Every finding on record at Broadway Living Center

Based on observation, record review, and interview, the facility failed to ensure a shared blood pressure cuff was sanitized between 2 (#38 and #19) of 2 sampled residents observed during medication administration. The DON identified 78 residents received medications at the facility. Findings: On 07/30/26 at 8:38 a.m., CMA #1 was observed to obtain a blood pressure wrist cuff from the cart and check the blood pressure of Resident #38. The blood pressure cuff was observed to be returned to the cart. On 07/30/26 at 8:52 a.m., CMA #1 was observed to obtain the wrist blood pressure cuff from the cart and take the blood pressure of Resident #19. CMA #1 was not observed to have sanitized the cuff between uses. A policy titled Cleaning and Disinfecting Non-Critical Resident-Care Items, dated 2001, read in part, The purpose of this procedure is to provide guidelines for disinfection of non-critical resident-care items.Non-critical items are items intended to contact intact skin but not mucous membranes.include bedpans, blood pressure cuffs .intermediate and low-level disinfectants for non-critical items include: a. Ethyl or isopropyl alcohol; b. sodium hypochlorite; c. Phenolic germicidal detergents; d. Iodophor germicidal detergents; and e. Quaternary ammonium germicidal detergents (low-level disinfection only). On 07/30/26 at 9:12 a.m., CMA #1 stated they should have used germicidal wipes to sanitize the blood pressure cuff between residents. On 07/31/26 at 10:30 a.m., the DON stated staff should have used sanitizing wipes for cleaning the shared equipment, including blood pressure wrist cuffs, between residents.

Based on observation, record review, and interview, the facility failed to ensure the deep fryer was skimmed for 1 of 1 deep fryer observed in the kitchen. The DON identified 78 residents resided in the facility. Findings: On 07/28/26 at 10:09 a.m., the deep fryer was observed unskimmed and unclean with the top layer of grease covered in pieces of food. A policy titled Deep Fryer Cleaning and Maintenance Policy, dated 10/01/19, read in part, All deep fryers will be maintained through daily skimming, regular oil filtration, and scheduled deep cleaning on Wednesdays and Saturdays. On 07/28/26 at 10:10 a.m., Dietary Aide #1 stated they could see a tater tot from Saturday floating in the grease. They stated the deep fryer was supposed to have been cleaned after each use. On 07/28/26 at 12:47 p.m., the certified dietary manager stated the deep fryer had not been skimmed. They stated the staff had not been cleaning the deep fryer daily.

Based on observation, record review, and interview, the facility failed to ensure a medication cart was locked for 1 of 5 medication carts observed. The DON identified 78 residents resided in the facility. Findings: On 07/28/26 at 3:05 p.m., Medication Cart A on [NAME] Hall was found unlocked and unattended. On 07/28/26 at 3:06 p.m., CMA #1 was observed walking from the North Hall hallway to Medication Cart A on [NAME] Hall. A policy titled Security of medication Cart, revised 04/2017, read in part, 4. Medication carts must be securely locked at all times when out of the nurse's view. 07/28/26 at 3:07 p.m., CMA #1 stated they had been talking to another staff on the other hall and had left Medication Cart A on [NAME] Hall unlocked and unattended.

