Every finding on record at Accura Healthcare of Creston

Based on Electronic Health Record (EHR) review, resident interviews, staff interviews, and policy review the facility failed to provide restorative services to maintain or improve residents abilities for 6 of 19 residents reviewed (Resident #12, #18, #19, #3, #4, and #23). The facility reported a census of 19.Findings include:1. The Minimum Data Set (MDS) dated [DATE] for Resident #12 documented a Brief Interview for Mental Status (BIMS) of 11 indicating moderate cognitive impairment. The MDS also documented diagnoses of age-related physical debility, generalized muscle weakness, abnormalities of gait and mobility and a need for assistance with personal care.Review of the residents EHR documented no restorative documentation. On 6/22/26 at 3:35 PM Resident #12 stated he would like any therapy especially with the falls. Stated he does not receive restorative therapy, physical therapy or occupational therapy. On 6/24/26 at 4:24 PM Staff B, Physical Therapy Assistant (PTA) stated Resident #12 was not currently on her case load and did not know if he had a restorative program. Staff B stated there were residents at the facility that would benefit from a restorative program. 2. The MDS dated [DATE] documented Resident #18 had a BIMS of 14 indicating no cognitive impairment. The MDS further documented Resident #18 as dependent on lower body dressing, personal hygiene. The MDS documented Resident #18 required substantial to maximal assistance with upper body dressing and bathing for functional abilities.On 6/22/26 at 3:28 PM Resident #18 stated she had requested to be in a restorative program and had not received an answer from the facility staff on when she could start the program. She further explained she would like to be involved in a therapy program to be able to move better. 3. The MDS dated [DATE] documented Resident #19 had a BIMS of 15 indicating no cognitive impairment. The MDS further documented Resident #19's functional abilities as dependent with toileting hygiene with partial to moderate assistance with upper body dressing, lower body dressing and personal hygiene. On 6/22/26 at 10:23 AM Resident #19 stated he would like to do a restorative program to continue to gain strength as his goal was to return home. Resident #19 further explained he used to do Physical Therapy (PT) though was unaware of why it stopped and was afraid he would regress in the progress he had made previously.On 6/24/26 at 4:28 PM Staff B, Physical Therapist Assistant (PTA) stated Resident #19 was discharged from Physical Therapy in November of 2025 without a restorative program initiated. Staff B further explained Resident #19's ambulation assessment documented he was a stand-pivot with 1 assist for transfers. Staff B stated Resident #19 would benefit from a restorative program and that she was unaware of any residents currently on a restorative program. On 6/24/26 at 10:23 AM Staff C, Social Services Coordinator/Admissions and Discharge Coordinator stated the facility did not currently have a restorative program as the facility needed to hire for the position.On 6/24/26 at 5:00 PM the Administrator stated the facility does not currently have an active restorative program.4. Review of the Restorative Binder presented by the Administrator documented Resident #3, Resident #4, and Resident #23. On 6/24/26 at 2:43 PM Staff D, Certified Nurse Assistant (CNA) stated she had worked at the facility for a little over a year. Staff D explained when she first started at the facility there was some restorative being completed. Staff D stated in the last several months restorative has not been done with any of the residents. Staff D stated when residents were on restorative they would have to look at the care plan because it was not on a task in the computer or in a book to document. On 6/24/26 at 5:00 PM the Administrator stated the facility had the Director of Rehab for the facility develop restorative programs for 3 residents but have not started the programs for those residents as of this time. The Administrator acknowledged there was no place to document the restorative was being completed and the restorative had fallen off. The Administrator stated there was not currently a restorative program at the facility for any of the residents but they were working on getting one going.Review of an undated policy provided by the facility titled, Restorative Program Process documented the purpose was to ensure the residents achieved and maintained the highest level of function. The process was upon admission, quarterly, and with significant change the resident's level of function would be assessed by the licensed nurse or in collaboration with therapy. Based on the results of the assessment the licensed nurse would develop a care plan showing the resident's individual problem, determine approaches/interventions and set goals. The licensed nurse would develop a restorative nursing program with individualized interventions and goals which may include recommendations for strategy and adaptive equipment from therapy. Review of a facility provided policy titled, Restorative Program Process dated 10/26/21 documented its purpose to ensure the facility's residents achieve and maintain their highest level of function based upon admission, quarterly assessments, and with significant changes with the resident's level of function. The policy documented residents will be assessed by the licensed nurse or in collaboration with the therapy department. The policy further documented based on the results of the assessment the licensed nurse will develop a restorative nursing program with individualized interventions and goals which may include recommendations for strategy and adaptive equipment from therapy. The nurse will educate all direct staff assigned to the resident(s) on their restorative program, monitor staff to ensure compliance with the program, monitor daily restorative documentation, care plan the specifics goals and interventions, write a monthly restorative nursing summary for the resident(s) progress, make referrals to therapy as needed and develop a discharge plan when the restorative program is no longer needed.

Based on resident interviews, staff interviews, Electronic Health Record (EHR) reviews and policy review the facility failed to provide residents with dignity, respect and interact with residents in a kind and considerate manner during cares for 2 of 2 residents reviewed (Resident #2 and Resident #19). The facility reported a census of 19 residents. Findings Include: 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #2 had a Brief Mental Interview for Mental Status (BIMS) of 1 indicating severe cognitive impairment. On 6/25/26 at 3:58 PM Staff J, Certified Nurse Assistant (CNA) stated she had witnessed Staff E, Register Nurse (RN) yelling at Resident #2 to act her age and comments to Resident #2 telling her to shut up on multiple occasions. Staff J stated she reported the incidents to Staff F, previous Director of Nursing (DON). 2. The MDS dated [DATE] documented Resident #19 had a BIMS of 15 indicating no cognitive impairment On 6/24/26 at 12:38 PM Resident #19 stated he had witnessed on multiple occasions Staff E yell at Resident #2 to shut the hell up and make belittling comments to her frequently. Resident #19 stated Staff E made him feel very uncomfortable, uneasy and that he was not able to ask for assistance when needed from Staff E. Review of document titled, Employee Termination Worksheet documented Staff E had a termination date of 4/8/26 for misconduct. On 6/24/26 at 2:43 PM Staff D, CNA stated she had witnessed staff yell at a resident. Staff D stated she reported the incident and the Director of Nursing (DON) came in and asked him to leave. Staff D explained the nurse was Staff E, Registered Nurse (RN) and he was terminated. Staff D stated she witnessed the incident. Staff D explained it was Resident #2 that Staff E yelled at. Staff D said Resident #2 was yelling and was confused. Staff D explained Staff E told the resident she was in a nursing home and where else would she be at her age. Staff D explained Staff F, Previous DON and Staff E were really close and Staff F would also talk down to Resident #2. Staff D stated she had called the DON because she felt it was verbal abuse. On 6/24/26 at 10:00 AM Staff G, CNA stated she did not hear Staff E yell at Resident #2 but her co-worker Staff D told her that Staff E had yelled at Resident #2. Staff G explained that Staff D told her that she wrote a report about the incident and Staff F came in and walked Staff E out. Staff G explained that Staff E had an attitude with everyone, all the residents and all the staff. On 6/24/26 at 9:09 AM Staff H, CNA stated Staff E was fired because he yelled at Resident #2. Staff H stated Staff E told Resident #2 to shut up and stop crying. Staff H explained she had heard about it the next day from Staff D. On 6/24/26 at 9:09 AM Staff I, CNA stated Staff E was fired because he yelled at Resident #2. Staff I stated Staff E told Resident #2 to shut up and stop crying. Staff I explained she had heard about it the next day from Staff D. On 6/24/26 at 12:24 PM the Administrator stated Staff E was terminated for yelling at a resident. The Administrator stated the incident was turned into the state office as a result and was determined to be a do not investigate incident. The Administrator stated his termination document explained the investigations. The Administrator stated human resources completed an investigation. The Administrator stated the incident occurred 4/1/26. Review of a policy provided by the facility dated 1/30/24 titled, Promoting and Maintaining Resident Dignity documented it was the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. Speak respectfully to residents; avoid discussions about residents that may be overheard.

Based on observations, staff interviews, Electronic Health Record review (EHR) and policy review the facility failed to provide a clean and homelike environment. The facility failed to remove black fuzzy substance from window air conditioning units, surrounding window trim and walls to 2 of 2 resident rooms reviewed (Resident #18 and #19). The facility reported a census of 19. Findings Include:1. The Minimum Data Set (MDS) dated [DATE] documented Resident #18 had a Brief Mental Interview for Mental Status (BIMS) of 14 indicating no cognitive impairment. On 6/22/26 at 3:11 PM an observation revealed a black and fuzzy substance inside of window air conditioning unit in Resident #18's window. On 6/22/26 at 3:13 PM Resident #18 stated she believed mold was inside her window air conditioning unit. She explained she reported it to the facility and was told it would be replaced in April. Resident #18 further explained that her room was musty and smelled because of it. 2. The MDS dated [DATE] documented Resident #19 had a BIMS of 15 indicating no cognitive impairment. On 6/22/26 at 3:52 PM observation revealed a black and fuzzy substance inside of Resident #19's window air conditioning unit, surrounding window trim and down the wall in his room. On 6/22/26 at 3:52 PM Resident #19 stated he was unsure why the window air conditioning unit was still in his window because it was not being used. Resident #19 further explained that he had a new wall unit he utilized for air conditioning. On 6/23/26 at 1:36 PM Staff A, Maintenance Director acknowledged a black and fuzzy substance in Resident #18's window air conditioning unit and in Resident 19's window air conditioning unit, the surrounding window trim and down the wall. Staff A stated he did not believe the substance was mold because it was impossible for it to grow in a window air conditioning unit. Staff A further explained he had been cleaning the area with bleach.On 6/25/26 at 1:39 PM the Administrator stated she would expect the window air conditioning units to be replaced.The facility was unable to provide a policy related to a clean / homelike environment for the residents at the facility.

Based on clinical record review, resident and staff interviews, and policy review, the facility failed to accurately complete a comprehensive Minimum Data Set (MDS) assessment for 3 of 15 residents (#5, #7, #8). The facility reported a census of 19 residents.Findings include: 1. Resident #5's quarterly MDS dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated completely intact cognition. It included diagnoses of orthostatic hypotension (drop in blood pressure upon standing), morbid obesity, and emphysema. It indicated the resident received tracheostomy care while a resident at the facility. The Electronic Health Record (EHR) did not include physician's orders for tracheostomy care. The Progress Notes did not include entries regarding tracheostomy care. The Care Plan revised 4/12/26 did not include tracheostomy care. On 6/22/26 at 12:46 PM, Resident #5 stated she never had a tracheostomy. On 6/24/26 at 12:21 PM, the Director of Nursing (DON) stated the tracheostomy was entered in the MDS in error. 2. The MDS dated [DATE] for Resident #7 documented a BIMS of 13 indicating no cognitive impairment. The MDS also documented a diagnosis of essential (primary) hypertension. Review of Resident #7's EHR titled, Orders since Resident #7's admission documented no use of anticoagulant therapy Review of Resident #7's MDS indicated use of anticoagulant therapy. Review of Resident #7's EHR titled, Care Plan documented no focus, goal, or interventions related to anticoagulant therapy. On 6/24/26 at 2:20 PM the Director of Nursing (DON) stated she would expect the MDS would have an accurate assessment of Resident #7. The DON stated Resident #7 was on aspirin and that was incorrectly identified as an anticoagulant. 3. Resident #8's annual MDS dated [DATE] identified a BIMS score of 06 out of 15 which indicated severely impaired cognition. It included diagnoses of blood clots in the lungs, irregular heartbeat, and difficulty walking. It also indicated the resident was taking an anticoagulant medication (blood thinner) in the 7-day look-back period. The EHR did not include a physician's order for a blood thinner. The Progress Notes indicated the resident received a blood thinner in the 7-day look-back period preceding 1/27/25. The Care Plan revised 4/11/26 did not indicate the resident took a blood thinner. On 6/24/26 at 12:21 PM, the DON stated the anticoagulant was entered in the MDS in error. Review of a policy updated 4/25 provided by the facility titled, Conducting an Accurate Resident Assessment documented The appropriate, qualified health professional will correctly document the resident's medical, functional, and psychosocial problems and identifies resident strengths to maintain or improve medical status, functional abilities, and psychosocial status. A registered nurse will coordinate the RAI completion process with the appropriate participation of health professionals. The registered nurse is responsible for certifying that the assessment has been completed.

