Every finding on record at Briarwood Healthcare Center

Based on observation, clinical record review, facility policy review, and staff interviews the facility failed to implement fall interventions per Care Plan for 2 of 4 residents (Resident #3 and Resident #4) reviewed for falls. The facility reported a census of 54 residents. Findings include:1. Review of Resident #3's Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated a severe cognitive impairment. The list of diagnoses included traumatic brain injury and depression. Per the assessment, Resident #3 used a walker, and required partial/moderate assistance for chair/bed to chair transfers.Review of Resident #3's Care Plan revealed the following Focus areas:a. Dated 4/6/24, [name redacted, Resident #3] is high risk for falls r/t (related to) gait/balance problems. Unaware of safety needs. b. Dated 4/13/24, [name redacted, Resident #3] has had an actual fall with no injury d/t unsteady gait. Interventions included, in part:1. 03/19/2026 Fall Intervention: Do not leave unattended in wheelchair in room.2. 03/21/2026 Fall Intervention: Keep Wheelchair in the hallway when in recliner3. 03/24/2026 Fall Intervention: Education done with staff to not leave resident unattended in his wheelchair in his room. Review of Resident #3's electronic health record (EHR) revealed the following Incident Reports:a. #1022 - Witnessed Fall. Date: 3/19/26 at 4:30 PM. Resident: [name redacted, Resident #3]. Incident Location: Resident's Room. Incident Description: Nursing Description - CNA (Certified Nursing Assistant) was walking past resident's room, resident was leaning forward in his wheelchair and dropped to his knees. No injuries resident did not hit his head, range of motion intact, denies pain, he was wearing his tennis shoes, alarm sounded.Resident Description: resident stated he was trying to adjust himself in the wheelchair and fell forward.Immediate Action Taken: Description: Fall Intervention - Do not leave unattended in wheelchair in room.b. #1024 - Unwitnessed Fall. Date: 3/21/26 at 9:40 AM. Resident: [name redacted, Resident #3]. Incident Location: Resident's Room. Incident Description: Nursing Description - Resident had an unwitnessed fall in his room. Staff reports that res (resident) is in his room on the floor. Upon entering the room res was observed sitting in an upright position on the floor in front of his recliner chair. Res encouraged to utilize call light for assistance. Resident Description: When asked what happened, res reports that he was trying to get from his wheelchair to the recliner chair. Immediate Action Taken Description: Upon assessment vitals. No injuries or bruising noted. Res then assisted up from the floor to his recliner chair with assist X3 and gait belt. Neuro flow sheet initiated per protocol. Fall Intervention: Keep Wheelchair in the hallway when in recliner. c. #1025 - Unwitnessed Fall. Date: 3/24/26 at 4:22 PM. Resident: [name redacted, Resident #3]. Incident Location: Resident's Room. Incident Description: Nursing Description - Resident was in his wheelchair when he leaned forward and tried to pick something up off the floor. 2 envelopes were on the floor. Resident Description: Resident attempted to transfer without help, and fell in his room. Immediate Action Taken Description: Vitals and assessment completed. Resident denies pain. Resident educated to call for help to transfer. Fail Intervention: Education done with staff to not leave resident unattended in his wheelchair in his room.During an interview on 6/10/26 at 11:36 AM, Staff A, CNA queried if Resident #3 could be in his wheelchair in his room and Staff A stated Resident #3 could be in his wheelchair in his room because he had a chair alarm on it. During an interview on 6/10/26 at 2:41 PM, Staff F, CNA queried if Resident #3 could be in his wheelchair in his room and Staff F stated she thought Resident #3 could be in his room in his wheelchair unsupervised for a little while. During an interview 6/10/26 at 3:51 PM, the Director of Nursing (DON) asked about the falls for Resident #3 on 3/19/26, 3/21/26, and 3/24/26 and the DON spoke of the interventions the facility tried with Resident #3. The DON stated the resident would self-propel into his room and no one would know Resident #3 in his room. The DON stated the staff needed to follow through with the interventions put in place. 2. Review of Resident #4's MDS assessment dated [DATE], revealed a BIMS score of 14 out of 15, which indicated intact cognition. The list of diagnoses stroke, diabetes mellitus, and depression. Per the assessment, Resident #4 required supervision/touching assistance with chair/bed to chair transfer and walking. The MDS documented an admission date of 4/22/26.Review of Resident #4's Baseline Care Plan dated 4/22/26 indicated Resident #4 an assist of 1 with transfer, walking, and toileting; and used a front wheeled walker.Review of Resident #4's Care Plan revealed the following Focus areas:a. Dated 5/13/26, [name redacted, Resident #4] is at risk for falling r/t hx (history) of fall with fx (fracture), high risk medications.b. Dated 5/13/26, [name redacted, Resident #4] has an actual fall with no injury. Interventions, in part:1. 05/01/2026 Fall Intervention: Reminder sign to call for assistance2. 05/02/2026 Fall Intervention: Education with staff to hold onto gait belt. [Name redacted, Resident #4] is assistance x 1 with a gait belt.3. 05/05/2026 1st fall - Fall Intervention: Education with staff to leave walker within reach.4. 05/26/2026 Fall Intervention: 1:1 with new CNA that took did not leave walker in reach education on keeping walker near [Name redacted, Resident #4].Review of Resident #4's EHR revealed the following Incident Reports:a. #1049 - Unwitnessed Fall. Date: 5/1/26 at 9:00 PM. Resident: [Name redacted, Resident #4]. Incident Location: Resident's Room. Incident Description: Nursing Description - No, resident found sitting on the floor in front of her tv. Resident Description: Resident said she was in front of her tv and tried to reach for her walker and lose her balance and fell. Immediate Action Taken Description: Assessed resident, no injuries noted. Resident denies hitting her head. Fall Intervention: Reminder sign to call for assistanceb. #1051 - Witnessed Fall. Date: 5/2/26 at 8:45 PM. Resident: [Name redacted, Resident #4]. Incident Location: Resident's Room. Incident Description: Nursing Description - Yes, Resident walking in her room trying to get her pajamas, try to turn around and started falling, CNA was with her in her room. Resident Description: Resident said she was trying to get he[r] pajamas and turned and started to fall. Immediate Action Taken Description: Assessed resident, CNA said she did not hit her head, no injuries noted, able to move all extremities without difficulty, eyes/pupils round and reactive to light bilaterally. Assisted resident on her feet, able to walk using her walker with assist x1 and GB. Denies any pain or discomfort. Fall Intervention: Education with staff to hold onto gait belt. Resident is assistance x 1 with a gait belt.c. #1055 - Unwitnessed Fall. Date: 5/6/26 at 4:25 PM. Resident: [Name redacted, Resident #4]. Incident Location: Resident's Room. Incident Description: Nursing Description - Resident was found on the floor next to her bed. Resident Description: Resident said she was trying to reach for her walker and just fell. Immediate Action Taken x Description: Assessed resident, no injuries noted. Fall Intervention: Education with staff to leave walker within reach.d. #1065 - Witnessed Fall. Date: 5/26/26 at 5:00 PM. Resident: [Name redacted, Resident #4]. Incident Location: Resident's Room. Incident Description: Nursing Description - Yes, CNA and nurse heard the chair alarm at resident's room, started to run at her room but was too late. CNA saw resident lost her balance reaching for her walker and fell. Resident Description: Resident said she was trying to reach for her walker and fell, and said she hit her head. Immediate Action Taken Description: Assessed resident, small bruise noted on her right elbow.Fall Intervention: 1:1 with new CNA that took did not leave walker in reach education on keeping walker near resident.During an observation on 6/9/26 at 1:23 PM, Resident #4 sat in her recliner and her walker positioned approximately 3 feet away against the closet doors. During an interview on 6/10/26 at 12:49 PM, Staff B, CNA queried where Resident #4 walker needed to be located and Staff B stated she liked to keep the walker at least 3 feet away from Resident #4. Staff B asked what an assist of 1 meant and Staff B stated assist with 1 CNA and gait belt. Staff B asked if the staff needed to hold onto the gait belt with transfers and Staff B stated yes, her hand or at least a couple of fingers needed to be under the gait belt. During an interview on 6/10/26 at 1:14 PM, Staff C, CNA queried on where Resident #4 walker needed to be located and Staff C stated she tried to keep Resident #4 walker in front of the closet and not within reach of the resident because Resident #4 will try to stand up on her own and try to move around. During an interview on 6/10/26 at 1:39 PM, Staff D, CNA queried on where Resident #4 walker needed to be located and Staff D stated she put Resident #4 walker up against the wall, not right next to Resident #4, probably 4 feet away because Resident #4 will try and get up and walk. Staff D asked what a one assist meant and Staff D stated assisting resident with 1 staff member, gait belt, and a walker. Staff D confirmed the gait belt needed held onto when ambulating in use. During an interview on 6/10/26 at 2:25 PM, Staff E, CNA asked where Resident #4 walker needed to be located and Staff E stated with all of Resident #4 falls, Staff E would not keep it within reach because Resident #4 tried to get up on her own.During an interview on 6/10/26 at 3:24 PM, Staff G, Licensed Practical Nurse (LPN) queried on falls with Resident #4 and Staff G stated one time Resident #4 was standing near the closet and fell before the CNA could get to her. Staff G asked if staff needed to keep their hand on the gait belt when using it, and Staff G confirmed staff needed to be on the gait belt at all times. Staff G asked where Resident #4 should be located in the resident's room and Staff G confirmed the walker should be within reach of the resident. During an interview on 6/10/26 at 3:40 PM, Staff H, CNA queried if she had ever been with Resident #4 when she had a fall and Staff H stated yes, when Resident #4 first admitted . Staff H stated Resident #4 got up out of her chair and headed towards her closet and fell when Staff H helped the roommate. Staff H asked when she used a gait belt with the resident if Staff H needed to hold onto the gait belt and Staff H confirmed a hand needed to be on the gait belt at all times. During an interview 6/10/26 at 3:51 PM, the DON asked about the falls for Resident #4 on 5/1/26, 5/2/26, 5/6/26, and 5/26/26 and the DON stated the facility did a lot of education with the staff on the interventions for falls. The DON stated some staff believed it was better to not have the walker near the resident who tried to self-transfer, but if a resident was going to self-transfer, it was better to have the walker near the resident for something to hold on to. The DON asked where the walker needed to be located for Resident #4 and the DON stated beside the recliner. The DON asked if by the closet door was within reach when resident in the recliner and the DON stated no, the DON didn't think that would be within reach. The DON asked about gait belt use and the DON confirmed staff should keep their hand on the gait belt at all times when using. Review of the undated facility policy titled Fall Procedure Policy revealed, in part: Come up with interventions THIS NEEDS TO BE CHARTED IN RISK MANAGEMENT. Every fall needs an intervention.

