Every finding on record at Bowdle Nursing Home

Based on Payroll Based Journal (PBJ) reports, interview, employee timecard review, schedule review, and facility assessment review, the provider failed to ensure a registered nurse (RN) was scheduled for eight consecutive hours of coverage for one day in quarter two (January 1 through March 31) of fiscal year 2026 and six of thirty-one days in July 2026. Findings include:1. Review of the PBJ report for quarter two of fiscal year 2026 revealed the provider did not have RN coverage for eight consecutive hours on 3/1/26, 3/14/26, 3/17/26, and 3/28/26. 2. Interview on 8/11/26 at 8:55 a.m. with assistant director of nursing (ADON) C during the facility entrance conference revealed that the provider had a waiver from 3/7/25 through 3/6/26 from the Center for Medicare and Medicaid Services (CMS) that exempted them from the requirement of an RN being in the facility for eight consecutive hours every day. The provider reapplied for that waiver did not receive confirmation from CMS if the waiver renewal was granted. 3. Review of the employee timecards for March 2026 revealed that the provider did not have RN coverage for eight consecutive hours on 3/28/26. 4. Review of the July 2026 employee schedule revealed there was no RN scheduled to work on 7/4/26, 7/5/26, 7/18/26, 7/19/26, 7/25/26, and 7/26/26. 5. Interview and review of the July 2026 employee schedule on 8/13/26 at 9:42 a.m. with ADON C revealed that ADON C verified there was no RN coverage for eight consecutive hours on 7/4/26, 7/5/26, 7/18/26, 7/25/26, and 7/26/26. 6. Review of the provider's 7/29/26 Facility Assessment revealed, the [redacted name] has applied for and been granted a Waiver of Nursing Staff Requirements effective March 7, 2025.

Based on record review, interview, and policy review, the provider failed to ensure the baseline care plan (personalized plan that addresses a resident's care needs, goals, and interventions) was reviewed with and a copy offered to the resident or the resident's representative within 48 hours of admission to the facility for four of five newly admitted residents (1, 4, 6, and 30).Findings include: 1. Review of resident 1's electronic medical record (EMR) revealed she admitted to the facility on [DATE]. There was no documentation that resident 1's baseline care plan was reviewed with her or her representative, and a copy was offered to her or her representative within 48 hours of her admission to the facility. 2. Review of resident 6's EMR revealed she admitted to the facility on [DATE]. There was no documentation that resident 6's baseline care plan was reviewed with her or her representative, and a copy was offered to her or her representative within 48 hours of her admission to the facility. 3. Review of resident 4's EMR revealed he admitted to the facility on [DATE]. There was no documentation that resident 4's baseline care plan was reviewed with him or his representative, and a copy was offered to him or his representative within 48 hours of his admission to the facility. 4. Review of resident 30's EMR revealed he admitted to the facility on [DATE]. There was no documentation that resident 30's baseline care plan was reviewed with him or his representative, and a copy was offered to him or his representative within 48 hours of his admission to the facility. 5. Interview on 8/12/26 at 2:05 p.m. with assistant director of nursing (ADON) C regarding reviewing and offering a copy of the resident's baseline care plan with the resident or their representative revealed that resident 4's spouse was provided with his comprehensive care plan, and resident 30's guardian could not be reached. She stated the comprehensive care plan was provided at the first scheduled care conference approximately 21 days after each resident's admission. She was aware that a resident's baseline care plan was to be completed within 48 hours of admission to the facility, but was not aware that it should have been reviewed with the resident or their representative and a copy offered to them. 6. Telephone interview on 8/13/26 at 12:45 a.m. with social service designee (SSD) I, revealed that the director of nursing (DON) B started the resident's baseline care plan at the time the resident admitted to the facility. The resident's comprehensive care plan was reviewed with the resident or their representative, about 14 days after the resident admitted to the facility, at that resident's care conference. The resident or their representative would be offered a copy of the resident's comprehensive care plan at that time. The resident or their representative would discuss what they would like to add to the comprehensive care plan during those care conferences. She was not aware that the baseline care plan should have been reviewed with the resident or their representative within 48 hours of admission. 7. Interview on 8/13/26 at 2:06 p.m. with director of nursing (DON) B and ADON C revealed that DON B stated she was aware the baseline care plan was to be completed and reviewed with the resident or their representative, and a copy offered to them, within 48 hours of the resident's admission. 8. Review of the provider's 2001 Care Plans – Baseline policy revealed A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission. The resident and/or representative are provided a written summary of the baseline care plan (in a language that the resident/representative can understand) . Provision of the summary to the resident and/or representative is documented in the medical record.

Based on observation, interview, and policy review, revealed the provider failed to ensure the staff follow standard food safety regarding hand hygiene and glove use by three of three observed employees (O, R, and an unidentified employee) during one of one meal service.Findings include: 1. Observation on 8/11/26 11:13 a.m. of activity director R serving the noon meal to the residents in the dining room revealed that she had gloves on. She carried a tray with a resident's meal on it from the steam table to the table. She removed the plate, drink cups, and other dishes from the tray and placed them on the table in front of the resident. With those same gloved hands, she walked back near the steam table, tucked her hair behind her ear, picked up another meal tray from the steam table, walked into the dining area, and placed those dishes of food in front of resident 27. She then placed a clothing protector on resident 27, picked up the top bun off his cheeseburger, opened a packet of ketchup, put the ketchup on his cheeseburger, reapplied the top bun, walked back into the kitchenette, removed her gloves, put those gloves in the trash can, washed her hands, and put on a new pair of gloves. Activity director R then removed a tray of food from the steam table and set those dishes of food in front of resident 3. Without removing her gloves or performing hand hygiene she returned to the steam table, took a tray of food from the steam table to resident 19 and placed those dishes of food in front of him. Activity director R picked up the top bun off resident 19's cheeseburger, opened a packet of ketchup, placed ketchup on his burger, and replaced the bun on top of his burger. She then went into the kitchenette, picked up a package of ketchup, and returned to resident 19's table. With those same gloved hands she picked up the top bun from resident 19's second cheeseburger, opened the ketchup packet, put ketchup on that burger, and then put the top bun on his cheeseburger. With those same gloved hands she returned to the steam table, picked up a tray of food, took the food to resident 28 and placed the dishes of food on the table in front of him. She took the tray back into the kitchenette, put it on a cart of dirty dishes, removed her gloves, put them in the trash can, did not perform hand hygiene, and entered assistant director of nursing (ADON) C's office. At 11:28 a.m. activity director R exited ADON C's office, went into the kitchenette, did not perform hand hygiene, opened a cupboard in the kitchenette and then left the dining room without performing hand hygiene. 2. Interview on 8/13/26 at 8:59 a.m. with activity director R revealed she was a certified nursing assistant (CNA) and had received training on hand hygiene, glove use, and serving residents' meal trays. She would wash her hands and put on a clean pair of gloves to serve the residents' meal trays. If her gloves became dirty, she would remove those gloves, put them in the trash, perform hand hygiene, and put a new pair of gloves on. If a resident was able to pick up their own hamburger bun, she would ask the resident to pick up the bun, and then she would put ketchup on the hamburger for them. If the resident could not pick up their own hamburger bun she would pick it up with her gloved hand and put the ketchup on the resident's hamburger. After she put the ketchup on the bun she would remove her gloves, put those gloves in the trash can, wash her hands and put on a new pair of gloves. She would not wash her hands and put on a clean pair of gloves after she had served a resident's meal, and before she picked up a resident's bun with her gloved hands. 3. Observation on 8/11/26 at 11:07 a.m. of cook O serving the noon meal to residents revealed he had a beard that covered the skin on his face, and was not wearing a beard net. He did not complete hand hygiene and put on a pair of gloves. 4. Observation on 8/11/2026 at 11:12 a.m. of cook O revealed he used his gloved hands to put a hamburger bun on a plate, used tongs to put a hamburger on the bun, held the bun with his gloved hands, and cut the hamburger in half with a knife. He continued placing a bun on each resident's plate with his gloved hand, used tongs to put a hamburger on the bun, and used separate tongs to put lettuce and tomato on the bun. He used his gloved hands to put a slice of cheese on each hamburger. During this meal service, he touched the cupboard and several utensils, including tongs, with his gloved hands. He used the same pair of gloves throughout the meal service. 5. Observation on 8/11/2026 at 11:17 a.m. revealed an unidentified employee in the dining room wearing disposable gloves. The employee touched her nose, did not change her gloves, and then served a resident their meal. She handled the dessert cup by touching the top of the cup with her gloved hand. 6. Observation on 8/11/26 at 11:20 a.m. revealed the same unidentified employee in the above observation, touch her nose again and rub her nostril back and forth three times with her gloved hand. She then served a resident their meal. The employee picked up the resident's juice glass by the top rim of the glass and handed it to the resident. 7. Interview on 8/12/26 at 1:55 p.m. with certified dietary manager (CDM) N regarding the use of disposable gloves when serving meals revealed that utensils should be used if they can be. To serve cheeseburgers, a mixture of gloves and utensils would be used. She indicated the cook should use disposable gloves to put the cheese on the cheeseburger at the point of service, unless they would have time to separate the cheese slices and put them on a plate, then they would use tongs to pick up the cheese slices. CDM N confirmed that hamburger buns and cheese were ready-to-eat foods. She stated that tongs were used to serve dinner rolls, but putting a hamburger bun on a plate would be more difficult. She stated, Dinner rolls are with a whole plate of food while cheeseburgers take quite a bit of compiling. She would have served the cheeseburger the same way that cook O had, unless she had touched something that was contaminated. CDM N stated the serving area was not always wiped off before serving but always washed afterwards. She confirmed that there was the potential for the serving area to be contaminated if it was not washed off before the meal service. She confirmed staff were to wash their hands before putting on disposable gloves. She agreed if a staff member wore disposable gloves and touched a door, the gloves would potentially be contaminated. CDM N confirmed staff members were to wear hair nets in the kitchen and while serving. She stated we do have beard nets, and if long enough [the beard] [the staff member] would wear one or if is a problem. She did not think [NAME] O's beard was long enough to require a beard net. 8. Interview on 8/13/26 at 2:14 p.m. with ADON C and DON B regarding safe food handling, glove use, and staff members wiping their nose when serving residents' meals, revealed DON B stated if a staff member is wiping their nose or touching a resident, they should wash their hands and put on new gloves. She stated, Glove use in dining and serving [meals] has been a very grey area for years. 9. Review of the provider's contracted dietary 2/2026 Food Preparation Policy revealed that: All staff will practice hand washing techniques and glove use. and All staff will use serving utensils appropriately to prevent cross contamination. Review of the provider's 1/2025 contracted dietary Authorized Kitchen Personnel policy revealed: All authorized personnel must wear appropriate head covering while in the kitchen or production (e.g., hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained). Review of the provider's 1/2025 contracted dietary Staff Attire policy revealed: All staff members will have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained. Review of the provider's 2/27/24 Handwashing/Hand Hygiene policy revealed, This facility considers hand hygiene the primary means to prevent the spread of infections. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: . Before and after direct contact with residents; . After removing gloves; . Before and after eating or handling food; Before and after assisting a resident with meals.

