Every finding on record at Care Nursing & Rehabilitation

Based on observation, interview and record review, the facility failed to have a written agreement with the hospice that is signed by an authorized representative of the hospice and an authorized representative of the LTC facility before hospice care is furnished to any resident and an interdisciplinary team member collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician and others participating in the provision of care for 2 (Resident #10, Resident #60) of 16 residents reviewed for hospice services.The facility failed to maintain a written hospice contract that was signed by the hospice authorized representative and the LTC facility representative before hospice care was furnished to Resident #60.The facility failed to communicate and document communication between the facility and the hospice provider, to ensure that the needs of the resident were addressed and met 24 hours per day for Resident #10.These failures could place the residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care, and communication of resident needs. Findings included: Record review of Resident #10's electronic face sheet, dated 05/26/2026, reflected he was a [AGE] year-old male admitted on [DATE] with diagnoses including Alzheimer's disease (a progressive disease that slowly destroys memory and thinking skills, eventually impairing the ability to carry out the simplest tasks) and Glaucoma (slowly progressive eye disease that damages the optic nerve. If enough damage occurs, a person could lose their vision). Review of Resident #10's quarterly MDS assessment, dated 04/16/2026 reflected Resident #10 had a BIMS score of 00 indicating severe cognitive impairment. Further review indicated he had physical behavioral symptoms directed toward others one to three days a week and other behavioral symptoms not directed toward others one to three days a week. Resident #10 had a life expectancy of less than 6 months. Review of Resident #10's comprehensive care plan, dated 02/02/2026, reflected Resident #10 had a terminal prognosis and received hospice services with intervention If receiving hospice services, work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met. Further review reflected Resident #10 had potential for impaired visual function related to Glaucoma with intervention Administer medications as ordered. Review of Resident #10's electronic Physicians Orders reflected: Admit to [nursing facility] with [hospice company] on 1/31/26 terminal dx: Alzheimer's disease. Call [hospice phone number] for any COC. Further review reflected an order dated 02/02/2026 for dorzolamide hcl-timolol mal ophthalmic solution 2-0.5 % instill 1 drop in both eyes two times a day for Glaucoma. An order dated 01/31/2026 for latanoprost ophthalmic solution 0.005 % instill 1 drop in both eyes one time a day for Glaucoma.Review of Resident #10's MAR, dated February 2026, reflected no documentation that hospice provider was notified of medication refusals: Resident #10 did not receive latanoprost eye drops scheduled for PM one time on:o2/5 with progress note resident hit at staff. Resident #10 did not receive dorzolamide eye drops scheduled for AM seven times on:o2/7 coded resident refused by RN B;o2/11 coded resident refused by RN B;o2/20 coded resident refused by RN B;o2/21 coded resident refused by RN B;o2/22 coded resident refused by RN B;o2/25 coded resident refused by RN B;o2/26 coded resident refused by RN B. Resident #10 did not receive dorzolamide eye drops scheduled for PM one time on:o2/5 coded resident refused.Review of Resident #10's MAR, dated March 2026, reflected no documentation that hospice provider was notified of medication refusals: Resident #10 did not receive latanoprost eye drops scheduled for PM one time on:o3/8 with progress note resident grabbing nurse's arms not allowing eye drops to be administered. Resident #10 did not receive dorzolamide eye drops scheduled for AM sixteen times on:o3/2 coded resident refused by RN B;o3/3 coded resident refused by RN B;o3/6 coded resident refused by RN B;o3/7 coded resident refused by RN B;o3/8 coded resident refused by RN B;o3/11 coded resident refused by RN B;o3/12 coded resident refused by RN B;o3/16 coded resident refused by RN B;o3/17 coded resident refused by RN B;o3/20 coded resident refused by RN B;o3/21 coded resident refused by RN B;o3/22 coded resident refused by RN B;o3/25 coded resident refused by RN B;o3/26 coded resident refused by RN B;o3/30 coded resident refused by RN B;o3/31 coded resident refused by RN B. Resident #10 did not receive dorzolamide eye drops scheduled for PM one time on:o3/8 coded resident refused.Review of Resident #10's MAR, dated April 2026, reflected no documentation that hospice provider was notified of medication refusals: Resident #10 did not receive latanoprost eye drops scheduled for PM one time on: o4/6 coded resident refused. Resident #10 did not receive dorzolamide eye drops scheduled for AM fifteen times on:o4/3 coded resident refused by RN B;o4/4 coded resident refused by RN B;o4/5 coded resident refused by RN B;o4/6 coded resident refused by RN B;o4/8 coded resident refused by RN B;o4/9 coded resident refused by RN B;o4/13 coded resident refused by RN B;o4/14 coded resident refused by RN B;o4/17 coded resident refused by RN B;o4/18 coded resident refused by RN B;o4/19 coded resident refused by RN B;o4/22 coded resident refused by RN B;o4/23 coded resident refused by RN B;o4/27 coded resident refused by RN B;o4/28 coded resident refused by RN B. Resident #10 did not receive dorzolamide eye drops scheduled for PM one time on:o4/6 coded resident refused.Review of Resident #10's MAR, dated May 2026, reflected no documentation that hospice provider was notified of medication refusals: Resident #10 did not receive latanoprost eye drops scheduled for PM two times on: o5/6 coded resident refused;o5/7 coded resident refused. Resident #10 did not receive dorzolamide eye drops scheduled for AM twelve times on:o5/1 coded resident refused by RN B;o5/2 coded resident refused by RN B;o5/3 coded resident refused by RN B;o5/6 coded resident refused by RN B;o5/7 coded resident refused by RN B;o5/11 coded resident refused by RN B;o5/12 coded resident refused by RN B;o5/15 coded resident refused by RN B;o5/16 coded resident refused by RN B;o5/17 coded resident refused by RN B;o5/25 coded resident refused by RN B;o5/26 coded resident refused by RN B;Review of Resident #10's progress notes, accessed on 05/27/2026, reflected no evidence of communication between the facility and the hospice provider for Resident #10's eye drop refusals.During an observation on 05/27/2026 at 10:03 a.m., LVN C attempted to administer eye drops to Resident #10. LVN C entered the room and donned clean gloves after performing hand hygiene. LVN C explained to Resident #10 that she needed to give him his eye drops. Resident #10 was lying in bed with eyes closed. Resident #10 refused to open his left eye. LVN C attempted to assist Resident #10 in opening his eye and Resident #10 began shaking his head back and forth and pushing on LVN C's arms. LVN C stepped back and attempted to explain the importance of the eye drops to Resident #10. Resident #10 opened his eyes and smiled. LVN C attempted to instill the eye drops and Resident #10 shut his eyes and pushed her away from him again.During an interview on 05/27/2026 at 1:55 p.m., LVN C stated she was the nurse for Resident #10 and had attempted to give him his eye drops that morning. She stated he would not let her give him the medication. She stated she documented on the MAR that he refused the eye drops. She stated she did not call the hospice provider about him refusing the eye drops. She stated the hospice provider was aware that he would refuse the eye drops and if she was present when the hospice nurse was in the building, she would tell her about him refusing. She stated she had not documented the conversations with the hospice nurse but she was in the building every week. She stated she would be who reached out to the hospice company if there was any change in condition. She stated she did not know if she had to reach out to the ordering physician every time a medication was refused. During a telephone interview on 05/28/2026 at 10:37 a.m., RN B stated she did document code refused on the MAR when Resident #10 refused his eye drops. She stated she would let hospice know if the hospice nurse was in the building on the day of his refusal but did not call them every time Resident #10 refused his eye drops. She stated she would make several attempts to administer the eye drops but Resident #10 would shut his eyes and push her away. She stated she felt the hospice was aware of his refusals without being called every day. She stated she never documented her conversations with the hospice nurse and did not know she should do that. She stated the hospice physician would be the physician that was ordering the eye drops and the hospice nurse would be the one to tell him about the refusals. During an interview on 05/28/2026 at 1:40 p.m., Resident #10's representative stated she was aware that Resident #10 not getting his eye drops for Glaucoma. She stated she had asked RN B how the eye drops were going and she was told they are not going. Resident #10's representative stated she was concerned he would go blind and that his behaviors would be worse if he could not see. She stated she had voiced her concerns with the facility and the hospice provider. She stated she was unsure if the facility was notifying the hospice provider after his refusals. She stated the hospice physician was ordering the eye drops. She stated she felt that it was in the approach to him stating that if he was sleeping then she thought the nurses could gently open his eyes and give the drops. She stated that if they woke him up and were talking to him explaining what was happening he would get agitated and grab at the nurse because he could not understand what they were doing. Review of Resident #60's electronic face sheet, dated 05/27/2026, reflected a [AGE] year-old male who was admitted on [DATE] and readmitted on [DATE] with diagnosis including heart disease. Review of Resident #60's comprehensive care plan, dated 05/05/2026, reflected Resident #60 had a terminal prognosis and was receiving hospice services with intervention work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met.Review of Resident #60's electronic physician orders, dated 05/22/2026, reflected Admit with [hospice company] 5/22/26. Dx: Heart Disease.Review of facility's contract binder reflected no evidence that the facility had a hospice contract with Resident #60's hospice provider.During an interview on 05/28/2026 at 1:08 p.m., the ADMN stated he was not able to locate a contract between the facility and Resident #60's hospice provider. He stated he had contacted the hospice company's Administrator to see if they had a copy of the contract to provide him and was waiting for them to send over the contract. He stated he had been hired two weeks ago. He stated he was told by the interim ADMN before him all of the contracts needed were in the contract binder. He stated he had not noticed the hospice contract was not in that binder until now. During a telephone interview on 05/28/2026 at 2:23 p.m., hospice staff stated that the medical director for the hospice company was the ordering physician for Resident #10's eye drops. The hospice staff stated they were aware of Resident #10 not taking the eye drops because Resident #10's representative would notify them. The hospice staff stated the facility would notify them when they came into the building but that was at the most once a week.During a follow-up interview on 05/28/2026 at 1:53 p.m., the ADMN stated his expectation would be for hospice contracts to be obtained prior to a resident being admitted on hospice services. He stated the ADMN was responsible for making sure the hospice contract was signed and stored in the facility. He stated he continued to wait for Resident #60's hospice company's Administrator to fax over the contract. He stated that the DON would be the hospice contact when she was in the facility per policy. He stated the DON would need to designate that task to another person if she was not in the facility. He stated he was told when he started on 5/11/2026 that all the contracts were in a binder by the interim ADMN and had not noticed the hospice contracts were not there. He stated the facility should have had a contract from the hospice in the facility before a resident on that hospice was admitted . During an interview on 05/28/2026 at 2:33 p.m., the DON stated she did not know she was the hospice contact per the facility policy. She stated she expected the nurses who could not administer medications to contact the ordering physician or the hospice provider via the hospice nurse. She stated typically after a resident refused medication three times, the facility would facilitate getting the physician to discontinue the medication. She stated she felt Resident #10's being adamant that he received the eye drops was why the physician had not been contacted to get the drops discontinued. She stated the staff were afraid of Resident #10's retaliating against them and she had been known to slam doors and raise her voice. She stated the eye drops were for glaucoma and if he did not receive them, he could lose his vision. She stated the nurses were making the attempts to administer, but they could not force him to receive the drops. She stated that the nurse should be putting in a nurses' note when the medication was refused including notification of the ordering provider which was the hospice provider in Resident #10's case. She stated she was not responsible for making sure the hospice contracts were in place prior to a residents referral approved. She stated the facility does have a system in place to make sure all of the appropriate documents were obtained prior to admission and felt the document had been obtained but that the facility could not locate it. During a telephone interview on 05/28/2026 at 3:50 p.m., the interim ADMN stated she thought all the contracts would be in the contract binder and had not realized Resident #60's hospice contract was not there. She did not know where else the contract may have been.Review of the facility's policy titled, Hospice Services, no date, reflected Procedures:.2. The facility must have a legally binding written agreement for the provision of arranged services with a recognized hospice provider. Authorized representatives of the facility and hospice provider must sign the agreement. A copy of the agreement will be maintained by the facility.The DON or designee will be responsible for immediately notifying the hospice of any significant changes in condition. Notification will be documented in the medical record.Review of the facility's policy titled, Medication Administration and General Guidelines, date, reflected 12. If a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time (e.g. resident not in facility at scheduled dose time, initial dose of antibiotic), the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record provided for PRN documentation. The physician must be notified when a dose of medication has not been given. If an electronic medical record is being utilized then the caregiver administering the medication will enter the correct documentation that will then be electronically date/time stamped with their initials.