Based on interview, clinical record review, Centers for Disease Control and Prevention (CDC) policy review, the facility failed to screen for pneumococcal vaccines, educate residents or responsible party about benefits and potential side effects, or offer pneumococcal vaccines for 4 of 5 residents (R#1, R#22, R#23, and R#35), reviewed for immunizations. The facility reported a census of 50 residents. Findings include: 1. Resident #1 example: The Minimum Data Set (MDS), dated [DATE], revealed the most recent facility admission or entry date of 5/23/22 and informed that Resident #1 had been up to date with Pneumococcal vaccination. The Electronic Health Record (EHR) immunization list revealed that Resident #1 received a Pneumococcal polysaccharide (PPSV23) vaccine on 4/19/2011, prior to facility admission. Immunization list lacked additional dose of Pneumococcal conjugate (PCV13, PCV15, or PCV20) recommended to complete the vaccination. 2. Resident #22 example: The MDS, dated [DATE], revealed that 1/03/20 had been the most recent admission or entry date into facility, and informed that Resident #22 had not been up to date with Pneumococcal vaccination without selected reason to indicate why vaccine not received. The EHR immunization list revealed that Resident #22 received a Pneumococcal conjugate (PCV 13) dose on 11/03/2015, prior to facility admission. Immunization list lacked additional dose of Pneumococcal polysaccharide (PPSV23) to complete the vaccination. 3. Resident #23 example: The MDS, dated [DATE], revealed that 5/28/24 had been the most recent admission or entry date into facility, and informed that Resident #23 had been up to date with Pneumococcal vaccination. The EHR immunization list revealed that Resident #23 received a Pneumococcal polysaccharide (PPSV23) dose on 9/21/2020, prior to facility admission. Immunization list lacked additional dose of Pneumococcal conjugate (PCV 13, PCV 15, or PCV 20) to complete the vaccination. 4. Resident #35 example: The MDS, dated [DATE], revealed the most recent admission or entry date into facility on 12/19/23 and had not been up to date with Pneumococcal vaccination without selected reason to indicate why vaccine not received. The EHR immunization list revealed that Resident #35 had not received any vaccine doses to protect against Pneumonia infection. On 10/08/24 at 10:52 AM, Assistant Director of Nursing (ADON) informed that upon admission the Immunization Registry Information System (IRIS) would be checked for all residents and documented into each resident's EHR immunization list. On 10/08/24 at 11:09 AM, Director of Nursing (DON) revealed the facility had been unaware of requirements for screening and offering Pneumococcal vaccinations to residents and stated Primary Care Provider (PCP) would order Pneumococcal vaccinations for residents when needed. On 10/10/24 at 08:30 AM, DON informed that facility had now added screening for pneumococcal vaccination to admissions to ensure completion and offered vaccine to all current residents who had been due for a Pneumococcal vaccine, The facility policy, titled Pneumococcal Vaccinations, dated 8/20/2022, revealed the purpose of policy would be for facility to provide vaccination against pneumococcal disease to prevent the spread of infection. Policy informed that facility would assess all residents upon admission for receiving Pneumococcal conjugate or Pneumococcal polysaccharide vaccine.

Based on observation, staff interviews, and policy review the facility failed to update the comprehensive assessment to ensure accuracy for 1 of 5 residents reviewed (Resident #16). The facility reported a census of 50 residents. Findings include: The Minimum Data Set (MDS) report, dated 9/26/24, listed diagnoses for Resident #16 included: cerebral vascular accident (stroke), non-Alzheimer's dementia with behavioral disturbances, and unspecified fall. The MDS Brief Interview for Mental Status (BIMS) score of 3 out of 15 indicated a severe cognitive impairment. The MDS assessed Resident #16 required total assistance for all transfers. The MDS did not document or identify the use of a bed, or chair alarm. The Care Plan, revised 10/04/24, included a Focus area to address [name redacted] has had an actual fall d/t Poor Balance, Unsteady gait self transferring. Interventions included: a. 1/11/2024: Fa;; - witnessed by staff slipping from recliner while attempting to reach forward intervention: Grabber given to resident to assist reaching for things safely. Date Initiated: 1/11/2024. Revision on: 7/15/2024 b. 4/16/2024: Fall out of bed no injury: Intervention: low bed. Date Initiated: 4/21/2024. c. 7/14/2024: Fall self ambulating Intervention: Sign on walker to remind her to call for assistance. Date Initiated: 7/15/2024 d. 8/7/2024: Fall with major injury fx (fracture) R hip intervention: floor mat. Date Initiated: 8/10/2024 e. 8/8/2024: Fall self ambulating Intervention: Floor mat every time in bed. Dated Initiated: 8/7/2024 Revision on 8/8.2024 f. Continue interventions on at-risk plan. Date Initiated: 2/18/2023 g. Document/report PRN (as needed) x 72 h (hour) to MD (medical doctor) for s/sx (signs and symptoms); Pain, bruises. Change in mental status, New onset: confusion, sleepiness, inability to maintain posture, agitation. Date Initiated: 2/18/2024. Revision on 5/21/23 During an observation on 10/08/24 at 11:06 AM, alarms were visible on Resident #16 bed and recliner. During an interview on 10/08/24 01:06 PM Staff B, Certified Nursing Assistant (CNA) explained the alarm in Resident #16's chair was placed after a fall about 2 months ago. The alarms were on her recliner and bed because she tries to take herself to the bathroom unassisted. It is not in the wheelchair as she doesn't try to get out of that. The alarms have not gone off recently. Therapy or the nurses tell CNA's when these interventions are put in place. There are Hall Sheets that tell about each resident and their care needs, including their transfer and ambulation needs. During an interview on 10/08/24 at 1:14 PM Staff D, CNA explained the alarms started after the resident fell about 2 months ago because she was trying to self-transfer and get herself to the restroom. She fell a couple of times, especially overnight. Staff were notified of new interventions by mass text or during report from the prior shift. During an interview on 10/09/24 at 7:51 AM the Director of Nursing (DON) explained prior fall interventions are looked to see if an alarm is needed. Sometimes it is family prompted and there is a lot of education given, especially that it may not prevent a fall. If they have tried several interventions it may be the last thing they have left to try. They don't really like to use them if they can avoid it. Family was prompting the alarms for Resident #16 because she liked to self-transfer. They held off a lot but after the fall with major injury they put it in place. They could probably discontinue it at this time as she is no longer trying to get up by herself. There is no permission form, just a conversation with the family and the change is noted in the nurse communication form. Then it gets transferred to the Hall Sheets and updated on the Care Plan and next MDS. They also put it out on the scheduling mass text application. The MDS coordinator is in charge of the Care Plan and the MDS updates. During an interview on 10/09/24 at 10:25 AM the MDS Coordinator explained every week she checks her calendar and opens up the Care Plan so changes can be made. She has been completing the MDS a month ahead of time for quarterly and annual reviews. If someone is on a bed or chair alarm it should be added in the MDS. She explained she does miss this at times. She noted she remembered adding the interventions for Resident #16 to the Care Plan so was unsure why they weren't there. She explained she must have just clicked through and missed it on the MDS. The facility policy titled Comprehensive Assessment and Reassessment, dated 5/10/17 instructed the assessment of the care or treatment required to meet the needs of the resident to be ongoing throughout the resident's facility stay, with the assessment process individualized to meet the needs of the resident population.

