Every finding on record at Cedargate Health Care Center

Based on observation, interview, and record review, the facility failed to provide resident care for activities of daily living (ADLs) when two residents (Residents #1 and #2) outside of five sampled residents did not receive a minimum of two showers per week. The facility census was 50.Review of the facility's policy titled, Resident Showers, revised 06/26/26, showed:- It is the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation, and help prevent skin issues as per current standards of practice;- Residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety. Review of the facility Resident Shower List showed:- Resident #1 scheduled for showers two times weekly on Wednesdays and Saturdays; - Resident #2 scheduled for showers two times weekly on Wednesdays and Saturdays. 1. Review of Resident #1's medical record showed:- An admission date of 03/14/19;- Diagnoses of chronic obstructive pulmonary disease- (COPD - lung disease), schizophrenia (a chronic mental illness that affects a person's thoughts, feelings, and behaviors), anxiety disorder (disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and heart failure (a chronic condition in which the heart does not pump blood as well as it should). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument to be completed by the facility staff), dated 05/06/26, showed:- Cognitively intact;- Dependent on staff for dressing and personal hygiene;- Dependent on staff for bathing. Review of the resident's care plan, revised 02/25/26, showed:- Dependent on staff assistance with showers;- Requires assistance of two staff with showers;- Requires total assistance with personal hygiene care;- Did not address the frequency and the schedule for the resident's showers. Review of the resident's shower sheets, dated 03/01/26 - 05/06/26, showed:- Did not receive showers on 03/18/26, 04/11/26, 04/22/26, and 05/02/26;- Four out of 19 opportunities missed. Observation on 05/07/26 at 8:55 A.M., of the resident showed:- The resident sat in his/her wheelchair with his/her hair unkempt and appropriately dressed. During an interview on 05/07/26 at 8:55 A.M., Resident #1 said he/she sometimes didn't receive a shower/bath two times a week. 2. Review of Resident #2's medical record showed:- admitted on [DATE];- Diagnoses of COPD and Crohn's disease (a chronic inflammatory bowel disease that causes inflammation of the digestive tract). Review of the resident's quarterly MDS, dated [DATE], showed:- Cognitively intact;- Dependent on staff for dressing;- Requires supervision or touching assistance of staff for personal hygiene;- Dependent on staff for bathing. Review of the resident's care plan, revised 01/16/26, showed:- Requires limited to extensive assist to complete ADLs;- Requires assist of one staff for dressing and toileting;- Did not address the amount of assistance required by the staff, the frequency, and the schedule for the resident's showers. Review of the resident's shower sheets, dated 03/01/26 - 05/06/26, showed:- Did not receive showers on 03/25/26, 04/01/26, 04/11/26, 04/22/26, 04/29/26, and 05/02/26;- Six out of 19 opportunities missed. Observation on 05/07/26 at 9:06 A.M., showed the resident lay in bed appropriately groomed and dressed. During an interview on 05/07/26 at 9:06 A.M., Resident #2 said he/she had a shower yesterday, but before that, he/she missed three shower days. Often, he/she didn't receive a shower twice a week. During an interview on 05/07/26 at 1:21 P.M., the Director of Nursing (DON) said all residents should have a shower twice a week unless they were care planned for once a week. She said there was no reason residents shouldn't have at least two showers a week. During an interview on 05/07/26 at 1:25 P.M., Licensed Practical Nurse (LPN) A said all residents should have a shower twice a week per the shower schedule. If showers were missed, it was likely due to a lack of time management of the staff. During an interview on 05/07/26 at 1:28 P.M., Certified Nurse Aide (CNA) B said all residents should have a shower twice a week, but sometimes showers didn't get done due to short staffing. During an interview on 05/07/26 at 2:00 P.M., the Administrator said she would expect all residents to have a shower twice a week. Complaint # 2994395

Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These practices had the potential to affect all residents. The facility census was 55. Review of the facility's policy titled, Food Receiving and Storage, revised 07/2014, showed: - Foods shall be received and stored in a manner that complies with safe food handling practices, food services or other designated staff will maintain clean food storage areas at all times; -When food is delivered to the facility, it will be inspected for safe transport and quality before being accepted; - Food in designated dry storage areas shall be kept off the floor (at least 18 inches) and clear of sprinkler heads, sewage/waste disposal pipes and vents. Review of the facility's policy titled, Refrigerators and Freezers, revised 12/2014, showed: - This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines; - Supervisors will inspect refrigerators and freezers monthly for gasket condition, fan condition, presence of rust, excess condensation, and any other damage or maintenance needs and necessary repairs will be initiated immediately. Maintenance schedules per manufacturer guidelines will be scheduled and followed; - Refrigerators and freezers will be kept clean, free of debris, and mopped with sanitizing solution on a scheduled basis and more often as necessary. 1. Observation on 05/19/25 at 9:34 A.M., and 10:40 A.M., of the dry food storage room showed: - Five cardboard case boxes filled with traditional stuffing mix, beef stew, rice crisps, white vinegar, and marinara sauce lay directly on the floor with all delivery items stacked above and in front of the food storage shelves; - One used hair net lay on the food shelf near the assorted spice containers. 2. Observation on 05/19/25 at 9:36 A.M., and 05/20/25 at 10:41 A.M., of the dry food storage room showed: - The ice machine interior horizontal plastic surface with a black substance above the ice, a white substance on the left and right exterior sides of the machine, and a 1/4 inch (in.) thick black substance covered the entire 6 in. exposed exterior surface of the 1 in. plastic drain; - A 15 foot (ft.) wall section below the ice machine without a baseboard and finished wall surface; - An 8 in. ceiling vent with a gray substance above the shelf with cereal containers in the dry storage; - A 12 in. x 12 in. ceiling vent with a gray substance near the ice machine; - A 6 ft. of metal ceiling tile frames with a gray substance; - A 4 ft. wall section below the fire extinguisher near the doorway without a baseboard and finished wall surface; - A 2 in. diameter (dia.) hole in the wall below the ice machine; - An opened 4 in. dia. floor drain without a strainer (a device that inserts into the floor drain and collects al debris entering the drain, preventing it from creating a clog); - Two upright deep freezers with 1/4 in. ice formation on all interior shelving; - The floor with scattered debris and a sticky film below the food shelves ; - One dented 3 quart (qt.) metal can of mandarin oranges, dated 11/10/24; - One dented 3 qt. metal can of applesauce, dated received on 05/05/25; - One dented 3 qt. metal can of diced pears in juice, dated 09/20/24; - One dented 3 qt. metal can of great northern beans, dated received on 03/24/25; - One dented 3 qt. metal can of sloppy joe sauce, dated best by 12/08/26; - One dented 7.25 ounce metal can of diced pears in juice, dated best by 02/25/27; - One metal cereal scoop lay uncovered directly on a shelf beside the plastic cereal container. 3. Observation on 05/19/25 at 9:40 A.M., and 05/20/25 at 10:45 A.M., of the walk-in refrigerator showed: - Interior baseboard area with a damp brown substance along the wall near the floor; - A gray substance between the square shaped plastic ventilation louvers; - A non-intact coated surface on two metal wire food shelves with a brown substance. 4. Observation on 05/19/25 at 9:45 A.M., and 05/20/25 at 10:50 A.M., of the kitchen showed: - The 24 in. x 24 in. ceiling vent with a brown and gray substance; - Four 12 in. x 12 in. ceiling vents with a brown and gray substance; - The steam table with a brown substance surrounding two screws through the clear glass viewing area; - The commercial electric range oven interior with a dark brown oily build-up, the floor surface below the range with food debris and an oily film, and the oven section not in working condition; - Two 4 ft. ceiling light fixture covers near the dishwashing sink and the dishwashing machine with a brown substance. During an interview on 05/19/25 at 10:16 A.M., Dietary Aide H said she needed to squeeze in between the food boxes stacked on the floor to be able to grab food items off the shelves. The night shift dietary staff that would come in to work this afternoon were supposed to put away the dry stock and the delivery truck comes every Monday morning. The day shift staff did not have time to put the boxes away, so it was left on the floor. The day shift put away the cold food items that were delivered. The night shift staff should be searching for dented cans before they stock it, but they didn't always catch all of them, so they wind up on the shelf. There was a lower shelf designated to place all of the dented cans and there were several items on the shelf. During an interview on 05/22/25 at 12:53 P.M., the Dietary Manager said he/she would expect the stand-up freezers to be free of ice build-up on the shelves and they appeared to have frost that shouldn't be there. The ice machine should not have lime build up on the exterior and the interior parts should be clean, but they seemed to have issues. Maintenance helped keep the ice machine clean. The baseboards should be in place in the dry storage room but had not been replaced yet. The walk-in refrigerator should have intact shelves but the coating was missing in some places. The appliances should be clean on all surfaces and the floor below them should be clean but there were problems. The staff signed off on what cleaning tasks they had done, and it matched the cleaning duties list. The ceiling and refrigeration vents should be clean but that was left for maintenance. The food should not be an issue on the floor when the truck delivers in the morning and it was always left for the workers that start in the afternoon. The dented cans should not have been on the upper food shelves with the non damaged food and it must have gotten overlooked. There was a separate shelf where dented cans were supposed to be placed. The commercial range oven did not work but would be useful. When it was tested, it created an oily mess in the oven that should have been cleaned. During an interview and kitchen tour on 05/22/25 at 1:15 P.M., the Administrator said the issues in the kitchen should be addressed. Food should not be allowed to be stored on the floor after the supply truck had delivered. Frozen foods should not be stored with ice buildup and freezers should be defrosted. Canned foods should not be stored on the shelves if they were dented, they should be placed together and returned. The ice machine should be clean and not have a black substance on the interior. The floor drain should be covered, and the drain pipe should be kept clean. The walls should be painted and have baseboards in place. The shelves should be clean in the dry storage and the ceiling vents should be clean. The metal shelves in the walk-in refrigerator should be in good repair and not have chipped surfaces, the ventilation louvers should be clean and should not have brown substance on the lower wall near the floor. The oven portion of the electric range should be repaired or replaced since it didn't work. It should have been kept clean and not have an oily grime build up. During an interview on 05/22/25 at 1:32 P.M., the Maintenance Director said the ice machine should be checked for cleanliness and well maintained. This was a maintenance responsibility and inspection, and cleaning was done about every two months. It was bad when he/she started in October because it was not maintained properly. Since October, he/she had cleaned the ice machine four times and the last time was in April when it was disassembled and chemicals ran through it. The drain line should be clean. Ceiling vents should be cleaned at least once per month. The dietary staff should let him/her know if there were problems with appliances or other issues. The last time the vents were cleaned was two or three weeks ago. He/She would not be able to repair the oven portion of the electric range and when the oven gets hot, grease leaks everywhere inside. The electric burners were replaced on top. He/She was not aware the wall sections in the refrigerator and dry storage area was left unpainted or without vinyl baseboards. No one from kitchen asked him/her to look into the issues. The ceiling vents were mentioned yesterday, the sheet metal can be repaired in the walk-in refrigerator near the floor, and he/she could get help called in if necessary.

Based on observation, interview, and record review, the facility failed to maintain a cover on the trash containers within the kitchen and failed to ensure the dumpster was maintained to keep pests out and/or to keep the garbage contained in the dumpsters. This failure had the potential to affect all residents. The facility census was 55. Review of the facility's policy titled, Garbage and Rubbish Disposal, undated, showed: - All garbage and rubbish containers shall be provided with tight fitting lids or covers and must be kept covered when stored or not in continuous use; - Outside dumpsters provided by garbage pick up services will be kept closed and free of surrounding litter. 1. Observations of the kitchen on 05/19/25 at 9:36 A.M., and 3:31 P.M., 05/20/25 at 8:27 A.M., 9:44 A.M., and 10:45 A.M., and 05/21/25 at 8:54 A.M., showed: - One uncovered 32-gallon (gal.) gray trash receptacle partially full of refuse near the dishwashing station; - One uncovered 32-gal. gray trash receptacle partially full of refuse near the food preparation area. 2. Observations on 05/19/25 at 8:30 A.M., and 3:45 P.M., 05/20/25 at 8:13 A.M., and 3:44 P.M., 05/21/25 at 8:05 A.M., and 05/22/25 at 9:12 A.M., showed: - The outside trash dumpster area located near the rear entrance of the facility had one 6-yard dumpster partially filled with one plastic lid completely opened. During an interview on 05/20/25 at 3:10 P.M., Certified Nursing Assistant (CNA) G said he/she was trained to take the trash out of the facility using a covered rolling trash can. It was difficult to reach and close the dumpster lid and he/she was only trained to dump the trash bags into the dumpster. Dumping the trash can often was part of the job. During an interview on 05/22/25 at 1:15 P.M., the Administrator said the dumpster should be closed when it was unattended and not being filled by the facility staff. The staff should be closing the dumpster once they have taken bags out of the facility and thrown them in the dumpster. The trash cans should be covered in the kitchen food preparation area if they were not actively being filled and they should have lids available. During an interview on 05/22/25 at 1:32 P.M., the Maintenance Director said the trash dumpster should remain closed when it was not being filled. He/She was not aware of training for the staff on trash removal other than it was supposed to go out the front door and walked back to the dumpster area. The staff were expected to close the dumpster when the trash was dumped in, but it was normally left opened and the shorter staff had trouble closing the lid.

