Every finding on record at Cerenity Marian of St Paul LLC

During observation, interview, and document review the facility failed to ensure supplemental oxygen was properly maintained for 1 of 1 resident (R40) reviewed for oxygen. Findings include: R40's quarterly Minimum Data Set (MDS) dated [DATE], indicated intact cognition and diagnoses of chronic respiratory failure with hypoxia (low oxygenation) and was dependent on supplemental oxygen. R40's physician's orders indicated the following:-on 5/22/25, R40 required continuous oxygen-wean as able per nasal cannula to keep oxygen saturation greater than or equal to 90%. Oxygen at 1 LPM every shift.-on 10/1/25, order directed staff to change and date an oxygen humidifying jar monthly.R40's treatment administration record (TAR) dated 3/2026, indicated R40's humidifying jar was last changed on 3/1/26 and oxygen tubing was changed on 3/12/26.R40's Care plan dated 1/28/25, indicated R40 had ineffective breathing patterns related to chronic respiratory failure with hypoxia, dysphagia (problems swallowing) with aspiration risk. Interventions included:-Administer oxygen per doctor's orders, 1 liter per minute (LPM) via nasal cannula.-Check humidifying jar daily to see if needs fluid. Change humidifying jar and oxygen tubing weekly. -Encourage compliance with oxygen. Check oxygen sats and liter flow every shift as needed/per medical doctor's order. -Monitor portable oxygen concentrators/tanks every shift to make sure tank is not empty. Fill portable tanks per facility policy.-Oxygen as ordered; Measure & document oxygen saturation rates as needed.-Resident likes to take off oxygen on her own. Staff to continue to encourage oxygen use.During observation on 3/16/2026 at 9:09 a.m., R40's oxygen tank (in her room) had a humidifying jar with water in it and was dated 2/1/26. The oxygen tubing had an illegible label that read either 2/8 or 3/8. During observation on 3/17/26 at 11:24 a.m., R40 was in her room with oxygen on. The oxygen tubing in place had an illegible label that read either 2/8 or 3/8. The oxygen tank had a humidifying jar with water in it and was dated 2/1/26. During observation and interview on 3/17/26 at 11:27 a.m., registered nurse (RN)-A confirmed the humidifying jar was dated 2/1/26 and the tubing label was illegible and read either 2/8 or 3/8. RN-A stated the tubing should be changed weekly, and the humidifying jar should be changed monthly. During interview on 3/18/26 at 11:55 a.m., RN-B stated nurses were responsible for changing the oxygen tubing and humidifying jars and the frequency depended on the doctor's orders for each specific resident. During interview on 3/18/26 at 12:00 p.m., RN-C stated nurses were responsible for changing the oxygen tubing and humidifying jars. The oxygen tubing should be changed weekly, and the humidifying jar should be changed monthly. This was determined by the facility's standing orders. During interview on 3/18/26 at 12:05 p.m., licensed practical nurse (LPN)-A stated nurses were responsible for changing the oxygen tubing and humidifying jars and there were standing orders for the tubing to be changed weekly and the humidifying jars to be changed monthly. LPN-A confirmed R40's TAR showed the humidifying jar was last documented as changed on3/1/26 and tubing was last documented as changed on 3/12/26, which did not match with the dates on R40's humidifying jar and oxygen tubing. LPN-A was starting education for staff who chart without completing the order.During interview on 3/18/26 at 1:30 p.m., the director of nursing (DON) stated nurses were responsible for changing the oxygen tubing and humidifying jars and there were standing orders for the tubing to be changed weekly and the humidifying jars to be changed monthly. The DON further stated this was important for infection control.The facility policy regarding oxygen therapy dated 5/28/24, was received however did not address how often oxygen tubing or humidifying jars should be changed.