Based on observation, staff interviews, and policy review the facility failed to prepare a medication as directed for for 1 out of 1 residents reviewed (Resident #31). The facility reported a census of 50 residents. Findings include: The Minimum Data Set (MDS) report, dated 8/07/24, for Resident #31 listed diangoses included: unspecified dementia due to known physiologic condition, shortness of breath, and allergic rhinitis (runny nose). The Brief Interview for Mental Status (BIMS) score of 7 out of 15 indicated a severe cognitive impairment. A review of Physician's Order revealed an order, dated 11/06/24, May crush medications if not contraindicated/use liquid equivalent as PRN (as needed) if difficulty swallowing. A Physican Order, dated 7/03/24, instructed staff to administer Mucinex Tab 600 milligrams (mg) ER 2 tabs every 12 hours, Do Not Crush. The Medication Administration Record (MAR) for 10/24 listed Mucinex 600mg ER 2 tablets (1200mg) by mouth every 12 hours, Do Not Crush. In an observation on 10/09/24 at 8:26 AM Staff E, Licensed Practical Nurse (LPN) dispensed 2 tabs of Mucinex ER 600mg and placed it with all other tab medications in a plastic sleeve. She then proceeded to crush all medications in the bag and administered them to Resident #31 mixed in pudding. In an interview on 10/09/24 at 11:13 AM Staff E confirmed all of the resident's tab medications were crushed. She explained it was in the computer system that they can crush them and deliver them in their vehicle of choice. Usually, if they do not want staff to crush them, pharmacy sends a substitute medication. Staff have asked about getting Resident #31 changed to liquid medications and the pharmacy couldn't change them all, which is why they are still crushing them all. She explained she thought the order was changed to allow everything to be crushed. In an interview on 10/09/24 at 11:17 AM the Director of Nursing explained she expected if there was an order not to crush certain medications they work with the pharmacy to get either a liquid form or a capsule they can open. The facility policy titled Medication Administration, dated 4/01/23 instructed staff to do the following: Medication labels will be checked against current MAR for individual resident's medication pass. Remove medication with labels facing the nurse/OMT. Check labels to MAR. Verify resident, drug, strength, dose, route and hours of administration with MAR. Dispense medication into medication cup. Return medications to cart. Close and lock medication cart. Identify the resident. Administer medication. Assure resident has taken the medication. Sign medication on the MAR.

Based on observations, interviews, and facility policy review the facility failed to cover food and drinks during meal tray distribution for six out of six room trays observed during one out of one meals. Findings include: On 8/8/23 from 11:55 AM to 12:45 PM observed the following: a. Staff C, Cook, while serving lunch pick up two menu tickets that fell to the floor during meal service. Without completing hand hygiene, Staff C resumed serving food from steam table to residents in the main dining room. b. The Dietary Supervisor prepared room trays; without covering the drinks and side dishes, she placed them in the cart. The Dietary Supervisor transported the covered cart from the kitchen to a central hallway location, near the nurses' station, and notified the Certified Nursing Assistants (CNA)s the trays were ready. On 8/8/23 at 12:46 PM, watched the nursing staff remove meal trays from the centrally located cart and distributed the trays to six resident rooms throughout the facility. The drinks and side dishes remained uncovered during transport through the hallways as residents and staff moved through the hallways. On 8/8/23 at 2:05 PM, Staff E, CNA, stated that when the kitchen makes the announcement, the available staff take each tray from the covered cart located centrally between hallways and then deliver to the corresponding resident's room. Staff E denied the requirement of further preparation of trays. Staff E reported that the cart remained at the central location throughout the meal tray distribution. On 8/8/23 at 2:33 PM, Staff C reported that she expected all food and drinks covered during room tray delivery. She added that she is expected to complete hand hygiene after she touched something of the floor. On 8/9/23 at 1:37 PM, Dietary Supervisor confirmed that she expected all food and drinks to be covered during room tray delivery to prevent contamination. She reported hand hygiene must be performed by all staff after picking items up from the floor. The Meal Service Schedule policy revised 2023, reflected that the dietary department had the responsibility for serving the meal onto a tray and covering all food items.

Based on clinical record review, policy review, and staff interview the facility failed to maintain accurate advance directive records based on resident preference for 1 of 24 residents reviewed (#12). The facility reported a census of 52. Findings include: Resident #12's Minimum Data Set assessment (MDS) dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. The MDS included diagnoses of coronary artery disease, non-Alzheimer's dementia, and Parkinson's disease. The Iowa Physician's Orders for Scope of Treatment (IPOST) signed [DATE] by Resident #12 reflected that if she did not have a pulse and/or is not breathing she wanted cardiopulmonary resuscitation (CPR). Resident #12's Code Status reviewed on [DATE] at 9:48 AM, displayed do not resuscitate (DNR). Resident #12's [DATE] Medication Administration Record (MAR) listed her advanced directive as DNR. The Advanced Directives Policy and Procedure dated [DATE], instructed the facility to implement the terms of the Advanced Directives in accordance with the appropriate direction of the resident, Power of Attorney, or resident's physician. On [DATE] at 1:17 PM Staff D, Certified Nurse Aide (CNA), explained that the staff looked both in the file and the electronic health record in an emergency, based on the staff's location. On [DATE] at 1:25 PM the Director of Nursing (DON) confirmed that the staff looked in both the computer and paper chart for advance directive information in an emergency. The facility sends the residents with a copy of the document in the paper chart when they leave the facility. At 1:34 PM the DON verified the inaccuracy of the code status in the computer.