Based on interview and record review, the facility failed to maintain an Infection Prevention and Control Program (IPCP) that included an antibiotic stewardship program to include an infection surveillance program and antibiotic use protocols. This deficient practice had the potential to affect all residents in the facility. The facility census was 55. Review of the facility's policy titled, Antibiotic Stewardship, revised July 2016, showed: - Antibiotics will be prescribed and administered to the residents under the guidance of the facility's Antibiotic Stewardship Program; - The purpose of the Antibiotic Stewardship Program is to monitor the use of antibiotics in the residents. Review of the facility's Infection Reports, Antibiotics Binder, showed: - No documentation for 01/01/24 - 12/31/24, February 2025, March 2025, and April 2025; - January 2025 showed incomplete documentation related to appropriate indication of antibiotic use; - May 2025 showed incomplete documentation related to appropriate indication of antibiotic use; - Did not include lab reports/findings. Review of the facility's Matrix (a listing of all facility residents), dated 05/19/25, showed: - Eight residents currently received antibiotics. During an interview on 05/20/25 at 2:50 P.M., Registered Nurse (RN) A/Minimum Data Set (MDS - part of a federally mandated process for clinical assessment of all residents in certified nursing homes) Coordinator said the new Director Of Nursing (DON) started at the end of April 2025. The infection surveillance logs from the previous DON could not be located. The previous DON was responsible for working as the Infection Preventionist (IP) and doing the surveillance logs. During an interview on 05/20/25 at 3:00 P.M., the Administrator said the new DON was working on getting her IP certification. The previous DON left and either just didn't do the IPCP or took the records for 2024. RN A/MDS Coordinator was certified as an IP and had been the interim DON from March - April 2025, but was not made responsible for the IP duties. During an interview on 05/20/25 at 3:20 P.M., the DON said she was working on the IP certification now. She had only been the DON for less than a month. During an interview on 05/22/25 at 1:30 P.M., the Administrator said the DON was responsible as the IP to complete the antibiotic stewardship and antibiotic surveillance.

Based on interview and record review, the facility failed to ensure at least one person with specialized training in infection prevention and control for the Infection Preventionist (IP - a professional who assures healthcare workers and residents are doing everything possible to prevent infection) was responsible for the duties of the position. This had the potential to affect all residents in the facility. The facility census was 55. Review of the facility's policy titled, Antibiotic Stewardship - Staff and Clinician Training and Roles, last revised July 2016, showed: - The IP will audit and the Director of Nursing (DON) will provide feedback to providers on antibiotic prescribing practices; - The IP will monitor over time and report to the Infection Prevention and Control Committee (IPCC); - The IP will obtain, and the DON will provide to clinical providers, educational resources and materials about antibiotic resistance and opportunities for improved antibiotic use; - The IP and DON will participate in IPCC meetings on a regular basis. Review of the facility's police titled, Infection Preventionist, last revised July 2016, showed: - The Infection Preventionist is responsible for coordinating the implementation and updating of our established infection prevention and control policies and practices; - Did not address the specialized training required for the IP role. The facility did not provide documentation of the completion for the specialized training required for the IP role for assigned to the Director of Nursing (DON). During an interview on 05/20/25 at 2:50 P.M., Registered Nurse (RN) A/Minimum Data Set (MDS - part of a federally mandated process for clinical assessment of all residents in certified nursing homes) Coordinator said the new DON had started at the end of April 2025. The previous DON was responsible for working as the IP. The current DON was working on the IP certification now and was responsible for IP duties. RN A/MDS Coordinator was a certified IP but the IP duties weren't his/her responsibility. During an interview on 05/20/25 at 3:00 P.M., the Administrator said the new DON was working on getting the IP certification. RN A/MDS Coordinator was certified as an IP and had been the interim DON from March - April 2025, but was not made responsible for the IP duties. During an interview on 05/20/25 at 3:20 P.M., the DON said she was working on her IP certification now. She had only been the DON for less than a month and was responsible for the IP duties.

Based on observation, interview, and record review, facility staff failed to maintain infection control with hand hygiene and glove changes during incontinent care for four residents (Residents #4, #5, #7, and #105) out of four sampled residents, urinary catheter care for two residents (Residents #4 and #7) out of two sampled residents, and colostomy (an opening for the colon (large intestine) through the abdomen created by a surgery to allow feces to exit the body) care for one resident (Resident #105) out of one sampled resident. The facility also failed to correctly screen two residents (Residents #19 and #27) for tuberculosis (TB - an infectious disease characterized by the growth of nodules in the tissues, especially the lungs) out of five sampled residents required by state regulation 19 CSR 20-20.100. The facility's census was 55. Review of the facility's policy titled, Handwashing/Hand Hygiene, revised August 2014, showed: - The facility considers hand hygiene the primary means to prevent the spread of infections; - All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors; - Wash hands with soap and water when hands are visibly soiled and after contact with a resident with infectious diarrhea; - Use alcohol-based hand rub or soap and water for the following: before and after direct contact with residents, before and after handling an invasive device (urinary catheter), before moving from a contaminated body site to a clean body site during resident care, after contact with a resident's intact skin, after contact with blood or bodily fluids, after handling used dressings or contaminated equipment, after contact with objects, after removing gloves, before and after entering isolation precaution setting; - Hand hygiene is the final step after removing and disposing of personal protective equipment (PPE). Review of the facility's policy titled, PPE - Gloves, dated July 2009, showed: - Wash your hands after removing gloves. Review of the facility's policy titled, Tuberculosis (TB) Screening Residents , revised July 2013, showed: - Any resident without a documented negative TB skin test (TST) within the previous 12 months will receive a baseline two step TST or one-step blood assay for Myobacterium tuberculosis (BAMT) upon admission. If the first TST is negative, a follow-up TST will be administered one to three weeks after the initial test is read. The BAMT is a one-step test. 1. Observation on 05/20/25 at 9:52 A.M., of Resident #5's incontinent care showed: - CNA C performed hand hygiene and put on a gown and gloves; - CNA C entered the room, did not disinfect the bedside table, and placed wet wash cloths on the bedside table with no barrier; - CNA C cleaned the resident's bottom and perineal area, removed the soiled brief, did not perform hand hygiene, did not change gloves, put a clean brief under the resident, and fastened the clean brief; - CNA C did not change gloves, did not perform hand hygiene, and touched the resident's rolled blanket between his/her feet, the top blanket and the side table; - CNA C removed the gown, removed the gloves, did not perform hand hygiene, exited the room, took the trash out to the trash container in the hall, and performed hand hygiene. 2. Observation on 05/20/25 at 10:02 A.M., of Resident #105's colostomy and incontinent care showed: - CNA C performed hand hygiene, put on gown and gloves, and entered the room with supplies; - CNA C did not disinfect the bedside table, and placed wet wash cloths on the bedside table with no barrier, and cranked the head of the bed down with the hand crank; - CNA C did not change gloves, did not perform hand hygiene, touched the resident's leaking colostomy bag, removed gloves, and did not perform hand hygiene; - CNA C entered the bathroom and obtained an empty canister, did not perform hand hygiene, and put on gloves; - CNA C unfastened the soiled brief, cleaned fecal material from the resident's abdomen with a wet wash cloth, opened the colostomy bag, emptied the fecal material into the canister, did not change gloves, did not perform hand hygiene, resealed the colostomy bag, and put the canister with the fecal material in a trash bag; - CNA C did not change gloves, did not perform hand hygiene, cleaned fecal material from the resident's abdomen, removed the soiled gown from the resident, and removed the soiled blanket from the resident's bed; - CNA C removed gloves, performed hand hygiene, and put on gloves; - CNA C washed the top of the colostomy bag and the resident's abdomen again, did not perform hand hygiene, did not change gloves, and applied a patch under the colostomy site where it leaked; - CNA C did not change gloves, did not perform hand hygiene, removed the soiled brief and soiled pad, removed gloves, did not perform hand hygiene, and put on gloves; - CNA C touched the resident's thigh, cleaned the resident's right buttock and hip, did not change gloves, did not perform hand hygiene, cleaned the resident's perineal area, did not perform hand hygiene, did not change gloves, touched the colostomy bag, did not change gloves, did not perform hand hygiene, touched the resident's left thigh, the resident's clean brief, did not change gloves, did not perform hand hygiene, put on barrier cream to the resident's buttocks, did not perform hand hygiene, did not change gloves, fastened the brief, and touched the resident's gown; - CNA C did not perform hand hygiene, did not remove gloves and gown, touched the resident's door and door knob, exited the resident's room, walked down the hall with the canister of fecal material covered in a bag to the soiled utility room, and touched the soiled utility room door knob to enter; - CNA C emptied and cleaned the canister and put the canister in a new bag; - CNA C removed gloves and gown, did not perform hand hygiene, put on gloves, picked up the bagged canister, went back to the resident's room, did not perform hand hygiene, did not change gloves, touched the resident's door and bathroom door, and placed the bagged canister in the bathroom; - CNA C picked up the soiled linen and trash, did not perform hand hygiene, did not change gloves, exited the room, put the soiled linens and trash in a soiled cart out in the hall, and did not perform hand hygiene and did not change gloves; - CNA C touched the clean linen cart, removed gloves, did not perform hand hygiene, touched the hall closet door, touched the supply cart, performed hand hygiene, put on gloves and gown, and entered the resident's room; - CNA C helped the resident to roll to the right and rolled up the soiled incontinent pad and bottom sheet, did not perform hand hygiene, did not change gloves, put a clean top sheet on the bed, removed the soiled incontinent pad and bottom sheet, did not change gloves, did not perform hand hygiene, and put on a clean bottom sheet and incontinent pad on the bed; - CNA C did not perform hand hygiene, did not change gloves, touched the resident's phone, changed gloves, did not perform hand hygiene, and pulled the resident's top sheet and blanket up to the resident; - CNA C removed gown and gloves, did not perform hand hygiene, exited the room, put the bag of soiled linen and trash in in a a soiled cart out in the hall, and performed hand hygiene. 3. Observation on 05/20/25 at 10:34 A.M., of Resident #4's urinary catheter and incontinent care showed: - CNA B and CNA C performed hand hygiene and put on gowns and gloves; - CNA C did not disinfect the side rails and placed wet wash cloths on the side rails with no barrier; - CNA B unhooked the resident's catheter drainage bag and placed it on the foot of the bed; - CNA C cleaned the resident's bottom, did not change gloves, did not perform hand hygiene, and placed a clean incontinent pad on top of the bed; - CNA B removed the dirty incontinent pad, did not change gloves, did not perform hand hygiene, and placed a clean incontinent pad under the resident; - CNA C did not perform hand hygiene, did not change gloves, and touched the resident's pillow; - CNA B did not perform hand hygiene, did not change gloves, and touched the resident's wedge; - CNA C did not perform hand hygiene, did not change gloves, performed catheter care and cleaned the front peri area; - CNA C changed gloves, did not perform hand hygiene, hung the catheter drainage bag from the bed frame, went to the bathroom and obtained a clean canister, put the canister on the floor, did not change gloves, did not perform hand hygiene, emptied the catheter drainage bag into the canister, took the canister to the bathroom, emptied the canister, did not change gloves, did not perform hand hygiene, cleaned the canister, removed gloves and gown, and performed hand hygiene; - CNA B removed gloves, and gown, did not perform hand hygiene, exited the resident's room, took the dirty linen and trash out to the soiled cart in the hall, and performed hand hygiene. 4. Observation on 05/22/25 at 9:11 A.M., of Resident #7 urinary catheter and incontinent care and transfer showed: - CNA E and CNA F put on gown and gloves and did not perform hand hygiene; - CNA E did not disinfect the bedside table and placed wet wash clothes on the bedside table with no barrier; - CNA E retrieved a wash cloth from the bedside table, cleaned the fecal material from the resident's back with fecal material on top of the left gloved hand, wiped the fecal material off the glove onto the soiled wash cloth, did not change gloves, and did not perform hand hygiene; - CNA E touched the resident's bare right knee with the left gloved hand soiled with fecal material, removed the partially unattached dressing from the resident's suprapubic catheter (a hollow flexible tube that is inserted into the bladder from a small cut in the abdomen and used to drain urine) insertion site, did not change gloves, did not perform hand hygiene, touched the resident's shorts, touched the velcro straps of the resident's left shoe, removed the shoe, removed the sock from the resident's left foot, lifted the catheter drainage bag and put it through the leg of the resident's shorts, did not change gloves, did not perform hand hygiene, retrieved a wet wash cloth from the bedside table, cleaned the lower legs, did not change gloves, did not perform hand hygiene, retrieved a clean wash cloth from the bedside table, touched the catheter tubing with the left gloved hand soiled with fecal material, cleaned fecal material from the pubic area and left groin, used the same area of the wash cloth soiled with fecal material for three wipes, folded the wash cloth in half, cleaned the right groin, and used the outside of the wash cloth soiled with fecal material to clean the pubic area wiping three times with same area of the wash cloth; - CNA E did not change gloves, did not perform hand hygiene, touched the catheter tubing, rolled and tucked the Hoyer lift (a mechanical lift) pad soiled with fecal material under resident, did not change gloves, did not perform hand hygiene, cleaned fecal material from resident's left buttock, used same area of wash cloth soiled with fecal material to wipe multiple times, did not change gloves, did not perform hand hygiene, retrieved a clean wash cloth from the bedside table, cleaned fecal material from the right buttock and the back of the thigh, placed the wash cloth soiled with fecal material on a clean incontinent pad, folded the wash cloth soiled with fecal material in half, continued to clean fecal material from the back of the thigh, did not change gloves, and did not perform hand hygiene; - CNA F removed gown and gloves, did not perform hand hygiene, exited and returned to the room with a gown and gloves on with more wash cloths, dropped one wash cloth on the floor, picked up the dropped wash cloth and added it back to other wash cloths in his/her hand, did not disinfect and without a barrier on the sink counter, placed all the wash clothes on the sink counter, retrieved and placed a clean brief under the resident, and wet the wash cloths and sprayed with peri cleaner; - CNA F did not change gloves, did not perform hand hygiene, and handed CNA E a prepared wash cloth; - CNA E cleaned the resident's right buttock and gluteal cleft with a wash cloth, folded the Hoyer lift pad soiled with fecal material and removed from the bed, sat the Hoyer lift pad soiled with fecal material on the floor, removed the brief soiled with fecal material from the Hoyer lift pad and placed in a trash bag, picked up the Hoyer lift pad soiled with fecal material and put in a trash bag, changed gloves, and performed hand hygiene; - CNA F did not change gloves, did not perform hand hygiene, applied a barrier cream to the resident's buttocks, wiped the cream from the gloves onto the inside of the clean brief, changed gloves, and did not perform hand hygiene; - CNA E retrieved a prepared wash cloth from the sink area, wiped fecal material from the groin and perineal area with the same area of the wash cloth soiled with fecal material multiple times, changed gloves, and performed hand hygiene, - CNA E performed catheter care, did not change gloves, and did not perform hand hygiene; - CNA E fastened the left side of the clean brief, retrieved a clean pair of shorts, assisted the resident to place the left leg in the shorts, picked up the catheter drainage bag and placed though the leg of the shorts, CNA E's left glove tore open, did not perform hand hygiene, retrieved a new glove from his/her pant pocket, put on a glove on the left hand, retrieved a clean Hoyer lift pad and placed it under the resident; - CNA F removed gown and gloves and handed them to CNA E who placed the them in a trash bag; - CNA F did not perform hand hygiene, exited the room, performed hand hygiene, entered the resident's room with gown and gloves on; - CNA E did not change gloves, did not perform hand hygiene, touched the resident's wheelchair handles, and assisted CNA F with the resident's Hoyer lift transfer from the bed to the wheelchair; - CNA E did not change gloves, did not perform hand hygiene, touched the catheter drainage bag, retrieved the resident's lanyard from the bedside table and placed it over the resident's head, removed gloves and gown, did not perform hand hygiene, exited the room with a trash bag, placed it the soiled cart in the hall, and performed hand hygiene; - CNA F removed the glove from the right hand, did not remove the glove from the left hand, did not perform hand hygiene, exited the room with the bag of soiled linens, performed hand hygiene to the right hand, took the soiled linens to soiled utility room, sat the soiled linen bag in the floor of the soiled utility room, removed the glove from the left hand, exited the room, and performed hand hygiene. During an interview on 05/20/25 at 3:53 P.M., CNA B said he/she should perform hand hygiene at least three times during care, before starting, when going from dirty to clean care, and when care was complete. Gloves should be changed when visibly soiled too. During an interview on 05/22/25 at 9:45 A.M., CNA F said hand hygiene should be completed when entering a resident's room, put on gloves, provide care, change gloves and perform hand hygiene, then wash hands when done. Gloves should be changed if visibly soiled during care, and soiled linens should not be on the floor but should be placed in a bag. During an interview on 05/22/25 at 9:49 A.M., CNA E said there should be two people for care, one to stay dirty and one to stay clean, wipe front to back, using a new area of the wipe each time or a new wipe. Soiled items should not be placed on clean items, and surfaces should be cleaned or paper towels be put down before laying clean items on it or keep clean items in a bag. Hand hygiene should be completed and gloves changed when moving from dirty to clean tasks or area, and when gloves were visibly soiled, and again at end of care. Linens should not be placed on the floor but always in a bag. During an interview on 05/22/25 at 9:53 A.M., the Director of Nursing (DON) said staff should gather supplies, if the resident required assistance of two, then one should be dirty and one should be clean. Hand hygiene and gloves on before care starts, perform hand hygiene and change gloves when going from dirty to clean care, and change gloves if they were visibly soiled. Hand hygiene and gloves should be changed when touching any clean items after care. Pick up supplies and soiled items and then sanitize hands when leaving the room. 5. Review of Resident 19's medical record showed: - admit date of 03/05/24; - TST administered on 03/06/25, with no read date and a negative result of 0 millimeters (mm); - TST administered on 03/26/25, with no read date and a negative result of 0 mm. 6. Review of Resident #27's medical record showed: - admit date of 02/28/25; - TST administered on 03/12/25, and read 03/14/25, with a 0 mm; - No second step TST administered. During an interview on 05/22/25 at 2:00 P.M., the Administrator said she would expect resident TB to be completed and documented correctly. She would also expect staff to follow infection control during care and perform it correctly.