Based on observation, interview and document review the facility failed to ensure the environment was free of potential hazards for 1 of 1 resident (R56) found to have a space heater operating in their room.Findings include:R56's quarterly Minimum Data Set (MDS) dated [DATE], identified moderately impaired cognition and no behaviors. R56 was independent with transfers and ambulation. Diagnoses included cardiopulmonary disease (heart and lung disease), diabetes and cataracts, glaucoma or macular degeneration (eye conditions that cause loss of vision).R56's Mood State care plan dated 3/12/26, identified she had a sleep pattern disturbance related to insomnia and to evaluate her room for noise, darkness, temperature and comfort.During an observation and interview on 3/16/26 at 7:42 a.m., R56 stated her room was too cool and she used a space heater provided to her from nursing. On the laminate style floor was a [NAME] brand with model number HFH610 space heater set at 84 degrees on the digital reading. The space heater was blowing warm air and when tipped over did not automatically shut off. R56 stated she usually used the heater only at night. R56 denied being injured by the heater and was unsure how long it had been in her room.During an interview on 3/16/26 at 7:49 a.m., nursing assistant (NA)-A stated residents were not able to have space heaters in their room and was not aware of any in use.During an interview 3/16/26t a 7:51 a.m., registered nurse (RN)-B stated it was okay to give a resident a space heater if they complained of their room being cold. RN-A stated there was a space heater at the nurse's station and was not aware of any space heaters in use currently in resident rooms. During an interview on 3/16/26 at 7:51 a.m., the director of nursing (DON) also stated residents could not have space heaters in their rooms and entered R56's room and removed the space heater. During an interview on 3/17/26 at 11:20 a.m., the administrator stated they do not allow space heaters in resident rooms for safety reasons. The administrator stated the facility did not have a policy because space heaters were not allowed.The undated Product Safety Commission website identified [NAME] HFH brand heaters had not been recalled. The [NAME] HFH610 instruction manual was not able to be located. The [NAME] Official Website - Premium Heaters dated 2026, identified [NAME] heaters came with safety features like overheat protection and auto shutoff, and it was always recommended to follow the instruction manual and never leave any heater unattended for long periods while sleeping.

Based on interview and document review the facility failed to ensure medications were administered per physicians' orders for 2 of 2 (R6, R150) residents reviewed for medication errors. This resulted in significant medication errors and actual harm when R6 received the wrong medications resulting emergent care and hospitalization for hypotension (low blood pressure), lethargy, and possible aspiration. Findings include: R6's quarterly Minimum Data Set (MDS) dated [DATE], indicate R6 had severe cognitive impairment and diagnoses of dementia, depression and high blood pressure. Furthermore, R6's MDS indicated R6 did not take narcotic medications. R6's Safety Events- Medication Error report dated 2/2/25, indicated R6 received R229's medications. The medications R6 received in error included the following: -Methadone (narcotic pain medication) 2.5 milligrams (mg) -gabapentin (medication to treat nerve pain) 900mg -omeprazole (medication to prevent acid reflux) 20mg -senna (medication to prevent constipation) 2 tablets -tamsulosin (medication to treat enlarged prostrate) 0.4mg -MiraLAX 17grams (medication to prevent constipation) The report further indicated R6's blood pressure had decreased from >100 systolic to 55 systolic over the course of 2 hours. Staff gave Narcan (medication to reverse the effects of narcotic medication) and R6 transferred to a higher level of care. Furthermore, R6 required additional observation overnight in the hospital. R6's provider orders lacked indication R6 had been prescribed Methadone, gabapentin, omeprazole, senna, tamsulosin or MiraLAX. R6's nursing progress note dated 2/2/25 at 9:28 a.m., indicated R6 had been given R229's morning medications. The error was noted at 9:00 a.m., and R6's vital signs were blood pressure (BP) 105/57, pulse 65, 97% oxygen saturation on room air. The on-call provider was notified and instructed vital signs to be taken every hour for 12 hours, then every 4 hours for 24 hours. If R6 became sedated, staff should administer Narcan and send to the hospital. R6's nursing progress note dated 2/2/25, at 1:39 p.m., indicated the provider was notified R6's blood pressure was low. R6's nursing progress note dated 2/2/25 at 2:39 p.m., indicated R6 had been transferred to the hospital. R6's vital signs dated 2/2/25 indicated the following: -at 11:06 a.m., BP was 107/67 and pulse 61 -at 12:34 p.m., BP was 98/62 and pulse 52 -at 1:35 p.m., BP was 55/35 and pulse 56 R6's Hospital Medicine History and Physical dated 2/2/25, at 8:14 p.m., indicated R6 was admitted for accidental ingestion and refractory hypotension. In the emergency department, R6 had ongoing sedation and hypotension. R6's mental status improved to near baseline however the hypotension continued. R6 had normal respirations and did not require supplemental oxygen. There was some concern for aspiration and R6 was started on an antibiotic however there was low suspicion for an infection onset prior to the accidental ingestion as it was reported R6 was in usual state of health before medication administration. R6 was admitted for close monitoring and management of blood pressures. R229's admission MDS dated [DATE], indicated R229 was cognately intact and had a diagnosis of bone cancer. R229 received hospice services. When interviewed on 2/4/25 at 9:04 a.m., family member (FM)-A stated R6 was given the wrong medication on 2/2/25. FM-A