Every finding on record at Brandel Health and Rehab

Based on Observation, interview and record review, the facility failed to ensure food items in the walk-in refrigerator were properly closed, labeled or dated. This practice has the potential to affect all 68 residents residing in the facility who receive food from the kitchen reviewed for dietary services. During an initial tour of the kitchen on 6/30/2026 at 10:06 AM, surveyor and V5 (Manager Dining Operations) observed in a walk in refrigerator a box with 1 clear bag containing 5 pounds (lbs.) of uncooked boneless skinless chicken with no label and no date, 1 clear bag containing 6 lbs. of uncooked chicken breast with no label and no date, 1 clear bag with 6 pieces of defrosted chicken thighs not sealed, labeled and no date and 2 bags of broccoli florets (3 lbs. each) labeled with a discard date of 6/28/2026.During an interview on 6/30/2026 at 10:09AM, V5 stated he is in charge of reviewing the food labels and date in the refrigerators. V5 stated it is expected that all food be closed, labeled and dated. V5 stated Food that has a discard date on it, it is expected to be thrown in the garbage and not used after the discard date. V5 states residents might be at risk for salmonella if they eat expired food.On 7/1/2026 at 9:58AM V2(Director of Nursing) the facility does not have residents whose diet order is nothing by mouth (NPO). V2 states residents who eat food after discarded date can get sick.Facility policy revised date 04-03 Food Storage:Policy Sufficient storage facilities are provided to keep foods safe, wholesome, and appetizing. Food is stored, prepared, and transported at an appropriate temperature and by methods designed to prevent contamination.Procedure: 14. Refrigeration: Foods should be covered, labeled and dated.

Based on observation, interview, and record review, the facility failed to follow its policy by failing to ensure that the oncoming nurse and off-going nurse completed the controlled substance count together and documented receipt on the Controlled Substance Shift Verification Form. The facility also failed to ensure that the administration of controlled medications was properly recorded in the individual residents' narcotic records for 3 residents (R10, R14, and R35) reviewed for pharmacy services/records in a sample of 17.The facility has two medication storage rooms located in the Chapel Hallway and Orchard Unit, and four medication carts located on the Orchard Wing, Chapel Wing, Meadow Wing, and Honeysuckle Wing. At the time of observation, three nurses were on duty.On 6/30/2026 at 12:25 PM, the medication cart on the Meadow Wing was inspected with the morning shift nurse, V3 (Registered Nurse/RN). During the inspection, the Controlled Substance Shift Verification log was noted to have missing nurses' signatures for the June 29 (outgoing shift) and June 30, 2026 (incoming shift) entries. V3 acknowledged that the log should be signed upon receiving and counting narcotics from the previous shift. V3 stated, I am from agency, I must have forgotten it.During the inspection, the Individual Patients' Narcotic Records were also reviewed and revealed that three (3) residents (R10, R14, and R35) had missing documentation for controlled medications that had already been administered.For R10, Pregabalin 50 mg, one (1) capsule was administered on June 30, 2026. For R14, Diazepam 5 mg, half a tablet was administered on June 30, 2026. For R35, Hydrocodone-Acetaminophen 5/325 mg, 1 tablet was administered on June 30, 2026. Review of the Electronic Medication Administration Record (eMAR) indicated that controlled medications were administered to R10, R14, and R35 on June 30, 2026 at approximately 9:00 AM. However, these administrations were not documented in R10, R14, and R35's Individual Patient Narcotic Records. V3 confirmed that she gave the three (3) controlled medications in the morning and acknowledged that she should have signed and documented the administrations immediately in the Individual Patient Narcotic Records after giving them to the residents.On 6/30/2026 at 1:20 PM, another medication cart on the Chapel Wing was inspected with V4 (RN). Review of the Controlled Substance Shift Verification Log revealed a missing nurse's signature for the June 30, 2026 incoming shift entry. V4 stated that he should have signed the log immediately after completing the controlled substance count with the outgoing shift nurse.On 7/1/2026 at 7:00 AM, the medication cart on the Honeysuckle Wing was inspected with V6, night shift RN. Review of the Controlled Substance Shift Verification Form revealed that the incoming nurse for the previous night shift, V6, failed to sign the form for June 30, 2026. V6 acknowledged that she should have signed the form after completing the controlled substance count with the outgoing nurse prior to the start of her shift.On 7/1/2026 at 9:53 AM, V2 (Director of Nursing/DON) stated that nurses are required to conduct controlled substance counts before and after each shift, including signing the Controlled Substance Shift Verification Form. V2 further stated that nurses are expected to notify the DON of any missed signatures or discrepancies identified in the count documentation. V2 also stated that the nurse who administers controlled medications is required to sign the Controlled Drug Record to document the administration in the Individual Patient Narcotic Records in accordance with facility policy.The facility's policy on Controlled Substance was reviewed, and according to the facility's Policy Statement (revision date November 2022):The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications (listed as schedule II-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976).The Policy Interpretation and Implementation on Dispensing and Reconciling Controlled Substances states:Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow up.The system of reconciling the receipt, dispensing and disposition of controlled substances includes the following:Records of personnel access and usage;Medication administration records;Declining inventory records; andDestruction, waste and return to pharmacy records. 3. Nursing staff count controlled medication inventory at the end of the shift, using these records to reconcile the inventory count. 4. The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing services.

Based on observation, interview, and record review, the facility failed to follow its policy by failing to monitor and document residents' personal refrigerator temperature logs daily to ensure the nutritional and food safety needs of 2 residents (R1, R80) reviewed for personal food policy in a sample of 17.On 6/30/2026 at 11:07 AM, during resident room rounds, R1 was observed sitting up in a wheelchair in her room with her husband at bedside. R1 granted permission to inspect her personal refrigerator. The thermometer inside the refrigerator displayed a temperature of 46 F; however, the temperature monitoring log for the month of June 2026 was only completed through June 12 and contained multiple missing initials of the staff responsible for documenting the temperatures. The refrigerator in the room was checked, and food items were noted inside.On 6/30/2026 at 11:40 AM, R80 stated that he had been in the facility for many years. The refrigerator in the room was checked and contained one bottle of shake nutritional supplement. A thermometer was present and measured 44 F. The refrigerator temperature log had been completed only from June 1, 2026 through June 4, 2026, with no entries documented after that date.On 6/30/2026 at 11:48 AM, V11 (Certified Nursing Assistant/CNA) responded to R80's call light. V11 acknowledged that the residents' personal refrigerator Daily Temperature Log should be completed by nursing staff on a daily basis. V11 stated that nurse aides are responsible for checking the logs. V11 also stated that food could spoil if staff do not monitor the refrigerator's temperature. While reviewing the log, V11 commented, I guess they have not been checking them as they should be.On 7/1/2026 at 9:53 AM, V2 (Director of Nursing/DON) stated that the refrigerator temperature daily log should be completed daily by the nurse aides. V2 further stated that staff are responsible for checking and documenting the refrigerator temperatures, as well as monitoring for outdated food items everyday. V2 explained that if refrigerator temperatures are not monitored, stored food may spoil.Record review of the facility's policy statement on Foods Brought by Family/Visitors (Initial Release date 11/9/2017) states that, Food brought to the facility by visitors and family is permitted. Facility staff will strive to balance resident choice and a homelike environment with the nutritional and safety needs of residents. The Policy interpretation and implementation states in number 15 that Refrigerators that are placed in resident rooms will be monitored daily by Nursing for temperatures and outdated foods.