Based on Electronic Health Record (EHR) review, staff interview, and policy review, the facility failed to refer a resident with a negative Level I result for the Preadmission Screening and Resident Review (PASRR), who had an identified mental disorder, intellectual disability or other related condition that was not addressed on the PASRR completed prior to admission to the facility, to the appropriate state-designated authority for Level II PASRR evaluation and determination for Resident #3. The facility failed to refer Resident #3 to the PASRR appropriate state-designated authority for Level II PASSR evaluation and review for determination when a new antidepressant medication was started. The facility failed to re-submit a Level II PASRR with a 180 day time limited approval to the appropriate state-designated authority for Level II PASRR evaluation and determination for Resident #14. The facility reported a census of 19 residents.Findings Include: 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #3 had a Brief Mental Interview for Mental Status (BIMS) of 14 indicating no cognitive impairment. The MDS further documented Resident #3 had a diagnosis of Post Traumatic Stress Disorder (PTSD) on admission with an admission date of 12/4/25. Review of document dated 12/2/25 titled, Preadmission Screening and Resident Review Screening Notice (PASRR) documented no diagnosis of PTSD under the diagnosis of mental health diagnoses portion of the screening. Review of document titled, Orders documented medication Mirtazapine oral tablet with drug classification antidepressant started on 5/18/26. Interview on 6/24/26 at 10:38 AM the Administrator stated they did not currently have any one in the facility assigned to do PASRR review or submission. She acknowledged the PTSD diagnosis and antidepressant medication would need to be on the PASRR or a new PASRR needed to be submitted with the information for review. 2. Resident #14's quarterly MDS dated [DATE] identified a BIMS score of 15 out of 15 which indicated completely intact cognition. It included diagnoses of depression and bipolar disorder. It revealed she required setup assistance with eating and oral hygiene, maximal assistance with bathing and upper body dressing, and was dependent with all other Activities of Daily Living (ADLs) and mobility. It revealed the resident admitted to the facility on [DATE]. The Care Plan dated 11/05/25 included the resident's Level II PASRR and documented the 180-day approval. A document titled Notice of PASRR Level II Outcome dated 10/31/25 revealed the resident was approved for a 180-day time limit. The Electronic Health Record (EHR) Miscellaneous tab document list did not include an updated Level I PASRR determination after the 180-day time limited approval ended on 4/29/26. On 6/23/26 at 9:43 AM, the Administrator stated she identified on 5/01/26 resident PASRRs were not up-to-date. On 6/25/26 at 1:30 PM, the Regional Clinical Specialist stated the facility did not have a policy specific to PASRR submission and follows regulatory PASRR requirements.

Based on clinical record review, resident and staff interviews, and policy review, the facility failed to follow the physician's orders for 1 of 3 residents (#1). The facility reported a census of 21 residents. Findings include:The Minimum Data Set (MDS) for Resident #1 dated 8/06/25 revealed a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated moderately impaired cognition. It included diagnoses of chronic obstructive pulmonary disease (COPD), anxiety, depression, cerebrovascular accident (stroke) with right side hemiplegia (paralysis), aphasia (inability to speak), and dysphagia (difficulty swallowing). It indicated the resident required setup assistance with eating, moderate assistance with oral hygiene, maximal assistance with toileting hygiene, upper body dressing, and personal hygiene and all mobility, and was dependent with bathing, lower body dressing, and footwear. It also indicated the resident had a feeding tube and more than 50% of his total caloric intake was provided by tube feeding but the resident did not experience coughing or choking when swallowing medications.The Electronic Health Record (EHR) included a physician's order dated 5/13/25 which indicated staff may crush medications and slurry/cocktail meds if appropriate and administer every shift for medication administration.The Care Plan revised 11/26/24 directed staff to administer the resident's medications as ordered.The October Medication Administration Record (MAR) confirmed the resident did not receive his scheduled evening medications on 10/24/25 and directed the reader to see Progress Notes.The Progress Notes dated 10/24/25 indicated seven (7) of the resident's scheduled evening medications were not done because the nurse could not access the G-tube (PEG tube <Percutaneous Endoscopic Gastrostomy> - a feeding tube surgically inserted directly into the stomach).On 10/30/25 at 5:35 am, Staff A, Registered Nurse (RN) stated he could not give Resident #1 his medications because he could not access Resident's #1's G-tube. He also stated he charted against them because he did not feel Resident #1 would miss any nighttime medications that would be detrimental.On 10/30/25 at 9:00 am, Resident #1 indicated he didn't receive his nighttime medications on 10/24/25.On 10/30/25 at 11:18 am, the Director of Nursing (DON) stated staff should have contacted the on-call nurse and escalated the situation higher if needed.On 10/30/25 at 12:21 pm, the Administrator indicated the facility did not have a policy regarding following physician's orders.

Based on clinic record review, resident and staff interviews, and policy review, the facility failed to maintain competent staff by failing to access a G-tube (a feeding tube surgically inserted directly into the stomach) to provide medications and failing to stop feeding a resident through a G-tube when the resident complained of pain for 1 of 3 residents reviewed (#1). The facility reported a census of 21 residents. Findings include: The Minimum Data Set (MDS) for Resident #1 dated 8/06/25 revealed a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated moderately impaired cognition. It included diagnoses of chronic obstructive pulmonary disease (COPD), anxiety, depression, cerebrovascular accident (stroke) with right side hemiplegia (paralysis), aphasia (inability to speak), and dysphagia (difficulty swallowing). It indicated the resident required setup assistance with eating, moderate assistance with oral hygiene, maximal assistance with toileting hygiene, upper body dressing, and personal hygiene and all mobility, and was dependent with bathing, lower body dressing, and footwear. It also indicated the resident had a feeding tube and more than 50% of his total caloric intake was provided by tube feeding.The Electronic Health Record (EHR) included physician's orders dated 8/08/23, 8/09/23, 6/11/25, and 9/13/25 for medications to be administered through the PEG tube. It also included a physician's order dated 8/01/25 that directed staff to give 360 milliliters (mLs) of Nutren 1.5 Enteral liquid (nutritional supplement) via PEG-tube 4 times a day related to dysphagia, oropharyngeal phase and flush with 60 mLs H2O (water) before and after feeding.The Care Plan revised 11/26/24 directed staff to administer the resident's medications as ordered. It also directed staff to provide Resident #1 with tube feeding as ordered and monitor for tolerance.The October Medication Administration Record (MAR) confirmed the resident did not receive his scheduled evening medications on 10/24/25 and directed the reader to see Progress Notes. It also indicated the resident received his AM nutritional supplement on 10/25/25.The Progress Notes dated 10/24/25 indicated seven (7) of the resident's scheduled evening medications were not done because Staff A, Registered Nurse (RN) could not access the G-tube.On 10/30/25 at 5:35 am, Staff A, Registered Nurse (RN) stated he could not give Resident #1 his scheduled medications because he could not access Resident's #1's G-tube and he charted against them. He also stated when he returned to work on 10/24/25, the resident had a new feeding tube with a different access port and he could not find the specific feeding syringe designed for the resident's new tube. He further stated he still had access to piston syringes (feeding syringe with a long, narrowing tip used to access feeding tubes) but indicated they were not the specific syringe for the resident's new feeding tube. He admitted he did not contact the on-call nurse and waited to report it to Staff B the following morning because he did not feel Resident #1 would miss any nighttime medications that would be detrimental. He mentioned when Staff A arrived for the morning shift, she confirmed the piston syringe was not the syringe specifically designed for the resident's feeding tube, and she contacted the Director of Nursing (DON). Staff A revealed the DON instructed Staff B on how to obtain the office keys to access the syringes specifically designed for the resident's feeding tube.The Progress Notes dated 10/25/25 revealed Staff B, RN, documented the resident's abdomen was non-distended and he did not have pain prior to the 10/25/25 morning tube feeding. It further revealed that when Staff B began pouring the nutritional supplement in the resident's tube, the resident got really jerky and made it difficult to finish. Staff B documented the resident started complaining of pain higher than 10 on a 0-10 pain scale and that she finished feeding the resident, flushed the tube, and assessed his abdomen which was described as distended and painful upon light pressure.On 10/30/25 at 9:00 am, Resident #1 confirmed he didn't receive his nighttime medications on 10/24/25. He also confirmed he notified Staff B of his pain when she began feeding him through his tube on 10/25/25.On 10/30/25 at 9:37 am, Staff B stated she continued feeding the resident after his complaints of pain because she thought he had not eaten enough during previous shifts and his pain was potentially due to hunger. She said she had no idea what his squirmy reaction was for but she knew patients were sometimes tender after surgeries. She stated based on his reaction, she didn't know whether to stop or finish because she didn't know if it was pain or hunger.On 10/30/25 at 10:20 am, the DON stated the piston syringes would have fit the resident's feeding tube. An observation of the accessible piston syringes and the resident's feeding tube revealed the syringes would have functioned in administering the resident's medications.On 10/30/25 at 11:18 am, the DON stated Staff A should have called the on-call nurse regarding the inability to access the resident's feeding tube and escalated it as needed. She also stated Staff B should have stopped the action and contacted the DON.An undated policy titled Care and Treatment of Feeding Tubes indicated the facility policy is to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible.