Based on observation, interview and record review, the facility failed to ensure the resident's right to reside and receive services in the facility with accommodation of residents' needs and preferences for 2 (Resident #10, Resident #26) of 24 residents reviewed for resident rights.The facility failed to ensure Resident #10's and Resident #26's call lights were within reach. This failure could place residents at risk of a diminished quality of life and lead to a loss of self-esteem and isolation.Findings included:Record review of Resident #10's electronic face sheet, dated 05/26/2026, reflected he was a [AGE] year-old male admitted on [DATE] with diagnoses including Alzheimer's disease (a progressive disease that slowly destroys memory and thinking skills, eventually impairing the ability to carry out the simplest tasks) and Glaucoma (slowly progressive eye disease that damages the optic nerve. If enough damage occurs, a person could lose their vision). Review of Resident #10's quarterly MDS assessment, dated 04/16/2026 reflected Resident #10 had a BIMS score of 00 indicating severe cognitive impairment. Further review indicated he had physical behavioral symptoms directed toward others one to three days a week and other behavioral symptoms not directed toward others one to three days a week. Resident #10 used a wheelchair for mobility, had impaired range of motion to both lower extremities, and was dependent on staff for bed mobility and transfers. Review of Resident #10's comprehensive care plan, dated 02/02/2026, reflected Resident #10 was a risk for falls related to fall history, confusion, medication side effects, and score on fall risk assessment with intervention of Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed.During an observation on 05/26/2026 at 3:28 p.m., Resident #10 was lying in bed with eyes closed. He was on an air mattress that had bolsters. His bed was against the wall and there was a fall mat to the right of the bed. His call light was wrapped around a square device on the wall out of the resident's reach.During an observation on 05/27/2026 at 1:47 p.m., Resident #10 was lying in bed with his eyes closed and the call light was wrapped around a square device on the wall out of the resident's reach. During an interview on 05/27/2026 at 1:47 p.m., CNA A stated she was familiar with Resident #10. She stated she kept the call light wrapped around the square box in his room because the night shift started doing it and she just continued. She stated Resident #10 would pull on the cord, would get tangled up in the cord and that was why it was stored the way it was. She stated he was not able to reach the cord when he was lying in the bed if it was wrapped around the square box.During an interview on 05/28/2026 at 1:40 p.m., Resident #10's representative stated she did not want his call light in his reach. She stated she did not understand why the facility would need to have it in Resident #10's reach and she would wind it around the square on the wall to keep it out of his reach when she was at the facility. She stated she did go to the care plan meetings, but no one had discussed his call light with her during those. She stated no one had ever told her his call light needed to be in his reach until now. Record review of Resident #26's electronic face sheet, dated 05/27/2026, reflected she was a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with diagnoses including dementia (a progressive disease that slowly destroys memory and thinking skills) and chronic pain (long history of pain).Record review of Resident #26's quarterly MDS assessment, dated 04/15/2026, reflected Resident #26 had a BIMS score of 13 indicating intact cognition. Further review reflected Resident #26 used a wheelchair for mobility, needed moderate assistance from staff for bed mobility and transfers, and had no falls since readmission. Record review of Resident #26's comprehensive care plan, dated 12/14/2025, reflected Resident #26 had risk for falls related to history of falls, medication side effects, high fall risk assessment score, and decreased safety awareness with interventions that included Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed.During an interview on 05/27/2026 at 7:35 a.m., Resident #26 was sitting on the side of her bed eating breakfast. Her call light was in reach to the right side of her bed. She stated sometimes the call light was kept out of her reach but did not think the staff did that on purpose. She denied any accidents or other negative occurrences from the call light being out of reach.During an observation on 05/27/2026 at 1:26 p.m. Resident #26 was sitting in a recliner in her room with a bedside table in front of her eating lunch. Her call light was hanging on the middle of her bed out of reach. She stated she did not notice that the call light was on the bed and stated that she needed assistance to get up. She stated she thought it was due to there was not enough staff in the building. She stated she could get her back scratch bar to attempt to reach over and get the call light if she needed assistance. She stated she could not reach the call light without using something to reach it.During an observation and interview on 05/27/2026 at 1:47 p.m., CNA A was picking up trays on the hall where Resident #26 resided. She stated Resident #26 could not reach the call light on the side of the bed if she was sitting in her recliner. She stated Resident #26 did need stand by assistance to safely transfer. She stated maybe the hospice aide had sat her in the recliner and forgot to move the call light after Resident #26's shower but was not sure why the call light was out of her reach.During an interview on 05/27/2026 at 1:55 p.m., LVN C stated she was the nurse for Resident #10 and Resident #26. She stated she was unsure why Resident #10's call light was not in reach but that Resident #10's representative would wrap it up sometimes because she was afraid he would hurt himself with the call light. She stated he was not able to reach the call light when it was wrapped up on the wall. She stated she had no documentation of the conversation between her and the representative in the past. She stated she did not know why Resident #26's call light was not in her reach. She stated she was responsible for making sure call lights were in reach of the residents. She stated she monitored the CNAs were keeping the call lights in reach. She stated not having call lights in reach could make the resident not be able to call for assistance.During an interview on 05/28/2026 at 9:06 a.m., the DON stated she expected residents to have access to their call lights. She stated everyone was responsible for making sure they put the call lights in residents' reach. She stated she monitored the direct care staff providing care and services based upon the care plans by actively rounding the hallways several times a day. She stated the facility had Champion rounds as well where an IDT member rounded their assigned rooms to check on the residents. She stated Resident #10's representative may have been storing the call light out of his reach because she had been told by the nursing staff the representative voiced that she did not want the call light in his reach because she was afraid of him hurting himself with it. She stated Resident #10 could not understand how to use the call light. She stated she had been in the care plan meetings with Resident #10's representative and the representative had made some comments but not on the call light. She stated she did not know why Resident #26's call light was stored out of her reach on 5/27/2026. She stated not having access to the call light could cause Resident #26 to possibly fall and she did not expect for her to use her back scratcher to reach the call light. During an interview on 05/28/2026 at 1:53 p.m., the ADMN stated his expectation would be for residents to have access to their call lights. He stated any direct care staff were responsible for making sure call lights were in reach of the residents. He stated the IDT were assigned rooms that were rounded on at least once a day in the morning and they monitored the call lights were in reach. He stated if the IDT member had a concern, they would round again before the stand down meeting in the afternoon. He stated he did not know off the top of his head who the IDT member would be for Resident #10 and Resident #26. He stated the call light could have been moved after the IDT member had checked the rooms but was not sure. He stated he was not aware that Resident #10's call light was being kept out of his reach. He stated call lights not being in reach of residents could cause the resident to fall or not be able to call for assistance. He stated the facility did not have a policy on call lights, but he would provide the resident rights policy.Record review of the facility's policy titled Resident Rights, no date, reflected The resident has the right to be informed of, and participate in, his or her treatment, including:.2. The right to participate in the development and implementation of his or her person centered plan of care, including but not limited to:.d. The right to receive the services and/or items included in the plan of care.

Based on interviews and record reviews, the facility failed to not use any individual working in the facility as a nurse aide for more than four months unless that individual had completed a training and competency evaluation program for 3 (SNA A, SNA B, and SNA C) of 6 student nurse aides reviewed for nursing services.The facility failed to ensure SNA A, SNA B, and SNA C were certified within four months of hire.This failure could place residents at risk for receiving inappropriate care from individuals whose skill level was not known. Findings included:Record review of SNA A's employee files revealed SNA A had a hire date of [DATE] and no evidence SNA A was certified as a nurse aide at that time. An employability status check dated [DATE] indicated SNA A had a CNA certification that expired [DATE]. Record review of SNA B's employee file revealed SNA B had a hire date of [DATE] and no evidence SNA B was certified as a nurse aide at that time. An employability status check dated [DATE] indicated SNA B had no CNA certification. Record review of SNA C's employee file revealed SNA C had a hire date of [DATE] and no evidence SNA C was certified as a nurse aide at that time. An employability status check dated [DATE] indicated SNA C had no CNA certification. During an interview on [DATE] at 11:00 AM, the RNC stated her expectation was when NAs were hired, they were enrolled in classes within 30 days and were certifiable at 60 days. She stated the facility had no policy on NAs, and there was no time limit other than what the NATCEP requirements were. The RCN stated SNAs should have been certified as a CNA no more than 4 months after hire. The RCN stated she felt the failure was due to the previous DON from a sister facility who monitored the SNAs education and time frames of becoming certified. She stated as of that day had changed the three SNAs to Hospitality Aides because they had worked for four months or more. During an interview on [DATE] at 5:29 PM, the ADMN stated SNAs should have been certified within 4 months of hire. She stated the sister facility's DONad not kept up with monitoring and tracking of the certification. She stated they had been performing direct care with residents even after the 4-month allotted time frame. The ADMN stated the DON had been responsible for monitoring the nurse aides, but she was no longer at that facility. The ADMN stated she felt the failure occurred with the previous DON not following up and completing the task she was given. She stated there was potential harm for residents if staff were not trained properly in not knowing what out of the range signs and/or symptoms to look for. Record review of the facility's email dated [DATE] from the NATCEP Program Specialist II, LTC Regulatory, Credentialing Unit, to the RCN read in part.3. A facility must not use any individual working in the facility as a nurse aide for more than four months. 4. If they fail the test they can continue to work as a student nurse aid for 4 months. A student nurse aide only has 4 months to test, so they will need to re-test before their 4-month timeframe is up. If the test is failed 3 times, they must complete the course again and will not be able to work as a student nurse aide and will have to complete the training again. Record review of the facility's policy, titled Job Description for a SNA dated 2014 revealed: Knowledge Base -Must provide written proof of the completion of 16-hour ADL training by authorized school instructor. Only perform patient care areas that they have been trained for, accountable for personal care (grooming, dressing, personal care, catheter care, peri care, and dressing), basic computer knowledge, identifies and reports any condition requiring management attention, ambulate and transfer residents utilizing appropriate assistive devices and body mechanics .Applicant declaration: I have read the qualifications and requirements of the position of student nurses' aide; I understand this position is not permanent but limited to 120 days in which I am required to test and obtain certification. I understand and certify that the foregoing is a non-exhaustive criterion that is consistent with the needs of this facility and is a legitimate measure of the qualifications for a Certified Nursing assistant and relates to the functions essential to a certified nursing assistant.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible, in four out of ten resident rooms on 1 of 4 halls (The middle hall) reviewed for accident hazards, in that; The facility failed to ensure that the hot water temperatures in the sinks for 4 resident rooms did not exceed the maximum of 110 degrees Fahrenheit. This failure could place residents at risk for injuries related to hot water temperatures. The findings included: Record review of Resident #15's admission record dated 02/26/2025 indicated she was admitted to facility on 04/25/2024 with diagnoses of dementia and major depression. She was [AGE] years of age. Record review of Resident #15's quarterly MDS dated [DATE] indicated in part: BIMS = 13 indicating the resident was cognitively intact. During an observation and interview on 02/25/25 at 03:40 PM the water temperature in Resident #15's room faucet was 117 degrees Fahrenheit. Resident #15 said she had never burned her hands when she washed her hands in her sink. Record review of Resident #26's admission record dated 02/26/2025 indicated he was admitted to facility on 01/09/2020 with diagnoses of contracture of muscle and muscle wasting and atrophy (muscles shrinking). He was [AGE] years of age. Record review of Resident #26's quarterly MDS dated [DATE] indicated in part: BIMS = 15 indicating the resident was cognitively intact. Record review of Resident #30's admission record dated 02/26/2025 indicated he was admitted to facility on 3/14/2024 with diagnoses of Alzheimer's disease and dementia. He was [AGE] years of age. Record review of Resident #30's quarterly MDS dated [DATE] indicated in part: BIMS = 12 indicating the resident was moderately impaired. During an observation and interview on 02/25/25 at 03:26 PM the water temperature in Resident #26 and Resident #30's shared room faucet was 115. Resident #26 said he had never been burned with hot water even though he was unable to access the water. Resident #26 said he had not been burned during his showers. Resident #30 said he had never burned himself while washing his hands in his room faucet nor when the staff gave him his showers in the shower room. Record review of Resident #10's admission record dated 02/26/2025 indicated he was admitted to facility on 3/10/2024 with diagnoses of dementia, muscle wasting and atrophy. He was [AGE] years of age. Record review of Resident #10's quarterly MDS dated [DATE] indicated in part: BIMS = 06 indicating the resident was severely impaired. During an interview and an observation on 02/26/25 at 03:18 PM the water temperature in Resident #10's room was 115 degrees Fahrenheit. Resident #10 was in his bed in bed awake and alert. Resident #10 voiced that he had never burned himself with the hot water from the faucet in his room. Record review of Resident #24's admission record dated 02/26/2025 indicated she was admitted to facility on 11/20/2024 with diagnoses of dementia and stroke. She was [AGE] years of age. Record review of Resident #24's quarterly MDS dated [DATE] indicated in part: BIMS = 08 indicating the resident was moderately impaired. Record review of Resident #38's admission record dated 02/26/2025 indicated she was admitted to facility on 06/22/2024 with diagnoses of muscle weakness, muscle wasting and atrophy. She was [AGE] years of age. Record review of Resident #38's quarterly MDS dated [DATE] indicated in part: BIMS = 15 indicating the resident was cognitively intact. During an interview and an observation on 02/26/25 at 03:44 PM the water temperature in Resident #38 and Resident #24's shared room was 114 degrees Fahrenheit. Resident #38 and Resident #24 were in their rooms sitting up in their wheelchair or bed awake and alert. Both residents voiced that neither of them had ever burned themselves with the hot water from the faucet in their room. During an interview and an observation on 02/25/25 at 03:52 PM the Maintenance Supervisor said the hot water was expected to be between 107 degrees Fahrenheit and 110 degrees Fahrenheit. The Supervisor was made aware of the temperature in 4 of 10 resident rooms on the facility's middle hall had been 112 to 117 degrees Fahrenheit. The Supervisor took his thermometer and at this time and went into Resident #15's room and took the water temperature. The water temperature on the Supervisor's thermometer reached 117 degrees Fahrenheit. The Supervisor said the temperature was too high and he would have to turn done the temperature on the water heater. The Supervisor said they had turned up the water heater's thermostat when the outside temperature had gotten very cold a couple of a days ago. The Maintenance Supervisor said the closet where the water heater was located was not well insulated so when it got very cold outside it would drop the temperature on the water heater. The Supervisor said that water heater was connected to the resident rooms named in the middle hall and the other rooms in the facility had different water heaters which the temperatures were within 100 - 105 degrees Fahrenheit. The Supervisor said they had forgotten to turn the temperature back down when the temperature outside had gotten warm again. The Supervisor said they would adjust the temperature on the water heater and bring it back down. The Supervisor said they would provide the surveyor with a copy of the water temperature log for the last weeks temperatures. During an interview on 02/27/25 at 02:05 PM the Administrator was made aware of the water temperatures in the rooms on the middle hall. The Administrator said the water temperature should be between 100 degrees Fahrenheit and 110 degrees Fahrenheit. The Administrator said the Maintenance Supervisor had turned up the thermostat on the water heater for the middle hall due to the cold weather they had - had a few days ago and basically forgot to turn it back down when the temperature got warm outdoors again. The Administrator said the failure occurred because the Maintenance Supervisor forgot to turn down the thermostats on the water heater. The Administrator said there were no residents that got burned or scaled due to the water being hot. During a record review and interview on 02/25/25 at 03:58 PM the surveyor conducted record review of the facility's Weekly Water Temperature Log dated 01/31/25, 02/06/25, 02/13/25 and 02/20/25. The temperatures all ranged from 107 degrees Fahrenheit and 109 degrees (F) Fahrenheit. (Note none of the temperatures went above 110 degrees Fahrenheit) The Maintenance assistant said that was the temperature they had been and it had not been any higher on the middle hall when asked about the water temperature log not exceeding 110 and not being at least 114. Record review of the facility's policy titled Hot water systems and dated 2003 indicated in part: The hot water system will be checked weekly for temperature variations. Proper operation of mixing valve (to maintain 100-110 degrees (F) Fahrenheit). Water temperatures should be maintained at 100 degrees F at a minimum, and 110 degrees F at a maximum.

