator of changes that need to be made to a resident's care plan by speaking with her or by adding acute changes with resident to the 24-hour report that is reviewed in the morning meetings with the leadership team to include the DON and Administrator.
During an interview on 05/18/2023 at 9:23 AM, LPN1 stated the MDS Coordinator was responsible for updating the resident's care plan. LPN1 stated she was unsure how to make changes to a resident's care plan. LPN1 stated the MDS Coordinator is alerted of acute changes of the residents by the DON looking through the resident's chart and updating the MDS Coordinator and the 24-hour report. She was unsure of when the pressure ulcer was first identified, however, remembered coming to work and the resident had wound care orders for the pressure ulcer. LPN1 stated she had not spoken with the MDS coordinator about any wounds.
During an interview on 05/18/2023 at 11:02 AM, LPN2 stated she couldn't remember if R17 had a pressure ulcer on admission, but she identified a pressure ulcer a few weeks ago. Once she identified the pressure ulcer, she notified the Provider and treated the wound. She also made note of the wound on the 24-hour report. LPN2 stated the MDS Coordinator updates the care plans, and she was not sure if she had access to update the care plan or how to update the care plan if she had access. LPN2 stated the MDS coordinator gets the information to update the care plan from the nurses or the DON. The DON gets the acute changes regarding residents from the 24-hour report.
During an interview on 05/18/2023 at 3:28 PM, the DON stated the MDS Coordinator updated the care plans, but the MDS Coordinator, the Administrator, and the DON talk about residents' care plans during the morning meetings. The DON stated the nurses do not update the care plans, only the MDS Coordinator. The DON also stated that if a resident is identified as having a wound, she expects the care plan to be updated to reflect the resident having a wound immediately, but definitely within 24 hours.
During an interview on 05/18/2023 at 3:54 PM, the Administrator stated she expects staff to complete skin assessments on admission. The Administrator stated the MDS Coordinator is responsible for developing and updating care plans. The Administrator also stated she expects the MDS to be completed accurately and care plans should be updated immediately once a problem is identified.

Based on review of the facility policy titled, Storage of Medications, and Controlled Substances, observations, and interviews, the facility failed to ensure a small metal box containing narcotics was permanently affixed in one of one medication refrigerators located in one of one medication storage rooms. The facility further failed to ensure discontinued narcotics were secured and double locked, while awaiting destruction. The facility additionally failed to ensure 4 insulin pens, in use, were dated with an open date and expiration date once opened in one of two medication carts.
Findings include:
Review of the undated facility policy titled, Storage of Medications, states, The facility stores all drugs and biological's in a safe, secure, and orderly manner. Number eight states, Schedule II-V controlled medications are stored in separately locked, permanently affixed compartments. Access to controlled medication is separate from access to non-controlled medications.
Review of the undated facility policy titled, Controlled Substances, states, The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications (listed as Schedule II-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976). Storing controlled substances, 1. Controlled substances are separately locked in permanently affixed compartments, except when using single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. Number 8. Medications returned to the pharmacy are recorded and signed by the director of nursing services (or designee) and the receiving pharmacy. Number 13, Controlled substances remaining in the facility after the order has been discontinued or the resident has bed discharged are securely locked in an area with restricted access until destroyed.
An observation on 05/17/2023 at 09:17 AM of the medication storage room revealed, narcotics locked in a metal box in the refrigerator. The metal box was not permanently secured within the refrigerator. Inside the metal box were 2 vials of Ativan 2 milligrams (mg) per milliliter (ml).
During an interview on 05/17/2023 at 09:17 AM, the Director of Nursing (DON) confirmed the narcotics in the metal box and the fact that the box was not permanently affixed in the medication storage refrigerator, in the medication room.
An observation on 05/17/2023 at 09:25 AM of the container used to store discontinued narcotics awaiting disposal by the DON and the Pharmacist revealed, a locked foot locker under the DON's desk in her office. The office door remained open and was observed open on multiple occasions on 05/16/2023 and no one inside.
Observation on 05/17/2023 at 09:25 AM revealed multiple medication blister packs containing discontinued narcotics. The DON stated that the narcotics needed to be written up and placed inside the foot locker. She stated that the Pharmacist comes once a month to destroy the medications.
The medications on top of the foot locker and not secured were:
1) Morphine Sulfate Sol 100 mg/5 ml - 30 mls are in the bottle
2) Morphine Sulfate Sol 100 mg/5 ml - 29.5 mls are in the bottle
3) Tramadol 50 mg- 13 tabs on the blister pack
4) Lorazepam 1 mg- 2 tabs
5) Tramadol 50 mg tabs- 30 tabs
6) Hydrocodone 5-325 mg- 8 tabs
7) Oxycodone 10 mg- 13 tabs
8) Oxycodone 10 mg- 28 tabs
9) Oxycodone 5 mg- 20 tabs
10) Morphine 20 mg/1 ml -12.75 mls
11) Morphine 30 mls
12) Lorazepam 1 mg- 19 tabs
An observation on 05/18/2023 at 11:25 AM of Medication Cart #2 revealed:
One Glargin Insulin (Lantus) Pens in use with no open date and no expiration date after opening.
Two Lispro Insulin (Humalog, Novolog) Pens in use with no open date and no expiration date after opening.
One Levemir Insulin Pen in use with no open date and no expiration date after opening.
Review of a Cheat Sheet, for nurses, provided by Registered Nurse (RN)1 indicated:
Humalog, Novolog and Lantus Flex pens once opened will expires in 28 days from the open date.
Levemir once opened will expire in 42 days from the open date.
An interview on 05/18/2023 at 11:25 AM with RN1 confirmed that the open date was not on the insulin pens and could not be sure of the date when the pens were first opened and used.