Every finding on record at Avera Eureka Health Care Center

Based on record review, interview, and policy review, the provider failed to ensure the code status (emergent treatment a person wishes to receive if their heart or breathing would stop) for ten of ten sampled residents (5, 6, 7, 8, 12, 22, 31, 39, 40, and 45) was documented in the residents' electronic medical records (EMR). Findings include: 1. Review of resident 7's EMR revealed she admitted to the facility on [DATE]. Her 4/24/26 Minimum Data Set (MDS) assessment indicated that she was rarely understood or able to understand others and was severely cognitively impaired. There was no documentation indicating that any advance directive (a document that expresses a person's health care wishes if they become unable to speak for themselves) paperwork was completed upon admission. A copy of her Durable Power of Attorney (someone designated on a legal document to act on behalf of a resident) was scanned into the Meditech EMR, but it did not address her code status. A 5/18/26 physician's order indicated her code status was DNR/DNI. There was no physician documentation supporting that code status order or indicating that her wishes were discussed with the resident or the resident's representative. 2. Review of resident 8's EMR revealed she admitted to the facility on [DATE]. Her 3/27/26 Brief Interview of Mental Status (BIMS) assessment score was 15, which indicated her cognition was intact. There was no documentation indicating that any advance directive paperwork was completed upon admission. A 5/18/26 physician's order indicated her code status was DNR/DNI. There was no physician documentation supporting that code status order or indicating that her wishes were discussed with the resident or her representative. 3. Review of resident 22's EMR revealed he admitted to the facility on [DATE]. His 4/6/26 BIMS assessment score was 00, which indicated his cognition was severely impaired. A 5/18/26 physician's order indicated his code status was DNR/DNI. There was no completed code status form in his EMR to indicate his wishes if his heart or breathing stopped. There was no documentation in his EMR that his wishes were reviewed with him or his representative. 4. Review of resident 40's EMR revealed he admitted to the facility on [DATE]. His 6/12/26 BIMS assessment score was 11, which indicated his cognition was moderately impaired. A 5/18/26 physician's order indicated his code status was DNR/DNI. There was no completed code status form in his EMR to indicate his wishes if his heart or breathing stopped. There was no documentation in his EMR that his wishes were reviewed with him or his representative. 5. Review of resident 12's EMR revealed he admitted to the facility on [DATE]. His 6/12/26 BIMS assessment score was 00, which indicated his cognition was severely impaired. A 5/18/26 physician's order indicated his code status was DNR/DNI. There was no completed code status form in his EMR to indicate his wishes if his heart or breathing stopped. There was no documentation in his EMR that his wishes were reviewed with him or his representative. 6. Review of resident 39's EMR revealed he admitted to the facility on [DATE]. His 6/12/26 BIMS score was 5, which indicated his cognition was severely impaired. A 5/18/26 physician's order indicated his code status was DNR/DNI. There was no completed code status form in his EMR to indicate his wishes if his heart or breathing stopped. There was no documentation in his EMR that his wishes were reviewed with him or his representative. 7. Review of resident 6's EMR revealed he admitted to the facility on [DATE]. His 3/10/26 BIMS assessment score was 00, which indicated his cognition was severely impaired. A 5/18/26 physician's order indicated his code status was DNR/DNI. Her EMR banner indicated her code status was DNR/DNI. His 7/13/20 Durable Power of Attorney indicated, I direct that life-prolonging treatment be withheld or withdrawn and that I be permitted to die naturally if two physician's certify that: (a) I am in a terminal condition that is an incurable or irreversible condition which, without the administration of life-prolonging treatment, will result in imminent death; (b) The application of life-prolonging treatment would serve only to artificially prolong the process of my dying; and It is my intention that this declaration be honored by my family and physicians as the final expression of my legal right to refuse medical or surgical treatment and that they accept the consequences of that refusal, which is death. There was no documentation in resident 6's EMR to indicate that two physicians had certified his condition to be terminal or incurable. 8. Review of resident 5's EMR revealed he admitted to the facility on [DATE]. His 5/12/26 BIMS assessment score was 14, which indicated his cognition was intact. A 5/18/26 physician's order indicated his code status was to be a full code (all resuscitation measures were to be implemented). His EMR banner indicated his code status was to be full code. There was no completed code status form in his EMR to indicate his wishes if his heart or breathing stopped. There was no documentation in his EMR that his wishes were reviewed with him or his representative. 9. Review of resident 31's EMR revealed she admitted to the facility on [DATE]. Her 4/7/26 BIMS assessment score was 00, which indicated her cognition was severely impaired. A 5/18/26 physician's order indicated her code status was DNR/DNI. Her EMR banner indicated her code status was DNR/DNI. Her 2/10/18 Living Will indicated, Provide life-sustaining treatment only if I have detectable brain activity, and there is a reasonable possibility of restoring to me the ability to thinks and act for myself. If my heart stops, provide restoration treatment until there is no hope of regaining a heartbeat. There was no documentation in her EMR that her wishes had changed since she signed her Living Will on 2/10/18. 10. Review of resident 45's EMR revealed she admitted to the facility on [DATE]. Her 4/7/26 BIMS assessment score was 0, which indicated her cognition was severely impaired. A 5/18/26 physician's order indicated her code status was DNR/DNI. There was no completed code status form in her EMR to indicate her wishes if her heart or breathing stopped. There was no documentation in her EMR that her wishes were reviewed with her or her representative. 11. Interview on 6/11/26 with director of nursing (DON) B revealed there was no documentation in residents' 5, 6, 7, 8, 12, 22 31, 39, and 45 EMRs to support their code status that was indicated on their EMR banners were discussed with that resident or the resident's representative to be sure the resident's wishes would be followed if their heart or breathing stopped. The provider did not have documentation that two physicians had certified that resident 6 had a terminal condition that was incurable or irreversible, as his Durable Power of Attorney indicated was his wish. She acknowledged that the staff could not determine if resident 31 had brain activity, or if there was a reasonable possibility of restoring her to the ability to think or act by herself when her breathing or her heart stopped as her Living Will stated was her wish. 12. Review of the provider's October 2025 Code Status/Resuscitation policy revealed that when a resuscitation decision has been made, the physician was responsible for documenting in the chart the rationale supporting the physician's order for resuscitation status. The physician also must document the risks, benefits, and choices that were discussed with the resident and with the family.

Based on observation, interview, record review, and policy review, the provider failed to ensure the manufacturer's instructions were followed for the installation of assistive devices ( T Shaped poles attached to the residents' bed frames to be used for bed mobility) to the residents' beds, alternatives to the assistive devices were attempted before the assistive devices were installed, and the date of installation was documented for nine of nine sampled residents (1, 9, 10, 32, 34, 35, 36, 43, and 47), a physician's order was obtained before the installation of the assistive device for five of nine sampled residents (1, 9, 32, 34, and 47), a safety assessment was completed for four of nine sampled residents (1, 9, 34, and 35), and informed consent was obtained for the use of the assistive device for two of nine sampled residents (9 and 34) who had assistive devices on their beds.Findings include:1. Observation and interview on 6/9/26 at 10:03 a.m. with resident 9 in her room revealed that she had an assistive device attached to the right side of her bed, which she used to reposition herself in bed. She was unsure whether she was educated about the risks and benefits of the assistive device. Review of resident 9's electronic medical record (EMR) revealed she admitted to the facility on [DATE]. There was no documentation of prior interventions attempted before her assistive device was installed, a signed consent, a physician's order for the use of the assistive device, or a quarterly assessment completed to assess her safe use of the assistive device. There was no documentation of the date the assistive device was applied to her bed. 2. Observation on 6/9/26 at 10:04 a.m. in resident 34's room revealed she had an assistive device attached to the left side of her bed. Review of resident 34's EMR revealed she admitted to the facility on [DATE]. There was no documentation of prior interventions attempted before her assistive device was installed, a signed consent, a physician's order for the use of the assistive device, or a safety assessment completed to assess her safe use of the assistive device. There was no documentation of the date the assistive device was applied to her bed. 3. Observation on 6/9/26 at 10:24 a.m. in resident 35's room revealed there was an assistive device attached to the left side of his bed. Review of resident 35's EMR revealed that he admitted to the facility on [DATE]. There was no documentation of prior interventions attempted before his assistive device was installed, nor of a safety assessment completed to evaluate his safe use of the device. There was no documentation of the date the assistive device was applied to his bed. 4. Observation on 6/9/26 at 10:38 a.m. in resident 43's room revealed that she had mobility bars on the left and the right side of her bed. The bed rail was attached to the bottom of the bed frame with a pole coming up vertically from that bed frame. The vertical pole had a horizontal pole on it to make a T shape. The right vertical bar had a gap of 30 inches from the head of her bed to that vertical pole, while the left vertical bar had a gap of 23.5 inches from the head of her bed to that vertical pole. The right horizontal bar had a gap of 6 inches from the top of the mattress to the bar while the left horizontal bar's gap was 7 inches. Review of resident 43's electronic medical record (EMR) revealed that she was admitted on [DATE]. She had a 7/22/22 physician's order for the bed rail. She had signed consent for placement of the bar on 11/22/22 and that consent listed risks and benefits of bed rail use. The provider could not provide documentation that alternatives were tried before use of the bed rail, an entrapment risk assessment was completed, or the date that the bed rail was applied. 5. Observation on 6/9/26 at 10:38 a.m. in resident 10's room revealed that she had mobility bars on both sides of her bed. The gap from the head of the bed to the vertical bar on the right side of her bed was 29 inches. That bed rail had a gap of 9 inches from the top of her mattress to the vertical rail. The bed rail was able to move 3 inches when it was shaken from the direction of the top of the bed to the foot of the bed. From side to side, that rail was able to move 1.5 inches. Review of resident 10's EMR revealed that she was admitted on [DATE]. She had a 7/29/22 physician's order for the bed rail. She had signed a consent for the placement of the bar on 11/22/22. That consent listed risks and benefits. The provider could not provide documentation that alternatives were tried before use of the bed rail, an entrapment risk assessment was completed, or the date that the bed rail was applied. 6. Observation and interview on 6/9/26 at 3:11 p.m. with resident 1 in his room revealed he had assistive devices attached on both sides of his bed, which he used to get in and out of bed. Review of resident 1's EMR revealed that he admitted to the facility on [DATE]. There was no documentation of prior interventions attempted before the assistive devices were installed, no physician's order for the use of the assistive devices, and no safety assessment was completed to evaluate his safe use of the device. There was no documentation of the date the assistive devices were applied to his bed. 7. Observation and interview on 6/9/26 at 4:01 p.m. in resident 36's room revealed that she had a bed rail on the right side of her bed that she used to get her from a seated to a standing position. She could not recall if she had been assessed or educated on the use of those bed rails. Review of resident 36's EMR revealed that she was admitted on [DATE]. She had a Brief Interview for Mental Status (BIMS) assessment score of 15, which indicated that her cognition was intact. She had a 2/7/23 provider's order for the use of a mobility device, with the comment assist pole to the right side of bed to assist with bed mobility. The provider could not provide documentation that alternatives were tried before use of the assistive device, or the date that the assistive device was applied. 8. Review of resident 47's EMR revealed that she was admitted on [DATE]. She had a 10/2/25 nursing note that indicated that she had requested a nurse apply an assistive device for help with mobility in bed. The note indicated that a consent was signed for a left bed assistive device. The provider could not provide documentation that alternatives were tried before the assistive device was installed, a physician's order for use of an assistive device, or the date that the assistive device was installed on her bed. 9. Review of resident 32's EMR revealed that he was admitted on [DATE]. He had a signed consent for the use of a left assistive device on 9/8/23 that listed the risks and benefits of having an assistive device attached to the bed. The provider could not provide documentation that alternatives were tried before use of the assistive device, a signed physician's order for the device, or the date that the device was installed on his bed. 10. Interview on 6/11/26 at 10:46 a.m. with licensed practical nurse (LPN) E regarding resident assistive devices revealed that the nursing staff was responsible for obtaining the resident's consent, going over risks and benefits, assessing the safety risk, documenting alternatives, and obtaining a physician's order prior to a resident getting an assistive device installed on their bed. She was aware that some of the assistive devices were able to move and that they were not supposed to move. If they moved, nursing was expected to put in a work order for the maintenance staff to assess the assistive device. She was also aware that some of the residents' assistive devices were able to be lifted off the bed mount. She could not recall if staff received any education regarding the new assistive devices because they were purchased and applied several years ago. 11. Interview on 6/11/26 at 2:50 p.m. with facilities coordinator I revealed that he would get the approval from director of nursing (DON) B before applying an assistive device to a resident's bed. He did not like the mount that came with that assistive device to mount it to the resident's bed securely, so he made his own mount bracket to apply the bar to the resident's bed. The nursing staff performed the safety assessments. He was aware that the assistive devices were able to be moved in different positions depending on the resident's physical needs. He was not aware that some of the assistive devices were able to be lifted completely off the mount that kept them attached to the resident's bed. 12. Interview on 6/11/26 at 4:21 p.m. with DON B revealed that she was not aware that the current assistive devices were not compatible with the resident's current bed frames per the manufacturer's manual. She agreed this could cause a risk for entrapment. She agreed that there was no documentation that alternatives were attempted before applying the bed rails for any of the current residents with those bed rails. She could not provide documentation of the date that the bedrails were applied to the beds for residents 1, 9, 10, 32, 34, 35, 36, 43, and 47. 13. Review of the provider's April 2026 Physical Restrain/Bed Mobility Device policy revealed that gaps or widths between handles on devices must be less than 4 ¾ inches. When considering if a resident was appropriate for use of a bed rail, the least restrictive method will be tried first and the results documented. The policy also stated that bed mobility devices will not be offered as part of routine care and family or surrogates of [the] resident may not request [a] bed mobility device. A physician's order must be obtained for the use of the bed mobility device, and that device must be in the care plan, reviewed quarterly by the interdisciplinary team, and documented on the usage every shift. 14. Review of the 2012 Invacare CS Series Beds User Manual stated to only use Invacare rails.and other accessories with Invacare bed products and that the use of non-Invacare bed accessories may result in injury or death. In the bedrail entrapment risk notification section of the user manual, a bullet point read, Invacare homecare beds are specifically designed and manufactured for use in conjunction with Invacare accessories, including bed rails. The end of this section in the user manual noted that use of other manufacturer's products in conjunction with an Invacare homecare bed may significantly increase the risk of entrapment; as such Invacare does not recommend their use. 15. Review of the ER100 Bedside Balance Assist Rail installation instructions revealed that incorrect installation or incorrect use of ER100 can result in serious injury or death.

Based on observation, interview, and policy review, the provider failed to ensure one of one walk-in refrigerators were free from rust on the metal wire storage shelf that had flaked off and landed on the uncovered raw vegetables that were stored on that metal wire shelf. Findings include:1. Observation on 6/9/26 at 9:53 a.m. in the kitchen walk-in refrigerator revealed four metal wire shelves. The metal shelves had started to rust, and some rust flakes were on the floor. The bottom metal wire shelf had several cardboard boxes of raw vegetables including a box of onions with rust flakes. 2. Interview with food service manager J on 6/10/26 at 1:56 p.m. revealed he was aware of the rust on the metal wire shelves in the walk-in refrigerator. He stated that the rust can flake off those metal wire shelves and potentially land on uncovered raw foods such as vegetables. If the rust were to land on a vegetable like a broccoli stalk, then he would not be able to clean off the rust flakes, and they could potentially end up in the residents' meals. 3. Review of the provider's September 2025 Standard Food Storage Guidelines revealed that food storage areas should be clean to prevent contamination and illness to the residents.

Based on observation, interview, record review, and policy review the provider failed to thoroughly assess for nutritional needs that included use of built up silverware, consistently implement, monitor, make care intervention revisions, notify the physician timely of unplanned weight loss; and ensure licensed nursing staff were aware of the reweigh policy and physician notification policy and all licensed nursing and dietary staff were aware of the enhanced food program for one of one sampled resident (43) at nutritional risk and with significant weight loss. Findings include: 1. Observation on 2/10/25 at 5:08 p.m. of resident 43 in the dining room revealed: *He propelled his wheelchair into the dining room by using his feet. *He was thin and had loose skin on his arms. 2. Observations on 2/11/25 at 11:05 a.m. of resident 43 in the dining room revealed: *At 11:05 a.m. he was eating his dessert and spilled some of it on the table. -He bent his head down and licked the dessert from the table. *At 11:07 a.m. he left the dining room before the remainder of his meal was brought to him. -At 11:08 a.m. a staff member returned him to the dining room, and his meal was brought to him. *A portion of his meal was a piece of sausage with a casing around it. -When he attempted to cut the sausage with a knife and fork, his plate slid back and forth on the table. -He placed the knife and fork on the table and pushed the plate across the table away from himself. -A few minutes later he pulled the plate towards himself and started to eat with his fingers. *He then picked up his knife and fork. They slipped from his hands, and fell on the floor. *He again pushed the plate of food across the table. *A staff member picked up the silverware from the floor, asked him if he was done eating, and then brought him clean silverware. *He thanked the staff member for the silverware, drank some water and started coughing. *The staff member did not assist him with bringing the plate back to his side of the table. *He then left the dining room without finishing his meal. *He had eaten the sausage, approximately 50 percent of his dessert, and two-thirds of a glass of water. There were no other fluids provided to him to drink. 3. Observation on 2/12/25 at 4:39 p.m. of the dining room revealed: *Resident 43 was not in the dining room. -His place at the table had a glass of orange juice, a bowl of peaches, and plastic container of orange Sherbet. 4. Observation and interview on 2/13/25 at 8:16 a.m. with resident 43 revealed: *He was in the dining room, seated at a table, with a clothing protector on. -No drinks or food were at his place at the table. -He stated the food is alright. 5. Observation on 2/13/25 at 8:20 a.m. of resident 43's place in the dining room revealed: *He was not at the table. *A glass of orange juice, toast, an egg, a banana, and a bowl of Cheerios was at his place at the table -No other drinks had been provided with his meal. 6. Review of resident 43's electronic medical record (EMR) revealed: *He was admitted on [DATE]. *His Brief Interview of Mental Status (BIMS) assessment score was a 10, which indicated he had mild cognitive impairment. *His diagnoses included: Dupuytren's contracture (a condition that causes the fingers to curl and become permanently bent) in both of his hands, anorexia, chronic kidney disease, diabetes, and Alzheimer's Dementia. *On 7/28/24 his hospital record provided to the facility indicated that occupational therapy (OT) was to evaluate his need for adaptive silverware. *His 7/30/24 admission orders included: Pt [patient] would benefit from PT [physical therapy]/OT. Review of resident 43's 2/12/25 care plan revealed: *He was independent with eating. -Staff were to provide setup assistance or assistance of one staff member with eating as needed. *His nutritional status focus area included: he had weakness of right shoulder, Dupuytren's contracture to both hands, diabetes, chronic kidney disease, and Functional limitations noted to UE [Upper Extremity]. -The outcome for that focus area included his weight will remain between 130 lbs [pounds] - 140 lbs. -His nutrition interventions included: --Carbohydrate Consistent Diet. --Apple juice, orange juice, and a banana with all meals. --Resident 43 is provided 3 meals and Siesta and HS [hour of sleep] snacks during nutrition pass daily, takes ice cream with boost [supplement] PRN [as needed] at HS snack. Review of resident 43's documented weights record revealed: *On 8/20/24 he weighed 134 pounds (lbs) and 8 ounces (oz). *On 9/24/24 he weighed 133 lbs. and 8 oz. *On 10/22/24 he weighed 127 lbs. and 5 oz. *On 11/19/24 he weighed 128 lbs. and 8 oz. *On 12/3/24 he weighed 125 lbs. *On 12/10/24 he weighed 121 lbs. *On 12/17/24 he refused to be weighed. *On 12/24/24 he weighed 119 lbs. and 8 oz. -That was a weight loss of 7 percent from 11/19/24 to 12/24/24 and considered a significant weight loss. *On 12/31/24 he weighed 117 lbs. *On 1/7/25 he weighed 117 lbs. Review of resident 43's registered dietitian (RD) nutrition notes revealed: *On 8/7/24 his admission nutrition assessment was completed by the RD and indicated: -He had unplanned weight loss in 2024. -Was hospitalized on [DATE] after a fall at home. -His diagnoses included: urinary tract infection, dehydration, weakness, chronic kidney disease, and diabetes. -He had bilateral hand contractures. -His weight was 134 lbs 5 oz. which was down from 148 lbs in July (2024). -His diet was a constant carbohydrate diet, he had no eating problems documented, and his own teeth were in good repair. *On 1/10/25 the RD note indicated: Alerted to resident's unplanned weight loss in [the] past month. Weight declined from 138-147 [lbs] per variety of scales at July admission to near 130 lbs in Oct/Nov. December weight declined current 117 [lbs.]- no eating dental problems 57% nursing intake records. he notified [medical doctor name] [on] 1/8/25 documentation that he had no appetite and she recommended adding daily chocolate BOOST supplement added Enhanced Food Program and daily Glucose Control BOOST at meals. Will review weight monthly. resident at risk for malnutrition. *On 2/5/25 the RD note indicated: nutrition status is moderately compromised with unplanned weight loss in 2024. Weight improved to 119 lbs from 117 lbs on 2/4/25 Some refusal of supplements. Mirtazapine [an antidepressant that my increase appetite] ordered 1/23/25. Review of resident 43's physician progress notes revealed: *On 1/8/25 the note indicated, Due to his weight loss, he was encourage to participate in all meals and will be started on chocolate boost. *Patient had significant weight loss with weight down to 117 pounds. He says he just has no appetite. *On 1/23/25 the note indicated, Patient continues to have anorexia and slightly depressed mood. He was started on supplemental nutrition and has gained 2 pounds with weight still low at 117 pounds. We will begin mirtazapine 15 mg [milligrams] nightly to see if this will help improve his appetite. Review of resident 43's nurses notes revealed: *On 1/7/25 Resident needs reminders to come out for meals. He does come out at times and then will go back to his room because he doesn't wait. Resident does eat well when he comes out. Reminders given at all meals to come out to eat. *On 2/6/25 Resident refusing to eat all day. Would come out for meals but then go back to his room. He will yell out if you try to get him to stay in the dining room to eat. 7. Record review and Interview on 2/12/25 at 3:53 p.m. with director of nursing B regarding resident 43's weight loss revealed: *She confirmed his 7/28/24 hospital discharge summary included the hospital's RD had recommended an OT consultation for adaptive eating devices, OT consult was ordered. -She stated an OT consultation was not completed as there was no occupational therapist available to complete the assessment. *Resident 43 was an avid organic farmer, and they had tried interventions of fresh fruits and vegetables. *When he did not come to the dining room for meals, they had attempted meal tray service in his room. -They had not provided meal tray service in his room since he had dumped his soup in the trashcan. 8. Interview on 2/13/25 at 8:31 a.m. with certified nursing assistant (CNA) R regarding obtaining residents weight revealed: *CNA's would weigh the residents. -If a resident had more than a three pounds weight loss, she would notify the nurse. -The nurse would decide what to do with that information. 9. Interview on 02/13/25 09:29 AM with registered nurse (RN) E regarding weighing of residents revealed: *All residents were to be weighed weekly, after their bath. -If a resident refused a bath, they were to have a bath within a week and would be weighed at that time. *If a resident had more than a five pound weight loss, the CNA was to reweigh them, or the nurse was to ask the CNA to reweigh them. -The second weight would not be recorded if it was the same as the first weight taken. *Resident 43 was to be weighed on a weekly basis. -She felt his weight had dropped steadily over time. *The provider had an enhanced food program that included the addition of fats and other items to food to increase the calories. -She was not sure if resident 43 was on an enhanced food program. *Weight loss would be reviewed during residents' care conferences, and the interdisciplinary team (IDT) would discuss what would be best for the resident with the weight loss. *The RD reviewed and made recommendations related to residents with weight loss and the IDT would follow those recommendations. 10. Follow-up interview on 2/13/25 at 10:14 a.m. with RN E regarding physician notification of a resident's weight loss revealed: *They should have a process of who was to notify the physician of a resident's weight loss related to refusals to eat. -She was not certain who would have been responsible for notifying the physician of resident 43's weight loss. -The weight loss notification was probably done on rounds (when the physician routinely reviews the resident's condition and their medical needs). *If a resident's weight loss may be related to a cardiac issue the nurse would notify the physician immediately. 11. Interview and review of resident 43's diet card on 02/13/25 at 9:34 a.m. with cook G revealed: *Resident 43 was diabetic, and his physician ordered diet was Carbohydrate Consistent Diet. *The areas for adaptive and feeding ability were blank. *He was to be offered a banana at every meal. -She just knows this; it was not on his diet card. *He was not receiving dietary supplements due to his refusals of them. *He was offered bananas and oranges, at times, as he would eat them. *She was not certain if he was on an enhanced food program. -She stated the enhanced food program included serving the resident foods with extra butter on vegetables, and extra cheese, milk, whipped toppings, and potatoes. -The current enhanced food program resident listing located in the kitchen did not include resident 43. 12. Interview on 2/13/25 at 10:38 a.m. with administrator A regarding resident weight loss revealed she: *Would have expected someone to assist resident 43 with cutting up his food. *Confirmed resident 43 had lost nine pounds between November and December that was a significant weight loss. *Confirmed the occupational therapist was not available to complete an OT evaluation for resident 43's need for adaptive silverware. *Stated the physician was only available for two half days each week. -A message would be left for the physician and the physician would enter a note in the resident's EMR when she received the message. *Would have expected the provider's policies to be followed by the staff. 13. Review of provider's 9/24 revised Weight and Weight Changes policy revealed: *Significant weight changes will be monitored by the LTC Weight Report and will be addressed by the Dietitian and Nutritional Risk Team. The Nutritional Risk Team will consist of the Dietitian, Dietary Manager, Resident Care Coordinator (s) Safety/Quality, IDT members that assist with feeding Residents and the Director of Nursing. *Each resident will be weighed at least monthly or more frequently (weekly or daily) per physician's order, nursing or dietitian recommendation. *Re-weight will be obtained if there is a weight change of 3 pounds or greater from prior weight. Re-weight will occur the next day. *Significant Interval % of Weight Change -1 month 5% -3 months 7.5% -6 months 10% *The LTC Weight Report will be run weekly. The dietitian and Resident Care Coordinator will reassess residents with a significant weight change. Appropriate recommendations will be documented in the medical record and Care Plan Updated. *Residents with significant weight change should be monitored by the Nutritional Risk Team, for Nutrition Risk. *Reweigh resident the next day if there is a 3# weight difference (greater or less) than prior weight. *In the event of significant weight loss, the resident's physician shall be notified by the Nurse or Resident Care Coordinator. *Review dining room seating and environment. Identify if resident needs increased assistance at meals. Contact Occupational therapy if needed. *Offer supplements or nourishments between meals. 14. Review of the provider's July 2023 Change in a Resident's Condition or Status policy revealed: *Our facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's condition and/or status. *The Charge Nurse will notify the resident's attending physician when: -There is a significant change in the resident's physical, mental or psychosocial status. -There is a need to alter the resident's treatment significantly. -Deemed necessary or appropriate in the best interest of the resident. *The Charge Nurse will record in the resident's medical record any changes in the resident's medical condition or status.