Based on observation, interview, and policy review, the provider failed to ensure infection prevention and control practices were followed by one of one registered nurse (RN) (D) while changing a dressing on a wound for one of one resident (11) who was on enhanced barrier precautions (EBP; glove and gown use when providing contact care). Findings include:1. Observation and interview on 8/12/26 at 2:13 p.m. of RN D changing the wound dressings on resident 11's legs revealed, there was a sign on his door that indicated he was on EBP and personal protective equipment (PPE (gown and gloves)) hanging on the outside of the door to his room. RN D was in resident 11's room with a gown on. She placed the wound care supplies on resident 11's bedside table without putting a clean barrier on the bedside table. Without performing hand hygiene RN D put on a pair of gloves. She removed resident 11's ace wraps from both his legs on placed them on resident 11's bed.RN D removed her gloves, put them in the trash can and did not perform hand hygiene. RN D exited resident 11's room with her gown on and walked down the hallway. When RN D returned to the room, she had a clean ace wrap in her hand and was wearing a gown and a pair of gloves. She removed the tape and gauze from resident 11's right leg wound, placed the dressing in the trash can, took off her gloves, put the gloves in the trash can, performed hand hygiene, and applied a clean pair of gloves.She used the clean gauze from the bedside table to wipe off the wound on resident 11's right leg. With the same gloved hands, she took the betadine-soaked gauze from the bedside table, placed it on resident 11's right leg wound, covered the betadine-soaked gauze with a dry gauze from the bedside table, and with the tape from the bedside table, taped the gauze to resident 11's right leg. RN D removed her gloves, put them in the trash can, did not perform hand hygiene, and wrapped resident 11's leg with a clean ace wrap without gloves on.RN D performed hand hygiene, put on a new pair of gloves, and removed the dressing from resident 11's left leg wound. With the same gloved hands, she put the betadine-soaked gauze from the bedside table on resident 11's left leg wound and covered the betadine-soaked gauze with a dry gauze from the bedside table. RN D removed her gloves, put them in the trash can, did not perform hand hygiene, and taped the gauze dressing to resident 11's left leg. She then put the ace wrap on resident 11's left leg, and pulled down both pant legs, without wearing gloves.Without wearing gloves, RN D wiped off the bandage scissor with a disinfectant wipe and put it into her shirt pocket. RN D left the room and entered the hallway. While in the hallway she removed her gown, placed it in a trash can, and performed hand hygiene.RN D stated hand hygiene was supposed to be completed before a pair of gloves were put on and after the gloves were taken off. She acknowledged she missed some opportunities for hand hygiene when she removed her gloves. She stated that her gloves were to be changed between the dirty and clean procedures during a dressing change. RN D acknowledged she wore the gown out of resident 11's room and into the hallway to get a clean ace wrap. She acknowledged she put on resident 11's ace wraps, applied tape to the gauze on his right leg, and pulled down his pant legs without wearing gloves and resident 11 was on EBP. 2. Interview on 8/13/26 at 2:01 p.m. with director of nursing (DON) B and assistant director of nursing (ADON) C revealed they expected the staff to perform hand hygiene before putting on gloves and after taking off gloves. They expected staff to wear PPE when assisting a resident on EBP if they were directly working with the residents wound or catheter (flexible tubing placed in the bladder to drain urine). The PPE should be put on when the staff member entered the resident's room and then taken off once the resident's cares had been provided at the threshold of the doorway.When a staff member was preparing to change a resident's dressing on their wound ADON B expected the supplies for changing that dressing to be prepared and placed on a clean barrier within the reach of the nurse who was changing the dressing. She expected the nurse to change her gloves and perform hand hygiene when changing after removing the soiled dressing and before putting on the clean dressing. 3. The infection preventionist was not available for interview during the survey process. 4. Review of the provider's 2/27/24 Handwashing/Hand Hygiene policy revealed, This facility considers hand hygiene the primary means to prevent the spread of infection. Use of alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations; .Before and after direct contact with residents; .Before handling clean or soiled dressings, gauze pads, etc.; .After handling used dressings, contaminated equipment, etc.; .After removing gloves. Hand hygiene is the final step after removing and disposing of personal protective equipment [gown and gloves]. 5. Review of the provider's December 2024 Enhanced Barrier Precautions policy revealed, Gloves and gown are applied prior to performing high contact resident care activity. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: dressing; .prolonged, high-contact with items in the resident's room with resident's equipment, or with resident's clothing or skin; .wound care (any skin opening requiring a dressing).6. Review of the provider's undated Dressings, Dry/Clean policy revealed, Steps in the Procedure Clean bedside stand. Establish a clean field. Place the clean equipment on the clean field.Wash and dry your hands thoroughly. Put on clean gloves. Loosen tape and remove [the] soiled dressing. Pull glove over [the] dressing and discard into plastic or biohazard bag. Wash and dry your hands thoroughly.Open dry, clean dressing(s) by pulling corners of the exterior wrapping outward, touching only the exterior surface. Label tape or dressing with date, time, and initials. Place on clean field. Using clean technique, open other products (i.e., prescribed dressing; dry, clean gauze). Wash and dry your hands thoroughly. Put on clean gloves.Cleanse the wound with ordered cleanser. If using gauze, use clean gauze for each cleansing stroke.Use dry gauze to pat the wound dry. Apply the ordered dressing and secure with tape or bordered dressing per order.Discard disposable items into the designated container. Remove disposable gloves and discard into designated container. Wash and dry your hands thoroughly.

Based on observation, interview, and policy review the provider failed to ensure single dose medications received from the pharmacy had a securely affixed label on the medication bottle for one random resident (14) and that glucometer test strips and medications with shortened expiration dates (medications that, after opening, expire prior to the manufacturer's expiration date) were labeled properly and disposed of after having expired for two random residents (13 and 36) in one of one medication carts. Findings include:1. Observation and interview on [DATE] at 10:43 a.m. of the medication cart with registered nurse (RN) (D) and assistant director of nursing (ADON) C revealed, there was an opened bottle of glucometer test strips in the top drawer of the medication cart. The bottle did not have a date to indicate when it had been opened. RN D verified there was no opened date on the glucometer tests strips. She stated it was their process to date the glucometer test strip bottles when they were opened. She was aware the glucose strips had a shortened expiration date after they were opened but did not know how long it was.In the top middle drawer of the medication cart was a blue pill bottle with a white paper strip wrapped around the bottle that was secured with a rubberband. The white paper strip had handwriting on it that indicated the pill inside the bottle was resident 14's tizanidine (a muscle relaxer). RN D stated she did not know why that bottle was in the top middle drawer of the medication cart or how long it had been in there. RN D checked resident 14's individually bubble packed medication cards and stated that the correct number of remaining medications were in each bubble pack.ADON C stated the pharmacy sent single dose medications in the blue bottles. She stated the label should not be wrapped around the bottle with a rubber band but should be secured to the bottle to ensure the label could not be lost, removed, or switched between bottles.Resident 13's bottle of latanoprost eye drops (a medication to lower eye pressure) did not have a date to indicate when the bottle had been opened and administered to resident 13. RN D verified there was no date on the latanoprost eye drops to indicate when it was opened and administered and that latanoprost eye drops were medications that had shortened expiration dates after they were opened.Resident 36's Breo Ellipta inhaler (a medication to treat asthma and chronic obstructive pulmonary disease; a group of lung diseases that block airflow and make it difficult to breathe) did not have a date on it to indicate when the inhaler had been opened and administered to resident 36. RN D verified there was no date on the Breo Ellipta inhaler. RN D stated she was aware that Breo Ellipta inhaler was a medication that had shortened expiration date after it was opened.ADON C stated she was unable to locate a reference of medications that had shortened expiration dates for the nurses to reference to be sure the medications were disposed of at the appropriate time frame according to their outdate after they were opened. 2. Interview on [DATE] at 2:01 p.m. with director of nursing (DON) B and ADON C revealed they expected the glucometer test strips and resident medications to be dated when they were opened for administration to the resident. They acknowledged that if they were not dated when they were opened, they would not be able to determine when the medication was outdated. DON B stated there was a note on the medication cart to remind the nurses to date the residents' medications when they were opened. 3. Review of the provider's February 2023 Medication Label and Storage policy revealed there was no information related to medication labels being securely affixed to prescription bottles or medications with shortened expiration dates after opening. 4. Review of the provider's [DATE] Nova Statstrip Glucose Meter System policy revealed, StatStrip Test Strips are good for 180 days after opening, or the expiration date printed on the label.

Based on record review, interview, and policy review, the provider failed to ensure a medication disposition record was completed for one of one reviewed discharged resident (37).Findings include: 1. Review of resident 37's electronic medical record revealed he discharged from the facility on 4/24/26 to his home with his wife. There was no documentation of the disposition of his medications, which included: metformin, rosuvastatin, losartan, hydrochlorothiazide, citalopram aspirin, amlodipine, and acetaminophen.2. Interview on 8/13/26 at 1:59 p.m. with director of nursing (DON) B and assistant director of nursing (ADON) C regarding disposition of medications for resident 37 revealed that when he discharged home, they thought his medications were sent home with him and his wife. They were unable to locate any documentation as to what happened to his medications. ADON C stated there was a medication disposition form that should have been filled out and included in the medical record, which included the resident's name, prescription number of the medications, and several other items. DON B and ADON C agreed that not documenting the disposition of medications created the potential for diversion of medications.3. Review of the provider's 2001 Discharge Medications Policy revealed The nurse shall complete the medication disposition record, including:a. the resident's name;b. the name of the person who will be assisting or administering the medication after discharge;c. the date of discharge;d. the name and prescription (Rx) number of each medication;f. the strength of each medication;g. any special instructions;h. telephone numbers for the physician, pharmacy, and facility; [NAME]. the signatures of the person receiving the medications and the nurse releasing the medications. The nursing staff shall forward completed drug disposition records to medical records.

Based on interview, observation, posted daily nursing staffing review, staff schedule review, and policy review, the provider failed to post the required daily nursing staffing information that clearly reflected actual hours worked by the nursing staff for 5 of 31 days in July of 2026. Findings include:1. Interview on 8/12/26 at 11:10 a.m. with registered nurse (RN) D revealed she did not know where the daily nursing staffing information was posted. She would know who was working and for how many hours by referring to the staff schedule. She did not change hours worked on any form other than the staff schedule when a staff member did not come to work due to illness. 2. Observation and interview on 8/12/26 at 11:16 a.m. with assistant director of nursing (ADON) C revealed the required daily nursing staffing information was posted on the door jamb of her office at eye level of a standing person. ADON C verified that the 8/12/26 posted daily staffing information indicated there were nursing assistants scheduled and not CNAs. She stated that nursing assistants were not used to cover shifts at the facility. Certified nursing assistants (CNAs) were the staff members used in the facility to care for residents.ADON C acknowledged that the posted daily nursing staffing information indicated there were six nursing assistants scheduled for the 8/12/26 day shift with the total hours for those six nursing assistants documented as 25 hours. ADON C stated that 25 hours was not accurate because there were three CNAs scheduled for eight hours each, one CNA scheduled for 12 hours, and two CNAs scheduled for 5 hours for a total of 46 hours.ADON C acknowledged that she and director of nursing (DON) B provided direct resident care while they were in the facility and their hours were not included on the required posted daily nursing staffing hours. ADON C stated their hours were not included because the night nurse who completed the daily nursing staffing posting would not know if DON B or ADON C were going to be in the facility that day and provide direct resident cares. DON B and ADON C did not update the posted daily staffing to include their direct resident care hours. 3. Review of the provider's July 2026 posted daily nursing staffing forms and staff schedules revealed that on 7/6/26, there were no CNAs identified as working on the posted nursing staffing hours, the hours were posted for nursing assistants. There were three nursing assistants for the day shift on the form for a total of eight hours for those three nursing assistants. The day shift nurse on the daily nursing staffing posting was identified as licensed practical nurse. The staff schedule indicated there were two nurses scheduled for the day shift on 7/6/26, one LPN and one RN.On 7/10/26 there were no CNAs identified as working on the posted nursing staffing hours, the hours were posted for nursing assistants. There were two nursing assistants for the day shift on the form for a total of eight hours for those two nursing assistants. The day shift nurse on the daily nursing staffing posting was identified as a licensed practical nurse. The staff schedule indicated there were two nurses scheduled for the day shift on 7/10/26, one LPN and one RN. On 7/22/26 there were no nurses identified as working for the day or night shifts on the posted daily nursing staffing.On 7/24/26 there was no night nurse identified as working on the posted daily nursing staffing. There were no CNAs identified as working on the posted nursing staffing hours; the hours were posted for nursing assistants. There were three nursing assistants for the day shift on the posted daily nursing staffing form for a total of eight hours for those three nursing assistants.On 7/29/26 there were no CNAs identified as working on the posted nursing staffing hours, the hours were posted for nursing assistants. There were three nursing assistants for the day shift on the posted daily nursing staffing form, for a total of eight hours for those three nursing assistants. 4. Interview on 8/13/26 at 2:01 p.m. with DON B and ADON C revealed that the night shift nurse completed and posted the daily nursing staffing forms each night. If there was a change in the staffing during any shift the charge nurse was responsible for changing the hours or staffing on the posted daily nursing staffing form. DON B and ADON C were aware that the posted daily nursing staffing forms were not being completed accurately according to the staff hours worked. They acknowledged there were times when there were no nurses on the posted daily nursing staffing form. ADON C stated that the provider had a nurse on staff 24 hours per day. 5. Review of the provider's August 2022 Posting Direct Care Daily Staffing Numbers policy revealed, Our facility will post on a daily basis for each shift nurse staffing data, including the number of nursing personnel responsible for providing direct care to residents. Within two (2) hours of the beginning of each shift, the number of licensed nurses (RNs, LPNs, and LVNs [licensed vocational nurses]) and the number of unlicensed nursing personnel (CNAs and NAs [nursing assistants]) directly responsible for resident care is posted in a prominent location (accessible to residents and visitors) and in a clear readable format. Directly responsible for resident care means that individuals are responsible for residents' total care or some aspect of the residents' care including, but not limited to: assisting with activities of daily living (ADLs), administering medications, supervising care provided by CNAs, and performing nursing assessments. The information recorded on the form shall include the following: .Type (RN, LPN, LVN, or CNA) and category (licensed or unlicensed) of nursing staff working during that shift who are paid by the facility (including contract staff); The actual time worked during that shift for each category and type of nursing staff; and Total number of licensed and non-licensed nursing staff working for the posted shift.