Based on observation,record review, and interview the facility failed to ensure the appropriate testing strips were used for checking sanitization levels for the dishwasher and the three compartment sink observed during one of two kitchen observations. The Director of Operations identified 82 residents resided in the facility. Findings: A Sanitation test strips policy, dated 08/06, read in part, .If Dishwasher sanitizing test strip is off, use best practice: stop machine, make 3 sink system and do manually while awaiting service repair call. A Washing by Hand instruction guide for wash, rinse and sanitize, undated, read in part, .Wash. Fill the first basin with hot water (at least 110 degrees F) .Sanitize the rinsed items in the third basin using either hot water or chemical solution . On 03/11/24 at 12:29 p.m., the dishwasher sanitization was tested by the DM to read between 100-200 ppm. It was observed to be dark purple (100-200 ppm) in color and did not match the shades of the blue color grid on the side of the bottle the DM used to test. On 03/11/24 at 12:30 p.m., the DM stated that if it read high then they would call the facility maintenance and the dishwasher company. They would then use the three compartment sink. The DM instructed the Dishwasher to stop using the machine and to use the three compartment sink. On 03/11/24 at 12:33 p.m., the DM called the dish machine company. On 03/11/24 at 1:49 p.m., the dishwashing machine was in use and there were dishes at the front and the end of the machine. The Dishwasher stated they were instructed to get the dishes through to not have them pile up. They stated staff would then run them through the machine later. On 03/11/24 at 1:51 p.m., the DM stated the dish machine company told them the strip could be purple but not black, and could be at 50-100 ppm. The DM stated that was the reason staff were using the dishwasher again. On 03/11/24 at 2:00 p.m., the dish machine sanitization was tested again with a strip that came from the container with the shades of blue color grid on the side and the strip came out dark purple. They tested again with a strip from a container with shades of green color grid on the side that read light green; which indicated a sanitization level below 25 ppm. On 03/11/24 at 2:06 p.m., the three compartment sink sanitization water was tested from a bottle that had a color grid with shades of green on it. The test strip was observed to be a light gray color reading that did not match the color grid on the bottle. On 03/11/24 at 2:09 p.m., the DM added one more sanitizing tablet to the water in the three compartment sink. On 03/11/24 at 2:12 p.m., the DM added two more sanitizing tablets to the water. The dishwashing machine representative arrived and tested the dish machine sanitizer cycle with Hydrion test strips that had the purple color grid on the container. The reading was 100 ppm. The representative informed the DM they had the incorrect strips and provided the correct container. On 03/13/24 at 2:20 p.m., the three compartment sink sanitizer continued to not have an accurate reading of light blue. There were dishes in the sanitizing sink. The DM instructed staff to stop washing and to wait for the dishwasher to be fixed. On 03/13/24 at 2:47 p.m., Dietary Aide #2 was observed to prepare the three compartment sink. The wash water temp was 104 degrees. Dietary Aide #2 stated they did not check the temperature of the water and that it couldn't be too hot to put their hands in. On 03/13/24 at 2:51 p.m., the DM stated the wash water should have been temped and they thought they had the correct strips for testing the sanitizer. On 03/13/24 at 2:57 p.m., the DM stated the sanitizer strips used in the three compartment sink were the wrong strips. On 03/14/24 at 10:58 a.m., the DM stated they assumed the test strips were correct even though the color grid was different, and they went by the actual amount of shading and not the color of the strip.

Based on record review and interviews, the facility failed to provide mail delivery to residents on Saturdays. The Director of Operations identified 82 residents resided in the facility. Findings: On 03/14/24 at 10:25 a.m., a Resident Council group meeting was held with 11 residents. They stated the mail did not get distributed on the weekends. On 03/14/24 at 11:30 a.m., the Director of Operations stated mail was delivered Monday through Friday and packages were put in the medication room until Monday morning when staff could verify that it belonged to the resident. On 03/14/24 at 11:54 a.m., the Director of Operations stated if weekend mail was actually brought into the facility it would be delivered, but mail delivered to the locked mailbox would not be delivered until Monday. 49701

Based on observation, record review and interview, the facility failed to ensure care plans were revised for two (#1 and #63) of 16 sampled residents reviewed for care plans. The DOO identified 82 residents resided in the facility. Findings: A Care Plan policy, revised 12/16, read in part, .The plan of care provides us with a profile on the needs of each resident, identifies the role of each service in meeting these needs, and the supporting measures each service will use to accomplish these goals .Resident care plans will be reviewed at least every three months to ensure that timely updating of problems, goals, and interventions are being done by the Multidisciplinary Team . 1. Resident #1 had diagnoses which included chronic pain, unspecified dementia, dysphagia, and spastic hemiplegia affecting left nondominant side. A Significant Change Resident Assessment, dated 03/24/23, documented Resident #1 had moderate cognitive impairment and the resident had an impairment on one side for the upper and lower extremity. Resident #1's care plan did not address the use of wedge pillows and there was no documentation of when the wedge pillows were initiated. On 03/13/24 at 11:48 a.m., CNA #1 was observed wheeling Resident #1 out of the dining room in their wheelchair. The resident was observed to have one blue wedge pillow in the wheelchair on both sides of them. On 03/13/24 at 12:53 p.m., Resident #1 stated the wedges helped with positioning but they didn't think they needed it. On 03/15/24 at 9:23 a.m., RN #2 stated Resident #1 leaned to the right. They stated they were unsure of what the positioning devices in the resident's wheelchair were called, but they believed hospice provided them. RN #2 stated they helped the resident sit up more. On 03/15/24 at 9:47 a.m., MDS Coordinator #2 stated they updated care plans as needed with anything that was personalized to the resident. On 03/15/24 at 9:49 a.m., MDS Coordinator #2 stated positioning devices would be something included in a resident's care plan. They stated Resident #1's wedge pillows were implemented because they leaned quite a bit to the side. They stated they did not know the date they were implemented. On 03/15/24 at 9:52 a.m., MDS Coordinator #2 stated they did not see the wedge pillows addressed in Resident #1's care plan. On 03/15/24 at 10:25 a.m., the DOO stated Resident #1's wedge pillows were for safety and positioning to aide in increased independence. On 03/15/24 at 11:26 a.m., the DOO stated they spoke to LPN #2 who reported they got the wedges out of the facility closet to use for positioning approximately one month ago. The DOO stated LPN #2 reported they spoke with hospice prior to initiating them, but they did not document it. The DOO stated they were unable to locate documentation of when the wedges were initiated. 46216 2. Resident #63 admitted on [DATE] with diagnoses which included benign prostatic hyperplasia with lower urinary tract symptoms. Resident #63 had a physician's order dated 03/09/24 for Bactrim BID for 10 days. The care plan did not document the resident having a UTI or interventions for the diagnoses of UTI. On 03/15/24 at 10:09 a.m., MDS coordinator #1 stated the care plans were updated with every MDS assessment and whenever there was a change with the resident. They stated there was no care plan for the UTI infection and it should have been in the care plan. 49701