Based on observation, interview, record review, and policy review the provider failed to ensure: *Items were not stored under the food preparation sink in one of one kitchen. *Documentation was completed for the cleaning and sanitation of one of one dishwasher. *A process was in place to test and document sanitation levels in sanitation buckets for one of one kitchen. *Refrigerator and freezer temperatures were documented for two of two refrigerators and two of two freezers in one of one kitchen. *Food temperatures were measured prior to serving by one of one cook (G) and documented. *Proper food handling processes were in place for four of four observed certified nursing assistants (CNA M, N, O, and Q) and two of two dietary staff (K, and L) during two of two observed meal services. *Refrigerators had daily temperature documentation completed for seven of seven resident refrigerators(37, 31, 45, 7, 14, 45, and 51) and one of one activity department refrigerator expired food was removed. Findings include: 1. Observation on [DATE] at 3:53 p.m. of the kitchen revealed: *Under the sink labeled Food Preparation sink were two cabinets. *One cabinet contained the following items: -A green bucket with an unknown black liquid in it. -A silver round pie plate with rust present on the surface. -A flat square metal instrument with a blue handle. -A box of griddle polishing pads stored in corrugated cardboard. -Three plastic fly swatters. -A corrugated cardboard box with ten cc (cubic centimeter) syringes. -A silver squeegee with a black handle. *The second cabinet contained the following items: -Potato press to make fries. -Four small frying pans. -A donut dispenser. -Two large saucepans. -Three small saucepans. -Two pan lids. -A grill cleaning brick. -A square metal dish. -A metal cylinder with multiple holes on the sides and a rod in the center. -A squeegee handle. *On the counter there was a white three-ring binder with tabs labeled for each month. *Under the monthly tabs were: -The dishwasher chemical log. -The dishwasher cleaning log. -The freezer and refrigerator temperature log. -The daily temperature for food log. -The walk-in refrigerator and freezer temperature log. Interview on [DATE] at 4:18 p.m. with food service manager C revealed the items stored under the sink were items used in the kitchen where residents' food was prepared. 2. Observation on [DATE] at 3:48 p.m. of the dishwasher revealed it was a chemical dishwasher. Review of the provider's [DATE] dishwasher chemical log revealed: *The dishwasher chemical log had a column to document the PPM (parts per million) sanitizer concentration. *This log did not include a column to document dishwasher temperature. *There were 13 days without documented chemical concentrations. *There was no chemical concentration documentation from [DATE]th through [DATE]th. Review of the provider's [DATE] dishwasher cleaning log revealed: *There were 12 days of missing documentation in January. *There was no cleaning documented for [DATE]th through [DATE]th. 3. Observation on [DATE] at 4:00 p.m. of the three-compartment sink in the kitchen revealed: *There are multiple buckets with liquid and a cloth in them. *There was no documentation of the liquid's chemical concentration. Interview on [DATE] at 4:04 p.m. with cook I revealed: *Those buckets were sanitation buckets used to wipe surfaces. *The chemical concentration was tested when the liquid was changed, but there was no documentation log. *He indicated the sanitation buckets were changed every hour. Observation and interview on [DATE] at 11:04 a.m. of cook H revealed: *He mixed a new bucket of sanitizer. *He did not test the chemical concentration of the contents in the new bucket. *He had filled a new bucket of sanitizing solution. *He did not test the chemical concentration of that solution. *There was no place to document the testing of the chemical concentration of the solution in the buckets. *He tested the buckets once daily. Observation and interview on [DATE] at 3:30 p.m. with cook K revealed: *He prepared a sanitation bucket. *He did not test the solution's chemical concentration. *When asked how he would know if the solution had the adequate chemical concentration, he tested the liquid. *The chemical concentration was read to be greater than 200 ppm. *When asked what ppm he expected the solution to be he indicated that he did not know. *He stated that he did not know where to locate that information. *Food service manager C directed him to a three-ring binder to find the information. *The information was observed above the three-compartment sink on a poster labeled Quaternary Sanitizer, which indicated the concentration should have been between ,d+[DATE] ppm. *Also on this poster was a statement that directed staff to Record the solution concentration reading in the appropriate log. 4. Interview on [DATE] at 4:14 p.m. with cook I revealed there were lines through the documentation areas on the temperature logs that indicated the temperatures had not been documented and those lines prevented someone from documenting a temperature on a later date. *Observation and interview on [DATE] at 11:10 a.m. with cook G during lunch service revealed: *The display on the Convotherm oven indicated the temperature was set at 212 degrees Fahrenheit. *She removed ground meat and mashed potatoes from the Convotherm oven. *She take had not taken the temperature of the meat or mashed potatoes removed from the Convotherm oven prior to serving. *She stated that the food had been in the Convotherm oven all morning and would be an adequate temperature. Review of the provider's walk-in refrigerator and freezer temperature logs for [DATE] revealed: *The temperature log contained an area for temperature documentation for the refrigerator and the freezer in the AM and the PM. *There was a line drawn through the area to document the AM temperatures on [DATE], [DATE], [DATE], [DATE], [DATE]. *There was a line drawn through the area to document the PM temperatures on [DATE], [DATE], [DATE], and [DATE]. Review of the provider's walk-in refrigerator and freezer temperature logs for February 2025 revealed there was a line drawn through the AM and PM documentation areas on [DATE]. Review of the provider's [DATE] Refrigerator and Freezer temperature documentation log revealed: *There was a column to document the refrigerator temperature and another to document the freezer temperature. *There was no documentation of the freezer or the refrigerator temperatures for the first seven days in January. *In addition, there was no temperature documentation for the refrigerator or freezer on [DATE], [DATE], [DATE], [DATE], and [DATE]. Review of the provider's [DATE] food daily temperature record revealed: *There was an area to document soup, meat, alternate meat, potatoes, vegetables, alternate vegetables, puree, and other for lunch and supper. *There was no area to document breakfast foods. *There was no area to document the temperatures of refrigerated foods. *There was no temperature documentation for lunch on [DATE] and [DATE]. *There was no temperature documentation for supper on [DATE], [DATE], and [DATE]. Interview on [DATE] at 3:40 p.m. with food service manager C revealed: *It was his expectation that the sanitation bucket concentration be tested each time a bucket was changed. *The buckets were changed every hour. *He verified there was no log to document the chemical concentration of the sanitation buckets. *He expected food temperatures to be taken and documented every day prior to every meal being served. *He verified there was missing documentation of food temperatures and there was no area for breakfast temperatures to be documented. *It was his expectation that the temperatures for the refrigerators and freezers in the kitchen were checked and documented daily. *Residents' personal refrigerator temperatures were to be monitored by housekeeping. 5. Observation on [DATE] at 5:06 p.m. of CNA N serving food revealed: *She had on a pair of gloves. *With those gloved hands she: -Pushed a resident closer to the table. -Turned pages on a 3-ring binder at the serving counter. -Delivered plates of food to residents by placing her thumbs on the edge of the plates. --She did not change her gloves during the meal service. Observation on [DATE] at 5:11 p.m. of CNA Q revealed she wore a pair of gloves and cut up two different residents' food items without changing them. Observation on [DATE] at 5:13 p.m. of food service work L revealed she had on a pair of gloves, and with those gloved hands she: *Picked up a plastic container of bread that was located in the serving area next to the steam table. *Took bread out of that plastic container and placed it on plates of food to be served to the residents. Observation on [DATE] at 5:16 p.m. of CNA M revealed she wore a pair of gloves and with those gloved hands she: *Served two plates of food to residents, with her thumb on the edge of the plate and touching the bread on the plate. *Continued to serve residents plates of food with those same gloved hands. Observation on [DATE] at 11:15 a.m. in the dining room of CNA O revealed she: *Used hand sanitizer on her hands and put on a pair of gloves. *Picked up a knife and fork and tried to cut up an unidentified resident's sausage. -The knife was dull, and she was unable to cut the sausage. *Picked up the sausage with those same gloved hands and removed the skin from the sausage. *Placed the skin on a napkin and then picked up that resident 's silverware and cut up his sausage. *Picked up his juice and gave him a drink. *Wiped her gloved hands on the napkin that the sausage skin was on. *Picked up a sausage piece with the resident's fork and then used her gloved hand to slide it off. Observation on [DATE] at 11:35 a.m. of CNA O revealed: *She took a pair of gloves out of her shirt pocket and put them on. -She had not completed hand hygiene before putting on the gloves. *She assisted an unidentified resident with the sausage on his plate. -She picked up the sausage with her gloved hands, removed the casing from it, and cut it up with a knife. Observation on [DATE] at 11:47 a.m. of food service worker J revealed she passed lunch trays to residents without performing hand hygiene between delivering of each resident's meal tray. Interview on [DATE] at 9:49 a.m. with CNA O regarding her observed glove use in the dining room revealed: *She used gloves if she was helping a resident with a sandwich or with the sausage if they had to peel the skin off. *She did not put gloves on if she used a utensil, like a spoon, to help a resident eat. *She stated she would use hand sanitizer if she changed her gloves. Interview on [DATE] at 10:55 a.m. with administrator A and DON B, who joined by phone, regarding staff glove use in the dining room revealed: *Glove use was not required in the dining room. *Staff were expected to use hand sanitizer if they were not wearing gloves in any area of the building. *They agreed staff had not used gloves appropriately. 6. Observation on [DATE] at 9:12 a.m. of resident 37's refrigerator revealed: *Refrigerator temperature documentation was missing for [DATE], [DATE], [DATE], and [DATE]. *In the refrigerator was a bag of dates that were not dated and two oranges with brown spots. Observation on [DATE] at 9:22 a.m. of resident 31's refrigerator revealed: *A croissant sandwich wrapped in plastic wrap dated ,d+[DATE]. *Refrigerator temperature documentation was missing for [DATE], [DATE], [DATE], and [DATE]. Observation on [DATE] from 8:35 a.m. to 9:10 a.m. of resident refrigerators revealed: *Resident 45's refrigerator was missing temperature documentation for [DATE], [DATE], and [DATE]. *Resident 7's refrigerator was missing temperature documentation for [DATE], [DATE], [DATE], and [DATE]. *Resident 14's refrigerator was missing temperature documentation for [DATE], [DATE], [DATE], and [DATE]. *Resident 45's refrigerator was missing temperature documentation for [DATE], [DATE], and [DATE]. *Resident 51's refrigerator had a form to document the refrigerator temperatures for January that indicated he had a new refrigerator on [DATE]. *There was not a form to document February refrigerator temperatures. *There was no thermometer in the refrigerator. Interview on [DATE] at 9:40 a.m. with housekeeping manager D regarding resident refrigerators revealed: *Housekeeping staff checked the temperatures of the resident refrigerators Monday through Friday. *No one was responsible for checking resident refrigerator temperatures on the weekends. Observation on [DATE] at 12:14 p.m. of the refrigerator in the room identified on the door as the activity room revealed: *There was a piece of paper on the refrigerator door that stated, This refrigerator is for resident and activity department only. *Refrigerator temperature documentation was missing for [DATE], [DATE], [DATE], and [DATE]. *Inside the refrigerator was a blue container labeled with a name that was dated [DATE]. 7. Review of the provider's ,d+[DATE] LTC Food Safety and Sanitation policy revealed: *Gloves will be worn when handling ready to eat foods to ensure that pathogens are not transferred from the food handlers' hands to the food product being served. Bare hand contact with food is prohibited. Anytime a contaminated surface is touched, the gloves must be changed-washing hands after removing the gloves and before putting on a new pair. *Hands must be washed before serving/distributing meals, & or after picking up soiled plates/waste. *Staff do not need to wear gloves when distributing food or when assisting residents to dine, as long as food is not touched with the bare hand, and or proper handling of utensils, dinnerware is adhered to. *Sanitizer buckets are changed when visibly soiled or per manufacturer's direction. The sanitizer is checked for proper concentration with test tape (per manufacture's instruction). *Cloths must be soaking in sanitizer until use, changing solutions every 4 hours to maintain active concentration. (or per manufacturer's instruction). *All refrigerators and freezers have thermometers and temperature is documented at least 1x [one *time] daily. *Cooked foods must reach the temperature recommended by Food Service Code. *Hot food is held at a temperature of 140 [degrees] F [Fahrenheit] or above. *Cold foods are held at a temperature of 40 [degrees] F [Fahrenheit] or less. *Dishwasher Temperature/appropriate sanitation levels are checked & [and] recorded daily. Review of the provider's ,d+[DATE] Food Temperatures policy revealed: *The food service will follow proper procedures in storing and monitoring food temperatures to prevent the spread of food borne illness. *Temperatures must be maintained at the following (Fahrenheit) settings for the items indicated below: -Frozen food 0 [degrees] or below; -Refrigerated food 41 [degrees] or below; Review of the provider's ,d+[DATE] Recording Hot-Cold Food Temperatures policy revealed: *Record temperatures on food temperature log. *Continue taking temperatures as needed for each item on menu and recording. 43844 45683