Based on observation, interview, and record review the facility failed to implement policies and procedures to prohibit and prevent Abuse. This deficiency affects all five (R1, R3, R4, R5 and R6) residents reviewed for Abuse Prevention Program.Findings include: R1On 9/9/25 at 9:51AM, Observed R1 lying in bed with low air loss mattress. She has oxygen via nasal cannula. She is lethargic but arousable and weak. She needs total care with ADLs (Activity of Daily Living) and transfers. Both V6 RN (Registered Nurse) and V7RN said R1 has declined in mental status and ADLs. She is re-admitted yesterday from hospital with pneumonia. R1 is initially admitted on [DATE] and re-admitted on [DATE] with diagnosis listed I part but not limited to Atherosclerotic heart disease, Hypertension, Stage 3 Kidney disease, Stage 4 sacral pressure ulcer, Dysphagia, Cognitive and communication deficit, Gait and mobility abnormalities, Severe protein calorie malnutrition, Chronic embolism, and thrombosis of femoral vein. Comprehensive care plan indicated: She has history of Stage 4 sacral pressure ulcer and at risk for developing. She has ADLs and mobility deficit. She is at risk for falls related injury. She has history of depression with insomnia managed with medication. Trauma screening assessment was not upon initial admission. Trauma screening was only completed when R1 was re-admitted on [DATE]. R1 has reported mental abuse allegation on 6/3/25. No trauma assessment was done after the abuse allegation. No Abuse prevention care plan was developed.R3On 9/9/25 at 10:05AM, Observed R3 up on high back wheelchair in front of her room. V7 RN said, R3 has bilateral shin protector due for skin tear prevention. R3 need total assist with ADLs and uses mechanical lift for transfer. She is awake but confused. R3 is admitted on [DATE] with diagnosis listed in part but not limited to Cerebral infarction due to embolism, Hemiplegia affecting left non dominant side, Dysphagia, Type 2 Diabetes Mellitus, Atrial fibrillation, Hypertension, Gait and mobility abnormalities, Lack of coordination, Metabolic encephalopathy. Comprehensive care plan indicated: She is at risk for falls related injury. She has ADLs and mobility deficit. She has cognitive and communication impairment due to CVA. She is at risk for inadequate oral/fluid intake. She is on hospice care 8/13/25. She is on psychotropic medications for antipsychotic and anti-anxiety. R3 refused admission Trauma screening/assessment as indicated in assessment dated [DATE]. R3 is a vulnerable resident with cognitive impairment and behavioral issues. No Abuse prevention care plan was initiated upon admission. R3 has reported sexual abuse allegation on 8/25/25. No trauma assessment was done after the abuse allegation. No Abuse prevention care plan was developed.R4On 9/9/25 at 10:58AM, Observed R4 up in wheelchair in the activity/dining room. She has hard of hearing. She is alert and confused, responsive to simple questions. She needs assistance with ADLs and transfers. R4 is admitted on [DATE] with diagnosis listed in part but not limited to Age-related osteoporosis, Alzheimer's disease, Dementia, Type 2 Diabetes Mellitus, Depression, Lack of coordination, Gait and mobility abnormalities, Repeated falls. R4 refused trauma assessment upon admission as indicated in assessment. Comprehensive care plan indicated: She is at risk for falls related injury. She has depression managed by medication. She has ADLs and mobility deficit. She is at risk for inadequate oral/fluid intake. She has cognitive deficits due to Alzheimer's and Dementia. She refused Trauma assessment as indicated in assessment. She has physical abuse allegation report on 9/1/25. No trauma assessment was done after the abuse allegation. No Abuse prevention care plan was developed.R5On 9/10/25 at 10:17AM, Observed R5 up in recliner chair. She is alert and responsive with period of confusion. She needs maximum assistance with ADLs and transfers. R5 is admitted on [DATE] with diagnosis listed in part but not limited to Cerebral infarction, hemiplegia affecting right dominant side, Dementia with mood disturbance, Anxiety disorder, Depression, Gait and mobility abnormalities, Dysphagia. Comprehensive care plan indicated she is prone to skin tear or bruising related to fragile skin. She has history of depression and anxiety managed by medications. She has ADLs and mobility deficit. She has presented with rapid significant health declined. Family wishes comfort measures only. She is on hospice care on 2/11/25. No Trauma assessment done upon admission. R5 is a vulnerable resident with cognitive impairment and behavioral issues. No abuse prevention care plan was initiated upon admission. R5 has physical abuse allegation (employee to resident) report on 3/26/25. No trauma assessment was done after the abuse allegation. No Abuse prevention care plan was developed.R6 was admitted on [DATE] with diagnosis listed in part but not limited to Urinary Tract Infection, Congestive heart failure, Atrial fibrillation, Parkinson's disease with dyskinesia, Type 2 Diabetes mellitus, gait and mobility abnormalities, lack of coordination, Dementia, Cognitive deficit. Comprehensive care plan indicated he is at risk for falls related injury. ADLs (Activity of daily living) and mobility deficits. He has short term memory deficit and moderately impaired decision making. He has shortness of breath on exertion and when lying in bed. He is at risk for inadequate oral/fluid intakes. No care plan for abuse prevention. No trauma screening assessment was done upon admission. R6 was sent out to the hospital on 5/23/25 for shortness of breathing and was admitted with diagnosis of hypoxia and ribs fracture. Facility completed and reported injury of unknown origin on 5/24/25. On 9/9/25 at 10:40Am, V3 SSD (Social Service Director) said that she completes trauma screening assessment of resident upon admission. They used trauma screening instead of abuse screening/assessment. She was told trauma assessment was only done upon admission. She said, she did not do trauma assessment after resident has reported abuse allegation. She did not develop abuse prevention care plan for vulnerable resident with cognitive impairment and behavioral issues nor develop abuse prevention care plan for resident who reported abuse allegation.On 9/9/25 at 11:47AM, V1 Administrator said that she is the abuse coordinator. She initiates reported abuse allegation investigation. They screen employees and residents as part of the abuse prevention program. The admission coordinator screens the resident prior to admission by checking criminal background checks. Upon admission, the social service does the trauma screening instead of abuse screening. V1 is not aware how often the trauma screening/assessment is done in the facility. She said that resident should be assessed after allegation of abuse has been reported. Trauma assessment should be completed. Reviewed Facility's policy on abuse prevention program revised 7/12/23 with V1 Administrator. Informed V1 that their policy did not have resident screening to prohibit and prevent both abuse and neglect. She said it should indicate screening for both resident and employees to prohibit and prevent abuse. She said that she will inform their corporate and consultant. On 9/9/25 at 12:19PM, Reviewed R1, R3, R4, R5 and R6 medical records with V2 DON and V3 SSD. Informed V2 DON and V3 SSD of concerns identified from the following residents: R1 is initially admitted on [DATE]. Trauma screening was not done upon admission. It was done completed when R1 was re-admitted on [DATE]. R1 has abuse allegation report on 6/3/25. No trauma screening was done. No abuse prevention care plan was developed. V3 said that she was on vacation when the abuse allegation incident occurred. V14 Memory Care coordinator was in charged in her absence. R3 is admitted on [DATE]. R3 refused trauma screening as indicated in R3's assessment. R3 is a vulnerable resident with cognitive impairment and behavioral issues. No Abuse prevention care plan was initiated upon admission. R3 has abuse allegation report on 8/25/25. No Trauma screening was done. No Abuse prevention care plan was developed. V3 said that she was on vacation when the abuse allegation incident occurred. V14 Memory Care coordinator was in charged in her absence. R4 is admitted on [DATE]. Trauma screening was not done. R4 has abuse allegation report on 9/1/25. No Trauma screening was done. No Abuse prevention care plan was developed. V3 said that she was on vacation when the abuse allegation incident occurred. V14 Memory Care coordinator was in charged in her absence. R5 is admitted on [DATE]. Trauma screening was not done upon admission. R5 is a vulnerable resident with cognitive impairment and behavioral issues. No abuse prevention care plan was initiated upon admission. R5 has abuse allegation report on 3/26/25. No trauma screening was done. No abuse prevention care plan was developed. R6 was admitted on [DATE]. No care plan for abuse prevention. No trauma screening assessment was done upon admission. R6 was sent out to the hospital on 5/23/25 for shortness of breathing and was admitted with diagnosis of hypoxia and ribs fracture. Facility completed and reported injury of unknown origin on 5/24/25. On 9/9/25 at 12:30PM, Both V2 DON and V3 SSD said that Trauma screening assessment should be done upon admission. Trauma assessment should be done to the resident after allegation of resident abuse. Abuse prevention care plan should be formulated after abuse allegation made. Abuse prevention care plan should also be developed for those vulnerable residents who has cognitively impaired with behavioral issues. On 9/10/25 at 10:37AM V15MDS Coordinator/Care Plan Coordinator said that Trauma screening assessment should be done upon admission. If resident has reported allegation of abuse, the social service should complete resident trauma assessment and develop abuse prevention care plan. Vulnerable resident who are cognitively impaired, with behavioral issues should be care planned for abuse prevention because resident can react negatively to other resident and the other way around. On 9/10/25 at 12:33PM, V14 Memory Care Coordinator said that she covers for V3 SSD in her absence. She said that upon admission, they completed resident's trauma screening /assessment. They use trauma assessment instead of abuse screening. She was told only do the trauma assessment once upon admission. She does not update resident's trauma assessment after allegation of abuse.On 9/10/25 at 2:30PM, Informed V1 Administrator and V2 DON of above concerns regarding implementation of abuse prevention program. Facility's policy on Abuse Prevention Program revised 7/12/23 did not indicated screening of residents as indicated in State Operating Manual. Facility's policy on Trauma-informed and culturally competent care revised August 2022 indicated: Purpose: To guide staff in providing care that is culturally competent and trauma-informed in accordance with professional standards of practice. To address the needs of trauma survivors by minimizing triggers and or re-traumatization. Resident screening: 1. Performed universal screening of residents, which includes a brief, non-specialized identification of possible exposure to traumatic events.Resident Care Planning:1. Develop individualized care plans that address past trauma in collaboration with the resident and family.

Based on interview and record review, the facility failed to conduct a Health Care Worker Registry background verification for an employee before working and caring for residents in the long term care facility. This failure has the potential to affect all 66 residents currently residing in the facility. Findings include: On 4/21/25 at 9:30 AM, V1, Administrator presented the survey team with the facility matrix showing 66 current residents. On 4/22/25 at 11:07 AM, V6, Human Resource Director was inquired of completing background screening checks for staff. V6 said, Yes, we check them upon hire. The health care worker background check was completed for random Certified Nurse Assistants (CNAs) and other direct care access staff members with V6. V3, CNA was hired in August of 2000. Upon review of V3 CNA's background check it was identified that the facility did not complete a UCIA (Uniform Conviction Information Act) check upon hire. The facility was also unable to provide V3's fingerprint based background check upon hire. On 4/22/25 at 12:42 PM, V6 said, We don't have any other background checks for V3 until 2006. On 4/23/25 at 10:25 AM, V6 provided this surveyor with a IDPH Health Care Worker Registry background check for V3 CNA completed on 4/23/25 at 8:03 AM. The September 2018 Illinois Department of Public Health Employer Health Care Worker Registry states in part: FINGERPRINTS/BACKGROUND CHECKS WHICH EMPLOYEES NEED TO BE FINGERPRINTED FOR A BACKGROUND CHECK? Health care employers must ensure that a fingerprint-based background check, initiated as a Fee Applicant Inquiry to the Illinois State Police, has been conducted for each employee who falls under the jurisdiction of the Health Care Worker Registry (HCWR). The HCWR is governed by the Health Care Worker Background Check Act [225 ILCS 46] and the Health Care Worker Background Check Code [77 Ill. Adm. Code 955]. The Act and the Code mandate which employees fall under the jurisdiction of the HCWR. The following types of employees fall under the HCWR's jurisdiction: o For all health care employers, an unlicensed individual employed as a home health care aide, a nurse aide, a personal care assistant, a private duty nurse aide, a day training personnel, or an individual working in any similar health-related occupation where he/she provides direct care. o Additionally, for long-term care facilities ONLY, an unlicensed individual who has or may have contact with long-term care residents or access to the living quarters or financial, medical, or personal records of long-term care residents (access workers). Therefore, the only employees who fall under the HCWR's jurisdiction are unlicensed staff providing direct care or unlicensed staff in long-term care facilities who have access to resident's living quarters or records. Licensed staff (such as nurses) do not fall under the HCWR jurisdiction and should not be added to the HCWR or sent for a fingerprint-based background check through the HCWR. Likewise, staff who do not provide direct care (except for access workers in long-term care facilities) also do not fall under the HCWR jurisdiction; those staff should not be added to the HCWR or sent for a fingerprint-based background check through the HCWR. Employers may have policies that require fingerprint-based background checks to be completed on all employees. For staff that do not fall under the jurisdiction of the HCWR, however, employers must have an alternative way to conduct those background checks. Background checks for those employees cannot be initiated through the HCWR. If a background check for an employee who does not fall under the jurisdiction of the HCWR discloses disqualifying convictions, the HCWR cannot process a waiver application for that employee, since that employee is not under our jurisdiction. WHAT IS A UCIA BACKGROUND CHECK? UCIA, which stands for the Uniform Conviction Information Act, is the type of background checks used by the HCWR prior to the implementation of the fingerprint-based background checks (prior to October 2007). A UCIA background check is no longer valid for use with the HCWR. If someone on the HCWR has a UCIA background check, that person's Work Eligibility will show Not Yet Determined. A new or potential employer must initiate a Livescan request to conduct a fingerprint-based background check for that individual. The March 2019 Personnel and Staffing Background Screening Investigation policy states in part: Policy Statement Our facility conducts employment background screening checks, reference checks and criminal conviction investigation checks on all applicants for positions with direct access to residents (direct access employees). Policy Interpretation and Implementation 1. For purposes of this policy direct access employee means any individual who has access to a resident or patient of a long term care (LTC) facility or provider through employment or through a contract and has duties that involve (or may involve) one-on-one contact with a patient or resident of the facility or provider, as determined by the state for purposes of the national background check program. 2. The director of personnel, or designee, conducts background checks, reference checks and criminal conviction checks (including fingerprinting as may be required by state law) on all potential direct access employees and contractors. Background and criminal checks are initiated within two days of an offer of employment or contract agreement and completed prior to employment. 3. For any individual applying for a position as a certified nursing assistant, the state nurse aide registry is contacted to determine if any findings of abuse, neglect, mistreatment of individuals, and/or theft of property have been entered into the applicant's file.

