Every finding on record at Alden Courts of Shorewood

Based on observation, interview, and record review, the facility failed to provide nutritional supplements to residents per physician's order.This applies to 4 residents (R42, R33, R26, and R6) reviewed for nutrition in a sample of 17.Findings include:Dining observations of lunch meal were made in the dining room of R42, R33, R26, and R6's unit on 7/29/25, 7/30/25, and 7/31/25. V15 (Activity Aide) served lunch/plates on all three days.1. V16's (Registered Dietician) Nutrition Progress Note dated 7/4/25 states R42 was readmitted to the facility on a pureed diet and recommendation to resume magic cup twice a day. On 7/29 and 7/30 V5 (CNA/Certified Nurse Assistant) fed R42 lunch and on 7/31 V6 (Unit Manager) fed R42 lunch. R42's POS (Physician Order Sheet) shows an order dated 7/4/25 that states magic cup two times a day for nutritional supplement, give with lunch and dinner. On 7/31/25, V6 (Unit Manager) gave R42 regular pudding, but not his physician ordered magic cup. R42 was observed for the duration of lunch service and did not get magic cup at lunch on 7/29, 7/30, or 7/31. R42's Care Plan initiated on 6/14/23 states he requires nutritional support with goal to maintain current nutritional status with current nutritional interventions. Intervention dated 7/6/24 states provide nutrition supplement as ordered. 2. V16's (Registered Dietician) Nutrition Progress Note dated 3/5/25 states R33 had a significant weight loss of 11.1 % in 6 months. Supplement changed to magic cup BID for nutritional support. Supplements will provide additional 865 calories and 36 grams of protein daily, if consumed 100%. R33's POS shows order dated 3/4/25 for magic cup two times a day for nutritional supplement, give with lunch and dinner and order dated 11/15/24 for mighty shake two times a day for nutritional supplement give with lunch. R33 was observed for the duration of lunch service and did not get magic cup or mighty shake during lunch on 7/29, 7/30, or 7/31. R33's Care Plan initiated 11/05/24 states she has had a significant weight loss and Care Plan initiated on 4/6/24 states she requires nutritional support with intervention dated 3/5/25 to provide nutrition supplement as ordered.3. V16's (Registered Dietician) Nutrition Progress Note dated 7/10/25 states R26 has had a decrease in appetite and has been sleeping through breakfast. V16's progress note states recommendation to continue nutrition supplements as ordered and supplements will provide R26 with an additional 1300 calories and 51 grams of protein daily, if consumed 100%. R26's last blood work drawn on 6/16/25 shows his total protein level was low at 5.9 g/dl (grams per deciliter). R26's POS shows order dated 6/28/24 for magic cup two times a day for nutritional supplement, give with lunch and dinner and order dated 6/4/25 for mighty shake three times a day for nutritional supplement with all meals. R26 was observed for the duration of lunch service and was not provided magic cup or mighty shake with lunch on 7/29 or 7/30. R26 was not in the dining room for lunch on 7/31 and was noted to still be asleep in bed. On 7/31 at 11:06 AM, V6 (Unit Manager) said R26 was having an off day and the staff tried to get him up a few times but he wanted to stay in bed. R26's Care Plan initiated 7/13/23 states he requires nutritional support with target goal dated 10/21/25 to maintain current nutritional status with current nutritional interventions. Intervention dated 8/31/24 states provide nutrition supplement as ordered.4. V16's (Registered Dietician) Nutrition Progress Note dated 7/7/25 states R6 has a noted weight loss of 13.2% in 3 months and 20% in 6 months. V16's note states R6 is receiving mighty shakes three times a day along with other supplements at breakfast and dinner and if she consumes all nutritional supplements 100%, she will receive an additional 1565 calories and 59 grams of protein daily. V16's note recommends to continue nutrition supplements as ordered. R6's POS shows an order dated 5/13/25 for mighty shake with meals for nutritional supplement, give with breakfast, lunch and dinner. R6 was observed for the duration of lunch service and was not provided mighty shake with lunch on 7/29 or 7/31. R6's Care Plan initiated on 7/20/23 states he requires nutritional support with target goal dated 10/27/25 to maintain current nutritional status with current nutritional interventions. Intervention dated 12/5/24 states provide nutrition supplement as ordered.On 7/31/25 at 12:04 PM, V15 (Activity Aide) was asked how she knows what each resident should be served for each meal and V15 said she refers to their laminated tray cards. V15 said if a change is made to the resident's diet, the tray cards are updated. On 7/31/25 at 12:07 PM V15 provided surveyor with the tray cards for R42, R33, R26, and R6 which showed the following:R42 has a standing order to receive a 4 fluid ounce magic cup with lunch.R33 has a standing order to receive both a 4 fluid ounce magic cup and a 4 fluid ounce mighty shake at lunch.R26 has a standing order to receive both a 4 fluid ounce magic cup and a 4 fluid ounce mighty shake at lunch.R6 has a standing order to receive 4 fluid ounce might shake at lunch.On 7/31/25 at 1:46 PM V16 (Registered Dietician) said supplements are ordered for residents for a number of reasons including nutritional support, to help with wound healing, to support appetite, and for the extra vitamins and extra protein. V16 said giving a resident regular pudding is not equivalent to a magic cup because magic cups have more calories and protein than regular pudding. V16 said staff should refer to a resident's tray card during meal service to know if a resident has supplements ordered. V16 said the harm in not providing every resident their physician ordered nutritional supplements is that the residents will not receive the extra calories and protein which could lead to weight loss and effect wound healing and immunity.The facility provided policy titled, Dietary Supplement last revised 1/18 states, Policy: A physician's order is required for a Dietary Supplement. Purpose: Dietary supplements may be required to enhance the resident's nutritional status. Procedure:.2. Nursing maintains the physician order in the MAR for commercially prepared liquid supplements.

Based on observation, interview, and record review, the facility failed to remove expired medications and store medications under proper conditions. This applies to 2 of 2 residents (R1 and R20) reviewed for medication storage in the sample of 17. The findings include: 1. On 07/30/25 at 3:33 PM, during the initial observation of the medication cart on the [NAME] unit, R20 had a box of Ipratropium Albuterol Solution 0.5 mg/3mg/3mL (milliliter). The directions for use on the box were one vial via nebulizer every six hours as needed. The expiration date was 06/2025. The box contained three packages with five vials in each package unopened. One package contained three unused vials. The medication cart had a box with one vial of Tuberculin Purified Protein Deprivative Diluted Aplisol 5tu (Tuberculin Units)/0.1 mL, opened on 07/27/25. The box contained a blue sticker which indicated to keep the vial in the refrigerator. On 07/31/2025 at 3:00 PM, V17 (Registered Nurse) stated the Tuberculin solution should always be refrigerated. It can lose its potency if not refrigerated. V17 stated after the vial of medication was found on the cart, she put it back in the refrigerator. V17 stated expired and discontinued medications should be removed from the medication cart and sent back to the pharmacy. R20 was admitted to the facility on [DATE] with multiple diagnoses which included dementia, acute respiratory failure with hypoxia, congestive heart failure, chronic obstructive pulmonary disease, and anxiety per the face sheet. R20's MDS (Minimum Data Set) dated 06/23/25 showed R20 had severe cognitive impairment. R20's current Order Summary Report for 07/2025 showed no active orders for Ipratropium Albuterol Solution. R20's Order Summary Report for 01/2025 showed Ipratropium Albuterol Solution was discontinued on 02/03/25. The facility's Storage/Labeling/Packaging of Medications Policy dated 12/2023 showed 4. Medications requiring refrigeration are stored in a refrigerator located in a locked room accessible only to authorized staff. 12. Medications requiring refrigeration should be stored at temperatures between 36 degrees Fahrenheit to 46 degrees Fahrenheit. 2. On July 29, 2025, at 11:26 AM, during initial tour, R1's bedside table contained a tube of Systane lubricant eye ointment nighttime severe dry eye relief 3.5 gram. On July 30, 2025, at 9:33 AM, R1 said her left eye does not close because of the stroke and she had an ointment she put into her eye. R1 said the medication was over the counter and she put the ointment in whenever she needed it. On July 31, 2025, at 12:39 PM, V8 (LPN/Licensed Practical Nurse) was R1's nurse. V8 said the residents in her hallway were not allowed to keep medications at the bedside. V8 said residents would need an order to have medications at bedside. V8 said medications are kept in the nurse cart because the residents on the dementia units have behaviors or wander. V8 said the staff explain to the family members medications need to be kept with the nurse. V8 said if a resident or family requested medications to be kept at the bedside, they would notify the doctor, who would most likely say no. On July 31, 2025, at 12:54 PM, V7 (CNA/Certified Nurse Assistant) said residents were not allowed to have medications at the bedside. V7 said if she saw a medication at the bedside, she would let the nurse know. On July 31, 2025, at 1:23 PM, V3 (Patient Care Coordinator/LPN) said none of the residents were allowed to have any medications at the bedside. V3 said the facility does not allow residents to keep medications at bedside, and they should be kept in the nurse's cart. V3 said lubricating eye ointments in the medication cart. On July 31, 2025, at 1:07 PM, V2 (DON/Director of Nursing) said none of the residents were allowed to have any medications at the bedside. R1's face sheet showed she was admitted to the facility with diagnoses including hemiplegia and hemiparesis, facial weakness following cerebral infarction, muscle weakness, unsteadiness on feet, lack of coordination, need for assistance with personal care, and dementia. R1's POS (Physician Order Sheet) does not show an order for the medication or an order for the medication to be kept at bedside. R1's care plan dated June 29, 2025, showed [R1] has dementia, Due to the disease prognosis, [R1] may not be able to make preferences known. [R1] has dementia. She has been assessed at Stage 5 on the FAST Scale. She has difficulties with short term memory loss. The facility's Medication Storage policy dated September 2020 showed All medication that are current orders can be utilized. Those medications no longer current should be returned to the pharmacy.