Based on observation, interview and record review the facility failed to ensure drugs and biologicals are labeled in accordance with professional principals , for 1 of 2 medication rooms (The front medication room) inspected for medication storage. The medication room had opened and undated vial of Tuberculin (TB) medication in the refrigerator. This failure could place residents at risk of receiving medications that were expired and not produce the therapeutic effect. The findings were: During an observation and interview on 02/25/25 at 11:55 AM one of the two medication storage rooms (the front medication room) was inspected with the DON present. Inside the small refrigerator was an opened 1 ml vial of tuberculin solution that indicated Once entered vial should be discarded after 30 days. the vial nor the box the solution came in had an open date written on it. The DON said staff was expected to date the vial whenever they opened it. The DON said the night shift was responsible for checking the refrigerator for expired medications and dispose of them. The DON said without the date on the vial it was hard to tell when the solution would expire and if used it might not produce an accurate reading. During an interview on 02/27/25 at 02:19 PM the Administrator was made aware of the opened and undated tuberculin vial found in the front medication room. The Administrator said that whoever opened it forgot to date it. The Administrator said if the tuberculin solution was used and not dated it could lead to inaccurate readings due to not knowing when it was opened. The Administrator said it was the night shift's responsibility to keep up with the medication room and remove undated medications. The Administrator said she did rounds and met with the DON about making sure staff did their rounds and inspections such as the medication room. Record review of policy titled Recommended medication storage and dated 07/2012 indicated in part: Below is a list of medications that require a date when opening and the recommended time frame the medication should be used. This is not an all-inclusive list, and the manufacturer recommendations will supersede this list. Multi dose vials for injection (Sterile water, vaccines etc) - unless otherwise noted - expire 30 days after first puncture.

Based on record review and interviews, the facility failed to maintain medical records on each resident that were accurately documented for 1 (Resident #15) of 27 residents reviewed for accuracy of records. The facility failed to ensure LVN A documented in Resident #15's record the holding of Lantus Insulin was because of the resident's request. This failure to place residents of risk of having incomplete and accurate records. Findings include: Review of Resident #15's electronic admission record revealed Resident #15 was a [AGE] year-old female who was admitted to the facility on [DATE] with admitting diabetes mellitus. Review of Resident #15's Quarterly MDS dated [DATE] revealed that Resident #15 had a BIMS of 13 out of 15 indicating resident was cognitively intact. Review of Resident #15's Care Plan, revised 05/14/2024, revealed Resident #15 was to be monitored for side effects and effectiveness of diabetic medications. Review of Resident #15's order summary revealed: -On 02/20/2025, Resident #15 was prescribed Lantus (Insulin Glargine) 10 units subcutaneously two times a day. -On 02/11/2025, Resident #15 was prescribed Lantus (Insulin Glargine) 10 units subcutaneously two times a day. It was discontinued 02/18/2025 due to hospitalization not related to diabetes. -On 02/05/2024, Resident #15 was prescribed Lantus (Insulin Glargine) 15 units subcutaneously two times a day. It was discontinued 02/11/2025 due to change in dosage. -On 11/14/2024, Resident #15 was prescribed Lantus (Insulin Glargine) 10 units subcutaneously two times a day. It was discontinued 02/05/2025 due to change in dosage. Review of Resident #15's electronic Medication and Treatment Administration Record revealed LVN-A held: -On 01/04/2025 at 8:00pm Lantus 10units with blood glucose reading of 125 with no signs or symptoms of low blood sugar. -On 01/17/2025 at 8:00pm Lantus 10units with blood glucose reading of 143 with no signs or symptoms of low blood sugar. -On 02/02/2025 at 8:00pm Lantus 10units with blood glucose reading of 113 with no signs or symptoms of low blood sugar. -On 02/05/2025 at 8:00pm Lantus 15units with blood glucose reading of 140 with no signs or symptoms of low blood sugar. -On 02/24/2025 at 8:00pm Lantus 10units with blood glucose reading of 154 with no signs or symptoms of low blood sugar. During an interview on 03/14/2025 at 5:42pm, LVN-A stated he had been a nurse at the facility for three months and had transferred from a sister facility. LVN-A stated he only worked the night shift. LVN-A stated he would only take Blood Glucose readings and administered insulin to Resident #15 during his shift. LVN-A stated Resident #15 was a retired nurse and was highly involved in her diabetic management. LVN-A stated Resident #15 wanted her Lantus held at night if her sliding scale insulin was also held. LVN-A stated he used his nursing judgement and the resident's right to determine to withhold the scheduled dose of insulin. LVN-A stated Resident #15 did not display any signs of low blood sugar such as severe sweating, increased pulse, fatigue, or restlessness. LVN-A stated that if Resident #15 did display signs of low blood sugar, he would have notified the doctor immediately. LVN-A stated, there is no good reason to why I did not document a more descriptive narrative in the progress note and that is an error on my part. LVN-A stated he understood the need to expand and explain the situation for continuity of care. During an observation and interview on 03/15/2025 at 2:16 p.m., Resident #15 stated she is highly active in her diabetic care and insulin. Resident #15 was not showing any signs of distress, sweating, increased pulse, fatigue, or restlessness. Resident #15 said she was an LVN and monitored her blood glucose closely. She stated at night, her and the nurse would discuss her blood glucose results and wanted her Lantus held because I don't want my sugar to bottom out. Resident #15 stated that LVN-A explained and discuss her diabetic management with her in great detail and appreciated her input in her care. During an interview on 03/14/2025 at 5:05 p.m., the Regional Compliance Nurse said the only location the nurses document medication information that differ from what is prescribed was on a progress notes. The Regional Compliance Nurse said the nurse should input the glucose number into the electronic record of the resident and an option box to expand would open. The Regional Compliance Nurse said the nurse would have space to document and explain what had occurred so the information would populate into a progress note. The Regional Compliance Nurse reviewed the TAR for Resident #15, dated 01/05/2025, and said the documentation confirmed LVN A withheld Resident #15's Lantus but said there was no documentation to explain why in Resident #15's Progress Notes, dated 01/05/2025. The Regional Compliance Nurse said she expected the nurses to document the reason the medication was withheld and the condition of the resident when glucose levels were low. The Regional Compliance Nurse said the lack of documentation did not meet her expectations. She said the facility had an issue with documentation, not just with LVN A. During a telephone interview on 03/12/2025 at 11:47 a.m., the Medical Director stated his expectation was for the nurses to use their nursing judgement, based on their training, in conjunction with the resident's request to determine nursing care. He stated that Resident #15 was highly active in her medication regiment. He also stated that if the nurse questioned their judgment or the resident's request, they were to call him; however, that was not the case with LVN A and Resident #15. He stated that he expected the resident's record to be accurate and complete for continuity of care. Record review of the facility's policy, Documentation, dated 2003, revealed documentation was the recording of all information, both objective and subjective, in the clinical record of an individual record. It included observations, investigations, and communications of the resident involving care and treatments. The facility will maintain complete and accurate documentation for each resident on all appropriate clinical record sheets. The facility will ensure that information was comprehensive and timely, and properly signed.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #22) of 2 residents reviewed for infection control. CNA A failed to change her gloves and wash her hands after they became contaminated during incontinent care while assisting Resident #22. This failure could place resident's risk for cross contamination and the spread of infection. Finding include: Record review of Resident #22's admission record dated 02/26/25 indicated he was admitted to the facility on [DATE] with diagnoses of Parkinson's (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) and muscle weakness. He was [AGE] years of age. Record review of Resident #22's care plan dated 09/27/24 indicated in part: Focus: The resident has bowel incontinence. Goal: The resident will not have any complications related to bowel incontinence. Interventions: Check resident every two hours and assist with toileting as needed. Apply barrier cream after every incontinent episode. Provide pericare after each incontinent episode. Record review of Resident #22's MDS assessment dated [DATE] indicated in part: Cognitive Skills for Daily Decision Making = 2. Moderately impaired - decisions poor; cues/supervision required. Urinary continence = Occasionally incontinent. Bowel continence = Frequently incontinent. During an observation on 02/25/25 at 12:10 PM CNA A and CNA B performed incontinent care for Resident #22. Both CNAs entered the resident's room washed their hands and put some gloves on. Both CNAs undid the residents brief and then CNA B wiped the resident's scrotum and penis area with some wet wipes. Both CNAs then turned the resident on his right side and then CNA A use some wet wipes to wipe the residents rectal area which contained some bowel movement. CNA A then removed her gloves and put on a clean pair of gloves. CNA A then took some barrier cream and applied some to the resident's rectal area and her gloves hand came in contact with the resident's rectal area. Next CNA A, while still wearing the same gloves that she used to apply the barrier cream to the resident's rectal area, took some more barrier cream and applied it to the resident's scrotum area with the same gloved hand that she used to apply the cream to the resident's rectal area. During a telephone interview on 02/26/25 at 10:52 AM CNA B said she recalled seeing CNA A applying some barrier cream to Resident #22's rectal area and then with the same gloved hand applying some barrier cream to the residents scrotum area. During an interview on 02/26/25 at 11:04 AM CNA A said she did not recall if she cross contaminated during the incontinent care. CNA A said she recalled wiping the residents bowel movement and then later applying the barrier cream to the resident's rectal area and then to the scrotum area. CNA A said if she had cross contaminated she had not meant to as she got so focused on what she was doing that she did not recall if she had cross contaminated. During an interview on 02/26/25 at 11:32 AM the DON said she was not quite sure that cross contamination had occurred. The DON said if the CNA had applied some barrier cream to the resident's buttocks area and then placed some cream to the scrotum did not necessarily mean that she had contaminated the resident's scrotum area unless the CNA really pressed into the resident's rectal area. The DON was made aware that CNA A had indeed applied barrier cream into the rectal area and had used that same gloved hand to then apply the barrier cream to the resident's scrotum which came in contact with the resident's penis and urethra area. The DON said she still believed it was not sufficient contact of barrier cream in between the rectal area or buttocks area and the scrotum area that it could lead to cross contamination. During an interview on 02/27/25 at 01:54 PM the Administrator said she did not have clinical background, so she was not sure if cross contamination was an issue in this case. The Administrator said she was aware that staff were supposed to wiped from front to back. During an interview on 02/27/25 at 02:35 PM with the ADON said she would do the proficiency audits with CNAs. The ADON said she would observe them wash their hands and give them pointers and check them off. The ADON said the proficiency's were done upon hire and annually. The ADON was told about the incontinent care and how CNA A wiped the bowel movement from Resident #22 and then applied barrier cream to the resident's rectal area and then to his scrotum area. The ADON said that CNA A should have changed her gloves before she applied the barrier cream to the residents scrotum. The DON said the CNA should have changed her gloves in case there was some fecal matter on the glove she used to apply the cream to the rectal area and then she would contaminate the scrotum area. The ADON said the failure could lead to UTIs or cross contamination. The ADON said the CNAs were trained to go from front to back or clean to dirty. The ADON said she had done the CNA proficiency with CNA A on 03/28/24 and she had done fine then. Record review of the facility's policy titled Infection control plan overview and dated 03/2023 indicated in part: Infection control - the facility will establish and maintain an infection control program designed to provide a safe and sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. Infection control program the facility will establish an infection control program under which it investigates, controls, and prevents investigations in the facility. Maintains a record of incidents and corrective actions related to infections. Record review of the facility's policy titled Perineal care dated 04/27/2022 indicated in part: This procedure aims to maintain the resident dignity and self-worth and reduce embarrassment by providing cleanliness and comfort for the resident, preventing infections and skin irritation, and observing the resident's skin condition. Equipment and supplies - personal protective equipment (e.g., gowns, gloves, mask, etc., as needed per standard precautions). Start: perform hand hygiene- DON gloves and all other PPE per standard precautions. Choose your PPE by considering the type of exposure, the durability and appropriateness for the task. Gently perform perineal care, wiping from Clean urethral area to dirty, rectal area to avoid contaminating the urethral area - clean to dirty. Always perform hand hygiene before and after glove use. Record review of the facility policy titled Fundamentals of infection control precautions dated 3/2023 indicated in part: A variety of infection control measures are used for decreasing the risk of transmission of microorganisms in the facility. These measures make up the fundamentals of infection control precautions. Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene: Before and after direct resident contact. Before and after assisting a resident with personal care (e.g., oral care, bathing.) Wearing gloves does not replace the need for hand washing because gloves may have small inapparent defects or be torn during use, and hands can become contaminated during removal of gloves.