Based on interview and record review the facility failed to develop an effective plan with interventions to prevent falls and falls with injury for a resident identified as high risk for falls, severe cognitive impairment and assessed with decreased safety awareness. This affected one of three residents R1 reviewed for falls and fall prevention. This failure resulted in R1 having multiple falls resulting in a non-displaced hip fracture 5.11.24, and another fall and fracture on 6.5.24 Findings Include: R1 admitted in the facility on 5/6/24 and with diagnoses but not limited to History of Falling, Restless Leg Syndrome, Depressive Disorder, and Dementia. Assessed as High Risk for fall upon admission, assessment date 5/7/24. Facility Reported Incident dated 5/11/24, reads in part: R1 is supervised with walking with lack of safety awareness as R1 ambulates at a fast pace. On May 11, 2024, R1's wife and personal caregiver were visiting R1. Wife asked R1 to take a walk. Then R1, wife and caregiver proceeded to walk in the hallway without asking for supervision. Upon walking in the hallway, R1 fell . R1 was experiencing pain, and was sent out to hospital, admitted with non-displaced fracture of right femur. Upon interviewing wife, wife does not know how R1 fell . The caregiver stated that R1 lost his balance. There were no staff member to witness this fall. Hospital record dated 5/17/24, reads in part: Orthopedic surgery was consulted and recommending non operative management and admission for further care. On 8/13/24 at 2pm, V2 (DON) stated that R1 has poor safety awareness. Wife visited with wife's caregiver and decided to walk R1 without asking for staff to assist. Walked R1 with walker and no wheelchair with them. Staff was not present at the time of the fall, it was just R1's wife and the caregiver. Educated wife and caregiver not to walk R1 without staff assistance for resident safety. R1 had right femur nondisplaced fracture. No surgical intervention needed. Facility Reported Incident dated 6/6/24, reads in part: On 6/6/24, R1 experienced an unwitnessed fall in the dining area, R1 complained right hip pain. R1 transported to ER for further evaluation. R1 was in the dining area due to wandering. Incontinence care provided as routine care. R1 is confused and needs reminders all the time. R1 sustained a non-displaced intertrochanteric fracture of the right femur and questionable tiny avulsion fratire of the right talar dome, which likely represent the residual of an old trauma. R1 received on 6/7/24 right transfemoral nailing/pinning surgery. R1 was discharge to facility on 6/9/24. On 8/14/24 at 2:30PM verified with V1 (Administrator) that the incident happened on 6/5/24 at 8:30PM, and that it was reported to IDPH on 6/6/24. Hospital record dated 6/6/24, reads in part: right hip x-ray shows non-displaced intertrochanteric fracture. Right ankle x-ray shows questionable tiny avulsion fratire of the right talar dome. Hospital record with date of service of 6/9/24, reads in part: R1 presented to the hospital with right hip fracture and underwent Open Reduction Internal Fixation (ORIF). Found to have a nondisplaced fratire of the right greater trochanter on 5/12/24 which was deemed non-op at the time. Now with nondisplaced intertrochanteric fracture of the right femur and questionable tiny avulsion fracture identified along the medial aspect of the right talar dome. On 8/13/24 at 2:215PM, V6 (nurse assigned on 6/5/24) stated R1 had a fall around 8pm in dining room. V6's med cart parked close by in the dining room. It happened so fast, I picked up something on the floor and found R1 on the floor. Heard a noise and observed R1 laying on the floor. Other residents was in the dining room also. There was no CNA in the dining room when R1 fell . The CNA that was in the dining prior to the fall, was assisting another CNA who called for help with a resident in another room having behavior. Assessed R1 and complaint of right hip pain. Called MD and with order for STAT x-ray. X-ray result came back around 6am and relayed to MD to send R1 to ER for further evaluation. V6 was not close to R1 and per V6, staff such as CNAs alternates to watch the resident in the dining room. To staff never leave the dining room, and must be physically present and close enough to monitor and redirect resident. R1 had another fall in the facility dated 5/27/24 at 10:15AM, reads in part: R1 was observed laying on the floor on his back, his legs were close to his dresser, there was no witness to this fall. R1 stated he slightly hit his head. R1 not on anticoagulant. Neuro check started. On 8/14/24 at 11:53AM. V8 (Assigned Nurse for the fall incident of 5/27/24) stated that R1 already up on wheelchair. Waiting for activity. R1 was by the door of his room by the hallway, V8 reported that V8 was two rooms away from R1. CNA assigned to R1 was answering call light of another resident. Next thing I turned around and heard a noise coming from his room and checked R1. R1 was on the floor, sitting on the floor, next to the foot board of his bed. In between wheelchair and walker. R1 stated he was trying to get something in his drawer. We keep an eye on R1 and visualized R1, R1 tends to stand up by himself. R1 was already high risk for fall upon admission. We are keeping close monitoring to redirect R1 to sit back down when observed trying to get up from wheelchair. R1 at that time of his fall needs staff supervision with ambulation and standing from wheelchair. R1 has impulsive behavior of getting up from his wheelchair on his own. We will need to remind R1 repetitively not to stand up from his wheelchair. On 8/14/24 at 9:30AM, V7 (Therapy Director) stated that R1 was admitted (5/6/24) as moderate to maximum for transfer, bed mobility was independent, walking was contact guard to moderate. Eating independent, toilet transfer contact guard. Shower and dressing contact to minimum. Contact guard somebody need to be with Resident walking with using walker with wheelchair behind R1 to follow. We did not allow the family to walk the resident. Staff will need to supervise the walking with the family. The wife had cognitive issue also and does not realized R1 has impairment. Care giver did not have the wheelchair behind R1 when they walked him that time. R1 was in Speech therapy for cognition. 5/6/24, 5/17/24: moderate to severe cognitive deficit with the SLUMS (cognitive test that assesses short term memory) score of 7/30. Readmission on 6/9/24 R1 score was 8/30 meaning moderate to severe cognitive deficit. Speech Therapy evaluation note (dated 5/11/24) documented as Reason for referral was exacerbation of decreased safety awareness, cognitive impairment, decreased functional ability tolerance, decreased socialization and decreased ability to respond to cues and instruction. On 8/13/24 at 2:40PM, V3 (ADON) stated that the fall on 5/11/24 were unwitnessed that the staff was not present at the time of R1's fall. Family came to visit and decided to walk R1. R1 had fallen. Probably due to R1 has a tendency to walk fast and maybe that's what happened during the first fall. R1 is cognitively impaired and very confused and with poor safety awareness, and that is the reason why R1 was being watch closely. Fall on 6/5/24, R1 was in the dining room along with other residents. CNA was supervising residents in the dining, but needed to leave to help another CNA who was having a behavior. The assigned nurse in that unit, was in the nurse's station getting endorsement, but the nurses station is enclosed room and needed to have the door open to see resident, but still physically far from residents in the dining room, just visual. Nurse heard the noise and observed resident on the floor. I cannot recall asking the nurse if the door was open at the time of the fall. On 8/14/24 at 9:20AM, memory care unit observation of the nurse's station with V3 (ADON. Nurse's station in the dining room enclosed room, can see the dining room but still far physically to any residents present in the dining room. Must also need to have the door open to have visual of the residents in the dining room. R1's care plan dated 5/10/24, reads in part: R1 is at risk for fall d/t weakness, unsteady transition and walking balance, Right hip and low back pain (s/p Right hip Fracture - non-surgical), daily use of antidepressant, impaired memory and safety judgment (forgetful), and a history of fall at home and nasal bone Fracture within 30 days before admission and one fall since admission to BHR on 5-11-24 resulted in Rt hip Fx (non-surgical). He scored 80 on Fall Risk assessment at re-admission. Unwitnessed fall on 5/11/2024, 05/27/24 and on 06/05/24. Intervention dated 5/26/24: Staff will take R1 to activities during daytime to stay in supervised environment. Managing Falls and Fall Risk policy dated 3/2018, reads in part: Based on previous evaluation and current data, the staff will identify interventions related to resident's specific risks and causes to try and prevent resident from falling and to try to minimize complication from falling. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with history of falls. If a systematic evaluation of resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions. If the falling recurs despite initial interventions, staff will implement additional or different intervention of indicate why the current approach remains relevant. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature category of falling, until falling is reduced of stopped, or until the reason for the continuation of the falling is identified as avoidable. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified.

Based on observation, interview, and record review, the facility failed to properly wear a mask and eye protection at all times when in the facility. This deficiency has the potential to affect all 54 residents currently in the facility. Findings include: On 02/09/21 at 10:46 AM, V14 (Cook) had her mask down under her chin while preparing food, then moved it over her face. At 11:07 AM, she moved her mask under chin again while preparing food. On 02/09/21 at 11:35 AM, V15 (Cook) left the kitchen and plated food to residents in the 300 unit dining room with no eye protection (goggles or face shield on). There were several residents and staff in the dining room. On 02/09/21 at 11:35 AM, V16 (Dietary Aide), also present in the 300 unit dining room, served trays to residents and staff with no goggles or face shield on. On 02/10/21 at 10:45 AM, V11 (Dining Operations Manager) stated staff should always wear a face mask covering their mouth and nose and a face shield or goggles when in the hallway and in the dining area. On 02/10/21 at 11:55 AM, V2 (DON) stated all staff should be following the green zone policy which states a face mask and face shield or goggles are worn in the facility at all times. We follow the latest Centers for Disease Control, (CDC) guidelines. Facility infection control policy, in COVID-19 requirements, notes staff should wear surgical masks and face shield/goggles for the general population of the building. CDC guidelines stated to place mask over nose and mouth.