Based on clinical record review, observations, facility policy review, and staff interviews the facility failed to administer levothyroxine (medication used to treat an underactive thyroid) per physicians' orders for 1 of 1 residents in the sample (Resident #302); and within the scheduled timeframe for 3 of 8 residents in the sample (Residents #6, #9, and #302). Findings include: 1. Resident #302's Minimum Data Set assessment (MDS) dated [DATE], identified a Brief Interview for Mental Status (BIMS) score as 15, indicating intact cognition. The MDS included diagnoses of hypothyroidism (underactive thyroid), arthritis (swelling and tenderness of one or more joints), and rhabdomyolysis (muscle breakdown). The Physician's Visit Note dated 7/28/23, listed an order for levothyroxine 25 mcg (micrograms) 1 tablet by mouth every morning before breakfast. The Mayo Clinic website related to Drugs and Supplements: Levothyroxine (Oral Route) updated 7/1/23 described levothyroxine as a medication used to treat hypothyroidism. The section related to proper use directed to take the medication in the morning on an empty stomach, at least 30 to 60 minutes before eating breakfast. On 8/9/23 at 9:46 AM, Resident #302 reported that she ate breakfast at approximately 8:30 AM that day. During an interview on 8/9/23 at 10:11 AM, Staff A, Certified Medication Aide (CMA), reported that she had not given Resident #302, her medications yet. On 8/9/23 at 2:10 PM, confirmed that Resident #302 received her levothyroxine after she ate breakfast. Staff A denied knowing the reason levothyroxine is prescribed, and did not know the medication needed to be administered prior to a resident eating. On 8/10/23 at 8:41 AM, Staff F, Licensed Practical Nurse (LPN), explained that she would administer levothyroxine in the morning, prior to a resident eating breakfast. On 8/10/23 at 9:12 AM, the Director of Nursing (DON) reported that she expected the nursing staff to administer levothyroxine in the morning, prior to breakfast unless ordered otherwise. The DON stated Resident #302 should have received levothyroxine before she ate her breakfast at 8:30 AM as ordered. Resident #302 Administration History Report reviewed on 8/10/23 at 9:38 AM reflected that she received the following scheduled 7 AM - 9 AM medications on 8/9/23: a. Centrum Silver tablet Adult 50 1 tab by mouth once daily at 9:43 AM b. Furosemide 40 mg (milligrams)1 tablet by mouth once daily at 11:00 AM c. Levothyroxine 25 mcg 1 tablet by mouth daily at 11:00 AM d. Losartan potassium 25 mg 1 tablet by mouth twice daily at 11:00 AM e. Metoprolol succinate ER (extended release) 25 mg 1 tablet by mouth daily at 9:43 AM f. Vitamin D3-1000 IU (international units)/25 mcg 1 tablet by mouth daily at 11:00 AM The clinical record lacked documentation of physician notification regarding the late administration of these medications. 2. Resident #6's MDS dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 9, indicating moderately impaired cognition. The MDS included diagnoses of cerebral palsy (a group of disorders that affect movement, muscle tone, balance, and posture), hypothyroidism, and depression. Resident #6's Administration History Report reviewed on 9:41 AM reflected that she received the following 7 AM - 9 AM medications on 8/9/23 at10:53 AM - 10:54 AM: a. Culturelle 1 capsule by mouth daily b. Levothyroxine 50 mcg 1 tablet by mouth c. Polyethylene glycol powder 17 gram in 8 ounces liquid d. Senna plus tab 8.6-50mg 1 tablet by mouth daily e. Sertraline 100 mg tab, with a 25 mg tablet to equal 125 mg by mouth daily f. Simvastatin 40 mg 1 tablet by mouth daily g. Vitamin C 250 mg 1 tablet by mouth daily Resident #6's clinical record lacked documentation of physician notification regarding the late administration of these medications. 4. Resident #9's MDS dated [DATE] identified a BIMS score of 9, indicating moderately impaired cognition. The MDS included diagnoses of a stroke, high blood pressure, and urinary retention (difficulty urinating). Resident #9's Administration History Report reviewed on 8/10/23 at 9:41 AM reflected that he received the following 7 AM - 9 AM scheduled medications at 10:25 AM: a. Cephalexin 250 mg 1 tablet by mouth twice daily b. Lisinopril 10 mg 1 tablet by mouth daily c. Loratadine 10 mg 1 tablet by mouth daily d. Senna plus tab 8.6-50mg 1 tablet by mouth daily e. Triamcinolone aerosol 55 mcg 2 sprays in each nostril The clinical record lacked documentation of physician notification regarding the late administration of these medications. On 8/9/23 at 2:10 PM, Staff A explained that she usually did not pass the medications during the first shift. She added that she did not what time she needed to have the morning medications completed, but believed at 9:30 AM. Staff A reported that she completed passing medications on the morning of 8/9/23 after 10:00 AM. The undated Medication Administration Times form provided by the facility listed the AM (morning) medication times as 6:00 AM to 10:00 AM. The form indicated that the times included the hour before and after listed in the electronic record. On 8/10/23 at 8:41 AM, Staff F explained that the morning medication pass needs completed by 10:00 AM. On 8/10/23 at 9:12 AM, the DON reported that she expected the staff to do the morning medications between 7:00 AM to 9:00 AM, with an hour before and after this timeframe being acceptable. The DON added that if a resident received medication after 10:00 AM it is late, and the physician should be notified. The Medication Administration policy revised 4/1/23 instructed that the staff could administer medications one hour prior (before) and one hour after the scheduled administration times. If the administration occurs outside of these time frames, physician notification is required.

Based on clinical record review, observations, facility policy, and staff interviews the facility failed to ensure indwelling catheters bags and tubing were off the floor for 3 of 4 residents in the sample (Resident #4, Resident #46, and Resident #203). Findings include: 1. Resident #203's Minimum Data Set assessment (MDS) dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 10, indicating moderately impaired cognition. The MDS included diagnoses of Parkinson's disease (a chronic and progressive movement disorder that starts with a tremor in one hand, stiffness, or slowing of movement), benign prostatic hyperplasia (enlarged prostate), and obstructive uropathy (difficulty urinating due to a blockage). The Order Summary Report included an order dated 8/4/23 for a urinary catheter due to benign prostatic hyperplasia with lower urinary tract symptoms. The Care Plan Problem revised 8/6/23 indicated that Resident #203 had a urinary catheter due to urinary retention. The Goal dated 8/6/23 indicated that Resident #203 would not have signs or symptoms of a urinary infection. On 8/7/23 at 10:53 AM, observed Resident #203's urinary catheter bag resting on the floor near his recliner. On 8/7/23 at 2:26 PM witnessed Resident #203's urinary catheter bag hooked on the side of his garbage can. On 8/8//23 at 1:43 PM, saw Resident #203's urinary catheter bag resting on the floor and hooked to the side of his garbage can. 34821 2. Resident #4's MDS dated [DATE] identified a BIMS score of 11, indicating moderately impaired cognition. The MDS indicated that she required extensive assistance from two persons for toilet use and dressing. Resident #4 had an indwelling catheter. The MDS included diagnoses of neurogenic bladder (lack bladder control due to nerve problem), and dementia. The facility provided Matrix on 8/7/23 at 12:23 PM identified that Resident #4 had a urinary tract infection (UTI) and used an antibiotic. The Care Plan Focus revised 6/17/23, indicated that Resident #4 used antibiotics due to chronic UTIs. The Care Plan Goal listed that Resident #4 would have no signs or symptoms (s/s) of Urinary infection through the review date of 11/3/23. The Care Plan Focus dated 12/24/22 listed that Resident #4 had an indwelling urinary catheter. The Intervention dated 12/24/22 directed to position Resident #4's urinary catheter bag and tubing below the level of the bladder and away from entrance room door. The Clinical Laboratories Urinalysis and Culture report dated 8/4/23, listed the following Physician's orders for: a. Bactrim double strength (DS) (antibiotic) one, two times a day for seven days b. Levaquin (antibiotic) 500 milligrams (mg) daily for seven days treatment of UTI. On 8/8/23 at 8:46 AM observed Resident #4 sitting at the dining room table while two inches of her urinary catheter tubing sat on the floor under her wheelchair (w/c). On 8/8/23 at 9:05 AM, watched the Restorative Aide pulled Resident #4 back from the table and ask her to wheel herself out of the dining room. On 8/8/23 at 9:20 AM, witnessed the Restorative Aide pushed Resident #4 approximately forty feet down the west hall to her room as her urinary catheter tubing dragged across the floor. The Restorative Aide left Resident #4 in her room in the w/c as the catheter tubing sat on the floor underneath her. On 8/8/23 at 1:46 PM, observed Resident #4's urinary catheter drainage bag sit in a wire basket on the floor in her room with about four inches of the catheter tubing sitting directly on the floor. 3. Resident #46's MDS dated [DATE], identified a BIMS score of 15, indicating intact cognition. The MDS indicated that she required extensive assistance from two persons for dressing and requires total assistance from two persons for toilet use. Resident #46 used an indwelling catheter. The MDS included diagnoses of neurogenic bladder anemia, and mild cognitive impairment. The Care Plan Goal dated 4/30/23, listed to Resident #46 would have no s/s of urinary infection through the review date. The Care Plan Intervention dated 4/30/23 directed to position the catheter bag and tubing below the level of the bladder and away from entrance room door. On 8/8/23 at 8:49 AM, observed Resident #46 sitting in her w/c in the dining room with her urinary catheter drainage bag covered in the front and back with a dignity bag. Approximately four inches of the urinary catheter's drainage bag's bottom sat directly on the floor. On 8/9/23 at 1:57 PM, Staff D, Certified Nurse's Aide (CNA), reported they keep Resident #46's urinary catheter drainage bag in the wire basket while she sat in the recliner to keep it off the floor. On 8/9/23 at 2:01 PM, Staff D, stated the staff are expected to keep the catheter tubing off the floor. On 8/9/23 at 2:06 PM, Staff B, Licensed Practical Nurse (LPN), reported the catheter and tubing are always kept off the floor . On 8/10/23 at 9:11 AM, the Director of Nursing (DON) said she expected catheter tubing and drainage bags kept off the floor at all times. She expected the catheter drainage bags placed under the wheel chairs off the floor or in the wire basket on the floor. She confirmed an infection control problem if a catheter drainage bag hung on the garbage can. The Catheter Care policy dated 10/1/18, instructed that the tubing and catheter bag should not touch the floor. The Urinary Catheter Handling and Storage policy dated 10/1/18, directed to handle and store urinary catheter supplies to minimize the risk of contamination and spread of infection.