Based on interview and record reviews, the facility failed to immediately consult with the resident's physician when there was a need to alter treatment significantly and a decision to discharge the resident from the facility to the hospital for 1 (Resident #1) of 3 residents reviewed for notification of changes. The facility failed to notify Resident #1's physician when Resident #1 was transferred and discharged to the hospital on 12/25/2024. This failure could place residents at risk of not having their change of condition communicated to their physician, delay of treatment, and a decline in the residents' health and well-being. The findings included: Record review of Resident #1's Facesheet, dated 01/01/2025, revealed Resident #1 was an [AGE] year-old female, with an admitted into the facility of 12/10/2024. Diagnoses included Unspecified systolic (congestive) heart failure (refers to a diagnosis of heart failure where the problem lies with the heart's ability to contract and pump blood effectively), Type II diabetes mellitus without complications (disease that occurs when the body does not use insulin properly, resulting in high blood sugar levels), Anemia with chronic kidney disease (occurs when the kidneys cannot produce enough erythropoietin (EPO), a hormone that signals the body to make red blood cells), and Essential (primary) hypertension (type of high blood pressure that develops gradually over time and no clear cause). Record review of Resident #1's Admission Minimum Data Set (MDS), dated [DATE], revealed Resident #1's BIMS score was 14, which indicated intact cognitive response. Record review of Resident #1's Progress Notes, dated 12/25/2024 at 10:44 p.m., documented by LVN B, revealed Resident #1, was sent to ER per resident request and family member request. Resident B/P continues to be high 199/80 with wrist cuff. Resident's B/P was 186/112 at 8:00 p.m., resident did not want to go to the ER at that time because she had been up and moving around, after the recheck, she called her family member and family member called the nurse home and told the nurse to send the resident to the ER, so the nurse went to the resident's room and told the resident her family member wanted her to go to the ER. During an interview on 01/01/2025 at 12:20 p.m., Resident #1's family member said Resident #1 called her and reported her blood pressure was high and Resident #1 needed to go to the emergency room . Resident #1's family member said she called the facility and spoke with LVN B and requested Resident #1 be sent to the ER. During an interview on 01/07/2025 at 11:11 a.m., the Administrator said when a resident was sent out by ambulance to the emergency room , her expectation was for the nurse to notify the physician and follow the facility policy. The Administrator said the physician should have been notified when Resident #1's blood pressure was elevated and when Resident #1 was transported to theER on [DATE]. The Administrator said lack communication could delay medical treatment. During an interview on 01/07/2025 at 11:31 a.m., Physician E said he was not notified when Resident #1 was transported to the emergency room due to high blood pressure on 12/25/2024. Physician E said he learned of the transfer and hospital admission on 12/31/2024 when he was notified by the facility after the fact. Physician E said it was his expectation for the facility to call him when a resident had elevated blood pressure. During an interview on 01/07/2025 at 1:05 p.m., LVN B said she was on duty 12/25/2024 when Resident #1's blood pressure was elevated, and Resident #1 was sent out the ER. LVN B said she took Resident #1's blood pressure at approximately 8:30 p.m., and recorded Resident #1's blood pressure reading at 186/112. LVN B said Resident #1 told LVN B that she did not want to go to the emergency room at that time because Resident #1 said she had been up moving around in her room. LVN B said she informed Resident #1 she would return and recheck her blood pressure in a few minutes. LVN B said she left Resident #1's room then received a call from Resident #1's family member who demanded Resident #1 be sent to the ER. LVN B said she immediately called 911. LVN B said Resident #1's family member arrived at the facility prior to the ambulance and Resident #1 was transported to the ER. LVN B said she had determined prior to Resident #1's family member phone call and arrival that she was going to transfer Resident #1 out by ambulance. LVN B said at the time of the incident, Resident #1 had received medical treatment and she was not sure why she failed to contact the physician and report Resident #1 was sent to the ER. During an interview on 01/07/2025 at 3:47 p.m., the DON said she was aware the physician for Resident #1 was not notified when Resident #1 was sent to theER on [DATE] due to high blood pressure. The DON said the nurse on duty was responsible to contact the physician, but she should also follow-up to ensure all notifications were made. The DON said by not contacting the physician, a delay in treatment could occur. Record review of the facility's policy, Notifying the Physician of Change in Status, dated 03/11/2013, revealed, the nurse should not hesitate to contact the physician at any time when an assessment and their professional judgement deem it necessary for immediate medical attention. The nurse will notify the physician immediately with significant change in status. The will nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record.

Based on observations, interviews and record review it was determined the facility failed to provide pharmaceutical services that ensure the accurate administering of drugs for 2 of 3 medication carts and 1 of 1 treatment cart observed for medications stored and properly labeled, in that:. Two of the medication carts had insulin pens that were opened but not dated when placed into use. The treatment cart had an opened undated TB vial. These failures could place residents at risk of receiving medications that were expired and not produce the desired effect. Findings included: During an observation and interview on [DATE] at 11:40 AM the treatment cart was inspected with the interim DON present. The interim DON was shown the opened and undated TB vial. The interim DON said she would have to first see what their policy indicated regarding opened TB vials. The interim DON was shown where the TB vial container indicated Once entered, vial should be discarded after 30 days and Store between (36 degrees and 46 degrees F). The interim DON said that perhaps whichever nurse placed it in the cart could have been in the process of discarding it. The interim DON said she would dispose of the vial. During an observation and interview on [DATE] at 12:28 PM the back hall medication cart was inspected with LVN C present. In the top drawer there were 2 insulin pens that had been opened but were not dated when opened. The manufacturer information on the pens indicated Use within 28 days after initial use. LVN C said she did not know who had opened the pens as other nurses had access to the cart as well. LVN C said she normally dated the pens and it was every nurses responsibility to date them or to check the cart for any undated pens. LVN C said she would remove the insulin pens and get some new pens. During an observation and interview on [DATE] at 12:40 PM the front hall medication cart was inspected with LVN B present. In the top drawer there was 1 insulin pen that had been opened but there was no open date on it. The manufacturer information on the pen indicated Use within 28 days after initial use. LVN B said she thought it was her that opened that pen sometime last week but was not sure what day it was. LVN B said she normally dated the pens when she opened them. LN B said it was each nurse's responsibility to date the pens once they were opened. During an interview on [DATE] at 12:02 PM the DON was made aware of insulin pens and the TB vial that were observed. The DON said her expectations were that they were supposed to be dated and initialed when opened. The DON said it was each nurses responsibility to make sure the insulin pens and TB vials were dated when opened. The DON said if the insulins or TB vials were not dated and then expired the medication would not be as effective or give a false reading. The DON said the failure probably occurred because the staff could have gotten distracted and forgotten to date them. During an interview on [DATE] at 12:34 PM the Administrator said he was aware of the insulin pens and TB vial not dated when opened. The Administrator said the insulins and TB vials were supposed to be dated when opened. Record review of the facility's policy titled Pharmacy policy and procedure manual dated 2003 indicated in part: A vial is considered opened if the stopper or seal has been punctured. Insulin storage recommendations at room temperature = KwikPen 28 days. Record review of the facility's policy titled Pharmacy policy and procedure manual dated 2003 indicated in part: Medication that require an Open date as directed by the manufacturer should be dated when opened in a manner that it is clear when the medication was opened. Below is a list of medications that require a date when opening and the recommended time frame the medication should be used. This is not an all-inclusive list and the manufacturer recommendations will supersede this list - Insulins (Vials, cartridge, pens), Multidose vials for injection (sterile water, vaccines, etc) unless otherwise noted-expire 30 days after first puncture.