Based on observation, interview, and record review, the facility failed to properly sanitize cooking area to prevent cross-contamination between raw meat and ready to eat meat, failed to store dented cans per their policy, and failed to label and date prepared food in the refrigerator. This failure has the potential to affect all 54 residents currently in the facility. Finding include: On 02/08/21 at 10:44 AM, 4 trays of banana cake were in the cold food preparation refrigerator with no no date. On 2/08/21 at 10:44 AM, V11 (Dining Operations Manager) stated they should be dated with the time and date they were made. On 2/8/2021 at 10:45 AM, during the initial tour of the kitchen, two dented cans of oyster flavored sauce noted in storage area mixed in with other cans they are currently using. On 2/9/2021 at 11:44 AM, V13 (Cook) was preparing turkey meat loaf. V13 placed the box of thawed out ground turkey on the counter top, then threw it away after use. Then, V12 (Cook) placed the container of ready to eat hotdogs on top of the same counter before it was placed into the blender. V12 placed the top to the blender face down on the counter (touching the counter) without sanitizing the area first. On 2/10/2021 at 2:15 PM, V11 ( Dining Operations Manager) stated the staff should clean and sanitize the surface after raw meet has touch the surface, before placing ready to eat food on the surface. On 2/11/2021 at 10:47 AM, Facility presented documentation from food safety information services on preventing cross-contamination that they are following as a guide, that states keep raw food away from ready to eat food. Facility policy and procedures states dented cans should be stored in a designated area (supervisor's office) to be returned to vendor for credit.

Based on observation, interview, and record review, the facility failed to meet the resident's special dietary requirements by providing her with food item that did not meet the criteria of the mechanically soft textured with pureed meat diet as ordered. This failure affected one (R31) of 14 residents reviewed during dining observation. Findings include: On 2/8/2021 at 12:30 PM, R31 was noted to be chewing for an extended period time. R31 eventually took a small golf ball size clump of meat out of her mouth and set it on her tray. At 12:32 PM, V4 (Certified Nursing Assissant/CNA) stated R31 should have pureed meat, and took the meat and placed it in a napkin to throw in the trash. Observation of R31's meal ticket states diet is Mechanical soft with pureed meat. On the bottom of the ticket it also states no ground meat. On 2/8/2021 at12:40 PM, V5 (Clinical Nutrition Manager) stated the meat on R31's tray looked like ground meat, and called V6 (Dietary Aide) who stated the meat was ground meat (not puree). On 2/10/2021 at 10:41 AM, V11 (Dining Operations Manager) stated the purpose of the meal tickets is for the server to know what diets the resident should be getting. The dietary aides are responsible for reading the tickets to the server who will prepare the plates to serve. Per medical record, on 11/17/2020 at 1:53 PM, V8 (Speech Therapist) charted on treatment note, R31 was seen for dysphagia therapy with current mechanical soft diet. R31 unable to follow directions for slow rate of self-feeding without max cue. R31 pocketed ground meats so I will change diet to pureed meats. R31 meal ticket states diet is mechanical soft with pureed meat, Give pureed meat and Give pureed meat not ground. R1 current diet order states Mechanical soft diet with pureed meat.

Based on interview and record review, the facility failed to develop a comprehensive care plan and interventions to prevent pressure ulcers for a resident assessed as high risk for alteration in skin integrity upon admission. This failure affected one (R14) of two residents reviewed for care planning. Findings include: R14 is a [AGE] year old male who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Facility Braden scale for skin assessment, dated 11/21/2020, coded resident as a 12 (High risk). Facility Minimum Data Set (MDS) assessment, dated 11/22/2020, coded resident as limited assist with 1 staff for all ADLs, set up only for eating, and coded as 3/2 meaning extensive assist with one person physical assist for bed mobility and transfer. On 02/09/21 at 1:49 PM, V9 (Wound Care Nurse) stated resident had a skin assessment upon admission and was determined to be at risk for skin alteration, but there was no care plan in place. V9 added she was not here when the resident was admitted , but the person who did the assessment was supposed to develop a care plan. On 02/10/21 at 10:41 AM, V9 stated she was able to find a baseline care plan for the resident that was still in a paper form in resident's chart, but there was no comprehensive care plan prior to the one dated 12/16/2020 -- after the unstageable pressure ulcer was discovered. Surveyor asked V9 how staff members know what type of care to provide to the resident. She said, I don't know, I was not here at that time. On 02/10/21 at 11:22 AM, V10 (MDS Coordinator) stated (regarding facility protocol on care planning) nursing does the initial care plan which covers all disciplines, including therapy and social service. After the initial, a complete care plan should be completed within 21days (14 days plus 7 days to finalize). A resident is supposed to have a complete care plan after 21 days of admission; all care plans are in the system except the baseline care plan that may still be in the resident's chart and eventually scanned to the system. He is not sure how long before they are scanned in the system. Facility policy titled, Care Planning-Interdisciplinary Team, (revision date September 2013), includes: policy statement that the facility's care planning/interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident. Under the policy interpretation and implementation, the policy states in part that a comprehensive care plan for each resident is developed within seven (7) days of completion of the resident assessment (MDS). The policy further states that the resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan.

Based on observation, interview, and record review, the facility failed to ensure that staff screened visitors prior to allowing entrance into the facility, failed to ensure that a resident was placed on isolation precautions while exhibiting symptoms of COVID and failed to ensure that staff were fitted for respirators in order to effectively care for residents diagnosed with [REDACTED]. These deficient practices also have the potential to affect all 62 residents. Findings include: On 11/18/20 at 9:35am, visitors were only allowed onto the facility campus via one gated entrance. All other entrances were blocked off. At this entrance, there was a kiosk that housed V8 (Security Guard) who was responsible for screening all visitors as well as taking their temperatures. At 9:50am, as this surveyor pulled up to the kiosk to be screened, V8 performed a temperature check and asked, Are you well? To which this surveyor replied, Yes. There were no other pre screening questions asked. V8 opened the gate and allowed this surveyor to drive through. On 11/18/20 at 9:55am, this surveyor entered the skilled nursing facility on the campus. V4 (Concierge) allowed entrance and asked for this surveyor's name and why this surveyor was on the premises. There were no other questions asked and no other pre screening activities performed. At 10:00am, V1 (Administrator) stated, I'll show you to where you can set up. This surveyor stopped V1 and asked, Should I be pre screened or asked any questions before entering? V1 and V4 stated, Didn't the person in the kiosk ask you questions? To which this surveyor replied, No. On 11/18/20 at 11:12am, V6 (Facilities Director) stated, I'm here to correct the (incident) that happened earlier with the pre screening at the check in gate. My regular guy went on break. Someone else took over and didn't screen you properly. (That's) our front line of defense to prevent people from coming into the building. Those questions should've definitely been asked and the pre screening should've been done. V6 confirmed that it was a crucial process especially with the COVID outbreak that the facility was experiencing. During investigation of this concern, it was confirmed that V8 is the regular security guard that does the pre screening. On 11/18/20 at 2:09pm, V4 stated, So, the first essential thing, is you enter through kiosk. The questionnaire of new symptoms, traveled, had COVID and/or been around anyone with COVID in the last 14 days, that's the responsibility of the person in the kiosk. Your situation was different because every morning they make sure to ask those questions. I'm not sure why you weren't asked those questions. Questionnaire, yes, is the responsibility of that person. (V8) was supposed to be reading everyone that list of questions. We don't do that in here. On 11/18/20 at 1:15pm, V3 (ADON-Assistant Director of Nursing) stated, Purpose of the screening process is to catch any symptoms before it gets in (to our facility) and to prevent anyone from getting through if they do have symptoms. A facility policy, with a revision date of 8/21/20, and titled Universal COVID-19 Screening Policy documents: Policy: The facility will use a checklist based screening protocol, administered verbally and recorded in written format, for each person entering the facility, including all staff, visitors and other persons. The facility will deny access if any findings are positive. PROCEDURE: Where: At (facility), all points of entry to the campus grounds have been closed except for one entrance from (road). Upon entry to the drive, all individuals arriving on campus will be stopped at the security checkpoint. While remaining in the car, the driver will roll down windows to engage in the screening process. This COVID-19 screening must be completed by all individuals before proceeding to park and enter any building on the property. On 11/18/20 at 10:05am, V1 (Administrator) confirmed that the facility was in a COVID outbreak which began with an employee testing positive on 10/30/20. Per facility roster, there were 20 residents in the red zone - residents that have tested positive for COVID, and there were 22 residents in the yellow zone - residents that were admitted /transferred from a hospital and/or possible exposure. R1's medical records document that R1 has been in the red zone since 11/11/20. R1 tested positive for COVID on 11/11/20. According to R1's progress notes, dated 11/9/20 at 12:15am, R1 developed a dry cough. R1 remained in the same room and was not placed on contact/droplet precautions. On 11/9/20 at 3:01am, R1's progress notes documented, dry cough continuous. (R1) febrile 103 degrees Fahrenheit (F). Rapid test for COVID performed which was negative. Will notify MD (medical doctor) in the morning. R1 continued to remain in her room and was not placed on contact/droplet precautions. On 11/9/20, a stat chest x-ray was ordered with the result: Bilateral airspace opacities. Per progress notes, at 7:54pm, an antibiotic was ordered for R1. R1 continued to remain in her room and was not placed on contact/droplet precautions. R1's COVID test was positive on 11/11/20 at 12:19pm. R1 was not placed on contact/droplet precautions until 11/11/20 at 4:50pm. R1's Physician order [REDACTED]. R1's Care Plan for COVID documents: Interventions: Monitor for fever, coughing, sneezing, sore throat, and respiratory issues every four hours. Update physician with changes as needed. On 11/18/20 at 1:15pm, V3 (ADON) was asked how the facility handles residents that develop symptoms. V3 stated, When (a resident) develops symptoms, we do a POC (point of care test/rapid test). Evaluated by Nurse Practitioner and then isolate them and wait for POC result and transfer to COVID unit if needed. If still have symptoms but negative (result), then they would be on contact/droplet precautions to be monitored closer for possible COVID. On 11/19/20 at 12:19pm, V3 confirmed that R1 developed symptoms and was not placed on contact/droplet precautions. V3 stated, We did not put her on contact/droplet isolation until 11/11/20 because the Nurse Practitioner assessed her and thought that the symptoms were due to her UTI (urinary tract infection). V3 indicated that R1 tested positive and was placed in the red zone. V3 stated, I see where you're coming from that (R1) should've been isolated on 11/9/20 when she had symptoms. On 11/19/20, V1 (Administrator) and V3 confirmed that one employee contracted COVID after contact with R1. That employee was identified as V12 (CNA-Certified Nurse Assistant). A facility policy, with a revision date of 5/18/20, and titled Suspected or Confirmed (Covid-19) documents: Procedure: Signs and Symptoms of COVID-19: Symptoms may appear 2 -14 days after exposure to [MEDICAL CONDITION]. People with these symptoms or combinations of symptoms may have COVID 19: Fever or chills, Cough, Shortness of breath or difficulty breathing, Fatigue, Muscle or body aches, Headache, New loss of taste or smell, Sore throat, Congestion or runny nose, Nausea or vomiting, Diarrhea. Screening: Actively screen residents daily for fever and symptoms of COVID-19; if symptomatic, immediately isolate and implement appropriate Transmission-Based Precautions. Upon entering the facility's COVID unit, it was noted that there were 20 residents in the red zone. On 11/18/20, V11 (CNA-Certified Nurse Assistant) confirmed that the red zone was for residents that tested positive for COVID. V11 was wearing an N95 mask. On 11/18/20 at 11:46am, V9 (CNA) stated, We have N95 masks and surgical masks. There is no fitting technique. The ADON (Assitant Director of Nursing) just asks us to try them on and see which one fits. No official fitting. On 11/18/20 at 1:15pm, V3 (ADON) stated when employees work in the COVID unit, the following personal protective equipment is utilized: Face shield or goggles, N95 masks, gowns and gloves. On 11/19/20 at 12:19pm, V3 was asked if staff are fitted for the respirator masks and V3 replied, No, they are not fitted. We called for the fitting kit. At first they told us October and now they are on backorder. According to the facility statistics of their COVID outbreak, since 10/30/20, 12 staff members and 31 residents have contracted COVID. The manufacturer specifications for the N95 masks that the staff were using documents: Follow all local regulations in the U.S., a written respiratory protection program must be implemented meeting all the requirements of OSHA (Occupational Safety and Health Administration) including training, fit testing and medical evaluation. A facility Respiratory Protection Program policy, dated 3/29/20, reads: Use of respirators - If caring for a patient with communicable-status TB ([MEDICAL CONDITION]) disease, or other communicable disease where the WHO (World Health Organization), CDC (Center for Disease Control) and LHD (Local Health Department) is mandating the use of airborne isolation PPE (personal protective equipment), the nurse will have had a successful fit test of the model and size of N95 within the prior 12 months, unless a FIT test waiver is issued by federal, state or local agencies. The facility's Respiratory Protection Program policy, dated 11/17/20, reads: 1. Purpose: 2) Fit testing to determine that the respirator selected for use fits properly.