Based on observations, staff interviews and facility policy review the facility failed to provide dignity covers for two out of four residents reviewed with urinary catheters (Resident #4 and #46). Findings include: 1. Resident #4's Minimum Data Set Assessment (MDS) dated 7.21.23, identified a Brief Interview for Mental Status (BIMS) of 1, indicating moderately impaired cognition. The MDS indicated that she required extensive assistance from two persons for toilet use and dressing. The MDS included diagnoses of neurogenic bladder (bladder malfunction caused by an abnormality of the brain) and dementia. The Care Plan Goal dated 8/1/23, identified Resident #4's dignity and autonomy will be maintained at the highest level throughout the review date. The Care Plan Intervention dated 12/24/22, directed to position Resident #4's urinary catheter bag and tubing below the level of the bladder and away from entrance room door. On 8/7/23 at 10:49 AM, observed Resident #4's urinary catheter drainage bag hang under her wheelchair without a dignity cover. On 8/7/23 at 12:47 PM, observed Resident #4 sit at the dining room table while the urinary catheter drainage bag hanged under her wheelchair without a dignity cover. On 8/7/23 at 2:13 PM, witnessed Resident #4 sitting in her recliner chair in her room with the door open and her urinary catheter drainage bag sat in a basket without a dignity cover. On 8/8/23 at 8:47 AM, observed Resident #4's urinary catheter drainage bag hang under her wheelchair without a dignity cover. On 8/8/23 at 1:40 PM, watched as Resident #4 sat in her room, with her urinary catheter drainage bag without a cover. On 8/9/23 at 1:58 PM, Staff E, Certified Nurse Aide (CNA), revealed the catheter drainage bag came with the dignity cover attached. Staff E stated the cover for the dignity catheter drainage bag got dirty or tore off. The cover is off until a new drainage bag is placed. 2. Resident #46's MDS dated [DATE], identified a BIMS score of 15, indicating intact cognition. The MDS indicated that she required extensive assist from two persons for dressing and required total dependence from two persons for toilet use. The MDS included diagnoses of neurogenic bladder, anemia (low blood iron), and mild cognitive impairment. The Care Plan Intervention dated 4/30/23, directed to position the catheter bag and tubing below the level of the bladder and away from entrance room door. On 8/7/23 at 10:31 AM, observed Resident #46's urinary catheter bag hanged without a dignity cover under her wheelchair with the room door open. On 8/9/23 at 2:05 PM, Staff B, Licensed Practical Nurse (LPN), reported that the urinary catheter drainage bags are changed every week and have the dignity covers attached to the drainage bags. She confirmed when the covers are removed, they failed to replace the covers. The catheter drainage bags and tubing are kept off the floor. She denied knowing that Resident #4 used two antibiotics at a time. Resident #46's family is very involved with her and will request the medications. She expected the doctor provided them education at the time but she did not know for sure. On 8/10/23 at 9:11 AM, the Director of Nursing (DON) reported that she always expected the staff to cover the urinary catheter bags with a dignity bag. The Resident [NAME] of Rights reviewed 2022, instructed that the resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in the section. a. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes or enhancement of his/her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the residents.

Based on clinical record review, staff interviews, and facility policy review, the facility failed to address insulin and anti-depressant medications on the residents' Care Plans for 3 of 5 residents reviewed for unnecessary medications. (Resident #3, #8, and #11). The facility reported a resident census of 44. Findings Include: 1. The Quarterly Minimum Data Set (MDS) dated [DATE] documented Resident#8 took insulin and an anti-depressant medications. The Resident scored a 9 out of 15 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. The MDS identified resident with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan failed to address the resident's use of insulin or anti-depressant medications. During an interview on 6/16/22 at 10:40 a.m., the Director of Nursing (DON) stated, expected a goal for the insulin, and administered per Doctor's Order on the resident's Care Plan. For the anit-depressant the resident's mood would be assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Then the anti-depressant would be reviewed by the Med-A -Tel Services. 2. The Annual Minimum Data Set (MDS) assessment dated [DATE] for Resident #3 revealed the resident unable to complete the Brief Interview for Mental Status (BIMS) exam. Per this assessment, Resident #3 had received antidepressant medication for 7 of the last seven days. The Care Plan for Resident #3 dated 10/1/20 revised 12/20/21 documented, Resident #3 with impaired cognitive function/dementia or impaired thought processes. The Care Plan lacked documentation of use of antidepressant medication. Review of electronic Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. The Quarterly MDS assessment dated [DATE] for Resident #11 revealed the resident scored 9 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated moderately impaired cognition. The Care Plan for Resident #11 dated 3/23/21 and revised 12/31/21 documented, Resident #11 uses [CONDITION(S)] medications [MEDICATION(S)] (antipsychotic medication) related to Behavior management. The Care Plan did not address the use of an antidepressant medication. Review of electronic Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR June 2022 revealed Resident #11 had received the medication in the month. The Facility Policy titled Comprehensive Care Plan dated 8/30/21 documented, This facility shall provide an individualized, interdisciplinary Plan of Care for all residents that shall be appropriate to the resident's needs, strengths, results of diagnostic testing, limitations and goals. The Facility Policy also documented, Results of the assessment shall be used to develop, review and revise the resident's Comprehensive Plan of Care.

Based on observations, interviews, and record review the facility failed to provide complete catheter care, failed to keep the catheter bag off the floor, and failed to complete hand hygiene after cares for 1 out of 1 residents reviewed with a Foley catheter (Resident # 30). The facility reported a census of 36 residents. Findings included: The Minimum Data Set (MDS) assessment dated [DATE], listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS read the Brief Interview for Mental States (BIMS) as 00 indicating a severe cognitive impairments. The MDS reflected Resident # 30 required extensive assist of 2 staff for toileting and personal hygiene. The Care Plan for Resident #30 dated 3/19/20, identified a goal: The resident will be/remain free from catheter-related trauma. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 4/27/21 at 9:32 AM, Staff A, Certified Nurses Aid (CNA) assisted Resident #30 to stand from the wheel chair, dropping the urinary catheter bag on the ground. Staff A picked up the catheter moved it over and dropped it back on the ground as she transferred Resident #30. Draining an observation on 4/28/21 at 7:52 AM, Resident #30 noted in bed as the Foley catheter bag sat directly on the floor under his bed. During an observation on 4/28/21 at 8:00 AM, Staff B, CNA raised Resident #30's bed to a working height, as the catheter drainage bag continued on the floor to the right of the bed. During an observation 4/28/21 at 8:02 AM, Staff B, provided cares with wet wipes washing down and up on both sides of Resident# 30's groin. Staff B failed to wash the shaft of the resident's penis, failed to pull back the foreskin, failed to wash the tip of the penis, and failed to wash the catheter tubing away from the resident's body. Staff B lifted the catheter bag off the floor, put the bag at end of bed and rolled the resident to the left and wiped away bowel movement from the rectal area. Staff B removed his gloves. Staff B continued to dress the resident, pushed the resident out into the hall walking by 2 hand hygiene stations and into another resident's room and failed to complete hand hygiene. During an interview on 4/29/21 at 7:58 AM, Staff C, CNA reported catheter care includes washing the shaft of the penis, pulling back the foreskin, washing the tip in a circular motion and down the catheter tubing away from the resident 4 inches. Staff C continued to report completing hand hygiene after front peri cares needs completed before going to clean the buttocks and rectal area of a resident. Staff C stated catheter bags are hung from the side of the bed not put on the floor. During an interview on 4/29/21 at 11:12 AM, the Director of Nursing (DON) reported she expected staff to wash the penis, pull back the foreskin, wash the tip of the penis, and wipe down the catheter tubing away from a resident's body when providing morning cares. The facility provided a policy titled Catheter Care dated, 10/1/18, directing staff to clean around the meatus, where the catheter enters the body. The policy continued to direct Nursing Staff hold the catheter and cleanse away from the body to the connection site. The policy also included directions a catheter bag should not touch the floor. The facility provided a policy titled Hand Hygiene - CDC Guidelines dated 8/1/17, directing hand hygiene after working on a contaminated body site then moving to a clean body site on the same person and after coming in contact with a bodily fluids including catheters.