Based on record review and interview, the facility failed to perform fingerprint background checks for two (CNA #1 and RN #1) of five sampled employees hired within the last six months. The administrator identified 29 employees hired in the last 6 months. Findings: An undated facility policy, titled RESIDENT ABUSE, MISTREATMENT, NEGLECT, MISAPPROPRIATION AND EXPLOITATION POLICY, read in part .The facility shall maintain and provide evidence of efforts to determine if newly hired persons have records of abuse. Screening potential for a history of abuse, neglect or mistreating residents includes attempting to obtain information from previous employers and/or current employers, and checking with appropriate licensing board and registries. This shall occur through background checks with appropriate licensed agency . CNA #1 was hired 07/21/22. RN #1 was hired 10/08/22. On 1/19/22 at 9:00 a.m., the HR director provided five employee files. She stated at that time CNA #1 did not have an OK screen clearance letter because she did not have an Oklahoma identification so the fingerprinting service would not complete the fingerprints. On 1/19/22 at 9:21 a.m., the HR director stated the administrator had been notified of the delay for CNA #1 a while back and the facility was going to take her off the schedule but because the facility was short staffed, she remained on the schedule. The HR director stated the fingerprinting background check for RN#1 was missed. On 01/19/22 at 9:28 a.m., the HR director provided documentation of the application for OK screen information for RN #1. The document was dated 01/18/22. The HR director stated the facility did not perform pre-employment screening for CNA #1 or RN #1.

Based on record review and interview, the facility failed to develop comprehensive care plans for anticoagulant use for two (#52 and #72) of five residents reviewed for unnecessary medications. The MDS coordinator identified eight residents who received anticoagulant medications. Findings: 1. Res #52 had diagnoses which included acute combined systolic (congestive) and diastolic (congestive) heart failure, nontraumatic subdural hemorrhage, and hypertension. A physician order, dated 08/04/20, documented to administer Eliquis (an anticoagulant) 5 mg two times a day for acute combined systolic and diastolic heart failure. A quarterly MDS assessment, dated 11/23/22, documented the resident was moderately cognitively impaired and received anticoagulant medications seven out of seven days during the review period. A care plan, reviewed 12/29/22, did not document anticoagulant use. On 01/18/23 at 12:47 p.m., the MDS coordinator stated anticoagulants should be documented under the disease process it is prescribed to treat. She stated it was not included in Res #52's care plan but should have been. 2. Res # 72 had diagnoses which included atherosclerosis of native arteries of extremities with intermittent claudication of the bilateral legs, peripheral vascular disease, and hypertension. A physician order, dated 3/22/22, documented to administer Eliquis (an anticoagulant medication) 5 mg two times a day for atherosclerosis of native arteries of extremities with intermittent claudication of the bilateral legs. A care plan, last reviewed on 11/3/22, did not document anticoagulant use. A quarterly MDS, dated [DATE], documented the resident was cognitively intact and received anticoagulants seven out of seven days during the review period. On 01/18/23 at 12:47 p.m., the MDS coordinator stated anticoagulants should be documented under the disease process it is prescribed to treat. She stated it was not included in Res #72's care plan but should have been.

Based on record review and interview, the facility failed to offer residents the choice to formulate advanced directives for six (#25, 39, 82, 37, 60, and #42) of 12 sampled residents reviewed for advanced directives. The Resident Census and Conditions of Residents report, dated [DATE], documented 85 residents resided in the facility. It documented there were no residents who had advanced directives. Findings: A facility policy titled Advance Directives, revised [DATE], read in parts .Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so .Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record . 1. Res #25 was admitted to the facility on [DATE]. The resident's record did not contain any documentation the resident was offered the choice to formulate an advance directive. Res #39 was admitted to the facility on [DATE]. The resident's record did not contain any documentation the resident was offered the choice to formulate an advance directive. 46387 2. Res # 82 was admitted [DATE]. A quarterly MDS assessment, dated [DATE], documented the resident was cognitively intact. Res #82's medical record was reviewed and documented the resident was a full code. There was no advance directive or documentation the resident was educated and declined to initiate an advance directive. 46582 3. Res #37 was admitted to the facility on [DATE]. A physician order, dated [DATE], documented the resident was to receive CPR if needed. There was no documentation the resident and/or their representative was offered a choice to formulate an advance directive. 4. Res #42 was admitted to the facility on [DATE]. A physician order, dated [DATE], documented the resident was to receive CPR if needed. 5. Res #60 was admitted to the facility on [DATE]. A physician order, dated [DATE], documented the resident was to receive CPR if needed. On [DATE] at 9:40 a.m., the administrator was asked to provide documentation the resident and/or representative was offered the choice to formulate an advance directive. On [DATE] at 10:19 a.m., the administrator reported the facility did not implement advanced directive forms before [DATE]rd, 2023. She reported before this date it was just documented in a note in the resident's chart by social services upon admission. She reported that if it was not in a note then it was not there.