Based on observations, clinical record review, staff interviews, and facility education record review, the facility failed to prepare and serve the recommended therapeutic meals in a form designed to safely meet their needs and according to physician orders for 3 of 3 residents reviewed (Resident #9, Res #16, Res #25). This had the potential of causing harm to the residents due to the risk of choking or aspiration related to eating food which was prepared at the improper consistency or being served the incorrect textured diet. The facility reported a census of 30 residents. On July 9, 2024 at 4:35 pm, the State Agency informed the facility the staff's failure to properly prepare and serve the therapeutic meals per orders creating an Immediate Jeopardy situation, which began on July 9, 2024. The facility staff removed the immediacy on July 10, 2024 when facility staff implemented the following Corrective Actions: a. Meal service for Res #9 and Res #16, puree diets, were audited by the Director of Nursing (DON)/Designee to validate they were served the meal at the correct therapeutic menu and pureed consistency on 7/9/24. b. An audit was completed by the DON/Designee on 7/9/24 to ensure required therapeutic diet consistency was provided as ordered by the physician. c. Dietary staff were re-educated beginning 7/9/24 by the DON/Designee regarding the requirements of serving therapeutic diets including pureed consistency per physician's orders. Any dietary staff not trained on 7/9/24 would be trained prior to the beginning of his/her next scheduled shift. d. An audit set up for completion by the Administrator/Designee weekly for 12 weeks to ensure dietary staff continue to provide therapeutic diet consistencies per physician's orders including puree consistency. The scope lowered from J to D at the time of the survey after ensuring the facility implemented education and their policy and procedure. Findings include: 1. The Diet Type Report, reviewed 7/9/24 at 11:34 am revealed Resident #9 has an order for puree texture diets. The Care Plan of Resident #9 revealed a Nutritional Problem which documented a diagnosis of dysphagia (difficulty swallowing foods or liquids). The Care Plan directed staff as follows: -Monitor/document/report to doctor as needed for signs and symptoms of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts to swallow, refusing to eat and/or appears concerned at meals. -Provide/serve diet as ordered. The Progress Notes of Resident #9 included the following: On 6/26/24 at 8:58 am resident is receiving a pureed diet with honey thick liquids. No complaints of chewing/swallowing at this time but does put food in mouth and then spit it out in a napkin at times. 2. The Diet Type Report, reviewed 7/9/24 at 11:34 am revealed Resident #16 has an order for puree texture diets. The Care Plan of Resident #16 revealed a Potential Nutritional Problem which documented a diagnosis of dysphagia. The Care Plan additionally documented the resident to also receive tube feedings. The Care Plan directed staff as follows: -Monitor/document/report to doctor as needed for signs and symptoms of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts to swallow, refusing to eat and/or appears concerned at meals. The Progress Notes of Resident #16 included the following: On 10/18/23: Nursing states that the resident has been coughing more at meals. On 4/9/24: Resident at birthday party and choked while eating ice cream. Heimlich performed and was able to get up thick phlegm in small amount. Continued to cough. Taken to room. Ambulance called and here. Resident able to drink small amount of thickened water. Ambulance did not feel transport was necessary. On 4/17/24 at 10:07 am dietary progress note: oral intake down since choking episode (4/9), averaging 0-25 percent at meals. 3. The Diet Type Report, reviewed 7/9/24 at 11:34 am revealed Resident #25 to have an order for mechanical soft texture diet. The Active Orders of Resident #25 revealed Resident #25 had a diet order of mechanical soft placed on 6/12/24. The Dietary Progress Notes documented the following for Resident #25: On 12/13/23 at 1:36 pm resident is receiving a dysphagia advanced with added moisture. No complaints of chewing/swallowing at this time with TUMS as needed. Observed no coughing at meals. On 3/6/24 at 3:11 pm resident is receiving a regular diet with added moisture to solid foods. No complaints of chewing/swallowing at this time with TUMS as needed. On 6/5/24 at 9:54 am resident is receiving a mechanical soft diet with added moisture to solids. No complaints of chewing/swallowing at this time with TUMS as needed. Continuous observation of preparation of pureed foods began on 7/9/24 at 10:40 am. Staff B, [NAME] was preparing foods for lunch service. The menu for the pureed residents included: Pureed ham salad sandwich Pureed deviled egg halves Pureed creamy cheddar macaroni salad Pureed fruit. Staff B first placed one #8 scoop of ham into the food processor and placed a second scoop into a separate food processor bowel. She pureed each serving separately and asked the State Surveyor if it looked ok. The State Surveyor informed Staff B the surveyor was making observations only and could not advise. She placed each serving in parchment paper and into a steam pan and then placed it in the refrigerator. Staff B next placed one #8 scoop of macaroni salad into one food processor and a second #8 scoop of macaroni salad into a separate food processor bowl. She added a minimal amount of Ranch salad dressing to the salad and ran the food processor. Staff B, [NAME] stated she thought that looked like pudding consistency. When complete, the individual ingredients were still identifiable and the puree was not smooth. Staff B, [NAME] repeated this for the second serving. She placed the individual servings in parchment paper and then into a steam pan and also placed these in the refrigerator. Staff B next pureed four deviled eggs. She placed 4 deviled eggs into the food processor and pureed the eggs. Using a spatula, she transferred the pureed eggs into a #10 scoop. Some of the puree was left in the food processor. She looked at the eggs in the scoop, placed the spatula approximately in the middle, dividing it into two, and placed half in one bowl and half in another. Staff B stated I guess I should have measured that but oh well, that's how it's getting done. She also asked the State Surveyor if the remaining eggs needed to be scraped from the bowl. The State Surveyor again stated the surveyor was making observations only and could not advise. At the end of observation, Staff B stated the fruit was not yet ready for puree and that it could be watched closer to lunch service. On 7/9/24 at 11:40 am, Staff B was observed pureeing the fruit for lunch. She used a 4 oz scoop and placed two scoops of mandarin oranges into the food processor. Staff B stated it appeared too thin. She then stated I don't know what to do. I need to do something. Maybe I should add some cookies, but I don't think I have any cookies. Staff B left the area and returned a short moment later with food thickener. She added food thickener to the pureed mandarin oranges and the oranges were thickened to an appropriate texture. She poured the oranges into a measuring cup and then into 2 bowls. She did not reference the Puree Conversion Chart for serving sizes. The Dietary Manager was not in the facility during the survey week as she was on vacation. Staff C, Activities Director (AD), a former Dietary Manager and Staff D, Certified Nurse Aide (CNA), also a former Dietary Manager were assisting to oversee the kitchen during the week in her absence. On 7/9/24 at 11:50 am, Staff C, AD, stated when she was the Dietary Manager, she would not have macaroni salad be pureed. She stated it would not puree smooth and a substitute such as cottage cheese should be used instead. She told Staff D, CNA, to inform the kitchen staff to make pureed cottage cheese instead of serving the macaroni salad. On 7/9/24 at 12:05 pm, Staff B, [NAME] began lunch service. At 12:10 pm Staff B began to prepare the plate of pureed food for Resident #9. The plate included the previously pureed macaroni salad. After plate being fully prepared, Staff B carried the plate to the serving area to be served to the resident. At this time, the State Surveyor intervened and asked the staff to stop service and not serve the plate to Resident #9. Staff D, CNA, former Dietary Manager was outside of the serving window and the State Surveyor asked him to step inside of the kitchen. After donning a hair net and washing his hands, Staff D came to the serving area. The State Surveyor asked him to look at the pureed food and verify if he felt the food was a safe texture for Resident #9 to eat. Staff D stated no, and informed Staff B to dispose of the macaroni salad and to puree cottage cheese as a substitute. Staff B opened the refrigerator and removed cottage cheese. She appropriately pureed two servings of cottage cheese and returned to the serving area to resume lunch service. On 7/9/24 at 12:20 pm, Staff B began preparing a tray for Resident #25. She made a BLT sandwich, and using her gloved hands, ripped it into several pieces and stuffed it into a two handled cup. Staff B, cook stated I know I didn't do that right. The State Surveyor asked Staff E, Dietary Aide what Resident #25's diet order is. He looked at the resident's tray card and replied that Resident #25's diet order was a regular diet with thin liquids. He further stated the resident eats all of his meals out of two handled cups. On 7/9/24 at 1:15 pm, the Registered Dietitian stated that Resident #16 has been seen by Speech Therapy. She stated he gets enteral tube feedings and eats orally a puree diet for pleasure feedings. The State Surveyor described to the RD what the macaroni salad looked like and she responded it did not sound like it was properly pureed. She stated milk or mayonnaise should have been added to make it a smooth, pudding-like consistency. She additionally stated that cottage cheese was not an appropriate substitution as the macaroni salad was a starch. She said mashed potatoes would have been a proper choice or another starch item. On 7/9/24 at 2:00 pm, the Speech Therapist stated Resident #16 had been picked up for Speech Therapy due to having a choking incident or having increased coughing spells. She stated he had a swallow study with a camera being placed through his nose recording oral intake. The recommendation was a puree diet with thickened fluids. She stated Resident #16 has significant oral deficits. On 7/9/24 at 2:35 pm, Staff C, AD, stated the RD has noted improperly pureed food in the kitchen in the past. She stated there was a recent meeting held for all kitchen staff which included multiple topics. She stated every kitchen staff member was educated on food storage, sanitizing the kitchen, food contamination, mechanical soft, puree textures. Everything was covered. Staff C provided copies of the paperwork from the in-service. She stated the instance of improper puree was not an isolated incident. Upon reviewing the diet order of Resident #25 on 7/10/24, the State Surveyor requested to see the menu tray card of Resident #25. Staff C, AD stated she had removed all of the tray cards. She stated during an audit she realized not all of them were correct. She verified that on 7/9/24, Resident #25's tray card was labeled as Regular diet and that it should have said Mechanical Soft. She additionally verified Resident #25 was served the incorrect diet during lunch observation on 7/9/24. On 7/10/24 at 11:44 am, the RD stated she completes a kitchen audit monthly. She stated towards the end of June she had a meeting with the Administrator and the Dietary Manager and informed them she had witnessed at least a couple of instances of food not being pureed correctly. She stated she had witnessed no concerns with Mechanical soft diets but the entire puree process was not being followed. She said in-services were to be done with the kitchen staff. Staff C provided copies of the paperwork from the in-service. Multiple topics were covered including food temperatures, proper sanitizing, food storage and the proper procedure for preparing mechanical soft and puree foods. An untitled document included in the paperwork provided was notes from the in-service. A portion of this note read I have a practice test I want all the cooks to do. It is on the puree and mechanical process. We had our audit and we did not pass the puree and/or the mechanical process. Additional documents included step by step process of mechanically grinding meat, step by step process of the puree process, and sign in sheets which reflected Staff B had attended the training on 6/27/24.

Based on observations and staff interview, the facility failed to maintain proper food temperature during lunch service. The facility reported a census of 30 residents. Findings include: Continuous observation of lunch service on 7/9/24 at 12:00 pm. Temperatures were obtained prior to meal service beginning which reflected the following: Creamy cheddar macaroni salad - 40 degrees Fruit - 38 degrees Ham salad - 40 degrees Tomatoes slices - 38 degrees Bacon (previously fully cooked) - 150 degrees Deviled eggs - 40 degrees. All of the cold items had been removed from the refrigerator just prior to checking temperatures. The bacon was placed on the steam table turned to heat. The macaroni salad, the fruit and the tomatoes were placed on the opposite end of the steam table which was turned off. The wells of the the cold end of the steam table were packed with ice. A full sized sheet pan of deviled eggs was placed on the counter with a cake pan underneath of it full of ice. It was noted during meal service the sheet pan was moved off of the cake pan of ice with approximately the half of the deviled eggs over the ice. Meal service was completed on 7/9/24 at 12:43 pm. When end of service temperatures were checked, the following was noted: Creamy cheddar macaroni salad - 50 degrees Tomato slices - 58 degrees Deviled egg - 60 degrees. On 7/11/24, Staff C, the current Activity Director and former Dietary Manager stated cold foods should be maintained at 41 degrees or colder. She stated the procedure is for the wells of the steam table to be filled with ice for cold foods and that this will be monitored. She additionally stated kitchen staff will continue to receive education regarding dangerous food temperatures and food borne illnesses. The facility document Sanitation and Food Production, dated 6/2015 documented: Point 7 - Maintain hot foods above 140 degrees F (Fahrenheit) and cold foods at or below 41 degrees F