Based on observation, interview, and record review, the facility failed to maintain an IV (Intravenous) dressing for a resident with a PICC (Peripherally Inserted Central Catheter)/Midline.This applies to 1 of 1 (R41) were reviewed for IV management in a sample of 17. The findings include:On July 29, 2025 at 2:06 PM, R41 had a PICC in the right upper arm. R41's PICC dressing was dated July 21, 2025. On July 30, 2025 at 1:23 PM, R41 had the same IV/Midline dressing which was dated July 21, 2025. On July 31, 2025 12:39 PM, V8 (LPN/Licensed Practical Nurse) said the PICC line dressing needs to be changed weekly. V8 said she did not change the dressing. V8 said when she checked the EMR (Electronic Medical Record) showed there was an order for the PICC line to be checked on July 24, 2025 and the midline was checked on July 25, 2025 by the PICC team. V8 said she did not see any documentation showing the dressing was changed. On July 31, 2025 at 1:23 PM, V3 (LPN/Patient Care Coordinator) said the dressings should be changed if the dressing was soiled, anything was malfunctioning, and/or every seven days. V3 said the dressing would need to be changed every seven days regardless of if it was intact to maintain its integrity. On July 31, 2025 at 1:07 PM, V2 (DON/Director of Nursing) said the PICC line and midline dressings needed to be changed every seven days even if the dressing was intact. V2 said the staff should sign off the dressing change in the MAR (Medication Administration Record) or the TAR (Treatment Administration Record). R41's face sheet showed she was admitted to the facility with sepsis, urinary tract infection, extended spectrum beta lactamase (ESBL resistance), and encounter for adjustment and management of vascular access device. R41's MAR showed an order for IV Midline: Transparent sterile dressing change weekly and PRN (As Needed) every day shift every Monday, which was signed off for July 28, 2025. R41's progress note dated July 21, 2025 at 8:48 PM showed R41 returned to facility via [Company] ambulance.Resident has a midline to right arm antecubital area. Midline intact. R41's Professional Nursing Service note dated July 25, 2025 showed Assessment: Right upper arm midline dressing intact. Intervention: Needless connector removal, catheter flushing and drawing blood. Catheter is good to use right now. The facility's PICC/Midline Catheters: Specific Maintenance Care policy dated April 2025 showed To maintain integrity of the catheter per proper assessment procedures and documentation of the catheter and catheter site. On Treatment Administration Record: 1. Document dressing change.

Based on observation, interview, and record review, the facility failed to follow infection control practices for resident under transmission-based and enhanced barrier precautions. This applies to 2 of 2 (R41, R34) reviewed for infection control in a sample of 17. The findings include: 1. On July 29, 2025, at 11:11 AM, R41's room was under contact isolation. R41's room had a contact isolation sign and an isolation bin with gowns, gloves, masks, wipes, and hand sanitizer in it. On July 29, 2025 at 11:55 AM, V11 (LPN/Licensed Practical Nurse) was in R41's repositioning R41. V11 was only wearing gloves. V11 boosted her up, removed her gloves, used hand sanitizer, and came out of the room. At 11:19 AM, V11 said R41 had ESBL (Extended Spectrum Beta Lactamase) in the urine. On July 31, 2025, at 12:54 PM, V7 (CNA/Certified Nurse Assistant) said they have to wear a gown and gloves before walking into the room. On July 31, 2025, at 1:19 PM, V4 (LPN/Licensed Practical Nurse) said for residents under contact isolation, gown and gloves need to be worn. V4 said a gown and gloves should be worn any time in a contact isolation room. On July 31, 2025, at 1:23 PM, V3 (Patient Care Coordinator/LPN) said for residents on contact isolation, a gown and gloves needed to be worn any time you entered the room. On July 31, 2025, at 1:07 PM, V2 (DON/Director of Nursing) said for residents on contact isolation, you need to wear a gown and gloves before entering the room. V2 said the staff should wear a gown and gloves to reposition the residents in bed. R41's face sheet showed she was admitted to the facility with sepsis, urinary tract infection, extended spectrum beta lactamase (ESBL resistance), and encounter for adjustment and management of vascular access device. R41's care plan dated July 23, 2025 showed Currently with isolation precautions and treated with antibiotics, ESBL UTI (Urinary Tract Infection) with interventions showing to Maintain isolation precautions as indicated and as ordered. The care plan dated July 22, 2025 also showed [R41] is on antibiotic therapy with isolation precautions (Contact; Single Room Isolation) [related to] ESBL with interventions including to use principles of infection control and universal/standard precautions. Post appropriate isolation outside of the room for staff and visitors. The facility's Contact Precaution signage dated December 2024 showed The purpose of contact precautions is to prevent transmission of infections that are spread by direct (e.g., person-to-person) or indirect contact with the resident or environment.All individuals entering the resident's room must use PPE (Protective Personal Equipment) appropriately, including gloves and a gown. Donning PPE upon room entry and doffing before exiting the resident's room is done to contain pathogens. 2. On July 29, 2025, at 10:29 AM, there was no EBP (Enhanced Barrier Precautions) signage on R34's door or any PPE (Personal Protective Equipment) set up outside her room. V13 (CNA--Certified Nursing Assistant) was assisting R34 with dressing and handling bed linen without wearing any PPE. R34 did not have any order for EBP in her POS (Physician Order Sheet). On July 30, 2025, at 10:00 AM, there was an EBP sign on R34's door and a PPE set up outside her room. Per V4 (LPN--Licensed Practical Nurse), R34 is currently on EBP for history of UTI (Urinary Tract Infection). R34's POS showed an order created by V3 (Patient Care Coordinator) on July 29, 2025, at 4:10 PM stating, EBP for ESBL Urine (ESBL--Extended-Spectrum Beta-Lactamase is an enzyme produced by bacteria that is spread through contact). On July 30, 2025, at 12:15 PM, V3 said R34 should have been on EBP since November 6, 2024, but the order had accidentally been discontinued. R34's Lab Results Report with review date of November 6, 2024, shows R34's urine culture is positive for Organism: Proteus Mirabilis ESBL (Proteus Mirabilis is a type of bacteria) that is resistant to several antibiotics (MDRO/Multidrug Resistant Organism). R34's POS shows an order EBP for ESBL Urine) was created on November 6, 2024; but discontinued on December 9, 2024. On July 31, 2025, at 2:30 PM V3 confirmed there was no set up or signage outside R34's door since the order had been discontinued (approximately 7 months ago). R34's EMR (Electronic Medical Record) reviewed. R34's face sheet showed she was admitted to the facility with diagnoses including dementia, history of cerebral infarction, hypertension, spinal stenosis, muscle weakness, and repeated falls. ­­ R34's MDS (Minimum Data Set) dated June 10, 2025, shows R34 is incontinent of bowel and bladder and requires staff assistance due to physical limitations and cognitive impairment. R34's MDS also states that R34 does not have any MDRO (Multidrug Resistant Organism, which includes ESBL-producing bacteria). R34's current care plan that was updated on July 29, 2025, does not include any interventions related to EBP or risk factors including R34's history of positive urine culture with ESBL-producing bacteria. Facility's policy titled, Enhanced Barrier Precautions with review date of December 2024, states that EBP involves gown and gloves during high-contact resident care activities for residents known to be infected or colonized with MRDOs (Multidrug Resistant Organisms) and that PPE (Personal Protective Equipment) should be changed before caring for another resident to reduce the transmission of MDROs in the facility. The policy also states that EBP signage from CDC (Centers of Disease Control and Prevention) should be posted outside the resident's room and that high-contact activities include dressing, bathing, transferring, changes linens, providing hygiene, device care or use (including central lines and urinary catheters), and assisting with toileting or changing briefs.