Based on record review, interview, and policy review, the provider failed to ensure the residents' care plans (a personalized plan that addresses a resident's care needs, goals, and interventions) were reviewed and revised to reflect the current care needs for two of four sampled residents (1 and 17) who received psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) for their symptoms and behaviors.Findings include: 1. Review of resident 1's electronic medical record (EMR) revealed she admitted to the facility on [DATE]. Her diagnoses included dementia (a group of symptoms affecting memory, thinking, and social abilities) with behavioral disturbances, anxiety (anticipation of future danger or misfortune with feelings of distress and/or sadness and symptoms such as restlessness or irritability), and depressive disorder (the persistent feeling of sadness, emptiness, and loss of interest). Her 6/25/26 long term care history and physical report stated she had, worsening behaviors associated with dementia at home. Her behaviors were almost exclusively towards family members and At the beginning of her hospitalization, she expressed comments that were felt to be more out of frustration, but did have an underlying tone of suicidality. She had a 6/24/26 physician's order for sertraline (an antidepressant medication) 100 milligrams (mg) to be administered daily. Her 8/12/26 care plan (personalized plan that addresses a resident's care needs, goals, and interventions) did not indicate she was on an antidepressant, what the side effects of that medication were, or what nonpharmacological interventions could be used by a staff member could use to help resident 1 with her symptoms or behaviors. She had an 8/5/26 physician's order for quetiapine (an antipsychotic medication; (a drug that alters neurotransmitter activity in the brain to reduce symptoms of mental health conditions) 50 mg to be administered daily at bedtime to reduce her anxiety and behavioral disturbances. Her 8/12/26 care plan did not indicate she was on an antipsychotic medication, what the side effects of that medication were, or what nonpharmacological interventions could be used by the staff for resident 1's symptoms or behaviors. 2. Review of resident 17's EMR revealed she admitted to the facility on [DATE]. Her diagnoses included anxiety and depression. She had a 7/16/26 physician's order for duloxetine (an antidepressant) 120 mg to be administered daily. Her 8/12/26 care plan did not indicate she was on an antidepressant, what the side effects of that medication were, or what nonpharmacological interventions could be used by a staff member to help resident 17 with her symptoms. She had a 7/21/26 physician's order for clonazepam (an antianxiety medication) 0.5 mg to be administered daily at bedtime. Her 8/12/26 care plan did not indicate she was on a medication for anxiety, what the side effects of that medication were, or what nonpharmacological interventions could be used by a staff member to help resident 17 with her symptoms. 3. Interview on 8/13/26 at 8:56 a.m. with certified nursing assistant (CNA) K revealed she would know what a resident's behaviors were and what interventions may be effective for helping that resident by referencing that resident's care plan or asking another staff member. 4. Interview on 8/13/26 at 10:54 a.m. with licensed practical nurse (LPN) F revealed that the staff members would be able to see what a resident's behaviors might be on their care plan. Nurses would be able to see what behaviors a resident has had in the past and the interventions that were attempted on the flowsheet in the resident's EMR where any resident behaviors were documented. The interventions on that flow sheet are not individualized, but the individualized nonpharmacological interventions should be on the resident's care plan. 5. Telephone interview on 8/13/26 at 12:54 p.m. with social service designee (SSD) I revealed the nursing department was responsible for documenting a resident's behaviors. She stated director of nursing (DON) B would ensure, that if a resident had suicidal ideation or known behaviors, it was on their care plan. SSD I stated, We [the residents' facility care team] decide if the resident should be referred to our psychologist; we just monitor behaviors. 6. Interview on 8/13/26 at 2:01 p.m. with DON B and assistant director of nursing (ADON) C revealed they expected that if a resident was receiving medications for a behavior that behavior would be identified on that resident's care plan. A new staff member would not be able to know what a resident's behavior may be or what the nonpharmacological interventions for that behavior were if it was not on that resident's care plan. The click boxes on the flowsheet in the resident's EMR were nonpharmacological interventions that were suggested by the EMR as possible interventions for the staff to use and were not personalized to each resident. ADON C expected that all the information related to a resident's mood or behavior be in that resident's care plan along with nonpharmacological interventions for that mood or behavior. She expected resident 1's history of suicidal comments to be identified within her care plan, along with potential interventions for the comments if she should express them later. 7. Review of the provider's 6/2020 Care Plans, Comprehensive Person-Centered policy revealed that: The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS [Minimum Data Set] assessment (Admission, Annual, or Significant Change in Status), and no more than 21 days after admission.

Based on observation, record review, interview, and policy review, the provider failed to ensure that staff protected the residents' right to dignity and privacy for two of three residents (7 and 11) observed with their catheter (flexible tubing placed in the bladder to drain urine) urine collection bags uncovered, with urine visible to others, when the residents were in public areas.Findings include: 1. Observation on 8/11/26 at 10:58 a.m. of resident 7 revealed that he was walking in the hallway, wearing a pair of shorts, and had a catheter urine collection bag with visible urine in it attached to his leg. There was no cover on the catheter bag.2. Observation on 8/12/26 at 8:03 a.m. revealed resident 7 was walking out of the dining room. He was wearing shorts, and there was no covering on his catheter urine collection leg bag, and it had urine visible in it.3. Observation on 8/13/26 at 9:33 a.m. revealed resident 7 and 18 random residents were seated in the dining room for an exercise program. Resident 7 was wearing shorts, his catheter leg bag was not covered, with urine visible in it.4. Review of resident 7's electronic medical record (EMR) revealed he admitted to the facility on [DATE]. His care plan indicated staff members were to ensure his catheter bag was covered for dignity.5. Observation on 8/12/26 at 7:58 a.m. of resident 11 revealed he was seated at a dining room table in his wheelchair. He had a catheter urine collection bag, with no cover clipped to his wheelchair under the seat of the wheelchair. There was urine visible in the catheter bag.6. Observation on 8/12/26 at 4:25 p.m. of resident 11 revealed he was seated in his wheelchair. He had a catheter urine collection bag, with no cover clipped to his wheelchair under the seat of the wheelchair. There was urine visible in the catheter bag.7. Review of resident 11's EMR revealed he admitted to the facility on [DATE]. His care plan indicated staff members were to ensure his catheter bag was covered for dignity.8. Interview on 8/13/26 at 10:37 a.m. with certified nursing assistant (CNA) J revealed that catheter bag covers were not always available for the staff to use to cover residents' urine collection bags, as they were sent to the laundry to be washed every night. In the morning, the staff members would have to wait until the laundry department washed the covers before they could be placed on the residents' catheter urine collection bags. She stated that resident 7 did not want his catheter urine collection leg bag covered, and he did not like to wear long pants that would cover that bag. She stated his care plan did not include his preference for that. She stated that resident 11 should have a cover on his catheter bag.9. Telephone interview on 8/13/26 at 12:50 p.m. with social service designee (SSD) I, revealed that residents who used a catheter urine collection bag were to have it covered to maintain their dignity. She was aware resident 7 did not have a cover for his catheter leg bag and she was not sure if there was a cover that was made and available for a catheter urine collection leg bag. She indicated the nursing department was responsible for ensuring the catheter urine collection bag coverings were available for the nursing staff to use.10. Interview on 8/13/26 at 2:09 p.m. with assistant director of nursing (ADON) C and director of nursing (DON) B regarding resident's use of catheter urine collection bag covers revealed that DON B stated those bags were to be covered at all times. ADON C indicated that resident 7 preferred to wear shorts, and she was not aware if a covering for a catheter urine collection leg bag was made, other than the resident wearing long pants. She stated that resident 7 did not want to wear long pants or to cover his catheter leg bag. She expected his preference for wearing shorts and to not have his catheter urine collection leg bag covered to be reflected in his care plan. ADON C stated the catheter bag coverings were to be washed every time the resident's wheelchair was washed, which was done weekly or when soiled. They were not aware that staff washed the catheter urine collection bag coverings each night.11. Review of the provider's 2001 Catheter Care policy revealed no information regarding covering catheter urine collection bags for the residents' dignity.

Based on payroll-based journal (PBJ) day review and interview, the provider failed to ensure eight hours of registered nurse (RN) coverage seven days per week for two consecutive quarters during July, August, and September 2024 and October, November, and December 2025. This citation is considered past non-compliance based on review of the corrective action the provider implemented following the inability to ensure eight hour of RN coverage seven days per week.Findings include: 1. Review of the PBJ data for quarter July, August, and September 2024 revealed: *There was no eight-hour coverage documented for five days (4, 7, 13, 20, 21) in July. *There was no eight-hour coverage documented for two days (20 and 25) in August. *There was no eight-hour coverage documented for six days (7, 14, 15, 21, 22, and 29) in September. 2. Review of PBJ data for quarter October, and November 2024 revealed: *There was no eight-hour coverage documented for two days (2 and 3) in October 2024. *There was no eight-hour coverage documented for one day (14) in November 2024. *There was no eight-hour coverage documented for seven days (22, 23, 24, 25, 26, 27, and 28) in December 2024. 3. Interview on 7/25/25 at 2:00 p.m. with director of nursing A and chief executive officer J regarding the requested documentation for RN coverage for the above listed days revealed: *They confirmed they did not have eight hours of RN coverage on the above listed days. *They had applied for and received a RN waiver for the eight hours per day of RN coverage that was approved on 3/7/25 and was good through 3/6/26. Review of the provider's facility assessment regarding RN coverage revealed it had not indicated the amount of RN hours that would have been provided. The provider implemented systemic changes to ensure 40 hours of RN coverage was provided to adhere to the granted waiver provided on 3/7/25. Based on the above information, non-compliance at F727 occurred on 7/4/25 and went through 12/28/24 for a total of 23 days with no RN coverage for eight-hour per day; and based on the provider's implemented corrective actions for the deficient practice on 3/7/25, the con-compliance is considered past non-compliance.