Based on observation, interview, record review, and policy review, the provider failed to ensure infection prevention practices were performed by: *Not following provider policy for use of personal protective equipment (PPE) for one of one resident (47) on enhanced barrier precautions by one of one staff (LPN F). *Not having placed one of one resident (37) with a pressure ulcer on enhanced barrier precautions. *Not performing appropriate hand hygiene during three of five observations of two of two staff (LPN F and RN S). *Not following provider policy for nebulizer tubing changes for one of two sampled residents (50). *Not cleaning multi-use items properly during three of four observations of one of one of one of one staff (RN S). *Not maintaining the appropriate cleanliness and storage of multi-use items in one of one observed beauty shop and one of one observed tub room. *Inappropriate glove use and hand hygiene during a blood sugar check and with insulin administration by one of one observed staff (RN S). Findings include: 1. Observation on 2/10/25 at 5:00 p.m. of resident 47's room revealed: *A sign on her door indicated enhanced barrier precautions (EBP) (use of gown and gloves during high-contact resident care activities) was required. *A plastic container with drawers containing gowns and gloves was present in her room. Interview on 2/11/25 at 10:18 a.m. with CNA W regarding EBP revealed a gown and gloves were to be when direct care was provided a resident on EBP. Observation and interview on 2/11/25 at 1:57 p.m. of licensed practical nurse (LPN) F while changing resident 47's dressing on her right lower leg revealed: *Resident 47 had an ordered daily dressing change to her right lower leg, where she received a skin graft. *LPN F was seated beside resident 47 as she changed the dressing. *LPN F was not wearing a gown. *LPN F removed her gloves after she completed the dressing change. -She did not perform hand hygiene after she removed those gloves upon completion of the dressing change. Interview on 2/11/25 at 2:03 p.m. with resident 47 revealed she felt staff at times wore a gown and gloves when providing her care or changing her dressing. 2. Observation on 2/11/25 at 1:49 p.m. of resident 37's room revealed: *Resident 37 was sitting in her recliner with a Prevalon boot (pressure reduction boots) on her left foot. *She stated that she wore the boot because she had a sore on her heel. *No personal protective equipment (PPE) (gowns, gloves, and eye protection) was observed in or near her room. *There was no sign on her door that indicated EBP was required. Interview on 2/11/25 at 4:05 p.m. with resident 37 revealed staff did not wear a gown when they changed her left heel dressing, helped her with getting dressed, or assisted her with her toileting needs. Review of resident 37's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Her 11/18/24 Brief Interview for Mental Status (BIMS) assessment score was 15, which indicated she was cognitively intact. *Her left heel ulcer was identified on 9/23/24 and was documented to be 4.4 cm (centimeters) by 5 cm, brown, dry, and intact. *2/11/25 wound documentation revealed she had a left heel ulcer that was Open, drainage moderate serosanguineous. *She was being seen by wound care for her left heel ulcer. *There were dressing changes ordered for her left heel ulcer. Review of resident 37's 2/12/25 care plan revealed: *She had an unstageable left heel Pressure injury/ulcer that was added to her care plan on 11/19/24. *The care plan did not include the use of EBP. 3. Observation on 2/10/25 at 5:00 p.m. of resident 50's room revealed: *An assembled nebulizer administration set was lying on the nebulizer machine. *There was a date written on the handheld nebulizer device of 1/29. *The date of 1/31 was written on the nebulizer tubing. Interview on 2/11/25 at 8:36 a.m. with resident 50 revealed: *She was admitted to the facility after being hospitalized with a respiratory infection. *She could not recall when she last received a nebulizer treatment. Interview on 2/12/25 at 1:25 p.m. with registered nurse (RN) E regarding resident 50 revealed: *Her last nebulizer treatment was administered on 1/27/25. *Her nebulizer treatments were ordered to be administered as needed. *When nebulizer treatments were administered as needed it was RN E's practice to dispose of the nebulizer set after a treatment was given and obtain a new set for the next treatment. *RN E reported the documentation in resident 50's EMR, indicated LPN F had documented that she changed resident 50's nebulizer tubing on 2/11/25 at 11:00 a.m. *RN E confirmed that the nebulizer set in resident 50's room was dated 1/29 and 1/31. Review of resident 50's EMR revealed: *She was admitted on [DATE]. *Her BIMS assessment score of 15, which indicated she was cognitively intact. *She had been hospitalized with pneumonia, bronchitis, and hypoxia (low oxygen in the blood) prior to her admission to the facility. *She had an order for a Xopenex nebulizer as needed for shortness of breath. *There was an order to change the nebulizer tubing weekly and as needed. Review of resident 50's care plan revealed nursing staff were to: *Provide NEBULIZER meds as ordered *Change filter as per facility protocol. *Change nebulizer tubing weekly. 52098 4. Observation on 2/11/25 at 9:35 a.m. of the facility beauty shop revealed: *One of two drawers of the sink vanity contained four small, white storage containers. *Those four containers stored a variety of beauty shop items. -One contained 11 combs and was visibly soiled with a build up of hair, lint and dust fibers. -One contained two pairs of cutting scissors located on top of the opened soiled scissor case. -The container was visibly dirty with hair, lint and dust fibers. -One contained various hair picks, combs, and tweezers and was visibly soiled with hair, lint and dust fibers. *Four of four rolling hairdryers had visibly soiled vent screens that contained a white, dry substance. 5. Observation and Interview on 2/11/25 at 9:41 a.m. with CNA V in one of one north hall tub room revealed: *A storage bin with divided compartments was labeled and stored in the tub room. -It contained the residents' personal nail trimming supplies. *One small compartment bin was unlabeled and stored in the tub room. -It contained one pair of scissors, one large nail clipper, one cuticle clipper, one pair of tweezers, approximately five disposable razors and multiple alcohol pads. -The items in the small bin were multi-use items used for the residents. -CNA V stated the residents' personal clippers and multi-use items were cleaned with alcohol wipes. 6. Observation and Interview on 2/11/25 at 9:58 a.m. with RN S revealed: *RN S performed hand hygiene, removed blood sugar supplies and insulin from the medication cart parked in the dining room. -RN S walked to resident room [ROOM NUMBER] and entered. -The supplies were placed on the residents visibly soiled walker seat. -RN S applied gloves but did not perform hand hygiene. -RN S did not clean or disinfect the surface area of the walker seat or apply a barrier for the supplies. -Resident treatments were completed and the dirty items discarded appropriately. -RN S removed her gloves, she did not perform hand hygiene, and exited the resident room. *Sani wipes with purple lid (germicidal wipes) were used for cleaning the glucometer. She stated, I wrap the glucometer in [a] wipe for ten minutes. *Staff were provided infection control training upon hire and through staff meetings. 7. Interview on 2/11/25 at 10:18 a.m. with CNA W revealed resident multi-use items and equipment were to be cleaned with Sani-wipes with the purple lid after each use. 8. Observations on 2/11/25 from 1:42 p.m. to 2:02 p.m. with RN S revealed : *Observed RN S exit resident 23 room. - She placed vital signs (VS) equipment (manual blood pressure cuff, an oxygen saturation monitor and a non-contact thermometer) on top of the medication cart. -A stethoscope remained around RN S neck. -RN S removed and discarded her gloves and did not perform hand hygiene. *RN S entered resident 22 room at 1:45 p.m., she performed hand hygiene, applied gloves and administered the residents eye drops. -RN S exited the room at 1:52 p.m. and returned to the medication cart. -She discarded her gloves and performed hand hygiene. *RN S applied gloves, and removed the VS equipment from on top of the medication cart and entered resident 45 1:55 p.m. -RN S placed the VS equipment on resident 45 bedside table. -Resident 45 bedside table was not cleaned or a barrier placed before the equipment was placed. -RN S obtained resident 45 vital signs and exited the room at 2:02 p.m. -RN S placed the VS equipment back on top of the medication cart. -RN S removed her gloves, discarded them but did not perform hand hygiene. *The VS equipment was not cleaned or disinfected before or after resident use. *Multi-use equipment and environmental surfaces were not properly cleaned and disinfected to help minimize cross-contamination and the spread of infection. 9. Interview on 2/12/25 at 4:12 p.m. with Infection Preventionist/DON B revealed: *She had completed infection prevention training in the summer of 2024 and obtained a Long-Term Care Infection Prevention Certification. -Staff were trained on infection control policies and procedures upon hire and yearly. -Staff were monitored through random observations, and audits that were tracked in a binder. -Staff were provided a variety of learning avenues with monthly meetings, annual trainings and competencies. -Infection surveillance was completed and reported to NHSN and QAPI. *Staff should use Sani-wipes (purple top) per the manufacturer's instructions. -She stated, those wipes had a wet time of two minutes. *She was unaware of the unlabeled compartment bin in the tub room that contained resident multi-use items. -She expected that no multi-use items were to be used and should be removed. *She was unaware staff had been using alcohol pads to clean the multi-use items. *Residents should have their own personal items to use. -Cleaning of multi-use items with alcohol pads was not appropriate. *Enhanced barrier precautions (EBP) training/education was provided to staff. *LPN T, or a floor nurse, or she could initiate EBP precautions. -Agreed EBP should be initiated during wound care treatment for residents with pressure sores. -Agreed that EBP was missed and should have been implemented for resident 37. -Agreed the nurse should have worn a gown during wound care treatment for resident 37. *She explained that the beauty personnel brought and stored their beauty products and supplies in the facility beauty shop. -She was unsure of who was responsible for cleaning, maintaining, and ensuring the proper storage of the beauty shop products and supplies and stated maybe the activities department. -The activities director was out of the facility on 2/12/25 and unable to interview. 10. Review of the provider's 10/24 Transmission Based Precautions and Enhanced Barrier Precautions policy revealed: *Enhanced Barrier Precautions (EBP): use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO's to staff hands and clothing. Enhanced Barrier Precautions are used during high contact resident care activities for the following residents and should be implemented as facilities are able: -Wound requiring a dressing, regardless of MDRO status. -If on EBP a gown and gloves must be used during high contact resident care activities including (but not limited to) --wound care (any wound requiring a dressing). Review of the provider's 12/17/24 Respiratory Equipment Care policy revealed: *Empty excess fluid, Rinse nebulizer with sterile (preferred) or distilled water, shake off excess moisture, and place on a clean, dry paper towel, and store in a clean, dry location in the resident's room to air dry for the next treatment. *Replace nebulizer set weekly or more frequently based on MIFU [manufacturer's instructions for use]. Review of the providers 6/13/2024 Infection Prevention Program and Authority policy revealed: *II. Purpose/Responsibilities: -A. The function and duties of the Infection Prevention Program shall be to: -b. Maintain surveillance of the healthcare facility infection potentials. -d. Develop and implement a preventative and/or corrective program to minimize infection hazards. -g. Supervise Infection Control in all phases of healthcare activities and to act upon recommendations made by the Program. This may include: -i. Standard precautions and transmission based precautions (Isolation) policies. -ii. Hand hygiene policy. -iii. Environmental Cleaning. -vii. Consultation on and approval of cleaning/disinfection products, procedures, agents, or techniques. -B. Infection Prevention Practitioner -h. The Infection Prevention Program must meet standards imposed by OSHA, CMS, and regulatory bodies. Review of the providers 11/2024 Hand Hygiene policy revealed: *I. Purpose. -I. Hand hygiene (HH) continues to be the primary means of preventing the transmission of infection. -A. To cleanse hands to prevent the spread of infection. -B. To provide a clean and healthy environment for residents, staff, and visitors. -II. Policy. -A. HH, either with soap and water or with alcohol based hand rub (ABHR). -1. immediately before touching a resident. -2. before a clean procedure or handling an invasive medical device. -3. after contact with potential for body fluid or contaminated surfaces. -4. after touching a resident or the resident's immediate environment. -5. after removing gloves. Review of the providers 10/2024 Disinfection of Non-Critical Patient Care Equipment policy revealed: *A. Purpose. -B. For the safety and comfort of patients, all reusable (non-critical) patient care items not sent to Sterile Processing Department (SPD) for reprocessing will be cleaned, disinfected, and maintained in a safe manner between patient use. -C. Reusable equipment may have specific cleaning and disinfection Instructions for Use (IFU). -I. Information. -1. Non-Critical items are those that come into contact with intact skin but not mucous membranes. Examples include crutches, blood pressure cuffs, commodes, walkers, wheelchairs, gurneys, pumps, etc. Low level disinfectants (quats) or bleach are used on this kind of equipment. -II. Policy. -A. Items taken from a patient's room for use by another patient will be disinfected before use by next patient. -E. All reusable patient care equipment removed from a patient room/procedure room is disinfected before use on another patient. -I. Disinfectant Recommendations. -1. Reusable patient care equipment. -a. Between each patient use. -b. Stethoscopes - since stethoscopes typically hang around your neck or in a pocket, disinfect the bell and diaphragm before and after use with an alcohol wipe. Tubing can also be disinfected with an alcohol wipe. This is based upon [NAME] Stethoscope Instructions for Use (IFU). -III. Procedure. -A. [NAME] appropriate personal protective equipment (PPE) as needed for the task at hand: -1. Gloves - per standard precautions. -2. Gown - per standard precautions. -3. Facial protection - per standard precautions. -C. Using friction, wipe all surfaces with hospital-approved disinfectant. Do not touch cleaned surfaces/items and allow to air dry. -2. Surfaces should remain wet per required contact time which is stated on the product label: -e. PDI Super Sani-Cloth Canister Wipes (purple top) = 2 minutes. -g. Product varies upon availability and staff are responsible for knowing required wet contact times.

Based on observation, interview, record review, and policy review, the provider failed to establish and maintain a process to accurately identify and reconcile as well as appropriately secure and store scheduled controlled medications in two of two medication carts for eight of eight sampled residents (1, 12, 15, 39, 49, 52, 206, and 306). Findings include: 1. Observation and interview on 2/12/25 at 9:32 a.m. in one of one medication storage room with registered nurse (RN) E and RN U revealed: *The medication storage room utilized a keyless lock entry system that required a code to enter. *There were two medication carts stored inside that room. *The carts contained drawers where the residents' individualized punch-style medication cards (bubble packs) and stock medications were stored. -There were two drawers of each medication cart that stored the majority of the residents' scheduled controlled (medications with risk for abuse and addiction) and non-controlled medication punch cards. -The remaining cart drawers stored stock medications, insulins, eye drops, inhalation medications and additional medical supplies. *Each medication cart had one drawer with a lockable box (lock box) inside of it. -The lock boxes contained a supply of the residents' as needed (PRN) non-controlled Tylenol (acetaminophen) and PRN controlled medications bubble packs. *The storage room utilized a key lock entry cupboard. -The cupboard contained a supply of the residents' scheduled and PRN controlled medications and the emergency medication kit. *A reconciliation/tracking record was used to document the PRN controlled medications and scheduled controlled Fentanyl (pain medication) patches. *There were no reconciliation/tracking records for the residents' other scheduled controlled medications. *They confirmed they used reconciliation/tracking records for the residents' PRN controlled medications and scheduled controlled Fentanyl patches to document the counted amounts of those medications. -They explained those medications were counted and documented on those tracking records every shift by two nurses. *They confirmed there were no reconciliation/tracking records maintained to document the amounts of the residents' other scheduled controlled medications. 2. Interview on 2/12/25 at 4:12 p.m. with DON B regarding the accountability of residents' medications process revealed: *The PRN controlled medications were tracked/reconciled. -They did not reconcile/track the scheduled controlled medications. -Two nurses, one coming on duty and one going off duty, were to count and reconcile/track those medications each shift. -The nurses were to count the medications in the bubble packs to reconcile the amounts of the scheduled controlled medications. -The nurses were to reconcile and document the scheduled count of those medications with each medication pass. *She was asked how she would know if a medication bubble pack was tampered with or had a medication missing: -She felt the nurses would notice if a medication bubble pack was tampered with or if there was a missing medication. -The nurses were trained to report a medication discrepancy right away to the DON. *She was asked if she reconciled or destroyed the controlled medications with the pharmacist. -She explained she did not reconcile or destroy medications with the pharmacist. -A nurse on duty would reconcile the medications when they were delivered by the pharmacy. -Two nurses on duty destroy the controlled medications. 3. Interview on 2/13/25 at 9:40 a.m. with administrator A regarding the accountability and storage of medications revealed: *She was unsure of the process for the accountability and storage of medications and requested the surveyor to speak to DON B. *Administrator A provided DON B's cell phone number as she was out of the facility on 2/13/25. 4. Interview on 2/13/25 at 10:19 a.m. with consultant pharmacist X revealed: *Asked what the process was to ensure the proper storage, security and tracking of all controlled medications. *Asked about the process for the scheduled controlled punch card (bubble pack) medications stored in the medication carts among other non-controlled punch card (bubble pack) medications that had no reconciliation log/tracking record. * Asked about the distributing pharmacy and consultant pharmacist responsibilities and processes related to controlled medications. -He explained he was not employed by the dispensing pharmacy but was contracted by the facility. -He completed the monthly resident chart medication reviews, and checked for outdated supplies and medications monthly in the medication storage room, and medication carts. -He did not review the scheduled controlled medications as the facility did not have reconciliation/tracking records for those medications. -He reviewed the PRN controlled and Fentanyl patch medication reconciliation/tracking records. -The scheduled controlled medications in the medication carts were to be monitored by the nurses. -The nurses were to monitor the medication bubble packs for signs of tampering and potential drug diversion as they administered medications during their scheduled shifts. -He stated schedule II through IV controlled medications should be locked, but some could be stored with non-controlled medications if there is a good system for tracking. -Nurses were to report medication discrepancies to the nursing supervisor. -He agreed that the medication carts are to be within their view at all times if controlled medications are secured with one lock. -He agreed that some controlled medications needed to be secured with two locks and reconciled/tracked at the change of each shift. 5. Interview on 2/13/25 at 12:04 p.m. with administrator A and DON B, who joined by phone at 12:06 p.m., revealed: *A report of residents who had ordered controlled medications was requested, but they were unable to run that report in the EMR system. *The medication error reports for the past six months were requested. -No medication error reports were provided. -Administrator A stated no medication errors had been reported in the past six months. 6. Observation and Interview on 2/13/25 at 12:10 p.m. in the medication storage room with RN E, LPN T, and consultant pharmacist X revealed: *Consultant pharmacist X stated the residents' medications were filled and delivered by the distributing pharmacy according to the printed medication administration records (MARs) provided to the pharmacy by the facility. -Medication bubble packs were filled with either a two-week supply or thirty-day supply of medications. -RN E and LPN T explained that the night nurse would check the medications in and if discrepancies were noted, the pharmacy would be contacted. -The EMR system did not automatically reconcile the scheduled controlled medications. -RN E explained that the nurses reconciled by the printed number on the card. -She further explained if it was the 11th day of the month, the nurse would punch the medication bubble marked with the number 11 to release that medication from the bubble pack medication card. -RN E stated that this was how the nurses would reconcile/track the scheduled controlled medications in the carts. -LPN T confirmed that process. *RN E and LPN T explained that the process was not always followed with new employed nurses. -Some bubble pack cards would be punched starting at the bottom of the card with the number 30. -Some bubble pack cards would be punched starting at the top of the card with the number 1. *Both nurses were unaware of a report that would indicate which residents had ordered controlled medications in the EMR system. *RN E and LPN T went through every resident medication bubble pack in each cart to identify residents who received scheduled controlled medications. -RN E and LPN T confirmed that this was the process they used to identify residents with ordered scheduled controlled medications that did not have reconciliation/tracking records. -After those residents' medication bubble packs were located, LPN T stated, I think that is all. -Eight residents with controlled medication bubble packs were identified as: *Resident 1 was on a schedule IV medication Lorazepam (a sedative medication) 0.5mg tablet by mouth twice daily (BID). *Resident 12 was on a schedule IV medication Xanax (antianxiety medication) 0.25mg tablet by mouth every night at bedtime (QHS). *Resident 15 was on a schedule IV medication Xanax 0.5mg tablet by mouth twice daily (BID). *Resident 39 was on a schedule IV medication Xanax 0.25mg tablet by mouth every night at bedtime (QHS). *Resident 49 was on a schedule IV medication Tramadol 50mg tablet by mouth twice daily (BID) *Resident 52 was on a schedule II medication Hydrocodone/APAP 5/325mg tablet by mouth every night at bedtime (QHS). *Resident 206 was on a schedule IV medication Xanax 0.5mg tablet by mouth twice daily (BID). *Resident 306 was on a schedule IV medication Tramadol 50mg tablet by mouth twice daily (BID). 7. Review of the provider's 4/8/2024 Controlled Substances-System Standard Policy revealed: *I. Policy: -A. It is the policy of [NAME] to properly acquire, receive, store, administer, track, reconcile, document, and dispose of controlled substances consistent with state and federal guidelines. *II. Purposes: -B. To accurately account for and reconcile controlled substances for prompt identification of loss or potential diversion. -D. To provide a system that oversees that controlled substances are acquired, handled, administered, reconciled, stored, and disposed of properly. -E. To assure proper record-keeping for controlled substances. *III. Procedure: -B. Record keeping: -1. Log all controlled substances on Resident's Controlled Substance Record form. -C. Place controlled substance(s) received from the pharmacy in a locked storage area with limited staff access. CII meds will be maintained in a separately locked permanent affixed compartment. Schedule III, IV, V may be stored in a separate locked container or may be integrated with other medications as long as there is a system for accountable tracking (punch cards). -E. One authorized person going off duty and one authorized person coming on duty must count and reconcile the accuracy of controlled substance supply for each resident and the facility at the shift change. -F. Controlled substance records are reconciled by a physical count of the remaining controlled substance supply at the change of each shift by the incoming and outgoing licensed nurse/designee. Controlled substance keys will be reconciled at the same time. -NOTE: The controlled substance supply of medication is always secured with two locks. (With the exception of medications that are part of a single unit package system when the supply is minimal and there is ability to detect a shortage promptly). The locks on the medication cart and the narcotic drawer are always secured.

Based on observation, interview, and policy review the provider failed to ensure the proper storage of hazardous products and sharp objects to prevent resident accidents in one of one observed facility beauty shop. Findings include: 1. Observation on 2/11/25 at 9:35 a.m. in the facility beauty shop revealed: *The door was open and no facility or beauty shop personnel were present. *There was a countertop vanity sink with two cupboards and two drawers where beauty shop products and supplies were stored. *There were 12 beauty shop products with printed warning labels on the containers. *Disinfectant Sani-wipes were stored on the countertop. -The container label read Keep Out of Reach of Children. *Bed Head hairspray was stored in one of the cupboards. -The container label read Keep Out of Reach of Children and Avoid Contact With Eyes. *Fanci Full instant hair color (liquid) was stored in one of the cupboards. -The container label read Keep Out of Reach of Children, Flammable, May Cause Eye and Skin Irritation, and For External Use Only. *Biolage shampoo was was stored in one of the cupboards. -The container label read For External Use Only, Keep Out of Reach of Children, and Avoid Contact With Eyes. *Biolage conditioner was stored in one of the cupboards. -The container label read For External Use Only, Keep Out of Reach of Children, and Avoid Contact With Eyes. *Fanci Full instant color mousse was stored in one of the cupboards. -The container label read Keep Out of Reach of Children, Danger, Flammable, May Cause Eye and Skin Irritation, and For External Use Only. *Acetone nail polish remover was stored in one of the cupboards. -The container label read Danger, Extremely Flammable Liquid and Vapor, Causes Serious Eye Irritation, Keep Away From Heat, Sparks, Open Flames, and Hot Surfaces. *Head and Shoulders shampoo was stored in one of the cupboards. -The container label read Keep Out of Reach of Children. *Rave 24 Hour extreme hold hairspray was stored in one of the cupboards. -The container label read Keep Out of Reach of Children, Danger, Flammable, Avoid Inhalation, and Avoid Contact With Eyes. *Vidal [NAME] mousse was stored in one of the cupboards. -The container label read Keep Out of Reach of Children, and Avoid Contact With Eyes. *Fanci Full color mousse white mix was stored in one of the cupboards. -The container label read Keep Out of Reach of Children, Danger, Flammable, May Cause Eye and Skin Irritation, and For External Use Only. *Suave hairspray was labeled was stored in one of the cupboards. -The container label read Keep Out of Reach of Children. *An electric blow dryer stored in one of the cupboards with the labeled products. *The cupboard that contained those hazardous products was unsecured and accessible to the residents. *In one of two sink vanity drawers there were four white containers that stored beauty supplies. - One container had two pairs of cutting scissors stored on top of the opened scissor case. *That drawer was unsecured and the scissors were accessible to the residents. 2. Observation on 2/10/25 in the resident dining room between 4:50 p.m. and 5:10 p.m. revealed: *Resident 13 had locomoted herself down the hallway and stopped at the beauty shop door and looked inside. -Staff personnel re-directed resident to the dining room for the evening meal. 3. Interview on 2/12/25 at 4:12 p.m. with director of nursing (DON) B regarding the beauty shop revealed: *She explained the beauty shop door was left open because it was located where the staff could easily access the phone and use it. -The beauty shop was located across the hall from the resident dining room. -The beauty personnel brought and stored their beauty products and supplies in the beauty shop. -She was unsure of who was responsible for cleaning, maintaining, and ensuring the proper storage of the beauty shop products and supplies and stated Maybe the activities department. -The activities director was out of the facility on 2/12/25 and unavailable for an interview. 4. Review of the providers 04/2023 Storage Areas policy revealed: *The providers policy defined storage procedures for the environmental services (housekeeping and laundry) departments. -These areas are to be maintained in a clean and safe manner. -Flammable liquids, combustible gases, etc., should not be stored in these areas where intense heat or open flame devices could ignite such matter. -Cleaning supplies, etc., shall be stored in areas separate from food storage rooms and shall be stored as instructed on the labels of such products. *No policy was provided on the proper storage of hazardous products for the facility beauty shop or for any resident environment areas.