Based on observations, record review and staff interviews, the facility failed to transfer 1 out of 2 residents reviewed needing assistance according to the Care Plan during 2 out of 3 transfers observed (Resident #30). The facility reported a census of 36 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE], listed diagnoses of dementia and urinary tract infection (UTI). The MDS read the Brief Interview for Mental States (BIMS) as 00 indicating a severe cognitive impairments. The MDS reflected Resident #30 required extensive assist of 2 staff for transfers and ambulation. The Care Plan for Resident #30 dated 3/19/20, directed staff the resident required 1 staff for transferring with front wheeled walker (FWW), and gait belt (GB). The Care Plan directed assist of 1 staff, FWW, and GB follow with wheel chair (w/c) as tolerated. During an observation on 4/27/21 at 9:32 AM, Staff A, Certified Nurses Aid (CNA) assisted Resident #30 to stand and transferred Resident #30 into a mini van with out the use of a gait belt. During an observation on 4/28/21 at 8:12 AM, Staff B, CNA sat Resident #30 up on the side of bed. Staff B put slippers on the resident and placed the walker in front of Resident #30. At 8:17 AM, Staff B told Resident #30 to stand up, and counted to 3. Staff B then held the residents arm and back as Resident #30 stood up. Staff pulled up the resident's pants, adjusted his shirt, directed the resident to walk forward. Resident #30 took 3 steps as the CNA moved the chair, and directed the resident sit, failing to utilize a gait belt during the transfer. During an interview on 4/29/21 at 7:54 AM, Staff C, CNA reported when transferring a resident Nursing Staff always use a gait belt. During an interview on 4/29/21 at 11:12 AM, the Director of Nursing (DON) reported she expected Nursing staff to use a gait belt with all transfers. The facility provided an undated Transferring Competency (one or two person assist) Protocol, directing at point # 11 for Nursing Staff to apply a gait belt.

Based on observation, clinical record review, staff interview, and manufacture insert directions, the facility failed to administer insulin medications in a professional manner by not ensuring insulin pens were primed prior to administrating the medication for 3 of 3 observations (Resident #20). The facility reported a census of 45 residents. Findings include: 1. The quarterly Minimum Data Set ((MDS) dated [DATE] indicated [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. Observation on 6/19/19 at 7:37 a.m., revealed Staff F, Licensed Practical Nurse (LPN) placed a needle onto the Humalog flex pen and dialed up 15 units of insulin. Staff F, placed a needle onto the [MEDICATION NAME] flex pen and dialed up 21 units, she then obtained another [MEDICATION NAME] flex pen and placed a needle on the end and dialed up 39 units of insulin. At 7:52 a.m., the [MEDICATION NAME] 21 units was administered without priming the pen. At 7:53 a.m., the 39 units of [MEDICATION NAME] was administered without priming the pen and at 7:57 a.m., the Humalog insulin was given to the resident and staff failed to prime the insulin pen prior to giving the medication. Instructions for use for Humalog Kwik Pen directs staff to prime before each injection. Priming the pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly. If you do not prime before each injection, you may get to much or too little insulin. To prime the pen turn the dose knob to 2 units and hold the pen with the needle pointing up, tap the cartridge holder gently to collect air bubbles at the top. Continue holding the pen with the needle pointing up and push the dose knob in until it stops and zero is seen in the dose window. In an interview on 6/19/19 at 3:30 p.m., the Director of Nursing (DON) stated she expects staff to prime the insulin pens prior to each use.

Based on Record review, observations and staff interviews the facility failed to develop and implement a comprehensive person centered care plan for 1 of 2 residents observed (Resident #40). The facility reported a census of 45 residents. Findings Include: 1. Resident #40's Minimum Data Set (MDS) significant change assessment completed 5/17/19 documented the following Diagnoses: [REDACTED]. It also identified the resident to be cognitively intact with a BIMS (brief interview for mental status) score of 15 out of 15, required limited staff assistance with most activities of daily living, had an indwelling catheter. A review of the physician orders [REDACTED]. a. On 3/27/19 maintain oxygen at 3 liters per minute per nasal cannula. b. On 4/21/19 change Foley catheter 18 french every 30 days. c. On 6/10/19 irrigate catheter three times daily. A review of the care plan revealed the orders for the indwelling catheter and the continuous oxygen had not been added until 6/19/19. During an interview on 6/19/19 at 10:17 a.m., Staff I, Licensed Practical Nurse (LPN), reported the MDS coordinator had been responsible for updating the care plans which should be updated with any changes, however, the MDS coordinator had been on medical leave for the past 2 weeks and the DON has been working on the MDS tasks. In an interview on 6/19/19 at 10:27 a.m., Staff J, Registered Nurse (RN), reported all nurses, therapy staff all work together to update the care plans, the MDS coordinator is responsible for updating, however, she has been on medical leave of absence for the past couple of weeks and the DON has been taking over her responsibilities. On 6/19/19 at 2:47 p.m., the Director of Nursing (DON) reported currently she is responsible for updating the care plans as the MDS coordinator is on medical leave. Care plans should be updated every 3 months, whenever an MDS is completed, or whenever there is a significant change.

Based on observation, record review and staff interview, the facility failed to utilize proper infection control techniques when providing incontinence care on 2 of 4 residents reviewed. (Residents #14 and #44). The facility reported a census of 45 residents. Findings include: 1. Resident #14's Minimum Data Set (MDS) assessment completed 3/19/19 documented the following Diagnoses: [REDACTED]. It also identified the resident as cognitively impaired with a Brief Interview for Mental Status (BIMS) of 11 out of 15, completely dependent on staff for most activities of daily living and always incontinent of bladder and bowel. A review of the care plan with the goal target date of 9/6/19 identified the resident with the problem of self-care deficit, incontinence and directed staff to offer the bedpan if needed, check and change the brief upon rising, before or after meals, bedtime and as needed. During an observation on 6/18/19 which began at 7:00 a.m. Staff C, Certified Nurse Aide (CNA) and Staff G, CNA used the correct technique to transfer the resident from the wheelchair to the bed using the hoyer mechanical lift. Then both aides washed their hands and donned new gloves. Staff G assisted the resident to turn to his side, the resident had been incontinent of stool, Staff C removed the sling from underneath the resident and placed it in a plastic bag. Staff C did not change gloves before he touched the mechanical lift, the doorknob to the bathroom and touching a new cloth and towel, then proceeded to cleanse the rectal from coccyx toward the scrotum and placed cloths into a plastic bag. Staff C did not change gloves before he placed a new incontinent brief under the resident, then both aides removed their gloves and washed their hands. During an interview on 6/19/19 at 9:47 a.m Staff A, CNA reported when providing incontinence care after the resident has a bowel movement, the CNA should wash hands, don gloves and cleanse the rectal crease front to back with disposable wipes, remove the soaker pad, change gloves and put the new incontinent brief on. In an interview on 6/19/19 at 9:57 a.m., Staff H, CNA reported when providing incontinence care after the resident has a bowel movement, the CNA should wash hands, don gloves and cleanse the rectal crease front to back with disposable wipes, then use a wet soapy washcloth, change gloves and put a new brief and sheets under the resident. During an interview on 6/19/19 at 10:17 a.m., Staff I, Licensed practical Nurse (LPN) reported when providing incontinence care after the resident has a bowel movement, the CNA should wash hands, don gloves, cleanse the rectal crease front to back, change gloves and place the new brief on. In an interview on 6/19/19 at 10:27 a.m., Staff J, Registered Nurse (RN) reported when providing incontinence care after the resident has a bowel movement, the CNA should wash hands, don gloves, cleanse the rectal crease front to back, change gloves and place the new brief on, and would expect the aide to change gloves after cleaning and before touching another surface. During an interview on 6/19/19 at 2:47 p.m., the Director of Nursing (DON) reported when providing incontinence care after the resident has a bowel movement, the CNA should wash hands, don gloves, cleanse the rectal crease front to back, change gloves and wash hands. 2. The Minimum Date Set Assessment ((MDS) dated [DATE] stated Resident #44 had an indwelling catheter and required extensive assist of 2 for toileting and hygiene. The Resident's [DIAGNOSES REDACTED]. The Care Plan directed staff to provide extensive assistance by (2) staff for toileting and extensive assistance by (1) staff with personal hygiene. The Communication Progress Note dated 3/8/2019 at 10:39 a.m., stated Resident #44 had burning with saline flush to urinary catheter and had a history of [REDACTED]. The physician ordered UA and Culture and Sensitivity (C&S) and start treatment with [MEDICATION NAME] 500 milligrams (mg) twice a day (BID) for 7 days and advised to send the resident to the emergency room (ER) for any worsening of symptoms. The Health Status Note dated 6/4/2019 at 7:43 p.m. stated the doctor notified that Resident #44's catheter collecting what appears to be blood, had small amount of blood the prior day and had complained of burning at the penis. Vital signs were temperature - 99.9, pulse -83, respirations -22, and blood pressure -130/72. The doctor ordered urine specimen via catheter and culture and sensitivity (C&S), if indicated. The doctor also gave orders for Bactrim DS 800/160 mg 1 pill, twice a day for 7 days The facility Peri-Care Audit Form directed staff to complete hand hygiene before and after resident care, after washing their hands and before putting on gloves. During observations on 06/18/19 at 09:23 a.m., Staff C, Certified Nurse Aide (CNA) entered Resident #44's room, donned gloves without doing hand hygiene. With gloved hands, Staff C closed room door and put gait belt on Resident. Staff C then put walker in front of the Resident, holding walker by the handles with the gloved hands, and clipped the catheter bag to the walker frame. Staff C, then assisted the resident to stand, counting to 3 and ambulated the resident to the bathroom, still wearing the same gloves. CNA C pulled down the resident's pants and brief, assisted the resident to sit on the toilet and then removed their gloves. Staff C put on new gloves without doing hand hygiene and pushed walker towards resident with gloved hands. Staff C removed gloves and left room without completing hand hygiene. Staff C returned to Residents room with disposable wipes and put on new gloves without completing hand hygiene. Staff E, CNA washed their hands with soap and water and put on new gloves. With gloved hand, Staff [NAME] used radio to and called nurse to check spot on residents back. Staff C assisted the resident to stand with Staff C's gloved hands under the residents arms. Staff [NAME] cleansed the residents buttocks with disposable wipes using new wipe for each swipe with gloved hands. Staff [NAME] then removed gloves and pulled up the resident's pants and brief without doing hand hygiene. Staff C (with gloved hands) and Staff [NAME] (with ungloved hands) walked Resident to wheel chair with walker and gait belt. After assisting the resident to sit in chair Staff C threaded catheter bag under wheel chair and clipped it to chair frame. Staff [NAME] used ungloved hands to again call the Nurse on with radio to do the resident's treatment. After completing radio call Staff [NAME] washed their hands with soap and water at bathroom sink. Staff C put the resident's feet on wheel chair pedals and combed the resident's hair. Staff C then went into bathroom, removed gloves and washed hands at sink. Neither CNA C or CNA [NAME] completed hand hygiene when entering the resident's room nor before assisting the resident or touching the resident's equipment. Staff failed to follow infection control practices to prevent the spread of infections.