Based on observations, interviews, and record review, the facility failed to ensure foods were covered, stored and prepared in accordance with food service safety; failed to properly prepare and monitor sanitizer solution to ensure food equipment and preparation surfaces are sanitized; and failed to prevent food contamination by wearing required hair coverings. These failures affect all 79 residents receiving meals prepared in the facility's kitchen. Findings include: On 04/22/19 at 09:46 AM, observed chocolate cookies placed on the bottom rack of a kitchen cart uncovered, several prepared potato salads and approximately two prepared apple pies in cooler uncovered, a bag of green leaf lettuce left open in walk in cooler. Observed V6 (Cook), V14 (Dietary Aide), V15 (Executive Food Service Chef), and V16 (Dining Services Aid) not wearing a beard coverings/protectors. Observed one 6 pound dented can of diced pears, three 6 pound dented cans of sliced apples, one 6 pound dented can of cherries stocked with undented cans. V15 (Executive Food Service Chef) stated We cannot use them because they can get spoiled. referring to dented cans. Observed one sanitizer bucket which contained 0 parts per million of sanitizer solution. V15 (Executive Food Service Chef) stated that this sanitizer bucket Was used this morning. On 04/23/19 at 10:45 AM, observed two sanitizer buckets which contained 0PPMs of sanitizer solution. Observed V17 (Sus Chef) with hair exposed from hairnet in the back of her head. Observed V18 (Cook), V14 (Kitchen Assistant), and V6 (Cook) not wearing beard covers/protectors. On 04/23/19 at 11:00 AM, observed one 6 pound dented can of applesauce and one six pound dented can of cherries stocked with undented cans. The facility's sanitizer solution log dated (MONTH) 2019 states: Required concentration of sanitizing solution must be set at 150 - 400ppm for all dispensing equipment, use on stationary equipment, spray bottles, solutions for storing wiping cloths. The facility's policy on food safety standards and requirements received 04/24/19 states: Employees must wear approved hair restraints, beard restraints, clean uniforms, aprons and shoes. The facility's policy on receiving and storage received 04/24/19 states: Swollen, rusted, or dented cans are stored outside of store room on a shelf labeled dented cans until they can be returned to purveyor for credit. The facility's policy on food safety standards and requirements received 04/24/19 states: Products must be checked to detect unacceptable items, i.e, dented, swollen or rusted cans, thawed, or refrozen items, crushed cases, etc. Dry food, which is opened or removed from original packaging, should be stored, properly covered, in food grade containers and clearly labeled. All foods prepared in operation must be covered and labeled as to contents and date of preparation prior to storage in refrigerators and freezers.

Based on observations, interviews, and record reviews, the facility failed to ensure that respiratory equipment was maintained in a manner to reduce the risk of infection; and failed to ensure that staff follow the facility policy for use of personal protective equipment for residents identified on contact isolation, for 4 of 32 residents (R81, R43, R288 and R286), reviewed for infection control. Findings include: On 04/22/19 at 10:48 AM, observed that R81's humidifier bottle was not dated; and the R81's nebulizer mask and tubing was placed on paper towels on top of R81's dresser. On 04/22/19 at 11:26 AM, observed R43's continuous positive airway pressure mask and connectors on top of R43's refrigerator. On 04/22/19 at 12:35 PM, observed R288's nebulizer mask and tubing equipment placed on R288's dresser. R43's physician order [REDACTED]. Facility staff failed to store the equipment, as ordered by the physician when not in use. R81's physician order [REDACTED]. R288's physician order [REDACTED]. The facility's respiratory therapy - prevention of infection policy states: Infection control considerations related to medication nebulizers/continuous aerosol: Obtain equipment (i.e. administration set-up, plastic bag, gauze sponges). After completion of therapy: Store the circuit in plastic bag, marked with date and resident's name, between uses. R286 is an [AGE] year-old resident admitted to the facility 04/01/2019. R286 has a [DIAGNOSES REDACTED]. On 04/22/19 at 12:04 PM, V8 (Speech Therapist) was observed sitting in R286's room wearing gloves and not wearing a gown. V8 stated that R286 [MEDICAL CONDITION] of the leg but it is covered and contained. V8 stated I don't touch him, so I wouldn't need the robe. I could be wrong but that's my understanding. R286's physician order [REDACTED]. R286's care plan revised 04/14/19 documents R286 was hospitalized and treated with antibiotics for wound infection. Infection still not resolved; admitted with orders for antibiotic. Interventions include: Observe contact isolation till resolved, status - active current; instruct staff about use of personal protective equipment (gloves, gowns, masks, etc.). The facility's policy on use of contact precautions received 04/24/19 states: Implement contact precautions whenever a resident is known or suspected to harbor organisms that may be transmitted by direct contact or indirect contact with the environment. Examples of potential agents include: MRSA or other conditions with multi-drug resistant organisms.

Based on observations and record review, the facility failed to ensure residents are provided with a dignified existence, when facility staff entered resident rooms without obtaining permission from the resident to enter, for 3 of 32 residents (R81, R287 and R288), reviewed for dignity. Findings include: On 04/22/19 at 11:05 AM, observed V9 (Certified Nursing Assistant - CNA) knocked on door and entered R81's room while V10 (Certified Nursing Assistant - CNA) was in the middle of announcing patient care. Observed V7 (Registered Nurse - RN) enter R81's room without knocking. On 04/22/19 at 11:50 AM, observed V11 (Occupational Therapy Assistant) knock and open the door to R287's room without waiting for acknowledgement from the resident. On 04/22/19 at 12:30 PM. Observed V12 (Certified Nursing Assistant - CNA) knock and then walked in R288s room without waiting for acknowledgement from the resident. Observed V13 (Registered Nurse - RN) enter R288's room without knocking. On 4/24/19, the facility presented a policy titled: Quality of Life-Dignity, which states: Resident's private space and property shall be respected at all times. Staff will knock and request permission before entering resident's rooms.

Based on observations, interview and record review, the facility failed to label and discard food in personal refrigerators for 3 of 32 residents (R43, R287, and R288), reviewed for safe, clean, comfortable, and homelike environment. Findings include: 04/22/19 at 11:26 AM, observed R43's refrigerator contained a bread roll on top the shelf in back of refrigerator, approximately seven grapes in an snack size storage bag with no use by date, a restaurant container of food in a plastic bag with no use by date. On 04/22/19 at 11:46 AM, observed R287's refrigerator that contained a cup approximately 12 ounces in size, filled with mixed fruit, with no use by date. On 04/22/19 at 12:35 PM, observed R288's refrigerator, which contained a sandwich size storage bag of cheese flavored crackers with no use by date; 2 mandarin oranges on door of refrigerator not stored in a dated container; and a container of cooked carrots and string beans with no use by date. R288 stated it needs to be tossed out. referring to container with cooked carrots and string beans. The facility's policy for safe food storage and handling of food brought to residents by family/visitors received 04/23/19 states: Food or beverage brought in from an outside source (home, restaurant, or carryout) for immediate consumption at a later date and stored in personal rooms will be monitored by designated facility staff to ensure safe and sanitary storage, handling and consumption. All prepared food or beverages brought by family or brought from elsewhere belonging to the resident should be labeled with the resident's name and a 3 day use by date. If the food or beverage is not dated with a use by date, it will be immediately discarded upon inspection. The facility's policy foods brought by family/visitors received 04/24/19 states: Perishable foods must be stored in re-sealable containers with tightly fitting lids in a refrigerator. Containers will be labeled with the resident's name, room number, the item and the use by date. No more than 3 days for perishable food. The nursing staff will discard perishable foods on or before the use by date.