Based on record review and interview, the facility failed to ensure the accuracy of MDS assessments for three (#16, 51, and #57) of 20 residents whose MDS assessments were reviewed. The Resident Census and Conditions of Residents form documented 85 residents resided in the facility. Findings: 1. Res #16 had diagnoses which included GERD, dementia, and diabetes. The weight record, documented on 08/12/22 the resident's weight was 168.0 lbs. The weight record, documented on 09/01/22, the resident's weight was 159.0 lbs. A nutrition progress note, dated 11/14/22, documented Res #16's weight as 155 lbs and had a 10% weight loss in the past 6 months. The weight record, documented on 12/02/22, the resident's weight was 154.0 lbs. A quarterly MDS, dated [DATE], documented the resident was severely cognitively impaired, weighed 154 lbs, and had no or unknown weight loss of 5% or more in the last month or loss of 10% or more in the last six months. On 01/18/23 at 3:00 p.m., the MDS coordinator stated she should have included the resident's weight loss on the quarterly MDS. 43023 2. Res #51 was admitted to the facility on [DATE] with diagnoses of dementia without behavior disturbance, recurrent depressive disorders, obsessive-compulsive disorder, psychosis not due to a substance or known physiological condition. A quarterly assessment, dated 12/08/22, documented the resident received an antipsychotic seven of seven days of the look back period. A review of the resident's medication documented the resident had never received an antipsychotic since admission to the facility. On 01/18/23 at 10:42 a.m., the MDS coordinator was asked if the resident had ever been on any antipsychotic medications. She stated she could not find that the resident had ever received an antipsychotic. She stated she had been coding Lamictal (an anticonvulsant medication) as an antipsychotic. 3. Resident #57 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus with diabetic polyneuropathy. A physician order, dated 08/15/22, documented Semglee Solution Pen-injector (insulin glargine) was discontinued. A quarterly assessment, dated 12/13/22, documented the resident received insulin injections seven out of seven days of the look back period. On 01/18/23 at 1:05 p.m., the MDS coordinator was asked why the assessment documented the resident received insulin injections when the physician's order documented the injections were discontinued 08/15/22. The MDS coordinator stated that the electronic record program pulled everything over and she should have made sure everything was documented correctly.

Based on record review and interview, the facility failed to review and revise a care plan for two (#71 and #60) of 21 sampled residents whose care plans were reviewed. The Resident Census and Conditions of Residents report documented 85 residents resided in the facility. Findings: Res #71 was admitted to the facility on [DATE] with diagnoses of schizophrenia, vascular dementia, and insomnia. A Wandering Risk Assessment, dated 07/12/22, documented the resident was at high risk for wandering. An incident report, dated 08/19/22, documented a good samaritan notified the facility that the resident was found wandering outside and they were currently sitting with resident. A care plan revision, dated 09/28/22, documented the resident was an elopement risk. The care plan documented the resident had an incident on 08/19/22 of climbing over the fence in the patio area and now the patio area was now locked with a key pad for safety. On 01/18/23 at 9:40 a.m., the MDS coordinator was asked if the resident's care plan should have been updated more timely right after the elopement. The MDS coordinator stated it should have. 47751 2. Res #60 was admitted with diagnoses which included schizoaffective disorder, bipolar disorder, and major depressive disorder. A quarterly assessment, dated 09/13/22, documented the resident had severe cognitive impairment, mild depression, and was independent with most ADLs. A behavior note, dated 10/24/22 at 9:36 p.m., documented the resident grabbed a piece of glass out of his bedside table and proceeded to cut his neck several times, but the glass was dull so it scraped and scratched his neck on the right lateral side. The resident was put on one on supervision until the time they were transported to the hospital. There was no documentation of behaviors on the care plan after the incident. A behavior note, dated 11/28/22 at 11:18 a.m., documented the resident had exchanged words with another resident due to the resident pushing his walker into the other resident while waiting to go smoke. There was no documentation of behaviors on the care plan after the incident. A behavior note, dated 12/18/22 at 6:39 p.m., documented the resident and a male peer got into an altercation during meal time. The note documented the male peer and the resident began cussing and threatening each other and getting in each others' faces. There was no documentation of behaviors on the care plan after the incident. On 01/18/23 at 11:51 a.m., the DON was asked if Res #60's care plan addressed behaviors. She stated it did not address behaviors, but it should have.