Based on observation, interview and facility policy review, the facility failed to properly label, date, store and serve resident foods. The facility reported a census of 30 residents. Findings include: During initial walk through of the facility kitchen on 7/8/24 at 12:05 pm, the following items were found in the kitchen refrigerator: - A gallon of chocolate milk, approximately half empty, with no open date noted. - Three 20 oz bottles of cola. One of the bottles was greater than 3/4 empty. None of the bottles were labeled with a resident name or dated. - The bottom shelf of the refrigerator had a large plastic bowl of ice. On top of this bowl was a second plastic bowl filled with hard boiled eggs. The eggs were not covered with any protective wrap and had no date on them. Continuous lunch service observation began on 7/9/24 at 12:00 pm with Staff B, Cook, serving the lunch meal and observed the following: The meal for residents with a regular diet consisted of: - Bacon, lettuce and tomato (BLT) sandwich - 2 deviled egg halves - Creamy cheddar macaroni salad - Fruit The meal for residents with a mechanical soft diet was the same with the exception of a ham salad sandwich in place of the BLT sandwich The meal for residents on a puree diet was the same as the mechanical soft, but all items were pureed. On 7/9/24 at 12:05 pm, Staff B, Cook, began lunch service. She washed her hands and placed gloves on her hands. After placing gloves on her hands, she picked up the steam table lid covering the bacon. She then removed a large pan of bread from the refrigerator and removed the plastic wrap from the bread pan and disposed of it in the trash. She then began, without changing gloves, to prepare lunch trays. She picked up a slice of bread with her gloved hand, placed bacon, lettuce and tomato on the bread using tongs, and then picked up a second slice of bread with her gloved hand to complete the process of making the sandwich. She then proceeded to use serving utensils to place the remaining food items on the plate, then walked to the counter and picked up 2 deviled eggs with her gloved hands to add to the plate and placed the plate on the tray to be served to residents. This process was observed for each resident of the facility that a regular diet order tray plated during observation. On 7/9/24 at 12:10 pm Staff B, Cook, began to prepare the plate of pureed food for Resident #9. The plate included pureed macaroni salad which was not at a proper or safe puree texture. Staff B was instructed by Staff D, Certified Nurse Aide (CNA) and also a former Dietary Manager, to discard the macaroni salad and puree a substitute item. Staff B opened the refrigerator and removed cottage cheese. She appropriately pureed two servings of cottage cheese and returned to the serving area. No glove change or hand hygiene was witnessed. Staff B then placed a clean plate on the serving area. She covered the macaroni salad with one gloved hand and dumped the plate upside down for the pureed ham salad sandwich to land on the clean plate. She went to the sink and obtained a paper towel, and wiped her soiled glove off with a paper towel. She then resumed lunch service. On 7/9/24 at 12:20 pm, Staff B was observed, with her gloved hands, having prolonged contact with contaminated portions of the steam table. She then began preparing a tray for Resident #25. She made a BLT sandwich, and using her gloved hands, ripped it into several pieces and stuffed it into a two handled cup. Staff B, [NAME] stated I know I didn't do that right. The State Surveyor asked Staff E, Dietary Aide what Resident #25's diet order was. He looked at the resident's tray card and stated he is on a regular diet with thin liquids. He further stated the resident eats all of his meals out of two handled cups. On 7/9/24 at 12:23 pm, Staff B removed her gloves, threw them in the trash can and placed clean gloves on. No hand hygiene was performed. She resumed meal services. At 12:32 pm she prepared the pureed meal for Resident #16. She went to the refrigerator, obtained a single serving of pureed ham salad sandwich which was wrapped in parchment paper and stored in a steam pan. She opened the parchment paper and held it over the plate, and scraped the parchment paper with her gloved hand to get as much of the salad off the parchment as she could. She took the contaminated pan and the parchment paper, disposed of the parchment and took the pan to the dishwasher and returned to the serving area. With no hand hygiene or glove change, she continued service. At 12:40 pm, service was ending, as Staff B was preparing the final plate. As she reached for the deviled eggs with her gloves hands, she stated I should probably be using tongs on those, oops. That might be a problem. Staff B stated she also should have used separate tongs for the tomato and lettuce which had been in the same steam pan. On 7/9/24 at 1:15 pm, the Registered Dietitian (RD) stated she has always encouraged tongs because gloves give a sense of false security and staff don't think about what they are doing. She stated she prefers staff to use tongs, a spatula, even a fork is a better choice instead of gloves. The Dietary Manager was out of the facility during the survey week. Staff C, the current Activities Director, and also the former Dietary Manager was assisting to oversee the kitchen in her absence. On 7/9/24 at 2:35 pm, Staff C stated there was a recent meeting held for all kitchen staff which included multiple topics. She stated every kitchen staff member was educated on food storage, sanitizing the kitchen, food contamination, mechanical soft, puree textures. Everything was covered. Staff C provided copies of the paperwork from the in-service. Included in this paperwork was an undated policy titled Bare Hand Contact with Food and Use of Gloves. Point 3 - Gloved hands are considered a food contact surface that can get contaminated or soiled. If used, single use gloves shall be used for only one task (such as working with ready to eat food or with raw animal food), used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. Point 6 - Remember, gloves are just like hands. They get soiled. Anytime a contaminated surface is touched, the gloves must be changed: - After handling garbage or garbage cans - After handling soiled trays or dishes - After handling anything soiled - Anytime you touch any contaminated surface Additionally found in the in-service packet was an undated document titled How To Store Food Properly. This document included direction to staff to label and date all stored food. The paperwork also included a sign in sheet for the meeting dated 6/27/24. Staff B's signature indicated she had attended the meeting. On 7/11/24 at 8:40 am, Staff C stated staff education will be continued to include food borne illnesses as well as other topics.

Based on personnel file review, the facility mandatory education calendar, and staff interview, the facility failed to implement resident rights training for 1 of 5 staff reviewed (Staff J). The facility reported a census of 30 residents. Findings include: The Employee List Report listed the following staff hire date: Staff J 3/28/23. The facility lacked documentation that Staff J completed training in resident rights. The 2024 Mandatory Education calendar included the following topics: effective communication, resident rights, QAPI, infection control, compliance and ethics, and resident behavioral health. The calendar stated all courses were required for all staff. On 7/11/24 at 12:07 p.m. via phone, the Director of Nursing (DON) stated she expected all staff to be current with required training.

Based on clinical record review, family interview, staff interviews and facility policy review, the facility failed to notify the family and/or physician of a medication error, a fall and a significant change for 4 of 6 residents reviewed (Resident #3, #24, #26, and #34). The facility reported a census of 30 residents. Findings include: 1. Observation of medication pass began on 7/9/24 at 7:35 am with Staff A, Registered Nurse. Staff A first administered medications to Resident #26. The administration of 18 medications were observed for Resident #26. Of the 18 medications administered, three of the medications were medication errors of the incorrect dosage. Following administering the medications to Resident #26, Staff A then administered Medications to Resident #3. One medication error was noted for Resident #26, also being an incorrect dosage. On 7/9/24 at 8:30 am, the Director of Nursing (DON) stated if a stock medication does not match the order, the nurse should notify the doctor and get an order change or get the correct dose from the pharmacy based on the doctor's preference. Review of the Progress Notes for Resident #26 and Resident #3 on 7/11/24 failed to reveal the physician had been notified of either resident having been administered medications not matching physician orders. 2. On 7/8/24 at 12:49 pm, a nurse at Resident #34's prior nursing facility stated she had come to visit Resident #34 at the current facility on 6/6/24. She stated she noticed a bruise on the resident's forehead and said Resident #34 had told her she had fallen out of her chair and also told her she was having pain in her legs. The nurse stated after the visit, she called Resident #34's family member who was not aware of Resident #34 having fallen or having any bruising or pain. On 7/8/24 at 1:50 pm, a family member of Resident #34 stated he had not been notified by the facility of Resident #34 having fallen or having any injuries. He stated he had not been aware of this until the nurse from the prior nursing facility informed him. Review of the Profile section of Resident #34's Electronic Health Record reflected the son of Resident #34 to be: - Responsible Party - Financial Responsible Party - Power of Attorney, Financial - Power of Attorney, Care - Emergency Contact #1 The Minimum Data Set (MDS) assessment of Resident #34, dated 5/27/24 identified a Brief Interview of Mental Status (BIMS) score of 7 which indicated severe cognitive impairment. The Risk Management form dated 6/3/24 documented Resident #34 was observed on the floor beside her bed, lying on her stomach. It revealed documentation the resident stated she was self transferring to her bed and slid off the side of the bed. Page 3 of the Risk Management document revealed the Nurse on call and the Physician were both notified of the incident. The Risk Management form failed to document the Power of Attorney/Emergency Contact for Resident #34 was notified. Review of Resident #34's Progress Notes failed to reveal any documentation of the Power of Attorney/Emergency Contact for Resident #34 being notified of the fall. On 7/11/24 at 12:27 pm, the DON stated staff should notify family for falls and/or change of condition as soon as possible for injuries and within an acceptable time for family preference unless the resident competently represents themselves. 50471 3. The MDS assessment dated [DATE] for Resident #24 identified a BIMS score of 4 which indicates severe cognitive impairment. The MDS revealed the resident to need minimal assistance with personal care and dressing. Resident is dependent on staff for toileting hygiene and shower/bathe self. The MDS documented diagnoses that included: cerebral infarction, unspecified, Non-Alzheimer's dementia, hemiplegia, depression, and vascular dementia. The Care Plan, revised 3/5/24, revealed resident incontinent of bowel and bladder, staff to encourage resident to toilet before and after each meal, at bedtime, and at least once during the night, Check him for incontinence at that time, staff to assist as needed. Revealed resident sometimes needs some help with sit to stand, resident is able to transfer independently with his walker. Revealed resident is usually able to toilet independently, resident does need cues and assist to complete toileting hygiene and needs reminders to change soiled clothing. The Progress Note of Resident #24 dated 6/28/24 at 7:24 PM documented: Daughter was updated, resident was found in another resident's room, exposed to marijuana. Daughter voiced concern about exposure to marijuana interacting with medications and comorbidities. The Progress Note dated 6/28/24 at 10:27 PM noted blood pressure of 82/60. Resident stated to Staff P, Licensed Practical Nurse (LPN) I think someone's trying to kill me. Staff P, LPN asked who and why he thinks that, resident stated I'll tell you tomorrow, I forgot how to talk. The Progress Note dated 6/29/24 at 12:04 AM noted blood pressure 112/63. Resident stated to staff I'm ok. The Progress Note dated 6/29/24 at 2:02 AM noted blood pressure 117/66. The Progress Note dated 6/29/24 at 4:00 AM noted blood pressure 119/68. On 7/9/24 at 4:09 PM Staff Q, Certified Nurse Aide stated on 6/28/24 she worked 6:00 PM to 6:00 AM shift. She stated Resident #24 baseline is stand by assist. She took care of Resident # 24 that evening and resident required maximum assistance to total assistance of one staff to complete personal cares and toileting. Staff stated this is not his normal, he is very out of it. She stated she reported to the nurse on shift. On 7/10/24 at 6:32 AM Staff P, Registered Nurse (RN) stated on 6/28/24 at 6:30 PM, Resident #24 was found smoking marijuana, in Resident # 11 room, she removed the resident from the room and assisted the resident to his room. She monitored the resident the remainder of the shift. She noted during shift the resident was having delusions, people were trying to kill him. Staff stated she updated doctor via fax. Staff stated she did speak with the Doctor regarding resident #11, but did not update the doctor about resident #24 having delusions. Staff stated the resident does not have delusions of someone killing him at baseline. On 07/11/24 at 2:43 PM Staff P, LPN stated the resident has delusions at baseline. The residents delusions come and go. The resident is seen by a Psychiatrist. Staff P stated the resident needs assistance from staff most of the time for cares, and transferring varies depending on his status that day. The facility policy titled Notification of Resident/Patient Change in Condition, Review date 11/2019 directs: Point 7: Notify the Physician and family/resident representative at the earliest possible time, during waking hours, if there is a change in condition. Point 10: Document in the Progress Notes the times notification was made and the names of the person(s) spoken to.