Based on interview and record review the facility failed to provide adequate supervision and assistance to a resident during ambulation who required moderate assistance from the staff. This failure resulted in R8 sustaining a fall, being hospitalized , and diagnosed with a fracture to her pubic rami and fourth proximal phalanx of the toe. This applies to 1 of 2 residents (R8) reviewed for falls in the sample of 12. The findings include: R8 is a [AGE] year old female with diagnoses that include Moderate Dementia, Sacroilitis, Spondylosis of the cervical and lumbar regions, and Osteoporosis. R8's Admission Minimum Data Sheet (MDS) dated [DATE] showed that R8 to have severe cognitive impairment. The MDS also showed that R8 requires partial/moderate assistance where the helper lifts, holds, or supports trunk or limbs, but provides less than half the effort when ambulating. R8's fall risk assessments dated May 13, 2024 and June 12, 2024 showed R8 was at risk for falls. R8 also has a history of a fall at the facility on June 12, 2024. R8's June 12, 2024 incident report noted that R8 has a history dementia and demonstrates impaired memory and poor safety awareness. R8's final incident reportable dated July 15, 2024 showed the following: Staff were interviewed and staff stated that after dinner [R8] was coming out of the dining room and stopped to converse with the nurse and another resident. While enjoying the conversation, the resident turned her head causing her to lose her balance and began to fall towards her right side. Nurse present on the left side and assisted resident to the floor. The reportable futher showed R8 had a witnessed fall, resident had a sudden change in condition and was sent to the hospital via 911. Per the hospital, R8 was admitted with a comminuted fracture of left medial superior pelvis and left forth toe fracture. The report also showed that the facility found that the factors contributing to the fall include a recent change in condition, distracted while ambulating, gait imbalance, cognitive impairment and poor safety awareness. On September 10, 2024 at 3:49 PM, V11 (Assistant Director of Nursing) stated she does the fall investigations for the facility. V11 stated that R8 had a fall in the activity room on June 12, 2024. V11 further stated that on July 7, 2024, R8 was walking to her room with V10 (Certified Nursing Assistant/CNA)). V11 stated that between the dining room and the hallway, R8 stopped to talk to nurse and then turned to talk to another resident. V11 stated that R8 then lost her balance and fell . V11 stated that V4 (LPN) wasn't able to get to resident in time to ease the fall. On September 10, 2024 at 4:01 PM, V10 (CNA) stated that on July 7, 2024, R8 stated she had to go to the restroom. V10 stated she then put a gait belt around R8 before she stood R8 up from the chair in the dining room. V10 stated between the dining room and the doorway R8 stopped to talk to V4 (Licensed Practical Nurse/LPN). V4 stated she was on R8's right side and holding resident with left hand and V4 was on her left side. V4 stated she left R8 with the nurse and went to answer a call light that was going off not far from the nurse's station. V10 stated on her way back from answering the call light, R8 was still talking to V4. V10 stated she then saw that R8 was starting to fall, and V10 stated she started running towards R8 and V4. V10 stated that V4 tried to grab R8 and was only able to grip her shirt and R8 landed on her right side. V10 stated she always stays close by when ambulating R8 because she was aware R8 was a fall risk and required one assist. On September 10, 2024 at 4:16 PM and 4:48 PM, V4 (LPN) stated that R8 was walking from the dining room and V4 was walking in the same direction. V4 stated R8 stopped to talk to him. V4 stated that another resident was on R8's left side and R8 turned to talk to the other resident and started falling in that direction. V4 stated he was only able to grab R8's shirt and not able to reach the gait belt that was around the R8's waist. V4 stated he held R8 by the shirt but the momentum brought her to the ground. V4 stated he did not recall where V10 was just before the fall, but no one was holding onto the resident. V10 stated they use a gait belt for assisting residents with transfers and escorting residents for safety reasons. V10 further stated that they use gait belts for all ambulatory residents who are fall risks. V10 stated that someone should have been holding R8's gait belt while she was talking to him. V10 stated he has seen before that residents get distracted, turn their heads and attention to other people, or get startled by others then can lose their balance. On September 11, 2024 at 12:59 PM, V2 (Director of Nursing) stated partial/moderate assistance is considered to be hands on assistance for transfers and ambulation of people who require it. If partial/moderate assistance is required then a gait belt is required to secure the resident for their safety. V2 stated R8 requires hands on assistance and staff should be holding the gait belt when ambulating, standing, and transferring the resident. On September 11, 2024 at 1:52 PM V14 (Rehab Director/Occupational Therapist) V14 stated they use a gait belt for safety during ambulation, standing, and transfer. V14 stated that staff has to hold the gait belt if the level of assistance required is partial/moderate assist. V14 stated that a gait belt should be used for someone who requires partial/moderate assistance with ambulation for safety. V14 stated even if the resident can walk 100 feet, the gait belt should be used because the resident could fatigue, get dizzy, or their legs could buckle. R8's therapy notes on the morning of July 7, 2024 showed that while receiving therapy, R8 uses a rollator walker and required minimum assist to contact guard assistance. On September 11, 2024 at 2:10 PM, V14 stated that minimum assist to contact guard assist means that the resident has hands on assistance with verbal queuing due to fluctuations of ambulation performance. V14 further stated that minimum assist to contact assistance was provided to R8 for proper foot placement and gait to improve ambulation. During the same interview V14 stated that when R8 is in the nursing unit, the nursing staff should us a gait belt for R8's safety. On September 11, 2024 at 2:28 PM, V15 (Medical Director) stated that he expects the facility's staff to follow their policies and procedures, and the professional recommendations of the therapists. R8's progress note dated July 7, 2024 at 8:40 PM showed that resident had a witnessed fall at 5:00 PM and at this time being sent to the hospital via 911. R8's hospital emergency room report dated July 7, 2024 showed that R8's son reported the he got a call from the memory care that R8 had a fall earlier today. The fall was witnessed by a staff member, R8 landed on her buttock, and was complaining of some left hip pain. Then later in the day R8 was reporting some lightheadedness/dizziness and the facility checked her oxygen and it was 93% and then dropped to 80%. The report also mentions that R8 had a confirmed fourth distal phalanx fracture of the toe. R8's ambulatory skills care plan dated May 17, 2024 showed the following: R8 has impaired ambulatory skills with or on: Changing directions, level surfaces, speeding up or slowing down, turning around. The related Interventions/Tasks dated May 17 2024 showed: Assist and instruct resident/caregiver with safety awareness while ambulating. R8's fall risk care plan dated May 13, 2024 showed the following: R8 is at risk for falls related to weakness/deconditioning, potential medication side effects, bowel and bladder incontinence, cognitive impairment/dementia, history of fall with fracture, and need for external physical assistance and use of assistive devices (wheelchair/walker). R8's Computed Tomograpy (CT) Pelvis without contrast report dated July 8, 2024 for left hip pain showed the following: Acute comminuted fractures of the left medial superior and interior pubic rami. Associated left pelvic sidewall hemorrhage and intramuscular hematoma the left obturator internus and externus muscles. The facility's Gait Belt/Transfer Belt policy showed the following: To assist with a transfer or ambulation. A gait belt will be used with weight bearing residents who require hands on assistance.

Based on observation, interview and record review, the facility failed to ensure that the dishes were sanitized during high temperature dishwashing procedure. This applies to 42 residents that receive foods prepared and served from the facility kitchen. The findings include: The facility provided information that on September 09, 2024 the facility census was 43 residents with 1 resident on NPO (nothing by mouth) status. On September 09, 2024 at 01:49 PM, the high temperature dish machine was monitored in the presence of V6 (Executive Chef). V7 (Dietary Aide) and V8 (Dietary Aide) were at the dish machine washing dishes, one employee each on the dirty and clean side respectively. During the dishwashing procedure, the 'Wash' temperature fluctuated between 158-167 degrees Fahrenheit, the 'Rinse' temperature fluctuated between 157-171 degrees Fahrenheit, and the 'Final Rinse' temperature fluctuated between 144-163 Fahrenheit. When a test strip that was adhered to a washed dish was sent through the dish machine, it remained white color. V6 stated that they had tested the dish machine with a test strip that morning and it had turned black color. A 'Dish Machine Temperature Log' was seen posted on the wall and the same log showed 186 degrees Fahrenheit logged on September 09, 2024 for breakfast. The test strip was sent through the dish machine two more times after waiting several minutes between each test and the test strips remained white color and light gray respectively with the Final Rinse temperature setting continuing to fluctuate between 152-166 Fahrenheit. After another couple minutes, another test strip was sent again through the dish machine and this time it turned black and it was noted that the Final Rinse showed 188 degrees Fahrenheit for a second or two at that time. The Final Rinse temperatures continued to fluctuate at temperatures below 180 degrees Fahrenheit thereafter during the dish washing process and V8 was seen placing the just washed dishes away on the clean rack ready for service. V6 (Executive Chef) was notified that the Final Rinse should show 180 degrees Fahrenheit on a consistent basis for the dishes to be sanitized and the dishes that were just washed and put away on the clean rack when the Final Rinse was not 180 degrees Fahrenheit, will have to be rewashed. Test strips labeled 1-Temp Thermolabel' included as follows: 1. Remove label from sheet. 2. Adhere to clean, dry dish using clean hands 3. Run through was and final rinse cycles. 4. The gray/white temperature sensitive element will turn black if the dish has reached the rated temperature . On September 10, 2024 at 1:03 PM, when the the high temperature dish machine was revisited again V6 (Executive Chef) stated that he notified the company that services the dish machine on September 9, 2024 and they came in that morning (on September 10, 2024) and checked the dish machine and told the maintenance that they need to boost up the water temperature. Customer Service Report from the Dish machine servicing company dated September 10, 2024 showed as follows: 'When arrived, the Final Rinse would go as low as 152 temperature. Incoming water too low, incoming should be at 140 [degrees Fahrenheit]. Told maintenance man, he adjusted some valves. Now machine is hitting 187-180 degrees after 4 racks. On September 11, 2024 at 01:02 PM, V12 (Dish Machine Company Service Personnel) verified that he was the one who serviced the dish machine on September 10, 2024. V12 stated that when checked, the temperature of the incoming water was at around 100 degrees Fahrenheit, and it should be best at 140 degrees Fahrenheit in order to maintain the booster at 180 degrees Fahrenheit at the Final Rinse setting. V12 stated that V13 (Maintenance Director) adjusted the value at a different site at the facility in order to raise the water temperature up. On September 10, 2024 at 04:24 PM, V5 (Dietary Supervisor, Registered Dietitian) stated that the Final Rinse should be at 180 degrees Fahrenheit in order for the dishes to be sanitized. Facility Policy and Procedure Mechanical Washing Sanitation Testing (revised June, 2024) included as follows: Policy: Dish machine test strips will be used to verify the dish machine sanitation system is working correctly. Purpose: To reduce the risk of food borne illness. Procedure: 2. For high temperature sanitizing machine: Attach a 160-degree Fahrenheit test strip to clean, dry, cool dish; weave a 180-degree Fahrenheit test strip per manufacture's direction or run through the wash/rinse cycle with a maximum reading thermometer to determine if the sanitizing water reaches 180-degree Fahrenheit. 4. If the test strip does not turn the correct color, the above procedure should be repeated. If the test strip does not the appropriate color after multiple attempts, the dish machine should be evaluated for proper functioning before the dishes are washed.