Based on record review, observations and staff interview the facility failed to assure residents' medication regimen was free from unnecessary medications for 1 of 6 residents reviewed (Resident #41). The facility reported a census of 45. Findings include: 1. The Minimum Data Set ((MDS) dated [DATE] stated Resident #41 had a Brief Interview of Mental Status (BIMS) of 99, indicating highly impaired cognitive status. The MDS further stated the Resident with disorganized thinking and fluctuated daily. Resident's [DIAGNOSES REDACTED]. Resident 41's care plan updated on 5/29/19 directed staff to monitor, document and report adverse reactions to Anti-anxiety therapy: Drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion, disorientation, depression, dizziness, lightheadedness, impaired thinking and judgment, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. It Further identified unexpected side effects to monitor were mania, hostility, rage, aggressive or impulsive behavior, and hallucinations. The Care Plan also directed staff to notify the nurse when Resident was restless or anxious and to use the ipod and headphones when Resident was restless or anxious. Review of the Briarwood Heath Care Center Communication Form - Physician Response dated 1/4/2019, directed staff to give the resident [MEDICATION NAME] 1 milligram (mg) as needed (PRN) at bedtime (HS). Review of the Community Pharmacy Services Note to Attending Physician/Provider Medication Regimen Review (MRR) dated 1/9/19 stated CMS regulations required all [MEDICAL CONDITION] medications be limited to 14 days. If medication were not an antipsychotic, the order could be extended beyond 14 days if the provider provided clinical rationale. It further stated Resident 41 had an order for [REDACTED]. The Physician's response on the form dated 1/11/19 stated to continue PRN order for [MEDICATION NAME] 1 mg as written for a duration of 6 months. Clinical rationale for extension intermittent symptoms. Review of the Community Pharmacy Services Note to Attending Physician/Provider Medication Regimen Review (MRR) for recommendations 1/1/2019 and 1/10/2019 stated Resident 41's PRN [MEDICATION NAME] was currently 1 mg at bedtime PRN. The previous order was 0.5 mg at bedtime PRN. It further stated the medication had only been administered 1 time within an hour of 8 p.m. Most were evenings and some were morning and there was one day it was administered twice in one day. It directed staff to contact the Physician if they thought the patient needed an order to be given more frequently or just added every day (QD) PRN. it further directed, if prescriber wrote a new order to remember PRN [MEDICAL CONDITION] could only be ordered for 14 day duration unless prescriber specified a longer duration. The Community Pharmacy Services Note to Attending Physician/Prescriber Medication Resident Review (MRR) for recommendations 12/1/2018 and 12/13/2018 stated No recommendations. The Behavior Note dated 12/30/2018 at 6:36 p.m., stated Resident #41 had been restless and spitting before supper, PRN [MEDICATION NAME] had been given at 6:30 p.m. with no further behaviors noted. The Behavior Note on 12/30/2018 at 5:10 a.m. stated Resident #41 was restless during the night and pulled the edge of Resident's [MEDICAL CONDITION] bag loose. A Certified Nurse Aide (CNA) informed the nurse and the [MEDICAL CONDITION] bag was changed without incident. The Health Status Note on 12/20/2018 at 1:48 p.m. stated Resident #41 was restless as noticed by CNA. It further stated the Resident's oxygen saturation was 85% and oxygen applied at 2 liters by nasal cannula. Documentation stated oxygen saturation was 93% when rechecked. The Behavior Note on 11/14/2018 at 7:56 p.m. stated Resident #41 was agitated after getting up for supper and calmed down after drinking 120 ml of Mighty Shake (nutritional supplement) and taking routine p.m. medications. Communication note dated 1/2/2019 at 5:57 p.m. stated Resident #41 had shown increased restlessness at mealtime, with cares and at bedtime. It further stated a fax had been sent to the doctor. to increase [MEDICATION NAME] dosage or frequency. Review of Medication Administration Record [REDACTED] a. On (MONTH) 18, (YEAR) at 10:55 a.m b. On (MONTH) 30, (YEAR) at 4:26 p.m c. On (MONTH) 2, 2019 at 4:05 p.m d. On (MONTH) 3, 2019 at 4:16 p.m e. On (MONTH) 3, 2019 at 4:18 p.m Review of Resident #41's record indicated no incidents of anxiety or agitation not relieved with 0.5 mg of [MEDICATION NAME] when it was given. During observations at breakfast on 06/18/19 at 8:01 a.m., Resident #41 blew food out of her mouth and made guttural type noises when Staff [NAME] attempted to feed her. Staff [NAME] escorted Resident from the dining room to her room. During observation on 06/18/19 at 10:40 a.m., Resident #41 calmly sat in her recliner, covered with blanket, neck pillow behind neck, and head phones on. Review of MAR, no PRN [MEDICATION NAME] given. During an interview on 06/19/19 at 3:34 p.m., the Director of Nursing (DON) stated PRN [MEDICATION NAME] should be increased if current dose or interventions were not effective.