Based on observation, interview and record review the facility failed to store all drugs and biologicals in locked compartments for 1 of 1 treatment cart and 2 of 3 nurse carts reviewed for medication storage and security. The treatment medication cart was left unlocked and unsupervised. The nurse medication carts were left unlocked and unsupervised. These failures could place clients at risk for drug diversion or accidental ingestion. Findings included: During an observation and interview on 01/16/24 beginning at 11:27 AM a medication cart was seen unlocked and unattended. There were a couple of residents that passed by the unlocked medication cart. LVN A entered into the building from an outside door and said it was her cart and she had just stepped out. LVN A said she usually locked cart when she stepped away. Inside the cart were several medications in blister packets and some insulin pens. During an observation and interview on 01/16/24 at 11:33 AM the treatment cart was seen unlocked and unattended. LVN B said the cart was supposed to be locked at all times and was not sure who left it unlocked. Inside the cart were some antimicrobial wipes, medicated creams, wound cleanser spray bottles and an opened TB vial. During an observation on 01/16/24 beginning at 12:47 PM the back hall nurse medication cart was left unlocked and unattended for approximately 17 minutes. During an interview on 01/16/24 at 1:05 PM LVN C said she had stepped away from the medication cart and forgot to lock it. LVN C said she always locked it and might have been called away and left it unlocked. LVN C said if the cart was left open and unattended residents could get into it and injure themselves. During an interview on 01/18/24 at 12:12 PM the DON was made aware of the unlocked carts observed. The DON said her expectations were that the carts should be locked if unattended. The DON said it was each nurses responsibility to make sure their carts were locked when they stepped away. The DON said the failure probably occurred because the staff could have gotten distracted and walked away and forgot to lock it. During an interview on 01/18/24 at 12:34 PM the Administrator said he was aware of the carts left unlocked and unattended. The Administrator said the carts were expected to be locked when not in use. Record review of the facility's policy titled Medication Carts indicated in part: The carts are to be locked when not in use or under the direct supervision of the designated nurse.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for two (Resident #42 and #29) of 4 residents reviewed for infection control in that; LVN C closed the faucet with her bare hands after she had washed her hands after assisting Resident #42. CNA E failed to perform incontinent care to Resident #29's peri-area after the resident used the urinal. These failures could place resident's risk for cross contamination and the spread of infection. Finding included: RESIDENT #42 Record review of Resident #42's admission record dated 01/17/24 indicated he was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease and dyspnea (shortness of breath). He was [AGE] years of age. Record review of Resident #42's MDS dated [DATE] indicated in part: BIMS = 08 indicating resident had moderately impaired. Record review of Resident #42's order summary report dated 01/17/2024 indicated in part: O2 @ 2-4 L/M VIA NC PRN as needed. Order date 11/04/2023. During an observation on 01/16/24 at 12:18 PM LVN C transferred Resident #42 into his bed and then placed the oxygen nasal cannula on him. LVN C then turned the faucet on and washed her hands, after she washed them, she closed the faucet with her bare hands and then dried them with some paper towels. LVN C then opened the door of the resident room and exited the room. During an interview on 01/16/24 at 1:46 PM after LVN C said the way she usually washed her hands was by turning the faucet on, washing her hands with soap and water, drying them and then using a paper towel to close the faucet. LVN C said the reason she used a paper towel to close the faucet was to prevent re-contaminating her hands. LVN C said if she closed the faucet with her bare hands then she could possibly re-contaminate herself and spread germs to other people. LVN C said she had messed up and forgot to close the faucet with a paper towel. RESIDENT #29 Record review of Resident #29's admission record dated 01/18/24 indicated he was admitted to the facility on [DATE] with diagnoses of muscular dystrophy (disease that cause progressive weakness and loss of muscle mass) and muscle weakness. He was [AGE] years of age. Record review of Resident #29's care plan dated 08/27/21 indicated in part: Focus: The Resident has occasional episodes of bowel and bladder incontinence. Goal: Resident will remain clean, dry, odor free and dignity will be maintained through the review date. Interventions: INCONTINENT care at least every 2 hours and apply moisture barrier after each episode. Record review of Resident #29's MDS dated [DATE] indicated in part: BIMS = 15 indicating resident was cognitively intact. During an observation on 01/17/24 at 09:35 AM CNA E performed incontinent care for Resident #29. CNA E first wiped the resident's rectal area as the resident had a bowel movement. CNA E then placed the urinal on the resident's penis to urinate. After Resident #29 urinated CNA E emptied the urinal, covered the resident and did not perform incontinent care to the residents penis or scrotum area. CNA E removed her gloves and then turned the faucet on washed her hands then closed the faucet with her bare hands. During an interview on 01/17/24 at 09:44 AM CNA E said she normally performed incontinent care to the resident's penis and scrotum area but had forgotten this time because she was nervous as she was being observed by the surveyor. CNA E said if she did not perform incontinent to Resident #29's penis area it could lead to infections or bad odors. CNA E said she should have closed the faucet with a paper towel after she washed her hands. CNA E said she got nervous and forgot that step but that she normally closed the faucet with a paper towel to prevent re-contamination of her hands which could possibly lead to the spread of germs. During an interview on 01/17/24 at 09:55 AM Resident #29 said he was not able to move his arms or hands or hold the urinal due to his condition. Resident #29 said he depended on staff to hold the urinal for him and the cleanse his peri-area since he could not do that. During an interview on 01/18/24 at 12:16 PM the DON was made aware of staff using their hands to close the faucet after they had washed them. The DON said it was expected for staff to use a paper towel to close the faucet. The DON said they orientated staff upon hire and conducted yearly audits. The DON said if staff did not use a paper towel to close the faucet, they could re-contaminate their hands. The DON said the failure probably occurred because the staff got nervous and forgot their steps. The DON was made aware of the incontinent observation performed by CNA staff. The DON said her expectation was for staff to perform pericare to the front as well and not just their bottom to prevent infections. The DON said she believed that staff got nervous and just did not do it. During an interview on 01/18/24 12:34 PM the Administrator was made aware of staff using their hands to close the faucet after they had washed them. The Administrator said they would conduct more training and in-services. The Administrator was made aware of the incontinent observation performed by CNA staff. The Administrator said staff were expected to perform thorough incontinent care and would be re-trained on providing personal care. Record review of the facility's policy titled Nursing personal care - Perineal care and dated 05/11/2022 indicated in part: This procedure aims to maintain the resident dignity and self-worth and reduce embarrassment by providing cleanliness and comfort to the resident, preventing infections and skin irritation and observing the resident's skin irritation. Male resident: Pull back the foreskin on uncircumcised males. Hold penis by the shaft. Wash in a circular motion from the tip down to the base. Continue perineal care to the scrotum and inner thigh. Record review of the facility's policy titled Infection control policy and procedure and dated 2019 indicated in part: Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene: Before and after resident contact. Recommended techniques for washing hands with soap and water included: Wetting hands first with clean, running warm water, apply the amount of product recommended by the manufacturer to hands and rubbing hands together vigorously for at least 20 seconds covering all surfaces of the hands and fingers then rinsing hands with water and drying thoroughly with a new disposable towel and turning off the faucet on the hand sink with the disposable paper towel. Record review of the facility's policy titled Infection control plan and dated 2019 indicated in part: The facility will establish and maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection.

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #42) reviewed for accident hazards in that: LVN C and CNA D did not demonstrate appropriate transfer techniques for Resident #42. This failure could put residents at risk of accidents and serious injuries which could result in a reduced quality of life. Findings included: Record review of Resident #42's admission record dated 01/17/24 indicated he was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease and muscle weakness. He was [AGE] years of age. Record review of Resident #42's care plan dated 01/12/24 indicated in part: Focus: The resident has an ADL Self Care Performance Deficit r/t weakness, sequencing issues. Date Initiated: 11/01/2023. Interventions: TRANSFER: The resident has requires 1-2 staff participation with transfers. Date Initiated: 11/28/2023. Record review of Resident #42's MDS dated [DATE] indicated in part: BIMS = 08 indicating resident had moderately impaired. Functional ability status - Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair) = 02. Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. During an observation on 01/16/24 at 12:16 PM LVN C and CNA D transferred Resident #42 from his Geriatric chair to his bed. Both staff members took the resident from underneath his arm pits and from the back of his pants. During the transfer the resident's feet slid some as he was wearing regular socks. During an interview on 01/16/24 at 1:38 PM LVN C said Resident #42 was a 2-person transfer. She said they normally transferred the resident like they did by taking him from underneath his armpits and by the back of his pants. LVN C said they did not use a gait belt because it would hurt Resident #42 and he had general pain. LVN C said he was a 1 person transfer but had declined more and was now a 2 person for transfers. During an interview on 01/16/24 at 2:12 PM CNA D said it had not been that long since Resident #42 was able to help more with assistance. CNA D said at other times they used to transfer the resident by one staff taking him from under his armpit and under his leg and the other staff doing the same on the other side. CNA D said she had not used the gait belt while transferring Resident #42 but maybe they should or also consider using the mechanical lift. CNA D said she knew what transfer status each resident was by looking at that resident's care plan on their POC. CNA D demonstrated where the POC was on the computer and searched Resident #42's POC which indicated resident required 1-2 staff for transfers. During an interview on 01/17/24 at 3:28 PM the DOR said they had done some training with a new CNA class about a month ago regarding transferring residents. The DOR was made aware of the transfer observation conducted on Resident #42 by LVN C and CNA D. The DOR said that she did not recommend residents by transferred liked that as that was not a proper way. The DOR said Resident #42 should probably be transferred with a mechanical lift from now on and that she would be looking into that. The DOR said unfortunately she was not aware too much of the transfer status of Resident #42 since his payor source and the resident being on hospice would not cover him receiving therapy services. During an interview on 01/18/24 at 11:53 AM the DON was made aware of Resident #42's transfer observation. The DON said that was not a proper way to transfer a resident. The DON said staff could see on the resident's POC and see what their transfer status was and all staff had access to that. The DON said they had conducted training transferring yesterday regarding proper transferring as they were already aware of the transfer. The DON said it was expected for staff to clarify what the resident's transfer status was and apply a gait belt almost during any situation for transfers unless they were a mechanical lift transfer. The DON said the staff could drop the resident, cause a skin tear or bruise them by transferring them like that. The DON said she believed the failure occurred because of possible lack of experience from the staff. During an interview on 01/18/24 at 12:34 PM the Administrator was made aware of the transfer observation. The Administrator said he was aware of the transfer and it that was inappropriate and they would conduct more trainings on transfers. Review of the facility's policy titled Moving a resident bed to chair/chair to bed and dated 2003 indicated in part: The purposes of this procedure are to allow the resident to be out of his or her bed as much as possible and to provide for safe transferring of the resident. If moving a resident from chair to bed: Place the chair so that it touches the side of the bed and faces the foot of the bed. Position a gait belt around the resident's waist and clasp it. Make sure it is tight enough that only a slight hand movement will guide the patient but not so tight that you cannot firmly grasp the belt without making the patient uncomfortable. If the resident requires two person (one on each side) should grasp the gait belt and gently stand and turn the resident and sit him or her on the edge of the bed.

Based on observation, interview, and record review, the facility failed to ensure that residents who received nutrition by enteral means received the appropriate treatment and services for 1 of 1 resident (Resident #2) reviewed for enteral feeding. The facility failed to ensure that Resident #2's enteral feeding bag was correctly labeled and dated. This failure could result in the resident receiving formula that is not appropriate for the treatment/service for the resident. Findings included: Record review of Resident #2's admission summary revealed resident was a [AGE] year-old-male admitted on [DATE] with diagnoses which included Traumatic brain injury, dysphasia (difficulty swallowing), aphasia (difficulty with speech), muscle wasting atrophy (loss of muscle mass), and gastroesophageal reflux (liquid content of the stomach back flows into the tube connecting the mouth and stomach). MDS dated [DATE] shows the resident relies on tube feeding for 51% or more for caloric intake, receiving 501 cc/ml of tube feeding daily. BIMS is not calculated. Resident was able to answer Yes/No questions by shaking his head. Observation on 1/16/2024 at 12:30 pm of Resident #2's room revealed an enteral feeding bag labeled only with the resident's name infusing via pump at 50 cc per hour. Interview on 01/17/24 at 03:08 PM LVN G stated everything used for tube feeds such as the feeding itself, tubing, syringe, and water should be dated every time the feeding was changed to ensure accurate care. LVN G stated if items were not dated staff could not guarantee when it had been changed. Interview on 01/18/24 at 09:51 AM LVN F stated that the tube feeding bag should be labeled with the name of resident, initial of who hung the feeding and date when the feeding was hung. She stated the date was important to know to be sure the feeding was running appropriately and to ensure they kept the feeding fresh. Interview on 01/18/24 at 02:10 PM with DON stated that tube feeding bags should be dated, timed, initialed and have what the pump should be running at written on the bag. This was to ensure the pump was set appropriately according to the order and to ensure the feeding was running without complication. If not, the resident could not be receiving nutrition. This practice also helped ensure the feeding was being changed appropriately. The nurses are responsible for ensuring the resident's tube feeding is managed per order. Record review of facility policies titled Enteral Nutrition dated 2003, revised 2/13/07 and Enteral Medication Administration dated 2003, revised 1/25/13 did not address the labeling of the enteral feeding bags used by the facility. The facility used prefilled bags of formula rather than an all-in-one system as described in the facility policy. All identifying information for the resident and formula had to be written onto the bag by the nurse administering or preparing the feeding.

Based on interview and record review, the facility failed to send a copy to the Office of the State Long-Term Care Ombudsman, of the transfer or discharge of a resident for one (Resident #1) of 1 resident reviewed for discharge rights. The facility failed to send a copy of the written notice of discharge to the Ombudsman when Resident #1's was being discharged immediately. The failure could affect resident by placing him at risk of not having access to available advocacy services. The findings included: Record review of Resident #1's face sheet revealed he was admitted on [DATE] and was discharged on [DATE]. Resident was an [AGE] year-old male with diagnoses that included: Dementia, Kidney failure, PTSD, and adult failure to thrive. Record review of Resident #1's Physicians order dated 03/16/2023 revealed no evidence of documentation to address reason the resident was being discharged , the needs of the resident the facility could not meet, and how the resident posed a danger to the existing resident population. Record Review Resident #1 nursing progress note dated 3/13/2023 at 4:23 PM revealed: Fax sent to Dr.'s office in regard to resident caught in another woman's room, tucked her into bed and kissed her. Resident had been redirected. Resident was constantly getting into other residents' room, taking their personal belongings, and taking food. Resident was touching everything in dining area. Administrator is looking for new placement for resident. Record review of Resident #1's nursing progress note dated 03/14/2023 10:24 PM revealed: Resident was down on south hall trying to enter Resident #2's room. When resident was redirected, he became very agitated and upset with resident started to scream and yelling and stated, that was his f . wife and he needed to see her. Resident was redirected down to north hall to his room with resident been very upset. With continued redirecting and explanation from nurse, she was not his wife, Resident #1 grabbed nurse's cheek and stated, it is his f . wife and to call his daughter. Record review of Resident #1's progress note dated 03/14/2023 6:40 PM revealed: Resident #1 was redirected from a female resident's room. Record review of Resident #1's SW Progress Note revealed no evidence of documentation to address reason the resident was being discharged , nor the needs of the resident the facility could not meet, and how the resident posed a danger to the existing resident population. Review of Resident #1's closed medical records reflected no evidence the State Ombudsman was notified by phone or in writing of resident's discharge. Further review of Resident #1's closed records reflected no referral to a higher level of medical or psychiatric care due to resident's dangerous and acute behaviors and subsequent immediate discharge. During an interview on 07/05/2023 at 3:13 PM, the DON stated she had been made aware of Resident #1 the morning of 07/05/2023 but did not work at the facility during the time of the incident. She stated she was told Resident #1 had been sent for a referral to assess his psychological needs which afterward was transferred to a VA home. The DON stated she was unable to give any further information on the incident. During an interview on 07/05/2023 at 3:25 PM, the SW stated the RR was helping them look for alternate placement. She stated there were no letters sent to the Ombudsman and did not feel the need to have the Ombudsman involved. She felt the discharge was facility initiated but stated since the family had already known of the discharge did not feel the Ombudsman needed to be notified. During an interview on 07/05.2023 at 3:53 PM, the RR stated it was the facility that suggested to her that Resident #1 needed to go somewhere else if possible. She stated she never spoke to the Ombudsman nor made aware she was available. During an interview on 07/05/2023 at 4:00 PM, The Interim ADMN stated the rules were different with VA residents and stated it was his understanding when residents were sent to a VA facility, there would be no need for the DC paperwork to be sent to the Ombudsman. During an interview on 07/06/2023 at 11:37 AM, the Ombudsman stated she did not have notifications concerning Resident #1's discharge. She stated this made her nervous that residents may have slipped through the cracks. She stated the last email received from ADMN was 01/2023, before the discharge of Resident #1. The Ombudsman stated anyone leaving facility should be on the monthly report so she could follow up. She stated even VA Residents were considered the same as any other residents and she should have been contacted about Resident #1. She also stated with any (Facility Related, or Resident Related) discharges, she should be notified in the monthly report as to their transfer so she can follow up with the resident and not slip through the cracks. During an interview on 07/06/2023 at 11:51 AM the previous ADMN stated he had spoken to RR telling her his concerns of Resident #1's behaviors. He stated typically there was an email they send to the Ombudsman on a monthly basis. He stated that should have been done per MR and felt it had. The previous ADMN stated he did not feel there was a negative impact for Resident #1 as the RR was involved and knew about the transfer. He stated the facility always involved the Ombudsman with discharges and with Resident #1 did not feel there was a failure. His expectations for discharge letters to go to the Ombudsman so she could follow up with the residents needs in being placed where needed. During interview on 07/06/2023 at 12:34 PM, MR stated that she was unaware of any letters that were sent to the ombudsman for resident any discharges. She also stated she was not sure if anyone in the facility sends any discharge letters. During interview on 07/06/2023 at 1:32 PM, the Interim ADMN, SW and DON stated there were no further documents to provide before the exit conference. A record review of the Facility's Policy titled Discharge or Transfer to another Facility not dated, revealed: Facility Initiated Discharge . .A. The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility . .C. These safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident . .Notification of Discharges For facility-initiated transfer or discharge of a resident the facility will notify the resident and the residents representative(s) of the transfer or discharge and the reasons for the move in writing and in language and manner they understand. Additionally, the facility will send a copy of the notice of transfer or discharge to the representative of the Office of the State Long-Term Care (LTC) Ombudsman.