Based on observation, interview, and policy reviews the provider failed to ensure:*One of one whirlpool tub had been disinfected according to the manufactures recommendations by one of one observed certified nursing assistant (CNA) (G).*Fifteen of fifteen observed air conditioning units located in residents' (1, 3, 4, 5, 6, 7, 8, 10, 12, 15, 16, 17, 18, and 20) rooms had been maintained and cleaned routinely to prevent the accumulation of dust and residue.Findings include: 1. Observation and interview on 7/24/25 at 8:03 a.m. of CNA G regarding the cleaning and disinfecting the whirlpool tub revealed: *She had started to fill the whirlpool tub with water and then added ten capfuls of disinfectant to it. *Then she ran the jets for 15 minutes and wiped down all the inside surfaces of the tub and the whirlpool chair. *She indicated she would let the tub get filled with water so the soap would hang on the sides of the tub to help disinfect it. *After the 15 minutes she had shut the jets off and scrubbed the sides of the tub and the tub chair with a scrub brush. *She drained the water from the tub and sprayed clean water on the inside of the tub and whirlpool chair to rinse the disinfectant for those surfaces. *She indicated clean water would have been run through the jets in morning before they used the tub. *She used a towel to dry the inside of the tub and chair surfaces. *She indicated that this had been her usually practice for disinfecting the whirlpool tub. *She stated the instructions for cleaning the whirlpool tub that had been posted in the whirlpool room were the old instructions. *She was not sure of how long they had been doing the current disinfectant process for the whirlpool tub. Review of the provider's current posted Bath Cleaning Procedure revealed: *1. Close and lock Door. *2. Rinse any tissue, residue, or fluids from tub with hand held shower sprayer and let drain. *3. Place the plug in the drain. *4. Press and hold the disinfectant button on left side of tub. *5. Thoroughly scrub inside of the tub with solution. *6. Remove plug from drain. *7. Rinse the inside areas of the the tub with shower sprayer. *8. Press and hold the rinse button on the left hand side of the tub to rinse the air jet system. *9. Leave tub door open at end. *10. Wipe out rubber seal on door. 2. Interview on 7/25/25 at 11:45 a.m. with CNA H regarding cleaning the whirlpool tub revealed: *He verbalized the same process cleaning and disinfecting the whirlpool tub as CNA G performed in the above observation. *He stated the sanitizer button on the whirlpool tub had been broken since before he started working there on 5/19/25. 3. Interview on 7/25/25 at 11:59 a.m. with maintenance staff C regarding notification of broken resident care equipment revealed: *Staff would have either texted him or wrote down the broken equipment in the maintenance binder for him to follow up on. *He had not known there a sanitizer function on the whirlpool tub or that it was broken and not working correctly. 4. Interview on 7/25/25 at 12:15 p.m. with director of nursing A regarding the cleaning and disinfectant of the whirlpool tub revealed: *She had measured the exact amount of disinfectant cleaner ten capfuls would have been to show the amount used by CNA G. -Ten capfuls measured a little over two ounces. *She agreed the amount of disinfectant CNA G used was not the correct concentration for the amount of water that had been filled in the whirlpool tub. *She agreed the posted whirlpool cleaning instructions had not been correct and did not reflect the manufacturers recommendations for disinfection of the whirlpool tub. Review of the provider's [NAME] Bathing Spas Disinfection Quick Guide revealed: *Step 1 Close and lock spa door. Install drain plug in drain. *Step 2 Push and hold disinfect jets button. *Step 3 Fill spa floor with disinfectant solution until a depth of 1/4 of solution is achieved. *Step 4 Using spa brush, dip brush into solution, and scrub entire spa interior along with top and underside of mobile transfer. Allow disinfectant to remain on contact for 10 minutes. *Step 5 Remove drain plug. Press and hold rinse jet button. Clean water will flush the remaining disinfectant from the jets. *Step 6 Press and release Aqua-Aire button allowing warm air to push any remaining water from the lines. *Step 7 Press and release hand spray button to activate shower sprayer. Starting at the top rim of spa, rinse any remaining disinfectant solution off spa walls and down spa drain. Rinse mobile transfer. *Step 8 Press and release Aqua-Aire button to turn off warm air. Replace shower sprayer to holder. Spa disinfection is now complete. 5. Observation on 7/23/25 at 9:40 a.m. of resident 6's room revealed: *An air conditioning (AC) unit was installed on the outside wall, with the following indicator lights on: -A green Cool light and the AC unit was set at 61° Fahrenheit (F). -A red Check Filter light, which indicated the unit needed servicing. *The intake vents on the AC unit were covered with fuzzy debris on all vents. 6. Observation on 7/23/25 at 9:49 a.m. of resident 18's room revealed: *The AC unit was installed on the outside wall, which was set at 70°F with the following indicator lights on: -A green Cool light and the AC unit was set on Low. -A yellow Check Filter indicator light was on which indicated the filter needed to be serviced. *The outflow vents, which directed the flow of air, had dust on the vents that came off with a finger swipe. 7. Observation on 7/23/25 at 10:05 a.m. of resident 25's room revealed: *The AC unit was installed on the outside wall. *The AC unit was not operating but had the red Check Filter light on. 8. Observation on 7/23/25 at 10:07 a.m. of resident 9's room revealed: *The AC unit was installed on the outside wall, which was set at 60°F with the red Check Filter indicator light on. *The AC unit had dust on the outflow vents that came off with a finger swipe. 9. Observation on 7/23/25 at 10:10 a.m. of resident 17's room revealed: *The AC unit was installed on the outside wall, and was operating on Cool set to 72° F. *The red Check Filter indicator light was on. *The vents on AC unit were dust covered with fuzzy debris on all vents. *The outflow vents had dust on the vents that came off with a finger swipe. 10. Observation on 7/23/25 at 10:13 a.m. of resident 5's room revealed: *The AC unit was installed on the outside wall and was operating on Coolest setting and on Low Cool. *There was dust on the outflow vents that came off with a finger swipe. 11. Observation on 7/23/2025 at 10:16 a.m. of resident 3 in her room with AC unit off revealed: *The vents on AC unit had been dust covered fuzzy debris on all vents. *There was dust on the outflow vents that came off with finger swipe. 12. Observation on 7/23/25 at 10:21 a.m. of resident 12's room revealed: *The AC unit was set on Cool at 64 degrees F. *The intake vents on the AC unit were dust covered with fuzzy debris on all the vents. *The outflow vents had dust on the vents that came off with a finger swipe. 13. Observation on 7/23/25 from 2:30 p.m. to 2:45 p.m. of residents within room AC units revealed: *Resident 8's air conditioner had been on with dust on the screen and a black substance on the exit air flow vents. *Resident 10's air conditioner had not been on, but it had dust on the screen and a black substance on the exit air flow vents. *Resident 7's air conditioner had been on with dust on the screen and a black substance on the exit air flow vents. *Resident 4's air conditioner had not been on, but it had dust on the screen and a black substance on the exit air flow vents. *Resident 15's air conditioner had not been on, but it had dust on the screen and a black substance on the exit air flow vents. *Resident 16's air conditioner had been on with dust on the screen and a black substance on the exit air flow vents. *Resident 20's air conditioner had been on with dust on the screen and a black substance on the exit air flow vents. *Resident 1's air conditioner had not been on, but it had dust on the screen and a black substance on the exit air flow vents. Interview on 7/23/25 at 11:28 a.m. with maintenance staff C regarding the residents' AC units revealed: *He maintained the AC units and serviced them as needed. *He stated housekeeping, nursing, or maintenance staff provided the routine cleaning of the AC units. *He agreed the air conditioner units had not been cleaned regularly and were not clean. Interview on 7/24/25 at 9:00 a.m. with housekeeper M regarding the cleaning of residents' AC units revealed: *He would have dusted the outside of the air conditioner every day that he had worked. *He agreed there was still dust on the outside of the AC unit after he had cleaned it. *He did not work on 7/23/25. *He used a green microfiber duster and dusted the outside of the unit but did not clean between the vents. Interview on 7/24/25 at 11:11 a.m. with assistant supervisor of housekeeping/laundry I regarding the cleaning of residents in room AC units revealed: *She had not been informed that housekeeping staff was required to clean the AC units. *Staff would have dusted the outside of the unit, and not have deep cleaned it. Request for a policy on cleaning residents in room AC units had been made on 7/24/25 at 9:00 a.m. from director of nursing A, but a policy had not been provided upon exit of the survey.

Based on observation, interview, and policy review provider failed to ensure their food storage policy had been maintained by dating open food packages in one of one kitchens. Findings include: 1. Initial observation on 2/5/24 at 3:50 p.m. of the kitchen storage room revealed: *Two bags of opened graham cracker crumbs bags that were opened not dated. *One bag of taco seasoning mix that was opened and not dated. *Cocoa powder package that was opened and not dated. *Orange gelatin mix package that was opened and not dated. *Vanilla instant pie filling package was opened and not dated. *Cheddar cheese powder sauce mix package was opened and not dated. 2. Observation on 2/5/24 at 4:15 p.m. of the main dining room food storage cupboards revealed: *Cheese puffcorn package that was opened and not dated. -Best use by date on the cheese puffcorn was 9/11/23. *Original puffcorn that was opened and not dated. -Best use by date on the original puffcorn was 10/3/23 *Plain potato chips opened and not dated. - Best used date was 4/2/23 *Rice Crispies cereal opened dated 9/14/23, and another bag of rice crispies that the date was rubbed off. -Rice Crispies, Cheerios, and flake cereal was in plastic containers, these containers were not dated when cereal had been poured into the container. Observation and interview on 2/6/24 at 11:36 a.m. of dietary staff E revealed: *Dietary staff E had removed items from a cupboard in the dining room while serving the resident's lunch. *When a package was opened it should have been dated by the person who opened it. Interview on 2/8/24 8:16 a.m. with dietary staff F revealed: *It is policy to date packages and containers once they are opened. Interview on 2/8/24 at 8:25 a.m. with dietary manager D revealed: *Dietary staff who opened packages were to have dated the packages, and the nursing home staff was to date when they opened packages in the dining room. *Cereals and other items in the left cupboard in the dining room was dietary's responsibility to manage, twice a week. *Activities personnel overseen the cupboard where chips, puffcorn and other snack items were stored. Review of the providers February 2023 food storage policy revealed: *Dry Goods Storage areas will be neat, arranged for easy identification, and date marked as appropriate. *Cold Food Storage policy states all food will be stored wrapped or in covered containers, labeled, and dated, and arranged in a manner to prevent cross contamination.