Based on record review and staff interview, the facility failed to document the bed hold policy had been reviewed with residents/families for 3 out of 6 residents reviewed who were transferred to a hospital (Residents #4, #34, #99). The facility reported a census of 45 residents. Findings include: 1. Resident #4's Minimum Data Set (MDS) quarterly assessment completed 5/30/19 documented the following Diagnoses: [REDACTED]. It also identified the resident to be cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15 and required extensive staff assistance with most activities of daily living. A review of the nurse's notes had documentation of the following: a. On 5/11/19 at 8:30 a.m. the resident had been sent to the hospital via ambulance had been sent to the hospital via ambulance. b. On 5/13/19 at 6:43 p.m. the resident returned from the hospital. A review of the social worker progress notes revealed no documentation entered that she reviewed the bed hold policy with the resident/family within 24 hours of the transfer. A review of the bed hold authorization form revealed the resident's power of attorney signed the form on 5/13/19. 2. Resident #34's MDS quarterly assessment completed 4/22/19 documented the following Diagnoses: [REDACTED]. It also identified the resident to be cognitively intact with a BIMS score of 15 out of 15 and required extensive staff assistance with transfers, toileting and showers. A review of the nurse's notes had documentation of the following: a. On 4/4/19 at 2:30 p.m. the resident had been sent out to the hospital via ambulance. b. On 4/9/19 at 3:21 a.m. the resident resting in bed receiving skilled services for [MEDICAL CONDITION]. A review of the social worker progress notes revealed no documentation that she reviewed the bed hold policy with the resident/family within 24 hours of the transfer. A review of the bed hold authorization form revealed the resident signed the form on 5/20/19. 3. Resident #99's MDS admission assessment completed 6/4/19 documented of the following Diagnoses: [REDACTED]. It also identified the resident to be cognitively intact with a BIMS score of 15 out of 15 and required extensive staff assistance with most activities of daily living. A review of the nurse's notes had documentation of the following: a. On 6/8/19 at 10:00 p.m. the resident had been sent out to the hospital via ambulance. b. On 6/12/19 at 7:41 p.m. resident returned from the hospital. A review of the social worker progress notes revealed no documentation that she reviewed the bed hold policy with the resident/family within 24 hours of the transfer. A review of the bed hold authorization form revealed the resident signed the form on 6/12/19. A handwritten note at the bottom of the form dated 6/11/19 (without a signature of who wrote the note) revealed the resident's daughter did not wish to hold the bed. During an interview on 6/19/19 at 10:05 a.m., the social worker reported she usually reviewed the bed hold form with the resident/family within 24 hours of the resident's transfer to the hospital. If the resident left during the weekend, she would review it on Monday. She reported she had one business day to complete the process and that the documentation to show it had been completed would be on the form which is kept in the resident's business file. In an interview on 6/19/19 at 10:17 a.m., Staff I, Licensed Practical Nurse (LPN), reported she could not recall the process for reviewing the bed hold policy prior to a resident being transferred to the hospital. During an interview on 6/19/19 at 10:27 a.m., Staff J, Registered Nurse (RN), reported when a resident is transferred to the hospital, the social worker reviews the bed hold policy with the resident or family within 24 hours. In an interview on 6/19/19 at 2:47 p.m., the Director of Nursing (DON) reported when a resident is transferred to the hospital, the social worker is responsible for reviewing the bed hold policy with the resident/family within 24 hours. If the resident is transferred during the weekend, it waits until she gets back on Monday.

Based on observation, clinical record review, facility policy review and staff interview, the facility failed to follow proper infection control procedures when cleaning a glucometer (blood sugar monitoring machine) for one of one blood glucose tests observed (Resident #44). The facility census was 50 residents. Findings include: 1. The Face sheet for Resident #44 documented [DIAGNOSES REDACTED]. A Physician order [REDACTED]. During observation on 4/1/18 at 11:25 a.m., Staff A, Registered Nurse, RN completed a glucose monitoring check on the resident. When finished with the testing Staff A took off one glove and rolled it up with the used alcohol pad in it and threw into the garbage. Staff A handed the blood strip bottle and glucometer to a Student Nurse training and the extra alcohol pad. Staff A instructed the Student Nurse to wipe off the bottle and glucometer with the alcohol wipe. With her gloved hand, Staff A took the rest of the supplies and disposed of them properly. The Nursing student came and reported she had cleaned the bottle and the glucometer with the alcohol pad and placed them on a clean wax paper barrier on top of the medication cart. During interview on 4/11/18 at 11:32 a.m., Staff A indicated she cleansed the glucometer using a alcohol wipe after each usage since the glucometer was a universal one used by more than one resident. Staff A stated that was how she always cleansed glucometers, with an alcohol wipe. Staff A opened a drawer at the bottom of the medication cart and pointed out a canister of Hydrogen-Peroxide wipes. Staff A stated she could use them to clean off the glucometer if the surveyor felt it was necessary and not sure of the facility policy for the cleaning of the glucometer. During interview on 4/11/18 at 11:45 a.m., the Director of Nursing to cleanse the glucometer the nurse was to utilize the Hydrogen Peroxide wipes and wrap the glucometer in the wipe for 3 minutes and then leave it to air dry. During interview on 4/11/18 at 12:10 p.m., Staff B, RN reported she cleanses the glucometer with a Hydrogen Peroxide wipe and wraps the glucometer in it for 3 minutes and then takes the wipe off and leaves the glucometer to air dry in a clean area. During interview on 4/11/18 12:17 p.m., Staff C, Licensed Practical Nurse (LPN) reported she cleansed a glucometer after utilized with a Hydrogen Peroxide wipe. Staff C explained the process of cleansing the glucometer. She would take the Hydrogen-Peroxide wipe and wrap the glucometer in the wipe and leave it for 5 minutes, then remove it from the wipe and place it in a clean spot and leave the glucometer to air dry. The undated Procedure for Glucometer Cleaning instructed that the glucometer must be cleaned after use of all residents. Use peroxide wipes and wrap the glucometer in the wipe and leave it on your med cart for 3 minutes. Let air dry after removing the wipe. It is clean for the next resident. Repeat after using.

Based on record review, observation and interview the facility failed to provide incontinent care for 3 of 5 residents reviewed (Resident #6, #7, #9). The facility identified a census of 59 residents. Findings include: 1. According to the Minimum Data Set((MDS) dated [DATE], Resident #6 had documented [DIAGNOSES REDACTED]. The MDS documented the resident required extensive assistance of two or more staff for transfers, toilet use and personal hygiene. Observation 2/7/17 at 8:56 a.m. revealed Staff C, CNA and Staff D, CNA completed perineal care for the resident. Staff C then cleansed the right and left groin area a second time using the same side of the washcloth they used to cleanse the groin area the first time. Observation revealed Staff D, CNA repositioned Resident #6 to his/her side, cleansed both buttocks, hip and then the rectal area with a up and down stroke and a back and forth stroke over the surfaces. 2. According to the Minimum Data Set((MDS) dated [DATE], Resident #7 had documented [DIAGNOSES REDACTED]. The MDS documented the resident required extensive assistance of 2 or more staff for transfers and toilet use. Observation 2/7/17, at 7:45 a.m. revealed Staff A, CNA, and Staff B, CNA provided perineal care to Resident #7. Observation revealed Staff B, CNA, cleansed the right and left groin areas with the same side of the cloth. Staff cleansed the entire genital areas in a dabbing motion, then an up and down stroke with the same surface of the cloth. Observation revealed the staff cleansed the left side of the groin with an back to front direction and with the same side of the cloth used on the genital areas. Staff A, CNA used Tena wipes, cleansed the rectal area twice with the same side of the wipe. 3. According to the Minimum Data Set((MDS) dated [DATE], Resident #9 had documented [DIAGNOSES REDACTED].([MEDICAL CONDITION]). The MDS documented the resident required extensive assistance of two staff for transfers and for toilet use. Observation 2/7/17 at 10:30 a.m. revealed Staff A, CNA, cleansed the resident's right and left buttock with an up and down direction with the same side of the washcloth. Observation revealed Staff A, CNA, completed the front genital area and then cleansed the right groin area with a back to front direction. An interview with the Director of Nursing on 2/8/17 at 9:55 a.m. revealed expectations for the staff to complete perineal care with a front to back direction and to use a clean surface of the wipe or cloth to cleanse the surface areas. The Director of Nursing revealed the facility used audits for policy/procedures. The facility provided an undated audit that instructed the staff to wash the soiled areas front to back.

Based on clinical record review and staff interview, the facility failed to ensure one of nine residents reviewed had a gradual dose reduction (GDR) attempted for a antidepressant medication. (Resident # 14). The facility census was 63 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #14 had [DIAGNOSES REDACTED]. A physician order [REDACTED]. During interview on 3/2/16 at 2:37 p.m., the administrator verified no GDR attempt was made for [MEDICATION NAME] in the past year.