Based on observations, clinical record review, resident interview, staff interviews, and policy review, the facility failed to fully review and revise the comprehensive care plan for 4 of 15 resident reviewed (#11, #12, #26, and #34). The facility reported a census of 30. Findings include: 1. An observation on 7/08/24 at 3:25 PM revealed Resident #26's legs and feet were swollen. The resident stated she was taking a water pill (diuretic) for a while for the swelling in her legs. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated completely intact cognition. It included diagnoses of hypertension, deep vein thrombosis (DVT; deep vein blood clot), hyperlipidemia (high cholesterol in the blood), diabetes mellitus, and morbid obesity. It revealed the resident was independent with eating and oral hygiene, required maximum assistance with upper body dressing, and was dependent in all other activities of daily living (ADLs) and all mobility. It also revealed the resident received a diuretic within the 7-day look-back period. The Electronic Health Record (EHR) included a diuretic medication order dated 11/03/23. A physician's order dated 1/23/24, increased the diuretic dose. The Care Plan did not include the resident's use of diuretic medication nor interventions. On 7/11/23 at 12:27 AM, the interim Director of Nursing (DON) stated Care Plans should be continuously revised to meet the needs of the resident's care. A document titled Care Plan Development dated 8/15 indicated the Care Plan will be reviewed and revised on an as needed basis and at least every 92 days. 50471 2. The MDS assessment dated [DATE] for Resident #11 identified a BIMS score of 15 which indicates cognition intact. The MDS revealed the resident totally dependent upon staff for all cares. The MDS documented diagnoses that included: quadriplegia, anxiety disorder, depression, autonomic dysreflexia, and muscle spasms. The Comprehensive Care Plan of resident #11 initiated 10/11/22 failed to reveal resident to be a smoker. The untitled facility document provided during survey listed 4 residents as smokers which included Resident #11. Observation on 7/9/24 at 2:41 PM, revealed Resident # 11 is dependent on staff for monitoring during vaping at the designated facility times and place. The facility policy titled Smoking: Resident/Patient Overview revised 9/19 included the following documentation: Evaluation/Assessment will include but is not limited to, the Admission/Re-Admission Documents & Initial Care Plan, Smoking Safety Screen, The RAI/MDS, and Physician orders. 3. The MDS assessment dated [DATE] for Resident #12 identified a BIMS score of 4 which indicates severe cognitive impairment. The MDS revealed the resident totally dependent upon staff for all cares with exception of eating. The MDS documented diagnoses that included: unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, or anxiety, non-Alzheimer's dementia, seizure disorder or epilepsy, anxiety disorder, schizophrenia, and dysphagia. The Care Plan of resident #12 revised 2/27/24 reveals the resident transfers with assistance of one staff member, the resident requires (supervision, cueing, encouragement, specify physical assistance) with transferring, and the resident can transfer with one assist and use of his walker. Assist as requested or as needed. The Progress Note dated 1/26/24 at 3:02 PM revealed the Social Worker (SW) states Resident #12 brother called facility, SW updated brother on the decline in condition. SW provided details of decline stated staff is assisting with meals and staff uses a Hoyer to transfer him into a wheelchair. On 7/08/24 at 1:20 PM Resident #12 observed sitting in wheelchair with a sling for a full body mechanical lift under him. On 7/09/24 at 1:15 PM Staff L, Certified Nurse Aide (CNA) assisted Resident #12 to his room. Staff K, CNA assisted Staff L. Staff gathered mechanical lift equipment, instructed resident of the task, permission granted, staff hooked up mechanical lift to sling, Staff L controlled the mechanical lift equipment, Staff K guided resident to bed, resident positioned over bed, Staff L lowered resident onto the bed. Staff unhooked the sling from the lift. Staff moved the mechanical lift away from the bed. On 7/11/24 at 12:27 PM, the Director of Nursing (DON) stated Care Plans should be continuously revised to meet the needs of the resident's care. On 7/11/24 at 3:50 PM Staff P, Licenses Practical Nurse, Nurse Manager stated she does not do care plan revisions. On 7/11/24 at 4:04 PM the Regional Director of Nursing stated MDS Coordinators are remote. He stated any care plan areas that trigger on the Care Area Assessments (CAA) of a comprehensive MDS are the responsibility of the remote MDS Coordinator to care plan. Daily updates should be done within the facility, and that is the responsibility of Staff P, LPN or of the DON. The facility policy titled Resident Assessment Instrument (RAI)/Minimum Data Set (MDS) dated ,d+[DATE] includes the following documentation: Comprehensive or full assessments include the admission, significant change, significant correction of a prior full assessment and annual include all required MDS items along with State-designated sections, use of Care Area Assessment (CAA) including CAT's and CAA summary. Within 14 days after the facility determines that there has been a significant change in the resident's status that will not normally resolve itself, which has an impact on one or more area of the residents' health status and requires an interdisciplinary review and/or revision of the care plan. 46873 4. The Minimum Data Set assessment of Resident #34, dated 5/27/24 identified a Brief Interview of Mental Status (BIMS) score of 7 which indicates severe cognitive impairment. The Care Plan of Resident #34 revealed a focus area of Actual Fall related to poor balance and unsteady gait dated 6/4/24. The intervention put in place was to monitor for 72 hours. No intervention was put in place to prevent or reduce future falls. The Risk Management form dated 6/3/24 at 8:45 pm documented Resident #34 was observed on the floor beside her bed, lying on her stomach. It revealed documentation the resident stated she was self transferring to her bed and slid off the side of the bed. The form noted no injuries observed at the time of the incident or post incident. On 7/10/24 at 1:17 pm, the Regional Director of Clinical Services stated a Risk Management form should be started by the nurse on duty at the time of the incident. From there, there should be a full investigation of the incident and it would be discussed in the morning meeting on the next business day. He stated during the meeting, it should be assured an intervention was put in place on the resident's care plan. If the intervention initially put in place was not an appropriate intervention, it would be changed. He additionally stated follow up assessment and charting by the nurses should be completed for 72 hours after an incident. The facility policy Fall Risk Reduction & Management, revision date 12/2015 documented the following: The Interdisciplinary team will develop a care plan for all residents/patients requiring a fall management program. The interdisciplinary team will develop the care plan with input from the resident/patient and/or the family/responsible party. Point 2: Develop the goal for fall risk reduction with the resident/patient and/or family/responsible party. Point 3: Develop interventions to assist resident/patient in reaching their goal.