Based on observation, interview and record review the facility failed to ensure that the oxygen was administered to the residents as ordered by the physician. This applies to 2 of 2 residents (R2 and R95) reviewed for oxygen use in the sample of 12. The findings include: 1. R2 had multiple diagnoses including dementia without behavioral disturbance and senile degeneration of the brain, based on the face sheet. R2's significant change in status MDS (minimum data set) dated July 26, 2024 showed that the resident was moderately impaired with cognition and required total assistance from the staff with her ADLs (activities of daily living). On September 10, 2024 at 10:45 AM, R2 was in bed, alert and verbally responsive. R2's oxygen concentrator was running to deliver oxygen via nasal cannula to the resident. R2's nasal cannula was on her mouth and the oxygen gauge was set to deliver oxygen below 2 liters per minute which was confirmed by V4 (Licensed Practical Nurse). V4 reapplied R2's nasal cannula to the resident's nostrils and checked the resident's oxygen saturation which registered between 96% and 97%. R2 had no shortness of breath and the resident did not complain of respiratory distress. R2's active order summary report showed an order dated July 20, 2024 for, Oxygen per nasal cannula at 2 liters per minute continuous every night shift for hypoxia, on at HS (bed time). On September 10, 2024 at 11:03 AM, V4 (LPN) checked R2's active orders for oxygen and stated that based on the physician's order, R2 should receive 2 liters per minute of oxygen via nasal cannula only at night, to be applied before bed time and continuously while R2 is asleep. 2. R95 was admitted to the facility on [DATE] with multiple diagnoses including acute respiratory failure with hypoxia, pneumonia, dementia with behavioral disturbance and adult failure to thrive, based on the face sheet. R95's admission MDS dated [DATE] showed that the resident was severely impaired with cognition and required moderate to maximum assistance from the staff with most of her ADLs. On September 9, 2024 at 11:02 AM, R95 was sitting in her wheelchair inside her room. R95 was alert, verbally responsive with hard of hearing and was confused. R95 had an ongoing oxygen at 3 liters per minute using an oxygen concentrator. On September 10, 2024 at 10:26 AM, R95 was sitting in her wheelchair inside her room. R95 was alert, verbally responsive but confused. R95 had an ongoing oxygen at 3 liters per minute using an oxygen concentration which was confirmed by V4. R95 had no shortness of breath and the resident did not complain of respiratory distress. R95's active order summary report showed an order dated August 23, 2024 for, oxygen via nasal cannula at 2 liters per minute as needed for respiratory symptoms. R95's active oxygen therapy care plan initiated on September 5, 2024 showed multiple interventions including administration of oxygen as ordered by the physician. On September 10, 2024 at 11:00 PM, V4 checked R95's active orders for oxygen and stated that based on the physician's order, R95 should only receive 2 liters per minute, as needed. On September 11, 2024 at 9:32 AM, V2 (Director of Nursing) stated that oxygen should be delivered as ordered by the physician because oxygen therapy is considered as medication since it is prescribed by the physician. V2 stated that for R2, it was specifically ordered to be given only at night/at bedtime because the resident would complain of shortness of breath at night and based on the physician's order it should not be administered during the day, especially since R2 had not complained of shortness of breath and her oxygen saturation was stable and within normal limits, when it was checked by V4. V2 added that for R95, the order was to deliver 2 liters per minute as needed for shortness of breath. The facility's policy regarding oxygen concentrator dated September 2020 showed in-part, Residents will be administered oxygen via oxygen concentrator upon Physician's orders by an RN (Registered Nurse), LPN (Licensed Practical Nurse) or RT (Respiratory Therapist).

Based on interview and record review, the facility failed to utilize an appropriate standardized tool/system to justify or warrant the necessity of an antibiotic. This applies to 8 of 8 residents (R1, R4, R11, R12, R13, R17, R26, R27) reviewed for antibiotic stewardship in a sample of 17 and has the potential to affect all residents. The findings include: 1. R1's face sheet documents an admitted [DATE]. R1's POS (Physician Order Sheet) for May 2023 documents orders of the following antibiotics: Cefuroxime Axetil Oral Tablet 500 MG (Milligrams): Give 1 tablet by mouth two times a day for UTI (Urinary Tract Infection) for 7 days. Diflucan Oral Tablet 100 MG (Fluconazole): Give 1 tablet by mouth one time a day for Vaginal Discharge for 7 days. R1's Lab Results Reports for urine cultures for 5/11/23 and 5/14/23 shows positive for Klebsiella oxytoca. 2. R4's face sheet documents an admitted [DATE]. R4's POS for June 2023 shows an order of Amoxicillin-Potassium Clavulanate Tablet 500-125 MG: Give 1 tablet by mouth two times a day for UTI for 5 days. R4's Lab Results Reports for urine culture for 6/9/23 shows positive for Enterococcus. 3. R11's face sheet documents an admitted [DATE]. R11's POS for April 2023 shows an order of Ciprofloxacin HCL Ophthalmic Solution 0.3%: Instill 1 drop in left eye every 6 hours for Conjunctivitis for 5 days. 4. R12's face sheet documents an admitted [DATE]. R12's POS for July 2023 shows an order for Levaquin Tablet 500 MG (Levofloxacin): Give 1 tablet by mouth one time a day for UTI for 7 days. R12's Lab Results Reports for urine culture for 7/14/23 shows positive for Escherichia. 5. R13's face sheet documents an admitted [DATE]. R13's POS for August 2023 shows an order for Levaquin 500 MG: Give 1 tablet by mouth one time a day for infection for 10 days order. 6. R17's face sheet documents an admitted [DATE]. R17's POS for August 2023 shows an order of Doxycycline Hyclate Oral Capsule 100 MG: Give 1 capsule by mouth two times a day for left heel wound for 14 days. R17's Lab Results Report for the wound culture many gram-positive cocci---Streptococcus Agalactiae (Group B). 7. R26's face sheet documents an admitted [DATE]. R26's POS for August 2023 documents an order of Macrobid Oral Capsule 100 MG (Nitrofurantoin Monohyd Macro): Give 1 capsule by mouth two times a day for UTI for 3 days. R26's Lab Results Reports for urine culture for 7/28/23 shows positive for Enterococcus. 8. R27's face sheet documents an admitted [DATE]. R27's POS for March 2023 documents an order for Amoxicillin-Potassium Clavulanate Tablet 500-125 MG. Give 1 tablet by mouth one time a day for UTI for 5 days. R27's urine culture report for 3/2/23 shows positive for Klebsiella. Review of R1, R4, R11, R12, R13, R17, R26, and R27's electronic medical record and facility's infection control binder did not contain a standardized tool, such as McGreer's critieria to justify the necessity of the antibiotics. On 8/30/23 at 1:41 PM, V2 (Director of Nursing/Infection Preventionist) stated I don't have McGreer's criteria for these residents. Yes, there should be one. I didn't get time to start the McGreer's criteria on all the residents who were put on antibiotics in August. We don't have a policy regarding McGreer's criteria. I don't have an ADON (Assistant Director of Nursing) to help me. The facility was unable to provide a specific policy regarding a standardized screening tool, such as the McGreer's tool, to track antibiotics and appropriately treat infections. Facility's Policy titled Infection Prevention and Control Program (4/2021) documents: It is the policy that the facility's Infection Prevention and Control Program (IPCP), is based upon information from the Facility Assessment and follows national standards and guidelines to prevent, recognize, and control the onset and spread of infection whenever possible. The infection Prevention and Control Program includes: 3. An antibiotic stewardship program that uses antibiotic protocols and a system to monitor antibiotic use. Antibiotic Stewardship and review include reviewing data to monitor the appropriate use of antibiotics in the resident population. F. Monitor antibiotic use to help determine if appropriate.

Based on observation, interview, and record review, the facility failed to properly label, date, seal, and store food items in the kitchen. This applies to all 44 residents that receive oral nutrition and foods prepared in the facility kitchen. Findings include: The Facility Resident Census and Condition of Residents (Form CMS-Centers for Medicare and Medicaid Services-672) dated 8/29/23 documents the total census was 44 residents. On 8/30/23 at 1:40 PM, V1 (Administrator) said there are no NPO (Nothing by Mouth) residents. V1 said all 44 residents eat from the facility kitchen. On 8/29/23 starting at 10:15 AM, the facility kitchen was toured in the presence of V5 (Executive Chef). On 8/29/23 at 10:27 AM in the dry storage room, 1 large cardboard box of lasagna noodles was found opened and not sealed with the date cut-off. The date showed /17/23, the month was not shown. On 8/29/23 at 10:36 AM, in the walk-in refrigerator, 1-large cardboard box labeled green leaf lettuce with a pack date of August 1st was found. The lettuce was browning and wilted. On 8/29/23 at 10:36 AM, V5 (Executive Chef) said all food should have a received by date so the kitchen staff know when to use the foods by and V5 said the lettuce should be thrown away. On 8/29/23 at 10:42 AM, in the walk-in refrigerator the following was found: 1 large cardboard box with 2 bunches of browning celery with a pack date of July 24th. 1 pint of cherry tomatoes, not dated with white fuzz growing on underside of container. 1 large cardboard box of bagged baby spinach not dated. 1 large full cardboard box of browning/wilted celery bunches not dated. 4 cantaloupes in cardboard box, not dated. The following day, on 8/30/23 at 9:31 AM, the walk-in refrigerator was again toured in the presence of V5 (Executive Chef). The wilted and browning celery and lettuce were still in the refrigerator as well as the pint of cherry tomatoes with white fuzz on it. The walk-in refrigerator also had 2 large cardboard boxes of 24 count cucumbers with no date on either box. At 9:34 AM, 2 large trays of not labeled, dated, or covered cut lemon cake were observed on racks in the refrigerator. On 8/30/23 at 9:26 AM, V5 said the vegetables that were observed the day before were still in the refrigerator, that he had not thrown them out yet. V5 said all food should have a label and date so the kitchen staff know when food should be thrown away to prevent foodborne illness. On 8/31/23 at 10:46 AM, V8 (Dietary Supervisor) said all foods should be labeled and dated to prevent spoiled food from being given to the residents and making them sick. V8 said all foods need to be sealed to prevent contamination. On 8/31/23 at 11:53AM, V5 (Executive Chef) said according to the FDA (Food and Drug Administration) Food Keeper Application, celery is safe to store in the refrigerator and serve for 1-2 weeks and lettuce is safe to store in the refrigerator and serve for 3-7 days. The facility's policy titled, Labeling and Dating revised 7/23 states, Policy: Ready-to-eat time/temperature control for safety foods may be stored in the refrigerator .for 7 days. Purpose: To reduce the risk of food borne illness. Procedure: .4. Ready-to-eat PHF (Potentially Hazardous Food) may be kept for 7 days in the refrigerator .6 Based on the food item, which each have a different shelf life the facility will discard any food item that shows signs of spoilage. Facility will review USDA Food Keeper app to determine how long that food can be stored for. The facility's undated policy titled, Handling of Fresh Fruits & Vegetables states, Policy: fresh fruits and vegetables will be stored and handled to maintain healthful standards. Purpose: to reduce the risk of and the spread of infestation and food borne illness. Procedure: .2. Fruits and vegetables will have a delivery or packed date noted on container or package which serve as delivery date 7. Based on the fruit or vegetable, which each have a different shelf life the facility will discard any fresh fruits or vegetables that show signs of spoilage. Facility will review FDA (Food and Drug Administration) Food Keeper app to determine how long fresh fruit or vegetable can be used for.