Based on observation, interview, record review, and policy review, the provider failed to: *Ensure one of one sampled resident's (52) nebulizer machine and one of one sampled resident's (48) continuous positive airway pressure (CPAP) machine tubing was appropriately cleaned per policy guidelines. *Develop and implement hygienic and infection control guidelines for the maintenance of one of one sampled resident's (54) perineal care (peri-care) wiping tongs (a long-handled device used to maintain independence in wiping oneself after toileting). Findings include: 1. Observation and interview on 10/17/23 at 10:25 a.m. with resident 52 revealed he: *Was sitting in his recliner in his room with the lights off. *Was noticeably short of breath (SOB). *Stated it had not been a good day with his chronic obstructive pulmonary disease (COPD). *Stated he administered his own nebulizer treatments up to four times a day. -The nebulizer machine and the nebulizer medication solution were sitting on a table next to the resident. *Stated he did not clean the nebulizer tank or the mouthpiece after each use as he feels he is getting weaker and already had multiple falls since he was admitted to the nursing home. *Stated he had not had a staff member help him clean the nebulizer tank or the mouthpiece after each use. Review of resident 52's electronic medical record revealed he: *Was admitted to the facility on [DATE]. *Had a Brief Interview for Mental Status (BIMS) of 15 indicating intact cognition. *Had diagnoses of COPD, pulmonary hypertension, bronchiectasis, impaired balance, history of falls, SOB, and was oxygen dependent. *Received oxygen at 4 to 6 liters per minute via nasal cannula. *Had a self-administration of medication evaluation completed on 8/16/23. *Had a physician's order to have been able to self-administer medications daily. *Had three falls since his admission. Interview on 10/18/23 at 1:37 p.m. with director of nursing (DON) B and registered nurse (RN) charge nurse E regarding the above observation and interview with resident 52 revealed they stated: *There was no cleaning policy or procedure for the certified nursing assistants (CNAs) to assist him in cleaning his nebulizer tank and the mouthpiece. -At the time the resident was admitted , he stated that he could clean his own nebulizer tank and the mouthpiece. *They were not aware that he now felt that he could not clean his nebulizer tank and the mouthpiece due to his weakness and unsteadiness. Review of resident 52's baseline care plan dated 8/9/23 and his most recent comprehensive care plan dated 10/2/23 revealed there was no documentation that the resident was responsible for cleaning his own nebulizer tank and the mouthpiece. 45901 2. Observation and interview on 10/17/23 at 9:06 a.m. with resident 48 revealed he: *Was resting in bed with the television on. *Had a continuous positive airway pressure (CPAP) machine on his night stand next to his bed. *Independently cleaned the mask for his machine daily. *Had not cleaned the tubing for the CPAP machine, and could not recall staff cleaning the tubing for the machine. Review of resident 48's care lan dated 6/5/23 revealed he: *Was admitted on [DATE]. *Had a BIMS score of 15, indicating his cognition was intact. *Had diagnoses of spinal cord injury, paraplegia, type 2 diabetes mellitus, and obstructive sleep apnea. *Had a CPAP machine and needed assistance with the maintenance and cleaning of the machine. Interview on 10/18/23 at 1:30 p.m. with DON B and RN F revealed: *Resident 48 had a CPAP machine on his admission. *The CPAP tubing was to have been cleaned weekly by staff. *Staff were to document in the resident's electronic medical record each time the tubing was cleaned. *They both confirmed there was no documentation that the CPAP tubing was cleaned weekly. 46453 3. Observation on 10/17/23 at 1:17 p.m. in resident 54's room revealed there was a pair of metal kitchen tongs with wooden handles sitting on a pile of papers and clothing in a chair. Continued observation on 10/18/23 at 11:20 a.m. with resident 54 in his room revealed: *He came out of the bathroom with the pair of tongs in hand. -There was a foul smell coming from the resident's vicinity as he rolled by in his wheelchair. -There were unidentified fibers sticking to the end of the tongs. -The metallic tip of the tongs had turned black in color. Interview on 10/18/23 at 11:26 a.m. with DON B about the above observation revealed she: *Confirmed that resident 54 used those tongs to help wipe himself after using the restroom. *Explained that was what he had done prior to moving into the nursing home. *Was not positive if there was a cleaning or a maintenance schedule for those tongs. Interview on 10/18/23 at 1:51 p.m. with charge nurse E about resident 54's cleaning tongs revealed: *Resident 54 had been evaluated by occupational therapy (OT) for the use of the tongs. -OT concluded that the tongs increased his independence. *She had previously educated resident 54 about storing the tongs in the bathroom. -She further explained that the resident was not always compliant with storing the tongs in the bathroom. *She had fashioned a bedside urinal as a place where he could store his tongs, but he did not want to keep them there. *When asked how often the tongs were cleaned, she confirmed that there was no cleaning schedule for any staff to clean or sanitize the tongs. -She was aware that the wooden handles were not a cleanable surface. -She indicated that the resident would clean the tongs with body wipes, but those wipes were not sanitizing wipes. Interview on 10/19/23 at 8:53 a.m. with DON B about the resident's tongs revealed she: *Confirmed there was no set schedule to clean or sanitize the tongs. *Was not sure how often the resident would clean the tongs with the body wipes. Review of resident 54's care plan dated 8/24/23 revealed: *Under the ADL (activities of daily living) section of his care plan: -Toilet use: Provide assist of 1 with toileting upon rising, before/after meals/activities, HS [hour of sleep] and as he calls for it or as he allows. At times he is independent with toileting as he is able. He uses a tong like device to hold toilet paper and wipe his rectal area after toileting that he brought from home and other times staff will assist him as he allows. *There was no indication in his care plan about who was responsible for cleaning his tongs, or when his tongs were supposed to have been cleaned. Review of the provider's 10/6/22 Disinfection of Non-Critical Patient Care Equipment policy revealed: *I. Purpose -A. Cleaning, disinfecting and storing equipment and supplies is important in preventing the transmission of potential pathogens within the long-term care facility. *III. Policy: -B. Resident equipment will be disinfected immediately following resident use when the item has been contaminated with blood or other potentially infectious material or is visibly soiled. -H. CPAP/BIPAP --1. Daily - wipe out the mask with clean wash cloth and empty water chamber. --2. Weekly - soak mask and head gear with mild soap and water for 30 minutes, rinse and air dry. Check and clean the filter on the back of the machine - replace when gray. --3. Change mask and tubing per home medical company recommendations. --4. Water Chamber to be filled with distilled or sterile water. -I. Nebulizers --1. Rinse with tap water, empty excess water from the neb cup, open to room air, and place on a clean, dry paper towel, covered with a paper towel in the patient's room to air dry for the next treatment. --2. The paper towel will be changed after each treatment. --3. Every 24hrs, disassemble and wash with soap and water, rinse and air dry as above, or when visibly soiled. --4. If not dry between uses, rinse with sterile water before use. --5. Discard and replace with new Neb set if grossly contaminated with the patient's secretions, malfunctions, or dropped on the floor. --6. Replace nebulizer set weekly or more frequently based on manufacturer instructions for use. -J. Disinfection Recommendations- --1. Reusable resident care equipment: All applicable label instructions on [Environmental Protection Agency]-registered disinfectant products must be followed . ---a. Between each resident use and when soiled . a. Therapy equipment . -N. Monitoring of disinfection recommendations will be done by observation by management staff .

Based on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (54) had his insulin medication stored in an appropriate and safe manner according to the provider's policy and accepted standards of practice Findings include: 1. Observation on 10/16/23 at 5:56 p.m. in the family dining room refrigerator revealed: *There was a black plastic bag in the lower righthand drawer. *The black bag contained two boxes of Lantus insulin pens, two boxes of Novolog insulin pens, and four loose Novolog insulin pens. -The boxes of insulin were not sealed, indicating they had been opened. *The loose pens and the boxes of insulin had prescription labels, indicating it was for resident 54. *The refrigerator had a piece of paper taped to it that read This refrigerator is for resident and Activity department only . *There was a temperature log for September 2023 taped to the outside of the refrigerator door. -Only the freezer temperatures were recorded on the temperature log. -There were only five days of freezer temperatures recorded. -There was no temperature log for the refrigerator. Observation on 10/17/23 at 9:32 a.m. of the same refrigerator revealed that the insulin was no longer in the refrigerator. 2. Interview on 10/18/23 at 11:26 a.m. with director of nursing (DON) B about the above observations revealed: *She was aware that the insulin for resident 54 was in that refrigerator. *They had kept it in there due to not having enough room in the nurse's medication refrigerator. *Resident 54's daughter had brought that insulin from home for the resident to use. -She thought that the resident's daughter had just brought the insulin in on 10/16/23. *The local pharmacist gave them approval to store the resident's insulin at their store. *She confirmed that the refrigerator in the family dining room, where they had been storing the resident's insulin, was not their normal practice and was not an appropriate area to store insulin. -All staff had access to that refrigerator. -Visitors also had access to that refrigerator if they were using the family dining room. -The refrigerator was not locked. 3. A phone interview was attempted with the resident's daughter on 10/19/23 at 10:26 a.m. with no answer. A voicemail was left explaining the purpose of the call. Resident 54's daughter returned the call on 10/23/23 at 9:48 a.m. after the conclusion of the survey. She confirmed she brought the insulin to the facility on [DATE]. 4. Review of a nursing note entered on 9/11/23 at 6:12 p.m. revealed: *Resident's daughter [name redacted] had called today and stated that they have some insulin that was rec'd [received] from the VA [Veteran's Administration], wanting to know if we can use it. I did check with [DON B] and we are able to use it, will need to take it to pharmacy when daughter brings it. I did leave message with [resident 54's daughter] on her voicemail notifying her of above, and also asked her to let us know when she is coming and to keep pens chilled until she can get them here. 5. Review of the provider's 1/1/14 Medication Storage policy revealed: *Policy: All drugs are stored under proper conditions with regard to sanitation, temperature, light, moisture, ventilation, segregation, safety and security. *Under the Procedure section: -Refrigerators used for drug storage shall maintain a temperature between 35 - 46 [degrees Fahrenheit] . at all times. -All refrigerated or frozen medications shall have the dates of reconstitution and expiration, pharmacist's initials, and storage requirements on all labeling. -All products in full, unopened cases can be stored in the general warehouse area with the exception of controlled substances or those requiring refrigeration. Once a case or carton is opened the contents are to be moved to the pharmacy area. -The following will be recorded on the environmental recording form on each business day: --The temperature of refrigerators and freezers: If the temperature moves out of the acceptable ranges, immediate action will need to be taken. A repair service will be called if necessary and the drugs/solutions will be checked for damage and discarded if necessary.

Based on observation, interview, record review, and policy review, the provider failed to implement a system of fall risk assessments and individualized interventions for: *One of three sampled residents (2) with a history of falls. *Three of three sampled residents (21, 26, and 38) with a history of falls and use of position change alarms. Findings include: 1. Observation and interview on 8/30/22 at 4:42 p.m. with resident 2 while she sat in her lounge chair in her room revealed: *A large bruise on the left side of her face. *She was not able to explain what happened and did not remember falling. Observation and interview on 9/1/22 at 1:23 p.m. resident 2's revealed answers after the surveyor asked about: *What help she needed from staff, she said, Maybe sometimes I need help. *How she got staff attention when she needed help, she reported she did not know. *The call light button clipped to her bed within reach from the lounge chair she was sitting on, she said, That's the call light. *Using the call light in the bathroom if she was on the toilet, she replied, I don't think there is a call light in the bathroom. *How she would get staff attention to help her get off the toilet, she would turn on the light and pointed to the call light clipped to her bed. Interview on 9/1/22 at 1:37 p.m. with licensed practical nurse (LPN) F regarding resident 2's fall risks revealed: *She is fairly independent. *The staff remind her to use the call light. *They keep her walker in reach. *She needs visual checks, which meant opening the door since she likes her door partly closed. *Once per hour was a good frequency for visual checks. *Before her fall, she was very trustworthy with using the call light, now she needs more frequent reminders. Interview on 9/1/22 at 1:44 p.m. with certified nursing assistant (CNA) L regarding resident 2's fall risks revealed: *She walks too fast or gets up too fast. She wants to be independent but CNA L goes into her room more to provide supervision. After asking about resident 2's use of the call light, CNA L responded, I haven't seen her use the call light. Comparative review of the 3/31/22 admission Minimum Data Set (MDS) assessment and the 6/13/22 significant change MDS revealed resident 2 was coded as: *Having severely impaired cognition during the cognitive function interviews conducted for both assessments due to: -Incorrect orientation to current year and month. -No recall of three previously repeated items. *Having improved activities of daily living (ADL) self-performance and assistance for: -Transfer, dressing, and toilet use from weight bearing with two persons to independent with no set-up or physical help. -Walking from no walking to independent with no set-up or physical help. *Not steady with balance and needing assistance to stabilize when moving from a seated to a standing position and moving on and off the toilet that improved to being able to stabilize herself. Comparative review of resident 2's care plan last reviewed: 6/13/22 that was printed by the provider from their previous electronic health record (EHR) system and the care plan in the current EHR system revealed: *She was admitted on [DATE]. *Fall risk factors included history of falls with a [CONDITION(S)] (3/22/22), impaired balance, hypertension [blood pressure pill] and diuretic [water pill] medications, impaired mobility and cognition. *There were no fall prevention interventions related to: -The frequency of visual checks. -Supervision of her independent performance of ADLs. -The resident's cognitive ability to remember to use the call light. -Ensuring she was keeping her walker within reach. *The problem for ADL status was related to the same factors listed under fall risk except impaired mobility was not included. Additional factors included thirteen diagnoses. *The ADL interventions noted she was independent with most of her ADL's but did not address staff supervision or visual checks during her independent performance of ADLs related to her impaired balance or cognition. *The care plan had not been reviewed or revised following resident 2's recent fall. Review of the fall investigation report entered by registered nurse (RN) M on 8/17/22 at 7:36 a.m. revealed: *The unwitnessed fall occurred on 8/16/22 at 11:40 p.m. *Resident 2's roommate came to the nurse station to inform staff that resident is on the floor in the bathroom. *Found resident sitting on the floor in front of the toilet, blood noted on the floor and on her night gown, noted 1 cm [centimeter] laceration to the left eyebrow. *As resident explained, she voided and got up and fell , bumped her head, she was using her walker and have a gripper slippers on [sic]. *Advised resident to call for assistance to go to bathroom and pull string. *Alarm was put on resident tonight as precautionary intervention in case she will forget to call for assistance. *The documentation fields were blank for the fall review areas regarding: -Details for previous fall risk score and post fall risk score. -If the call light was sounding at the time of the fall. -The time of the last purposeful hourly rounding for resident 2. -Why the resident thought the fall occurred. -Staff involved in the Post Fall Huddle. Interview on 9/1/22 at 10:30 a.m. with director of nursing services (DNS) B after copies of fall risk assessment and position change alarm documentation had been requested revealed: *The alarm during the night of 8/16/22 after resident 2's fall was trialed and discontinued. *Fall risk assessments were completed only at admission but she did not provide one for resident 2. Review of the provider's Falls and Accidents policy last revised on 11/2021 revealed: *The policy statement was to provide a systematic approach to fall and accident prevention and monitoring, include identifying and evaluating hazards and risk, individualized approaches to reduce the risk of falls and accidents, and monitoring for effectiveness of interventions when necessary. *The definition for supervision/adequate supervision was based on the individual resident's assessed needs and identified hazards in the resident environment. Adequate supervision may vary from resident to resident and from time to time for the same resident. *The policy for resident assessment and intervention stated: -Upon admission/readmission, quarterly, and with status changes, staff will assess each resident's individual risk factors. -Based on assessment of fall risk .staff will implement appropriate individualized, resident-centered interventions to reduce the likelihood of falls .and communicate the risk and intervention to the staff through the plan of care. After a fall occurs, it must be investigated for cause. *Review of individualized, resident-centered interventions, including adequate supervision and assistive devices .must occur. The plan of care must be updated/modified accordingly. 2. Observation and interview on 8/30/22 at 2:55 p.m. with resident 26 revealed: *She was lying on her right side facing the wall in her bed that was positioned low to floor. *A soft cushion mat was on the floor on the left side of the bed and the same length of the bed. *Her eyes were open, and when the surveyor spoke to her, she turned her head slightly, smiled, and responded with unclear words and continued talking as the surveyor withdrew from her line of vision. *She was wiggling her feet and a pillow was positioned between her legs. *The lights in the room were not on, the curtains were closed, and the television was on with a low volume. Observation and interview on 8/30/22 at 4:35 p.m. in the hallway outside resident 26's room revealed: *CNA G had just opened the door from inside resident 26's room. *Resident 26 was seated in a reclining four wheeled chair with pillow behind head, leaning her head and upper torso slightly to the right. *CNA G stated she and another CNA had just transferred her out of bed into the chair and they try to get her hips square so she doesn't lean to the right. *She explained resident 26 had been using the reclining chair for about one week. Interview on 9/1/22 at 1:37 p.m. with LPN F regarding resident 26's fall risks revealed: *She liked to do more frequent visual checks than hourly. *Resident 26 gets squirrelly. She did not explain what that meant. Comparative review of the 12/6/21 annual MDS and the 7/25/22 quarterly MDS revealed resident 26 was coded as: *Having severely impaired cognition during the cognitive function interviews conducted for both assessments due to: -Incorrect responses to time orientation questions. -Inability to repeat and recall three items *Having continuous inattention or easily distracted and fluctuating disorganized thinking. *Needing weight bearing support with one person for ADL performance for transfer and toilet use, and having a decline in walking performance to not walking. *Having balance that was not steady and needing assistance to stabilize when moving from a seated to a standing position and moving on and off the toilet. *Having fallen one time with no injury prior to each MDS, two separate falls. *Use of two other alarms daily on 12/6/21 MDS but use of bed and chair alarms daily on the 7/25/22 MDS. Comparative review of resident 26's care plan last reviewed: 7/26/22 printed from the previous EHR and in the current EHR revealed: *She was admitted on [DATE]. *Fall risk factors included history of falls (last on 7/17/22), impaired balance with [CONDITION(S)], hypertension medication, and impaired cognition. *There was no intervention related to frequency of visual checks related to her squirrelly behavior. *The fall prevention interventions included safety equipment of: -Call light in reach, and encourage and remind resident to use. -Walker for ambulation with one person assistance and gait belt with wheelchair following close behind as needed. -Pressure pad alarm in bed, wheelchair, or recliner to alert staff when resident is up and out of bed/chair to prevent falls/injury. -Bed in low position when she is in it and keep floor mat at bedside on her left side. -Geri chair to prevent falls and aid with positioning. -Toilet as needed in ADL Status section. *The ADL status interventions noted: -DO NOT LEAVE ALONE IN THE W/C [wheelchair] OR TOILET. SHE TRIES TO STAND UP ON HER OWN. STAY WITH [resident] UNTIL SHE IS TRANSFERRED INTO A RECLINER. BE SURE SHE HAS THE PRESSURE ALARM UNDER HER AT ALL TIMES. -Assist with toileting upon rising, before and after meals, at HS [hour of sleep] and during rounds at night as needed. Review of the fall investigation report entered by RN N on 7/17/22 at 6:43 p.m. revealed: *The unwitnessed fall occurred on 7/17/22 at 4:15 p.m. *Resident 26 was found by staff by bed lying on her right side. *When asked, resident stated that she hit her head when she fell . *Pressure alarm was on bed, but was not sounding. *The call light questions revealed the call light was not on at the time of the fall but was within reach. *The resident was unable to state why she had not attempted to use the call light. She has dementia and history of trying to get up per self. *The last time staff had contact with the resident was at 4:10 p.m. There was no explanation about what service was provided at that time. *There was no documentation under the contributing information section to indicate potential causes for the fall. *The outcomes section noted: -Pressure pad was in place, but did not sound. Checked after fall and it was working correctly. -Continue to keep bed in low positions, [head of bed] down and pad on floor. *The reviewing manager's comments section noted DNS B commented on 8/3/22 that the care plan reviewed and appropriate. Review of care activity for resident 26 on 7/17/22 revealed CNA L had documented: *At 2:34 p.m., she was incontinent of bowel a small amount and continent of bladder. *At 2:41 p.m., the bed alarm was in place and working. Interview on 9/1/22 at 10:08 a.m. with DNS B revealed: *She was unable provide copies of fall risk assessments and position change alarm documentation including an assessment of the medical symptom that warranted the use of the alarms and a physician order. *The nurses today agreed to remove the alarm from use for resident 26. *Resident 26 had recently moved from using the wheelchair to the Geri chair but occupational therapy had not been involved to help with the positioning assessment. Review of the provider's LTC [Long Term Care] - Physical Restraint/Bed Rails Policy last revised on 12/2021, provided by DNS B when the survey team requested a policy regarding alarm use, revealed: *The purpose of the policy was to standardize guidelines for the appropriate use of physical restraints, bed rails/bed mobility devices. *The Policy Statement included the philosophy to keep residents unrestrained and as independent as possible. If the results of a comprehensive, interdisciplinary assessment determine that there are no alternative to provide resident safety, or that the alternative methods have been unsuccessful, a restraint/bed rail may be recommended. *Physical restraint was defined as any manual method, physical or mechanical device, material or equipment attached to or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. *The Definitions section also defined: -Freedom of movement as any change in place or position for the body or any part of the body that the person is physically able to control. -Removes easily as can be removed intentionally by the resident in the same manner as it was applied by staff. *Policy Implementation included: -The interdisciplinary team (IDT) will evaluate the resident's safety needs. -The use of restraints shall require clinical justification must not be used to limit mobility, for convenience of staff .or as a substitute for supervision. -*If a restraint is found to be necessary, appropriate health professional will complete the appropriate documentation in the electronic health record (EHR). The assessment will include medical condition requiring the need for restraint and will be documented in the intervention. -Physician notification is required for all restraints initiated and a physician's order must be obtained prior to implementation. -Resident and family will be educated on restraint use, reasons for use, assessment results, and risks and benefits associated with restraint use. -Resident or resident's family must sign a consent form for restraint use. -Interdisciplinary team and physician will evaluate restraint usage monthly at minimum and will be reviewed at quarterly care conference by care planning team, resident and resident's family. -Staff will check the resident's restraint every 30 minutes provide exercise and therapeutic interventions .provide an opportunity for motion, exercise, and elimination for not less than ten minutes during each two-hour period . 3. Observation on 8/30/22 at 1:39 p.m. of resident 38 revealed: *She was lying on the bed sleeping under a blanket. *A pull tab alarm was attached to her wheelchair at the bedside. *A thin mat was on the floor next to the bed. Review of resident 38's medical record revealed: *She was admitted on [DATE]. *Diagnoses included Alzheimer's, [CONDITION(S)], anxiety, and dementia. *The 6/6/22 quarterly MDS assessment listed: -A Brief Interview for Mental Status (BIMS) score of 00 indicating severe cognitive impact. -Walking/locomotion required 1 to 2 person assist. -A bed alarm was used daily. -A chair alarm was not used. -She had two falls without injury and one fall with injury. *The care plan had dementia with behaviors and falls listed with the following interventions: -History of enjoying walks/assist for walks with 1 person and assistive device. -Take for wheelchair rides. -If she is walking, go to her and offer assistance. -May use wheelchair pushed by another. -Handwritten on the care plan and dated 7/12/22 was pressure pad alarm in bed @ [at] all times and pull string alarm while in wheelchair or chair. *An 8/8/22 fall investigation report revealed: -The incident occurred on 8/8/22 at 3:55 p.m. -Staff were notified from the pull tab alarm sounding and staff went to investigate and found the resident on the floor in the day room laying on her right side in front of her chair sideways one foot pedal was up pushed aside. -It looked as if resident had tried to get up and walk, she is very weak and does not understand her limitations. -Injury, not major/laceration to right ear with first aid provided. -Contributing factors to fall: unexpected movement. -No call light within reach (pull tab alarm on, she was in day room). -Bed/chair alarm used and sounding at time of fall. -Assessment: Resident liked to walk independently, she is now too weak to walk safely and is cognitively unable to understand her limitations. -Time of last purposeful hourly rounding on resident was 15:30 [3:30 p.m.]. -Staffing level at or above matrix and properly trained for situation. -Family notified 8/8/22 at 16:24 [4:24 p.m.]. Interview and review of previously requested records on 9/1/22 at 10:30 a.m. with DNS B about resident 38 revealed: *The facility did not: -Complete a fall risk assessment. -Complete a bed/chair alarm assessment. -Document education with the resident's family or representative for the bed or chair alarm. -Obtain consent from the family or representative for the bed or chair alarm. -Obtain a physician order for the bed or chair alarm. *Following a nurses meeting on 8/31/22 at 7:00 p.m., the bed and chair alarm had been discontinued. Interview on 9/1/22 at 1:25 p.m. with CNA H regarding resident 38 revealed: *She started working at the facility in 2018. *She was assigned to the hallway where resident 38 resided. *The resident was full cares and I just observe her. *The resident's most recent fall was approximately one month ago. *The resident had a history of a fall resulting in a [CONDITION(S)] and surgery. *Interventions in place to prevent falls were: -A bed and chair alarm had been in place for a long time, since 2018 when I came here. -A mat on the floor next to her bed. -We usually lay her down facing the wall so she does not get out of bed, if you put her in bed not facing the wall, she will get out of bed and fall. -We monitor her often every 30 minutes. -Encourage water. -Check to see if she was incontinent. If she is messy she gets restless, so we make sure she is clean. She does not sit on the toilet anymore, she is incontinent all the time now. -Sometimes she liked to go for walks but not anymore. She is not walking now, sometimes she stands up and takes maybe three steps. -These things are in place because she has had a lot of falls. Interview on 9/1/22 at 1:45 p.m. with RN I regarding resident 38 revealed: *She had worked at the facility for one and a half years. *The resident was a fall risk due to weakness and confusion. *Falls had occurred when the resident was trying to stand up from her wheelchair or bed. *Her last fall was approximately one month ago. *The resident had sustained injuries from her falls such as bruises, skin tears, and history of a fracture related to a fall. *Mobility alarms were in place to prevent falls. *The bed was in the lowest position. *Regular checks were completed every hour or more between the nurse and the CNAs. *Nursing was always assessing the resident. *She had not documented a fall risk assessment. *Staff knew what interventions or assistance the resident needed from experience, shift reports and checking the chart to see if there had been a change in condition. *Staff identified interventions were suitable for this resident just the day by day assessment and change in her status. *Her son was involved and here almost every day. *Staff were monitored to ensure they were implementing care-planned interventions by just making sure it is done and going to check the residents to make sure things are in place the way they should be and if they are not making sure they get done and follow up. Interview on 9/1/22 at 2:05 p.m. with activity assistant J regarding resident 38 revealed: *She completed restorative therapy with residents weekly on Tuesdays. *The nurse completed the restorative plan and the schedule. *The resident did not currently participate in restorative therapy. *The nurse had not implemented a restorative therapy plan for this resident since she fell approximately 6 months ago. *She assumed restorative therapy stopped because she had a fall and was in bed and then she started using the wheelchair. *Prior to six months ago, the resident would use the NuStep machine, pulleys, and did range of motion exercises. *Interventions in place to prevent falls were: -Bed in the low position. -A pull tab alarm when she was in the wheelchair or bed. *She never fell during restorative therapy. 4. Observation on 8/30/22 at 1:21 p.m. of resident 21 revealed: *She had sat up at the end of her bed, causing her bed alarm to be activated with an audible alarm. *CNA K came in and turned off the bed alarm and resettled resident 21 in bed, then left. *While the surveyor was still in the room, resident 21 moved herself to the foot end of the bed and sat up, causing the bed alarm to sound again. CNA K responded and stated, [Resident name] let's go out of here, and assisted her out of the room. Observation on 8/30/22 at 2:02 p.m. revealed resident 21: *In her wheelchair in the hallway, during which time she stated, I want to go home. *She self-propelled her wheelchair with a clip attached to the back of her shirt at the top right shoulder, to which a string was fastened leading to an alarm that was attached to her wheelchair. Observation on 8/31/22 at 3:10 p.m. revealed resident 21 in her wheelchair in the hallway by the facility's front entrance with the alarm again attached to her wheelchair and clipped to the back of her shirt. Interview on 8/31/22 at 3:13 p.m. with CNA E revealed: *Resident 21 had the alarm mostly for bed due to her unsafe transfers, but staff also transfer the alarm to her wheelchair during the day. *She demonstrated how staff documented the alarm use in the provider's electronic charting. *The electronic charting stated the pull string alarm was to be used .in bed at night. *She stated, during the morning, she's usually walking with her walker and tires by late afternoon/evening, but she will attempt to stand so we use the alarm on the chair as well. Interview on 8/31/22 at 3:38 p.m. with DNS B regarding resident 21 confirmed: *The pull string alarm was to be used when the resident was in bed at night. *When the surveyor asked if the noise from the pull string alarm may have been a bother to resident 21, she was not aware of any concern. *She revealed they had a pressure pad floor alarm that connected to the call light system and activated the bedside call light when pressure was placed on the floor pad. Interview on 9/01/22 at 1:11 p.m. with CNA D regarding resident 21 revealed: *During the daytime, the alarm would sound once or twice when the resident was in bed. *She did not recall hearing it go off when the resident was in her wheelchair. *When asked if the alarm noise seemed to bother the resident, she stated, Yeah it does, she would look around to see where the noise is coming from. *She stated the alarm was used to prevents falls. Interview on 9/01/22 at 1:30 p.m. with social worker C revealed: *Resident 21's alarm was so she doesn't get up and the alarm was used in both the wheelchair and bed. *She stated resident 21 doesn't seem to be bothered by them. Review of resident 21's medical record revealed: *She had been admitted on [DATE]. *Her diagnosis included: unspecified dementia without behavioral disturbance, history of falling, other specified anxiety disorders, and weakness. *She had a BIMS assessment score of double zero indicating severe cognitive impairment. *She required extensive assistance of staff with her bed mobility, transfers, dressing, toilet use, and personal care. *Her initial care plan developed on 12/3/21 identified she was a fall risk and had PULL STRING alarm handwritten on her care plan. *A 12/4/21 Fall Risk Assessment identified: -Three or more falls during the last 90 days. -Safety devices of a pull string alarm on her chair and bed. *A 12/13/21 nurse note at 2:13 p.m. stated, .Daughter requesting we discontinue use of pull string alarm, concerned it is restricting resident's freedom of movement, concerned it is affecting resident's mood and adjustment. Informed daughter that staff placed alarm out of abundance of caution due to recent falls at assisted living prior to coming. Daughter agreed res [resident] is a fall risk but would like to trial no alarms. Will alert all staff and encourage res to use call light, practice close supervision of resident when ambulating. *A 12/13/21 progress note at 2:42 p.m. documented the bed and chair alarm were in place and working. *Her 12/13/21 admission MDS identified no bed alarm or chair alarm was used in the previous seven days. *A 12/22/21 progress note documented the bed and chair alarm were in place and working. *Resident falls were documented on the following dates: -1/16/22 at 7:50 p.m. in the resident's room. -5/10/22 at 2:30 p.m. in the dining room. -5/27/22 at 4:40 a.m. in the resident's room. -6/9/22 at 6:41 p.m. in the resident's room. -7/28/22 at 1:30 p.m. in the resident's room. -8/12/22 at 3:42 p.m. in the resident's room. *Her 2/14/22 quarterly review MDS assessment identified no bed alarm or chair alarm used in the previous seven days. *Her 5/2/22 quarterly review MDS assessment identified no bed alarm or chair alarm used in the previous seven days. *Her 7/18/22 quarterly review MDS assessment identified a bed alarm was used daily in the previous seven days, but no chair alarm was used. *An eight page MDS summary form completed on 7/18/22 included the fall prevention interventions used in the last 90 days noted, See Care Plan. Pull string Alarm used @ NOC [night], while elder is in bed. *Her care plan dated 7/19/22 identified her problem of fall risk with a goal to prevent falls and fall related injury through the next target date identified as 10/16/22. This problem included the intervention initiated on 12/10/21 of safety equipment, Attach the pull string alarm to [resident's first name] when she is in bed at noc [night], to alert staff when she attempts to get out of bed. This intervention's status was active. *A physician order dated 8/31/22 for a pressure pad floor alarm connected to call light system at bedside. Pull string alarm when resident up in wheelchair. *A nurse note dated 8/31/22 stated, Family update re [regarding] pressure pad alarm at night and pull string alarm during the day. Interview on 9/01/22 at 9:43 a.m. with DNS B regarding resident 21's daughter's concern with the alarm and request for a trial with no alarms revealed: *She stated they had conducted a trial period with no alarms, however, there was no clear trial period identified in the resident's record. *Review with DNS B of the initial care plan, fall risk assessment, four MDS assessments, and current care plan regarding alarm use failed to reveal a timeline on when the alarm use was broadened to be used in both the bed and wheelchair and/or when the trial with no alarms was completed. *DNS B did reveal a note in resident 21's record that stated the alarm was D/C [discontinued]12/13/21 per daughter. *She confirmed that resident 21 was currently using a chair alarm and a bed alarm. Further interview with DNS B on 9/1/22 at 9:43 a.m. regarding the use of position change alarms or pull string alarms revealed: *Assessment of these alarms for individual resident use were not documented. *She had verbal discussion with staff on the need for the position change alarms. *The fall risk assessments for residents were completed only once, upon admission. Interview on 9/1/22 at 10:20 a.m. with DNS B revealed: *The provider had a Physical Restraint/Bed Rails Policy last revised on 12/2021. *The provider did not have a policy specifically addressing position change alarms by name. *There was no procedure or process in place for the use of resident position change alarms. *There were no consent forms signed by family/representative for use of alarms prior to use. *The provider had not obtained physician orders for mobility alarms prior to use.