Based on observation, record review, staff interview, and policy review, the facility failed to implement infection control practices to prevent cross contamination by staff failing to perform appropriate hand hygiene during resident cares, medication administration, and meal service for 5 of 5 residents (Resident #3, #6, #12, #16, and #26) reviewed for infection control. The facility also failed to ensure resident equipment was sanitized after use for 2 of 2 residents (Resident #6 and #12). The facility reported a census of 30 residents. Findings include: 1. An observation on 7/08/24 at 1:18 PM revealed Resident #3's indwelling catheter tubing had a dependent loop with clear, yellow urine and sediment in it. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated severely impaired cognition. It included diagnoses of neurogenic bladder (nerves that control the bladder do not function), epilepsy, cognitive communication deficit, mild intellectual disability, normal pressure hydrocephalus (fluid buildup in the brain), and benign prostatic hyperplasia (prostate enlargement). It also revealed he was independent with eating but dependent with all other activities of daily living (ADLs) and all mobility. It indicated the resident had an indwelling catheter. The Care Plan revised 10/20/23 indicated the resident's catheter goal was to show no signs or symptoms of a urinary tract infection (UTI) and directed staff to position the catheter bag and tubing below the level of the bladder an away from the entrance room door. The Electronic Health Record (EHR) progress notes indicated the resident Suprapubic (indwelling) catheter was changed on 6/22/24. On 7/10/24 at 2:33 PM, Staff N, Certified Nurse Aide (CNA) performed Resident #3's catheter care. Staff N donned a protective gown and gloves and entered Resident #3's room. She obtained a graduated cylinder (container used to measure urine) from the resident bathroom cabinet then opened the resident's chest-of-drawers and night stand to get alcohol wipes. She opened the urine collection bag drain spout with her right hand, emptied the urine into the cylinder, opened the alcohol wipe package, grabbed the alcohol wipe with her right hand, and wiped the drain spout. She closed the spout and secured it to the drain bag. She emptied the urine into the toilet, removed her gown and gloves, performed hand hygiene with soap and water, and left the room. At 2:42 PM, Staff N and Staff O, Nurse Aide (NA) returned to the resident's room. Staff N donned a protective gown, entered the resident's room and donned gloves. Staff O did not don a protective gown nor gloves. Staff O connected the resident's transfer sling to the mechanical lift, picked up the indwelling catheter drainage bag, and held it while Staff N raised the resident from the wheelchair. Staff O handed the drainage bag to Staff N. Staff N held the drainage bag in her right hand, grabbed the upper handle on the mechanical lift above the resident's bladder, and lowered the resident onto his mattress. Staff N laid the drainage bag on the resident's mattress, removed her gloves and donned new gloves without performing hand hygiene. Staff O moved the mechanical lift, and both Staff N and Staff O adjusted the resident's pants. Staff N handed Staff O the periwipe package. Staff O removed a periwipe and gave it to Staff N. Staff N wiped Resident #3's waistline at the level of the suprapubic catheter (SPC) insertion site. They repeated this process three (3) times. They pulled the resident's pants back up, connected the sling to the mechanical lift, raised the resident off the bed, and positioned him over the wheelchair. Staff N held the drain bag above the resident's bladder while she leaned around the left side of the mechanical lift, adjusted the wheelchair seat antiskid pad, and lowered the resident down onto the wheelchair seat. At 4:20 PM, Staff O stated the facility requires hand hygiene after bathroom use, removing gloves, changing resident briefs, risk of body fluid exposure, and working with indwelling catheters. He stated the policy does not require staff to wear gloves while touching residents. At 4:35 PM, Staff N stated hand hygiene and gloves are required before and after resident care and when contacting visibly soiled items or residents. She stated she should've washed her hands prior to beginning the procedures. On 7/11/24 at 12:27 PM, the interim Director of Nursing stated staff should follow the orders of the care plan and the drainage bag is to remain below the resident's bladder. She also stated hand hygiene should be done before, after, and as needed during a procedure. A document titled Catheter Care dated 1/13 directed staff to not allow the end of the drainage spout to touch other surfaces and position the catheter and drainage bag below the level of the resident's bladder. 2. On 7/09/24 at 9:01 AM, Resident #16 pointed to his abdomen and indicated he had a gastric tube (G-tube; tube directly into the stomach). The Electronic Health Record (EHR) included a Speech Therapy note dated 11/21/23 which directed staff to continue an alternate means of hydration and nutrition. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have a Brief Interview for Mental Status (BIMS) score. It included diagnoses of cerebrovascular accident (stroke), aphasia (inability to speak), left sided hemiplegia (one-sided paralysis), and dysphagia (difficulty swallowing). It also revealed he was independent with eating, required moderate assistance with bathing and rolling in bed, and was dependent with all other activities of daily living (ADLs) and all mobility. It indicated the resident had a feeding tube. The Care Plan revised 8/14/23 directed staff to provide local care to the G-tube site as ordered and monitor for signs and symptoms of infection. A physician order dated 8/09/23 directed staff to clean the peg tube site with normal saline and cover with a split 4 x 4 gauze one time per day. On 7/10/24 at 2:56 PM, Staff A, Registered Nurse (RN) performed G-tube site care. Staff A entered the resident's room, performed hand hygiene with soap and water, closed the door with her foot, and donned a protective gown and gloves. She opened the bottle of normal saline (NS) and the package of 2 x 2 s, saturated the 2 x 2 s with the NS, pulled up the resident's shirt, wiped the top of the insertion site, folded the 2 x 2 s, and wiped the bottom of the insertion site. She removed her gloves, sanitized her hands, donned new gloves, and put slit dressing on his site. She taped the slit together for secure and dated it. She removed her gown and gloves and performed hand hygiene. At 3:03 PM, Staff A stated the opportunities to perform hand hygiene are when gloves are soiled, when moving from dirty to clean cares, and between patient-to-patient care. She stated packaged supplies should be opened after gloves are donned. On 7/11/24 at 12:27 PM, the interim Director of Nursing stated hand hygiene should be done before, after, and as needed during a procedure. 50471 3. On 7/9/24 at 1:28 PM, Staff L, Certified Nurse Aide (CNA) entered resident #6 room. Observed Resident #6 in her wheelchair. Staff M brought the mechanical lift in the room to assist resident and Staff L. Staff did not complete handwashing or hand hygiene. Staff provided privacy and stated to resident, assist with transfer and incontinent care. Staff hooked sling to equipment, transferred to bed, unhooked sling, and placed equipment by her door. Staff gathered items for incontinent care. Staff L stated task steps to resident. Staff removed pants, and unfastened incontinent product. Staff L gathered wipe from Staff M, wiped front to back the outer labia, disposed the soiled wipe, gathered wipe from Staff M, wiped front to back the outer labia, and disposed soiled wipe. With assistance from Staff M, Staff rolled resident to her right side toward the wall. Staff tucked the mechanical lift sling under the resident, Staff M held onto resident, Staff L took soiled incontinent product and wipe bowel movement from anus then disposed soiled incontinent product. Staff L gathered wipe from Staff M, wiped perineum, anus, sacrum, disposed wipe, gathered wipe from Staff M wiped perineum, anus, sacrum, disposed wipe, gathered new incontinent product and placed under resident buttocks. Staff L tucked incontinent product fastener under right buttock, Staff rolled resident to her left onto her back, Staff rolled resident to her left side, Staff removed the mechanical lift sling. Staff L adjusted the incontinent product fastener, and staff assisted resident to her back. Staff L closed and fastened incontinent product. Staff L removed soiled gloves and completed hand hygiene. Staff assisted resident to comfortable position, covered resident, placed call light within reach, placed floor mat at bed side, and lowered bed to appropriate level. Staff L completed hand washing, Staff M took soiled bag and mechanical lift equipment to hallway, Staff M placed mechanical lift equipment against the wall, Staff M put soiled bag in soiled utility room, another staff member took the mechanical lift, mechanical lift was not disinfected. Staff M went back to resident's room, and performed hand washing, Staff shut off light and exited room. On 7/11/24 at 3:01 PM the Director of Nursing (DON) stated the staff should perform hand washing or hand hygiene before and after incontinent care, when soiled, and when gloves are removed. Stated the staff should change gloves before and after cares, during cares when soiled. Mechanical lift equipment should be cleaned per policy, routine cleaning. The facility policy titled Perineal Care revised 4/13 included the following documentation: -Separate the labia with one hand and wash with the other, using gentle downward strokes from the front to the back of the perineum. -Remove gloves, wash hands, and apply clean gloves if original gloves were visibly soiled. -Clean, rinse, and dry the anal area, starting at the posterior vaginal opening and wiping from front to back. -Remove gloves, wash hands, and apply clean gloves. The facility policy titled Infection Control Manual: Equipment revised 3/15 included the following documentation: -A facility specific cleaning schedule will be developed for the routine cleaning of noncritical equipment such as, but not limited to, the following: Resident/patient care equipment: Mechanical lifts 4. On 7/09/24 at 1:15 PM Staff L assisted resident #12 to his room. Staff K assisted Staff L. Staff gathered mechanical lift equipment, instructed resident of the task, permission granted, and staff completed hand washing. Staff hooked up mechanical lift to sling, Staff L controlled the mechanical lift equipment, Staff K guided resident to bed, resident positioned over bed, Staff L lowered resident onto the bed and Staff unhooked the sling from the lift. Staff moved the mechanical lift away from the bed. Staff gathered items for incontinent care. Staff L stated task steps to resident. Staff remove pants, and unfastened incontinent product. Staff L gathered wipe from Staff K, wiped right groin then left groin, disposed the soiled wipe, gathered wipe from Staff K, Staff L wiped left groin, disposed soiled wipe, with assistance from Staff K, and Staff rolled resident to his right side toward the wall. Staff tucked the mechanical lift sling under resident, Staff K held onto resident, Staff L disposed soiled incontinent product, Staff L gathered wipe from Staff K, wiped perineum, anus, sacrum, disposed wipe, gathered wipe from Staff K wiped perineum, anus, sacrum, and disposed the wipe. Staff failed to wash hands or change gloves. Staff gathered new incontinent product and placed under resident buttocks, Staff rolled resident to his left onto his back, Staff rolled resident to his left side, Staff removed the mechanical lift sling, Staff L adjusted the incontinent product, and then Staff assisted resident to his back. Staff L closed and fastened incontinent product. Staff L removed soiled gloves, and completed hand washing. Staff assisted resident to comfortable position, covered resident, placed call light within reach, and lowered bed to appropriate level. Staff removed soiled bag. Mechanical lift equipment was not disinfected. On 7/11/24 at 3:01 PM the Director of Nursing (DON) stated the staff should perform hand washing or hand hygiene before and after incontinent care, when soiled, and when gloves are removed. Stated the staff should change gloves before and after cares, during cares when soiled. Mechanical lift equipment should be cleaned per policy, routine cleaning. The facility policy titled Perineal Care revised 4/13 included the following documentation: -Hold the shaft of the penis with one hand and wash with the other, beginning at the tip and working in a circular motion from the center to the periphery. -Gently retract the foreskin, if uncircumcised, and clean beneath it. -Replace the foreskin to avoid constriction of the penis. -Wash the rest of the penis, using downward strokes toward the scrotum. -Clean the top and sides of the scrotum gently. -Position resident to expose, clean the bottom of the scrotum and the anal area. -Remove gloves, wash hands, and apply clean gloves. The facility policy titled Infection Control Manual: Equipment revised 3/15 included the following documentation: -A facility specific cleaning schedule will be developed for the routine cleaning of noncritical equipment such as, but not limited to, the following: Resident/patient care equipment: Mechanical lifts 46873 5. Observation of morning medication pass began on 7/9/24 at 7:35 am. Staff A, Registered Nurse was passing medications. She stated she would begin with Resident #26. Staff A brought the medication cart to the doorway of Resident #26. She knocked on the door to verify the resident was awake and let her know she was preparing her medications. Staff A brought the Medication Administration Record of Resident #26 up on the computer screen and opened the medication drawer to remove the medications. She prepared the oral medications and administered them. After administering the medications, she stated she needed to check the resident's blood sugar. She gathered supplies, donned gloves, swabbed the resident's finger with an alcohol wipe and obtained her blood sugar. She held a cotton ball to the resident's finger to stop any bleeding. She disposed of the contaminated items in a sharps container and removed her gloves. She placed the glucometer back in the medication cart near the front of the top drawer. The State Surveyor asked Staff A if the glucometer was dedicated to a single resident or if it was shared. She stated it was dedicated to Resident #26 and she moved the glucometer from a general area in the cart to a divided area in the cart which was labeled with Resident #26's name. The glucometer was not sanitized before or after use. She also failed to sanitize the top drawer of the medication cart where the glucometer was initially placed. Staff A then prepared the first of three insulin shots for Resident #26. After preparing the insulin pen, she donned gloves, and administered the insulin appropriately. After administering the insulin and disposing of sharps, she removed her gloves. She repeated this for two more injections. Staff A then administered an inhaled medication and a nasal spray medication to Resident #26 which completed medication pass for this resident. No hand hygiene was witnessed during the observation. 6. Staff A then moved the medication cart across the hall to Resident #3. With no hand hygiene witnessed, Staff A prepared and administered all morning medications to Resident #3. The facility policy Medication Administration, dated 01/2013 documented the following: Point 6: Wash hands Point 7: Assemble equipment for administering medications Point 15: Administer oral medication with a full glass of water unless otherwise ordered. Point 18: Wash hands.

Based on personnel file review, the facility mandatory education calendar, and staff interview, the facility failed to implement required training for multiple topics for 5 of 5 staff reviewed (Staff F, G, H, I, J). The facility reported a census of 30 residents. Findings include: The Employee List Report listed the following staff hire dates: Staff F 3/1/23 Staff J 3/28/23. The New Hire Report listed the following staff hire dates: Staff G 11/16/23 Staff H 10/6/23 Staff I 4/6/23 The facility lacked documentation that Staff F, Staff G, Staff H, Staff I, and Staff J completed training in communication, Quality Assurance and Performance Improvement (QAPI), compliance and ethics, and behavioral health. The facility lacked documentation that Staff J completed training in resident rights and infection control. The 2024 Mandatory Education calendar included the following topics: effective communication, resident rights, QAPI, infection control, compliance and ethics, and resident behavioral health. The calendar stated all courses were required for all staff. On 7/11/24 at 12:07 p.m. via phone, the Director of Nursing (DON) stated she expected all staff to be current with required training.

Based on personnel file review, the facility mandatory education calendar, and staff interview, the facility failed to implement communication training for 5 of 5 staff reviewed (Staff F, G, H, I, J). The facility reported a census of 30 residents. Findings include: The Employee List Report listed the following staff hire dates: Staff F 3/1/23 Staff J 3/28/23. The New Hire Report listed the following staff hire dates: Staff G 11/16/23 Staff H 10/6/23 Staff I 4/6/23 The facility lacked documentation that Staff F, Staff G, Staff H, Staff I, and Staff J completed training in communication. The 2024 Mandatory Education calendar included the following topics: effective communication, resident rights, QAPI, infection control, compliance and ethics, and resident behavioral health. The calendar stated all courses were required for all staff. On 7/11/24 at 12:07 p.m. via phone, the Director of Nursing (DON) stated she expected all staff to be current with required training.

Based on personnel file review, the facility mandatory education calendar, and staff interview, the facility failed to implement behavioral health training for 5 of 5 staff reviewed (Staff F, G, H, I, J). The facility reported a census of 30 residents. Findings include: The Employee List Report listed the following staff hire dates: Staff F 3/1/23 Staff J 3/28/23. The New Hire Report listed the following staff hire dates: Staff G 11/16/23 Staff H 10/6/23 Staff I 4/6/23 The facility lacked documentation that Staff F, Staff G, Staff H, Staff I, and Staff J completed training in Behavioral Health. The 2024 Mandatory Education calendar included the following topics: effective communication, resident rights, QAPI, infection control, compliance and ethics, and resident behavioral health. The calendar stated all courses were required for all staff. On 7/11/24 at 12:07 p.m. via phone, the Director of Nursing (DON) stated she expected all staff to be current with required training.

Based on personnel file review, the facility mandatory education calendar, and staff interview, the facility failed to implement compliance and eithics training for 5 of 5 staff reviewed (Staff F, G, H, I, J). The facility reported a census of 30 residents. Findings include: The Employee List Report listed the following staff hire dates: Staff F 3/1/23 Staff J 3/28/23. The New Hire Report listed the following staff hire dates: Staff G 11/16/23 Staff H 10/6/23 Staff I 4/6/23 The facility lacked documentation that Staff F, Staff G, Staff H, Staff I, and Staff J completed training in Compliance and Ethics. The 2024 Mandatory Education calendar included the following topics: effective communication, resident rights, QAPI, infection control, compliance and ethics, and resident behavioral health. The calendar stated all courses were required for all staff. On 7/11/24 at 12:07 p.m. via phone, the Director of Nursing (DON) stated she expected all staff to be current with required training.