Based on observation, interview and record review the facility failed to administer medications as ordered by the physician, for 3 of 32 residents (R32, R22 and R43), reviewed for medication pass. There were 32 opportunities with 4 errors, which resulted in a medication error rate of 12.5%. Finding include: During medication pass with V7 RN (Registered Nurse) on 4/23/19 at 9:00 AM, V7 failed to follow the physician's orders [REDACTED]. V7 administered to R32, one tablet by mouth labeled [MEDICATION NAME] 25mg (milligrams). On review of the physician's orders [REDACTED]. On 9:21 AM on 4/23/19, V7 was observed administering medications to R22. During the medication pass, V7 omitted the following medications: [REDACTED]. [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME] 0.5mg-3mg(milligram) (2.5mg base) 3ml (milliliter) nebulization soln(solution) (3ml) [MEDICATION NAME] for nebulization (ml) inhalation. On review of the physician's orders [REDACTED]. 2. Duoned order dated 3/27/18 ([MEDICATION NAME]-[MEDICATION NAME] 0.5mg -3mg-(2.5mg base) 3ml nebulization soln (3ml) [MEDICATION NAME] for nebulization (ml) inhalation. Two times daily. On 4/23/19 at 11:34 AM, V7 administered the following medications to R43: Humalog insulin 5 units in the Left Lower Abdomen using a prefilled insulin pen. V7 never checked the insulin pen to make sure it was functioning. R43 has an order dated 4/26/18 for Humalog KwikPen (U-100) Insulin 100unit/ml subcutaneous (inject 5 units) insulin pen (ML) subcutaneous two times daily Notes: Hold if blood sugar less than 150 or skipping meal. R43's accucheck taken by V7 at 11:05 AM on 4/23/19 is with a result of 128 blood sugar. Facility Medication Administration General Guidelines page 3 of 6 number 1. is as follows in part; Medications are administered in accordance with written orders of the prescriber. Facility Medication Administration Subcutaneous Insulin page 3 of 6 is with communication that the pen should be checked for a safety check before use. On 4/24/19 at 2:41PM V3 ADON (Assistant Director of Nursing) was interviewed regarding the facility's medication administration policy. During the interview V3 stated, Nurses are not to give medications without a physicians order, and they are expected to follow the physicians orders.

Based on observation, interview and record review, the facility failed to provide physician-ordered pain medication prior to performing wound care for 1 of 4 residents reviewed for pain from a sample of 18 residents. This failure caused R1 to endure pain during wound care procedures for his facility-acquired stage-3 pressure sores. Findings include: Per facility face sheet dated 6/27/18, R1 is a [AGE] year old resident originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R1's BIM(Brief Interview for Mental Status) score is a 15 on the latest MDS (minimum data set) dated 6/5/18 and shows he is cognitively intact. R1's first facility-acquired wound to his sacrum was first observed on 6/1/18. Per V17 (Wound Physician) notes titled Wound Care Specialist Evaluation shows, Stage 3 Pressure Wound Sacrum. Etiology: Pressure. MDS 3.0 Stage: 3. Wound size (L X W X D): 2.5 x 2.0 x 0.1 cm. Indication: Remove Necrotic (Dead)Tissue and Establish the Margins of Viable Tissue. Recommendation: Off-load wound, Reposition per facility protocol. R1's other facility-acquired wound shows per the Wound Care Specialist Evaluation dated 6/1/18: Stage 3 Pressure Wound of The Right Upper Back. Wound Size (L X W X D): 1.0 x 1.0 x 0.1 cm. Recommendations: Off-load wound, reposition per facility protocol. Wound Care Specialist Evaluation dated 6/22/18 states, Patient has a wound on their upper back. He presents with a stage 3 pressure wound of the right upper back of at least 21 days duration. Appetite: Fair. Musculoskeletal system: Deconditioning. Wound Size: 4.5 x 2.5 x 0.1 cm. Wound Progress: Deteriorated. Wound Deteriorated. recent wound culture revealed pseudomonas (infected). Recommendations: Off-load wound, reposition per facility protocol. On 6/25/18 at 11:45 am, V12 (LPN-Licensed Practical Nurse) performed wound care for R1. V12 peeled off the bandage while R1 started grimacing and moaning loudly with pain saying, oh my god that hurts. V12 stated to R1, Are you in pain? R1 responded loudly, yes! V12 stated, Ok, let me finish this first, I'm almost done. V12 continued to remove the old dressing from the first wound, went to the bathroom to wash her hands, and returned to cleanse the wound and apply clean dressing. R1 stated again several times during the procedure, That really hurts. I'm in real pain, you have to stop. V12 stated again, Where does it hurt (R1)? R1 stated, My knee and my back, are you almost done? V12 stated,I just need to finish your other wound but I have to come back because I ran out of ointment.V12 then proceeded to leave the room to obtain more wound care items. While V12 went to obtain more wound supplies, R1 was asked if he was given any pain medication prior to the nurse conducting his wound care. R1 stated, No, they never give me pain medications before they do my dressing changes. Asked if he requests them, No but shouldn't they be asking me if I need them. Sometimes, they just barge in here and tell me It's time to do your dressing change and I don't even have a chance to tell them I'm in pain because I'm not. It's only when they're turning me here and poking at my skin is when it hurts. Asked how much it hurts from a scale of 1-10 when the nurse does his wound care, R1 stated, 11. It's like they put a cold knife to your skin it's that painful. At 12:10 PM V12 returned with her wound supplies and laid them beside R1's bedside table. V12 did not ask whether R1 was still in pain nor if he needed any pain medications before she started. V12 asked R1 to grab on to the side rail as he struggled to turn over to his left side. Asked if there were any aides to help her turn and reposition R1 and assist in the wound care, V12 stated, No (R1) can do this, he usually can turn himself. I usually do this myself with him. (R1's latest MDS dated [DATE] shows that (R1) requires a 2-person assist with bed mobility.) Asked if she gave R1 any pain medications prior to the procedure, V12 stated, No I didn't give him anything. R1's Physician order [REDACTED]. There were no other physician orders [REDACTED]. R1's MAR (Medication Administration Records) for (MONTH) and (MONTH) do not show any type of pain medication given to R1 prior to wound care. R1's care plan does not address pain related to pressure sore treatments. 6/26/18 interview at 3:00 PM with V2 (DON), V2 was asked to provide any policy on pain relief. V2 stated, We don't have any policies on pain. Asked how her nurses address pain, V2 stated, My nurses will use other nonpharmacological methods to address pain such as massage and we would refer them to therapy for e-stim (electronic stimulation). Asked if residents should be pre-medicated for pain prior to wound care, V2 stated, Not always, they (residents) would have to ask for it, I guess. Asked again about a policy and procedure, V2 stated, No we don't have one, we just use the same protocols you (public health) would use which would be the CMS (Centers for Medicare/Medicaid Services). Asked how her nurses would obtain access to this policy and procedure, V2 stated, They'd have to go on the CMS website. Asked again if her nurses are provided a policy and procedures on providing pain relief for their residents, V2 stated, We don't have any actual printed policies and procedures on pain. Nurses should know this and if they don't they are directed to go onto the CMS website. 6/27/18 Interview with V17 (Wound Doctor) states, Stage 3 pressure ulcers can be very painful. I would provide pain medications prior to performing wound care an hour prior to lessen any pain the resident may experience. If the resident is in pain during the procedure, the procedure should stop immediately and not be finished. The attending physician should be contacted so they can prescribe a more effective [MEDICATION NAME] for pain. Abstract literature from Ostomy Wound Management dated 2009 states in part, Pain is an ever-present problem in patients with pressure ulcers. The literature established that 1) pressure ulcers cause pain; 2) pain assessment was typically found to be self-reported using different versions of the McGill Pain Questionnaire, Faces Rating Scale, or Visual Analog Scale; 3) pain assessment instruments should be appropriate to patient cognitive level and medical challenges; 4) in some cases, topic medications can ease pain and although information on systemic medication is limited, pain medications have been found to negatively affect appetite; and 5) wound treatment is painful, pain on nutrition, and pressure ulcer pain considerations for special groups (e.g., children, end-of life patients, and bariatric patients.) The NPAP (National Pressure Ulcer Advisory Panel) presents this white paper as the current scientific knowledge base on the topic. Pain is an ever-present problem in patients with pressure ulcers. As a protective physiologic mechanism, pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Irrespective of a patient's age or health status, pressure ulcer pain needs to be assessed and treated because it has widespread physical and psychosocial implications for the patient, family and clinician. Pathophysiology of Pressure Ulcer Pain: Pressure ulcer pain may be caused by tissue trauma from sustained loads, inflammation, damaged nerve endings, infection, dressing changes, debridement, operative procedures,a and other treatments. The skin has more sensory nerves than any other body organ. As the pressure ulcer cellular damage expands, chemicals are released that irritate nociceptive nerve terminals. Nociceptive pain is an appropriate physiological response to a painful stimulus and involves acute or chronic inflammation.