Based on observation, interview, and policy review the provider failed to ensure the following: *Appropriate hand hygiene with glove use for one of one certified nursing assistant (CNA) I with one of one sampled (8) resident while providing personal care. *Changing the oxygen concentrator humidifier bottles for three of three (6, 7, and 21) sampled residents. Findings include: 1. Observation on 2/5/24 at 3:57 p.m. of CNA I while transferring resident 8 with the stand aid mechanical lift from her wheelchair to the bathroom revealed: *Resident 8 was raised to a standing position with the stand aid mechanical lift and transferred to the bathroom. *CNA I applied a pair of gloves without performing hand hygiene and removed the resident's brief. *Removed her gloves and without performing hand hygiene lowered the resident to the toilet. *She then retrieved a clean brief from the resident's closet. *Applied a new pair of gloves without performing hand hygiene and assisted the resident to a raised position and provided personal care. *Removed her gloves and applied a new pair of gloves without performing hand hygiene and secured a clean brief. *Removed her gloves without performing hand hygiene and assisted the resident to her wheelchair. Interview with CNA I following the above observation regarding glove use and hand hygiene revealed: *She did not have any hand sanitizer in her pockets, but she would use the hand sanitizer on the wall outside of the resident's room. *Hand hygiene training was offered online and hand washing competency was completed in front of a nurse. *She had received her hand hygiene training with her CNA training, but she could not remember any training regarding hand hygiene and glove use. Interview on 2/8/24 at 10:40 a.m. with infection preventionist C and director of nursing (DON) B regarding the above observation revealed: *They both agreed that they do frequent hand hygiene audits. *DON B agreed that CNA I had an opportunity to perform hand hygiene while assisting the resident. Review of the provider's Handwashing/Hand Hygiene policy revealed: *Perform hand hygiene before applying non-sterile gloves. *After gloves had been removed perform hand hygiene. 49958 2. Review of the provider's Cleaning of Oxygen Equipment Policy #2021-04 effective 4/2001 revealed: *D. Oxygen cannula, mask and tubing 1. Change oxygen cannula and mask once a week. Discard the dirty cannula and mask into the garbage. 3. If humidifier bottle is used, change the oxygen tubing once a week. Discard the dirty tubing into the garbage. E. Humidifier bottle 1. The use of humidifier bottles with oxygen is not recommended as they significantly increase the risk of bacterial contamination of the oxygen equipment. However, if humidifier bottles are used, i.e. for the treatment of nasal dryness: i. Use only sterile distilled water to fill the humidifier bottle. ii. Completely empty the sterile distilled water out of the humidifier once a day, clean with soap and water, rinse well, allow to air dry and then refill the bottle. iii. If the humidifier bottle is disposable, change the bottle once a week. Discard the dirty humidifier bottle. 3. Observation on 2/5/24 at 5:09 p.m. of an oxygen concentrator located in dining room near the entrance door revealed: *The nasal cannula had been dated 1/22 on the green end nearest humidifier bottle. *The plastic zip bag the oxygen tubing and nasal cannula had been dated 1/24. *The clear plastic tube from concentrator to humidifier was labelled DO NOT REMOVE. *The single use oxygen humidifier bottle had been dated 1/3/24. *The oxygen concentrator and tubing had not been labeled with the resident name. Observation on 2/5/24 at 5:31 p.m. of the same oxygen concentrator in dining room revealed: *Resident 21 was seated at dining room table wearing oxygen connected to the oxygen concentrator. Observation on 2/7/24 at 11:00 a.m. of resident 21's oxygen concentrator in the dining room revealed: *The nasal cannula had been dated 2/5 on the green end nearest the humidifier bottle. *The plastic zip bag containing the oxygen tube and nasal cannula had been dated 2/5. *The clear plastic tube from concentrator to humidifier had been labelled DO NOT REMOVE. *The single use oxygen humidifier bottle had been dated 1/3/24. *The oxygen concentrator and tubing had not been labeled with resident name. Review of resident 21's electronic medical record (EMR) revealed: *He had a physician's order dated 1/29/23 for oxygen (O2) in order to keep O2 level above 90% -- usually 2-4 liters per nasal cannula. *The care plan and doctor order stated oxygen tube change ordered weekly. -The oxygen humidifier change frequency order stated .Protocol. *The oxygen humidifier change order had been created 8/16/23 and had been placed on hold 1/8/24 and resumed 1/12/24. *The oxygen humidifier changes had been documented as completed 8/30/23, 9/24/23, 10/17/23, 1/19/24, and 2/5/24, 4. Observation on 2/7/24 at 11:05 a.m. of an oxygen concentrator in dining room located near the food service line revealed: *The nasal cannula had been dated 2/5 on the green end nearest the humidifier bottle. *The plastic zip bag containing the oxygen tube and nasal cannula had been dated 2/5. *The clear plastic tube from concentrator to humidifier had been labelled DO NOT REMOVE. *The single use oxygen humidifier bottle had been dated 1/5/24. *The oxygen concentrator and tubing had not been labeled with resident name. Observation and interview on 2/7/24 at 11:13 a.m. with restorative aide G in the dining room revealed: *She had assisted resident 7 to put on the nasal cannula connected to oxygen concentrator. *She had known who the oxygen tubing belonged to, because she sits there all of the time. Observation on 2/7/24 at 2:03 p.m. in resident 7's room revealed: *The resident was in bed and was wearing oxygen. *The nasal cannula had been dated 2/5 on the green end nearest the humidifier bottle. *The single use oxygen humidifier bottle had not been dated. 5. Observation on 2/7/24 at 1:29 p.m. of the oxygen concentrator located in resident 6's room revealed: *The resident was in bed and was wearing oxygen. *The nasal cannula had been dated 2/5 on the green end nearest the humidifier bottle. *The clear plastic tube from the concentrator to the humidifier bottle had been labelled DO NOT REMOVE. *The single use oxygen humidifier bottle had been dated 1/3/24. Review of resident 6's electronic medical record revealed: *Resident 6 had been hospitalized with Covid-19, Sepsis, Respiratory distress, and severe acute respiratory distress on 1/12/23 and returned 1/16/23. *The care plan and doctor order stated oxygen tube change ordered weekly. -The oxygen humidifier change frequency order stated .Protocol. *The oxygen humidifier change order had been created 7/23/23 and had been placed on hold 7/28/23 and resumed 7/31/23. *The oxygen humidifier changes had been documented as completed 8/31/23, 9/24/23, 10/12/23, 1/1/24 and 2/5/24. 6. Interview on 2/7/24 at 12:31 p.m. with director of nursing (DON) B regarding her expectations on how staff were to have identified to whom the oxygen concentrators and tubing belonged to revealed: *The regular staff all know whose concentrators are in the dining room because there are just two *Oxygen use would have been care planned and communicated by herself to staff. *She stated their policy prohibited the labeling of oxygen concentrators Interview on 2/8/24 at 10:08 a.m. with DON B and phone interview with infection preventionist (IP) C revealed: *There had not been a policy for labeling the concentrator or oxygen tube with the resident information. *They planned to initiate labeling of oxygen tube with resident initials for improved identification. *They were not aware that their policy had stated humidifier bottles were to be changed weekly. 7. Review of seating diagram posted in dining room at the front of meal service tray line revealed: *It had been dated 11/30/23. *It indicated that resident 3 was to have been seated at the table nearest the food service line. *It indicated that resident 21 was to have been seated at the table nearest the door.

Based on observation, interview, and policy review the provider failed to ensure they had followed their policy for counting controlled medications in one of one medication storage room waiting for destruction. Findings include: 1. Initial observation on 2/7/24 at 8:56 a.m. of the medication storage room with registered nurse (RN) H revealed: *The controlled medications that were to have been destroyed were kept in a double-locked cabinet. *Medication sheets with the amount of the medication to have been destroyed were kept with the medication until the destruction. *The list of controlled-medications that were due to have been destroyed included the following: -Lorazepam 15 milliliters (mls). -Morphine 14.5 mls. -Clonazepam 0.5 milligram (mg) 27 tablets. -Clonazepam 0.5 mg 7 tablets. -Tramadol 50 mg 13 tablets. Interview with RN H regarding the accountability of the above medications revealed: *Once a controlled medication was discontinued and needed to have been destroyed the process included: -The medication would have been removed from the medication cart and the amount recorded on a form that was kept with the medication. -The medication was then double-locked in the medication storage room for destruction. -The verification of the count of those medications that were scheduled for destruction were not verified with each nursing shift change. *Nurses had access to the keys to the narcotic cabinet in the medication storage room. Interview with RN H regarding the above observation revealed: *No specific nursing shift was responsible for checking the medication cart for outdated medications. *Nurses were responsible for checking for outdated medication that they were administering. Interview on 2/8/24 at 7:58 a.m. with director of nursing (DON) B regarding the accountability of controlled medications that were scheduled to have been destroyed revealed: *She agreed that the controlled medication had not been counted with each nursing shift change and had not followed their policy. *She had spoken to the pharmacist and discussed the urgency of destroying controlled medications as soon as possible. Review of the provider's June 2002 Controlled Drug policy revealed: *Narcotics are counted at the change of each shift by the off going and the on-coming nurse and both sign the change of shift count record. -When controlled keys change hands during a shift, controlled drugs are recounted and both nurses sign the count record. *The nurse has two keys: one key for controlled drugs and one for the medication drawers. These two keys must be kept on separate holders.

Based on observation, interview, record review, and policy review, the provider failed to ensure assessments had been completed related to monitoring and preventing skin issues for five of twelve sampled residents (1, 5, 10, 16, and 27). Findings include: 1. Interview with resident 5 on 11/2/21 at 8:45 a.m. revealed she: *Was sitting in a recliner. *Had a bed in her room that contained many of her items. *Stated she preferred to sleep in her recliner. *Had an open area to her bottom. *Stated it had been there for a little while. *Stated staff were aware of the area. Surveyor : Observation and interview on 11/2/21 at 1:00 p.m. with registered nurse(RN)/minimum data set (MDS) coordinator D and certified nursing assistant (CNA) F revealed: *Resident 5 had two open areas to her bilateral posterior upper thighs. *The two areas appeared to be 2 centimeters (cm) by 0.5 cm. *Resident 5 also had two dark purple macerated areas in her bilateral buttocks area. -Those two round dark purple areas appeared to ready to open. Surveyor : Interview on 11/2/21 at 1:15 p.m. with CNA F revealed: *Resident 5 did have open areas on the back of her thighs. *She had noticed the open areas that morning. *She had informed RN/MDS coordinator D about the areas. Interview on 11/2/21 at 2:00 p.m. with RN/MDS coordinator D regarding resident 5's wounds revealed: *She had been aware of the one open spot on one posterior upper thigh. *They had been putting Cavlion spray on the wound. *CNAs let licensed nurses know during resident's baths if they have any skin issues. *Surveyor asked if they do routine skin assessments on residents who are at risk for skin breakdown or have had skin issues: -RN/ MDS coordinator D stated they did not. Review of resident 5's Braden assessments revealed: *On 5/27/21 she was determined to be at moderate risk for skin breakdown. *On 8/25/21 she was determined to be at mild risk for skin breakdown. Review of resident 5's skin assessments revealed: *On 5/27/21 she had been admitted to the facility. *On 6/3/21, her first skin assessment was completed and revealed: -On Left buttocks, skin original was purplish red on admission here at [nursing home name] had prior open area from previous hospital admission. -The area on the left buttocks was marked as open. -She also had an open area to her left upper posterior thigh. -The right upper posterior was noted to have a similar area to the left but they will monitor. -They noted they would use [MEDICATION(S)] spray for the areas. *On 6/7/21: -There was no documentation if the area on the left buttock was open or closed. -Upper left thigh was open. -The note about the right upper posterior was the same as the above 6/3/21 skin assessment. -Continue to use [MEDICATION(S)] spray daily. *On 6/14/21: -Now the right upper posterior thigh was marked as open. -There was the same note about the right upper thigh like the left thigh but not open. -Just below that was noted the wound was open. *On 6/21/21: -Buttocks was healed. -There were open areas to her left and right upper posterior thigh. -There was still a note stating it was open and will monitor. *The skin assessments noted open and closing wounds. *The treatment had always been marked as [MEDICATION(S)] spray or open to air. *From 6/3/21 through 11/2/21 she had areas on her left and right upper posterior thighs and buttocks that were open. *There were inconsistencies in frequency of documentation. Review of resident 16's skin assessments revealed: *He had two skin assessments completed for 2021. *One was completed in January 2021. *The other skin assessment was completed October 2021, after he had a skin tear. Review of resident 1's skin assessments revealed: *His admission skin assessment on 3/10/21 stated: -wife states coccyx was open but not at this time, has very fragle [fragile] skin, gets pink when on buttock for to [too] long of period, does have gel cushion in wh/ch [wheelchair] . *The next skin assessment was completed about three months later on 6/11/21. *The 6/11/21 assessment stated: -He had a 5.0 centimeters (cm's) by 2.0 cm red area. -Although he had been noted to have fragile skin and red areas his skin assessments had gaps in documentation. -Some assessments were completed weekly, others had more than a month of missing assessments. Review of resident 1's two most recent Braden assessments revealed he was at high risk for skin breakdown. Review of resident 27's skin assessments revealed: *He had no issues on his admission skin assessment completed on 4/20/21. *On 4/23/21 he: -Had a blister to his left heel. -3.5 cm by 3.5 cm. -They would treat it with [MEDICATION(S)] two times per day and heel protectors. *On 4/28/21 he: -Had the same note as the 4/23/21 note. *On 5/3/21 he: -Had the same blisters on his left heel. -The area was noted to have very little fluid left in the blister. -Had a blister that was intact. -Would receive twice a day [MEDICATION(S)] treatments to his heel as well as heel protectors. *On 5/10/21 he still had an intact blister on his left heel. *On 5/17/21 the blister was assessed to be healed. *He had not had any skin assessments completed from 5/17/21 through 11/2/21. Review of resident 10's skin assessments revealed she had one skin assessment completed for the year of 2021. Interview on 11/3/21 at 9:37 a.m. with the director of nursing (DON) C revealed; *She considers the Braden assessments as their skin assessments. *Nurses only complete skin assessments after they had been notified of a skin issue. Interview on 11/3/21 at 11:26 with physicians assistant (PA) G revealed he: *Was a provider for the facility. *Was not aware that nurses would not do skin assessments unless there had been an issue. *Not aware of the skin issues that resident 5 had. Review of the provider's 11/2/21 Resident Census and Conditions of Residents form filled out by the provider revealed: *They had one resident with a pressure ulcer, resident 22. -That resident was not resident 1, 5, 10, 16, or 27. *They did not have any residents who had rashes. *They did not have any residents receiving preventive skin care. Review of the provider's May 2019 Prevention and Assessment of Pressure Ulcers policy revealed: *The purpose of this procedure is to provide information regarding identification of pressure ulcer risk factors and interventions for specific risk factors. *The facility should have a system/procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician, and family, and addressed. *Charge nurse will assess resident's skin for every MDS assessment and as indicated and document the condition of the resident's skin per facility wound and skin care program for any signs and symptoms of irritation or breakdown. *The care process should include efforts to stabilize, reduce or removed underlying risk factors; to monitor the impact of the interventions; and to modify the interventions as appropriate.