Based on observations, interview, and record review the facility failed to ensure that 3 of 4 (Residents #32, #34, and #47 ) residents reviewed for respiratory care were provided care consistent with professional standards of practice in that: Resident #32 did not have her SVN mask bagged when not in use. Resident #34 did not have her CPAP mask bagged when not in use. Resident #47 did not have his nebulizer bagged when not in use. This deficient practice could place residents who received oxygen treatments at risk of respiratory infection. Findings include: Resident #32 Review of Resident #32's Admission Record, dated 11/30/22, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included major depression, single episode and generalized anxiety disorder. Review of Resident #32's quarterly MDS Assessment, dated 11/4/22 revealed she was on oxygen. Review of Resident #32's care plan, updated 7/14/22, revealed Focus: Resident has a Respiratory Infection. Goal: The resident will be free from signs or symptoms of infection by the review date. Interventions/Tasks: Bronchodilators via nebulizer as ordered by physician. Review of Resident #32's Order Summary Report, dated 11/30/22, revealed orders dated 9/15/22 for Albuterol Sulfate Nebulization Solution 0.083% vial inhale orally via nebulizer four times a day related to Chronic Obstructive Pulmonary Disease . Observation on 11/27/22 at 11:27 a.m. revealed Resident #32 was in her room. She had an SVN mask on her nightstand, that was open to air, not bagged and not in use . Resident #34 Review of Resident #34's Admission Record, undated, revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included sleep apnea, and chronic obstructive pulmonary disease. Review of Resident #34's quarterly MDS assessment, dated 8/20/22, revealed: She scored a 15 of 15 on her mental status exam with no signs of delirium indicating she was cognitively intact. She received oxygen therapy. BiPAP/CPAP was not checked. Review of Resident #34's care plan, updated 12/06/2020, revealed: Focus: Resident has a history of Chronic Obstructive Pulmonary Disease, Sleep Apnea, and seasonal allergies. She uses oxygen and CPAP. Review of Resident #34's Order Summary, dated 11/30/22, revealed orders for CPAP to be worn at bedtime every night shift dated 7/30/2 2. Observation on 11/28/22 at 11:20 a.m. revealed Resident #34 was in her room. Her CPAP mask was on the made bed, not bagged and not in use. Resident #47 Review of Resident #47's Admission Record, dated 11/28/22, revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included atherosclerosis of arteries to the right leg; atherosclerotic heart disease ; muscle weakness; muscle wasting; hypertension; chronic kidney disease; and type 2 diabetes mellitus. Review of Resident #47's care plan, updated 10/28/22, revealed, Focus: Resident is at risk of hypertension and hyperlipidemia and is at risk for complications. Goal: The resident will remain free from complications related to hypertension and hyperlipidemia through the review date. Interventions/Tasks: Monitor for signs and symptoms of malignant hypertension: headache, visual problems, confusion, disorientation, lethargy, nausea, vomiting, difficulty breathing. Observation on 11/29/22 at 08:30 a.m. revealed Resident #47 was not in his room. He had a nebulizer on the bedside table along with a dirty breakfast tray. The mouthpiece was touching the surface of the bedside table. Interview on 11/30/22 at 2:05 PM the Corporation RN stated the expectation was nebulizer tubing be changed weekly and bagged when not in use. She said the same thing for CPAP masks, they were to be bagged when not in use. She said the DON or designees did periodic checks to monitor for compliance. Record review of the facility's policy titled, Oxygen Administration, revised [DATE], reflected in part, the resident will be free from infection; change the tubing (including nasal prongs or mask) when it becomes visibly contaminated; oxygen concentrators should be cleaned according to manufacturer recommendations; change or clean oxygen concentrator filters according to manufacturer recommendations.

Based on interview and record review the facility failed to ensure that residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record for one (Resident #32) of 5 residents reviewed for unnecessary medications. Resident #32 was placed on the antipsychotic Olanzapine without an appropriate indication for use. Resident #32's antipsychotic Olanzapine was increased without indicator documented supporting the increased dosage. These failures put residents at increased risk of side effects as a result of being administered an unnecessary antipsychotic. Finding include: Review of Resident #32's Admission Record, dated 11/31/22, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included major depression and single episode and generalized anxiety disorder. She was admitted under hospice services. Review of Resident #32's quarterly MDS Assessment, dated 11/4/22 revealed: She scored a 15 of 15 on her mental status exam indicating she was cognitively intact. She showed no signs of delirium. She scored a 3 of 27 on her depression screening (indicating active depressive symptoms) She had no behaviors such as delusions or hallucinations identified. Her flagged medications included an antipsychotic medication for 7 of 7 days. Review of Resident #32's Care Plan, updated 8/2/22, revealed: Focus: Resident requires anti-psychotic medications. Goal: Resident will remain free of drug related complications including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction, or cognitive/behavioral impairment through review date. Secondary Goal: Resident will reduce the use of psychoactive medication through review date. Interventions included: 1) Administer medications as ordered. Monitor/Document for side effects and effectiveness. 2) Discuss with doctor, family about ongoing need for use of the medications. Review of Resident #32's Order Summary Report, dated 11/30/22, revealed she was on psychotropic medications including antipsychotic Olanzapine 10 mg at bedtime for major depressive disorder, order date 7/7/22. Review of Resident #32's Admission Monthly Pharmacy Review, dated 5/18/22, revealed Resident #32 was on the psychotropic medications of the antianxiety Clonazepam and the antidepressant Mirtazapine only. Review of Resident #32's Progress Notes revealed: Nursing Note on 5/31/2022 at 9:04 a.m. the hospice nurse here to visit resident, she was very upset claiming that a doctor or someone in a gray suit was spraying raid to kill cockroaches outside her room and across the hall. The hospice nurse went and asked around to everyone if they were spraying anything in or around the resident's room and did not find anyone. The hospice nurse also tried to calm the resident down with no effective result. The hospice nurse ordered a one-time, extra dose of Clonazepam and then 1- 5mg tab every day as needed. This additional dose did help calm the resident down but was still insisting they were all in This together and did not believe her. Nursing Note on 6/2/2022 at 1:35 p.m.: Received new order from hospice for Olanzapine 5 mg by mouth at bedtime. The pharmacy and responsible party notified. Social Services Note on 6/13/2022 at 11:32 a.m.: Resident participated in the MDS assessment today. She scored a 15 on her cognition test indicating that her memory was good. She scored a 16 on her mood which was significant for depression. (There was no documentation about significant behaviors, hallucinations, or delusions) Nursing Note on 7/7/22 at 2:01p.m.: New order to increase Olanzapine to 10 mg every night at bedtime. Nursing Note at 11/16/2022 at 1:41 p.m.: Hospice was contacted by this LVN. The resident's family requested a medication review due to insomnia and sleepiness during the day. 8:00 a.m. meds changed to 7:00 p.m. and resident/family made aware. Review of the Resident #32's available hospice notes revealed, in part, dated 07/5/22 (prior to the increase): Female with COPD, comorbidities included depression and anxiety. She was alert and oriented with intermittent confusion and hallucinations. She had increased anxiety requiring an increase in as needed antianxiety. The antipsychotic was added for the hallucinations with improvement. Interview on 11/30/22 at 02:05 p.m. the Corporate RN and the ADON reveled Resident #32 had respiratory symptoms, occasional confusion in the evening and was on hospice. The ADON stated Resident #32 liked to keep to herself. She said Resident #32 was on Olanzapine for depression. She said an antidepressant was not an indication for use of an antipsychotic. The ADON stated the antipsychotic use was probably for her anxiety. She said an antipsychotic was not indicated for the treatment of anxiety. The ADON stated the facility contacted hospice and the hospice agency managed her medication. The Corporate RN stated Resident #32 was admitted to the facility on hospice and on the antipsychotic. She was informed Resident #32 was not on any antipsychotic when she was admitted to the facility. The Corporate RN reviewed the available hospice records and could not find any documentation supporting the increase in the Olanzapine. They did not answer if anyone asked the hospice agency why the antipsychotic was increased . Interview on 11/30/22 at 4:03 p.m. Resident #32 stated her medications made her sleepy, dizzy, and nauseated. She stated she was going to fall again because she fell eight times through 2022. She stated she fell backwards, and it was scary. Resident #32 said she did not know what medications she was on. She stated she just knew she had anxiety and panic attacks. She said she did not see things that other people were not seeing and that things just got strange. Resident #32 said she did not know when the last time it happened was just a while back. Interview on 11/30/22 at 5:17 p.m. Resident #32's doctor stated Resident #32 started having hallucinations in June of 2022. She said the hallucinations were of a man spraying for roaches in her room. The Doctor stated Resident #32 was placed on Olanzapine 5 mg at bedtime which helped but Resident #32 still saw roaches, so she increased the dose to 10mg in July 2022. The Doctor stated Resident #32 seemed to be doing well on the increased dose. The Doctor stated Resident #32 had a history of psychosis prior to admission to facility. She stated they had discussed Resident #32's use of the medication and hallucinations in the interdisciplinary team meetings. The Doctor said it should be documented in her chart. The Doctor said she was certain the hospice chart had documentation of the medication indication, the hallucinations, and the resident's medical history prior to admission. She stated she would have hospice send all records to the facility to add to the resident's chart . Interview on 11/30/22 at 5:50 PM the Administrator stated the nurses should have been documenting on Resident #32 after she began the antipsychotic medication. He confirmed there was no documentation after the progress note about the man spraying for roaches. He said there was no follow-up documentation by facility staff in Resident #32's chart about the Olanzapine or Resident #32's behavior after the medication was started or what happened after the dosage was increase. The Administrator said the facility was aware of Resident #32's history of psychosis when she was admitted . He stated he could not explain why there was no documentation to support the diagnosis in her chart. The Administrator said he was unsure why the ball got dropped on Resident #32 because the staff were typically very good about documenting or monitoring behaviors and the facility worked hard to keep the antipsychotic use in the building low. Review of the facility's policy and procedure on Psychotropic Drugs, revised 10/25/17, revealed: The intent of this policy is that each resident's entire drug/medication regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial wellbeing. The facility must will ensure that - Resident who have not used psychosocial drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. Antipsychotic Medications - as with all medications, the indication for any prescribed antipsychotic must be thoroughly documented in the medical record. While antipsychotic medications may be prescribed for expressors or indications of distress, the interdisciplinary team must first identify and address any medical, physical, psychological causes, and/or social/environmental triggers. Any prescribed antipsychotic medication must be administered at the lowest possible dosage for the shortest period of time. Diagnoses alone do not necessarily warrant the use of antipsychotic medication. Antipsychotic medications may be indicated if: Expressions or indications of distress that are significant distress to the resident. If antipsychotic medications are prescribed, documentation must clearly show the indication for the antipsychotic medication, the multiple attempts to implement care-planned, non-pharmacological approaches, and ongoing evaluation of the effectiveness of these interventions.