Based on observation, interview, and record review, the facility failed to ensure a urinary indwelling catheter (a tube inserted into the bladder to drain urine) drainage bag was maintained in proper position and not above the bladder, for two residents (Residents #4 and #7) out of two sampled residents. The facility also failed to properly provide incontinent care for three residents (Residents #5, #22 and #29) out of four sampled residents. The facility census was 55. Review of the facility's policy titled, Catheter Care, revised September 2014, showed: - The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. Review of the facility's policy titled, Urinary Continence and Incontinence - Assessment and Management, revised September 2010, showed: - Did not address the procedure of incontinent care. 1. Review of Resident #4's medical record showed: - admitted on [DATE]; - Diagnoses of pressure ulcer (damage to the skin and/or underlying tissue as a result of pressure) of sacral region stage 4 (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling), dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning), hemiplegia (paralysis of the muscles of the lower face, arm, and leg on one side of the body), cerebral vascular accident (CVA - stroke), and receive hospice care (health care that focuses on the quality of life of a terminally ill person). Review of the resident's Physician Order Sheet (POS), dated May 2025, showed: - An order to change catheter monthly on the 28th on night shift and as needed with a 22 French (Fr. - the size of the catheter) 30 milliliter (ml) bulb needed and provided by hospice, dated 04/29/24; - An order to record the Foley (a type of indwelling catheter)catheter output at the end of every shift and document, dated 04/29/24; - An order to change the Foley drainage bag weekly on Saturday night shift on the 28th of each month every night shift dated 03/28/24; - An order for Foley catheter care every shift for wound management, dated 03/04/24. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated process for clinical assessment of all residents in certified nursing homes), dated 03/15/25, showed: - Used an indwelling catheter; - Required assistance for toileting. Review of the resident's Care Plan, dated 04/02/25, showed: - Urinary catheter due to wound care management. Position the catheter bag and tubing below the level of the bladder; - Activities of daily living (ADLs) deficit and dependant for toileting. Observation on 05/20/25 at 10:34 A.M., of the resident's urinary catheter and incontinent care showed: - Certified Nurse Assistant (CNA) B unhooked the catheter drainage bag from the bed frame and placed it on the foot of the bed; - CNA B and CNA C performed incontinent and catheter care; - CNA B failed to keep the catheter drainage bag below the level of the resident's bladder. 2. Review of Resident #5's medical record showed: - admitted on [DATE]; - Diagnoses of sacral (the bottom of the spine, between the bottom of the lumbar spine and tailbone) spinal bifida (a condition that occurs when the spine and spinal cord don't form properly), and paraplegic (paralysis of the legs and lower body). Review of the resident's quarterly MDS dated [DATE], showed: - Incontinent of bowel and bladder; - Dependent for toileting. Review of the resident's Care Plan, dated 01/19/24, showed; - Assist with ADLs; - Extensive to dependent assistance for toileting and a Hoyer lift (a mechanical lift) for transfers. Observation on 05/20/25 at 9:52 A.M., of Resident #5's incontinent care showed: - CNA C provided incontinent care for the resident; - CNA C failed to clean the resident's groin, buttocks, and thigh area. 3. Review of Resident #7's medical record showed: - admitted on [DATE]; - Diagnoses of chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should), flaccid neuropathic bladder (condition that results in lack of bladder control due to a brain, spinal cord or nerve problem), benign prostatic hyperplasia (BPH - enlargement of the prostate causing difficulty in urination) with lower urinary tract symptoms, and spinal stenosis cervical region (the narrowing of one or more spaces within the spinal canal of the neck which causes symptoms like back or neck pain and tingling in the arms or legs). Review of the resident's POS, dated May 2025, showed: - An order to change the catheter drainage bag weekly on Saturday every night shift with foley maintenance and care, dated 03/31/24; - An order for a suprapubic (a catheter surgically inserted into the bladder through a small incision in the lower abdomen) catheter care: Cleanse with soap and water every day and night shift, dated 11/06/24; - An order to flush the suprapubic catheter tubing with 50 cubic centimeters (cc) sterile water daily and as needed every night shift and every 12 hours as needed related to flaccid neuropathic bladder, dated 03/31/25. Review of the resident's quarterly MDS, dated [DATE], showed: - Used an indwelling catheter; - Dependent for toileting hygiene, shower/bath, and personal hygiene. Review of the resident's Care Plan, dated 11/27/23, showed: - Suprapubic catheter placement done on 08/01/23; - Needs supervision for some ADLs and extensive with others such as transferring due to safety. Interventions included extensive assist for his/her toileting needs. He/She had a suprapubic catheter. Observation on 05/22/25 at 9:11 A.M., of the resident's Hoyer lift transfer, incontinent care, and catheter care showed: - CNA E removed the catheter drainage bag from under the wheelchair and placed in the resident's lap; - CNA E and CNA F transferred the resident from the wheelchair to the bed with the Hoyer lift to bed. CNA E moved the catheter drainage bag from the resident's lap to the mattress handle to assist the resident to turn to the side to remove the Hoyer lift pad; - CNA E removed the catheter drainage bag from the mattress handle and lay it on the mattress near the foot of the bed; - CNA E and CNA F performed incontinent care; - CNA E picked up the catheter drainage bag, placed it though the leg of the resident's shorts and placed the catheter drainage bag on top of the resident's lower abdomen where the resident held the catheter drainage bag during the Hoyer lift transfer from the bed back to the wheelchair. CNA E retrieved the catheter drainage bag from the resident and hooked it under the wheelchair; - CNA E and CNA F failed to keep the catheter drainage bag below the level of the resident's bladder during transfers and care. 4. Review of Resident #22's medical record showed: - admitted on [DATE]; - Diagnoses of muscle weakness, trochanteric bursitis (pain that occurs on the outside of the hip) right hip, and spinal stenosis lumbar region without neurogenic claudication (narrowing of the spinal canal in the lower part of the back without pain that originates from the nerves). Review of the resident's quarterly MDS, dated [DATE], showed: - Frequently incontinent of bowel and bladder; - Dependent for toileting hygiene, shower/bath, upper and lower body dressing, and personal hygiene; - Substantial/Maximal assistance to roll left and right. Review of the resident's Care Plan, revised 04/15/25, showed; - Resident has an ADL Self Care Performance Deficit and requires assist with all ADLs related to confusion, limited mobility, spinal stenosis, and pain; - Resident has potential for pressure ulcer development related to decline in functional, cognitive abilities, and incontinent of bowel and bladder. Observation on 05/20/25 at 1:58 P.M., of the resident's incontinent care showed: - The resident's brief to be soaked with urine and fecal material; - CNA E provided incontinent care for the resident; - CNA E failed to clean the resident's pubic area, groin, and inner thighs. 5. Review of Resident #29's medical record showed: - admitted on [DATE]; - Diagnoses of cerebral infarction (a type of stroke due to a blockage in the blood vessels supplying blood to the brain), vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to various regions of the brain, depriving them of oxygen and nutrients), neuromuscular dysfunction of the bladder (condition that results in lack of bladder control due to a brain, spinal cord or nerve problem), seizures (a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements like stiffness, twitching or limpness, behaviors, sensations, or states of awareness), muscle weakness, and pain. Review of the resident's quarterly MDS, dated [DATE], showed: - Always incontinent of bowel and bladder; - Upper extremity impairment to one side; - Lower extremity impairment to both sides; - Dependent for toileting hygiene, shower/bath, and upper and lower body dressing. Review of the resident's Care Plan, dated 01/09/24, showed: - Resident has an ADL self care performance deficit and requires assist with ADLS related to a history of stroke with left sided hemiparesis (a loss of strength in the arm, leg, and sometimes face on one side of the body)/hemiplegia; - Interventions of extensive to dependent assist with bed mobility, bilateral grab bars to hold him/herself on his/her side while staff provides care related to left sided hemiplegia, dependent with mechanical lift transfers, dependent with bath/showers, does not wash any part of him/herself, and dependent with toileting hygiene and brief changes. Observation on 05/20/25 at 2:12 P.M., of the resident's incontinent care showed: - The resident's brief to be soaked with urine; - CNA E provided incontinent care for the resident; - CNA E failed to clean the resident's pubic area, groin, and the perineum (area between the genitals and the anus). During an interview on 05/20/25 at 3:55 P.M., CNA E said a resident's pubic area, the perineum, and both sides of the groin should be cleaned. Everything should be cleaned during incontinent care. During an interview on 05/20/25 at 3:55 P.M., CNA B said during incontinent care that all parts should be cleaned such as the pubic area, the groin, the perineum, the buttocks, and thighs. During an interview on 05/22/25 at 9:45 A.M., CNA F said the catheter drainage bag should be lower than the the resident's bladder. The catheter drainage bag should be hooked to the bed frame or hooked under the wheelchair. During an interview on 05/22/25 at 9:49 A.M., CNA E said the catheter should allow the urine to flow down and drain so the catheter drainage bag should be below the resident's bladder. The catheter drainage bag should not touch the floor, it should be hooked on the bars under the wheelchair, on the bed frame, or on the strap on the side of the mattress. CNA E was unsure if the catheter drainage bag should be on the bed. During an interview on 05/22/25 at 9:53 A.M., the Director of Nursing (DON) said the catheter drainage bag should be hung on the bed, so many inches off the floor, and make sure the tubing was not taut. The catheter drainage bag should not be placed on the bed with the resident or in the resident's lap during transfers and it should always be below the resident's bladder so the urine could not backup into the bladder. She said all areas should be cleaned during incontinent care, such as the pubic area, groin, buttocks, thighs, and back if needed. During an interview on 05/22/25 at 2:00 P.M., the Administrator said she would expect staff to follow policy and procedures to ensure the catheter never was above the level of the bladder. She would also expect staff to follow procedures to ensure the whole resident was cleaned during incontinence care.