Based on record review and interview, the facility failed to ensure accuracy of a level I PASRR for one (#75) of five residents who were reviewed for PASRR evaluations. The Resident Census and Conditions of Residents form documented 85 residents resided in the facility. Findings: Res #75 was admitted on [DATE] with diagnoses which included schizophrenia. A PASRR level one screening form, dated 05/20/22, documented the resident did not have a diagnosis of a serious mental illness (for example, schizophrenic, paranoid, panic, mood, or other severe anxiety or depressive disorder, somatoform disorder, personality disorder, or other psychotic disorder, or another mental disorder that may lead to a chronic disability). On 01/17/23 at 10:40 a.m., the MDS coordinator stated Res #75's level one PASRR documented no serious mental illness. She stated the schizophrenia diagnosis at admission was not included on the screening form but should have been.

Based on observation, record review and interview, it was determined the facility failed to ensure one (#64) of one sampled residents was provided a means to ambulate in the facility without being confined to a wheelchair. The facility identified 25 residents who required assistance with mobility and 87 residents who resided in the facility. Findings: Resident #64 had [DIAGNOSES REDACTED]. An annual assessment, dated 01/23/20, documented the resident's cognition was severely impaired and was independent with the use of a wheelchair for mobility. A care plan for ADLs, dated 02/11/20, documented the resident was primarily independent with her ADL tasks. She was able to self transfer, dress and toilet herself. She utilized a wheelchair for mobility and at times would stand up and push the backwards facing chair, and was unable to be redirected. Interventions included to encourage the resident to participate to the fullest extent possible with each interaction. The clinical record documented the resident was receiving weekly restorative care and continued to work with ambulatory lower extremity exercises, both active and passive. On all days of the survey, the resident was observed to stand up, face her wheelchair and push it down the hall. When staff observed the resident, they stopped her and told her to sit in the wheelchair. The resident complied and would sit down. On 03/05/20 at 9:43 a.m., CNA #5 was asked if the resident could ambulate by herself. She stated the resident could walk behind her wheelchair and she transferred herself. She was asked if the resident had any falls. She stated she was not aware of any. The CNA was asked if she observed the resident ambulate safely. She stated yes. She was asked why the resident was encouraged to use a wheelchair instead of another means. She stated it was because it was in her care plan to use a wheelchair and they were to direct her to sit down if they observed her up. She stated it was up to the DON and ADON as they were the ones who made the care plan. At 11:19 a.m., the DON was asked if the resident was capable of ambulating. She stated yes, she could walk behind the wheelchair. She was informed of the observations of staff telling her she needed to sit in her wheelchair when they observed her up walking behind it. She stated yes, it did take away from her independence. They would look at that concern.

Based on observation, record review and interview, it was determined the facility failed to ensure one (#5) of one sampled residents were provided timely incontinent care. Findings: A quarterly assessment, dated 11/14/19, documented the resident's cognition was severely impaired, required extensive assistance of one person with toilet use and was incontinent of bowel and bladder. A care plan, dated 05/30/19, documented the resident had bladder incontinence related to [MEDICAL CONDITION] and impaired mobility. Interventions documented for staff to check and change the resident every two hours and as needed for incontinence. On 03/04/20 at 8:31 a.m., the resident was resting in bed with her eyes closed. She was in a supine position with the head of her bed at approximately 45 degrees. At 9:31 a.m., staff entered the room and provided incontinent care to the resident's roommate. At 10:00 a.m., CNA #2 went into resident's room. She opened the blinds and turned off the light. No incontinent care or repositioning was provided. At 10:35 a.m., staff entered the room and provided incontinent care to the resident's roommate. At 11:58 a.m., CNA #6 stood at door watching the resident for 3 minutes. At 12:46 p.m., ACMA #1 and #2 were observed to provide incontinent care to the resident's roommate. The resident was observed from 8:31 a.m. until 1:02 p.m., to be in the same position and was not provided incontinent care. At 1:02 p.m., ACMA #1 and #2 went into the resident's room to assist with incontinent care. The brief was removed and was observed to have dried urine stains and smears of dried feces. The bed pad and sheets were saturated with urine. The resident had not been repositioned or provided incontinent care for four hours and thirty-one minutes. ACMA #1 was asked what the pad and sheets were saturated with. She stated probably urine from not being changed. ACMA #2 stated she did not feel like the every two hour bed check had occurred like it was supposed to. ACMA #1 and #2 were asked how often a dependent resident was to be repositioned and provided incontinent care. They stated at least every 2 hours. ACMA #2 also stated sometimes more often than every 2 hours. On 03/05/20 at 11:11 a.m., the DON and the corporate RN were asked how often a resident should be repositioned and provided incontinent care. The DON stated at least every 2 hours and as needed. The corporate RN nodded her head up in down in agreement.