Based on observation, interview and record review, the facility failed to establish and maintain a resident environment that is free of accident hazards for shower room [ROOM NUMBER] of 4 shower rooms. The South Hall shower room was unsecured and unattended, leaving razors, shampoo, denture cream, shaving cream, and fingernail clippers accessible to residents. Residents could injure themselves or ingest materials, placing them at risk of harm. Findings included: Observation on 11/29/22 at 08:40 AM revealed the shower room located on the South Hall was open and unlocked. There was no staff was in sight on the hall. The shower room had a cabinet that was unlocked. The unlocked cabinet revealed 10 disposable razors, a quart of shampoo with a pump, 2 tubes of denture cream, 2 bottles of shaving cream, and a large pair of fingernail clippers. On 11/29/22 at 08:40 AM the Administrator came into the shower and stated that [CNA A] is probably getting ready to shower someone and left it open. Five minutes later, the ADON came by and locked the door. In an interview on 11/30/22 at 11:00 AM the Administrator stated it was not normal practice to leave the shower door unlocked. The Administrator stated they did not want any residents getting into the shower room unattended. The Administrator stated there was shampoo and other items that could harm them. The Administrator stated they could slip and fall and there would be no way for staff to know they were in there or for them to call for help. In an interview on 11/29/22 at 09:43 AM CNA A was working South Hall and stated it was important to lock the shower room when not occupied because residents could go in slip on a wet floor and fall. CNA A stated they also had chemicals that they did not want residents getting into and there were razors they could hurt themselves with. The CNA stated that she would ensure door stays locked and would remind the other CNA's to keep it locked as well. Record review of the facility's policy titled, General Safety Policy, dated 2003, reflected in part, employees will report all unsafe or potentially hazardous acts or conditions to the supervisor immediately. Record review of the facility's policy titled, Preventative Strategies to Reduce Fall Risk, dated 10/5/2016, reflected in part, The goal of fall prevention strategies is to design interventions that minimize fall risk by eliminating or managing contributing factors and maintain non-slip floor surface.

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 (Residents #6) of 7 residents reviewed for activities of daily living as evidenced by: 1) Resident #6 fell out of Hoyer lift due to strap breaking, receiving a fracture to right femur, when aides used a Hoyer sling that was brittle and not designated for resident. This failure could place residents at risk of not being transferred correctly and could lead to a fall resulting in injury to resident. Findings include: Record Review of Resident #6's Face Sheet, undated, revealed she was a [AGE] year-old female admitted on [DATE] with the following diagnoses; [MEDICAL CONDITION] with hypercapnia, [MEDICAL CONDITION], Muscle weakness, [MEDICAL CONDITION], Sleep apnea, Type 2 diabetes, Hypertension, Malignant neoplasm of uterus, [MEDICAL CONDITION], and Vitamin D deficiency. Review of Resident #6's Annual MDS dated [DATE], revealed a BIMS of 15 (no cognitive deficiency) MDS revealed Resident #6 required extensive assistance of two staff to transfer, dress, toilet use, bath and personal hygiene. She utilized a wheelchair for a mobility device. MDS revealed Resident #6 had no falls, utilizes oxygen, had [MEDICAL CONDITION], had occupational therapy. MDS revealed Resident #6 had no preference (what is important) between showers, bed baths or sponge baths. MDS revealed Resident #6's weight at 451 pounds. Review of Resident #6's Care Plan, dated 12/10/19, revealed ADL Self Care Performance Deficit related to [MEDICAL CONDITION] and weakness and required assistance with transfers (using Hoyer lift) and bathing. Revealed a Risk for Falls due to obesity and weakness and revealed Resident #6 refused to be weighed, refused blood sugar checks and refused to let staff get oxygen saturation readings In an interview on 2/14/20 at 10:22 a.m. Resident #6 (In-Hospital) stated she fell out of Hoyer sling, after strap broke on right lower extremity, resulting in a fracture to Right femur. Stated that she had always felt anxious when the Hoyer lift was used and stated she informed staff that a bed bath would be acceptable occasionally. Stated she never informed staff that she would not like to use Hoyer. Resident #6 stated she had not had an accurate weight due to scale having different readings, so she is unsure of her weight at this time. Resident #6 stated that when she fell out of sling she landed on the floor on her buttocks. Stated she is unsure how her Right lower extremity landed when she fell but stated that the staff had to lift her right leg to remove Hoyer lift from beneath it. Resident #6 stated that aides at facility had lifted her from her bed with Hoyer and transferred her to shower room (stated shower is two doors down hall from her room). Stated that after her shower aides had lifted her out of shower chair and was taking her back to her room and when they entered her room is when strap broke. Stated she was not aware of details after this occurred. Resident #6 stated that she was very anxious about recent incident and stated she had been informed in (MONTH) 2020 (by her oncologist) that the spots on her lungs had increased. Stated she is having trouble processing everything that had occurred over the last two months. In an interview on 2/14/20 at 10:45 a.m. Hospital RN stated Resident #6 arrived at hospital for treatment of [REDACTED]. Stated that traction is the usual treatment but due to Resident #6's obesity and Resident #6 being bed-ridden for years and Orthopedic physician made the decision to not provide usual treatment and applied a soft cast to keep extremity immobile. Hospital RN stated that the emergency room did not obtain a weight at time of admission. Stated that resident has not been able to bend knees for years and when she took over care of Resident #6 she was complaining of pain to bilateral knees. Observation on 2/14/20 at 11:08 a.m. Hospital RN obtained current weight for Resident #6 (bed scale) with a reading of 151.4 kilograms (333 pounds). In an interview on 2/14/20 at 1:25 p.m., LVN A stated that on the day of incident (2/11/20) she was on the opposite end of hall (from Resident #6) passing medications when she was informed by aides that Resident #6 had fallen out of Hoyer sling. Stated she immediately went to Resident #6's room, upon entering room Resident #6 was lying on the floor with her Right lower extremity on top of Hoyer lift leg and Resident #6's head was lying on top of the other Hoyer leg (with pillow under head). LVN A stated the Hoyer was standing and did not fall over, stated with the assistance from aides Resident #6's leg and head were lifted to remove Hoyer. LVN A stated she performed assessment of Resident #6 and contacted EMS for assistance with transferring Resident #6 up off the floor. LVN A stated that aides and firefighters transferred Resident #6 back to her bed using Hoyer lift, stated they did not use sling that broke and used two slings (at one time) to lift Resident #6 off the floor and ensure slings would not break again. After Resident #6 was transferred back to bed her physician ordered a portable x-ray of Right hip and Right lower extremity to be done at facility. When x-ray technician arrived at facility and performed x-rays they observed fracture and contacted physician who ordered Resident #6 to be transferred to emergency room for assessment with orthopedic physician. LVN A stated that she had never witnessed aides in the facility transferring Resident #6 to shower using Hoyer lift. LVN A stated that she had observed aides transporting Resident #6 to shower in shower chair. LVN A stated that she had never had any prior incidents with Hoyer lift or slings prior to this. In an interview on 2/14/20 at 2:27 p.m. CNA A stated that on day of incident with Resident #6 (2/11/20) she was picking up breakfast trays with CNA B when Resident #6's call light came on. CNA A stated that she answered call light assisted Resident #6 off bed pan and informed Resident #6 that she would return with CNA B to transfer to shower care for scheduled shower. CNA A stated that Resident #6 did not say anything about not using Hoyer or bed bath. CNA A stated Resident #6 was transferred from bed to shower chair (in Resident #6's room) and taken to shower room in shower chair. CNA A stated that CNA B was performing shower while she changed Resident #6's bedding. CNA A stated that when CNA B came into Resident #6's room to transfer using Hoyer lift CNA B stated that she was not able to find slings usually used for Resident #6 (size extra-large/2X) and was only able to find a large sling which was used to transfer using Hoyer lift. When CNA B was through performing shower for Resident #6 CNA A and CNA B returned Resident #6 to her room using the shower chair. CNA A stated that when both aides were lifting Resident #6 from shower chair, she moved shower chair out from under Resident #6 when she heard a POP and Resident #6 fell to the floor. CNA A stated that Resident #6's legs dropped first and landed on her buttock in sitting position. CNA A stated that Resident #6's right leg was on top of one of the Hoyer lifts leg. CNA A stated that Hoyer lift did not fall over during incident. CNA A stated she left CNA B in the room with Resident #6 and went to get charge nurse on the floor (LVN A). CNA A stated that CNA B laid Resident #6 down (head on other Hoyer leg) and put a pillow under her head. CNA A stated that LVN A came into Resident #6's room and with assistance from aides Hoyer lift was moved out from under Resident #6. CNA A stated that LVN A assessed Resident #6 and then contacted EMS for assistance off floor. CNA A stated that Resident #6 kept saying she did not want to go to hospital and wanted to be transferred back into bed because she was cold on the floor. CNA A stated that when EMS (firemen) arrived the aides and firemen transferred Resident #6 back into bed using Hoyer lift. CNA A stated that housekeeping brought in two slings which were used to lift Resident #6. CNA A stated that Resident #6 was not complaining of pain to lower extremities until she was transferred to bed and aides where re-positioning her. Stated this was when she said her knees were hurting. CNA A stated that Resident #6 was still refusing to be transported to emergency room . CNA A stated that when she was re-positioning Resident #6 she observed Resident #6's right foot was turning black and blue. CNA A stated that she then left room to attend to other residents with LVN A in room with Resident #6. CNA A stated she checked on Resident #6 later that morning (unable to say how long after incident) and stated Resident #6 was resting with eyes closed. CNA A stated that her shift was over at 2PM and x-ray company were in Resident #6's room at that time. CNA A stated that she had never had any issues with slings or Hoyer lift prior to this incident. CNA A stated that training on Hoyer lifts instruct that aides should inspect slings before each use with a resident. Stated that size of sling is on tag or marked on plastic bag that laundry places sling in after cleaned. In an interview on 2/18/20 at 11:00 a.m. CNA B stated when she went to laundry closet to get sling for Resident #6 on the morning of incident (2/11/20) she was not able to find slings that are usually used to transfer Resident #6 (size XL or 2X) so she got sling available. CNA B stated that she was informed that large slings have maximum weight capacity of 450 pounds. CNA B stated that she inspected sling and did not observe and wear or tear or fraying. CNA B stated that Resident #6 was transferred from bed to shower chair, using Hoyer lift with size large sling, within Resident #6's room and pushed to shower room in shower chair. CNA B stated that after shower Resident #6 was pushed back to her room in shower chair. CNA B stated that when she and CNA A were transferring Resident #6 from shower chair to bed she raised Resident #6 up out of shower chair and when CNA A pushed shower out from under Resident #6 the strap holding Resident #6's right lower extremity snapped with Resident #6 falling legs first to floor landing in a seated position. CNA B stated that she observed Resident #6's right leg lying on top of metal Hoyer leg. CNA B stated that Hoyer did not fall over at time of fall. Stated that CNA A left room to get charge nurse she attempted to make Resident #6 more comfortable with lying Resident #6 head down on other metal Hoyer leg using pillow between head and metal Hoyer leg. CNA B stated that Resident #6 had a history of [REDACTED]. CNA B stated that when CNA A left room Resident #6 was calm and had complaints of knee pain and stated that Resident #6 had a history of [REDACTED]. CNA B stated that fire fighters arrived at facility and informed Resident #6 and staff that Resident #6 could not be moved before Emergency Medical Services (EMS) came to facility to assess Resident #6. CNA B stated that EMS arrived shortly after fire fighters and informed Resident #6 that she should be seen at emergency room for possible unseen injuries with Resident #6 refusing to go. CNA B stated that after emergency services assessed Resident #6 fire fighters and facility staff transferred Resident #6 to bed using Hoyer lift. Stated that laundry staff brought two (2X size) slings into room and slings were doubled during lift per fire fighters request. CNA B stated that Resident #6 did not have complaints of pain to lower extremities until she went to roll Resident #6 (after transferring to bed) when assisting nurse performing skin assessment of posterior. CNA B stated she observed bruise on upper right shin (right below right knee). CNA B stated that after attempted rolling of Resident #6 she left residents room with charge nurse still in room with Resident #6. CNA B stated that she checked on Resident #6 later that morning (unsure how long after leaving room) and observed Resident #6 lying in bed with eyes closed and no signs of distress noted. CNA B stated Resident #6 consumed approximately 50% of her lunch and was checked on right before leaving for end of shift at 2:00 p.m. and observed Resident #6 lying in bed with eyes closed. CNA B stated slings are sent to laundry after each use. CNA B stated she was not aware of the size of sling since the label was not intact and the plastic bag sling was in was not labeled. Stated that the smallest size sling within the facility is a large. CNA B stated that Resident #6 never mentioned wanting to switch from showers to bed baths and stated that Resident #6 had stated she preferred showers stating she feels cleaner after a shower than after a bed bath. Observation on 2/14/20 at 3:08 p.m. of sling used on day of incident (2/11/20) revealed straps (nylon) areas dry and brittle, right lower extremity strap was torn in half, the left lower extremity strap was intact with investigator able to tear (in the same area as right lower extremity strap break) by hand. Sling was not frayed, and no tag was located on sling to indicate size of sling. Nylon area of upper extremity straps were more pliable than lower extremity straps. In an interview on 2/14/20 at 3:30 p.m. Administrator stated that CNA's are to check the condition of slings with every use and notify Central Supply if wear and tear, fraying or other issues are observed with slings. Administrator stated that laundry personnel were checking slings with each washing and training performed to contact Central supply with new concerns of slings. Stated that Central Supply had the duty to check slings periodically for wear and tear to slings since she is the one who orders them. Administrator stated that the last time new slings were purchased was 11/30/17 from facility appointed supply company. Administrator stated that on 2/11/20 (date of incident) maintenance was instructed to check all slings and Hoyer lifts. Administrator stated that a new check list was generated on 2/11/20 for Hoyer and Hoyer sling checks. Stated that maintenance and housekeeping supervisor will be checking slings monthly for arising wear and tear. In an interview on 2/18/20 at 10:11 a.m. Resident #6 stated she had not allowed facility staff to use Hoyer since her return to facility on 2/15/20, stated she had been getting bed baths. Resident #6 stated she is too anxious to allow staff to transfer with Hoyer lift. Resident #6 stated that counselor (from Deer Oaks Mental Health) assessed her this morning and was unsure if she will be started on any medication for her increased anxiety. Resident #6 stated she will be following up with orthopedic physician in the next couple of weeks for fracture to Right femur. In an interview on 2/18/20 at 10:33 a.m. Resident #6's family member entered room, stated that Resident #6 was admitted to hospice prior to leaving hospital. Resident #6's family member stated that Resident #6's anxiety had increased since incident. Record review of Invoices revealed Hoyer lifts were inspected on 11/18/19 and 2/18/20 with no repairs recommended. Scale Company does not inspect Hoyer slings. Record review of Order Forms revealed sling (# L) involved in incident was purchased on 11/30/17. Order form revealed that sling # L was a large size sling. In an interview on 2/18/20 at 1:40 p.m. central supply associated with supply company stated manufacturer recommendations regarding replacement of slings could be found in owner's manual (for slings). Stated that replacement varies depending on the patient and amount of usage of sling. Stated that company does not have specific recommendations when to replace slings. Central supply associate provided web site to find owner's manual that are provided with each sling. Record review of Healthcare supply website revealed the following in owner's manual for sling L: Your product is warrantied to be free of defects in material and workmanship for 6 months from the date of purchase .this warranty does not cover devise failure due to owner misuse or negligence, normal wear and tear, excessive washing or incorrect washing and drying weight capacity 450 pounds, .WARNING-inspect patient slings for wear prior to each use, if signs of tearing, fraying or wear are found discard the sling immediately, worn out slings are not safe for use and may result in injury or death . Review of Facility Policy for Use of Mechanical Lift, not dated, revealed specific product utilized by the facility may vary according to the manufacturer recommendations. No other documentation regarding checking slings for damage or wear and tear noted.