Based on interview and record review, the facility failed to attempt a gradual dose reduction (GDR) for psychotropic (medications that affect how the brain works and causes changes in mood, awareness, thoughts, feelings, or behaviors) medications for three residents (Residents #4, #16, and #22), failed to provide an appropriate diagnosis for the use of an antipsychotic (medications used to treat psychosis, a mental health condition characterized by delusions, hallucinations, and disorganized thinking) medication for one resident (Resident #4), and failed to limit the use of as needed (PRN) psychotropic medication orders for 14 days for two residents (Residents #4 and #12) out of eight sampled residents and one resident (Resident #30) outside the sample. The facility census was 55. Review of the facility's policy titled, Tapering Medications and Gradual Drug Dose Reduction, last revised April 2007, showed: - Tapering that is applicable to antipsychotic medications shall be referred to as gradual dose reduction; - Residents who use antipsychotic drugs shall receive gradual dose reductions, unless clinically contraindicated, in an effort to discontinue the use of such drugs; - Within the first year after a resident is admitted on antipsychotic medication or after the resident has been started, the staff and practitioner shall attempt a GDR in two separate quarters (with at least one month between the attempts), unless clinically contraindicated. After the first year, the facility shall attempt a GDR at least annually, unless clinically contraindicated. The physician has documented the clinical rationale for why any attempted dose reduction would be likely to impair the resident's function or cause psychiatric instability by exacerbating an underlying medical or psychiatric disorder; - The policy did not address the 14-day timeframe of PRN psychotropic medication use or a rationale to increase the timeframe. 1. Review of Resident #4's May 2025 POS showed: - Diagnoses of dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning) with agitation and hospice care (health care that focuses on the quality of life of a terminally ill person); - An order for lorazepam (an anti-anxiety medication) concentrate 2 milligram (mg)/milliliter (ml) 0.5 ml by mouth every one hour PRN for anxiety/terminal restlessness or shortness of breath for 90 days, dated 02/26/25 - 05/27/25, with no rationale for the 90 day timeframe for the order; - An order for risperidone (an antipsychotic medication) 0.5 mg two times a day related to dementia, dated 04/29/24, with a black box warning of increased mortality in elderly patients with dementia-related psychosis; Elderly patients with dementia-related psychosis treated with antipsychotic medications are at an increased risk of death. Risperidone is not approved for the treatment of patients with dementia-related psychosis; - The facility failed to provide a 14 day stop date order for the lorazepam or a documented rationale for the greater than 14 day time frame; - No documentation of an appropriate diagnoses for risperidone. Review of the resident's Nurse's Note, dated 02/26/25, showed: - The consultant pharmacist recommended to reduce the risperidone to 0.25 mg every morning and 0.5 mg every evening; - The primary physician disagreed and documented the patient was doing well presently. Review of the resident's medical record showed: - The physician did not document a detailed clinical rationale for the risperidone GDR refusal; - No documentation the consultant pharmacist addressed the need for an appropriate diagnosis for the risperidone; - No documentation the primary physician addressed an appropriate diagnosis for the risperidone. 2. Review of Resident #12's May 2025 POS showed: - Diagnoses of depression and severe protein-calorie malnutrition; - An order for lorazepam concentrate 2 mg/ml 0.25 ml by mouth every 4 hours PRN for restlessness or agitation, dated 05/02/25. Review of the resident's medical record showed: - No documentation for a greater than 14 day time frame rationale for the lorazepam PRN order; - The facility failed to provide a 14 day stop date order for the lorazepam or a documented rationale for the greater than 14 day time frame. 3. Review of Resident #16's May 2025 POS showed: - Diagnoses of anxiety and bipolar; - An order for trazodone (an antidepressant medication) 150 mg two tablets at bedtime for insomnia, dated 04/29/24; - An order for lamotrigine (an anticonvulsant medication used to treat bipolar disorder) 100 mg by mouth three times a day related to bipolar disorder, dated 04/29/24; - An order for buspirone (an anti-anxiety medication) 30 mg by mouth three times a day related to schizophrenia, dated 04/29/24; - An order for lurasidone (an antipsychotic medication) 40 mg by mouth one time a day related to bipolar disorder, dated 06/24/24; - An order for amitriptyline (an antidepressant medication) 50 mg by mouth at bedtime for depression, dated 04/29/24. Review of the resident's Nurse's Notes, dated 06/04/24, showed: - The Pharmacist Consultant monthly pharmacy review performed, reviewed GDR medications; - Did not address which medications were reviewed for GDR. Review of the resident's Pharmacy's last GDR Tracking Report, dated 08/20/24, showed: - Amitriptyline for schizophrenia, with a therapy start date of 04/25/22, with next GDR evaluation due 06/08/24; - Buspirone for schizophrenia, with a therapy start date of 01/29/21, with next GDR evaluation due 06/08/24; - Lamotrigine for schizophrenia, with a therapy start date of 01/29/21, with GDR evaluation 06/08/24; - Lurasidone for bipolar disorder, with a therapy start date of 06/24/24, with GDR evaluation of 12/24/24; - Trazodone for insomnia, with a therapy start date of 01/29/21, with GDR evaluation of 06/08/24. Review of the resident's medical record showed: - No documentation of any GDR reviews after 08/20/24; - The facility failed to attempt a GDR for the amitriptyline, buspirone, lamotrigine, lurasidone, and trazodone. 4. Review of Resident #22's May POS showed: - Diagnoses of acute and chronic respiratory failure with hypoxia (a condition where there's not enough oxygen or too much carbon dioxide in your body), chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs), and bipolar disorder; - An order for buspirone 30 mg by mouth two times a day related to bipolar disorder, dated 09/25/23. Review of the resident's Pharmacy's Last GDR Tracking Report, dated 08/20/24, showed: - Buspirone for bipolar disorder, with a therapy start date of 07/05/21, with next GDR 08/09/24. Review of the resident's medical record showed: - The facility failed to attempt a GDR for the buspirone. 5. Review of Resident #30's May 2025 Physician Order Sheet (POS) showed: - Diagnoses of Alzheimer's disease (progressive mental deterioration), major depressive disorder (long-term loss of pleasure or interest in life), and anxiety disorder; - An order for alprazolam (an anti-anxiety medication) 0.25 mg by mouth every four hours PRN for anxiety, dated 04/29/24. Review of the resident's medical record showed: - No documentation for a greater than 14 day time frame rationale for the alprazolam PRN order; - The facility failed to provide a 14 day stop date order for the alprazolam or a documented rationale for the greater than 14 day time frame. During an interview on 05/21/25 at 11:30 A.M., the Director of Nursing (DON) said that the current pharmacy took over in September 2024, so there was not a lot of GDRs completed. During an interview on 05/22/25 at 1:45 P.M., the DON said psychotropic PRN medications should all have a 14 day stop when ordered, especially the anti-psychotic medications. During an interview on 05/22/25 at 2:20 P.M., the Administrator said she would expect there to be a 14 day stop order on psychotropic PRN medications or a documented rationale by the physician. Also, GDRs should be completed per the regulations.

Based on interview and record review, the facility failed to provide documentation of on-going assessments and monitoring after dialysis (a process for removing waste and excess water from the blood) center per facility policy for one resident (Resident #27) out of one sampled resident. The facility's census was 55. Review of the facility's policy, Dialysis Services, undated showed: - This facility is committed to ensuring safe, high-quality dialysis care for residents who require dialysis services; - The goal is to promote positive health outcomes, minimize complications, and ensure resident safety and dignity throughout dialysis treatment; - Resident's receiving dialysis will have an individualized care plan in coordination with the dialysis provider; - The care plan will include access site monitoring; - Dialysis access sites will be monitored daily for signs of infection, clotting, or other contamination risks; - Facility will monitor resident's before and after dialysis for access site integrity and all observations and interventions will be documented in the resident's medical record and communicated to the dialysis provider. 1. Review of Resident #27's Physician's Order Sheet (POS), dated May 2025, showed: - admitted on [DATE]; - Diagnosis of end-stage renal disease (ESRD - the last stage of kidney failure when treatment is essential to preserve body functions and is treated by dialysis); - An order for pre-dialysis weight and vital signs every day shift on Tuesday, Thursday and Saturday; - An order for post-dialysis weight and vital signs every day shift on Tuesday, Thursday and Saturday; - No order to assess the dialysis site and/or dressing before and after dialysis. Review of the resident's admission Minimum Data Set (MDS - part of a federally mandated process for clinical assessment of all residents in certified nursing homes), dated 03/08/25, showed: - The resident received dialysis. Review of the resident's Care Plan, dated 03/24/25, showed: - Problem of at risk for complications related to diagnosis of ESRD and requiring dialysis three times a week. At risk for fluctuations in blood pressure and mental status post-dialysis; - Interventions of having dialysis three times a week as scheduled and be alert for complications such as edema, shortness of breath, abnormal heart rate, labored respirations, cough, congestion, redness and/or edema at dialysis catheter site, fever, hypotension, change in mental status or abnormal vital signs; - Send communication form to dialysis; - Check and change dressing daily at access site and document. Review of the resident's medical record showed: - No documentation of the dialysis site and/or dressing being assessed before and after dialysis. Review of the resident's Dialysis Communication Reports, dated 03/27/25 - 05/15/25, showed: - Assessment of the dialysis site/dressing after dialysis with 11 missed opportunities out of 11 opportunities. Review of the resident's Nurses Notes, dated 03/27/25 - 05/22/25, showed: - Assessment of the dialysis site/dressing after dialysis with 11 missed opportunities out of 11 opportunities; - No daily documentation of the dialysis site/dressing. During an interview on 05/19/25 at 10:15 A.M., Resident #27 said he/she went to dialysis on Tuesday, Thursday and Saturday. Facility staff did not observe his/her dialysis port , only the dialysis staff at the dialysis center. During an interview on 05/21/25 at 11:00 A.M., Licensed Practical Nurse (LPN) D said when a resident returned from dialysis, an assessment of the site should be completed and it should be documented in the nurse's notes. Resident #27's assessment and documentation didn't get done like it should. During an interview on 05/22/25 at 11:15 A.M., the Director of Nursing and Administrator said the facility didn't have documentation of the resident's dialysis site being assessed. It should be done daily and after dialysis and then documented.

Based on interview and record review, the facility failed to maintain quarterly Quality Assessment and Assurance/Quality Assurance and Improvement Program (QAA/QAPI - a written plan containing the process that will guide the facility's efforts in assuring care and services are maintained at acceptable levels of performance and continually improved) committee meetings with the required members. The facility census was 55. Review of the facility's policy titled, Quality Assurance and Performance Improvement Program, dated April 2014, showed: - The facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that builds on the Quality Assessment and Assurance Program to actively pursue quality of care and quality of life goals; - Establishing a QAPI committee/sub-committee that works in tandem with the facility leadership and the QAA Committee; - Did not address who the required committee members should be. Review of QAA Meetings, dated 12/24 through 5/25, showed: - A QAA Meeting, dated 12/13/24, with signatures of the Administrator, Minimum Data Set (MDS - part of a federally mandated process for clinical assessment of all residents in certified nursing homes) Coordinator, Medical Director, Social Service Designee (SSD). The facility didn't have an Infection Preventionist (IP) and the Director of Nursing (DON) in attendance; - A QAA Meeting, dated 01/17/25, with signatures of the Administrator, Medical Director, MDS Coordinator, and the DON. The facility didn't have an IP and at least one other staff member in a leadership role in attendance; - A QAA Meeting, dated 02/14/24, with signatures of the Administrator, MDS Coordinator, DON, and the Medical Director. The facility didn't have an IP and at least one other staff member in a leadership role in attendance; - A QAA Meeting, dated 03/13/25, with signatures of the Administrator, Medical Director, DON, and MDS Coordinator. The facility didn't have an IP and at least one other staff member in a leadership role in attendance; - A QAA Meeting, dated 04/11/25, with signatures of the Administrator, MDS Coordinator, Medical Director, and SSD. The facility didn't have an IP and the DON in attendance; - A QAA Meeting, dated 05/07/25, with signatures of the DON, Medical Director, and Administrator. The facility didn't have an IP and at least two other staff members in a leadership role in attendance. During an interview on 05/22/25., the Administrator said the facility didn't have anyone in the IP position at this time due to the DON was working on becoming certified as the IP. The QAA committee should include the DON, Medical Director, Administrator, IP, and at least two other staff members.

Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These practices had the potential to affect all residents. The facility census was 49. The facility did not provide a kitchen policy. Review of the facility's policy titled, Food Preparation and Service, revised 07/2014, showed: - Only pasteurized shell eggs will be cooked and served when residents request undercooked, soft-served or sunny side up eggs and preparing foods that will not be thoroughly cooked example (e.g.) hollandaise sauce, French toast, ice cream, et cetera (etc); - Unpasteurized eggs will be cooked until all parts of the egg (yolk and whites) are completely firm. 1. Observation on 05/07/24 at 8:38 A.M., of the walk-in refrigerator showed: - One partially full, 15 dozen case box of non-pasteurized shell eggs, received 05/06/24; - Interior surface of the door with a 3 foot (ft.) diameter (dia.) section with a brown substance. During an interview on 05/07/24 at 8:45 A.M., Dietary Aide J said eleven residents had been served eggs today that were fried over easy using the non-pasteurized shell eggs in the walk-in refrigerator. The facility did not have pasteurized eggs available to cook. Review of the resident dietary service cards, dated 05/02/24, showed eleven resident dietary service cards with an egg of choice to be fried over easy for today. During an interview on 05/07/24 at 8:50 A.M., the Dietary Manager (DM) said dietary staff cooked eggs to order using the fresh shell eggs that were non-pasteurized. The menu showed egg of choice. Several of the residents wanted fried eggs and liked them medium or over easy, so they were not always cooked well done. There were eleven residents who requested eggs fried today and they were served the non-pasteurized fried eggs with runny or medium yolks. Pasteurized eggs had not been ordered recently. During an interview on 05/07/24 at 9:56 A.M., the Administrator said she would expect eggs to be served according to the menu and the resident's choice. The menu showed egg of choice for breakfast today and some of the residents requested their eggs fried over easy. The cooks should be using only pasteurized shell eggs if they were going to serve the eggs under cooked. The eleven residents that were served non-pasteurized under cooked eggs this morning will be monitored for issues with food poisoning. The non- 2. Observation on 05/07/24 at 8:38 A.M., and 05/10/24 at 11:08 A.M., of the dry food storage room showed: - The ice machine interior horizontal plastic surface with a black substance above the ice, a 4 ft. by 6 inch (in.) vertical white substance on the entire right side of the machine and a black substance covered the entire 6 in. exposed exterior surface of the 1 in. plastic drain; - Separated floor tiles with a damp black substance below the ice machine; - Three 10-pound hamburger sticks in the upright deep freezer with 1 in. frost build up, 1/4 in. ice formation on all interior shelving and lower shelf of the freezer; - The floor with a sticky film; - A 1 ft. cabinet baseboard peeled away and exposed a black substance; - Three dented 3 quart (qt.) metal cans of chocolate pudding; - Two dented 3 qt. metal cans of mandarin oranges; - Two 50 ounce (oz.) metal cans dented of cream of mushroom soup. 3. Observation on 05/07/24 at 8:45 A.M., and 05/10/24 11:18 A.M., of the kitchen showed: - The can opener with a sticky film and black substance on the worn knife blade, base portions with black build up; - The dishwasher with white and brown build up on the exterior surfaces near the base about 1/4 in. thick; - Three 12 cup muffin pans with a brown build up on the interior surface of the cups; - Two 18 in. x 24 in. cookie sheets with brown build up; - Four 12 in. x 18 in. baking pans with brown build up; - Twelve trays of approximately 10 oz. plastic drinking cups with white build up; - Six cardboard case boxes with 6 gallon bottles of bleach liquid stacked outside the DM's office. 4. Observation on 05/10/24 at 11:24 A.M., of the walk-in refrigerator showed: - One partially full, 15 dozen case box of non-pasteurized shell eggs, received 05/06/24; - One 18 in. x 24 in. metal cookie sheet filled with round sausage patties partially covered with parchment paper; - Door interior surface with a 3 ft. dia. section with a brown substance. During an interview on 05/10/24 at 11:27 A.M., the DM said the maintenance director was supposed to keep the ice machine cleaned. The floor should be clean and in good repair, freezers should be cleaned and defrosted and were done as needed. Dented cans should be placed to the side and sent back to the supplier. The cans should be checked for dents before they were placed on the shelf. Lime scale shouldn't be on the drinking cups, weekly cleaning and brushing should be done to prevent the build up. The bleach should not be stored in the kitchen near the office door. During an interview and kitchen tour on 05/10/24 at 11:54 A.M., the Administrator said the refrigerated foods should not be stored with ice build up and refrigerators should appear defrosted. Sausage patties should not be stored in the walk in without a covered storage container. There should not be brown substance or rust in the refrigerator. There should not be canned foods on the shelves that were dented. The can opener should not have sticky film build up or brown substance along the base and the knife should appear clean. The baking pans should not have brown carbon build up. The dishwasher should appear clean and not have any build up on the exterior. The pasteurized eggs should not have been served undercooked. The ice machine should appear clean and not have a black substance on the interior. The drain should not have a black substance. During an interview on 05/10/24 at 12:19 P.M., the Maintenance Director said the ice machine should be checked for cleanliness and well maintained. This was a maintenance responsibility and inspection but it had not been checked since he/she started here three weeks ago.

Based on observation, interview, and record review, the facility failed to ensure the environment remained free of accident hazards by not maintaining water temperatures between 105 degrees Fahrenheit (F) to 120 degrees F in five occupied resident room sinks and a community shower, which put residents at an increased risk of injuries from exposure to the hot water. This practice had the potential to affect all the residents at the facility. The facility census was 49. Review of the facility's policy titled, Safety of Water Temperature, revised 12/2009, showed: - Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 120 degrees F; - Maintenance staff will be responsible for checking thermostats and temperature controls in the facility and recording these checks in a maintenance log; - Maintenance staff shall conduct periodic tap water temperature checks and record the water temperatures in a safety log. Review of the Burn Foundation website showed hot water caused third degree burns (full thickness burns which go through the skin and affect deeper tissue resulting in white or blackened, charred skin) at the following temperatures and time parameters: - In one second at 156 degrees F; - In two seconds at 149 degrees F; - In five seconds at 140 degrees F; - In 15 seconds at 133 degrees F; - In one minute at 127 degrees F. 1. Observation and interview on 05/09/24 at 10:40 A.M., showed: - Nursing Aide (NA ) E turned the water on at the resident' sink in room [ROOM NUMBER]; - NA E said the water got really hot. Observation on 05/09/24 at 10:40 A.M., through 11:05 A.M., of water temperatures taken at 30 and 60 seconds which ran for two minutes, with a digital thermometer showed: - room [ROOM NUMBER] water temperature recorded at 130.1 degrees F at the resident sink; - room [ROOM NUMBER] water temperature recorded at 131.5 degrees F at the resident sink; - room [ROOM NUMBER] water temperature recorded at 131.7 degrees F at the resident sink; - room [ROOM NUMBER] water temperature recorded at 129.2 degrees F at the resident sink; - room [ROOM NUMBER] water temperature recorded at 131.2 degrees F at the resident sink; - room [ROOM NUMBER] water temperature recorded at 130.1 degrees F at the resident sink; - room [ROOM NUMBER] water temperature recorded at 134.5 degrees F at the resident sink and 132.4 degrees F at the resident shower. Observation on 05/09/24 at 11:07 A.M., of the electrical room showed: - One digital hot water heater with a reading of 131 degrees F and an operational set point of 135 degrees F; - An error message that read alert occurred 11 hours and 40 minutes ago with no current detected in one or more heating circuits, will continue to heat water in this container; - Another non-digital hot water heater. Review of the facility's Weekly Temperature Check Logs showed: - Eleven rooms on the 100 Hall with a temperature range of 59 to 62 degrees F, dated 03/14/24; - Eleven rooms on the Memory Care Hall with a temperature range of 110 to 111 degrees F, dated 03/21/24; - Eleven rooms on the 200 Hall with a temperature range of 122 to 127 degrees F, dated 04/08/24; - Eleven rooms on the 200 Hall with a temperature range of 99 to 116 degrees F, dated 04/15/24; - Eleven rooms on the 200 Hall with a temperature range of 101 to 116 degrees F, dated 04/22/24; - Three rooms with a temperature range of 68.3 to 118.2 degrees F, dated 04/29/24; Review of the facility's plumbing invoices, dated 01/09/24 to 05/10/24, showed a new water heater ordered and installed on 04/03/24. During an interview on 05/09/24 at 11:30 A.M., the Administrator said the facility had water temperature issues for months. The problem had been low temperatures but never hot. They had a plumber in multiple times and even had a new water heater installed last month. During an interview on 05/09/24 at 3:46 P.M., the Maintenance Supervisor said he/she checked the water temps weekly. There were checks completed since 04/29/24. The hot water heater had been turned up to compensate because they only had one heater instead of two for a period of time. Now they were back to two hot water heaters, the temperature didn't need to be up as high.

Based on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a facility-initiated transfer when two residents (Residents #11 and #45) out of five sampled residents transferred to the hospital. The facility census was 49. Review of the facility's policy titled, Emergency Transfer or Discharge, revised August 2018, showed: - Emergency transfers or discharges may be necessary for the resident's welfare and the resident's needs cannot be met in the facility; - Did not address written notification to the resident or resident's representative. 1. Review of Resident #11's medical record showed: - admitted [DATE]; - The resident transferred to the hospital for medical evaluation on 01/11/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital for medical evaluation on 02/04/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital for medical evaluation on 04/18/24, and readmitted to the facility on [DATE]; - No documentation of the written notifications provided to the resident and/or the resident's representative for the resident's transfers to the hospital on 01/11/24, 02/04/24, and 04/18/24. 2. Review of Resident #45's medical record showed: - admitted [DATE]; - The resident transferred to the hospital for medical evaluation on 05/06/24, and readmitted to the facility on [DATE]; - No documentation of the written notification provided to the resident and/or the resident's representative for the resident's transfer to the hospital on 05/06/24. During an interview on 05/09/24 at 1:45 P.M., Registered Nurse (RN) A said when a resident was transferred or discharged to the hospital, the nurse filled out the hospital transfer packet. It contained the Nursing Home to Hospital Transfer form, the hospitalization s Worksheet and the Notice of Transfer or Discharge form. The Nursing Home to hospital Transfer form went with the resident upon the transfer. The hospitalization s Worksheet and the Notice of Transfer went into the basket for the front office. The nurse was to notify the responsible party, if it was someone other than the resident. If the responsible party was not the resident or in the facility, the nurse would leave a message for the responsible party if there was no answer, and document everything in the nurses note. During an interview on 05/09/24 at 1:55 P.M., the Administrator said the transfer/discharge packet was done by the nurse, then it went to the business office, where it was matched with the census, then it went to medical records to be filed in the chart. She said the white copy was mailed to the resident's responsible party, and the pink copy went to medical records. During an interview on 05/09/24 at 2:00 P.M., the Social Services Designee (SSD) said he/she received the yellow copy of the Notice of Transfer or Discharge document. He/She looked in the resident's medical record to verify the family was notified, and then filed it. If there was no note stating the family was notified, he/she sometimes checked with the nurse to see if they notified the family, have them update resident's medical record, and if not, he/she would notify the family. During an interview on 05/09/24 at 3:36 P.M., the DON said the Transfer/Discharge forms were completed by the nurse and were supposed to be provided in writing to the resident, the guardian, or the legal representative. During an interview on 05/10/24 at 9:50 A.M., the Business Office Manager (BOM) said the Notice of Transfer or Discharge was a three-part form and the nurses completed it. The one page went with the resident upon the transfer. The white copy was supposed to be mailed by the nurse to the family or representative. The yellow copy went to the SSD. The pink copy went to the BOM. The nurses had envelopes and the facility used a postage machine. The nurses usually brought the envelope to him/her to run through the postage machine and for them to be sent out. 47445

Based on observation, interview and record review, the facility failed to ensure proper storage of nasal cannulas when not in use for two residents (Resident #27 and #42) and failed to follow oxygen orders for one resident (Resident #42) out of four sampled residents. The facility census was 49. Review of the facility's policy titled, Oxygen Administration, revised, July 2010, showed: - Verify there is a physician's order for this procedure; - Review the physician's orders or facility protocol for oxygen administration; - Review the resident's care plan to assess for any special needs of the resident; - Assemble the equipment and supplies as needed; - The nasal cannula (plastic tubing placed in the nostrils to provide supplemental oxygen) is a tube that is placed approximately one-half inch into the resident's nose. It is held in place by an elastic band placed around the resident's head; - Check the tubing connected to the oxygen cylinder to assure that it is free of kinks; - Place appropriate oxygen device on the resident (i.e., mask, nasal cannula and/or nasal catheter); - Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered. 1. Review of Resident #27's medical record showed: - admitted [DATE]; - Diagnosis of chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Review of the resident's Physician Order Sheet (POS), dated May 2024, showed; - An order to change the oxygen tubing on Saturdays, dated 02/26/24; - An order for oxygen at 2 liters per minute (L/min) per nasal cannula continuously, dated 02/26/24. Observation of the resident on 05/08/24 at 9:30 A.M., showed: - The resident's nasal cannula lay on the floor and the prongs touched the floor; - Certified Nurse Assistant (CNA) C pushed the resident into the room in a wheelchair, picked up the nasal cannula from the floor, and put it in the resident's nostrils. 2. Review of Resident #42's medical record showed: - admitted [DATE]; - Diagnoses of congestive heart failure (CHF - an inability of the heart to pump sufficient blood flow to meet the body's needs) and atherosclerotic heart disease (a buildup of cholesterol plaque in the walls of the arteries causing obstruction of blood flow). Review of the resident's POS, dated May 2024, showed; - An order to change the oxygen tubing weekly on Saturdays, dated 03/30/24; - An order for oxygen at 2 L/min per nasal cannula continuously, dated 03/30/24. Observation of the resident on 05/07/24 at 11:19 A.M., showed: - The resident lay in bed not wearing a nasal cannula and the oxygen concentrator set at 2.5 L/min at the bedside; - The nasal cannula attached to the oxygen concentrator, undated, lay in the floor without a sealed container; - The nasal cannula for the portable oxygen tank, undated, lay in the wheelchair seat without a sealed container. Observation of the resident on 05/09/24 at 1:34 P.M., showed: - The resident lay in bed and the oxygen concentrator set at 3 L/min at the bedside; - The nasal cannula, dated 05/04/24, held by the resident in bed while he/she attempted to untangle the coiled tubing and the nasal cannula hung from the resident's left ear; - The nasal cannula for the portable oxygen tank, undated, lay in the wheelchair seat without a sealed container. Observation of the resident on 05/10/24 at 8:39 A.M., showed: - The resident lay in bed and the oxygen concentrator set at 3 L/min at the bedside; - The nasal cannula, dated 05/04/24, lay under the resident's pillow near the resident's feet; - The nasal cannula for the portable oxygen tank, undated, lay in the wheelchair seat without a sealed container. During an interview on 05/09/24 at 1:35 P.M., the resident said staff changed the tubing, but he/she wasn't sure how often. The oxygen was used and was helpful, but the tubing got tangled sometimes. During an interview on 05/09/24 at 3:40 P.M., the Director of Nursing (DON) said oxygen cannulas shouldn't touch the floor ever. If it did touch the floor, it should be replaced. During an interview on 05/10/24 at 1:00 P.M., Registered Nurse (RN) A said nasal cannulas should never be left in the floor, under a pillow, or hanging from a resident's ear. The concentrator should be set according to the physician's orders. Nasal cannulas for portable oxygen tanks on the resident wheelchair should be in a sealed container when not in use by the resident. During an interview on 05/10/24 at 1:05 P.M., Licensed Practical Nurse (LPN) G said nasal cannulas should never be left in the floor, under a pillow, or hanging from a resident's ear. When they were not in use, the tubing and parts should be in a sealed container. The concentrator should be set according to the physician's orders. Nasal cannulas for portable oxygen tanks should be in a sealed container. During an interview on 05/10/24 at 1:20 P.M., the Administrator said she would expect nasal cannulas to be placed in bags for storage if not in use and the nasal cannula should be placed properly on the resident when in use. The cannula should not be in the floor, under a resident's pillow, or hanging loosely from a resident's ear. Portable tubing and accessories should also be stored in a sealed container when not in use. Concentrators should be set according to the physician's order. 46521