Based on observation, interview and record review, the facility failed to properly supervise a resident requiring supervision during meals. This applies to 1 of 1 resident (R20) reviewed for supervision in a sample of 17. The findings include: On 08/29/2023 at 11:43 AM, R20 was in his room while the other residents and staff were in the dining room being served for lunch. Staff delivered R20's meal tray to his room. On 08/30/2023 at 12:11 PM, R20 was again observed with his meal tray in his room without any staff supervising him eating his meal. On 08/31/2023 at 8:41 AM, R20 was observed in his room with his meal tray without any supervision from staff. On 08/31/2023 at 10:38 AM, R20 had a straw in his beverage cup. The beverage cup had nectar thick written around the top rim of the cup. On 08/31/2023 at 10:43 AM, V11 (Certified Nurse Assistant/CNA) said R20 ate in his room and would take a long time to eat his food. V11 said he watches TV and gets distracted by the TV. V11 said she had not received any instructions on how R20 should be set up to eat. On 08/31/2023 at 12:17 PM, V10 (Registered Dietician) said R20 was on a nectar thick diet. V10 said R20 was supposed to have line of sight supervision with all meals and encouragement. V10 said R20 should be eating his meals in the dining room so that there is supervision for dysphagia and encouragement to eat meals. V10 said with the dysphagia diet, R20 was at an increased risk for choking. On 08/31/2023 at 12:31 PM, V13 (Director of Rehab Services) said R20 had aspiration precautions ordered for him. V13 said R20 was not supposed to use a straw and required line of sight supervision for intake. V13 said line of sight supervision meant staff should always be able to see the resident. On 08/31/2023 at 12:32 PM, V15 (CNA) delivered R20's meal tray to his room for lunch service. Staff did not provide supervision for R20. On 08/31/2023 at 12:42 PM, V2 (Director of Nursing) said line of sight supervision would mean the resident should be within view of the staff. V2 said if the resident had aspiration precautions, he or she should be observed during mealtimes. V2 said R20 should not be eating by himself in his room. On 08/31/2023 at 1:22 PM, R20 still had a straw in his nectar thick beverage cup. On 08/31/2023 at 1:29 PM, V9 (Unit Manager/Scheduling and Staffing) said anyone who was on a nectar thick diet should not use straws. V9 said R20 should not have a straw in his beverages and if they were on aspiration precautions, they could choke using a straw. On 08/31/2023 at 1:45 PM, V2 said if a resident was on aspiration precautions, they should not be using a straw. On 08/31/2023 at 2:09 PM, V2 said the facility did not have any policies on aspiration precautions or supervision with meals. V2 was unable to provide policies. R20's POS (Physician Order Sheet) showed an order for nectar thick consistency. R20's POS also shows directions for line of sight supervision during meals. R20's Nutrition assessment dated [DATE] showed R20 required line of sight supervision for eating. R20's progress note dated 07/11/2023 at 6:54 PM showed R20 requires supervision/line of sight at meals. R20's progress note dated 08/07/2023 at 10:15 AM showed R20 required supervision/line of sight at meals. 44387

Based on observation, interview, and record review, the facility failed to serve food at a safe temperature. This applies to 1 of 6 residents (R5) reviewed for pureed food temperatures in a sample of 17. Findings include: On 8/30/23 at 11:17 AM, food temperatures were checked on the steam table in the facility's East pantry by V6 (Dietary Aide). The pureed potato measured 132 degrees F and the pureed vegetable measured 127 degrees F. At 11:25 AM, V6 said the pureed potato and pureed vegetable were not safe to serve, they must measure 135 degrees F. V6 then placed the pureed cornbread, pureed potato, pureed beef brisket, and pureed vegetable in the hot box. V6 said the hot box would reheat the foods placed inside. On 8/30/23 at 11:40 AM, V7 (Activity Aide) came into East pantry and asked V6 (Dietary Aide) for a pureed tray for R5. V6 then removed the pureed foods from the hot box and served pureed beef brisket, pureed vegetable, and pureed cornbread onto R5's plate. V6 then handed the plate to V7 and V7 turned to leave the pantry to bring the plate to R5. Surveyor then stopped V7 and asked V6 if he needed to recheck the temperatures. V6 said yes. V6 rechecked the temperatures with the following results: pureed beef-126 degrees F, pureed cornbread- 131 degrees F, and pureed vegetable- 128 degrees F. V6 said that plate was not safe to serve. On 8/31/23 at 11:08 AM, V8 (Dietary Supervisor) said foods on the steam table need to be held at 135 degrees or above. On 8/30/23 at 12:13 PM, V5 (Executive Chef) said the plate of pureed food should have been reheated prior to serving it to R5 to get rid of any risk of foodborne illness. The facility's policy titled, Flow of Hot Food from Preparation to Service revised 6/18 states, Policy: Hot food will be handled safely from preparation to resident service. Purpose: to reduce the risk of foodborne illness. Procedure: .3 .If hot food is below 135 degrees F it will be rapidly reheated to 165 degrees F .

Based on observation, interview, and record review, the facility failed to safely transport residents using a wheelchair. The facility also failed to ensure a resident with a history of falling had footrests in place when self-propelling. This failure resulted in R1 sustaining a head laceration, requiring medical attention at the local emergency room and 15 sutures. This applies to 3 of 4 residents (R1, R2, R4) reviewed for accidents and supervision in the sample of 4. The findings include: 1. On April 4, 2023, at 10:55 AM, R1 was sitting in his wheelchair. R1 was not able to be interviewed due to his cognitive status. R1 had a laceration on his forehead that measured about 5 inches in length and was V-shaped. R1 had 1.5 to 2 inches of the laceration scabbed over. R1 also had a foam dressing to the left hand, and steri-strips on two of his knuckles of his hands. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE], with multiple diagnoses including encephalopathy, urinary tract infection, dementia, syncope, and collapse, and polyosteoarthritis. R1's MDS (Minimum Data Set) dated March 27, 2023, shows R1 has severe cognitive impairment, and requires extensive assistance from a facility staff member for bed mobility, locomotion on and off unit, dressing, eating, toileting, and personal hygiene. R1 requires extensive assistance from two facility staff members for transferring. The facility's fall incident log from January 1, 2023, to present documents R1 fell on [DATE], January 3, 2023, January 5, 2023, January 28, 2023, twice on March 15, 2023, and on March 26, 2023. The facility's incident report for R1, dated March 22, 2023, shows on March 15, 2023, R1 sustained an injury following transport in wheelchair by a staff member leading to a fall requiring medical treatment at the local hospital. The incident report shows: On March 15, 2023, resident fell and was observed with laceration to forehead. Physician gave orders to send out to [emergency room ] for evaluation. Resident returned to facility same day with sutures to forehead. Orders received from hospital were carried out. Hospital documentation dated March 15, 2023, shows R1 was seen in the local emergency room for a fall with a scalp laceration. R1 returned to the facility on [DATE], with sutures to his laceration. R1's initial nursing assessment dated [DATE], shows R1 had 15 sutures to the forehead and 10 steri-strips applied to the back of his left hand. On April 4, 2023, at 10:31 AM, V3 (Nurse) said on March 15, 2023, before dinner, she was pushing R1 in his wheelchair to the dining room when he put his legs on the ground, causing him to fall forward onto the floor. V3 said R1's wheelchair did not have footrests on them. V3 said R1 had increased confusion all day and was being worked up for an infection. V3 said when R1 has an infection, he becomes very confused and is unable to follow commands. V3 said on March 15, 2023, she had told R1 to keep his feet up, but he suddenly put his feet down. On April 4, 2023, at 10:58 AM, V4 (Activity Aide) said she was a 1:1 sitter with R1 as he was very confused and was not redirectable. V4 said on March 15, 2023, V3 came to R1's room to get him to come to the dining hall for dinner and began pushing him to the dining room. V4 said as V3 was pushing him to the dining hall, R1 suddenly put his feet down and went flying out of the wheelchair. V4 said he did not have footrests on his wheelchair. On April 4, 2023, at 11:12 AM, V5 (CNA/Certified Nurse Assistant) said residents should have footrests on their wheelchair if staff are transporting them. V5 said if they do not have footrests, they can fall out of their chair or injure their feet. V5 also said R1 is not himself when he has an infection and requires more assistance with activities of daily living. On April 4, 2023, at 1:05 PM, V2 (DON/Director of Nursing) said V3 (Nurse) had called him on March 15, 2023, at 4:05 PM to assist when R1 fell . V2 said R1 needed to go to the hospital because the laceration was too deep to be taken care of by the facility. V2 said earlier that day around midnight, R1 had fallen out of his bed and the facility staff called the doctor to request labs to work him up for an infection. V2 said R1 was not himself and had behaviors. V2 said on March 15, 2023, the activity aide was assigned to his room because he was experiencing agitation. V2 said V3 should have done an assessment on him to know what his mental status was prior to wheeling him to the dining hall. On April 4, 2023, at 3:32 PM, V11 (NP/Nurse Practitioner) said the fall was the reason he had the laceration and went to the hospital. R1's progress note dated March 14, 2023, at 7:26 PM shows the following: [Power of Attorney] notified staff that [R1] has hallucinated both yesterday and today in addition to an extended crying episode. Requested [urinalysis] be collected due to past histories of [urinary tract infections]. R1's progress note dated March 15, 2023, at 12:34 AM shows the following: Resident laying on the floor. Upon entering the resident's room, writer noted resident to be laying on the floor beside his bed with his blankets. R1's progress note dated March 15, 2023, at 12:42 AM shows the following: [Registered Nurse] notes no injury but does state over the past 3 days has been more confused than usual. 2. On April 4, 2023, at 11:42 AM, R2 was in the dining hall without footrests on her wheelchair. At 3:45 PM, R2 was in her room in her wheelchair without footrests. R2 was self-propelling in her wheelchair using her arms only, while her legs touched the ground while transporting. R2 said she does not really use her legs to transport herself and could not remember her last fall. On April 4, 2023, at 12:02 PM, V8 (CNA/Certified Nurse Assistant) said R2 should have footrests on her wheelchair, but she did not have time to put them on this morning. The facility's accident log documents R2 had a fall from her wheelchair on January 11, 2023 and sustained a skin tear to the right elbow. The EMR shows R2 was admitted to the facility on [DATE], with multiple diagnoses including multiple sclerosis, dementia, polyosteoarthritis, lymphedema, and peripheral vascular disease. R2's MDS dated [DATE], shows R2 has severe cognitive impairment, and requires extensive assistance from one facility staff for locomoting on and off the unit, and personal hygiene. R2 requires extensive assistance from two facility staff members for bed mobility, transferring, dressing, and toileting. R2's Functional Abilities and Goals assessment dated [DATE], documents R2 requires partial/moderate assistance to travel 50 feet in her wheelchair. 3. On April 4, 2023, at 12:20 PM, R4 was being pushed in her wheelchair without footrests by V9 (CNA). V9 transported R4 from R4's room to the beauty salon to retrieve a weight, and then back from the beauty salon to the nurse's station. Surveyor noted the distance was about 150 feet in total. V9 said R4 should have had footrests on while she was pushing her because R4 could put her feet down and fall without the footrests in place. The EMR shows R4 was admitted to the facility on [DATE], with multiple diagnoses including dementia, epilepsy, and a history of falling. R4's MDS dated [DATE], shows R4 has moderate cognitive impairment and requires extensive assistance from one facility staff for bed mobility, transferring, locomoting on and off the unit, dressing, toileting, and personal hygiene. On April 4, 2023, at 1:38 PM, V10 (Director of Rehab) said if a resident is being transported by staff, they should have their footrests on their wheelchair. V10 said not having the footrests on the wheelchair while being pushed by staff could cause the resident to fall. V10 said if R1 was confused, R1's wheelchair should have had footrests on them. V10 also said if a resident cannot use their legs to self-propel, they should have footrests on their wheelchair.