Based on personnel file review, the facility mandatory education calendar, and staff interview, the facility failed to implement infection control training for 1 of 5 staff reviewed (Staff J). The facility reported a census of 30 residents. Findings include: The Employee List Report listed the following staff hire dates: Staff J 3/28/23. The facility lacked documentation that Staff J completed training in infection control. The 2024 Mandatory Education calendar included the following topics: effective communication, resident rights, QAPI, infection control, compliance and ethics, and resident behavioral health. The calendar stated all courses were required for all staff. On 7/11/24 at 12:07 p.m. via phone, the Director of Nursing (DON) stated she expected all staff to be current with required training.

Based on personnel file review, the facility mandatory education calendar, and staff interview, the facility failed to implement Quality Assurance and Performance Improvement (QAPI) training for 5 of 5 staff reviewed (Staff F, G, H, I, J). The facility reported a census of 30 residents. Findings include: The Employee List Report listed the following staff hire dates: Staff F 3/1/23 Staff J 3/28/23. The New Hire Report listed the following staff hire dates: Staff G 11/16/23 Staff H 10/6/23 Staff I 4/6/23 The facility lacked documentation that Staff F, Staff G, Staff H, Staff I, and Staff J completed training in QAPI. The 2024 Mandatory Education calendar included the following topics: effective communication, resident rights, QAPI, infection control, compliance and ethics, and resident behavioral health. The calendar stated all courses were required for all staff. On 7/11/24 at 12:07 p.m. via phone, the Director of Nursing (DON) stated she expected all staff to be current with required training.

Based on clinical record review, facility policy review, staff interviews and provider interviews, the facility failed to implement interventions to prevent the development and deterioration of pressure ulcers for 1 of 3 residents reviewed (Resident #5). The resident was admitted to the facility with intact skin and developed a Stage III pressure ulcer along with other wounds over the course of 3 months. The facility reported a census of 28 residents. Findings include: Determining the Stage of Pressure Injury: Stage 1 Pressure Injury: Non-blanchable erythema of intact skin Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuant) on the heel or ischemic limb should not be softened or removed. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. The Minimum Data Set (MDS) dated [DATE] of Resident #5 reflected an admitted to the facility of 10/31/2023. The MDS revealed the resident to be dependent for bed mobility of rolling left and right. The MDS documented a height of 60 inches and a weight of 95 pounds. The MDS documented the resident to be at risk of development of pressure ulcers, but no unhealed pressure ulcers present on admission. The MDS documented the resident had no venous or arterial ulcers and no other ulcers, wounds or skin problems present. The Care Plan of Resident #5 revealed a focus area of potential for pressure ulcer development, with initiation date of 11/13/2023. It directed staff to administer medications as ordered, administer treatments are ordered, document and report changes in skin status, and clean and dry the resident's skin promptly after incontinence episodes. The care plan failed to reflect a need for repositioning, specialty mattress, limb elevation or other pressure ulcer preventative measures. The care plan failed to document a focus area for activities of daily living to include how the resident turned in bed, transferred, ate, or any other daily activities. The care plan lacked any documentation of her pressure ulcer risk on admit and lacked any interventions to prevent pressure ulcer development prior to 11/13/2023. The care plan lacked updates or revisions with pressure ulcer development or deterioration. The Braden Scale dated 10/31/2023 documented the resident as high risk for pressure ulcer development. The Kardex reviewed on 1/31/2024 at 11:38 am for Resident #5 (a snapshot of highlights of the complete care plan, used by the Certified Nurse Aides to know how to care for a resident) failed to document the need for bed mobility or any other interventions for the prevention of skin injury. The Orders section of the Electronic Health Record (EHR) of Resident #5 documented an order dated 11/13/2023 to complete a weekly skin assessment. The Progress Notes for the resident documented the following: On 11/15/2023 at 11:02 pm fax sent to provider regarding area on coccyx. Awaiting return fax. The Progress Notes lack any documentation of follow up on the fax sent on 11/15/2023. On 11/27/2023 at 1:50 pm area on right buttock measuring 5 cm x 5.5, wound bed has a shiny pink appearance. Will consult hospice on treatment. At 11:23 am hospice nurse here to see resident and recommending triad cream for buttocks. Will attempt to get order. On 12/7/2023 at 11:18 pm open area on coccyx. Hospice called and returned call with order from provider for triad cream three times per day and as needed (prn) and cover with cushion pad. Measure weekly. The Progress Notes revealed the facility waited 10 days to follow up on the triad. The Assessments section of the EHR, reviewed on 1/31/24 at 10:40 am, revealed skin assessments completed for resident #5 on 11/13/2023, 11/20/2023/ 12/4/2023 and 12/8/2023. No skin assessments completed after 12/8/2023. Staff B, Registered Nurse (RN) began a skin assessment on 1/31/2024, more than 7 weeks after the last assessment completed. The Weekly Skin Assessments for the resident documented the following: On 11/20/2023 the resident to have normal skin color, warm/dry skin and skin integrity was intact. This reflects a conflict to the progress note on 11/15/2023. On 12/4/2023 sacrum redness and left heel stage I pressure measures 3 x 3.5 cm. On 12/8/2023 coccyx a stage II pressure measures 2 x 1.5 x .5 cm. No documentation of the heel. The assessment lacked any new interventions. The record lacked any other Weekly Skin Assessments. The Assessments section of the EHR revealed Pressure Injury assessments as being complete on 11/27/2023, 12/11/2023, 12/27/2023 and 1/8/2024. The Pressure Injury Assessments for the resident documented the following: On 11/27/2023 right buttock stage II measures 5.5 x 5 x 0 cm. On 12/11/2023 right lower rear leg stage II pressure measures 2 x 1 cm. Right buttock stage II measures 1.5 x 1.5 x 0.3 cm. Right buttock second area stage II measures 4 x 2 x 0 cm. Left buttock stage II measures 1 x 1 x 0 cm. On 12/27/2023 sacrum pressure stage III measures 1 x 1.5 x 1 cm. left rear lower leg stage II measures 0.5 x 0.5 cm and right rear lower leg stage II measures 0.5 x 0.5 cm. On 1/8/2024 sacrum pressure stage III measuring 2 cm x 1 cm with a depth of 2 cm. No documentation of the legs. On 1/22/2024 documented as a late entry, sacrum pressure stage III 1 x 1.8 x 2 cm. Left lower leg blister 2.5 x 0.5 cm. The record lacked any other Pressure Injury Assessments. The Treatment Administration Record for January 2024 for the resident documented the following orders: -Apply Vaseline to area on back of right calf and cover with island dressing daily with order date 12/12/2023. The order was not signed off as complete on 1/9/23 and 1/15/23. -Apply Xerofoam gauze and cover with island dressing once daily to coccyx with order date 12/20/23. The treatment was not signed off on 1/9/23 and 1/15/23. -Apply betadine to left heel two times a day for pressure ulcer with order date of 12/29/23. The treatment was not signed off as complete on the morning of 1/9/23 and 1/15/23. On 1/31/2024 at 11:14 am, the Director of Nursing stated her expectation is that skin assessments are to be done once a week and documented in the EHR. She verified Resident #5 developed the wounds while a resident at the facility. She verified the resident has been on hospice care since admission to the facility and stated that normally when a resident is in hospice, it is the hospice company who provides interventions such a specialty mattress or air mattress. She stated Resident #5 does not have a specialty mattress. She stated preventions for skin injury vary depending on the resident but that they normally include barrier creams, repositioning, tucking pillows under one side of the body and incontinence cares. The document provided by the facility titled Skin Care & Wound Management, dated 06/2015, directed: Components of the skin care and wound management program include, but are not limited to, the following: Identification of resident/patients at risk for developing pressure ulcers. Implementation of prevention strategies to minimize the potential for developing pressure ulcers and skin integrity issues. Weekly monitoring of resident/patient skin status Daily monitoring of existing wounds Application of treatment protocols based on clinical best-practice standards for promotion of wound healing. Interdisciplinary review of identified skin impairments. Monitoring for consistent implementation of interventions and effectiveness of interventions. Review and modification of treatment plans, applicable. Analysis of facility pressure ulcer data for quality improvement opportunities. Additionally the Skin Care and Wound Management document also directed: 1. Complete the Braden Scale on admission and weekly x4 and then quarterly. 2. Complete Admission Skin Sweep on admit and then weekly. 3. Determine the reason(s) a resident is at risk for pressure ulcer developement. 4. Develop a care plan with input from the interdisciplinary team and the resident/patient and family/responsible party. Document individualized goals and interventions to manage risk factors. 5. Communicate risk factors and interventions to the caregiving team, resident and family/responsible party. 6. Evaluate for consistent implementation of interventions and evaluate effectiveness. 7. Modify and document goals and interventions as indicated. 8. Communicate changes.