Based on interview and record review, the facility failed to implement a care plan with specific interventions to meet individual needs for three residents (Resident #5, #7 and #18) out of 13 sampled residents. The facility census was 49. Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated March 2020, showed: - A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; - The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident; - The care planning process will include an assessment of the resident's strengths and needs; - The comprehensive, person-centered care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 1. Review of Resident #5's medical record showed: - An admitted [DATE]; - A diagnosis of Alzheimer's (a progressive disease that destroys memory and other important mental functions) disease. Review of the resident's care plan, revised on 09/12/23, showed the care plan did not address specific interventions related to Alzheimer's disease. 2. Review of Resident #7's medical record showed: - admitted [DATE]; - Diagnoses of anxiety disorder (persistent worry and fear about everyday situations) and major depressive disorder (long-term loss of pleasure or interest in life). Review of the resident's care plan, last revised 3/13/24, showed: - Did not address anxiety disorder with specific interventions; - Did not address major depressive disorder with specific interventions. During an interview on 05/10/24 at 9:45 A.M., Resident #7 said anxiety and depression medicines were helping mostly to deal with his/her concerns. Depression had been a problem for many years. 3. Review of Resident #18's medical record showed: - admitted [DATE]; - Diagnosis of dementia (a group of thinking and social symptoms that interferes with daily functioning). Review of the resident's care plan, dated 04/18/24, showed the care plan did not address specific interventions related to dementia. During an interview on 05/10/24 at 12:20 P.M., the Social Services Designee (SSD) said it was expected that anxiety, depression, and dementia were addressed in a resident's comprehensive care plan. During an interview on 05/10/24 at 12:16 P.M., the Minimum Data Set (MDS) (a federally mandated assessment instrument completed by the facility staff) Coordinator said anxiety, depression, Alzheimer's disease and dementia should be included in a comprehensive care plan. There should be pharmacological and non-pharmacological interventions addressed. Correcting and updating the care plans had been an on-going concern. During an interview on 05/10/24 at 12:25 P.M., the Administrator said issues like dementia, anxiety, and depression should be included in the comprehensive care plan and should include pharmacological and non-pharmacological interventions. 46521

Based on observation, interview and record review, the facility failed to ensure placement of the Foley catheter (a tube inserted into the bladder to drain urine) tubing and drainage bags for two residents (Resident #4 and #7) and failed to consistently use a dignity bag for one (Resident #7) out of 2 sampled residents. The facility census was 49. Review of the facility's policy titled, Catheter Care, Urinary, revised September 2014 showed: - The purpose of this procedure is to prevent catheter-associated urinary tract infections; -If breaks in aseptic technique, disconnection, or leakage occur, replace the catheter and collecting system using aseptic technique and sterile equipment, as ordered; - Infection Control, use standard precautions when handling or manipulating the drainage system, be sure the catheter tubing and drainage bag are kept off the floor. The facility did not provide a policy in regards to Foley catheter placement. 1. Review of Resident #4's medical record showed: - admitted [DATE]; - Diagnosis of unstageable (full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black)) sacral (the bottom area of the spine) wound; - The resident's Physician Order Sheet (POS), dated May 2024, showed an order to change the catheter monthly on the 28th and as needed with an 18 French catheter for Foley catheter maintenance care, dated, 03/04/24. Observation on 05/08/24 at 11:20 A.M., showed: - Registered Nurse (RN) A used his/her foot to push the resident's bedside table away from the bed and RN A's shoe touched the catheter tubing. 2. Review of Resident #7's medical record showed: - admitted [DATE]; - Diagnosis of benign prostatic hyperplasia (BPH - an enlargement of the prostate causing difficulty in urination); - The resident's POS, dated May 2024, showed an order to change the resident's suprapubic (a catheter inserted into the bladder through a surgical incision) monthly on the 15th with a 16 French catheter every night shift, dated 03/31/24. Observations of the resident showed: - On 05/09/24 at 9:24 A.M., the resident lay in bed and the uncovered catheter drainage bag hung from the bed frame and the bottom of the drainage bag touched the floor; - On 05/09/24 at 1:46 P.M., and on 05/10/24 at 8:36 A.M., the resident sat in a wheelchair in his/her room and the catheter tubing touched the floor; - On 05/10/24 at 9:45 A.M., the resident lay in bed and the uncovered catheter drainage bag hung from the bed frame During an interview on 05/10/24 at 9:45 A.M., Resident #7 said the catheter drainage bag was changed on the weekends and it got placed under the bed or wheelchair. It was hard to see if the bag or tubing touched the floor since it was placed below his/her bed and wheelchair. During an interview on 05/09/24 at 3:40 P.M., the Director of Nursing (DON) said catheter bags and tubing should not touch the floor, be touched by a shoe or anything else. The catheter bags should be always in a privacy bag. During an interview on 05/10/24 at 1:00 P.M., Registered Nurse (RN) A said catheter drainage bags should be changed weekly and should be kept in dignity bags and not touching the floor. During an interview on 05/10/24 at 1:05 P.M., Licensed Practical Nurse (LPN) G said catheter drainage bags should be changed weekly and should be kept in dignity bags and not touching the floor. During an interview on 05/10/24 at 1:20 P.M., the Administrator said she would expect the catheter drainage bag to be off the floor and tubing should not be on the floor. They should be kept in dignity bags and not touching the floor.

Based on observation, interview and record review, the facility failed to ensure staff treated residents with dignity and in a respectful manner by leaving one resident (Resident #6) out of nine sampled residents and one resident (Resident #19) outside the sample, exposed during care. The facility census was 49. Review of the facility's policy titled, Dignity, dated August 2009, showed: - Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality; - Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. 1. Review of Resident #6's medical record showed: - admitted [DATE]; - Diagnoses of diabetes mellitus (DM - a condition that affects the way the body processes blood sugar), atrial fibrillation (irregular heart rate), chronic diastolic heart failure (a condition in which your heart's main pumping chamber becomes stiff and unable to fill properly), anxiety disorder (persistent worry and fear about everyday situations), major depressive disorder long-term loss of pleasure or interest in life), and insomnia (difficulty sleeping). Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 03/19/24, showed: - Cognition intact; - Always incontinent of bladder and bowel; - Impairment to one side of upper limbs and both lower limbs; - Dependent for toileting, hygiene, and mobility. Observation of the resident on 05/08/24 at 9:20 A.M., showed: - The resident lay in bed closest to the window; - Nurse Aide (NA) E and Certified Nurse Aide (CNA) F entered the resident's room to perform incontinent care; - NA E and CNA F did not close the blinds on the window; - The back yard could be seen from the resident's window. 2. Review of Resident #19's medical record showed: - admitted [DATE]; - Diagnoses of dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning), contracture (damage to muscle tissue or joint that prevents normal mobility) of the hand muscle, anxiety disorder, convulsions (a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements like stiffness, twitching or limpness, behaviors, sensations, or states of awareness), Parkinsonism (a motor syndrome that manifests as rigidity, tremors, and slowness of movement and speed), aphasia (loss of ability to understand or express speech caused by brain damage), and a history of transient cerebral ischemic attack (a neurologic deficit that produces stroke symptoms that resolve within 24 hours). Review of the resident's quarterly MDS, dated [DATE], showed: - Cognition severely impaired; - Always incontinent of bladder and bowel; - Impairment to both upper and lower limbs; - Dependent for toileting, hygiene, and mobility. Observation of the resident on 05/08/24 at 9:42 A.M., of incontinent care showed: - The resident sat in a wheelchair in his/her room; - NA E and CNA F entered the room to perform incontinent care; - NA E and CNA F did not close the blinds on the window; - NA E and CNA F transferred the resident via hoyer lift (a mechanical lift) to the bed closest to the window and provided incontinent care; - The courtyard could be seen from the resident's window. During an interview on 05/09/24 at 3:30 P.M., the Director of Nursing (DON) said the window blinds should always be closed prior to any resident care being provided. During an interview on 05/10/24 at 10:05 A.M., NA E said the door, curtain, and window blinds should always be closed prior to any care being provided for a resident. During an interview on 05/10/24 at 11:00 A.M., the Administrator said all measures of privacy should be provided prior to performing any resident care.

Based on interview and record review, the facility failed to provide written notification of the bed-hold policy to residents and/or their representatives at the time of transfer for two residents (Resident #11 and #45) out of five sampled residents. The facility census was 49. Review of the facility's policy titled, Bed Holds and Returns, revised 03/2020, showed prior to transfers, written information will be given to the residents and the resident representatives that explain in detail: the rights and limitations of the resident regarding bed holds; the reserve bed payment policy as indicated by the state plan (Medicaid residents); the facility per diem rate required to hold a bed (non Medicaid residents), or to hold a bed beyond the state bed hold period (Medicaid residents); and the details of the transfer (per the Notice of Transfer). 1. Review of Resident #11's medical record showed: - admitted [DATE]; - The resident transferred to the hospital on 01/11/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital on 02/04/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital on 04/18/24, and readmitted to the facility on [DATE]; - No written documentation of the notification for the bed hold policy provided to the resident and/or the resident's responsible party. 2. Review of Resident #45's medical record showed: - admitted [DATE] ; - The resident transferred to the hospital on 05/06/24, and readmitted to the facility on [DATE]; - No written documentation of the notification for the bed hold policy provided to the resident and/or the resident's responsible party. During an interview on 05/09/24 at 1:55 P.M., the Administrator said the transfer/discharge packet was done by the nurse, then it went to the business office where it was matched with the census, and then it went to medical records to be filed in the chart. The white copy was mailed to the resident's responsible party and the pink copy went to medical records. She said the facility did not charge to hold a bed. During an interview on 05/09/24 at 2:00 P.M., the Social Services Designee (SSD) said he/she received the yellow copy of the Notice of Transfer or Discharge document. He/She looked in the resident's medical record to verify the family was notified, and then filed it. If there was no note stating the family was notified, he/she sometimes checked with the nurse to see if they notified the family, had them update the resident's medical record, and if not, he/she would notify the family. During an interview on 05/09/24 at 3:36 P.M., the Director of Nursing (DON) said the Transfer/Discharge forms were completed by the nurse and were supposed to be provided in writing to the resident, the guardian, or the legal representative. The bed hold was part of the Notice of Transfer or Discharge. During an interview on 05/10/24 at 9:50 A.M., the Business Office Manager (BOM) said the Notice of Transfer or Discharge was a three-part form and the nurses completed it. The one page went with the resident upon the transfer. The white copy was supposed to be mailed by the nurse to the family or representative. The yellow copy went to the SSD. The pink copy went to the BOM. The nurses had envelopes and the facility used a postage machine. The nurses usually brought the envelope to him/her to run through the postage machine and for them to be sent out. 47445

Based on observation, interview, and record review, the facility failed to provide a safe, clean and comfortable homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 49. The facility did not provide a policy regarding the environment. Observations on 05/07/24 at 8:21 A.M., 05/08/24 at 11:18 A.M., and 05/09/24 at 08:32 A.M., showed water dripped on the floor beside a yellow caution cone beneath a heating ventilation and air conditioning (HVAC) ceiling vent near room [ROOM NUMBER] and the west wing nursing station. Observations on 05/09/24 at 9:12 A.M., 9:33 A.M. and 9:47 A.M., showed: -The east wing men's handicap shower room [ROOM NUMBER] with two 6 inch (in.) diameter piles of fecal material about 1/4 in. above the floor surface below the shower chair outside of the shower stall, the toilet with separated caulk seal and a black substance along the entire toilet base along the floor and 6 white 1 in. x 1 in. ceramic tile surfaces with a black substance; -The east wing women's shower room [ROOM NUMBER] stall floor with a thin, round, metal drain cover in the center raised one in. above the floor and the side exposed a sharp edge hazard, the toilet with separated caulk seal and a black substance along the entire toilet base along the floor; - room [ROOM NUMBER] toilet seat with an 1 in. diameter of fecal material smeared on the rim and a separated caulk seal along the toilet base near the floor with a black substance. During an interview on 05/09/24 at 9:47 A.M., the resident in room [ROOM NUMBER] said there had been a problem with fecal material smeared around the bathroom yesterday. Observations on 05/10/24 at 8:31 A.M., showed: - A 6 in. x 6 in. brown area on the ceiling tile in the corner by the exit door on the memory care hall; - A 1 in. wide stripe with a 1 foot (ft.) brown area beside the vent closest to the memory care dining room door; - A 3 in. x 6 in. brown area on the ceiling tile outside of room [ROOM NUMBER]; - A 1 ft. x 3 ft. brown area down the tile wall between the high and low ceilings in the dining room; - Eight ceiling tiles with brown areas on the lower ceiling in the dining room; - A 1 ft. x 2 ft. brown area on the ceiling tile beside the window in room [ROOM NUMBER]; - A 6 in. x 4 in. brown area on the ceiling tile outside the medical record storage on the 100 Hall; - A 6 in. x 8 in. brown area on the ceiling tile between room [ROOM NUMBER] and room [ROOM NUMBER]; - The men's shower room on the 100 Hall with the white caulk around the toilet with a black substance, 36 white tiles around the toilet with a black substance, and the separation wall between the shower and the bath with a brown substance beside the wall with a 2 ft. section of missing caulk; - Five ceiling tiles around the vent across the hall outside the janitor closet with brown areas; - A 2 in. x 6 in. brown area on the ceiling tile across the hall closest to the fire panel; - A 6 in. x 4 in. brown area and a 2 in. x 6 in. brown area on the ceiling tile beside a vent across the hall outside of room [ROOM NUMBER]; - The women's shower on the 100 Hall with caulking around the toilet with a black substance. Review of the facility's Maintenance Log showed no completed work orders since December 2023. During an interview on 05/10/24 at 11:26 A.M., the Maintenance Supervisor said he/she had received work orders on the plumbing and the electrical since starting this job three weeks ago. Work orders should be provided and he/she then completed them. During an interview on 05/10/24 at 11:30 A.M., the Administrator said staff should complete work orders for the maintenance supervisor to complete.