Based on observation, interview and record review, the facility failed to develop an individualized plan of care and identify/implement interventions to address immobility/poor nutrition to prevent the development of facility-acquired pressure ulcers for a resident. This failure resulted in R1 acquiring an unstageable pressure ulcer on her left heel, an unstageable pressure wound on her right heel and a Stage 2 sacral pressure wound at the facility. This applies to 1 of 2 residents (R1) reviewed for new or worsened pressure ulcers in a sample of 16. The findings include: Physician order [REDACTED]. POS showed R1's [DIAGNOSES REDACTED]. The MDS (Minimum Data Set), dated March 24, March 31 and April 14, 2017, all showed that R1's cognition was intact and required the assistance of two staff members for bed mobility and transfers. Facility Admission Data Collection and Documentation form dated March 17, 2017, showed that R1 was alert and oriented to person/place and time. R1 did not have [MEDICAL CONDITION] of both lower extremities. The form showed that R1 had a surgical scar to her sternum, scratch marks to her right upper arm, a surgical scar to her abdominal area, a peripheral line inserted to her right arm, ten staples to R1's right upper hip, sixteen staples to the right hip, and three staples to the right incision above the knee. No pressure ulcers were identified on the Admission Data Collection form. R1 had an indwelling urinary catheter on admission. R1's POS showed that the indwelling urinary catheter was discontinued per physician order [REDACTED]. On May 22, 2017 at 9:45 AM during initial tour of the facility with E2 (Director of Nursing), E2 was asked why R1 developed pressure ulcers after admission to the facility. E2 responded that R1's pressure ulcers were the result of poor nutritional intake and decreased movement. On May 22, 2017 at 12:40 PM in R1's room, R1 was sipping a nutritional supplement. R1 stated she had not been eating at the facility but noted some improvement in appetite recently. R1 stated, Apparently I was in bed when I first got here - just laying here . R1 also stated, something killed my appetite! On May 23, 2017 at 9:05 AM, R1 was sitting upright in bed with her head of bed at 45 degrees and slowly nibbling on breakfast. R1 had a pillow under her knees and protective boots on both feet. R1 did not have pillows under her calves or heels. R1's bilateral heels were resting on the bed. At 9:20 AM, E7 (Registered Nurse) examined the position of R1's heels and stated, It should be off more. We should have used more pillows. On May 27, 2017 at 12:20 PM, E8 (Certified Nursing Assistant) stated that R1 did not want to get out of bed and her tolerance sitting in the wheel chair was not good when she was admitted . E8 stated that two staff were needed to turn and change R1 in bed. E8 also stated that R1 was in a lot of pain on admission and could not assist with repositioning in bed. E8 stated that he would offer to turn R1, however, R1 would complain that she could not see the television. E8 said that the staff would encourage R1 to sit in the wheelchair, however, R1 preferred to be in bed. E8 described the proper way to off-load the heels by placing a pillow under a resident's calves so there is no pressure placed on a resident's heels. E8 further stated that the heels should not be in contact with the bed. Nursing notes dated March 17- 22, 2017, showed that R1 required extensive assistance of two staff for transfers and toileting. Nursing notes showed that R1's pain was being managed by [MEDICATION NAME] and [MEDICATION NAME]. The nursing notes dated March 18, 2017, showed that R1 rested quietly in bed throughout the day, pain is increased by position changes. The notes lacked documentation regarding R1 being turned or repositioned, the use of heel protectors or R1's heels being floated while in bed. The nursing notes did not show any concerns with R1 refusing care, declining turning or repositioning or declining to have her feet off-loaded. ADL (Activities of Daily Living) Verification Worksheet dated March 18-March 22, 2017, showed that R1's meal intake on March 19 and March 22, 2017 was less than 25 % for all three meals and the rest of the days it was less than 25 to 50 %. The Nursing notes dated March 22, 2017, showed, This RN (Registered Nurse) called to resident's room by staff reporting wetness on sheet by BLE (Bilateral Lower Extremities). Writer assessed to find resident with two intact blisters on bilateral heels measuring, one small bluish discoloration on right great toe, and an excoriation on right upper leg distal to incision. R1's blister on the right heal measured 66 cm (centimeters) by 7 cm, intact (writer did not observe opening) with clear fluid. The blister on left heel measured 4 cm by 4 cm, intact (writer did not observe opening) with clear fluid. Bluish discoloration on right great toe, non-blanchable, skin was intact, measuring 1 cm by 1 cm. Excoriation on right upper leg measuring 2 cm by 1 cm with scant sanguineous drainage. No signs/symptoms of infection present on wounds. Resident was unable to describe when or how the wounds occurred. R1 said, I don't know how it got there. R1 did not complain of pain at sites. Writer informed Z1 (Advanced Practice Nurse) with new orders carried out. Bunny boots placed on BLE. Skin prep applied to blisters, heels floated while in bed, elevated while in chair. Low air loss mattress ordered. Care plan updated. The APN (Advanced Practice Nurse) notes dated March 22, 2017, showed, Evaluation of blisters to BL (Bilateral) lateral heels noted this am. No injury, no fall, no prior history of similar symptoms in past. No any other associating symptoms. No fever, chills, numbness or tingling or extremities. Patient also denies pain. Patient was unable to describe when or how wounds occurred. Patient appeared more awake and alert Plan: .Blisters, Pressure ulcers. Start skin prep BID (twice daily) to bilateral heels (blisters). Wear bunny boots and float heel while in bed and continuously 24 hours. Refer to wound doctor to eval and treat. Monitor skin integrity every shift. Reposition patient per facility protocol Nutrition support Wound Care Specialist Evaluation dated March 24, 2017, showed that R1 had an unstageable DTI (Deep Tissue Injury) of the left heel and the etiology was pressure. The duration of the wound was less than one day and the wound measured 5.5 cm by 5 cm. Wound evaluation shows R1 had an unstageable DTI of the right heel, the etiology was pressure, and the wound measured 5.5 cm by 5 cm. Recommendations for both heel wounds include off-loading of the wound and reposition per facility protocol. The wound evaluation describes R1's appetite as good and does not indicate any sacral wounds on examination. The wound evaluation shows Factors complicating wound healing: Diabetes mellitus without mention of complications - type II or unspecified type - not stated as uncontrolled, [MEDICAL CONDITION] - unspecified. The POS dated March 22, 2017, showed the physician orders [REDACTED]. R1's care plan initiated and effective March 22, 2017, showed that R1 was identified as, At risk for impaired skin integrity evidenced by actual skin breakdown; bilateral intact blisters on heel, sacral redness, and excoriation on right hip. The approaches all initiated on March 22, 2017, included offloading heels while in bed and chair, bunny boots bilaterally at all times, remove for integrity checks twice daily, reposition per facility protocol and encourage food and fluid intake. ADL Verification Worksheet, dated March 23-28, 2017, shows R1's meal intake for March 23 and March 24, 2017 was less than 25% for all three meals and rest of the time R1's intake was 25 % to 50 % with occasional 75 % consumed. Nursing note, dated May 29, 2017, shows a low air loss mattress was delivered to R1. Physiatrist note, dated March 29, 2017, shows R1's Doppler to her right lower extremity, was negative. Wound Care Specialist Evaluation, dated March 31, 2017, describes R1's appetite as good and shows R1's left heel wound had no changes however R1's right heel wound deteriorated. R1's right heel wound measurements were 6 cm by 6 cm. ADL Verification Worksheet, dated March 31, 2017 to May 3, 2017, show R1's meal intake was usually <25-50% of most meals with an occasional meal consumed 75% or 100%. Wound Care Specialist Evaluation, dated April 7, 2017, shows R1's left heel had no change. R1's right heel now included the description as unstageable (due to necrosis) and included the description of thick adherent black necrotic tissue (eschar) covering 50% of the wound. R1's right heel wound size decreased to 5 cm by 6 cm. Wound evaluation included a new Stage 2 pressure wound on R1's sacrum which was less than 11 day in duration. The sacral wound measured 2 cm by 0.8 cm by 0.1 cm with light serous exudate noted. The wound description included moisture associated with skin damage. Recommendations included off-load wound, reposition per facility protocol, multivitamin, zinc and Vitamin C supplementation, a low air loss mattress, complete blood count, comprehensive metabolic profile, and [MEDICATION NAME] lab draws. R1's wound was surgically debrided to remove necrotic tissue and establish the margins of viable tissue. POS, dated April 6, 2017, shows R1 received a physician order [REDACTED]. Advanced Practice Nurse notes, dated April 13, 2017, shows Patient complains of feeling 'very tired' in past two days. She states she has not been able to participate in therapy and 'cannot stay awake.' She is also complaining of having poor appetite Nutrition 30 Day / Skin Assessment, dated April 13, 2017, shows R1's most current weight as 181 pounds and PO intake is fair and she is encourage to eat, take fluids and drink (supplement). Will continue to monitor PRN. No further nutritional interventions were recommended for R1's poor PO intake. POS, dated April 13, 2017, shows R1's indwelling urinary catheter was removed. Advanced Practice Nurse notes, dated April 19, 2017, show DP (Dorsalis Pedis) pulses intact, sensation intact, circulation intact. Wound Care Specialist Evaluation, dated April 26, 2017, shows R1's left heel wound was described as a Stage 3 pressure wound measuring 4 cm by 1.8 cm, 100% thick adherent black necrotic tissue (eschar). R1's right heel continued to be unstageable, measured 4 cm by 5.5 cm, and included 70% eschar. R1's stage 2 sacral pressure wound measured 1.8 cm by 0.6 cm by 0.1 cm with light serous exudate. Wound Care Specialist Evaluation, dated May 19, 2017, shows R1's Stage 3 pressure wound of the left heel measured 3.5 cm by 1,8 cm and was 100% eschar. R1's left heel wound was debrided. R1's right heel unstageable wound measured 4 cm by 5.5 cm and was 60% eschar. The right heel wound was surgically debrided. R1's stage 2 sacral pressure wound measured 1.5 cm by 0.5 cm by 0.1 cm with light serous exudate. Wound Care Specialist Evaluation, dated May 19, 2017, show little changes in heel or sacral wound measurements. Both heels were again surgically debrided. Wound Care Specialist Evaluation, dated May 24, 2017, shows Stage 3 Pressure wound of the left heel was 100% eschar measuring 3.5 cm by 1.58 cm and R1's unstageable of the right heel was 60% eschar and measured 3.8 cm by 5.5 cm. The stage 2 pressure wound to the sacrum measured 1.5 cm by 0.5 cm by 0.1 cm. On May 24, 2017 at 11:10 AM R1's skin was checked with E7 (Registered Nurse). R1 had pressure sores on the left heel, right heel, and sacrum as described above. R1 also had two small areas of skin breakdown on the right and left buttocks. The area on the left buttock measured 0.8 cm by 0.8 cm by 0.1 cm. The area on the right buttocks measured 0.5 cm by 0.5 cm by 0.1cm. Advanced Nurse Practitioner note, dated May 11, 2017, shows R1's appetite is described as poor. Progress note shows, Plan: Weight loss, nutrition eval, nutrition support, check weights weekly. Physical examination shows, General: frail . On May 25, 2017 at 10:20 AM, Z1 (Advanced Nurse Practioner) stated she had followed R1 since she was admitted to the facility. Z1 stated R1 may have developed the heel breakdown due to high doses of [MEDICATION NAME] and R1 not being able to move in bed. Z1 stated R1 was very lethargic due to the [MEDICATION NAME] and was not able to move independently in bed. Z1 stated R1's heel ulcers declined so Z1 ordered a wound physician to follow R1's wounds. Z1 also stated R1 was depressed and R1's appetite was fair. Z1 stated that R1 had altered mental status due to depression which contributed to poor food intake which could contribute to the deterioration of the pressure ulcers. On March 25, 2017 at 11:45 AM, Z4 (Dietician) stated if she had been aware R1 was eating only 25-50% of most meals in the five days prior to the development of R1's pressure ulcers, she would have been concerned. Z4 stated R1 only started losing a lot of weight recently. Z4 confirmed there were no new nutritional interventions recommended for R1 after R1's weight loss of ten pounds from April to May, 2017 was identified and R1 continued to have three documented facility-acquired, pressure ulcers. The Facility's policy titled, Prevention of Pressure Ulcers, dated July 1, 2009, showed, Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area, which destroys the tissues If pressure ulcers are not treated when discovered, they quickly get larger Pressure ulcers are often made worse by continual pressure, .decline in nutrition and hydration status Ensure that the resident drinks plenty of fluids and eats a well-balanced diet. The document shows, 1. Risk Factor: Bedfastness/ Chairfastness Preventive Actions: For a person in bed - change position at least every two hours; use a special mattress that contains foam, air, gel, or water, as indicated 2. Risk Factor: Immobility Preventive Actions: .When in bed, every attempt should be made to 'float heels' (keeping heels off the bed) by placing a pillow from knee to ankle or use of other devices 4. Risk Factor: Poor Nutrition Preventive Actions: Monitor nutrition and hydration status. Encourage proper dietary and fluid intake. If a normal diet is not possible, talk to physician about supplements. The Facility policy titled. Turning A Resident On His/Her Side Away From You, dated July 1, 2009, showed, The purposes of this procedure are to provide comfort to the resident, to prevent skin irritation and breakdown, and to promote good body alignment. Policy shows, The following information should be reported to the staff/charge nurse and should be documented in the resident's clinical record: 1. The date and time the procedure was performed 6. Any problems or complaints made by the resident related to the procedure. 7. If the resident refused the treatment and the reason(s) why. 8. The signature and title of the person recording the data.