Based on observation, interview, record review, and policy review, the provider failed to ensure four of four sampled residents (1, 10, 13, and 16) had been assessed for the use of a scooped mattress, positioning chairs, and chair and/or bed alarms as restraints or enablers. Findings include: 1. Observation of resident 13 on the following dates and times revealed on:*11/1/21 at 5:00 p.m. she had been sitting reclined in a Geri-chair in the lounge area. *11/2/21 at 9:30 a.m. and at 11:00 a.m. she had been sitting in a reclined Geri-chair in her room. Review of resident 13's medical record revealed: *diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . *The 9/13/21 quarterly Minimum Data Set (MDS) assessment had been documented she required: -Total assistance of two staff with transfers and toilet use. -Extensive assistance of two staff with dressing and personal hygiene. *She had used a sit-to-stand lift for transfers. *On 8/26/21 she had an incident where she had started to slip out of the sit-to-stand lift and they had changed her to a total mechanical lift. *There was not an evaluation/assessment for the use of a Geri-chair. *The Geri-chair had not been listed on her care plan. Interview on 11/3/21 at 10:00 a.m. with registered nurse/minimum data set (RN/MDS) coordinator D regarding resident 13 and the Geri-chair revealed: *She used the Geri-chair for repositioning. *It had helped decrease her falls. *She had been found to be unsafe in a wheelchair. *She felt resident 13 would be able to get out of the Geri-chair if she wanted to. *They had not done an assessment for resident 13 to use the Geri-chair. *She confirmed there was no documentation: -They had done an assessment for her to use the Geri-chair. -She could get out of the Geri-chair by herself. Interview on 11/3/21 at 12:17 p.m. with DON C regarding resident 13 and the Geri-chair revealed: *The Geri-chair had not been listed on the care plan. *Resident 13 began using the Geri-chair on 8/26/21. *They had not done an assessment for her to use the Geri-chair. 2. Observation on 11/1/21 at 5:00 p.m. of resident 10 revealed she: *Was sitting in her wheelchair, in the doorway of her room. *Had a chair alarm on her wheelchair. *Was very confused and worried she was going to miss supper. 3. Observation on 11/1/21 at 5:22 p.m. of the facility's main dining room revealed: *Residents 1, 10, and 16 were eating supper. *Resident 1 was in a Geri-chair. *Resident 10 and 16 both had alarms on their wheelchairs. Observation on 11/1/21 at 6:00 p.m. of resident 16's room revealed he had a scooped mattress. Review of the provider's 11/2/21 Resident Census and Conditions of Residents form filled out by the provider revealed they did not have any residents who had restraints. 4. Observation and interview on 11/2/21 at 10:00 a.m. with resident 1 revealed: *He was reclined back in a Geri-chair. *An unidentified staff member came in his room to get a lift that was positioned behind his Geri-chair. *He asked the staff member: -Are you going to sit me up now? *The staff member had not answered his question and took the lift and left the room. Interview on 11/3/21 at 9:37 a.m. with director of nursing (DON) C revealed: *They have no residents that had restraints. *She had not felt that alarms, chairs, or mattresses could be considered restraints. *They did not have assessments for the devices. *She did not feel that alarms could be restraints because they were used to alert staff when the resident moved. *She agreed resident 1 would be unable to reposition himself in a reclined Geri-chair. Review of resident 16's record revealed: *He had a bed, chair alarm and scooped mattress as of 12/2/20. *He had seven falls after the implementation of those devices. Review of resident 10's medical record revealed: *She had devices removed 2/20/19. *Staff were unsure of when the devices were implemented again. *She had continued to have falls. Interview on 11/3/21 at 11:45 a.m. with DON C, physician assistant (PA) G and the director of quality and compliance B revealed: *They have a fall committee that meets every week. *They did not have any documentation of the fall committees' discussions or recommendations. *They felt that falls had improved since implementing the devices. *Nursing decides who had a device or alarm placed. *They had not tracked or monitored if the devices were effective or if they were restraints. Review of the provider's September 2017 Restraint Use Policy and Procedure revealed: *It is the philosophy of [facility's name] to keep residents unrestrained and as independent as possible. If the results of a comprehensive, interdisciplinary assessment determine that there are no alternative[s] to provide resident safety, or that the alternative methods have been unsuccessful, a physical and/or chemical restraint will be recommended for use . *Physical restraint: any manual or 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 .

Based on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (8) who had an indwelling Foley catheter had been reassessed for its continued use. Findings include: 1. Observation and interview on 11/1/21 at 4:35 p.m. with resident 8 revealed: *She was in her room seated in a wheelchair. *There was a Foley catheter bag hanging from the right armrest of her wheelchair. -Above the resident's bladder level for proper drainage. *She stated she had fallen on 8/23/21 at her residence while on trial leave from the nursing home and had the catheter ever since. *Had fractured her right femur. -The fracture was inoperable. *Had been admitted for observation to the hospital on 8/24/21. *The Foley catheter was placed at that time. *Was readmitted to the nursing home on 8/25/21 with Foley catheter in place. Review of resident 8 physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/3/21 at 11:00 a.m. interview with director of nursing (DON) C regarding resident 8's Foley catheter revealed: *She stated that physical therapy was managing the need for the Foley catheter. *She also stated that physician assistant (PA) G was also managing the need for the Foley catheter. Interview on 11/3/21 at 11:00 a.m. with (PA) G regarding the medical necessity for resident 8's Foley catheter revealed: *Resident 8 had been incontinent of urine and feces upon admission to the emergency department (ED) on 8/24/21. *Resident 8 was non-weight bearing to right leg for 6-8 weeks *He had been aware of her history of urinary tract infection ([CONDITION(S)]) when catheter was placed. -Resident 8 had UTIs in the past related to her incontinence. *He stated that due to resident's immobility and convenience the catheter was still in place. *He had been aware that her activity was increased to 50% weight bearing to her right leg on 10/25/21. *Provider was unable to provide documentation for order and rational for Foley catheter. Review of resident 8's 10/12/21 dated progress notes revealed: *Blood was noted in resident 8 Foley catheter. *There was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . *Her urinalysis was positive for a urinary tract infection. -No urine culture was ordered. -Order for [MEDICATION(S)] 500 milligrams orally twice a day for seven days. Review of resident 8's 10/25/21 dated progress notes revealed: *There had been an x-ray of her right femur that showed some healing through the fracture site. *She had an increase in her activity to 50% weight bearing to right leg. *The need for Foley catheter was not addressed with increase in mobility. Review of resident 8's 8/25/21 care plan revealed: *Staff were to: - Provide catheter care/incontinence care -Clean perineal area with each incontinent episode *She had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] Review of provider's 7/7/21 Urinary Catheterizations policy revealed: *Purpose of urinary catheterization is to facilitate urinary drainage when medically necessary. -Urinary catheters should be evaluated every day for the need and removed promptly when no longer necessary. -The purpose of this procedure is to prevent catheter-associated urinary tract infections. *Urinary catheters should be inserted only when medically necessary. Urinary catheters should not be solely for the convenience of health care workers. -Urinary catheters should be placed under the direction of provider order.

Based on observation, interview, record review, and policy review, the provider failed to ensure safety for handling and preparing cytotoxic (means they can present significant risks to those who handle them as well as the intended use of altering cells by damage or death, when treating a patient/resident) medication. Findings include: 1. Observation and interview on 11/2/21 at 8:00 a.m. with registered nurse (RN) E during medication administration revealed: *Resident 1 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . -Medication had been crushed for administration. *The medication is a cytotoxic medication with black box warning risk. *There was no warning of cytotoxicity warning on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] *RN E was aware that medication was a cytotoxic medication. -She had not worn gloves while handling and preparing the medication. -She had not noticed that it had not been flagged for cytotoxicity on MAR. Interview on 11/3/21 at 11:20 a.m. with pharmacist H regarding labeling medication revealed: *He was surprised to learn there was instruction to dissolve medication in water was on the medication MAR. -Medication is crushed for administration for resident 1. *He was aware the medication was cytotoxic. *He was going to change the information on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the provider's 6/29/21 signed pharmacist consultant agreement revealed. *The pharmacist consultant should: -Ensure prescriptions were properly procured and maintained. -Ensure narcotics and dangerous and legend drugs had been properly accounted for. Interview on 11/3/21 at 1:00 p.m. with director of nursing C regarding education of medication safety revealed: *She had not performed any education with nursing staff on properly handling cytotoxic medication. *She hoped nursing staff were aware of side effects of medication they had prepared and administered. *Stated staff were to drug reference book for reference if unsure of medication. *She had not been aware the medication had not be flagged for cytotoxicity on MAR. *She stated, since the interview with pharmacist H he had added the warning to updated MAR. *She agreed the pharmacist had not labeled medication cassette with warning of cytotoxicity. *The medication had been administered without warning since 3/19/21. Review of provider's 7/7/17 Medication Administration policy revealed: *The director of nursing will supervise and direct all nursing personnel who administer medication or have a related function. *The individual administering the medication must verify the right medication, right dosage, right time and right method of administration before giving the medication.

Based on observation, interview, record review, and policy review, the provider failed to ensure infection control policies and procedures for COVID-19 were followed for appropriate personal protective equipment (PPE) use for five of five randomly observed staff (A, B, C, D, and E). Findings include: 1. Observation on 9/25/20 at 12:00 noon of registered nurse B revealed she was only wearing a cloth face mask and did not have eye protection on while passing medications on both wings A and B. Observation and interview on 9/25/20 at 12:15 p.m. of certified nursing assistant (CNA) E revealed: *She was in the hallway on wing B. *She had been wearing an N95 face mask and face shield. *She always wore both, because she was going into COVID-19 positive residents' rooms. Observation and interview on 9/25/20 at 12:23 p.m. of physical therapist D revealed: *She had been in an unidentified resident's room on wing B only wearing a medical face mask. *The resident was a new admission who had just arrived at the facility. *She usually wore a face shield but had forgotten to put it on when she came to see the resident. Observation and interview on 9/25/20 at 12:28 p.m. of CNA C revealed: *She had been going in and out of residents' rooms in wing A collecting lunch trays. *She was wearing a cloth face mask. *She did not have eye protection on. *She had been told she could wear a cloth mask if she was not working with residents who had tested positive for COVID-19. *Only staff going into a COVID-19 positive resident's room were to wear a medical face mask and face shield. Observations and interviews on 9/25/20 between 12:00 noon and 2:10 p.m. with director of nursing A revealed: *She had been wearing a medical face mask. *She had not been wearing eye protection. *She had told staff they could wear a cloth face mask if they were not going into a resident's room who had tested positive for COVID-19. *When staff had cared for or entered residents' rooms with COVID-19 they had been required to wear an N95 face mask, face shield, gown, and gloves. *She was not aware cloth face coverings were not considered PPE. *She was not aware eye protection was recommended even if those staff were not going into residents' rooms that had COVID-19. Review of the provider's undated log for county positivity rates revealed on: *9/14/20 it was 17.5 percent. *9/21/20 it was 12.8 percent. *Those numbers indicated the county positivity rate was high. Review of the provider's 9/4/20 Nursing Home COVID Outbreak September 2020 policy revealed: *Staff working on Wing A must wear full PPE - gown, gloves, N95 mask, and face shield. *Other staff throughout the facility must wear an N95 mask and face shield. Those not able to wear an N95 mask should wear a cloth or surgical mask and face shield. Review of the Center for Disease Control and Prevention (CDC) 7/15/20 Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic Infection Control Guidance revealed: *Cloth face coverings should NOT be worn instead of a respirator or facemask if more than source control is needed. *HCP (healthcare personnel) working in facilities located in area with moderate to substantial community transmission are more likely to encounter asyptomatic or pre-symptomatic patients (residents) with [DIAGNOSES REDACTED]-CoV-2 infection (COVID-19). *They should wear eye protection in addition to their face mask to ensure the eyes, nose, and mouth are all protected from exposure to respiratory secretions during patient care encounters.