Based on observation, record review and interview, it was determined the facility failed to ensure fluids and/or ice were provided for two (#13 and #55) of three sampled residents who were reviewed for hydration. The facility identified 87 residents who resided in the facility. Findings: 1. Resident #13 had [DIAGNOSES REDACTED]. A care plan, dated 09/22/19, documented the resident was unaware of her needs and wants. Interventions documented staff were to anticipate for her. A quarterly assessment, dated 11/22/19, documented the resident's cognition was severely impaired and she required limited assistance of one staff member for eating. The current physician's orders [REDACTED]. On 03/04/20 from 8:28 a.m. through 11:47 a.m., there was no water or cup observed in the resident's room for hydration. At 9:11 a.m., CNA #2 was observed to pass ice and water to residents on the East hall except for resident #13. At 9:28 a.m., the AD was observed to open a mouth swab and clean the resident's mouth. The resident clamped her mouth onto the swab as soon as it was placed in her mouth and began sucking on it. The AD did not offer the resident any fluids to drink. At 10:00 a.m., CNA #2 entered the resident's room, went to the window and opened up the blinds and turned the light off. She was not observed to offer the resident any fluids to drink. At 10:35 a.m., CNA #2 and #3 transferred the resident from her bed to the geri chair. At 10:50 a.m., the resident was assisted to the dining room for the noon meal. The CNAs were not observed to offer the resident any fluids. At 11:15 a.m., staff were observed to be passing fluids to the residents in the dining room. This resident was not offered any fluids. At 11:36 a.m., dietary staff had a cup of water and asked her if she wanted a drink. The resident shook her head no. At 11:47 a.m., CNA #3 sat down in front of the resident, put the cup to her mouth and asked if she wanted a drink of water. The resident immediately drank from the cup. The resident was not provided a drink of water except for a small amount with the medication pass provided in the dining room. At 3:29 p.m., ACMA #1 and the corporate RN were asked how often residents should be offered fluids. ACMA #1 stated every hour at least. The corporate RN stated fluids should be offered during rounding or every time staff entered a resident's room. At 3:37 p.m., CNA #4 was asked how often fluids were offered to the residents. She stated rounds were made with the hydration cart every morning, afternoon, evening and every two hours in between. She was asked when dependant residents were offered fluids. She stated they always provided them their fluids. The CNA was observed to pass fluids on the East hall except for resident #13. At 3:49 p.m., CNA #4 was asked when residents who required thickened liquids were offered fluids. She stated either herself or another staff member passed thickened liquids every two hours. She was asked if they had been passed. She stated the thickened drinks are in the kitchen. 2. Resident #55 had a [DIAGNOSES REDACTED]. A quarterly assessment, dated 01/17/20 documented the resident's cognition was moderately impaired, required limited assistance with one staff member for eating The current physician's orders [REDACTED]. On 03/02/20 at 2:59 p.m., there was no water or cup observed in the resident's room for hydration. On 03/03/20 from 9:32 a.m. through 11:10 a.m., there was no water or cup observed in the resident's room for hydration. On 03/04/20 from 8:49 a.m. through 10:44 a.m., there was no water or cup observed in the resident's room for hydration. At 3:23 p.m. the resident was asked if he received fluids in his room between breakfast and lunch. He stated no. He was asked of any staff offered any fluids. He stated no. He was asked if he would have like to had been offered a drink. He stated yes.

Based on record review and interview, it was determined the facility failed to establish and maintain a comprehensive infection prevention and control tracking and trending program. The facility identified 87 residents who resided in the facility. Findings: On 03/05/20 at 10:02 a.m., the infection prevention tracking documentation was reviewed. There were 67 skin/soft tissue infections, 41 urinary tract infections and 31 respiratory infections identified in the facility in 2019. There was no documentation provided for the current year. At 10:50 a.m., the DON was asked about the infection control program. She stated they had not documented infection trends, researched the rationale for the infections, or enacted appropriate interventions to help prevent the development and transmission of infections within the facility.