Based on observation, interview, and policy review, the provider failed to ensure infection control techniques were maintained by one of one certified nursing assistant (CNA) (B) during one of one observed resident's (1) bath. Findings include: 1. Observation on 10/15/21 at 10:54 a.m. of CNA B while assisting resident 1 with her bath revealed she: *Had entered resident 1's room, gathered clothing and bathing items touching several surfaces in the room, and pushed resident 1 out of the room in her wheelchair (w/c). -She had not performed hand hygiene. *Pushed resident 1 into the whirlpool room and without performing hand hygiene she: -Put on a pair of gloves. -Assisted resident 1 to stand up out of the w/c. -Pulled down resident 1's pants and incontinence pull-up and assisted her to sit in the bath chair. -Removed resident 1's shoes, pants, and incontinence pull-up. -Took her gloves off, and assisted resident to remover her shirt, bra, and watch. -Used the controller on the bath chair to raise the resident into the air. -Put on a pair of gloves and performed perineal care. -Removed the gloves, and pushed the resident to the bathtub. -Picked up a pen and paper and wrote down resident 1's weight. -Picked up a clean towel and set it on the handle of the lift chair she had used to push the chair to the bathtub. -Put on a pair of gloves, assisted resident 1 to wash her face and then washed her perineal area. -Changed her gloves and continued to assist resident with the bath. Interview on 10/15/21 at 11:30 a.m. with CNA B regarding the above observation revealed she: *Usually carried hand sanitizer in her uniform pocket but had set it on the shelf in the whirlpool room. *Agreed she had missed several opportunities to wash her hands. *Agreed she had been educated on appropriate hand hygiene and should have washed her hands: -When entering and exiting a residents room. -Before and after glove use. -When moving from a clean task to a dirty task. -After touching residents or their belongings. Interview on 10/15/21 at 11:40 a.m. with director of nursing A regarding the above observation and interview revealed: *She agreed CNA B had missed several opportunities to perform hand hygiene. *She had expected staff to perform hand hygiene when: -Entering and exiting a residents room. -Before and after glove use. -Moving from a dirty task to a clean task. *Provider had done hand hygiene competencies with all staff about one year ago. Review of the provider's April 2021 Hand Washing policy revealed: *Staff will use proper handwashing to prevent the spread of pathogens. *It had not indicated when staff should perform hand hygiene.

Based on observation, interview, record review, and policy review, the provider failed to ensure appropriate processes were in place for the delegation of medication administration by certified nursing assistants (CNA) for six of nine sampled residents (4, 22, 29, 30, 40, and 46). Findings include: 1. Observation and interviews revealed CNAs had been administering a topical physician ordered medication. Medication administration was not included in the CNAs scope of practice. Refer to F554.

Based on observation, interview, record review, and policy review, the provider failed to ensure consistency in assessment and implementation of self-administration of medication for six of nine sampled residents (4, 22, 29, 30, 40, and 46) Findings include: 1. Observation and interview on 3/11/20 at 9:45 a.m. with certified nursing assistant (CNA) A revealed: *A tube of Aspercreme in the tub room on a one drawer stand. The Aspercreme had a pharmacy label on it for resident 22. *She stated the CNAs applied the Aspercreme or a similar type of topical pain ointment on the residents for pain. She stated they had been instructed by the nurses to apply those medications. Review of resident 22's medical record revealed: *A 3/26/18 physician's order for Aspercreme. Apply to affected areas twice daily for pain. *There was no physician's order received for her to have self-administered the Aspercreme. *There were no self-administration of medications assessments. *Her 8/16/19 last reviewed care plan revealed pain interventions that included: Administer Tylenol 650 mg (milligram) bid (twice daily) and prn (as needed) and aspercreme bid as ordered (nurse). 2. Observation on 3/11/20 at 10:00 a.m. in resident 46's room revealed a tube of Aspercreme in her bathroom. Review of resident 46's medical record revealed: *A 9/6/18 physician's order for Aspercreme to apply to both knees as needed. Could be kept at bedside. *She had a 2/24/20 self-administration of medication assessment. That assessment revealed (resident name) requires assistance with the adminstration of her meds (medication) for the safety of both (resident name) and others around her R/T (related to) her cognitive impairment AEB (as evidenced by) BIMS (Brief Interview of Mental Status) score of 0 (zero) and Dx. (diagnosis) of dementia. *Review of her 2/27/20 care plan under her pain assessment interventions revealed, May administer Aspercreme PRN for bilateral knee discomfort. 3. Interview on 3/11/20 at 10:30 a.m. with CNA A revealed she stated quite a few of the residents had the above medication in their rooms for the CNAs to apply. Interview on 3/11/20 at 10:45 a.m. with registered nurse (RN) E revealed the nurses should have applied those ointments. She was not aware the CNAs had been applying those medications. 4. Observation on 3/11/20 at 3:15 p.m. of resident 30's bathroom revealed a tube of muscle rub cream in her bathroom. Review of resident 30's medical record revealed: *A 10/9/19 physician's order DC (discontinue Aspercreme when gone - ctn (continue) Muscle Rub Cream affected areas PRN. (May keep in room). *A self-administration of medications assessment on 9/11/18 revealed she had been able to self-administer medications. On 2/27/19 it stated no. Monthly checks had been done but it was not clear which medications were checked 10/9/19. *A 1/27/20 self-administration of medications assessment revealed (Resident name) requires assistance with administration of all her meds for the safety of both (resident name) and others around her due her physical functional limitations of her shoulders. *Review of her 1/28/20 last reviewed care plan revealed a 9/11/18 self-administration intervention: (Resident name) is not able to administer her medications safely due to limited function to her upper extremities. The nurse administers them to her. 5. Observation and interview on 3/11/20 at 3:30 p.m. with resident 40 revealed she had a tube of Aspercreme ointment in a drawer under her television. She stated she had the CNAs apply it to her legs. Review of resident 40's medical record revealed: *A 8/29/15 physician's order for Aspercreme May keep at bedside and apply to skin topically as needed. *Her self-administration assessment after set-up on 2/17/20 revealed: (Resident name) is alert and physically able to self-administer her own meds after set-up in regards to the safety of both (resident name) and others around her. It did not address her ability to self-administer her topical medications. *Review of resident 40's 2/20/20 last reviewed care plan revealed a 2/14/16 intervention for the self-administration of medications. May administer own meds after set up assist. 6. Observation and interview on 3/11/20 at 4:00 p.m with resident 29's husband revealed: *A tube of Aspercreme ointment was in her bedside table. *Resident 29's husband stated the CNAs applied that when they assisted her in the morning. Review of resident 29's medical record revealed: *She had no physician's order for the self-administration of medications. *A self-administration of medication after set-up assessment on 1/27/20 stated she required total assistance with her medications. 7. Observation on 3/11/20 at 4:15 p.m. of resident 4's room revealed a tube of Aspercreme in her room. Review of resident 4's medical record revealed: *A 9/25/19 physician's order: (Resident name) may administer her medications safely after setup with harm to other residents. *There was no order for her to keep any medications in her room to self-administer. *A 12/16/19 self-medication administration after set-up assessment revealed (Resident name) is alert and physically able to self-administer her meds after set-up - nursing staff report that she takes her meds as they are given to her. *Review of her 12/17/19 last revised care plan revealed no information on the self-adminstration of Aspercreme and her keeping it in her room. 8. Interview on 3/12/20 at 9:30 a.m. with director of nursing F revealed: *A self-administration of medications comprehensive assessment was completed on admission in the electronic medical record (EMR). *Then every quarter she completed a hand written assessment. *That assessment did not include all the same questions as the assessment on the EMR and usually only addressed oral medications. *She was not aware the CNAs had been applying the Aspercreme. *She did state the above residents had a physician's order for having the medication at bedside. *She did not know that was only if the resident was able to self-administer which included topicals. Review of the provider's last revised November 2018 Self-Administration of Medication policy revealed:*An assessment of the residents' ability to self-administer medication will be performed by the IDT (interdisciplinary team) every three months, based on changes in the residents' medical decision-making status, and as needed, *A physician's order will be obtained and recorded in the chart. The order also will include which specific medications can be kept at the bedside.

Based on observation, interview, record review, and policy review, the provider failed to ensure: *Appropriate hand hygiene and glove use during two of four sampled residents (19 and 40) personal care by four of five certified nurse assistants (CNA) (C, D, H, and I) was used. *Mechanical lifts had been sanitized by three of three CNAs (D, H, and I) between residents' use during two of two observations. *Appropriate hand hygiene and glove use during one of two sampled resident (47) dressing changes by one of two nurses (E) was done. Findings include: 1. Observation on 3/10/20 at 8:45 a.m. revealed: *CNA C entered resident 19's room and put on gloves. She had not completed any hand hygiene. *With those same gloves she retrieved the resident's clothes from her closet, raised the bed, put lotion on both of the resident's legs, put on her support stockings, and her shoes. *Put on new gloves and without performing any hand hygiene she assisted the resident with washing her face, hands, and back. *Removed her gloves and used hand sanitizer then retrieved a standing lift from the hallway. *Entered the room with the lift and put on gloves. *CNA C and CNA D assisted the resident to a standing position with the lift. *Moved the resident into the bathroom with the lift, and CNA C removed the resident's incontinence brief. She removed her gloves and did not perform any hand hygiene. *After resident 19 had finished on the toilet CNA D provided perineal care. She used the same disposable wipes to clean from front to back twice and then used a second cloth in the same way. *When they had put resident 19 in her wheelchair CNA D removed the standing lift from the room and took it into another resident's room. *She had not sanitized her hands or the standing lift. Review of resident 19's 1/8/20 care plan revealed: *A goal to be free from infections through the next target date. *A intervention: History: Noted a discharge [DIAGNOSES REDACTED]. Interview on 3/12/20 at 9:30 a.m. with director of nursing (DON) F revealed: *CNAs C and D had not followed proper handwashing and glove use. *She monitored handwashing and glove use on a regular basis. *She was aware resident 19 had been classified as a CRE bacteria carrier. *Staff had not been instructed on any enhanced precautions. 2. Observation and interview on 3/11/20 at 9:28 a.m. of registered nurse (RN) E with resident 47 during a dressing change revealed: *She cleaned the wound. *Then she removed her soiled gloves. *She had new clean gloves on the barrier with her dressing supplies and when she had reached for them one glove had fallen into the contaminated sink. -She picked up the glove and put both the gloves on. *She did not perform hand hygiene between changing her gloves. *After the dressing change was completed she removed her gloves and washed her hands at the sink. -She did not wash her hands for twenty seconds. *She had agreed she should have washed her hands between glove use. *She had not noticed her clean glove had fallen into the sink. *Agreed her hand washing time was not long enough. 3. Observation and interview on 3/10/20 at 2:53 p.m. of CNAs H and I assisting resident 40 revealed: *Both CNAs had clean gloves on and were assisting the resident to change a soiled incontinence brief in bed. *CNA I had performed perineal (peri) care, and then with those same contaminated gloves on she: -Had applied protective ointment to the resident's bottom. -Assisted the resident into a new incontinence brief. -Pulled up her pants. *CNA I then changed her contaminated gloves with no hand hygiene in between. *CNA H had assisted CNA I with rolling the resident back and forth in the bed to complete the task then removed her gloves. -She did not perform hand hygiene after removal of those contaminated gloves. *Then they put the Hoyer sling under her. *After CNA I removed her contaminated gloves, and did not perform hand hygiene she grabbed the mechanical lift. *Both CNAs assisted to hook the resident in the Hoyer sling to the mechanical lift and put her into her wheelchair (w/c). *CNA H had taken candy out of drawer, given it to the resident, and then proceeded to comb her hair. -She still had not performed hand hygiene. *CNA I pushed the mechanical lift out of the room and left it in the hallway, then she took the garbage to the dirty utility room, and then performed hand hygiene when she was back in the hall. *CNA H assisted the resident in her w/c down the hall to an activity, and then stopped to perform hand hygiene. *Both CNAs agreed: -They should have performed hand hygiene each time they removed their gloves and before leaving the resident's room. -The mechanical lift could be contaminated due to them not performing hand hygiene. *CNA I thought the night shift cleaned the lifts. *CNA H said she would have cleaned the mechanical lift if it was visibly soiled otherwise housekeeping cleaned them. Interview on 3/11/20 at 8:14 a.m. with housekeeping manager J revealed: *Housekeeping did not clean the mechanical lifts. *Nursing was responsible to clean the mechanical lifts. Interview on 3/12/20 at 10:40 a.m. with DON F about the above observations revealed: *She agreed staff should have washed their hands with each glove change and before leaving a resident's room after care. *She agreed the mechanical lift should have been cleaned. *The night shift CNAs had a cleaning schedule, and the mechanical lifts were on the schedule. *The CNAs had been educated to use the sanitizer wipes on the mechanical lifts after use if it had become contaminated. *The housekeepers did not clean the mechanical lifts. Surveyor: 4. Review of the provider's last reviewed March 2020 Hand Hygiene policy revealed: *Wash hands with soap when visibly dirty, contaminated with blood or body fluids. *To use friction for twenty seconds. *Change gloves when moving from a contaminated area to a clean area of care. *Always wash hands or use alcohol cleaner after the removal of gloves. Review of the provider's last reviewed January 2020 Disinfection of Non-Critical Patient (resident) Care Equipment policy revealed: *Non-critical resident care items between/after each resident use. *They require low level disinfection by cleaning periodically with a disinfectant, detergent, or germicide.