Based on observation, interview, and record review, the facility failed to serve correct portion sizes of Italian Sausage Rotini as shown on the diet spreadsheet for regular and mechanical soft diets. This applies to 4 of 4 residents (R19, R21,R29, R184) reviewed for dining in the sample of 12. The findings include: On 09/12/22 starting at 11:55 AM the lunch meal service was observed in the facility dining room, V8 and V9 (dietary aides) served 2 scoops (4 oz/ounce per scoop, a total of 8 oz) of Italian Sausage Rotini to R29, R21, R19, R184. Diet spread sheet for 9/12/22 (cycle day 2) showed residents on Regular and Mechanical soft diets should receive one and half cup (1-1/2 cups, 12 oz) of Italian Sausage Rotini. On 09/12/22 at 12:53 PM, V7 (Dietitian) stated that the residents on Regular and Mechanical soft consistencies should have received three 4 oz scoops (12 oz) as shown on the diet spreadsheet. Facility Recipe for Pasta Rotini Italian Sausage included portion size 1-1/2 cup Facility Diet Type Report included that R21 and R29 are on Regular diets and R19 and R184 are on Mechanical soft diet.

Based on observation, interview, and record review, the facility failed to follow their policy to obtain a consent when an order was received to increase a [CONDITION(S)] medication dosage. The facility also failed to document targeted behaviors for an as needed [CONDITION(S)] medication. This applies to 1 of 5 residents (R28) reviewed for [CONDITION(S)] medications in a sample of 12. The findings include: R28's EMR (Electronic Medical Record) showed R28 was admitted to the facility on [DATE], with multiple diagnoses including left femur [CONDITION(S)], dementia without behavior disturbance, anxiety disorder, and depression. R28's MDS (Minimum Data Set) dated September 7, 2022, showed R28 was cognitively intact. The MDS continued to show during the review period, R28 did not exhibit behaviors. R28's [CONDITION(S)] medication care plan initiated on June 23, 2022, showed R28 is receiving [MEDICATION(S)] (antianxiety medication) and [MEDICATION(S)] (antidepressant medication), [CONDITION(S)] medication. Noted with behavior or mood issues of restlessness and sadness. The care plan continued to show multiple interventions dated June 24, 2022, including document mood and behaviors as needed as they occur, and obtain informed consent prior to initiation of medication or increase in dosages. On September 12, 2022, at 11:52 AM, R28 was in his room, lying in bed. R28 was calm, cooperative, and behaved appropriately during interaction with surveyor. R28's September 2022 MAR (Medication Administration Record) showed R28 was receiving [MEDICATION(S)] tablet 0.5 mg, give one tablet by mouth every eight hours as needed for agitation/anxiety related to anxiety disorder, ordered September 1, 2022. R28 received as needed doses of [MEDICATION(S)] on September 5, 2022, September 8, 2022, and September 14, 2022. The MAR continued to show R28 was receiving [MEDICATION(S)] 50 mg tablet, give one tablet by mouth one time a day related to depression, ordered September 1, 2022, and discontinued on September 12, 2022. The MAR showed an increase in R28's [MEDICATION(S)] to 100 mg by mouth one time a day related to depression, ordered on September 12, 2022. The MAR continued to show R28 received the [MEDICATION(S)] 100 mg on September 13, 2022, and September 14, 2022. Facility document titled Combined Medication Informed Consent Form: [CONDITION(S)] Medications- Updated 12/2018 dated August 2, 2022, by V2 (DON/Director of Nursing) showed consent was obtained for the following medications: [MEDICATION(S)] 0.5 mg every eight hours as needed, [MEDICATION(S)] 0.5 mg every night, and [MEDICATION(S)] 50 mg once daily. The facility did not have documentation to show consent was obtained for [MEDICATION(S)] 100 mg prior to R28 receiving the increased medication dose. The facility did not have physician documentation to show why the [MEDICATION(S)] dosage was increased. Review of R28's progress notes from September 1, 2022 through September 14, 2022, does not show any documentation of R28 having behaviors. Review of R28's behavior charting from September 1, 2022 to September 14, 2022, does not show R28 was having behaviors prior to receiving the as needed [MEDICATION(S)]. On September 14, 2022, at 9:18 AM, V2 said, Consent should be obtained when there is an increase in a [CONDITION(S)] medication. Consent is obtained prior to giving the increased medication. Facility policy titled, [CONDITION(S)] Medications- Use of, dated September 2020, showed Purpose: To establish a standardized system to inform residents and/or their responsible parties about [CONDITION(S)] medications and their side effects. Policy: 1. A resident will not receive [CONDITION(S)] medications unless behavioral programming and/or environmental changes have failed to sufficiently modify a resident's target behavioral disturbance. A resident will not receive [CONDITION(S)] medications unless such a medication is needed to treat a specific condition and each [CONDITION(S)] medication will be given to treat clearly defined target behaviors. 2. Consistent monitoring of all target behaviors will be done to assist in the assessment of the risks and benefits of psychotherapy drug therapy . Documentation: Prior to the administration of an antipsychotic medication, the following must be documented . 2. Target behaviors will be identified with supporting documentation in the clinical record . 4. Residents who display target behaviors will be identified with supporting documentation in the clinical record . Consent: 1. For each [CONDITION(S)] medication ordered either a verbal or a written consent from the resident or the resident's responsible party will be obtained prior to initiation of the medication. Consent will not be obtained for a dosage decrease . 4. The resident and/or resident's responsible party will be notified regarding any changes in medication dosage; this information will be documented in the resident's medical records.

Based on observation, interview, and record review, the facility failed to follow their policy and ensure a resident had their call light in reach at all times. This applies to 1 of 1 resident (R234) reviewed for call lights in a sample of 12. The findings include: R234's EMR (Electronic Medical Record) showed R234 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Facility documentation titled Medicare/Managed Care Progress Note, dated September 6, 2022, by V14 (LPN/Licensed Practical Nurse) showed R234 was alert and oriented times two to three and able to make needs. R234's ADL (Activities of Daily Living) care plan dated September 6, 2022, showed R234 has and ADL self-care performance deficit. The care plan continued to show multiple interventions dated September 6, 2022, included assist with ADL tasks as needed. R234's fall care plan dated September 6, 2022, showed R234 is at high risk for falls. The care plan continued to show multiple interventions including promote placement of call light within reach. On September 12, 2022, at 11:32 AM, R234's room door was closed and R234 was sitting in her room, in a chair. R234's call light was on R234's bed, 5 feet away from R234, and out of R234's reach. R234 said, I cannot reach my call light. If I need help then I just go to sleep. On September 13, 2022, at 9:09 AM, R234 was sitting in her room, in a chair. R234's call light was on R234's bed, 5 feet away from R234, and out of R234's reach. On September 13, 2022, at 2:45 PM, R234 was sitting in her room, in a chair. R234's call light was on R234's bed, 5 feet away from R234, and out of R234's reach. On September 14, 2022, at 9:14 AM, R234 was sitting in her room, in a chair. R234's call light was on R234's bed, 5 feet away from R234, and out of R234's reach. On September 14, 2022, at 9:23 AM, V2 (DON/Director of Nursing) said, A resident's call light should always be within reach of the resident. On September 14, 2022, at 9:38 AM, V14 (LPN) said, [R234] cannot get out of her chair by herself. If [R234] is in the chair she cannot reach her bed. The facility's policy titled Call Light, Use of dated September 2020, showed, Purpose: 1. To respond promptly to resident's call for assistance. Procedure: 1. All facility personnel must be aware of call lights at all times . 6. Orient all new residents to the call light at the bedside as well as the call light in the bathroom and in the shower or tub rooms. Have the resident demonstrate the use of the call light to be sure he/she understands your instructions. 7. Be sure call lights are placed within resident reach at all times.