Based on record review, observation, interview, record review, policy review, and job description review, the provider failed to ensure: *One of one sampled resident (1) was transferred safely with the use of a Sara 3,000 mechanical stand aide by one of one certified nursing assistant (CNA) (C). *All thirty-six residents who resided in their facility had initial and on-going transfer assessments completed for their safety. *A transfer assessment policy was in place for the professional staff to use when determining a transfer type for a resident. *A process was in place to educate, monitor, and assess the unlicensed staff on a routine basis to ensure they were knowledgeable on the safe and proper use of the mechanical lifts. *The staff had followed: -Their policy and procedure on safe lifting and movement of the residents. -The manufacturer's recommendations for the use of the Sara 3,000 mechanical stand-aide on four of five observed resident transfers (3, 4, 5, and 6). *Four of four mechanical transfer lifts had been placed on a preventative maintenance program and checked on a routine basis per the manufacturer's instructions and the safety of fifteen residents who had required their use. *The administrative staff had been involved and supported the social services designee (SSD) with the investigations of all reportable and non-reportable incidents. Findings include: 1. Review of the provider's 5/14/19 final incident report and investigation submitted to the South Dakota Department of Health (SD DOH) for resident 1 revealed: *She was in the process of being transferred on 5/6/19 at 7:55 a.m. by CNA C. *The CNA was transferring the resident with a Sara 3,000 mechanical stand aide. *Conclusionary summary statement of facility investigation: -CNA reported: I started to lift up resident in the sit to stand (Sara) lift. Resident let go of handle on the right side of the lift. She swung her right arm so fast. It knocked off the sling on (R) (right) side. It caused resident to fall forward. The other side of the sling also came unhooked. Resident fell to the floor. I couldn't stop resident from falling to the floor. It happened so fast. I reported resident's fall to CNA B and registered nurse (RN) F. CNA B came to the resident's room and RN F came in also with the vital (sign) machine. They examined resident. Resident complained of burning in her (R) elbow area. She had a skin tear on her (R) elbow. RN F and CNA [NAME] transferred resident to her wheelchair. *She had complained of right elbow burning from the skin tear and was able to move it without difficulty. *She remained in the facility and was monitored by the staff until the morning of 5/7/19. *On 5/7/19 she: -Had gone to the clinic to see physician assistant (PA) M to have her toes checked. -Had been complaining of pain in her (R) elbow, PA M examined it, and ordered an x-ray of that area. *The investigation did not support a full root cause analysis to determine: -How many staff members were present and assisting the resident with the transfer when the fall occurred. -When education for CNA C and the other direct caregivers had occurred to ensure the continued safety for the other residents during the transferring process. -How the director of nursing (DON) had determined resident 1 could no longer use the Sara 3,000 mechanical stand-aide. -What the administration had done to ensure the continued safety for all thirty-six residents after resident 1 had fallen from the mechanical lift. -If there was an inspection completed on the mechanical lifts to ensure they had been working properly and safely. Review of resident 1's 5/7/19 physician's orders [REDACTED]. *She had an x-ray completed of her right elbow. *The x-ray results had revealed a displaced olecranon fracture (fx) of her right elbow. *The family had refused to have surgery and fixation of that right elbow due to (d/t) her age and multiple co-morbidities. *PA M had completed a closed reduction and splinting of that arm in the emergency room per the direction of an orthopedic surgeon. Review of resident 1's complete medical record revealed: *She was ninety years old and was admitted to the facility on [DATE]. *Her [DIAGNOSES REDACTED]. *Her memory recall had been moderately impaired. *She had required the staff to assist her with activities of daily living (ADL). -Those activities included bed mobility, transfers, toileting, and personal hygiene. *She had: -A history of falls and required the use of a wheelchair (w/c) for mobility. -Been on an antidepressant, antianxiety, and diuretic medication. -Acquired a major injury from a fall during a transfer with the Sara lift on 5/6/19. *There was no documentation to support a transfer assessment had been completed: -On a regular basis with her facility assessments. -As needed with health status changes. -From the time she had been admitted through 5/16/19. -To support the need of a mechanical lift for all transfers. *There was no documentation to support how the staff had assessed her and determined the type of transfer method that was the safest for her. Review of resident 1's 5/4/19 mood and behavior documentation revealed she had refused to hold onto the mechanical lift. -She had kept her arms down during a transfer off the toilet with two staff members. Review of resident 1's 3/7/19 comprehensive care plan revealed: *She had required the use of a sit-to-stand mechanical lift for transfers. *Those transfers: -Required two staff assistance. -Were changed on 5/6/19 to a Hoyer total body transfer mechanical lift and two staff assistance after a fall that day. *No documentation to support when the sit-to-stand mechanical lift had been initiated. Observation on 5/15/19 at 11:05 a.m. of CNAs A, B, and D with resident 1 revealed: *They had prepared to assist the resident with personal care and repositioning. *She: -Was laying in bed and had been incontinent of bowel movement. -Had a splint on her right arm up past her elbow that was held in place with an Ace wrap. -Did not open her eyes nor comment when spoken to by the staff during the entire personal care process. -Had occasionally lifted her left arm up over her head and mumbled softly. *They had repositioned her onto her right side and left the room. Interview on 5/15/19 at the time of the above observation with CNAs A and B regarding resident 1 confirmed: *The resident had recently fallen out of a lift while a CNA attempted to transfer her with it. *She had fractured her right elbow and was possibly being admitted to Hospice services. *Her health had been declining prior to the fall, and she currently had an urinary tract infection [MEDICAL CONDITION]. Attempted interview on 5/15/19 at 11:17 a.m. with resident 1 revealed she had: *Not been capable of participating in an interview with the surveyor. *Remained silent with her eyes shut as observed above with the staff. 2. Random observations and interviews on 5/15/19 from 11:20 a.m. through 12:50 p.m. of CNAs A, B, C, D, and [NAME] with six mechanical lift transfers with residents 2, 3, 4, 5, and 6 revealed: *They had used two staff members with both the Sara 3,000 stand-aide and Hoyer mechanical lifts. *Five of those transfers had required the use of the Sara 3,000 mechanical stand-aide. -The staff had not placed the safety strap around the resident's legs to ensure safety had occurred for all five of those transfers. -Those safety straps remained draped over a ledge attached to the mechanical pole on the lift for all the transfers. *Resident 3 had required cueing to leave his feet on the stand-aide base during the transferring process. *They were to have used two staff members when a resident required a mechanical lift to assist them with their transfers. Chart reviews for residents 2, 3, 4, 5, and 6 from 2/1/19 through 5/15/19 revealed: *They had all required the use of a mechanical lift to assist them with transfers from one surface to another. *There was no documentation to support initial and routine transfer assessments had been completed on them to support: -How those transfers had been determined. -The continued safety of the residents had occurred with transfers from the use of a mechanical lift. Interview on 5/15/19 at 1:20 p.m. with RN F regarding resident 1 revealed: *She had been charge nurse the day the resident fell from the Sara mechanical stand-aide. *The resident had: -Been experiencing a decline in her health prior to the fall. -Episodes of increased anxiety and could be very demanding. -Her [MEDICATION NAME] medication to relax the bladder had been decreased per pharmacy recommendations, and she was not tolerating that well. *She stated: -Apparently during the transfer she lifted her right arm, knocked the sling off, fell forward, and the other side came unhooked to. -She just complained of burning where she had skin tears from the fall. -She never really complained of pain and she moved it just fine. -So I was surprised when they said she broke it. *She confirmed the staff: -Were to have used two CNAs when transferring the residents with a mechanical lift. -Should have been using the safety strap to secure the resident's legs in place when using the Sara 3,000. -Used the care plans as a guide to help them with the residents' care. *She had not been aware: -The staff were not using the safety strap on the resident's legs when transferring with the stand-aide. -How the residents were assessed for the appropriate transfer type. *She had never completed a transfer assessment on a resident to guide her with determining a transfer. *Stated: -I'm sure they involve the physical therapist to help decide transfers, actually I know they do. -Typically a CNA will tell us when a resident has changed or not feeling well and what they did. -We will just tell the next shift. -No I wouldn't necessarily document that, because later that day or the next day the resident might be fine and back to their normal self. -We have great and seasoned staff here so, they know the residents well, and I trust them to decide what transfers to use. -Yes, the CNAs can determine that and yes, I'm comfortable with them deciding what to do. -Actually (resident name) at any given time can be a stand pivot transfer or maybe the Sara lift or Hoyer. --It depends on his mood and behaviors, and the girls know when he is being bad to use the lifts. -No I don't document those transfer changes as they might be short lived and the resident might be feeling better later. *There had been no staff education after resident 1 had fallen from the Sara lift to ensure transfers were being completed in a safe manner. *She had not been aware of any staff competencies having been done to ensure the mechanical lifts had been used properly before or after the fall with the mechanical lift. *To her knowledge no residents had been re-assessed for the proper transfer type to ensure their safety had occurred. *She stated: We are a no lift facility you know, we can't lift their arms to transfer them. Interview on 5/15/19 at 2:00 p.m. with CNAs B and C regarding resident 1 revealed: *They confirmed: -Resident 1 had acquired a fracture to her right elbow after a fall from the Sara 3,000 mechanical stand-aide lift. -Two staff members were to assist all residents with transfers that had required the use of a mechanical lift. -Both of them had been working when she had fallen from that mechanical lift. *CNA C: -Confirmed she had assisted the resident with the transfer when she fell from the mechanical lift and fractured her right elbow. -Had completed that transfer by herself and without the assistance from another staff member. -Supported the above investigation review and interview that had been submitted to the SD DOH. -Stated: --I know we are supposed to use two people with the lifts, but I was in a hurry and did it by myself. --There are no excuses we were just busy, busy, and she stands well so I did it by myself. --She really didn't have much pain, just kept complaining of a burning sensation where the skin tears were, she even moved it ok. -Had not been interviewed or re-educated on the proper use of the mechanical lifts after the resident had fallen. -Was not asked how she completed that transfer during the investigative process. *They were not sure how the transfers were determined for the residents. *The resident required reminding to hold onto the lift with transfers. *They stated: -But we can't decide that (types of transfers), the nurses do and the therapy department does. -We are told we can always go up (such as from a stand-aide to a total body lift) with a transfer but never back down. The nurses have to okay that process. And of course, we have to tell them when this happens. *The resident had been changed to a Hoyer (total body) mechanical lift after her fall. --The DON had made that change. *There had not been: -Staff education on mechanical lifts and the required process for resident safety after she had fallen. -Competency reviews completed on the staff when assisting the residents with a transfer. *They: -Had never been reviewed and watched to ensure transfers with the residents were completed safely and as directed. -Had not been educated on the proper use of those lifts. -Agreed they should have been reviewed for competent and proper use of those lifts for the resident's safety. 3. Interview on 5/15/19 at 2:30 p.m. with CNAs A and G revealed they: *Confirmed two staff members had been required to assist residents who used a mechanical lift for transfers. *Did not have the capability of determining the transfer types for the residents. *Could have gone to a higher level of transfer for a resident but never back down. *Stated: -We can't do whatever we want to (regarding transfers). -The nurses determine the transfers for the residents, and they checked with us periodically to make sure that transfer was still working for any resident in question. *Confirmed resident 3 was sporatic with his moods and had created the frustration with the type of transfer to assist him with. -Stated: We typically use the Sara lift with him and yes he needs reminding to keep his feet in place. *Were unaware of how the nurses' determined what type of transfer was the safest for the residents to use. *Had never been watched or monitored by the administrative department to ensure they had used the mechanical lifts properly and in a safe manner. *Were aware of the safety strap for the legs on the Sara 3,000 mechanical stand-aide. *Stated: -I'm not sure if we are supposed to use it. -I guess it would make it safer for the residents, but we've never been told to use it. *CNA G stated: Have you seen the Sara lifts? There is one that the arms are uneven. 4. Observation and interview on 5/15/19 at 2:50 p.m. with CNAs A and G of the Sara 3,000 mechanical lift in question revealed: *It had been located on the same wing as resident 1's room. *The arms used to attach the transfer sling were not even. -The right arm was approximately three to four inches higher in height than the left arm. *CNA G stated: -The other Sara lift was like that but just not as bad. They fixed that one. -We've told maintenance about this one, so I know they know. -There is a book that we put our concerns in and they check it. *They: -Could not confirm that mechanical lift had been used on resident 1. -Stated: There are only two of them and they get moved back and forth between the two wings. Observation and interview on 5/15/19 at 3:00 p.m. with maintenance director L revealed he: *Confirmed: -There was a concern with one of the Sara lifts, and he had fixed that one. -There was a book the staff wrote their concerns in for them to check. *Had not been aware of a concern with the other Sara lift and the arms not even. -After observation of that lift with the surveyor he confirmed there was a safety risk for the residents who used that lift. *Did not have the mechanical lifts on a preventative maintenance program and would have checked them only upon request from the staff. *Had not been asked to check the mechanical lifts after resident 1 had fallen from one. -He agreed he should have been to ensure the continued safety of the residents who required their use for transfers. Review on 5/15/19 at 3:10 p.m. from 2/1/19 through 5/15/19 of the maintenance work order book revealed no documentation to support a request and concern with the two Sara 3,000 mechanical stand-aides by the direct caregivers. 5. Interview on 3/15/19 at 3:20 p.m. with resident 1's daughter revealed she had no complaints on the care her mother had received. She had been aware of the fall, the injury, and decline in condition. She stated: My mother has been declining for some time now so that part is no surprise. No, I can't say she was in a lot of pain, I saw her, and she was moving that arm. All is good with us and her. Interview on 5/15/19 at 3:30 p.m. with physical therapist (PT) H revealed: *On occasion she would have been asked to assess a resident to determine the type of transfer that was safest for them. -Those assessments had been informal and not documented on. *All of her recommendations for the residents had been verbal and not documented. *She: -Agreed if it was not documented on it did not support those recommendations and reviews had occurred. -Stated: My assessments and recommendations are conservative to make sure the residents are safe. -Was not aware if the residents had been assessed on a routine basis to support what type of transfer they had required. *The staff had asked her about resident 1 and the concern of her not holding onto the lift with transfers. *She: -Stated: Rule of thumb, is if they don't hang onto the lift and continue to not be safe they should be a Hoyer lift. -Was not aware of any competencies or reviews completed on the CNAs with transfers to ensure the residents' safety. -Agreed there should be competency reviews completed on the direct care givers. -Was not a part of the staff education after they were hired and completed their orientation process. *Her education had been on safety and the proper body mechanics to use when they transferred or took care of a resident to prevent injury to themselves. *She: -Did not support the use of the safety strap for the resident's legs with a transfer using the stand-aide. -Stated: I consider that a restraint, because they can't move their legs. -Thought the CNAs were competent and knew the residents well enough to decide what type of transfer they had required without professional staff involvement. Chart review for resident 1 from 2/1/19 through 5/15/19 revealed: *She had all required the use of a mechanical lift to assist her with transfers from one surface to another. *There was no documentation to support initial and routine transfer assessments had been completed on her to support: -How those transfers had been determined. -The continued safety of the resident had occurred with transfers from the use of a mechanical lift. 5. Interview on 5/15/19 at 4:25 p.m. with RNs J and K revealed they: *Had not been aware of all the issues and concerns identified above through: -Observations. -Interviews. -Limited record review. *Confirmed there was no: -Formal transfer assessment policy in place for the staff to follow to ensure the continued safety of their residents through that process had occurred. -Transfer assessments completed upon admission, as needed with health condition changes, and with their routine assessments. -Documentation to support the PT assessments and recommendations made from their requests. *Were not aware: -There was a concern with both of the Sara 3,000 mechanical stand aides. --They confirmed the process the maintenance department had in place for them to use to inform him of any identified concerns for him to check. -The investigation for resident 1 and her fall from a mechanical lift had not been complete. -There had not been any initial or ongoing competencies and reviews of the CNAs while using the mechanical transfer lifts to ensure the residents' safety. *Agreed their processes above had placed the residents at risk for potential injury while being transferred with the mechanical lifts. Interview on 5/16/19 at 8:30 a.m. with PA M revealed regarding resident 1 revealed he: *Had been aware of her major injury from a fall during a transfer with a mechanical lift. *Had been working in the clinic on 5/7/19 when she had an appointment to have her toenails checked. *Confirmed the staff had informed him of the fall, and he had assessed her for injuries. *Confirmed he had been informed of the skin tears on her right elbow and that she had complained of a burning sensation to that area. *Stated: -But it was so confusing, because she used it like it was not broke. -Plus she had a lot of arthritis too. -When she came for her appointment they had asked me to check her arm. -She had a lot of bruising there and complained of some pain, so I decided to X-ray it. *Confirmed the above review of his progress note and the closed reduction completed on her right elbow. *Was not aware how the staff determined the type of transfer she required or for the other residents in the facility. *Agreed the administrative staff should have completed a full review of the situation to ensure the safety of the other residents had occurred. *Stated: -There should have been a re-evaluation of that situation with education to the staff. -We need to make sure the others (residents) are safe and that the current process is ok. -They should have followed their policies and the manufacturer's recommendations on the lifts. Interview on 5/16/19 at 9:25 a.m. with the DON revealed: *She confirmed: -The fall with major injury for resident 1 on 5/6/19. -The investigation of that incident with resident 1, and the changes that had occurred from that fall. *She: -Was not aware the investigation had not supported that a full root cause analysis had been completed. -Would not have supported and assisted the SSD in the investigation process for reportable and incorporable events. -Agreed: --The SSD did not have a nursing degree and should have had support from the nursing department when completing those incidents and investigations. --There should have been a full review on the investigation for resident 1 and the fall from a mechanical lift. *She confirmed: -The staff were to have used two staff members at all times when transferring the residents with the mechanical lifts. -There was not a formal transfer assessment completed on resident 1 after her fall from the mechanical lift and should have been to support the continued use of a total body transfer. -There was no formal process in place and documentation to support the involvement of the PT department and her assessments and recommendations. -There were no competency reviews and education completed with the staff while using the mechanical lifts on a routine basis. *She had been assisting the staff on the floor with the residents frequently and would have completed a visual assessment of the residents when doing a transfer with them. -There was no documentation to support those visual assessments. *She stated: -I have seasoned staff working here, and I am ok with them making a decision with a transfer. -Yes, they should report that change to the nurse, so they check into it. -No, the CNAs cannot go back down to a lesser type transfer on their own but can always go up to a higher level of a transfer. *She was not aware: -RN K had not completed transfer assessments upon admission and routinely with their MDS assessments. -There was a problem with both of the Sara mechanical stand aides. *It would have depended on the resident and their cognition status on whether it was safe to use the safety strap with a transfer or not. *She agreed the investigation for resident 1 was incomplete and should have included: -How many staff members had been involved with the transfer. -Education with CNA C and all the other staff regarding the proper use of the mechanical transfer aides. -Competencies completed on the CNAs to ensure they were knowledgeable on the proper use of the mechanical lifts. -A review of all the residents and their current type of transfer to ensure it was appropriate for them and their safety. -The review of the mechanical lifts by the maintenance department to ensure they had been working properly and safely. -Support from the nursing department and administration to ensure the investigation was completed in a manner to ensure the safety of all the residents had occurred. Interview on 5/16/19 at 10:00 a.m. with the SSD revealed she had: *Completed: -The initial and investigative report to include interviews from the staff on resident 1. -That investigation without support from administration or the nursing department. *Informed the administrator and DON of the incident involving resident 1, and that it had required a full investigative report submitted to the SD DOH. *Placed a copy of the report on the DON's desk for review. *Not been aware the report did not support a full investigation of the incident with the resident. -After a review of the above observations, interviews, and record reviews she agreed they were incomplete. -There was no documentation to support the continued safety for all the other residents had occurred. *Always completed the investigations and reports without support from the other departments. -She agreed there should have been support from them. Review of CNAs B, C, and F's employee files revealed no documentation to support: *Education had been provided on the proper use of the mechanical lifts. *There was no documentation: -Of training, instruction, or competency performed on the mechanical lifts. -Review on the process for use of those lifts had been completed after resident 1's fall with a major injury from the Sara 3,000 mechanical transfer aide on 5/6/19. Refer to 610, finding 1. Refer to F835, finding 1. Refer to 908, finding 1. 6. Review of the provider's (MONTH) (YEAR) Safe Lifting and Movement of Residents policy revealed: *In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. *Resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. *Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. *Staff will document resident transferring and lifting needs in the care plan. *Only staff with documented training on the safe use and care of the machines and equipment used in this facility will be allowed to lift or move residents. *Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques. *Maintenance staff shall perform routine checks and maintenance of equipment used for lifting to ensure that it remains in good working order. *Safe lifting and movement of residents is part of an overall facility employee health and safety program, which: -Provides training on safety, ergonomics, and proper use of equipment. Review of the provider's (MONTH) (YEAR) Lifting Machine, Using a Mechanical Lift policy revealed: *At least two nursing assistants are needed to safely move a resident with a mechanical lift. *Lift design and operation vary across manufacturers. Staff must be trained and demonstrate competency using the specific machines or devices utilized in the facility. *Before using a lifting device, assess the resident's current condition including: -Can the resident assist with transfer? -Can the resident understand and follow instructions? -Does the resident express fear or appear anxious about the use of a lift? -Is the resident agitated, resistant, or combative? *Make sure that all necessary equipment is on hand and in good condition. Review of the provider's 6/1/15 Director of Nursing Job Description revealed: *Supervises planning and administration of all nursing care, to provide and maintain high quality resident care. *Responsible for the organization, management, guidance, and supervision of Nursing Service Department and nursing facility guidance and supervision and assist with administrative decisions in the absence of the administrator. *Have knowledge and support of the philosophy, policies, and standards of the nursing home and assume responsibility for the development and maintenance of all policies and standards of the nursing department including providing means to assure their explanation and implementation. Review of the provider's 6/1/96 Registered Nurse Job Description revealed: *Supervises planning and administration of all nursing care working directly with assigned nursing staff in the provision and maintenance of high quality resident care. *Assumes responsibility for safety and comfort for both staff and resident. Review of the provider's 6/1/13 Certified Nursing Assistant Job Description revealed: *Is accountable for all resident care he/she gives during a shift. *Ensures that equipment is maintained and in working condition. -If not, making sure that maintenance knows about the issue. *Revealed no documentation to support the maintaining safety for the residents.