Based on observation, interview, record review, job description review, and policy review, the provider failed to identify and document assessed needs and interventions for three of three sampled residents (5, 25, and 48) with medically related social service needs. Findings include: 1. Review of resident 5's medical record revealed: *She was admitted on [DATE]. *Her [DIAGNOSES REDACTED].>-Heart failure. -Hypertension. -[MEDICAL CONDITION] disorder. -GERD. A review of resident 5's 1/14/19 Minimum Data Set (MDS) assessment revealed: *Her Brief Interview for Mental Status (BIMS) assessment score was fifteen indicating she was cognitively intact. *She was independent in all activities of daily living including: -Bed mobility. -Transferring. -Ambulating. -Dressing. -Toileting. *She was always continent of bowel and bladder. Observation and interview on 4/9/19 at 1:30 p.m. with resident 5 revealed: *She thought she would be a short term resident as her hip was healing. *She wanted to go home but had not worked on any discharge planning since admission. *She had a [AGE] year old son at home that she had always lived with until her admission. *She understood her physician thought it would be best for her to stay at the facility, but that was not what she wanted. Interview on 4/9/19 at 1:57 p.m. with the licensed social worker (LSW) regarding resident 5 revealed: *The resident frequently talked about going home and in those conversations with the LSW she agreed the nursing home was the best place for her. -There was no documentation of those conversations. *Her son who had a mental illness lived with her at home prior to her admission. -He currently was doing well with community services in their home. *The physician who treated her was also the physician for her son. *The physician felt that with her doing well and her son doing well her going home was not a good idea. *She had talked with the resident about what it would take for her to return home. -There was no clarification of what that meant or documentation to support it. *She only talked to residents about discharge if they told the nurse completing their quarterly assessment they would like to be discharged . Review of resident 5's social services documentation from 2/28/18 through 4/8/19 revealed: *On 2/28/18: When asking her about the nursing home she will say what she has said since she first came to live at AEHCC (Avera Eureka Health Care Center). I would like to go home because my son needs me and I feel I could help him but I need to be here. *There was no other social services documentation. Review of resident 5's current undated care plan revealed there were no goals or interventions related to social services or discharge planning. 2. Review of resident 25's medical record revealed: *She was admitted on [DATE]. *Her BIMS assessment score was fifteen indicating she was cognitively intact. *She had a [DIAGNOSES REDACTED]. Observation and interview on 4/9/19 at 8:15 a.m. with resident 25 revealed: *She was tearful when talking about her move to the nursing home. *She stated, Closing the door to my home, knowing I would not be coming back was one of the hardest things I have ever done. *She was still struggling with the transition from her home to the nursing home. *She also stated, Everyone has their problems, I miss my home, but I have to accept living in the nursing home now. Interview on 4/9/19 at 4:02 p.m. with the LSW regarding resident 25 revealed: *She had gone to the resident's home prior to admission to assist her with the transition. *She had visited with her about the transition. *The had never seen the resident tearful about her move. *There was a housekeeper who visited with her daily while she cleaned her room. -There was no documentation of those interactions. *They had the ability to refer individuals to Northeastern Mental Health Center for therapy services but had not referred resident 25. Review of resident 25's social service documentation from admission to present date revealed: *On 3/30/18 a note was written by the LSW about her moving to the facility. *On 9/5/18 a note was written about a conversation regarding her having a roommate. -It acknowledged she had struggled with having a roommate in the past. -She did not want to pay for a private room. -The LSW had suggested she, Try to relax the first couple of days as it is an adjustment for all who move in. *On 9/24/18 a note was written about a conversation regarding a possible new roommate as the last possible roommate had not moved in. -She did not want to pay for a private room. -The note acknowledged her difficulty with roommates in the past. -The note also acknowledged the struggles such as the resident not wanting to talk much and needed the bathroom to be available when she needed it. -There was no documentation of social service intervention regarding her struggle with moving to the nursing home or the above concerns she had about getting a roommate. Review of resident 25's 2/27/19 care plan revealed: *On 4/10/18 it was identified the resident was struggling with her adjustment to the facility. *The only interventions were to get her involved in activities of her choice. *There were no updates to those goals or interventions since 4/10/18. 3. Review of the provider's 12/1/17 Transfer and Discharge from Facility policy revealed there was no direction for discharge planning as it pertained to resident initiated discharges. Review of the provider's 3/20/19 Behavioral Health policy revealed: *It is the policy of the facility that each resident must receive and the facility must provide the necessary behavioral health care and services and medically - related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment (483.20) and plan of care. *The objective of the Behavioral Health Policy and Procedure is to provide a plan of care that is individualized to resident needs based upon the comprehensive assessment by the interdisciplinary team. This plan of care will include medically related social services to address behavioral health concerns and care planning to attain or maintain the highest practicable well-being. *The interdisciplinary team will document assessment findings, care plan approaches/interventions and behavior/mood tracking results in the medical record per facility policy. Review of provider's Documentation by Standards policy revealed: *The collection of data about the health status of the patient is systematic and continuous and the the data is accessible, communicated and recorded. *All of the procedure spoke directly to skin assessments and not social service documentation. 4. Observation and interview with resident 48 on 4/8/19 at 5:30 p.m. revealed she refused to come out of her room for supper. Interview on 4/8/19 at 5:30 p.m. with registered nurse (RN) C regarding resident 48 revealed she frequently would not come out of her room for meals. It depended on her mood. That is just (resident's name). Observation on 4/9/19 at 11:00 a.m. revealed resident 48 would not come out of her room for the noon meal. At that time she was approached by this surveyor and as I entered the room, she shook her head as if to say no she did not want to talk at that time, and had an angry look on her face. Interview on 4/9/19 at the above time with RN C who was just outside resident 48's room revealed: *She was just that way. *Sometimes she could be in a good mood, but she was frequently angry or upset. *You just had to let her be, and she was left to eat in her room. Review of resident 48's 3/25/19 Minimum Data Set (MDS) assessment revealed she: *Felt down, depressed, and hopeless. *Had a poor appetite nearly every day. *Exhibited physical behavior symptoms one to three days. *Exhibited verbal behaviors daily. -Those behaviors put her at risk for injury or illness. -They interfered with her daily care. -They impacted others and put others at risk for injury. *Rejected care four to six days but less than daily. -Her behaviors had gotten worse. Review of resident 48's 8/13/18 through 4/11/19 social services progress notes revealed: *The LSW had only documented twice on her. *There was no evidence the LSW was addressing her behaviors or assisting her with psychosocial issues. Interview on 4/9/19 at 3:30 p.m. with the LSW regarding resident 48 revealed: *The resident did not like to come out of her room. *She had a very dependent relationship with her son whom she lived with prior to admission. *Her moods varied and changed quickly. -She got angry, hollered, cussed, or cried. *She felt like she had been with the resident often addressing issues. -Her documentation did not address or reflect that. *She was not really aware of how nursing completed the behavior portion of the MDS assessment because nursing did that. -She did completed the mood portion of the MDS assessment. *She normally documented off the MDS, but that documentation had not been done. *They did not have mental health services available, but did not think the resident would accept those services if they were available. 5. Review of the provider's (MONTH) (YEAR) Social Worker job description revealed: *Job summary: Plans, organizes, develops, implements, evaluates and directs the overall operation of the Social service department to assure that an on-going program is designed to meet in accordance with the comprehensive assessment, the physical, the mental, and the psychosocial well-being of each resident. *Essential Job Functions: -Identifies social and emotional problems and assists in planning behavior interventions as appropriate. -Works with all staff to promote optimum resident independence and function. *Assesses resident's psychosocial needs at admission and reviews quarterly. *Performs timely documentation of Social Service interventions and assessments in resident's chart. *Reviews and revises, as necessary, the plan for Social Service intervention. *The ability to present concise and meaningful reports both verbally and in writing.

Based on observation, record review, and interview, the provider failed to ensure interventions were reviewed, updated, and implemented to prevent weight loss for one of five sampled residents (49). Findings include: 1. Review of resident 49's on 7/16/18, 12/31/18, and 3/25/19 Minimum Data Set (MDS) assessments revealed she required supervision, oversight, cuing, or encouragement with set-up help for eating. Observation on 4/8/19 from 5:13 p.m. through 5:30 p.m. revealed CNA A was sitting with four residents at an assistance table including resident 49. During that time resident 49 received no cuing or encouragement while she was eating. Observation on 4/9/19 from 11:20 a.m. through 11:42 a.m. revealed CNA B was sitting with four residents at an assistance table, including resident 49. During that time resident 49 received no cuing or encouragement while she was eating. There was also no intervention when she drank another resident's supplement. Review of resident 49's following weights revealed on: *11/2/18 her weight was 129.0 pound (lb). *12/7/18 her weight was 130.0 lb. *1/1/19 her weight was 124.0 lb. -That was a 4.62% weight loss in thirty days. *2/1/19 her weight was 116.0 lb. -That was a 6.45% weight loss in thirty days. *3/1/19 her weight was 123.5 lb. -That was a 6.03% weight gain in thirty days. *4/1/19 her weight was 114.0 lb. -That was a 7.32% weight loss in thirty days. *That was a significant weight loss of 11.63% in six months from (MONTH) (YEAR) to (MONTH) 2019. Review of resident 49's nutrition progress notes by the registered dietician revealed: *On 11/21/18, her weight was ranging around 130 lbs, and she would be removed from quarterly weight monitoring. *On 4/9/19, an unplanned significant weight loss was identified. She then recommended to start her on the enhanced food program. *There were no other notes from the RD regarding her weight loss. Review of resident 49's 4/2/19 care plan revealed: *She had a goal to maintain her current nutritional status and a weight between 117 to 127 pounds. *She had no interventions for preventing unplanned weight loss from 1/30/18 until 4/9/19. Interview on 4/9/19 at 4:30 p.m. with the director of nursing about resident 49's weight loss revealed: *There was no documentation in her medical record regarding her weight loss. *There was no nursing documentation for consolation with the RD or the unplanned weight loss. *She talked to the RD bi-monthly when she visited about residents who were losing weight. -There was no bi-monthly documentation for this resident. *There was a nursing intervention on 1/27/19 to add apple ensure with breakfast. *There were no other nutritional interventions in place.

Based on record review, interview, and policy review, the provider failed to ensure interventions to maintain resident safety had been implemented for one of one sampled resident (41) who had a fall with an injury. Findings include: 1. Review of resident 41's medical record revealed: *She had been admitted on [DATE]. *Her [DIAGNOSES REDACTED]. *She had been dependent on staff for transfers, bed mobility, and eating. *She had a fall with minor injury on 2/12/19. *Her care plan had indicated that a body pillow was to be used at all times while she was in bed for positioning and safety. Review of resident 41's 3/13/19 Physician order [REDACTED].>*A handwritten entry by the physician stated: -Using body pillow with no further falls. Review of resident 41's 2/12/19 Fall Follow-Up report revealed: *Fall Occurrence Score: Initial fall. *Fall Severity: Injury- not major. *Trauma Event Description: -Resident was found laying on the floor in front of her bed. -Bed was in low position. -Pull string alarm was sounding. -The body pillow was not on. *Has Skin Integrity Changed: Yes. -Did not indicate what had changed. *Did the Resident Hit His/Her Head: Yes. *What can be done in the future to prevent another fall: -Make sure the body pillow is used for positioning when in bed. Interview on 4/10/19 at 8:07 a.m. with the director of nursing (DON) regarding resident 41's 2/12/19 fall revealed: *She had conducted an internal investigation with the direct care staff. *She did not feel the certified nursing assistant (CNA) had been neglectful. -The CNA had not placed the body pillow in the bed for positioning. *The internal investigation had not been documented. *Resident 41 had been sent for x-rays. -She had bruises on the right side of her face, hip, and knee. -All x-rays were negative for injury. *She had not felt the incident would need to be reported. -The fall had not resulted in serious injury. Review of the provider's (MONTH) (YEAR) Fall policy revealed: *To be proactive in preventing resident falls and accidents. *The fall must be investigated for cause and documented in the facility incident report system for tracking and monitoring. *Review of individualized resident centered interventions including adequate supervision and assistive devices to reduce individual risks related to hazards in the environment must occur. *The fall must be reported to the South Dakota Department of Health if the incident meets the reportable incident criteria. *The policy had not indicated what criteria would make the incident reportable to the Department of Health. Review of the provider's (MONTH) (YEAR) Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property policy revealed: *Definition of neglect: Is the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. *It was the policy of the facility that reports of abuse (neglect) would be promptly and thoroughly investigated. *The investigation was the process used to try to determine what happened. *The designated facility personnel would begin the investigation immediately. *The information gathered was given to administration or designed for submission. *The results of the investigation would be recorded and attached to the report. *Internal reporting would be done immediately to the administrator. *External reporting:-Report would be done to the State Agency. -If the event caused serious bodily injury it would be reported in two hours. -Otherwise it would have been reported no later than twenty-four hours. *The policy had not been specific related to falls with injury. *The policy had not been specific to incidents related to neglect.

Based on observation, interview and record review the provider failed to have comprehensive care plans for two of sixten sampled residents (5 and 25). Finding include: 1. Review of resident 5's current undated care plan revealed it was not individualized or person-centered, or comprehensive for discharge planning. Refer to F745, finding 1. 2. Review of resident 25's 2/27/19 care plan revealed it was not individualized, person-centered or comprehensive, for behavioral health needs. Refer to F745, finding 2.