Based on observation, interview and record review, the facility failed to follow menu serving portion sizes for pureed lunch meal. This applies to 4 of 4 residents (R6, R24, R28, R31) reviewed for pureed diets in the sample of 12. The findings include: On 03/01/21 at 11:15 AM, V5 (Chef) was observed preparing the pureed meal items for lunch in the facility kitchen. V5 stated that the menu items for the pureed meal included Sloppy Joe on bun, cauliflower instead of coleslaw and mashed potatoes instead of French fries. V5 was noted to prepare all the items stated except the pureed bun. On 03/01/21 at 12:03 PM, V6 (Dietary Aide) was seen platting food on the West wing for the lunch meal service. While serving the pureed meals, V6 used a green colored scoop and plated one scoop of pureed Sloppy Joe meat on the plate. There was no visible portion size marked on the scoop and V6 stated that it was a 3 oz/ounce portion. V6 also used a slotted spoon (about 2 oz portion) to plate the pureed cauliflower and ivory colored scoop to serve the mashed potatoes. R6 and R28 received the above servings for the pureed meal. On 03/01/21 at 12:25 PM, R24 and R31 were seen in the North dining room eating pureed Sloppy Joe meat from a small bowl. R24 and R31 were also served ice cream which was identified as magic cup by V8 CNA (Certified Nursing Assistant). R31 was seen scrapping the bottom of his pureed bowl and magic cup container with a spoon and stated that he would like more food. V8 stated that she had asked for a pureed meal and this was all she received from the server V7 (Dietary Aide). On 03/01/21 at 12:30 PM, V7 was seen finishing up plating foods for East and North wings. V7 stated that he only served one scoop of pureed sloppy Joe meat (using a yellow colored scoop) along with the magic cup to R31 and R24. There was no visible portion marked on the yellow scoop and V7 was not sure what size scoop it was. The mashed potatoes and pureed cauliflower remained untouched in the serving containers in the steam table. V7 stated that he did not serve those items to any of the pureed diets and only serves what the CNA's request for. On 03/02/21 at 9:45 AM, V4 (Registered Dietitian) stated that the dietary staff should have used a #8 scoop (4 oz portion) to serve the pureed Sloppy Joe along with 2 #20 scoops (1.84 oz/scoop) of pureed bread. V4 stated that the menu spread sheets should have been followed as indicated for serving sizes of the menu items. Facility menu spread sheet for Cycle day 2 (which included March 01) showed to serve pureed Sloppy Joe using a #8 scoop and pureed bun using 2 #20 scoops. The same menu also showed to serve 1/2 cup mashed potato and #10 scoop of pureed vegetable of the day. Recipe titled Pureed Sand (sandwich) Sloppy Joe on bun included serving portion sizes of #8 scoop of sandwich filling and 2 #20 scoops of bread. Facility scoop sizes listed the following measures by weight: yellow scoop #20=1.8 oz green scoop #12= 2.90 oz Ivory scoop #10=3.33 oz Gray scoop #8=3.80 oz Facility Diet Type Report included R6, R24, R28, R31 on pureed diets.

Based on observation, interview, and record review the facility failed to ensure that residents' external prescription medications were stored separately from residents' oral prescriptions and failed to store each resident's medications separately. The facility also failed to store insulin according to manufacturer's instructions. This applies to 5 of 12 residents (R4, R16, R28, R34, R138 and R140) reviewed for medication storage. The findings included: 1) On March 3, 2021 at 11:00am, V17 (Registered Nurse) participated in the medication cart review on the east wing. It was noted that residents' oral prescription medications and external prescription medications were stored in the same drawer. This included the following: a) An open container of R140's prescription labeled [MEDICATION NAME] Cream 0.1 mg/gm ([MEDICATION NAME]), with instructions to insert one application vaginally every night shift Monday, Wednesday and Friday- wear gloves when handling, was in the same drawer as the R140's oral medications. b) An open container of R4's prescription labeled, [MEDICATION NAME] 0.1 % Cream with instructions to apply to the resident's back topically every 12 hours as needed, and R4's eyedrops labeled, Refresh Tears 0.5 % Solution, with instructions to instill one drop into each eye every 12 hours as needed were stored together. In addition, R4's medications were stored in the same drawer as R138. c) An open container of R34's prescription labeled, [MEDICATION NAME] Cream 0.1 % , with instructions to apply to behind right ear/neck topically every 12 hours as needed for skin condition. In addition, R34's medications were stored in the same medication drawer as R16. The facility provided their policy, Storage/Labeling/Packaging of Medications (dated March 2018) stated in part, 6. Each resident's medications are kept separately from others. 8. All medications for external use are kept in a separate section from internal-use medications. 2. On 3/03/21 at 10:11 AM, medication room and medication cart inspection were conducted in the West Wing with V14 (Nurse). R28's Insulin [MEDICATION NAME] Flex Pen and [MEDICATION NAME] Flex touched was found stored in the medication cart unlabeled and not dated. V14 was unable to determine if it's used or not and how long it has been stored in the cart. Both of these Insulin pens were in small zippered plastic container with a sign that showed Refrigerate until opened. On 3/03/21 at 12:58 PM, V2 (Director of Nursing/DON) stated, unopened insulin should be stored in the refrigerator and if it's opened it should be labeled and dated of when it was opened. Facility's Policy and Procedure for Prefilled Multi Dose Pens stated: Purpose: To provide for the appropriate use and disposal of injectable packaged by the manufacturer in prefilled multi-dose pens (MDPs). Procedure: 1. If required by the manufacturer, MDPs should be refrigerated until initial use. a. All insulin pens received from the pharmacy should be refrigerated until initial use. Facility provided additional information with regards to the stability of common insulins in vials and pens which showed that at room temperature whether opened or unopened the [MEDICATION NAME] Flex Pen has a lifespan of 42 days while Insulin [MEDICATION NAME] has 28 days.

Based on observation, interview and record review, the facility failed to follow standard infection control practices during provisions of care with regards to glove change, hand hygiene, and storage of hygiene products. This applies to 3 of 6 residents (R6, R19, R88) reviewed for infection control during provisions of care in the sample of 12. The findings include: 1. R88's physician order [REDACTED]. R88 was on contact and droplet precautions. On 3/01/21 at 2:44 PM, V9 (Nurse) changed R88's wound dressing to bilateral feet. V9 did one foot at a time, by removing soiled dressing, cleaning the wounds and applying new dressing while using same gloves all throughout the procedure. V9 did not change gloves nor sanitize hands in between task. 2. On 3/02/21 at 12:56 PM, V12 and V13 (Both Certified Nursing Assistant/CNA) rendered incontinence care to R6 who was wet with urine and had a bowel movement. V13 held and used a spray cleanser multiple times during peri-care while wearing soiled gloves. After completing the peri-care, V13 stored the spray cleanser in R6's bedside drawer without cleaning or sanitizing it. 3. On 3/02/21 at 1:21 PM, V12 and V13 rendered incontinence care to R19 who was wet with urine and had a bowel movement. V12 held and used a spray cleanser multiple times during peri-care while wearing soiled gloves. After completing the peri-care, V12 stored the spray cleanser in R19's closet without cleaning or sanitizing it. On 3/3/21 at 12:58 PM, V2 (Director of Nursing/DON) stated that staff must sanitize hands and change gloves every time the staff worked from dirty to clean task, and before and after the procedure. When using hygienic product such as spray cleanser to clean the resident, the staff must clean or sanitize the product after usage prior to storage to prevent potential contamination. Facility's Hand Washing/Hygiene Policy and Procedure dated 6/4/2020 stated: Purpose: Appropriate hand hygiene is essential in preventing the spread of infectious organism in healthcare settings. Guidelines: Hand hygiene must be performed after touching blood, body fluids, secretions, excretions, and contaminated items.

Based on observation, interview and record review, the facility failed provide peri-care in a manner that would prevent infection. This applies to 2 of 4 (R6, R5) residents observed for bowel and bladder care in the sample of 12. The findings include: 1. On 3/02/21 at 12:56 PM, V12 and V13 (Both Certified Nursing Assistant/CNA) rendered incontinence care to R6 who was wet with urine and had a bowel movement. V13 cleaned R6 from front to back. When V13 completed cleaning R6's rectum and buttocks and was about to apply clean incontinence brief, V12 and V13 noticed that R6 urinated again. Urine trickled down to her upper inner thighs. However, V13 continued to apply A and D ointment and new incontinence brief without cleaning R6's perineum again. 2. On 3/03/21 at 10:35 AM, V10 and V11 (Both CNA) provided incontinence care to R5 who was wet with urine and had a large bowel movement. V10 cleaned R5 from front to back. Then proceeded to apply incontinence brief and stated that she's done cleaning R5 and applied new incontinence brief. Surveyor prompted V10 and V11 to open R5's new brief and re-check the mid perineum which showed the posterior area R5's scrotum was still soiled with fecal matter. R5's list of [DIAGNOSES REDACTED]. On 3/03/21 at 12:58 PM, V2 (Director of Nursing/DON) stated when the staff provides incontinence care they (staff) are expected to ensure a complete peri-care from front to back. When rendering care for male resident the staff must clean the pubic area, abdominal folds, penis, scrotum, groins, rectum and buttocks. For female resident, staff must clean the inner and outer labia, groins, urethra, pubic area, abdominal folds and rectum/buttocks area. If the resident voided again, the staff should clean the resident again before they put a new incontinence brief. This is done to prevent infection. Facility's Policy and Procedure for Perineal Care dated 09/2020 showed: Purpose: To cleanse the perineum, prevent infection and odor, and to maintain skin integrity. Procedure: For female perineal care: - Utilized appropriate cleaning solution or wipe. Separate the labia. Clean downward from front to back with one stroke repeat it again until the area is clean. For male perineal care: - Utilized appropriate cleaning solution or wipe. Wash shaft of penis and scrotum and repeat it until area is clean.