Based on observation, interviews and record review, the facility failed to ensure residents received the appropriate care and services to prevent urinary tract infections to the extent possible for 1 of 2 residents (Resident #1) reviewed for indwelling catheters. The facility failed to ensure Resident #1's catheter tubing did not drag the floor and CNA B failed to clean the tubing with disinfectant prior to placing the tubing into the catheter dignity bag. This failure could place residents at risk by increasing the potential for complications due to additional infectious organisms entering the urinary tract via contaminated tubing. Findings included: Review of Resident #1's electronic Admission Record, accessed on 6/18/19, revealed he was [AGE] years old. He was admitted to the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's 14-day scheduled Medicare Minimum Data Set ((MDS) dated [DATE] revealed he had a Brief Interview for Mental Status score of 3, which indicated his cognitive function was severely impaired. Documentation on the MDS indicated he had an indwelling catheter. Review of Resident #1's electronic care plan, last reviewed on 5/1/19, revealed the following: The resident has Foley catheter, [DIAGNOSES REDACTED].wipe out dignity bag every shift making sure they are dry every shift. Review of the facility's infection control log revealed Resident #1 had signs and symptoms of urinary tract infections, each subsequently treated with antibiotics on 10/31/18, 12/26/18, 1/19/19, 2/17/19, 3/6/19 4/24/19, and 5/14/19. During an observation and interview on 6/18/19 at 5:20 p.m., Resident #1 was sitting in his wheelchair, self-propelling it with his feet at the nurse's station. His catheter bag was in a dignity bag for privacy, but the catheter tubing was looped underneath his wheelchair and dragging on the floor as he propelled around the nurse's station. This surveyor brought the tubing to the attention of CNA B, who was standing near-by. CNA B said, the tubing should be inside the dignity bag, and she was observed gathering up the tubing and placing it in the bag. CNA B did not clean or disinfect the portion of the tubing that had been dragging on the floor prior to placing it into the dignity bag. In an interview on 6/19/19 at 2:20 p.m., this surveyor asked CNA B if there should have been something done prior to placing Resident #1's catheter tubing into the dignity bag, and CNA B replied, I should have cleaned it to prevent cross-contamination. CNA B said the method of cleaning the tubing would have been probably clean it with a warm wet wash cloth and then dry it with a dry wash cloth. In an interview on 6/14/19 at 10:11 a.m., Resident #1's daughter said he had frequent urinary tract infections and she felt the facility did not care for his indwelling catheter properly. She said she had seen them toss the catheter bag on the floor and had seen the catheter tubing dragging on the floor when he was in his wheelchair. In an interview with CNA C, on 6/19/19 at 12:05 p.m., this surveyor asked CNA C what staff were supposed to do, if they noted a resident's catheter tubing dragging the floor. CNA C replied the staff was supposed to put the tubing back in the dignity bag. This surveyor asked CNA C if something else should be done prior to placing the tubing in the dignity bag and CNA C replied she would get some wipes-just something to clean it off with. In an interview with the Director of Nursing (DON) and the Regional Compliance Nurse (RCN), on 6/19/19 at 11:35 a.m., the DON said the staff had problems keeping Resident #1's catheter tubing in the dignity bag, because his daughter insisted that he wore long pants, so the tubing would come out of the bottom of his pants leg and would brush the floor. The DON said if Resident #1 was up in his wheelchair, the catheter tubing should be in the dignity bag, not dragging the floor. When asked what staff should do to attempt to keep the tubing from dragging on the floor, the DON said the staff should monitor and watch to make sure the tubing was off the floor. The RCN said monitoring would get the tubing off the floor quicker, but it was not going to keep it off the floor. She said if the staff noted the catheter tubing on the floor, they should wipe the tubing with disinfectant wipes, located on the nurse's carts, before placing the tubing back in the dignity bag. The RCN said Resident #1 had chronic bacteria in his bladder and his doctor said he always would. In an interview on 6/19/19 at 1:40 p.m., Physician A said Resident #1 was colonized with bacteria in his urine and was becoming increasingly resistant to antibiotics used to treat the infections. She said Resident #1 had been hospitalized several times [MEDICAL CONDITION] related to the urinary tract infections. Physician A said, if Resident #1's catheter tubing was found to be dragging the floor, the staff needed to wipe the tubing and the port down with alcohol before placing the tubing back into the privacy bag, in an effort to prevent additional bacteria types from entering his urinary system. Review of the facility's policy, Catheter Care, revised 2/13/07, revealed: General Guidelines: .5.Keep tubing off floor .

Based on observation, interviews, and record review, the facility failed to ensure its nursing staff had the necessary competencies and skills to provide nursing and related services to ensure resident safety during transfers for 1 of 3 residents (Resident #1) reviewed for transfers. LVN (Licensed Vocational Nurse) A and CNA (Certified Nurse Aide) A performed a stand and pivot transfer with Resident #1, by placing their arms underneath his armpits and lifting him from his bed to a standing position, without the use of a gait belt. This failure placed residents at risk for injury, including pain, bruising or the dislocation of a shoulder. Findings included: Review of Resident #1's electronic Admission Record, accessed on 6/18/19, revealed he was [AGE] years old. He was admitted to the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's 14-day scheduled Medicare Minimum Data Set ((MDS) dated [DATE] revealed he had a Brief Interview for Mental Status score of 3, which indicated his cognitive function was severely impaired. Documentation indicated his height was 74 inches (6 feet, 2 inches), and his weight was 188 pounds. He required extensive assistance with transfers using two persons physical assist. Balance during transitions and walking was documented as not steady, only able to stabilize with staff assistance in moving from seated to standing position, and during surface to surface transfers (between bed and chair or wheelchair). Review of Resident #1's care plan, last reviewed 5/1/19, revealed the following: The resident has an ADL (activities of daily living) deficit. The resident will maintain current level of function in ADLs through the review date. Transfer: The resident requires 1-2 staff participation with transfers. (MONTH) use hoyer lift (mechanical lift) prn (as needed) for safety. Observation on 6/18/19 at 11:44 a.m., revealed LVN A and CNA A assisting Resident #1 out of bed and into his wheelchair in preparation for lunch. Standing on each side, facing Resident #1, LVN A placed her right arm underneath his right armpit, and CNA A placed her left arm underneath his left armpit, then they lifted Resident #1 to a standing position, assisted him in pivoting and lowered him to his wheelchair. In an interview on 6/18/19 at 1:25 p.m., LVN A said the protocol for transferring a resident by the stand and pivot method was to tell the resident what you are doing. She said it was standard procedure to lift the resident up by placing your arms under their armpits. She said a gait belt was used if the resident was not able to assist and the staff felt he needed it. She said Resident #1 was helping quite a bit today. When this surveyor asked what staff would do if the resident started to fall, LVN A said, we put his shoes on and then we place our feet in front of the resident's feet when standing him up to keep him from slipping or sliding. In an interview on 6/18/19 at 1:50 p.m., CNA A said Resident #1 was usually a two-person transfer. She said sometimes he would help but lately he had not been able to help at all. When asked if Resident #1 had been able to help with the transfer observed today, CNA A said, he was not able to help today, he was 'pretty out of it'. She said for stand and pivot transfers, the staff placed their arms underneath the resident's armpits. When this surveyor asked if a gait belt was ever used, CNA A said the gait belt was used when Resident #1 was incoherent, out of it. When this surveyor asked about her earlier statement that Resident #1 was out of it today, CNA A said today, the resident could help a little but not like he usually did. Review of a Resident Grievance document, dated 5/1/19, revealed Resident #1's daughter had expressed concerns that included staff transferring resident #1 by his pants and not using a gait belt. Corrective action documented on the grievance form included: in-service done with CNAs to educate them on the following: Don't pull him up by his pants . Review of an undated in-service related to Resident #1, attached to the grievance form, revealed: Use a gait belt-DO NOT pull him up by his pants!!! CNA A had signed that she attended the in-service. LVN A's signature was not on the sign-in portion of the in-service. In an interview on 6/18/19 at 8:14 a.m., Resident #1's daughter said it took a year for her to get the facility get Resident #1 a gait belt for transfers, but they were not consistently using it. In an interview on 6/18/19 at 4:05 p.m., CNA D said it usually took two staff to transfer residents by standing and pivoting. She said, put the gait belt around them, put your hand under the gait belt and hold their pants, instructing them to stand and pivot, then sit. In an interview on 6/19/19 at 11:00 a.m., CNA C said most of the time Resident #1 was a one-person assist with transfers, but sometimes it took 2-3 persons. She said she usually used a gait belt to transfer him. CNA C said there was maybe one time she did not use the gait belt. She said it was in the shower when he was a two-person lift. CNA C said the staff had Resident #1 hold onto the grab bar and staff helped him stand by placing their arms underneath his armpits. In an interview on 6/18/19 at 1:17 p.m., the Physical Therapy Assistant (PTA) said it was very important to always use a gait belt when performing a stand and pivot transfer with a resident. He said staff should place the belt snuggly around the resident's waist, in the umbilical area, and secure it where two fingers could be inserted between the belt and the resident. The PTA said one person should stand in front of the resident and another person should act as the guide. He said the resident should be instructed to scoot to the edge of the bed or chair and on the count of three, the person in front, holding the gait belt on each side should assist the resident to stand and pivot. The PTA said the guide person should assist with the resident's placement of his buttocks into the chair or onto the bed. He said, never scoop them up by placing your hands or arms underneath the resident's armpits. It could cause injury. In an interview on 6/18/19 at 2:30 p.m., the DON said staff should use a gait belt for stand and pivot transfers. Review of the facility's policy Moving a Resident, Bed to Chair/Chair to Bed, from a Nursing Policy and Procedure Manual 2003, revealed: .Purpose: The purposes of this procedure are to allow the resident to be out of his or her bed as much as possible and to provide for safe transferring of the resident. Steps in the Procedure: . h. Position a gait belt around the resident's waist and clasp it. Make sure it is tight enough that only a slight hand movement will guide the patient, but not so tight that you cannot firmly grasp the belt without making the patient uncomfortable. i. If the resident requires, two persons (one on each side) should grasp the gait belt and gently stand and turn the resident and sit him or her in the chair k. Support the resident by placing a gait belt around the resident's waist for you to hold and steady the resident .