Based on observation, interview, record review, and protocol review, the provider failed to identify and implement individualized interventions to prevent facility acquired pressure injuries for two of five sampled residents (32 and 51). Findings include: 1. Review of resident 32's medical record revealed: *She had been admitted on [DATE]. *Her [DIAGNOSES REDACTED]. *She was cognitively impaired and required staff assistance with all her activities of daily living (ADL). *She had no pressure injuries at the time of her admission. *During her stay she had declined in her ADLs abilities and had a decline in her range of motion to her extremities. -Refer to F676 and F688 for further details. Observation and interview on 1/9/18 at 9:43 a.m. with certified nursing assistants (CNA) J and K during resident 32's morning care revealed: *She was thin and appeared frail. *She had contractures to both upper arms. *She was dependent on the CNAs for personal hygiene, bed mobility, dressing, and transfers. *During her care a dressing was noted on her coccyx area. -According to CNA J the opened area had been there a week or two. *There was also a quarter-sized red area noted to her bony area of her left hip. -The CNAs stated that was new. -CNA J applied an unidentified cream to that area. *When questioned what the area was CNA J asked what they should have done, and then he decided to call for the nurse. *At 9:47 a.m. licensed practical nurse (LPN) F came into the room. -She told the CNAs they needed to move her more. -She stated it was not a stage one pressure injury, but she had not really assessed the area. -She stated she would come back in a minute to measure it. -She left and came back with a measuring device and measured the left hip area. -She stated it was a two centimeter (cm) by one cm stage one pressure area, because she had been laying too long in one spot. -She told the CNAs she wanted to look at it again later that day. -When asked about the coccyx dressing she stated she was unsure when that needed to be changed, but that it could be looked at later as well. -Then she left the room. Continued observation and interview on 1/9/18 at 9:55 a.m. with CNAs J and K in resident 32's room revealed:*They moved the resident from her bed to her wheelchair using a gait belt after they got her dressed. *The wheelchair had a foam-type cushion in the seat. *According to CNA J the red area to her hip was not there before. -He thought it might have been because she had been laying in the same spot all night. -They were just getting to her for morning care now due to running behind. -Their shift had started at 6:30 a.m. *When asked if the resident was on a repositioning schedule: -CNA J said she was not. -During the day they got her up into her wheelchair for breakfast and lunch. -She was assisted to lay down usually after lunch, but there was no specific schedule. -He was not sure if there was a repositioning schedule for her at night or in the evening either. Observation on 1/9/18 at 11:24 a.m. of resident 32 revealed: *She was sitting in her wheelchair in the dining room at the table. -She needed staff assistance to eat and drink her meal. *At 12:00 noon she was still sitting in her wheelchair in the dining room. -That was over two hours from the time she had been put into the wheelchair at 9:55 a.m. Observation and interview on 1/09/18 at 1:09 p.m. with CNA L and LPN F in resident 32's room revealed:*The resident had just been assisted to lay down in her bed and was laying her back. *CNA L indicated the resident had been up in her wheelchair since the CNAs had gotten her up that morning. *LPN F completed the dressing change to the resident's coccyx area. *After she removed the partially crumpled dressing from the resident's coccyx area: -A pencil-eraser sized stage two pressure injury was observed with a scarred area below it. -There was another stage two pressure injury near that one on her left inner buttock that was slightly smaller than the coccyx area. -The stage one pressure injury to her left hip remained reddened. -There was another quarter-sized stage one pressure injury to her right upper buttock area. *LPN F left the room to get more wound supplies and when she returned she confirmed the staging of the above pressure injuries. -She stated the left hip, left inner buttock, and right upper buttock were new pressure injuries. *She measured three of the areas and applied a dressing to the coccyx area that also covered the left inner buttock area. -She had not measured the stage two area to the left inner buttock. *LPN F thought the resident's coccyx pressure injury had been an area that was open before, had healed, and then re-opened. *LPN F and CNA L were unsure if the resident's concave mattress on her bed was pressure relieving. *They thought the cushion in her wheelchair was foam and were unsure if that was pressure relieving. *The surveyor asked them what the resident's repositioning schedule should have been. -CNA L did not respond. -LPN F stated the resident should have been repositioned at least every hour and a half due to her skin being so fragile. *LPN F confirmed the resident was at high risk for pressure injuries due to her impaired mobility, nutrition, impaired cognition, dependence on staff for care, and incontinence. *According to the CNA and LPN nursing staff typically only documented residents' repositioning once at the end of their shift not each time it had occurred. -The end of shift documentation should have indicated the repositioning had occurred every two hours. Continued interview and record review on 1/9/18 at 1:24 p.m. with LPN F regarding resident 32 revealed:*The only pressure injury assessment for the coccyx area had been on 1/5/18 by the DON. -At that time it had measured 0.4 cm by 0.3 cm and was a stage two pressure injury. *There was no mention or assessments of the areas we had observed during the above dressing change. *There was nothing in the resident's 1/5/18 nurse's notes regarding any pressure injury or skin concern. *She stated with any new skin concerns for a resident the nurse should have: -Implemented a physician's standing order for a treatment to the area. --The carbon copy of that standing order was retained, the original copy was sent to the physician to sign and notify them, then that would return to the facility to be put into the resident's medical record. -The care plan should have been updated and interventions implemented at that time to promote healing. *The resident's family should have been updated. *Nursing staff were told in verbal report to increase the frequency of repositioning the resident. *For resident 32's 1/5/18 coccyx pressure injury she: -Could not say if the physician had been updated since the original copy had not returned to them yet. -Could not tell if the family had been notified. -Could not confirm the nursing staff had been told of increasing the repositioning schedule since report was not documented. It was just verbal instructions. --She had not indicated how many shifts they would have discussed concerns in verbal report. -Confirmed individualized interventions had not been implemented for prevention of pressure injuries or changed prior to or as a result of the 1/5/18 coccyx area. Interview on 1/9/18 at 2:45 p.m. with CNA I regarding resident 32 revealed:*She usually worked on the resident's hallway. *She had not been aware of skin concerns with the resident. *She stated the CNAs got verbal report from the night nurse when they started their shift in the morning. -That report was not documented anywhere. *If a resident had a specific repositioning schedule it should have been listed on their care plan. *If the resident had an intervention to reposition every two hours the CNAs only documented that once at the end of their shift, and not each time it had occurred. Phone interview on 1/9/18 at 4:24 p.m. with resident 32's husband revealed he:*Visited his wife two to three times a week. *Was aware of one opened area to her buttocks. *Stated his wife's condition had declined overall. -She had lived at home prior to her hospitalization and was walking when she had been admitted in March 2017. -Now she was in the wheelchair if she needed to get around anywhere. *Had just been told of the three new pressure injuries. *Questioned how those areas could have occurred and asked if it could have been hygiene related since she was incontinent. -He further stated he had not seen her not being toileted or anything, but he was curious. *Stated she never had skin problems on her buttocks prior to this. Interview and record review on 1/10/18 at 10:48 a.m. with the director of nursing (DON) regarding resident 32's pressure areas and care plan revealed: *She confirmed the resident had developed four new facility-acquired pressure injuries in the last week. -Three of those areas were noted on 1/9/18. *She was the nurse who had noted the pressure injury to the resident's coccyx on 1/5/18. -She had implemented the standing order for a dressing change that day. *She had updated the resident's care plan with the new pressure area and the dressing change. -She had not changed or added other interventions for her skin breakdown at that time. *The resident was at very high risk for skin breakdown and did not have pressure injuries when she was admitted . *She did not think the resident had other pressure areas until the record review indicated she had an unstageable pressure area to her right inner heel. -That area had been noted on 4/11/17 and was healed on 4/22/17. *The resident's revised 1/5/18 care plan had not been updated with individualized interventions for pressure relief and healing as her condition changed, other than the addition of the 1/5/18 dressing change. *The resident's 11/22/17 care plan with handwritten updates revealed no changes in pressure relieving interventions such as: -An individualized more frequent repositioning schedule. -What kind of pressure relieving devices had been in place or implemented other than heel protectors. -That she was at risk for skin breakdown and had a history of [REDACTED]. *Her care plan had indicated staff were to assist her with repositioning every two hours which had not been followed in the above observation. *When she had noted the resident's coccyx pressure injury on 1/5/18 she: -Wrote a physician's standing order for a dressing change to that area. --The original copy of that order had been sent to the physician to sign, but she had not specifically notified the physician other than sending the standing order. -She had not notified the family on 1/5/18. ---She thought she had told the resident's daughter on 1/8/18, but the note did not say they were notified of skin concerns. -She had updated the resident's care plan with the new pressure injury and only the dressing change. --She had not implemented other interventions for prevention of further pressure injuries. *The CNAs and other nurses would have been aware of the resident's pressure injury through verbal report and by looking at the care plan. *When asked of dietary's involvement with the resident's skin concerns she indicated they had not been notified yet. -She emailed the registered dietitian an update during this interview. Continued interview and record review with the DON regarding resident 32 revealed:*The resident's pressure ulcer to her right heel had started as unstageable on 4/11/7 and was healed on 4/22/17. -There were no assessments in- between those dates. -She stated all pressure injuries should have had weekly assessments. *On 11/15/17 there had been a reddened area documented to her left upper anterior iliac (hip) that they thought had been caused by her incontinence brief. -It was healed on 11/19/17. -The DON thought that could have been the same area as the new stage one area to her left hip now that it was being discussed. *The resident had: -Other medical concerns related to her behaviors and weight loss that the nursing staff were working on. -Been declining in her ability to perform activities of daily living. -Cognitive impairment and was dependent on staff for assistance with all care. *As the resident's condition changed her interventions for pressure injury prevention had not been adjusted accordingly. -The interventions on the resident's care plan had remained the same other than the 1/5/18 addition of the dressing change to her coccyx pressure injury. *She expected all resident's to have been repositioned at least every two hours for pressure relief. *Resident 32 was at high risk for skin breakdown and should have been repositioned more frequently because of that. *Nursing staff should have repositioned residents every two hours, but they documented that repositioning only once at the end of their shift to support it had been done. Review of resident 32's CNA documentation and interview with the DON indicated: *An intervention to elevate her legs every shift with no documentation for five out of the nine days from 1/1/18 through 1/9/18. *The intervention for turn and reposition had no specific frequency indicated for how often to do that. -There had been no documentation other than for that morning of 1/10/18. -She was unsure why that intervention had not been initiated and had no documentation prior to 1/10/18. *Interventions had to be initiated by the nurse in order for them to show up for the CNAs. *During the continued interview she confirmed there was no documentation to support the resident had been repositioned at the minimum of every two hours. Review of the resident 32's Braden Risk Assessment scores for risk of skin breakdown for the following dates with the DON revealed: *Scores of twelve or less indicated residents were at high risk. *On 4/11/17 her score was eighteen, at risk, and she had a right heel unstageable pressure injury. *On 5/11/17 her score was seventeen, at risk, with the right heel area healed on 4/22/17. *On 6/5/17 her score was eighteen, and she was at risk. *On 8/28/17 her score was fifteen at low risk. *On 11/20/17 her score was sixteen at low risk. *None of those assessments indicated what types of interventions had been implemented to prevent pressure injuries from occurring. *The DON confirmed the resident's score had not indicated she was at high risk for pressure injuries. *She agreed the resident was considered higher risk for breakdown related to her: -History of a pressure injury to her heel after admission. -Poor nutrition and weight loss. -Sensory perception concerns related to her cognitive impairment. -Dependence on staff for all activities of daily living. -Impaired mobility and inability to walk. -Incontinence. --Those factors should have had individualized interventions implemented for pressure injury prevention. *She confirmed as the resident's condition changed and declined her risk for pressure injuries increased. -Interventions for pressure injury prevention had not been updated or increased as her condition had changed, and they should have been. *When asked about pressure relieving devices she was unsure what type of cushion was in the resident's wheelchair, what type of mattress was on the bed, or if those were considered adequate for a resident at higher risk for skin breakdown. *Review of the vendor supply catalog with the DON indicated the resident's wheelchair cushion was a basic flat foam/gel cushion that: -Provides basic pressure management support. --Information for the mattress was requested at that time and not received by the end of survey. *She indicated about two to three different types of mattresses were used that were standard to the bed frame. -They did not have air mattresses or mattresses specific to provide higher pressure relief. Review of resident 32's Minimum Data Set assessments related to pressure injuries revealed:*On the 3/21/17 admission and the 6/5/17, 8/28/17, and 11/20/17 quarterly assessments she was at risk for pressure injuries but had none. -For skin and treatments no interventions were listed as implemented. *Interventions that could have been implemented included: -Pressure reducing devices for chair and bed. -Turning/repositioning program. -Nutrition or hydration intervention to manage skin problems. -Pressure ulcer care. -Application of nonsurgical dressings (with or without topical medications) other than to feet. -Application of ointments/medications other than to feet. -Applications of dressings to feet (with or without topical medications). *The care area assessment note for the 3/21/17 admission assessment related to pressure injuries stated: -(Resident) has no pressure ulcers upon admission. She requires total dependence for bed mobility. She has a Braden Risk Assessment score of 15 indicating that she is at a low risk for pressure ulcers. She is [DIAGNOSES REDACTED]. Will care plan for healthy skin interventions and monitor for changes. *According the the above concerns the care plan had not been updated as changes occurred. Interview on 1/10/18 at 3:30 p.m. with LPN D regarding resident 32 revealed:*She was often the charge nurse for the resident's hallway. *The resident had multiple medical concerns since she had been admitted in March 2017 including behaviors, weight loss, and an overall decline. *She had changed the resident's foam/gel cushion in her wheelchair that day, because the other one was not soft enough. *The new stage one pressure injury on the resident's left hip was actually the same as the area that had been noted in November 2017. *The physician had visited the resident that day (1/10/18) and made some order changes for the pressure injuries. *She thought the resident's recent pressure injuries could have been related to her decline and poor nutrition. *She thought the staff were repositioning her every two hours but might not have been documenting that. *She confirmed pressure injury prevention interventions had not changed as the resident's condition worsened, and they should have. Further interview on 1/10/18 at 3:52 p.m. with the DON revealed:*Her and one other nurse had gone to a pressure injury training course in May 2017. *The other nurses also had an inservice in May 2017 on pressure injuries. *She confirmed: -More pressure injury education should be done for all nursing staff. -Prevention interventions were important and should have been implemented for resident 32. *She confirmed the facility had four resident's currently with pressure injuries and one that had recently healed. -Three of those four resident's had pressure injuries that were facility-acquired. *She agreed pressure injuries were a serious concern and more education and training was needed. -The week before she had assigned the nurses a few online training courses but most had not started those yet. *The surveyor requested any other information the DON thought might support pressure injury prevention had occurred for resident 32. -None had been received by the end of survey. The resident's physician, who was also the medical director, was in the facility most of the day on 1/10/18 performing residents' visits. Due to the physician seeing other residents and not wanting to interrupt that process the DON was asked to check with the physician for time to discuss resident 32's skin concerns and the facility practices. Twice the surveyor requested the DON check with the physician. The DON stated the physician was too busy seeing residents and was not able to meet with the surveyor. During the exit conference on 1/10/18 at 6:15 p.m. the DON and administrator were asked again for any other supporting information regarding resident 32's pressure injuries to be given to the surveyor and none was received. 2. Observation and interview with resident 51 on 01/09/18 at 10:09 A.M. revealed he: *Stated he had a sore on his left heel, but it's better now. *Had on orthopedic shoes. Interview on 01/9/18 at 10:10 a.m. with LPN F regarding resident 51 revealed: *He had an opened area to his left posterior ankle, and it was not on his heel. *A [MEDICATION NAME] dressing change had been ordered for every three days. -That dressing change was due on 1/10/18. *She was unsure when the opened area to his left heel had developed. -The current measurement was 2.5 centimeters (cm) in length (L) by 1.8 cm in width (W). *There had been an abrasion to his right heel on 12/4/17 and to his left foot on 12/7/17. *She stated she Thinks it started out as an abrasion but then opened. -The right heel pressure ulcer is healed. -He has heel protectors for both feet. He is to wear them all the time except when he walks. -He is to elevate his feet when he is in his chair and use a pillow under them. that is to avoid rubbing the back of his ankles. -He does have a pressure ulcer on the posterior left ankle. Review of resident 5's medical record review revealed: *He had been hosptalized on [DATE]. *He returned from the hospital on [DATE]. *There had been no skin breakdown documented at that time. *A physician's orders [REDACTED]. [MEDICATION NAME] lite to areas bilat; secure c (with) kerlix, chg (change) q3 (every three) days et (and) PRN (as needed) *A physician's orders [REDACTED]. Shoes for transfers et ambulation only. Review of the following care activity assessments revealed: *On 11/12/17, 11/19/17, 12/26/17, and 11/1/17 indicated there had been a right heel pressure ulcer prior to hospitalization that had been healed. -It had been documented as a stage II pressure ulcer on 11/12/17 at 0.6 cm L by 1.3 cm W and had been documented as healed on 12/1/17. * On 12/26/17 the left heel stage II pressure ulcer had been 0.8 cm L by 1.8 cm W. -On 1/1/18 assessments stated the pressure ulcer as stage II and 0.5 cm L by 1.5 cm W in size. -On 1/8/18 assessment stated the pressure ulcer had been stage II and 0.5 cm L by 1.8 cm W in size. Observation on 1/9/17 from 11:15 a.m. through 11:45 a.m. of resident 51 while he had been sitting in the dining room revealed: *No heel protectors on either foot. *His legs had not been elevated. *He had shoes on. Observation on 1/9/17 at 2:30 p.m. of resident 51 while he was playing cards revealed he did not have on heel protectors. His legs had not been elevated, and he had on shoes. Interview on 1/10/18 at 10:00 a.m. with LPN D and RN E revealed: *Resident 51 was to have had: -A pillow under his lower legs when he was in bed or sitting in his recliner. -A heel protector on his left heel ulcer at all times. -LPN D stated He doesn't always have them on though. Observation on 1/10/18 at 10:10 a.m. of LPN D while she completed the treatment to resident 51's left posterior ankle pressure ulcer revealed: *The area was clean and dry. *She stated the wound measurements were about the same. *The resident's physician was present during the treatment. She stated the opened area had steadily improved but had not yet healed. Review of resident 51's following Minimum Data Set (MDS) assessments revealed: *The 10/23/17 quarterly assessment Section G-Functional Status: -Limited assistance of one for bed mobility, transfers, walking in room, corridor, and locomotion on the unit, and in his room. -Independent in dressing. -Supervision and set-up assistance with toilet use. -Independent with eating and personal hygiene. -Oversight assistance for set-up help only for toileting. *The 12/1/17 significant change in status MDS assessment revealed: -Section G-Functional Status: --Extensive two person assistance with physical assistance for bed mobility, transfers, and walking in room. --There had been no activity in the corridor. --Total dependence of one person for physical assistance for locomotion on the unit and off the unit. --Extensive assist of two for for eating. --Extensive assist of two for toileting. --Total dependence of one person physical assistance with personal hygiene. _Section M-Skin Conditions. --Had no unhealed pressure ulcers. Review of resident 51's care plan revealed the following interventions had been initiated on 11/22/16 with a target date of 1/23/18. *The resident had been admitted to the hospital on [DATE] and returned on 11/26/17. -He had not been at the care center on 11/22/17 when his care plan interventions had been iniated. *Bed mobility extensive assistance of one to two staff. *Transfer and walking in room was extensive assist of one to two staff using a gait belt. *Limited to extensive assist of one to dress. *Toilet use limited to extensive use. *Feet were to be lotioned every morning and bedtime. *Assist of one to two with bathing and report skin irregularities to nurse. *Nurse to do weekly skin assessment. *Bilateral posterior heel skin breakdown: Cleanse wound with wound wash, pat dry, apply [MEDICATION NAME] and secure Q3days. *Wears heel protectors at all times except while walking. -Contradicted order of 12/8/17 Heel protectors on at all times and elevate heels to alleviate pressure. Shoes for transfers and ambulation only. *No mention of elevating his feet and using a pillow in the recliner chair. Interview on 1/10/18 at 2:01 p.m. with the director of nurses regarding resident 51's left posterior ankle pressure ulcer revealed: *He had been admitted to the hospital on [DATE] with [MEDICAL CONDITION] and also during that same hospitalization had been diagnosed with [REDACTED]. -He had returned from the hospital on [DATE]. -His care level had increased from limited assistance of one to extensive assist of one staff person. -He currently had a pressure ulcer on his left posterior ankle. -It had first been identified on 12/24/17. -She stated it just developed. It probably developed from where his ankles laid on the bottom of his recliner chair. We just found it there. -She acknowledged his care level had changed when he had returned from the hospital. -She agreed the pressure ulcer had been facility acquired. -Had been aware he had a pressure ulcer on his right posterior ankle area and it had healed. 3. Review of the provider's revised April 2016 Skin Assessment/Wound Care protocol revealed:* .Measures will be taken to predict residents at risk, describe prevention activities, and to promote rapid healing in the event a pressure ulcer develops.*Preventions activities included:-1. For residents unable to reposition themselves, reposition every two hours and as needed.-3. Apply pressure reduction support surface to the bed and chair (foam, gel or static air mattress).-4. Use site specific support surfaces on the resident's extremities and bony prominences, and keep bony areas from direct contact with each other.-8. Restorative therapy and range of motion as tolerates.-9. Don't massage reddened areas . -10. Assess nutrition and hydration . *For pressure ulcers: -a. Standing order - Avoid pressure! . -b. Notify physician of ulcer (SO (standing order) telephone form) and complete Weekly Pressure Ulcer Record. -c. Manage nutrition - Follow dietitian's recommendations. Notify dietary staff on changes as appropriate for individual resident.-d. Stage Pressure Ulcers as follows: --Stage I - A persistent area of redness that does not disappear when pressure is relieved or does not blanch when pressure is applied (without a break in the skin). --Stage II - Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister or shallow crater. --Stage III - Full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia . --Stage IV - Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures . --There was no description for an unstageable pressure injury. Review of the RAI Manual, MDS 3.0, Version 1.15, pages G-2 and M-1 through M-2 revealed: *Health-related quality of life related to activities of daily living: -As inactivity increases, complications such as pressure ulcers, falls, contractures, depression, and muscles wasting may occur. *Health-related quality of life related to skin conditions: -Pressure ulcers occur when tissue is compressed between a bony prominence and an external surface. In addition to pressure, shear force, and friction are important contributors to pressure ulcer development. - .Skin and soft tissue changes associated with aging, illness, small blood vessel disease, and malnutrition increase vulnerability to pressure ulcers. -Additional external factors, such as excess moisture, and tissue exposure to urine or feces, can increase risk.*Planning for care included:-The care planning process should include efforts to stabilize, reduce, or remove underlying risk factors; to monitor the impact of the interventions; and to modify the interventions as appropriate based on the individualized needs of the resident. *Examples of risk factors for pressure ulcers included:-Immobility and decreased functional ability. -Co-morbid conditions. -Impaired diffuse or localized blood flow. -Refusal of care and treatment. -Cognitive impairment. -Exposure of skin to urinary and fecal incontinence. -Under nutrition, malnutrition, and hydration deficits. -History of a healed ulcer.

A. Based on observation, interview, record review, and policy review, the provider failed to implement appropriate interventions to prevent future falls for three of eight sampled residents (3, 4, and 12) who had falls. Findings include: 1. Review of resident 12's medical record revealed: *She had been admitted on [DATE]. *She was alert and oriented. *She had a BIMS (memory test) score of 14 which indicated no memory issues. *She had impaired vision. *Her [DIAGNOSES REDACTED]. Random observations from [DATE] through [DATE] revealed resident 12 at times: *Used a walker and one staff person assistance to move around. *Used a wheelchair with one staff person assistance to move around. Interview on [DATE] at 8:20 a.m. with resident 12 revealed: *She had fallen in the past. *She could not walk by herself. *She had been to restorative exercises twice, but she had not been since the restorative therapy (RT) aide had been out on leave. *She knew she needed exercise for her legs. *She walked to the dining room for supper but would have staff give her a ride in the wheelchair for lunch. Review of resident 12's Fall Follow-Up progress notes by nursing revealed on the following dates: *[DATE] she had a fall with no injury. -She had attempted to transfer herself. -She had not used her call light to ask for assistance. -To prevent another fall it stated again highly remind and encourage to use her call light which is always given and explained to her and was at this time also in her easy chair when she was found on the floor in front of her bed. She always says, ya, Maybe I should when encourage and reminded but yet 'thinks' she can get there whether it's to the bathroom, bed, or chair. Will continue use of motion monitor also. *[DATE] she had a fall and hit her head. -She had been walking with a certified nursing assistant (CNA) and tried to reach for an item and fell . -To prevent another fall it stated staff should always use a gait belt when ambulating/transferring (resident's name). *[DATE] she had a fall with no injury. -She had been walking with staff to the dining room and tripped. -To prevent another fall it stated use gait belt with amb (ambulation). *[DATE] she had a fall and hit her head. -She had been transferring herself from the bed. -To prevent another fall it stated encourage res (resident) to call for help and not get up per self. *[DATE] she had a fall with no injury. -She had been walking to the bathroom with staff, kicked the wheel of the walker, lost her balance, and was lowered to her knees. -To prevent another fall it stated continue to assist resident. Remind resident with transfers to be aware of assistive device. *[DATE] she had a fall and hit her head. -She was attempting to transfer herself to the bathroom. -She had a hematoma (swollen bruise) and two lacerations (cut) to the back of her head, and was sent to the emergency room for stitches. -To prevent another fall it stated resident understands the risks toileting herself. However she refuses to wait for staff to assist her. Review of resident 12's reviewed [DATE] care plan revealed: *She was a high risk for falls and she had a history of [REDACTED]. *Interventions for falls included: -Keep call light attached to her upper body clothing so that she can find it when she wants to call for assist. -Keep room clutter free. Do not change environment in her room without input from (resident's name). Keep room well lighted. -Wear non-skid footwear when out of bed. -Uses w/c (wheelchair) for mobility (moving around) which is pushed by others. She will also self propel (move) w/c at times. -Knock and announce yourself when you enter the room so as not to startle (resident's name). -Wears hearing aide to both ears - assist as needed. -Provide assist of 1 with all transfers. -Keep bed in lowest position while in bed - check every 2 hours. -Wears eye glasses - assist with cleaning and putting them on. -Medicated with Systane (brand name of eye drop) Solution eye drops as ordered. -Infrared monitor on when resident in bed. That had been discontinued on [DATE]. *There were no specific interventions related to the falls dated above. 2. Review of resident 3's medical record revealed: *She had been admitted on [DATE]. *She was alert but confused. *Her [DIAGNOSES REDACTED]. Random observations of resident 3 from [DATE] at 8:35 a.m. through [DATE] at 1:20 p.m. revealed: *She sat in her lift chair (type of recliner with a mechanical lift) in her room frequently. *Staff assisted her to the dining room in a wheelchair. *She had a concave (specialty mattress with raised edges to help prevent her from rolling out) mattress on her bed. *She used a walker in her room for going to and from the bathroom. Review of resident 3's Fall Follow-up progress notes by nursing revealed on the following dates: *[DATE] she had a fall with no injury. -She was found sitting on the bathroom floor. -To prevent another fall it stated nonslip shoes. *[DATE] she had a fall and hit her head. -She was walking to supper with her walker and staff assistance. -To prevent another fall it stated use wheelchair to transfer to meals. *[DATE] she had a fall with no injury. -She was attempting to transfer herself from the bathroom to her bed. -To prevent another fall it stated resident does have a uti (urinary tract infection) so no ua (urinalysis) chemstrip (test) obtained as she is on antibiotics. Continue to monitor closely and assist as needed with cares, toileting, etc. Tylenol given for temp. *[DATE] she had a fall and received a skin tear to her left elbow. -She had been found lying on her left side in front of the bed. -To prevent another fall it stated remind resident to use call light for staff assist. Review of resident 3's [DATE] reviewed care plan revealed: *There was no problem area related to falls. *No mention of a history of falls. *There were no interventions related to falls or prevention of falls. 3. Review of resident 4's medical record revealed: *He had been admitted on [DATE]. *His [DIAGNOSES REDACTED]. *He was alert with mild confusion and forgetfulness. *He had a [DATE] pre-operative history and physical and chest x-ray that showed multiple displaced left rib fractures related to a recent fall. Random observations from [DATE] through [DATE] revealed he used a walker independently to move around in his room and the hallways. Review of resident 4's Fall Follow-up progress notes by nursing revealed: *[DATE] he had a fall with abrasions to his left arm and leg. -He had slipped while undressing for bed. -To prevent another fall it stated resident informed to always wear shoes or gripper socks. *[DATE] he had a fall and hit his head. -He was in his wife's room and stumbled when he was trying to leave. -To prevent another fall it stated remind resident to slow down when turning and walking. *[DATE] he had a fall with no injury. -He said he had slipped out of his recliner. -To prevent another fall it stated remind resident to call for assistance. *[DATE] he had a fall with no injury. -He stated he slid off the edge of the bed. -To prevent another fall it stated encourage resident to slow down and be aware of positioning. Review of resident 4's [DATE] reviewed care plan revealed: *He was at a high risk for fall and he had a history of [REDACTED]. *The last fall was listed as [DATE]. *There was no mention of his rib fractures related to the fall. *The interventions for falls included: -Wear non-skid footwear when out of bed. -Keep call light within reach when in bed. -(resident's name) ambulates with walker in his room independently. his gait (walking) is unsteady but is able to stabilize self with use of walker. he may require supervision, cueing (reminders), and direction reminders to slow down and use of walker when ambulating outside of his room or outside of the facility. Ensure that he uses his walker when ambulating. -Announce yourself as you enter the room so as not to startle (resident's name). -Uses 4 wheeled walker for ambulation at all times - ensure that he uses it when ambulating. -Handrails X (times) 2 to bed to assist with bed mobility (moving) and positioning. 4. Interview on [DATE] at 10:20 a.m. with licensed practical nurse K revealed: *Charge nurses did the Fall Follow-up notes for all falls. *The nurses implemented the interventions to prevent future falls. *Interventions might have included to remind the resident to use the call light or not to leave them unattended. *Appropriate interventions would have depended on the circumstance related to the fall and the resident involved. *If a resident had memory impairment then reminders to use the call light would not be appropriate. *The nurses did not make the changes on the care plan for the interventions related to the fall. Interview on [DATE] at 1:30 p.m. with the director of nursing revealed: *Fall interventions should have been appropriate for the resident to prevent future falls. *Sometimes it would have been appropriate to remind the resident to use the call light but not for residents with memory issues. *The care plans should have been updated to reflect appropriate interventions to prevent falls. Review of the provider's [DATE] Fall Prevention policy revealed: *1. Every resident fall is followed by a fall investigation completed by the RN/LPN (registered nurse/licensed practical nurse) in charge of resident care at the time of the fall. The fall investigation involves but is not limited to evaluation of the resident's current medication regimen and/or changes in medications, previous fall history, behavior issues, medical conditions, bowel and bladder habits, cognitive (memory) condition, and environmental factors. The nurse is also required to offer recommendations to prevent further incidents for this resident. Review of the provider's [DATE] Accidents, Falls, and Safety Precautions policy included: *1. All residents are assessed for the risk of falling on admission, annually, quarterly with significant change, and as needed based on clinical assessment. *2. Criteria for residents at risk for falling includes: residents who have fallen 2 or greater times in the past 3 months, new residents for the first month, incontinence, disoriented or intermittent confusion, unsteady gait, sensory impairment (vision and/or hearing), medications, and predisposing conditions. *3. An individualized plan of care will be developed and implemented for residents at risk for falling. *8. Call lights and bedside articles are to be kept within reach. *10. Non-skid footwear should be used. *11. Pathways are to remain free of obstacles. *13. Residents who have fallen will have a urine chemstrip (test) done with their next voiding (urination) to rule out UTI (urinary tract infection). *16. Dates of all falls are to be documented on the care plan. B. Based on record review, interview, and policy review, the provider failed to assess and document elopement (leaving facility without staff knowledge) precautions for one of two sampled residents (6) who had attempted to elope. Findings include: 1. Review of resident 6's medical record revealed a [DATE] admitted . Review of resident 6's [DATE] through [DATE] nursing notes revealed: *[DATE] at 2:00 p.m., Use of walker upon ambulation (walking) about her room and to and from activity and meals. Needs directions and cueing (reminders or prompting) as has stated she feels a bit lost as unable to know where to go or what to do. *[DATE] at 6:26 a.m., Resident up wandering times 2. Easily redirected and assisted back to bed. *[DATE] at 11:15 p.m., I was in another resident's room assisting them in the bathroom when she walked in. She said she was looking for someone and stood in the doorway. I assisted her out of the room explaining that the person she was looking for was not there and called for a certified nursing assistant (CNA) to come and assist her. She was easily redirected. The CNA found her down the hall in another resident's room. They showed her back to her room and where the bathroom was. *[DATE] 9:30 p.m., Resident came out into the hall looking for a bathroom. She was easily redirected back into her room and shown where the bathroom was. *[DATE] at 5:05 a.m., She was noted to be up a couple times by staff. They showed her where her bathroom was as she could not remember. *[DATE] at 6:55 a.m., Resident eloped at 5:30 a.m. Staff walked with resident outside. Resident was fully dressed without her walker and carrying two small bags of belongings. Staff attempted multiple interventions. Tried to redirect and reorient. Resident became more upset and resistant. Took 3 staff to redirect the resident back to facility and room. Resident attempted to elope 2 more times and threw a bottle at the staff. Staff offered to call family and resident stated no. Told the staff she was being held hostage and would not do any good. Resident very upset and refused to talk and refused other suggestions and interventions. Resident was left safe in her room and monitored from a distance and given space. Oncoming staff notified. *[DATE] at 11:52 a.m., Resident sat in her recliner this morning. She would not look at the person speaking to her. She kept looking down with her eyes closed. I informed her I had her medicine if she would take it. She did open her eyes and look at me. She then proceeded to take her medications. She has not attempted to leave the facility. *[DATE] at 1:27 p.m., Obtained a urine specimen with results positive for leukocytes (indicates infection). Resident informed of urine test results and doctor's orders and stated she knew she had a bladder infection. *[DATE] at 5:45 p.m., Daughter called the facility at 3:30 p.m. She was updated on her event (the resident's) early this morning and the urinary tract infection and the treatment. She voiced appreciation. She did say her mother has done this in the past looking for her husband. Mom did that in the apartment she was living in. That is why we decided she needed to live in the nursing home. *[DATE] at 3:58 p.m., Admission care plan reviewed with resident present as well as various staff and daughter via (by) phone. Discussed possibility of placing a Wanderguard (bracelet that alarms when a resident goes out an alarmed door) device on her if she would attempt to leave the facility. As noted she has tried two times. Recently diagnosed with [REDACTED]. *[DATE] at 12:20 p.m., A urine sample was obtained and positive for leukocytes. Resident's daughter called facility and was updated on her incident this morning and the [DIAGNOSES REDACTED]. *[DATE] at 4:31 p.m., Since her admission she has attempted to leave the facility. All three attempts were between the hours of 9:00 p.m. and 6:00 a.m. During the day she is content. A Wanderguard device was placed on her walker as she refused to allow it to be placed on her ankle or wrist. She was given instructions as to why the device was placed, where it will be placed, and how it works. She stated she would rather be dead than wear one of those prison alarms. She told me she would cut it off. After discussing it with her she reluctantly agreed to have it placed on her walker. The device will be on for ninety days and will be determined at that time if she remains an elopement risk. *[DATE] at 9:41 a.m., The night nurse reported this morning that she became very upset last evening because of the Wanderguard attached to her walker. She threatened to leave the facility. The night nurse removed the Wanderguard. This morning she has been content and smiling. *[DATE] at 11:43 a.m., Resident finished her last dose of Cipro (antibiotic). A chemstrip urinalysis was done with positive results for leukocytes, blood, and protein. *[DATE] at 10:49 a.m., Received call from the doctor and orders obtained for a urinary tract infection. Oral antibiotic therapy begun. *[DATE] at 10:46 a.m., Another resident reported she came into her room at 11:00 p.m. last night and asked her if she heard the med talking in the hallway as to where they were going to sleep. She would not leave her room right away and kept talking. Finally she left the room. *[DATE] at 3:27 p.m., Daughter called and stated resident's oldest son died . Family members decided to take resident home with them for a week. *[DATE] at 11:28 a.m., Due to her [DIAGNOSES REDACTED]. She will often become more confused in the evenings and look for her husband who has passed away or want to leave and puts on her shoes with still wearing her night clothes. *[DATE] at 5:49 a.m., Was awake and dressed by midnight. She was up walking in the halls but did agree to lay down in bed and rest with her clothes on. She was up again by 4:30 a.m. Review of resident 6's [DATE] initial wandering assessment guide revealed: *To the question is the resident resistance to being placed in a long-term care facility there was documentation Voiced dissatisfaction. *She has attempted to elope three times since her admission on [DATE]. All three occurred 9:00 p.m. to 6:00 a.m. *The Wanderguard device was placed on her walker and she became angry with it being placed on her ankle. Review of resident 6's [DATE] care plan revealed Consider Wanderguard to prevent wandering. Interview on [DATE] at 2:30 p.m. with the director of nursing regarding resident 6 revealed: *The initial wandering assessment was not completed on [DATE] when she was admitted as she was showing no wandering behavior. *She was uncertain why the assessment had not been completed on [DATE] when she attempted to elope three times. *She was unsure why the Wanderguard device had not been started on [DATE] after it had been discussed in a care plan meeting and the daughter had agreed to it's use. *The Wanderguard device was started on [DATE] as the resident was experiencing some respiratory symptoms, and they thought her behavior might change. *She knew the staff did more frequent checks on her with her wandering behavior but did not consistently document them. Review of the provider's [DATE] Wanderguard in Conjunction with Door Alarm policy revealed: *The Wanderguard system will be utilized to ensure the safety of wandering residents. *Assessments will be completed on residents who are a risk for wandering at the time of admission. If a resident flags as a wandering risk, a Wanderguard pendant will be put on the resident's ankle or wrist. *There will be an assessment completed every ninety days on residents who are wearing the Wanderguard pendants. Review of the provider's [DATE] Elopement Prevention policy and procedure revealed: *It is the policy of this facility to identify and prevent potential elopement of residents.*The facility will identify wandering behavior through the utilization (use) of admission, assessment process, and the Minimum Data Set (MDS).*Individualized approaches will be developed for each resident to provide a safe environment. *Assess risk for elopement on admission based on cognitive status and behavior suggesting elopement such as statements about going home or running away. *Develop an individualized care plan based on assessment, identification of causes, and specific approaches used to provide a safe environment. *Educate staff regarding elopement policies and procedures during department orientation.