Based on interview and record review, the facility failed to provide safe transfer to a resident requiring extensive assistance from two staff. This applies to 1 of 3 residents (R2) reviewed for fall in the sample of 5. This failure resulted in R2 sustaining acute fracture to the upper end of the right and left tibia after a fall during a one staff manual transfer. The findings include: R2 has multiple [DIAGNOSES REDACTED]. R2's fall risk assessment dated [DATE] and 9/12/20 (post fall) shows that the resident is at risk for fall. R2's quarterly MDS (minimum data set) dated 7/20/20 shows that the resident is severely impaired with cognition. The same MDS shows that R2 would require extensive assistance from two staff during bed mobility and transfer. R2's incident report dated 9/12/20 (6:15 AM) shows, Nurse informed that resident was on the floor in her room. Writer entered room and observed resident lying on the floor by her wheelchair next to her bed with head on a pillow. Per CNA (Certified Nursing Assistant), she attempted to transfer resident from bed to wheelchair when her knees gave out and she was slowly lowered to the floor and did not bump her head. Resident unable to give description. The incident report documented under level of pain shows, Repeated troubled calling out. Loud moaning or groaning. Crying; Facial Grimacing; Rigid, Fist Clenched, Knees pulled up, Pulling or Pushing away. Striking Out; Unable to Console, Distract or Reassure. The incident report has a witness statement which shows in-part, I moved her to the edge of the bed and arranged the bed to be the same height as w/c (wheelchair) and applied the gait belt. She is normally able to bear weight for a moment during pivot transfer. When I stood her up, the gait belt slipped underneath her shirt. I didn't want to pinch her skin, so I did not use the gait belt during the transfer. I attempted to use her pants to stabilize her, but I felt the brief tear and both her knees gave out. I was unable to transfer her, so I held her and slowly lowered her to the floor. Her bottom touched the floor and she did not bump her head. Before leaving the room to get the nurse, I placed a pillow under her head. The same incident report under the notes section shows in-part, Nurse was informed that resident had a witnessed fall. Bilateral knees observed to be swollen with abrasion to right knee without active bleeding. Resident was transferred via extensive assist of two staff and gait belt into w/c and brought to nurse's station for close monitoring. Resident c/o (complained of) pain to ble (both lower extremities), and prn (as needed) [MEDICATION NAME] was administered per (physician) orders. X-rays completed in house confirmed proximal tibial shaft fracture of left and right tibia without displacement. The incident report shows that R2 was sent to the hospital for evaluation and treatment. The facility's final report to the State Agency dated 9/17/20 shows in-part, On September 12, 2020 resident was being pivot transferred with gait belt from bed to wheelchair via assist of one staff. (R2) was weak during the transfer and staff lowered her to the floor. R2's left tibia/fibula x-ray result dated 9/12/20 (completed at the facility) shows, Acute proximal left tibial fracture without displacement. R2's right tibia/fibula x-ray result dated 9/12/20 (completed at the facility) shows, Proximal tibial shaft fracture, similar to left tibia. R2's ADL (activities of daily living) self-care performance deficit care plan effective 7/20/2020 through 9/14/2020 shows multiple interventions which included, Assist with transfers as needed. (R2) requires two-person assistance with transfers. R2's skin integrity care plan initiated on 8/1/2017 with a target date of 10/18/2020 shows multiple interventions which included, (R2) will require the use of two people assistance during transfer due to skin being fragile and limited assistance from (R2) during transfers. On 10/29/20 at 11:00 AM, V2 (Director of Nursing) was asked how the nursing staff would know how much assistance is needed to transfer a resident. V2 stated that each resident has a posting on a board on top of the bed to indicate how much assistance each resident need during transfer. The board on top of R2's bed had a posting of letter T. According to V2, T meant total assistance with transfers. V2 stated that the T posting was placed after R2 returned from the hospital on [DATE], post fall (9/12/20). V2 stated that when R2 had a fall on 9/12/20, there should be a posting on the board above R2's bed of number 2. According to V2, 2 meant two staff assistance during transfers. On 11/4/20 at 10:32 AM, V4 (CNA) stated that on 9/12/20 during the first hour of her shift (started at 6:00 AM), she attempted to assist R2 from bed to the wheelchair without any other staff assistance because the resident normally is able to bear weight during a pivot transfer. According to V4, she took care of R2 before and there are times that the staff (including her (V4)) would transfer R2 with or without assistance from another staff. V4 stated that after she assisted R2 with dressing on the morning 9/12/20, she (V4) applied a gait belt around R2's waist to assist with transfer. V4 stated that when she assisted R2 to stand up, the gait belt started to slip underneath R2's shirt because the resident's shirt was short. To avoid pinching R2's skin, she (V4) moved to the right side of R2 (while still holding on to the gait belt), grabbed the back of R2's pants (back of the waist) with her (V4) left hand to assist with transfer, while using her right hand to hold on to R2's right arm. According to V4 she did not use the gait belt to transfer R2. V4 stated that it was during the middle of the transfer, while holding on to R2's pants (back of the waist) and right arm, that R2's knees gave out (bent forward) and the resident's body started leaning forward. According to V4, it was during this time that she lowered R2 to sit on the floor, then eventually laid the resident on the floor and placed a pillow under the resident's head before calling the nurse. V4 claimed that R2 did not hit her head, her knees, her legs or any part of her body during the attempted transfer. V4 was asked how the nursing staff would know how much assistance is needed to transfer R2. V4 responded, normally there is a posting on the board on top of the resident's bed, but I do not remember if there was one on R2's board. On 11/6/20 at 10:55 AM, V8 (nurse) stated that on 9/12/20 at around 6:15 AM, she was called by V4 to inform her that R2 was on the floor. V8 immediately went to R2's room, saw the resident lying on the floor with a pillow behind her head and R2's wheelchair was by her side. V8 stated that according to V4, she was attempting to transfer R2 from the bed to the wheelchair by herself, but for some reason, R2 was not able to help with the transfer and she (V4) had to lower R2 to the floor, placed a pillow behind the resident's head and call for the nurse (V8). V8 stated that she assessed R2 from head to toe and noted an abrasion on the resident's right knee and a small lump/swelling on both knees. According to V8 during her assessment of R2, the resident did not complain of pain however, R2 was very anxious, nervous, with facial grimacing, and occasional moaning and groaning. V8 stated that R2 was able to move her upper extremities without pain or limitation and when her lower extremities are being moved, she would start to moan, groan and show facial grimacing. According to V8, she gave R2 a pain medication which calmed the resident. However, after about 30 minutes she noticed that the swelling on R2's bilateral knees increased in size. V8 stated that since the incident was close to the change of shift, the morning shift nurse contacted the physician and obtained the order for the x-ray. On 11/4/20 at 10:39 AM, V5 (Physician) stated that with regards to R2's transfer assistance (such as how many and what device should be used during the transfer), he would like the facility to refer to R2's plan of care to ensure proper and safe transfer. The facility's policy and procedure regarding gait belt/transfer belt dated 9/2020 shows that, To assist with a transfer or ambulation. A gait belt will be used with weight-bearing residents who require hands on assistance.

Based on interview and record review, the facility failed to follow the physician's orders for the use of a slide board during resident transfer from the bed to wheelchair. This failure resulted in R1 sustaining a right tibia and fibula fracture. This applies to 1 of 3 residents (R1) reviewed for falls with injury in the sample of 3. The findings include: On (MONTH) 13, (YEAR), V3 (RN-Registered Nurse) documented: Caregiver and writer attempted to transfer (R1) from the bed to wheelchair using gait belt and lateral transfer at approximately 11:10 AM. First (R1) was positioned on the side of the bed for proper balance. While transferring patient from the side of the bed into the wheelchair, patient became unsteady and stumbled over her feet. Writer and caregiver then eased (R1) down to the floor due to weakness and inability to bear full weight on legs. Knees started buckling and (R1) missed the wheelchair seat. V8's (Physician) documentation dated (MONTH) 14, (YEAR) shows R1 sustained a right lower extremity non-displaced acute tibia/fibula fracture. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on (MONTH) 1, (YEAR) with multiple [DIAGNOSES REDACTED]. The EMR shows R1 discharged to the local hospital on (MONTH) 13, (YEAR) following her fall, and returned to the facility on (MONTH) 21, (YEAR). R1 was discharged from the facility on (MONTH) 2, (YEAR) to a different facility. R1's MDS (Minimum Data Set) dated (MONTH) 8, (YEAR) shows R1 had severe cognitive impairment, required extensive to total assistance with all ADLs (Activities of Daily Living), and was always incontinent of bowel and bladder. The MDS showed R1 had a functional deficit in range of motion of the bilateral upper and lower extremities. The EMR showed the following order dated (MONTH) 2, (YEAR): Two person slide board transfer from bed/wheelchair. On (MONTH) 15, (YEAR) at 12:12 PM, V4 (Caregiver) said, (R1) required the assistance of two people for transfers because she was non-weight bearing. She cannot stand, she cannot walk. (V3) (RN) came into the room to help me. I applied a gait belt to the resident, and we attempted to do a stand and pivot transfer of the resident. I assumed the nurse knew the patient, but it didn't seem like the nurse knew the resident couldn't stand. As soon as we started the transfer, I could tell we weren't going to be able to transfer the resident. The gait belt was too high, and the resident couldn't help us. I told the nurse we had to put her back down on the bed, but the nurse insisted we continue with the transfer. We had to lower her to the floor because we couldn't hold her up, and she ended up on the floor on her knees. (V3) said to me that she didn't know the resident couldn't stand. I am not her usual caregiver. I had never transferred the resident before that day. The nurse told me she had never transferred the resident prior to that day. We did not use the slide board for the transfer the day of the fall. On (MONTH) 15, (YEAR) at 1:51 PM, V3 (RN) said, On (MONTH) 13, the caregiver pressed the call light and asked for help to transfer (R1) from the bed to the wheelchair. We attempted to transfer the resident from the bed to the wheelchair with the gait belt. Both of us were holding the gait belt. The resident became weak, so I decided to lower her down to the floor. Her knee was bent when we lowered her. I asked the caregiver prior to the transfer, and she said the resident could not bear weight on her legs at all. I float a lot at the facility, so I haven't taken care of this resident often. I looked at the nurse-to-nurse report and it showed to use a slide board for transfers for this resident. I did not see the slide board in the room. I know she had a physician order to use the slide board and two people for transfers. On (MONTH) 19, (YEAR) at 11:35 AM, V7 (RCC-Resident Care Coordinator) said, The way facility staff find out how to transfer a resident is to look at the physician orders. Transfer orders are put on the POS (Physician Order Sheet). Staff should follow the transfer orders on the POS. On (MONTH) 19, (YEAR) at 12:00 PM, V8 (Physician) said, It would be my expectation that facility staff followed my orders and should have used a slide board for (R1's) transfer. They should not have transferred her using a gait belt. This failure resulted in the resident's right leg fracture. Even if the resident had a pressure sore on her coccyx, they should have used the slide board for transferring the resident. They should have followed my order. The facility's Transfer Techniques Policy dated (MONTH) (YEAR) shows: Purpose: To safely transfer the resident from bed to chair or from one location to another. Equipment: 1. Appropriate type and size of wheelchair. 2. Mechanical lift, if necessary. 3. Physical devices to assist with transfer (i.e. sliding boards, belts, spin disc, etc.).