Based on observation, interview, record review, job description review, and policy review, the provider failed to ensure the facility was operated in a manner that ensured the safety and overall well-being for all residents by ensuring: *A formal process was in place for determining and supporting any resident transfer from one surface to another. *All staff were trained and regularly monitored in the safe use of the mechanical lifts per manufacturer's recommendations. *Investigations for all incidents whether reportable or not reportable to the South Dakota Department of Health (SD DOH) had been completed thoroughly and involved the assistance from the appropriate departments involved in the incident. Findings include: 1. Interview on 5/16/19 at 11:03 a.m. with the administrator revealed she had: *Not been aware: -There were no formal assessments, documentation, and policy to follow for determining and supporting any of the transfers including transfers using lifts. -Who assessed, monitored, and approved the changes on transfers for all of the residents in the facility. -The nursing staff had not been properly trained to use the mechanical lifts according to the manufacturer's recommendations. -There were no competencies completed on the use to ensure the proper use of the mechanical lifts had occurred. *Not been involved in the investigation of any incidents involving the residents to ensure their safety and over-all well being had occurred. -She agreed she should have been. *Not been aware: -The social services designee (SSD) had completed any and all of the incident investigations with no support from the other departments. -The investigation on resident 1 after she fell from a mechanical lift and acquired a major injury was completed to support: --A root cause analysis had been reviewed to ensure the safety of the other residents. --Staff education had occurred on the proper use of the mechanical lifts. --The certified nursing assistant (CNA) C involved in the transfer had been educated and monitored to ensure she was knowledgeable on the proper use of the mechanical lifts. --All the residents had been re-assessed for the appropriate transfer type and the support needed during a transfer. --The mechanical lifts had been assessed by the maintenance department to ensure they had been working properly. -The mechanical lifts were on a preventative maintenance program per their manufacturer's recommendations and monitored routinely for safe use. *She stated: -Typically the (social services designee name) will tell me about it (incidents and investigations) and whether she had to report it or not to the state (SD DOH). -But no, I don't help with the investigations and should be. *She agreed the process above had created the potential for further falls with injuries to have occurred from the use of the mechanical lifts. Refer to 610, finding 1. Refer to 689, finding 1, 2, 3, 4, 5, and 6. Refer to 842, finding 1. Refer to 908, finding 1. Review of the provider's undated Administrator Job Description revealed the following duties and responsibilities: *Transmitting, interpreting, and implementing policies, rules, and regulations affecting all facility activities, and personnel. *Establishing procedures for systematic performance of nursing duties and coordinating activities of all departments. *The executive department had primary responsibility for the safety and protection of patients (residents). *Formulating sound personnel policies and disseminating these policies to all employees, developing an organizational structure with clearly defined lines of authority and areas of responsibility which will enable the employees to work together toward common objectives, selecting and training qualified department heads, coordinating all department activities, and establishing lines of communication between administrative and line employees.