Based on observation, interview, record review, and policy review, the provider failed to prevent the occurrence or re-occurrence of pressure ulcers (an injury to the skin and underlying tissue caused by unrelieved pressure, usually over a bony area) for one of two sampled residents (3) who had pressure ulcers. Findings include: 1. Review of resident 3's medical record revealed: *She had been admitted on [DATE]. *Her [DIAGNOSES REDACTED]. *She currently had pressure ulcers to both buttocks. Random observations of resident 3 from 8/11/15 at 8:35 a.m. through 8/12/15 at 1:20 p.m. revealed: *She sat in her lift chair (type of recliner with a mechanical lift) in her room frequently. -There was no seat cushion in that chair. *Staff assisted her to the dining room in a wheelchair. -There was no seat cushion in her wheelchair. *She had a concave (specialty mattress with raised edges to help prevent her from rolling out) mattress on her bed. *She used a walker in her room for going to and from the bathroom. Observation and interview on 8/11/15 at 10:17 a.m. with registered nurse (RN) A during resident 3's personal care revealed: *The resident had been in the bathroom. *She was able to walk herself to and from the bathroom with her walker. *She was usually continent (able to control her bowel and bladder). *She wore disposable briefs. *RN A assisted her with personal care and checked the placement of the duoderm (type of dressing) patches to her buttocks. *The patches were in place, and the area around them appeared to be dark purple in color. *RN A stated the resident had pressure ulcers on both of her buttocks, and the duoderm patches were the current treatment for [REDACTED]. *The patches had been changed yesterday by her, and again by the night nurse. *She stated the resident liked to sit in her chair a lot which did not help the healing of the pressure ulcers. *The staff had just changed her chair back to a facility lift chair the previous evening because she had not been sitting up as well in the other one. Observation and interview on 8/12/15 at 8:15 a.m. with certified nursing assistant (CNA) J regarding resident 3 revealed: *The resident had pressure ulcers on her buttocks that the nurse did the treatments for. *The resident normally walked herself to the bathroom with her walker. *The CNAs only helped her as needed, maybe once a shift. *She was not on a toileting or repositioning schedule. *She sat in the chair most of the time, but they tried to get her to lay in her bed sometimes after lunch. *Staff pushed her in the wheelchair to and from meals in the dining room. *She agreed the resident did not have a seat cushion in her chair or her wheelchair. *Her mattress was just the same (a regular mattress with no special features to prevent pressure areas from forming) as other residents. Interview on 8/12/15 at 10:20 a.m. with licensed practical nurse K regarding resident 3 revealed: *She did not like to lay down and liked to spend a lot of time in her chair. *She had seat cushions in her chair and wheelchair in the past, but she was unsure what happened to them or when they had been removed. *She should have had seat cushions in her chair and wheelchair for pressure relief. *She had a standard mattress. *The charge nurses would have done the weekly assessments of pressure ulcers. -Those assessments should have been documented. *The nurses completed pressure ulcer treatments as ordered by the physician. *For a resident that had a pressure ulcer: -Interventions should have included repositioning, pressure relieving cushions, dietary involvement, and physician involvement. -Nurses should have implemented interventions and educated the CNAs. *She would have expected changes in the care plan for pressure ulcer care and prevention. Review of resident 3's physician's orders [REDACTED]. *On 3/8/15 there was an order to: -Avoid pressure to small superficial non-infected areas to the buttocks. -Cleanse with wound wash. -Dry. -Apply [MEDICATION NAME] (special type of dressing). -Assess on Sundays. *They had healed on 5/10/15. *On 5/14/15 there was an order for [REDACTED].>-Cleanse with wound wash. -Dry. -Apply [MEDICATION NAME] to both buttocks. -Assess on Thursdays. *They had healed on 6/19/15. *On 7/20/15 there was an order for [REDACTED]. *On 8/10/15 there was an order for [REDACTED].>-Avoid pressure to area. -Cleanse with wound wash. -Dry. -Apply duoderm (another type of dressing). -Notify physician of non-healing or signs/symptoms of infections. -Assess every Monday. Review of resident 3's Minimum Data Set Summary assessment forms for skin revealed: *On 12/22/14: -A Braden Risk Assessment (scale indicating risk of developing pressure ulcers) score of twenty that indicated low risk. -Risk for pressure ulcer was circled No. -No was circled for currently having one or more pressure ulcers. *On 3/16/15: -A Braden score of twenty. -Risk for pressure ulcer was circled for No. -No was circled for currently having one or more pressure ulcers. *On 6/18/15: -A Braden score of sixteen that indicated low risk. -Risk for pressure ulcer was circled Yes. -Yes was circled for currently having one or more pressure ulcers. Review of resident 3's weekly Skin Ulcer/Complex Assessment Notes for March 2015 through August 10, 2015 revealed documentation had been done by several different nurses. The following months revealed weekly documentation for: *March, three times. *April four times. *May, three times. *June, two times. *July, one time. *August, one time on the tenth. *They had not been completed weekly as ordered by the physician. *The stage (scale to determine severity) of the pressure ulcers had not been documented for several of those assessments. Review of resident 3's last reviewed 6/16/15 care plan revealed: *She required: -Assistance of one staff person with dressing. -Set-up and supervision with personal hygiene. *She was independent with toilet use during the day, but she required assistance with perineal (peri-)(private area) care. *A handwritten entry on 3/18/15 to monitor for skin cracks/tears to buttocks r/t (related to) shearing (friction from moving) and apply [MEDICATION NAME] PRN (as needed). *The resident had weakness, knee pain, was able to walk short distances with a walker, and used the wheelchair as needed. *A handwritten entry on 5/14/15 for a problem of stage 2 (open area to the top lay of skin) pressure ulcers to both buttocks. -The intervention for them was apply [MEDICATION NAME] to buttocks, secure with [MEDICATION NAME]. Assess q (every) week. Avoid pressure. -That was not the current treatment for [REDACTED]. *There was no mention of a repositioning or toileting schedule. *There was no mention of a pressure relieving mattress or seat cushions for the chair and wheelchair. *There was no mention of any: -Pressure ulcers that had started in March 2015. -Changes in interventions since that time. Interview on 8/12/15 at 12:00 noon with the medical director revealed: *She was resident 3's primary physician and stated she: -Was aware of the pressure ulcers on her buttocks. -Thought she had a gel mattress on her bed. -Was unsure what other preventative measures the facility had implemented. *For pressure ulcers the key is to change position. *She had been aware of an increase in the number of the facility's pressure ulcers related to staffing issues. -She felt the number of pressure ulcers had improved as staffing had improved. Interview on 8/12/15 at 1:30 p.m. with the director of nursing revealed: *Resident 3 was not on a repositioning program. -Repositioning would have been done during or around the facility's five meals a day. -She did not always go to the dining room for meals. -She liked to spend a lot of time in her chair. *Resident 3 was not on a toileting program. -She should have been assisted to the toilet before and after meals and as needed. *Resident 3 had a seat cushion in her chair at one time but did not like it. -She was unsure when that had been exactly. -She was unsure if implementing a seat cushion would help her now. *Charge nurses did the pressure ulcer assessments weekly. *There was no specific wound or skin nurse at the facility. *They would have contacted the primary physician before sending residents for a consultation related to pressure ulcers. *She agreed there was missing documentation related to resident 3's weekly pressure ulcer assessments. *She agreed resident 3's care plan had not been updated with changes related to her pressure ulcers. -The only mention of her pressure ulcer treatments and interventions was the 5/14/15 entry for [MEDICATION NAME]. *She agreed resident 3 was identified at a low risk for pressure ulcers but had developed them at the facility. *She confirmed resident 3's pressure ulcers had started in March 2015 and had healed and re-opened a few times. *When new pressure ulcers had been identified the nurses should have notified the physician and helped the resident to avoid pressure to those areas. *The facility did not have air mattresses. *All the mattresses were considered pressure reducing from the supplier. *She agreed maybe more could have been done more for resident 3's pressure ulcers. Review of the provider's October 2003 Skin Assessment/Wound Care Protocol policy revealed: *It is the policy of this facility that all residents will be monitored for impaired skin integrity at admission, weekly, and as needed. Measures will be taken to predict residents at risk, describe prevention activities, and to promote rapid healing in the event a pressure ulcer unavoidably develops. *4. If the pressure ulcer is not healing and/or signs of additional skin breakdown are evident, alternative interventions will be considered every two weeks and attempted at least every 30 days with consult of a physician. *Prevention activities included: -1. For resident's unable to reposition themselves, reposition every two hours and as needed. -3. Apply pressure reduction surface to the bed and chair (foam, gel or static mattress). -4. Use site specific support surfaces on the resident's extremities and bony prominences, and keep bony areas from direct contact with each other. *Pressure ulcer protocol included: -a. Standing order - Avoid pressure!.) -b. Notify physician of ulcer (SO (standing order) telephone form) and complete Weekly Pressure Ulcer Record. -d. Stage Pressure Ulcers as follows: -Stage I (1) - A persistent area of redness that does not disappear when pressure is relieved or does not blanch (temporary whitening of skin) when pressure is applied (without a break in the skin). -Stage II (2) - Partial thickness skin loss involving epidermis (outer layer of skin), dermis (middle layer of skin), or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. -Stage III (3) - Full thickness skin loss involving damage to, or necrosis (dying tissue) of, subcutaneous (lowest layer of skin) tissue that may extend down to, but not through, underlying fascia (connective tissue under the skin). The ulcer presents clinically as a deep crater with or without undermining (wearing away under the edge) of adjacent tissue. -Stage IV (4) - Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. Undermining and sinus tracts also may be associated with Stage IV pressure ulcers.

Based on record review, interview, and policy review, the provider failed to ensure the policy for the front door alarm was reviewed and followed to prevent one of one resident (5) from eloping and injury. Findings include: 1. Review of resident 5's Minimum Data Set (MDS) Summary Forms revealed: -The MDS Summary quarterly assessment dated [DATE] and the annual assessment dated [DATE] revealed his decision making was severely impaired. Behavioral symptoms included physically hitting at staff, resisting care, and verbally abusive to staff and visitors on a daily basis. He believed the facility was his home, and others present were trespassing. His [DIAGNOSES REDACTED]. He had tried to elope from the facility on 2/7/11 but was redirected by staff. Falls with injury included on 1/1/11 (bruise to top left side of head), on 1/10/11(abrasion to right knee), and on 1/17/11 (abrasion to left temple). Review of resident 5's care plan revealed: -Problem two stated "Resident is cognitively impaired with indicators of mood and behaviors compromising the ability to perform ADLS (activities of daily living) and his safety." The onset date for that problem was 6/8/08, and the last review was 2/11/11. -He had been medicated with tramadol HCL 50 milligrams (mg) upon rising and up to twice daily as needed. Due to that medication he was to be monitored for "Potential adverse side effects as follows but not limited to - dizziness, somnolence, vertigo, anxiety, confusion, and malaise." -He had impaired vision and refused to wear his glasses. His room arrangement was to be maintained to avoid confusion. Review of the initial elopement report called to the Office of Licensure and Certification (OL&C) on 1/11/11 at 1:30 p.m. by the administrator revealed: -Resident 5 was found missing after supper around 7:00 p.m. -It was estimated he was missing approximately 15 minutes. -Staff found him standing on the highway. -When he was returned to the facility his temperature was 94 degrees Fahrenheit (F). -Staff wrapped him in warm towels/blankets and gave him warm milk to drink. -He had a normal temperature within 15 minutes after he was found. -He had not known why he had left. -A Wander Guard was placed on the resident. Review of the investigation form submitted by the administrator to the OL&C for the incident dated 1/10/11 revealed: -The date of the incident was 1/10/11. The time was noted as "17:00 pm." (As per the administrator that time should have been "19:00 pm" military time or 7:00 p.m.). -The elopement had resulted in a small one centimeter abrasion to the right knee due to a fall. -The resident had left the facility at night wearing only a shirt, jeans, and shoes. -The summary of the witness who was a certified nursing assistant (CNA) stated resident 5 was sitting in the dayroom when the CNA walked by and went to assist another resident down the hall. When the CNA came back (approximately ten minutes) resident 5 was gone. The CNA told the nurse on duty. When the CNA opened the front doors he heard the resident yelling for help. -The summary of the investigator's findings stated the resident had left the facility, walked to the end of the parking lot, and fell by the edge of the highway. He had been outside approximately 10-15 minutes before he was found by staff. He was taken back inside and put in his pajamas. Warm towels were placed on his hands, feet, and around his neck. A passerby had called 911, and the sheriff had arrived as the resident was brought back into the building. -A Wander Guard was applied to the resident's ankle. Review of the fall follow-up dated 1/10/11 at 7:30 p.m. revealed: -Resident 5's temperature was 91.7 F when brought back into the facility after the elopement. -His respiratory rate was 20, blood pressure was 126/88, and heart rate was 70. -The event description noted resident 5 was found lying on the highway outside after staff were notified by hospital personal who were notified by someone else. -He was assisted to his feet by a CNA, assisted into a wheelchair, and taken into the facility. -He was wearing only a shirt, shoes and jeans. He was not wearing a coat. -He was seen by "this" nurse exactly 20 minutes before receiving the call from the hospital. "So resident could not have been outside more than 15 minutes." -He was taken to his room, toileted, changed out of his clothes and into pajamas, and put into bed. -Warm towels were put on his hands, feet, neck, and ears. -Warm milk was given to the resident to drink. -A one centimeter abrasion to the right knee was noted. -He denied hitting his head. -The physician, director of nursing (DON), and family were notified. -"A wander guard alarm was placed on his ankle to prevent this from happening again." -The resident was confused. Review of the nursing notes dated 1/10/11 at 10:00 p.m. revealed: -Warm towels were placed on the resident's extremities and were changed every 15 to 30 minutes until now. -The resident was resting in bed. -His temperature now was now 97.1 F. -His toes, hands, and fingers were pink and warmer than previously. He was able to move all extremities without difficulty. -A Wander Guard was on his right ankle. -The resident had thermal blankets on, had not attempted to get out of bed, and was very compliant with cares. Random observations from 4/11/11 to 4/13/11 of the front entrance/exit door revealed: -It was not in direct sight of the nurses' station, the office, the dining room, or the north, west or east halls. -A resident sitting area was located directly across from the front entrance/exit door. -There were several times when there had been no staff in direct view of the front entrance/exit door. -Residents walked past that door to go to the dining room, beauty shop, social worker's office, chapel, restrooms, and family room. Interview on 4/12/11 at 4:30 p.m. with the administrator and DON revealed: -Resident 5 had eloped on 1/10/11. -He was found on the side of the highway on the ground. -That had been the first time he had eloped. Interview on 4/13/11 at 9:30 a.m. with licensed practical nurse (LPN) B revealed: -The front door alarm was sometimes on during the day. -The alarm was usually turned on about 7:00 p.m. -There was no set time to turn on or off the alarm. -Everyone was to watch the door. -No specific person was in charge of monitoring the door or turning off and on the alarm. -Office staff were not able to hear the door alarm or see the front exit door. Interview on 4/13/11 at 11:00 a.m. with CNA A revealed: -The front door alarm was usually on during the day and sometimes in the afternoon when residents were wandering more. -It was not on now, because people were coming in and out to pick-up their flowers. -All staff were to monitor the front door when they were walking in that area. -No specific staff were to be in charge of turning the alarm off or on. Interview on 4/13/11 at 2:30 p.m. and at 4:20 p.m. with the DON revealed: -She was not sure if a written policy or procedure existed for monitoring the front door or for specific times to alarm the front door. -She thought the alarm was turned off during the day and during business hours. -She was not sure when the front door alarm was turned on at night, but she thought it was when the night shift came about 7:00 p.m. -She agreed if the night shift had turned on the alarm, the elopement would not have occurred. -After resident 5's elopement an assessment of the front door alarm had not been done. -No education with staff was done about the front door alarm after the elopement. -She agreed an assessment of when and who should turn on the front door alarm should have been done. -No documentation was noted on 1/10/11 after the initial report and assessment at 7:30 p.m. until 10:00 p.m. His beginning temperature at 7:30 p.m. was 91.7 F and at 10:00 p.m. it was 97.1. (The 1/11/11 verbal report to the OL&C stated the resident had a normal temperature within 15 minutes.) -She stated there should have been documentation of assessments between 7:30 p.m. and 10:00 p.m. Review of the provider's Wanderguard in Conjunction with Door Alarms policy revised November 2008 revealed: -"At 7:00 a.m. each morning the west and north doors will be unlocked by the nursing staff and the front door alarm will be shut off." -"At 7:00 p.m. each evening the west and north doors will be locked by the charge nurse from the outside and the front door alarm will be turned on."