Based on clinical review, observation, staff and resident interview, and facility policy, the facility staff failed to ensure residents with a limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decline in the range of motion for three of ten residents (Residents #6, #8 and #9) The facility reported a census of 33 residents. Findings include: 1. The quarterly Minimum Data Set (MDS) Assessment Tool dated 3/29/14 documented Resident #9 had an impaired cognition as evidenced by a BIMS (Brief Interview for Mental Status) score of 5 (the BIMS scale for cognitive impairment states a score of 0-7 indicates severe impairment, 8-12 indicates moderate impairment, and 13-15 indicates the resident is not cognitively impaired). The MDS documented [DIAGNOSES REDACTED]. The MDS indicated the resident required total assistance from two staff members for bed mobility, transfers, and activities of daily living due to functional limitations of one side of the upper and lower extremities. Resident #9's plan of care documented a problem for the resident that stated the resident had weakness and limited range of motion (ROM-ability to move a joint) related to his/her non-weight bearing status and weakness. Interventions for the resident directed staff to provide lower extremity exercises, ankle pumps, quadricep sets, gluteal sets, bend knee and straighten knee, keep knee straight and lift and lower leg, keep knee straight and move side to side (initiated on 11/19/13) and to have physical therapy (PT) and occupational therapy (OT) departments evaluate and treat as needed (initiated on 3/13/14). The goal date initiated for the resident on 11/19/13 was revised to 11/1/14 and stated the resident would maintain 30-45 degrees of ROM to the lower extremity. A second problem identified on the care plan for Resident #9 stated the resident had right hand contracture and staff was directed to provide gentle passive-assist ROM (PROM-Staff moves the joint through the range of motion with no effort from the resident) for the upper left extremity to the elbow, wrist, and fingers. The initiation date was 11/19/13 and the target date of 9/1/14. The care plan noted a recommendation by OT to place a soft roll splint or rolled cloth in the left hand when the resident was up in the wheelchair and to place the splint in the resident ' s right hand when the resident was in bed. Review of a Rehabilitation Screen request from the facility to the PT/OT department stated the resident displayed increased difficulty with self- feeding and complained of pain in hands and lower extremities. The request stated the resident might benefit from OT for self-feeding and PT for ROM of the lower extremities. Review of an Occupational Therapy plan of Care for the resident revealed the OT department evaluated and worked with the resident from 3/4/14 through 4/4/14 and recommended the resident use silverware with a curved spoon and a plate guard to assist the resident with self- feeding. The OT notes revealed staff was educated about the schedule for the placement of the soft splint in the hands. . Review of a Rehab Communication dated 3/26/14 from OT department to staff reinforced the instructions for placement of the soft splint in the left hand when up and the right hand when in bed. Observation of morning hygiene cares on 6/25/14 at 9:35 a.m. revealed the resident did not have a soft splint in either hand while in bed for cares. After cares were completed the resident was settled in the bed for a nap and did not attend the morning exercise class. Further observation on 6/25/14 at 10:30 a.m. revealed the resident was still in bed without a soft splint in either hand. Observation of Resident #9 on 6/25/14 at 3:00 p.m. in the dining room playing bingo revealed the resident did not have a soft splint in either hand while in bed for cares. The resident was using the right hand to slide bingo chips onto the bingo card. Record review of a PT department recommendation for the resident revealed the department had evaluated the resident from 3/4/14 through 3/29/14 and discharged the resident with directions for staff to provide active-assist ROM (AAROM- resident uses the muscles surrounding the joint to perform the exercise but requires some help from staff) exercises to both lower extremities for 10 repetitions each joint. Clinical record review of the Restorative Care Flow Record for the second quarter of 2014 revealed staff was to provide the following restorative services to the resident three to six times a week: AAROM/PROM, dining, upper extremity and lower extremity activities, massage digits, low extremity exercises, and group exercises. The following documentation was noted on the flow sheets: 1. April- services for dining and PROM were noted 9-10 times out of the month. Group exercise was documented 4 times for the month and the other activities on the April dates were recorded as N/A. Staff only initialed completion of the required exercises for April 9 times. 2. May- services for dining and PROM were noted one time of the month (5/6/14). The other activities on that date were documented as N/A. 3. June- services for dining were noted six times out of the month. Group exercise was documented one time on 6/3/14 and the other activities on the 5 dates were documented as N/A. Of the six dates with documentation the staff members only recorded initials on 3 days. Clinical record review of the Activity Attendance Record for the second quarter of 2014 revealed active ROM was provided for the resident as follows " 1. April- Resident attended 18 times and refused to go once. 2. May- Resident attended 10 times. 3. June- Resident attended 11 times. During an observation on 6/26/14 at 9:30 a.m. the resident was noted to be supine in bed. Staff D, Certified Nurse Aide (CNA) performed PROM on the resident ' s right knee and Staff L, Physical Therapy Aide (PTA), measured the degree of flexion with a goniometer (device used in physical therapy to measure the range of motion around a joint in the body). The CNA and the PTA repeated the procedure for the left leg/knee. During the ROM demonstration the resident was asked to wiggle his/her toes and flex his/her ankles. The resident was able to do this. The resident was also able to demonstrate that he/she was able to wiggle fingers on both hands but could not flex the distal joint of the #4 and #5 fingers of each hand. During an interview with the resident on 6/26/14 at 9:45 a.m. the resident stated the staff rarely helped him/her with ROM exercises and stated staff came into his/her room "maybe once a week " to help perform ROM exercises. The resident stated he/she occasionally attends the exercise class in the mornings but did not like to attend because it was " boring " and all the resident did was sit there. During an interview with Staff D, CNA, on 6/25/14 at 12:30 p.m. she stated the N/A on the Restorative Care Flow Record meant the resident was not (N) available (A) for exercises at that time. During an interview on 6/25/14 at 10:53 a.m. with Staff C, Activity Director, stated she holds the exercise class daily Monday-Friday. She leads the resident in exercises for each joint of the body and Staff B, OTA, assists the residents during the class. She stated Resident #9 attends the class approximately 1-3 times a week and states the resident actively participates with upper and lower body exercises. During an interview on 6/25/14 with Staff B, OTA (Occupational therapy Aide) she stated OT was responsible for the resident 's therapy " from the waist up " (upper extemities) and PT was responsible for therapies " from the waist down " . She stated Resident #9 was not currently on the OT case load and recommendations submitted by the department were recommendations and not physician orders. During an interview on 6/25/14 at 11:50 a.m. with the Director of Nursing (DON) she agreed the facility staff was responsible for providing restorative services for the residents. She stated over the past year a problem with documentation of restorative activities had been noted. She stated she was aware that some activities were not being provided by staff consistently and this became an issue when the facility no longer employed a restorative staff member and the floor CNAs became responsible for providing ROM exercises. She stated she has in-serviced staff and sent reminders to staff to complete the services and document that services were provided. During an interview with the Administrator on 6/26/14 at 8:39 a.m. she provided a facility policy on restorative nursing services which was dated 5/14. She stated this was a new policy and had not yet been implemented by staff. She stated prior to this the facility did not have a policy for restorative services. She stated she felt recent staff terminations had an effect on the bath and restorative services being provided consistently. She stated she feels that when three staff CNAs are working day shift they had time to complete all scheduled baths and ROM exercises. During an interview on 6/26/14 at 3:30 p.m. with the Physical Therapist contracted by the facility for services he stated he evaluated and treated Resident #9 for physical therapy services from 3/4/14 through 3/28/14. He stated staff notified his department that the resident was having decreased functioning of the lower extremities and increased pain. He stated he noted during evaluation that the resident had a "bony block" (stiffening and calcification in the knee joint) in both knees which prevented any increase in function because when forcing this type of joint for increased function the staff risk injuring the staff. For this reason the PT goal for Resident #9 was to maintain ROM function of the knees and not necessarily improve function. He stated when Resident #9 was discharged from PT services on 3/28/14 the resident had approximately 50% ROM function in each knee. He recommended the resident receive AAROM to bilateral lower extremities. When he compares the resident ' s level of knee ROM and the measurements taken by Staff L, PTA, this morning with the discharge measurements the resident showed a 10% loss of ROM function in the right knee and a 5% loss of function in the left knee since PT discharge on 3/28/14. The therapist stated in his experience he has noted in facilities that have active restorative exercise programs where ROM is provided consistently there is less decrease in overall ROM function with residents. He stated there is a cycle which develops when consistent ROM exercises are not provided to residents identified with loss of function. He stated when residents discharged from PT services are not given ROM as recommended by PT then they lose functioning and staff then requests a subsequent PT evaluation and a cycle develops with return requests for PT evaluations and treatments. 2. The quarterly minimum data set (MDS) assessment dated [DATE] documented Resident #6 with [DIAGNOSES REDACTED]. The MDS assessment documented the resident with a severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 6 (the BIMS scale for cognitive impairment states a score of 0-7 indicates severe impairment, 8-12 indicates moderate impairment, and 13-15 indicates the resident is not cognitively impaired). The MDS noted the resident needed total assistance from the staff for activities of daily living (ADL's). Section O of the MDS noted the resident failed to receive active or passive range of motion during the assessment period. The resident #6's plan of care dated 11/19/13 revealed a focus area of decline related to arthropathy associated with neurological disorders. Interventions included the following: resident to participate in RA (restorative) program, slow stretch with elbows and shoulders, straighten elbows and hold for 15 seconds, abduction of both arms, massage upper arm pit area to loosen muscle, slow stretch to both hands, palms to lower cupping. Review of the resident's Restorative Care Flow Record for July 2013-April 2014 (no record available for May and June 2014) revealed hand activities and upper extremity passive range of motion as the restorative program. The record further revealed staff offered and the resident refused to do the exercises three times in the month of July 2013; staff offered and the resident refused two times in the month of August 2013; staff failed to offer any restorative exercises the months of September 2013 through January 2014. Hand restorative was offered one time in February 2014 and March 2014 revealed staff failed to offer restorative. In April 2014, staff offered and performed upper extremity passive range of motion 18 times (4/1-16, 4/21, 4/24). Review of the resident's Activities Attendance Record for June 2014, revealed he/she failed to participate in the facility's exercise group. During an interview with the facility's Activity Director on 6/25/14 at 10:53 a.m., she reported the resident chose not to participate in the daily exercise group offered Monday-Friday. Review of the resident's Physical Therapy Progress and Discharge Summary dated 6/21/13 revealed Physical Therapy saw the resident for assessment and treatment of [REDACTED]. The resident ended with negative 37 degree knee flexion for the right knee and negative 27 degrees for the left. Physical therapy ordered bilateral dynamic extension braces for the knees. Review of the resident's Physical Therapy Progress and Discharge Summary dated 4/25/14 revealed Physical Therapy saw the resident for the resident's refusal to wear bilateral dynamic extension braces. The resident started and ended with negative 40 degree knee flexion for the right and left knees. Physical therapy recommended for the resident to participate in the nursing restorative program to maintain lower extremity range of motion. During an interview with the Director of Nursing (DON) on 6/25/14 at 11:50 a.m., she reported the problem with the restorative program as mainly a documentation issue over the last year, but admitted some residents failed to receive the program. She reported the problem with the restorative program started when the position for a restorative aide was deleted. She reported the floor CNA's (certified nurse aide), as responsible for completing the restorative program with the residents. She said the resident's current restorative program should include bilateral lower extremities range of motion per Physical Therapy's recommendation. During an interview with Staff L, Physical Therapy Assistant, on 6/26/14 at 9:05 a.m., she reported she last worked with the resident in April 2014. Staff referred the resident to physical therapy due to the resident's refusal to continue to utilize bilateral dynamic extension braces. She reported when she started working with the resident, the resident knee extension equaled negative 40 degrees (resident able to extend knee straight 60 percent). She reported the resident last ended physical therapy in June 2013, and the resident's knee extension at end of care equaled negative 37 degrees in the right knee and negative 27 degrees in the left (able to extend right knee 63 percent straight and left knee 73 percent straight). She reported Physical Therapy at that time recommended bilateral dynamic extension braces and restorative to do range of motion to the bilateral lower extremities. Physical Therapy expected the resident to improve to a negative 20 degree knee extension. Staff L reported the resident lost function from last time physical therapy worked with the resident to the most recent time in April 2014. She said in April 2014 she worked with resident's bilateral lower extremities. She said when she started, the resident was minimally contracted. She reported the resident as able to extend his/her knees to negative 10 degrees by the end of care. She acknowledged the discharge summary reported a negative 40 degrees, but said the report was incorrect. She said Physical Therapy again recommended restorative nursing to do bilateral lower extremely range of motion. She said the range of motion would save the resident from contractures, but the resident's condition would decline without it. Observation on 6/26/14 at 9:53 a.m. revealed Staff L to measure the resident's current ability to extend his/her knees bilaterally. Staff L reported the right knee as a negative 60 degrees and the left knee as a negative 30 degrees. She said the physical therapist would have to interpret the results. During an interview with the facility's Physical Therapist on 6/26/14 at 3:16 p.m., he revealed that based on the testing results, the resident improved in the left knee, but lost function in the right. He reported range of motion for the bilateral lower extremities needed to be done at least 3 times per week to maintain function. 3. The quarterly minimum data set (MDS) assessment dated [DATE] documented Resident #8 with [DIAGNOSES REDACTED]. The MDS assessment documented the resident without a cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 (the BIMS scale for cognitive impairment states a score of 0-7 indicates severe impairment, 8-12 indicates moderate impairment, and 13-15 indicates the resident is not cognitively impaired). Section O of the MDS noted the resident failed to receive active or passive range of motion during the assessment period. Resident #8 ' s plan of care dated 1/31/13 revealed a focus area of risk for decline in ADL's related to weakness and history of falls. Interventions included restorative program 3-6 times per week and ambulate daily with wheeled walker from room to group exercises and room to dining room per Physical Therapy recommendations. Review of the resident's Restorative Care Flow Record for April-June 2014 revealed restorative exercises for upper extremities, dressing/ADL's, Group exercise and walk to dine. In April, the record revealed the resident walked to dine 14 times out of a possible 30, completed dressing ADL's 14 times out of 30, participated in group exercise 5 times, and failed to do any upper extremity exercises. In May, the resident walked to dine and completed dressing ADL's 4 times, failed to do any upper extremity exercises, participated in group exercise twice. In June (through 6/25/14), the resident walked to dine 4 times, completed dressing ADL's 5 times, participated in group exercise twice, and failed to do any upper extremity exercises. During an interview with the facility's Activity Director on 6/25/14 at 10:53 a.m., she reported the resident participates in her exercise group Monday-Friday, and does both upper and lower body exercises. During an interview with Resident #8 on 6/25/14 at 1:44 p.m., he/she reported doing dressing ADL's with staff encouraging her to do as much as possible for him/herself daily.