Based on observation, interview and record review, the facility failed to ensure proper hand washing was done after handling dirty dishes and before touching clean dishes. This applies to all residents receiving an oral diet at the facility. The findings include: The Facility Resident Census and Condition of Residents Form, dated May 22, 2017, showed the facility census was 78. The Facility diet order list dated May 22, 2017, showed that all residents at the facility receive an oral diet. On May 22, 2017 at 9:20 AM during initial tour of the kitchen with Z2 (Chef), E6 (Food Service Worker) had disposable gloves on his hands and was placing dirty dishes in racks and pushing the racks into the dishwasher. E6 immediately rinsed his soiled gloved hands under running water at the dishroom pot and pan sink. E6 did not utilize any soap and did not remove his disposable gloves. E6 then immediately walked to the clean side of the dish machine where green rubber gloves were soaking in a red bucket, placed the green rubber gloves over the soiled disposable gloves still on his hands, and began touching clean silverware. On May 22, 2017 at 9:25 AM, E6 was wearing disposable gloves and was touching dirty dishes and loading them into the dishwasher. E6 immediately walked to the clean side of the dish machine and placed the green rubber gloves over his soiled disposable gloves. E6 did not attempt to wash his hands. E6 immediately began stacking clean dishes with the green rubber gloves. On May 24, 2017 at 11:15 AM, E5 (Food Service Worker) was wearing disposable gloves, placed dirty dishes in the dish machine rack, and sent the dishes through the dish machine. E5 immediately walked to the dishroom pot and pan sink where the water was running and water was standing in the sink basin. Without removing his soiled disposable gloves, E5 rinsed his hands by splashing them in the standing water. E5 then shook the water off of the disposable rubber gloves and immediately walked to the clean side of the dish machine. Without changing his gloves, E5 grabbed two clean hotel pans with the same soiled disposable gloves and placed them on the pot and pan storage rack. On May 22, 2017 at 9:25 AM, Z2 stated the staff are expected to wash their hands at a hand washing sink and not at the pot and pan sink. Z2 also stated the staff are expected to wash their hands and change their gloves after handling dirty dishes. Facility Handwashing and Personal Cleanliness Policy, dated January 27, 2012, shows, The (name of the company) policy requires that all employees wash hands .after handling dirty equipment, after handling trash and other contaminated objects 1. Wash hands thoroughly with with approved antibacterial or antibacterial hand soap. Pay particular attention to the areas underneath fingernails and between fingers. Wash hands and exposed parts of arms for at least 20 seconds. Rinse thoroughly with clean water. Dry hands with disposable towels or use an air dryer 5 Never contaminate food by washing you hands in sinks used to clean food or food equipment, or by using wiping cloths to remove perspiration.

Based on observation, interview and record review, the facility failed to identify and implement interventions for residents who experienced falls to prevent further falls. This applies to 3 of 10 residents (R1, R3 and R12) reviewed for falls in a sample of 16. The findings include: 1) Physician order [REDACTED]. POS shows R1's [DIAGNOSES REDACTED]. MDSs (Minimum Data Set), dated March 24, March 31, and April 14, 2017, all show R1's cognition was intact. MDSs also all show R1 required two staff to assist R1 with bed mobility and transfers. Facility Admission Data Collection and Documentation form, dated March 17, 2017, shows R1 was alert and oriented to person/place/time. Documentation form fall evaluation shows R1 had 1-2 falls in the past three months and scored a 9 indicating a fall management program/care plan was to be initiated. Fall care plan, created March 17, 2017, shows, Problems: At risk for falls related to post-operative condition. Goal: Will not sustain fall during stay. Interventions: Assess changes in mental status, mood, and behavior Assist with ADLs (Activities of Daily Living) as in transferring, hygiene, toileting, bathing. Interim ADL care plan, created on March 20, 2017, shows Assist with ADLs ADL deficit care plan, created and effective April 7, 2017, shows R1 requires extensive assist with bathroom transfers, toileting, dressing, grooming and bathing. Due to right leg pain, decreased strength, and unsteady functional balance (partial weight bearing on right lower extremity) Mobility care plan, created and effective April 20, 2017, shows R1 had a mobility deficit due to fracture of right hip, toe touch weight bearing and need for extensive assist for transfers, toileting, bed mobility. May 15, 2017 order for weight bearing as tolerated right leg Interventions: (Created April 20, 2017 and Effective April 7, 2017) Transfer with 1-2 assist to assure safety and comfort. Use gait belt, sliding board. Physical Therapy progress note, dated April 9, 2017, showed, Gait training with wheeled walker a few steps x3 .with moderate assist of 2 .verbal/tactile cues for to touch weight bearing on right lower extremity Wears bilateral pressure reducing ankle foot orthosis boots with moderate assist of of 2 . Complains of lightheadedness when initially standing. Physical Therapy progress note, dated April 10, 2017, shows R1 was provided gait training with a wheeled walker a few steps x3 with moderate assist of 2 . Verbal/tactile cues for to touch weight bearing on right lower extremity . Wears bilateral pressure reducing boots with moderate assist of 2 .Physical Therapy notes, dated April 11, 2017, shows R1 received gait training with bilateral platform wheeled walker and bilateral PRAFO boots .using weight scale right foot . weight > (greater than) 30 points with verbal/tactile cues for decrease weight bearing Took only a few steps with moderate assist of two. Physical Therapy notes, dated April 12, 2017, show R1 was able to use slideboard with set up and stand by assistance with verbal encouragement to complete task . The nursing notes dated March 17- 22, 2017, showed that R1 required the extensive assistance of two staff for transfers and toileting. The notes showed that R1's pain was being managed by morphine and tramadol. Nursing notes, dated April 12, 2017, showed that R1, Requires x 2 maximum assist for transfers and toileting. The nursing notes dated April 14, 2017 showed, R1, Requires x2 extensive assist with transfer and toileting. The Occurrence Report dated April 14, 2017, showed, Resident was being weighted by staff. While at the scale with E11 (CNA-Certified Nursing Assistant) present, resident was standing and holding on to the grab bar of scale when she lost her balance and was lowered to the floor by E11. Per resident, my right leg went out and I couldn't stand, and She (CNA) lowered me to the floor onto my butt, and I didn't hit my head and nothing hurts Witness statement showed, I was weighing her when she looked like she lost her balance. I noticed she was going to fall so I grabbed her and lowered her to the floor On May 25, 2017 at 2:00 PM, E2 (Director of Nursing) stated that R1's fall was investigated and intervention was to weigh R1 in her wheel chair with two staff present. E2 stated there was only one CNA present weighing R1 when she fell . 2) R12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On May 24, 2017 at 9:25am R12 was sitting up in the wheelchair sleeping in the room. R12's bedside table was between his wheelchair and his bed. R12's call light was resting on the bed. R12's MDS (Minimum Data Set) dated September 2016 showed R12 requires extensive assistance of 2 staff persons for transfer and toileting. R12's care plan for falls effective April 20, 2017 showed staff to reinforce the call light use and keep the call light within reach of R12. R12's is at risk for falls according to R12's care plan for falls dated April 20. 2017. R12's fall record showed R12 had eight (8) fall incidence since June 30, 2016. On January 12, 2017 and February 5, 2017 R12 was lowered to the floor by 2 CNAs (Certified Nurse Assistants) during transfer. On June 30, 2016 and May 18, 2017 R12 was being assisted by 1 CNA and was lowered to the floor during transfer. On February 23, 2017 R12 slid to the floor while trying to reach his crackers according to R12's fall incidents report. New interventions were not put in place after each fall incident in R12's care plan for falls. 3) R3 was admitted to the facility on [DATE] and resides in the Dementia unit of the facility. R3 has a [DIAGNOSES REDACTED]. R3's MDS (Minimum Data Set) showed R3 is cognitively impaired and BIMS (Brief interview for Mental Status) score cannot be assessed. R3 is at risk for falls according to R3's care plan for falls dated December 10, 2016. R3's fall incident reports showed R3 sustained 1 fall on December 10, 2016. On May 23, 2017 at 1:35pm, E9 (Certified Nurse Assistant, CNA) and E10 (CNA) assisted R3 to the toilet using a transport/transfer device. R3 was instructed to hold onto the hand bars of the device by E10. R3 was not holding onto the bars and did not seem to understand what E10 was asking R3 to do. E10 then placed R3's left hand on the left bar and held it in place with E10's hand. E10 then instructed E9 to do the same to R3's right hand. The facility's manufacture guidelines for transporting a resident using a non-powered transport device dated 2011, Procedure #3 showed staff to instruct the resident to grasp the padded grip bar. Then ask the resident to place his/her feet forward onto the foot plate with knees against the pad. Procedure #4 showed staff to ask the resident to elevate his/her body to a standing position by pulling up on the padded grip bar. On May 25, 2017 at 12:30 PM, E2 (DON-Director of Nursing) stated that R3 was not assessed prior to the use of transfer device. No assessment was done to ensure that R3 can safely transfer using the transfer device. E2 stated it was a directive from their central office to start using the transfer device on all residents who required assistance with transfers. The facility's Fall Prevention policy revised on February 17, 2017 showed, Implementation and Guidelines: .9. Communication to staff regarding plans of care for residents and changes to plans of care. 12. Post fall evaluation and assessment with updated care plan interventions. Thorough investigation of all falls with recommendations to prevent recurrence.