Based on interview and record review, the facility failed to ensure one resident (Resident #4) out of three sampled residents receiving hospice (palliative care for the terminally ill with a life expectancy of six months or less) services had a complete hospice coordinated plan of care. The facility failed to provide needed care and services in accordance with professional standards of practice for one resident (Resident #23) out two sampled resident who required positioning due to an impairment. The facility census was 49. The facility did not provide a hospice policy. 1. Review of Resident #4's medical record showed: - admitted to hospice on 02/27/24; - No facility staff signatures for the hospice coordinated plan of care, dated 02/09/24; - The facility failed to provide a complete hospice coordinated plan of care for the resident. Review of the facility's policy titled, Repositioning, revised 05/2013, showed: - The purpose of this procedure is to provide guidelines for the evaluation of resident repositioning needs, to aid in the development of an individualized care plan for repositioning, to promote comfort for all bed- or chair-bound residents and to prevent skin breakdown, promote circulation and provide pressure relief for residents; - Review the resident's care plan to evaluate for any special needs of the resident; - Repositioning is critical for a resident who is immobile or dependent upon staff for repositioning; - A turning/repositioning program includes a continuous consistent program for changing the resident's position and realigning the body. A program is defined as a specific approach that is organized, planned, documented, monitored and evaluated; - Residents who are in bed should be on at least an every two hour repositioning schedule. - For residents with a Stage I (intact skin with non-blanchable redness) or above pressure ulcer (an injury to the skin and underlying tissue resulting from prolonged pressure on the skin), an every two hour repositioning schedule is inadequate; - Notify the supervisor if the resident refuses the procedure; - If the resident refuses care, an evaluation of the basis for refusal, and the identification and evaluation of potential alternatives is indicated. During an interview on 05/09/24 at 3:30 P.M., the Director of Nursing (DON) said hospice coordinated plans of care should be signed by both hospice and the facility staff. 2. Review of Resident #23 medical record showed: - An admitted [DATE]; - Diagnoses of cerebral ischemia (an acute brain injury resulting from an impaired blood flow to the brain), hemiplegia (paralysis of one side of the body) from a stroke affecting the left non-dominant side, muscle weakness, lack of coordination, Type 1 diabetes mellitus (a lifelong condition where the pancreas makes little or no insulin which leads to high blood sugar levels) with diabetic chronic kidney disease (a decrease in kidney function from diabetes), major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities), morbid obesity, and left hand contracture (a shortening and hardening of muscles, tendons and other tissue); - Maximum assist of staff with mobility. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated process for clinical assessment of all residents in certified nursing homes), dated 03/27/24, showed: - Upper and lower extremity, impairment to one side; - Substantial/maximal assistance to roll to left and right from the back; - Always incontinent of bladder; - Diabetic foot ulcer; - At risk for pressure ulcers; - Moisture associated skin damage (MASD); - Turing/repositioning program. Review of the resident's care plan, updated on 04/11/24, showed: - Bowel and bladder incontinence; - An Activity's of Daily Living (ADL's) performance deficit and required assistance with all ADL's; - Impaired skin integrity and at risk for further impaired skin related to impaired mobility and incontinence; - Interventions of check the resident every two hours and as required for incontinence, resident required extensive assist of two staff to reposition and turn in the bed, turn and reposition every two hours and as needed, heel lift boots while in bed, and provide incontinence care after any incontinent episode followed by barrier cream. Observations of the resident showed: - On 05/07/24 at 8:57 A.M., 10:55 A.M., 12:09 P.M., 12:55 P.M., 2:00 P.M., and 3:15 P.M., the resident lay in bed on his/her back with a wedge under the left upper arm; - The resident lay in same position in the bed on his/her back for four hours and 20 minutes on 05/07/24; - On 05/08/24 at 8:15 A.M., 9:25 A.M., 10:38 A.M., 11:10 A.M., 12:15 P.M., 1:35 P.M., and 2:45 P.M., the resident lay in bed on his/her back and leaned to the left; - The resident lay in the same position in the bed on his/her and leaned to the left for six hours and 30 minutes. During an interview on 05/08/24 at 9:25 A.M., Resident #23 said staff must have two people to assist him/her to move or turn because he/she cannot move the left side since having a stroke. The staff would place a wedge under his/her left arm, but they didn't turn him/her off his/her back and bottom. He/She had wounds on his/her bottom before, and they put cream on him/her sometimes, but not always. During an interview on 05/09/24 at 2:15 P.M., Certified Nursing Assistant (CNA) I said Resident #23 was to be checked and changed every two hours since he/she was incontinent of bowel and bladder. The resident's plan of care did not show the resident on a two hour turn schedule. During an interview on 05/09/24 at 3:36 P.M., the DON said residents that can't turn themselves should be turned or repositioned every two hours. 47445

Based on observation, interview, and record review, the facility staff failed to provide a safe transfer technique during a transfer from the resident's bed to wheelchair, for one resident (Resident #24) out of the 14 sampled residents. The unsafe transfer resulted in the resident falling and hitting head on the bed rail. The resident sustained [REDACTED]. The facility's census was 54. Record review of facility's policy titled Falls and Fall Risk, Managing revised (MONTH) (YEAR) showed: - Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling; - The staff, with the input of the attending physician, will identify appropriate interventions to reduce the risk of falls. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions. Record review of facility's policy titled Gait Belt Transfers, not dated, showed: - Gait belts are provided to assist staff to safely transfer or ambulate residents; - Always make sure that the wheelchair is locked prior to attempting to transfer a resident; - Apply belt around resident waist; - Assist resident to standing position by grasping belt at the waist from underneath; - Never grab the resident by the arm during the transfer. Obtain the assist of another staff member if needed. Record review of Resident #24's Occupational Therapy Discharge Summary dated 2/14/19 showed: - Patient and Caregiver Training: Instructed patient and primary caregivers in compensatory strategies, energy conservations techniques, proper body mechanics, positioning/pressure relieving techniques, safe transfer techniques and use of adaptive equipment in order to increase safety and decrease need for assistance and increase functional mobility skills with 100% carryover demonstrated by primary caregivers; - Remaining Impairments: Balance deficits, decreased dynamic balance, decreased functional activity tolerance, decreased safety awareness, strength impairments and pain. Observations of Resident #24 showed: - On 4/2/19 at 9:10 A.M., the resident lay in bed. The resident's right forehead had a pressure bandage with a red liquid oozing out of the bandage; - On 4/4/19 at 9:00 A.M., the resident had three steri strips to the forehead. He/she sat in shower chair as the staff pushed the resident to his/her room. The resident's right side of face showed deep purple to reddish colored bruising from the forehead down the face to jawline and a wound dressing on right elbow. Record review of the facility's Event Report Review & Root Cause Investigation completed on 4/2/19 showed: - Event date 4/2/19 at 5:45 A.M.; - Staff failed to use gait belt during transfer resulting in a fall; - Gait belt to be used at all times; - Resident appeared to have hit head on other bed; - Resident had knot with swelling, bruising and a cut to head; - First aide treatment provided in the facility; - Cut cleansed and steri strips and gauze bandage applied; - Root cause as improper transfer; - Intervention implemented as educate staff to use gaitbelt. Record review of resident's quarterly Minimum Data Set (MDS; a federally mandated assessment instrument completed by the facility staff), dated 1/8/19 showed: - [DIAGNOSES REDACTED]. - Other health conditions: shortness of breath or trouble breathing with exertion (walking, bathing, transferring); - Has not had any falls since admission or the prior assessment; - Extensive assistance with transfer: two or more person assist; - Brief Interview for Mental Status(BIMS; a short performance-based cognitive screener for nursing home (NH) residents) score 7 out of 15 (severe cognitive impairment). Record review of resident's care plan dated 11/7/18 showed: - Has difficulty walking; - Requires limited assist of one person for transfers and ADLs (activities of daily living). - The care plan had not been updated or revised to reflect the resident required extensive assistance of two or more persons with transfers as assessed on the quarterly MDS dated [DATE]. Record review of resident's (MONTH) 2019 Physician order [REDACTED]. - Aspirin (a medication used as a blood thinner) EC ([MEDICATION NAME] coated, may be less likely to cause stomach irritation) 81 milligrams (mg), take one tablet by mouth once daily; - Eliquis (a medication used to treat and prevent blood clots, keeps the blood thin) 2.5 mg, take one tablet by mouth twice daily. Record review of resident's Nurse's Notes dated 4/2/19 at 10:35 A.M. showed: - Resident in the floor at 5:45 A.M.; - Injury noted to right side forehead, cleaned, steri-striped, and bandage applied; - Stated just fell in the floor; - Stated he/she was ok at that time; - Denies any pain at breakfast; - Reassessed stated my head hurts and medication given; - Directory of Nursing, Guardian, and Physician notified. Record review of an undated witness statement signed by CNA I showed CNA I tried to get Resident #24 from the bed to the wheelchair . CNA I had ahold of Resident #24's pants and tried to keep the wheelchair from moving. The resident was in midturn and tumbled out of CNA I's hands. The resident hit his/her head and neuro checks were started. Record review of CNA I's employee record showed training regarding resident safety that included fall prevention, gait belts and fall assessments. During an interview on 4/2/19 at 9:10 A.M., Licensed Practical Nurse (LPN) H said the resident fell this morning and hit his/her head. The resident sustained [REDACTED]. During an interview on 4/3/19 at 1:30 P.M., LPN H said the resident fell on [DATE] at 5:45 A.M. Certified Nurse Assistant (CNA) I was with the resident when he/she fell . CNA J was coming in the room when the resident fell and hit his/her head. Neuro checks (assessment for level of consciousness) were started for 72 hours. Last night staff noted a skin tear on the resident's right arm around the elbow that was bleeding. LPN H notified the resident's guardian, Director of Nursing (DON) and the physician regarding the fall. During a phone interview on 4/3/19 at 10:40 P.M., CNA J said he/she was in the room when CNA I attempted to transfer the resident from the bed to the wheelchair. CNA I did not have a gait belt on the resident and the resident slipped out of CNA I's hands. CNA J said he/she didn't know why CNA I transferred the resident without a gait belt. CNA I had the resident by the arm and told the resident to walk. The resident was unsteady, stood up and fell . CNA I did not try to stop the resident from falling. The resident hit his/her head on the bottom part of the roommate's bed rail. CNA J notified the nurse. During an interview on 4/4/19 at 8:52 A.M., Resident #27 (roommate to Resident #24) said CNA I did not use a gait belt to transfer Resident #24 and told Resident #24 to get up and walk. CNA I had Resident #24 by the arm when he/she stood up and fell . Resident #27 said Resident #24 hit his/her head on Resident #27's bed rail. During an interview on 4/4/19 at 9:05 A.M., Resident #24 said his/her head hurt a little bit. Resident #24 said he/she did not remember what happened when he/she fell . During an interview on 4/4/19 at 4:26 P.M., the Administrator and Director of Nursing (DON) said they would expect gait belts to be used to assist residents with transfers. During an interview on 4/12/19 at 12:35 P.M., Resident #24's guardian said he/she was notified of the accident on 4/2/19. He/she was told that the resident had fallen. He/she said he/she would expect the facility to use proper transfer methods.