Based on observation, record review and interviews, it was determined the facility failed to ensure one (#40) of one sampled residents call light system was accessible and functioning. Findings: Resident #40 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 01/06/20, documented the resident's cognition was intact, ambulated independently and had one fall with a major injury. A care plan, dated 02/13/20, documented the resident was at risk for falls due to routine use of [MEDICAL CONDITION] medications and had a history of [REDACTED]. Interventions documented staff were to ensure the call system pull string was within reach, encourage the resident to use the call system for assistance as needed and to provide prompt response to all requests for assistance. On 03/03/20 at 9:45 a.m., the resident's call light string was observed to be caught in two drawers of two separate dressers and was not accessible to the resident. At 9:57 a.m., the resident was asked if she had a call light. She stated she was not aware she had a call light. At 10:04 a.m., CNA #1 was asked where the call light cord was located. She stated the call light string was stuck in between two separate dressers and the wall and was not accessible to the resident. She freed the call light string from the drawers and furniture. The CNA pulled the call light string from waist level, from bed level, and one foot directly from the wall and the call system would not activate. She stated the call system was not in working order. On 03/04/20 at 10:42 a.m., LPN #1 stated CNA #1 had reported the call system was not functioning and was not accessible to the resident. The LPN stated she reported this to the maintenance director. At 11:09 a.m., the maintenance director stated he had repaired the call system. He stated he added string to the switch to ensure accessibility for the resident and installed an I-hook in the cement wall to ensure the call system would be activated when the string was pulled.

Based on observation and interview, it was determined the facility failed to ensure one (#13) of two sampled residents were treated with dignity during dining for two of two dining observations. The facility identified nine residents who required assistance with eating. Findings: On 03/03/20 at 11:00 a.m., resident #13 was observed to be in the dining room at the assisted table. At 11:29 a.m., the resident was served her meal and was assisted by ACMA #3. At 11:50 a.m., the ACMA asked for a plastic spoon from dietary staff. ACMA #3 used the plastic spoon to feed the resident her dessert. At 12:02 p.m., the resident finished her dessert. The ACMA was asked why this resident was fed with a plastic spoon, She stated she used the plastic spoon because her metal spoon had food stuck on it from her lunch. She was asked if a plastic spoon was used due to availability of metal silverware or due to a preference. The ACMA stated it was just her preference to use a plastic spoon. On 03/04/20 at 10:50 a.m., resident #13 was assisted to the dining room for the noon meal. At 11:15 a.m., staff were observed to be passing fluids to the residents in the dining room. This resident was not offered any fluids. At 11:36 a.m., dietary staff had a glass of water and asked her if she wanted a drink. The resident shook head no At 11:47 a.m., CNA #3 sat down in front of the resident, put the cup to her mouth and asked if she wanted a drink of water. The resident immediately drank from the cup. The resident waited 57 minutes sitting at the dining room table for staff to sit and offer fluids. On 03/05/20 at 11:11 a.m., the DON and the corporate RN were asked if it was okay for residents to be fed with plastic ware at the preference of the staff. The DON stated no, not at the preference of the staff. The corporate RN stated no, never. Not at the preference of the staff, no. They were asked how long a resident should wait to be provided a drink while waiting on their meal. The corporate nurse stated approoximately 15 - 20 minutes.

Based on record review and interview, it was determined the facility failed to notify the physician and resident's representative of a fall for one (#1) of three sampled residents reviewed for fall interventions. This had the potential to affect all 89 residents who resided in the facility. Findings: Resident #1 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 07/18/19, documented the resident was moderately impaired in cognitive skill for daily decision making and required extensive assistance from staff for transfers. A progress note, dated 10/06/19 at 4:46 p.m., documented the resident was found on the floor after an unwitnessed fall. Neurological checks were initiated due to possible head involvement. There was no documentation to indicate the physician or resident's representative were notified of the fall. On 10/22/19 at 3:34 p.m., the director of nursing was shown the progress note and asked if the physician and resident's representative were notified of the fall. She stated, No.

Based on record review and interview, it was determined the facility failed to provide a properly completed notice of an involuntary discharge for one #1 of two sampled residents who had received an involuntary discharge notice. The facility identified no additional residents who had received involuntary discharge notices. Findings: Resident #1 had a [DIAGNOSES REDACTED]. An annual assessment, dated 06/06/19, documented the resident was cognitively intact. On 06/27/19 the facility provided documentation resident #1 had been provided with an involuntary discharge notice. The notice did not contain a date of issuance, a statement of necessity from the resident's physician, and the name of the facility that had agreed to accept the resident. At 2:00 p.m., the administrator stated she had failed to provide the resident and his power of attorney (POA) with all of the required written information for an involuntary discharge.