Based on observation, interview and record review, the facility failed to provide adequate supervision and monitoring to ensure two (Residents #3 and #11) of 15 reviewed residents at risk for elopement did not leave the facility without supervision. The facility identified 14 residents at risk for elopement. Resident #3 exited the facility through an alarmed door without staff knowledge and was found outside the facility looking into an adjacent facility. Resident #11 removed a code alert bracelet and was found outside the facility in a parking lot. The facility's census was 76. 1. Record review of the physician's orders [REDACTED]. The resident had previously resided in the facility from [DATE] through 2/25/11. Review of the Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 5/6/12, showed staff identified the resident as severely cognitively impaired with no behaviors. The resident did not use a device for mobility and had no recent falls. Staff did not identify the resident wandered on the MDS. Review of the care plan, updated 5/31/12, showed staff identified the resident as alert and oriented to self only. The care plan directed staff to apply a code alert bracelet. The care plan did not address further interventions to prevent elopement. Review of a nurse's note, dated 4/30/12, showed the resident attempted to go outside. Review of a nurse's note, dated 5/25/12 at 5:00 A.M., showed staff received a call that the resident was found outside the facility looking into an adjacent facility. Staff noted the resident wore a code alert bracelet, but the alarm did not sound when he/she exited the facility. The nurses' notes did not include further assessment of the resident's condition, monitoring or interventions to prevent further elopement. Review of the facility's investigation, dated 5/25/12, showed staff from the adjacent facility notified staff that the resident was found outside their facility looking into the front door. Staff last saw the resident at the nurses' station at 4:50 A.M. Staff noted the resident wore a code alert bracelet, but the alarm did not sound when he/she exited the facility. Staff informed maintenance of the door alarm malfunction at 6:30 A.M. Staff faxed the physician concerning the resident's elopement and noted staff had been inserviced. The investigation did not contain further information related to assessment of the resident's condition, monitoring or interventions to prevent further elopement. Review of blank behavior monitoring sheets in the medical record, dated May 2012 and June 2012, showed staff did not identify elopement or wandering behavioral symptoms or address interventions. Review of nurses' progress notes showed the resident's medical record contained two undated, incomplete notes and two additional notes, one dated 6/23/12 and one dated 7/7/12. Staff did not address the resident's elopement or wandering in the medication/behavior section of the progress notes. Review of a physician's note, date 6/25/12, showed the physician identified the resident had end-stage dementia and described the resident as quite demented. During an interview on 7/12/12 at 1:15 P.M., the Administrator and Assistant Administrator said the resident had been out of the facility for only a few minutes and sustained no injuries. Staff had applied a code alert bracelet, but the alarm did not sound. Staff determined the alarm to one door had been unplugged. Staff monitored the doors regularly and the weekend supervisor tested the code alert bracelets periodically. The Administrator and Assistant Administrator said staff should have updated the resident's care plan to address elopement and Director of Nursing (DON) A had been directed to report the elopement. Record review of the code alert monitoring log showed staff documented they monitored the resident's code alert bracelet on 6/2/12. The log contained no further documentation related to monitoring Resident #3's code alert bracelet to ensure proper function. During an interview on 7/12/12 at 1:25 P.M., the Maintenance Supervisor said he/she monitored doors on a weekly basis to ensure the code alert system worked. Following Resident #3's elopement from the facility, he/she found that the plug to one of the doors (the Southwest door) had been knocked out of the wall and the zip tie used to hold the plug in place had been broken. The Maintenance Supervisor plugged in the cord, reapplied a zip cord and talked to the three staff on 200 hall. He/she did not complete a formal inservice for all staff and no new interventions had been put into place. Record review showed staff documented the door checks to ensure the code alert system worked on a weekly basis from May through July, 2012. Observation on 7/2/12 at 2:05 P.M., showed the plug to the southwest door code alert system plugged into an outlet approximately 20 feet from the door. The outlet was 3 feet 9 inches from the floor. Staff had zip tied the plug to the outlet. During an interview on 7/12/12 at 2:05 P.M., the Assistant Administrator said staff had previously zip tied the plug to the outlet and no changes had been made. Observation on 7/12/12 at 2:10 A.M. showed Registered Nurse (RN) C checked Resident #3's code alert bracelet to ensure it functioned properly following a discussion related to monitoring the bracelets. During an interview on 7/17/12 at 10:25 A.M., RN D said staff signed the medication administration record (MAR) to indicate placement of the bracelet. RN D said he/she checked the resident's code alert bracelet if it beeped to indicate batteries needed changed. He/she did not monitor the bracelet with the monitor to ensure proper function. During an interview on 7/17/12 at 10:55 A.M., DON A said he/she came in early (on 5/25/12) following a report of the resident's elopement. DON A could not recall how the resident was dressed or the weather condition. DON A said staff monitored the resident every 15 minutes for a few days and monitored code alerts every shift for a couple of days following the incident, but did not document the monitoring. DON A said he/she did not report the incident. Observations on 7/17/12 at 11:25 A.M. and 7/18/12 at 8:58 P.M. showed the resident set off the code alert alarm on the southwest door. Staff redirected the resident away from the door. During an interview on 7/19/12 at 5:45 A.M., Certified Medication Aide (CMA) J, who was employed at the adjacent facility, said on 5/25/12 at 5:00 A.M., he/she opened the shades and saw Resident #3 standing outside the building, in front of the window. The resident appeared confused and could not tell his/her name. CMA J did not know how long the resident had been outside, but said he/she knew the resident did not need to be outside so CMA J brought the resident in and provided a drink of water. CMA J called facility staff who came to the adjacent facility and identified the resident as one who lived on the opposite hall. Staff got a wheelchair and returned the resident to the facility. The resident had a shuffling gait and wore jeans, a T shirt and slippers at the time of the elopement. CMA J did not recall seeing a code alert bracelet. CMA J said he/she was concerned as it was still dark with the sun just starting to rise and the facility was adjacent to a large ditch, highway and bar. 2. Record review of Resident #11's POS showed the resident entered the facility on 6/8/12 with a [DIAGNOSES REDACTED]. Review of a social service note, dated 6/7/12, showed the Social Services Director (BSW) noted he/she spoke to the Assistant Director of Nursing (ADON) and RN D and notified them that the resident needed a code alert bracelet due to elopement risk. Review of nurses' notes, dated 6/8/12, showed the resident entered the facility at 3:45 P.M. Staff identified the resident had elephantitis (gross enlargement) and [DIAGNOSES REDACTED] (swelling) of lower legs. Staff applied a code alert bracelet due to a history of elopement. At 7:30 P.M., the resident was found in the parking lot without his/her code alert bracelet. Staff noted 30 minute checks were instituted. The nurses' notes contained no further documentation related to the resident's condition, monitoring or interventions to prevent further elopement. Review of a behavior monitoring form, dated 6/8/12, showed staff did not complete the form to indicate elopement behaviors or address interventions. Review of a nurses' note, dated 6/10/12, showed staff noted the resident kept trying to elope from the front door of the facility. Review of the initial social service history, dated 6/15/12, showed the resident at risk for elopement. Review of a nurses' note, dated 6/18/12, showed staff documented the resident tried to go out the front door twice. Staff talked the resident into coming back inside the facility. Review of a nurses' note, dated 6/20/12 showed the resident tried to go out the front door. Review of a care plan, with a start date of 7/6/12 (after the resident's discharge date ), showed staff identified the resident as cognitively impaired and had a code alert bracelet for safety. Staff did not address further interventions to prevent elopement. Review of the medical record showed no completed investigation related to the resident's elopement. During an interview on 7/17/12 at 10:25 A.M., RN D said the resident eloped on his/her first night in the facility and Housekeeping Staff L immediately brought the resident in from the parking lot. RN D said he/she wrote up an incident report and documented the incident in the nurses' notes. The resident did not experience injuries. RN D said he/she applied a code alert bracelet to the resident prior to the elopement, but could not recall if he/she applied the bracelet to the resident's arm or leg. During an interview on 7/17/12 at 2:45 P.M., the BSW said the resident had a history of [REDACTED]. During an interview on 7/17/12 at 3:15 P.M., DON A said she did not recall being aware of Resident #11's elopement from the facility. DON A said the resident had edema (swelling) of the legs and staff should have placed the code alarm bracelet on the resident's wrist. DON A then said, following the resident's elopement, he/she told RN D to monitor the resident every 15 minutes for a while then every 30 minutes. DON A said he/she did not recall seeing a report concerning the resident's elopement. During an interview on 7/17/12 at 4:00 P.M., DON A said he/she could not find information related to the resident's elopement and that he/she may have dropped the ball at that time due to the resident having falls around the time of discharge. During an interview on 7/18/12 at 10:30 A.M., the Administrator and Assistant Administrator said they were not aware Resident #11 eloped and the facility had not completed an investigation or reported the incident. During an interview on 7/18/12 at 11:03 A.M., Housekeeping Staff L said, during the evening on the day the resident entered the facility, a visitor came into the dining room and told him/her that a resident was in the front parking lot by the cars. Housekeeping Staff L went outside and got the resident. Resident #11 did not have a code alert bracelet applied and did not have shoes on. Staff later found the resident's code alert bracelet in the resident's room. The nurse applied a new bracelet. Housekeeping Staff L said the resident did not appear to have injuries and had not gotten to the highway adjacent to the parking lot. During an interview on 7/18/12 at 11:12 A.M., RN D said he/she completed an incident report following the resident's elopement and placed the report in a box for the DON. The resident had no signs of injury. RN D said, following the resident's admission, he/she had loosely applied the alarm bracelet to the resident's leg using two bands due to the elephantitis. The resident slid the loosely applied bracelet off. Following the elopement, RN D said he/she applied the code alert bracelet to the resident's wrist. RN D said he/she did not think to apply the bracelet to the resident's wrist initially. 3. Record review of the facility's undated elopement policy showed it directed staff to provide a safe and secure environment for all residents. Following an elopement, the policy directed staff to complete an investigation. Complaints MO , MO and MO *NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level "J". Based on observation, interview and record review, completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. During the onsite visit, the facility changed the resident's care plan to address elopement risk, covered code alert plugs with locked boxes, developed and implemented a new policy pertaining to elopement and implemented bracelet and door alert monitoring. Inservices related to the new policies and procedures and proper application of code alert bracelets were scheduled for 7/20/12. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the "D" level. The facility needs to ensure all staff receives the inservice training regarding monitoring and assessment of the residents who are at risk for elopement and utilize the new policies and procedures. This statement does not denote that the facility has complied with state law (Section 198.026.1 RSMo) requiring that prompt remedial action be taken to address Class I violations.

Based on observation, interview and record review the facility failed to provide treatment and services to ensure two (Resident #9 and #14) of five residents reviewed identified as at risk for pressure sores did not develop pressure sores and received the necessary care and treatment. A total of 15 residents were selected for review in a facility census of 76. 1. Record review of Resident #9's physician's orders [REDACTED]. Review of the plan of care (POC), dated 2/23/12, showed it directed charge nurses to provide and record weekly skin assessments. Review of the treatment administration record (TAR), dated 5/30/12, showed it directed staff to check and record skin assessments weekly. The medical record contained no documentation related to completion of weekly skin assessments. Review of weekly skin assessments, dated June 2012 and July 2012, showed no assessments for Resident #9. Review of nurses' notes for July 2012 showed staff did not document any skin changes for Resident #9. Review of the TAR, dated July 2012, showed no treatment orders for the resident's buttocks. Review of a shower/skin assessment report, dated 7/13/12, showed staff identified the resident had no skin problems. Observation of Resident #9 on 7/17/12 at 9:26 A.M., 11:50 A.M., 12:45 P.M., 1:30 P.M. and 2:25 P.M. showed the resident sat in a wheelchair. Observation on 7/17/12 at 2:25 P.M. showed Certified Nurse Aide (CNA) H and CNA Q transferred Resident #9 to bed with the use of a lift. The resident had been incontinent of urine. The resident wore a urine soaked brief, shirt which was wet with urine all the way up the back and urine soaked pajama pants. Resident #9 had a three by three inch, bloody, open area on the right, lower buttock and a two by two inch red area on the left, lower buttock. During an interview on 7/17/12 at 2:30 P.M., CNA H and CNA Q said they did not know if Resident #9 had pressure sores before that day. Review of the Wound Specialist Family Nurse Practitioner's (FNP) progress note, dated 7/18/12 at 8:30 A.M. , showed the FNP identified Resident #9's right buttock had a four centimeter (cm) area of blanchable [DIAGNOSES REDACTED] (redness) with [MEDICATION NAME] (outermost layer of skin) sloughing (necrotic tissue in the process of separating from viable tissue); right ischial tuberosity (sitting bone) with three cm area of blanchable [DIAGNOSES REDACTED]; some induration (hardening); possible early manifestation of deep tissue injury which may evolve into an ulcer; and left ischial tuberosity with unstageable area of two to three cm of slough, surrounded by blanchable [DIAGNOSES REDACTED]. The FNP ordered a treatment of [REDACTED]. During an interview on 7/18/12 at 11:00 A.M., Restorative Nurse Aide (RNA) S said he/she got Resident #9 up on 7/17/12 at 7:00 A.M. RNA S said Resident #9 had a red bottom and open areas on 7/17/12. RNA S said he/she had filled out an Aims report (a tool used to identify and report resident changes to charge nurses) about Resident #9's redness and open areas on 7/6/12 and gave it to Licensed Practical Nurse (LPN) E. RNA S said he/she had gotten Resident #9 up other times since 7/6/12 and had seen [MEDICATION NAME] (an occlusive dressing) on the resident's buttocks so he/she assumed the resident had a treatment order. During an interview on 7/18/12 at 11:30 A.M., Director of Nursing (DON) B said he/she had not been able to find any staff who gave incontinent care or repositioned Resident #9 since 7:00 A.M. on 7/17/12. DON B said he/she had not been able to find out what staff had been putting [MEDICATION NAME] on Resident #9. During an interview on 7/18/12 at 7:30 P.M., DON B said he/she did not know how the Aims report got into her office without a Charge Nurse doing a skin assessment for Resident #9. DON B said there should have been an assessment done at that time and a treatment order sought from the resident's physician. 2. Record review of Resident #14's POS, dated July 2012, showed the resident entered the facility with [DIAGNOSES REDACTED]. On 7/4/12 the physician ordered staff to cleanse the resident's buttocks with [MEDICATION NAME] every day and apply [MEDICATION NAME] AG (dressing) to both bleeding wounds on buttocks, apply skin prep around wounds and secure with [MEDICATION NAME] (dressing designed to stay on a wound for four days) and re-evaluate every four days. Record review of the POC, updated 7/4/12, showed staff identified Resident #14 at high risk for skin breakdown. The POC directed staff to reposition the resident at least every two hours, to assess the skin weekly and as needed and to provide treatment as ordered to the resident's buttocks. Review of the TAR, dated July 2012, showed staff had not signed off the treatment as administered on eight of 15 opportunities. Staff did not document the completion of re-evaluations every four days as ordered. Review of the medical record showed staff did not address the resident's skin issues in nurses' notes or weekly skin assessments. The medical record did not contain a baseline assessment of the wound. Observation on 7/18/12 from 6:45 P.M. through 7:30 P.M. showed Resident #14 sat in a wheelchair in the hall along the wall. During an interview on 7/18/12 at 7:01 P.M., RN D said staff left the resident in the hall after the dinner meal until they put him/her to bed. RN D said the resident had been up for the dinner meal which started at 5:00 P.M. Observation on 7/18/12 at 7:30 P.M. showed CNA P and CNA T transferred Resident #14 with a Hoyer lift. Resident #14 wore an incontinent brief. Urine had soaked through his/her sweat pants and down both legs. Resident #14 had a two inch by two inch round, red area to both lower buttocks. The right lower buttock had a one inch round open area with bloody drainage with no dressing covering the wound. During an interview on 7/18/12 at 7:35 P.M., DON B said charge nurses needed to re-evaluate the wound by completing a wound assessment every four days as the physician requested. During an interview on 7/18/12 at 7:40 P.M., DON B said it was the policy of the facility to preform weekly skin assessments for residents who were at risk of skin breakdown and to provide services to prevent skin breakdown. During an interview on 7/18/12 at 7:45 P.M., the Assistant Director of Nursing (ADON) said he/she did not know why the CNAs did not tell someone if the [MEDICATION NAME] came off the resident. The ADON said it was the CNA's responsibility to tell the charge nurse and it was the charge nurse's responsibility to check on dressings every day to make sure they were intact. Complaints MO , MO and MO