Based on observations, record review and interviews, it was determined the facility failed to prevent avoidable pressure ulcers for one (#6) of four sampled residents who were reviewed for pressure ulcers. Resident #6 developed pressure ulcers on his right and left buttocks.The facility identified 42 residents who resided in the facility and were at risk for alteration in skin integrity. Findings: Resident #6 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan, dated 09/16/16, documented the resident was at risk for impaired skin integrity due to episodes of incontinence. Skin assessments were to be completed weekly by the nurse and the resident observed through his care for signs and symptoms of skin impairment. A quarterly assessment, dated 11/07/16, documented the resident's cognition was moderately impaired, he required supervision with ambulation and extensive assistance with toileting. The resident was unsteady of gait and incontinent of bladder. A nurse's note, dated 02/10/17 at 6:10 a.m., documented the resident had a fall without injury. A nurse's note at documented at 2:00 p.m., the resident had been in his wheelchair the entire day and would not get out of it even to go to the restroom. A nurse's note documented at 10:00 p.m., the resident self propelled in his wheelchair throughout the shift. A nurse's note, dated 02/11/17 and 02/12/17, documented the resident used the wheelchair for ambulation. A nurse's note, dated 02/13/17, documented the resident was unable to stand or walk, extremely weak and had a low grade fever. A nurse's note, dated 02/15/17, documented the resident used a wheelchair for ambulation. A nurse's note, dated 02/21/17 at 4:00 p.m., documented large open areas were observed to the lower buttocks and upper thighs. A wound assessment, dated 02/21/17, documented a pressure ulcer to the lower right buttock/hip measuring 8.5 centimeters (cm) in length, 8 cm in width and the depth was unable to be determined due to slough/eschar. The note further documented a pressure ulcer to the left buttock measuring 6 cm in length, 4 cm in width and was unable to be determined the depth due to slough/eschar. A physician's telephone order, dated 02/21/17, documented to clean the wound with a wound cleaner, pat dry, cover with a wet dressing (Petroleum Xeroform) and secure with an abdominal pad. A nurse's note, dated 02/22/17 at 2:00 p.m., documented the facility was discouraging the use of the wheelchair until a gel cushion could be provided. A physician's telephone order, dated 02/27/17, documented a new order was received to apply Santyl/[MEDICATION NAME] 1:1 compound to the necrotic area on the right hip daily and cover with a clean dry dressing. A physician's telephone order, dated 03/01/17, documented a clarification order was obtained which documented to continue with the previous wound care to the left buttock. A wound assessment, dated 03/01/17, documented a stage III pressure ulcer to the lower right buttock/hip measuring 5.0 cm in length, 5.3 cm in width and the depth was unable to be determined due to slough/eschar. The note further documented a stage I pressure ulcer to the left buttock measuring 1.8 cm in length, 1.3 cm in width and the depth was unable to determined due to necrotic tissue. A wound assessment, dated 03/06/17, documented a stage II pressure ulcer to the lower right buttock/hip measuring 11cm in length by11 cm in width. The note further documented a stage II pressure ulcer to the left buttock measuring 6 cm in length by 4 cm in width. A progress note documented the pressure ulcer was possibly a shearing from a wheelchair which was too small. On 03/09/17 at 9:32 a.m., registered nurse (RN) #1, was asked when she became aware the resident had acquired the pressure ulcers. She stated she observed the pressure ulcers on 02/21/17 while the resident was being assisted with pulling up his pants. She further stated they thought the pressure ulcers were due to shearing caused by the arm-rests on the wheelchair. The RN was asked why the resident had been using a wheelchair. She stated the resident usually ambulated independently with the use of a walker, but had become weak and unable to support himself due to acquiring the flu. She further stated the facility only had one wheelchair available at the time, although it was not an appropriate fit for the resident, he was placed in the wheelchair to keep him mobile. RN #1 was asked if the wheelchair provided was too small. She stated, Yes. The RN was then asked how long the resident had used the wheelchair. She stated for about two weeks. She was asked if they had attempted to order an appropriate sized wheelchair for the resident. She stated they had not expected the resident to be in the wheelchair for very long, but they had ordered one. She then produced an invoice, dated 02/22/17, which documented the facility ordering two wheelchairs. RN #1 was asked how long it took for the facility to order wheelchairs and receive them back. She stated about three days. At 10:05 a.m., RN#1 and certified nursing assistant (CNA) #7 were observed to provide wound care on the resident. The pressure ulcer on the right buttock/thigh appeared to be red, granulated, healing tissue. The surrounding tissue was observed to be reddish/pink healed tissue surrounded by purple, healed tissue. The pressure ulcer on the left buttock/thigh appeared to be reddish/pink healed tissue. The surrounding tissue was purple, healed tissue. At 12:00 p.m., CNA #7 was asked if she had provided incontinent care for the resident during the month of February. She stated, Yes. She was asked her process for providing incontinent care. She stated she cleaned the entire area, made sure to clean in skin folds, would then apply lotion/gel to the area. The CNA was asked what she would consider a change in skin condition. She stated bruising, swelling, redness and sores. She was asked if she had noticed or reported any changes in the resident's skin condition during the month of February. She stated, No. At 12:20 p.m., CNA #8 was asked if she had provided incontinent care for the resident during the month of February. She stated, Yes. She was asked what she was trained to observe for when providing incontinent care. She stated she would observe for redness, irritation, bruising, skin breakdown and open wounds. She was asked if she had noticed or reported any skin changes in the resident's skin during the month of February. She stated, No.