stated there was a newer nurse and R6 was given R229's morning medications as both had the same first name. FM-A stated they had been in contact with the hospital and due to the Methadone and gabapentin, R6's blood pressure was low and needed intravenous fluids and monitoring. When interviewed on 2/5/25 at 10:27 a.m., trained medication assistant (TMA)-A stated they were working with licensed practical nurse (LPN)-A on 2/2/25 when the medication error happened. TMA-A stated during medication pass, LPN-A asked if there were any of his residents in the dining room. TMA-A stated R6 was seated in the dining room for breakfast and told LPN-A. R6 from room [ROOM NUMBER] was. TMA-A stated LPN-A went over to where R6 was seated and administered medication. A short while later, LPN-A then asked where R6 was. TMA-A stated R6's medications were given as R6 was seated in the dining room. TMA-A asked LPN-A if R229's medications were given to R6 as they have the same first name. It was then LPN-A had realized he administered R229's medications to R6. TMA-A stated LPN-A had notified the provider and monitored R6 for any changes. TMA-A stated R6 appeared to have a normal morning and had normal behaviors during breakfast. At one point, TMA-A stated R6 wanted to lay down and did before lunch. TMA-A stated when R6 came out for lunch, R6 was falling asleep during lunch at the dining room table. TMA-A stated this was unusual for R6. R6 appeared weak and very tired so he was laid back in bed. That was when R6's blood pressure was 50's over 30's. LPN-A had notified the provider again and gave Narcan. R6 was then sent into the emergency room . TMA-A stated R6 appeared to have a normal morning before the wrong medications were given and after, appeared to be tired and lethargic. When interviewed on 2/5/25 at 10:42 a.m., registered nurse (RN)-A stated nurses should be making rounds and introducing themselves when they were new to the unit. RN-A further stated residents could be identified with their pictures, names on their rooms and by other staff who worked the units regularly. RN-A acknowledged LPN-A gave R229's medications to R6 in error and further stated there were two residents with the same name. LPN-A had worked on other units in the building however it was the first time working on this floor. RN-A expected nursing staff to use the seven rights for medication administration and verify the correct resident received the right medications. When interviewed on 2/5/25 at 1:30 p.m., nurse practitioner (NP)-A was aware R6 had been given R229's medications in error. NP-A further stated the medication error absolutely contributed to R6's low blood pressure and was the reason R6 required additional monitoring in the hospital. When interviewed on 2/5/25 at 2:35 p.m., clinical pharmacist (CP) was aware of R6's medication error. CP stated R6 had received R229's methadone and gabapentin which had the greatest potential for a negative outcome. CP explained the methadone dose was low; however, gabapentin can potentiate the methadone making it have greater effects. CP stated this was a significant medication error that resulted in R6 needing hospitalization . When interviewed on 2/6/25 at 8:49 a.m., the administrator acknowledged R6's medication error and need for hospitalization . The administrator further stated the unit had two residents with the same first name and LPN-A did not clarify the correct name when giving morning medications. The administrator had been leading the facility investigation into the error. The administrator stated education was ongoing for all nurses and TMAs before the start of their shift about resident identification. Furthermore, pictures of all residents have been reviewed to ensure they were up to date and clear. When interviewed on 2/6/25 at 11:49 a.m., the Director of Nursing (DON) expected all staff to utilize the 7 rights of medication administration. DON further stated there were names on the doors, pictures on file, or staff who were nor familiar with the unit were expected to verify with other staff who normally worked on the unit. 22580 R150's initial Minimum Data Set (MDS) dated [DATE], indicate R150 had severe cognitive impairment. R150's face sheet indicated R150 had diagnoses of humerus fracture, type 2 diabetes mellitus, chronic kidney disease, and hearing loss. R150's Safety Events- Medication Error report dated 2/3/25, indicated R150 received R149's medications. The medications R150 received in error included the following: -amlodipine (medication totreat high blood pressure) -citalopram (medication to treat depression) -furosemide (medication to treat fluid retention) -gabapentin ( medication to treat seizures and peripheral neuropathy) -metformin (medication to treat type 2 diabetes) R150's provider orders lacked indication R150 had been prescribed amlodipine, citalopram, furosemide, gabapentin, or metformin. R150's nursing progress note dated 2/3/25 at 10:10 a.m., indicated R150 had received wrong medication given by nurse from other unit. R150's vital signs were blood pressure (BP) 109/65, heart rate 92bpm (beats per minute), respirations 17, O2sat (oxygen saturation) 97% and temperature 97.5 F. The on-call provider was notified and instructed to hold the PRN Oxycodone (as needed pain medication) for 24 hours, and to check vital signs every hour and monitored for any adverse reaction accordingly. R150's nursing progress note dated 2/3/25, at 1:13 p.m., indicated the resident was observed slashing around in bed with her bed at the end of the bed and feet at the pillow(sic). Resident was yelling out and son is present. He was unable to get her to tell him what was wrong and bothering her. Son sat with resident and writer called NP Nurse practioner) to give update. NP gave order to send resident to the ED (emergency department) for cardiac monitoring due to resident receiving another residents medication this morning. R150's nursing progress note dated 2/3/25 at 5:40 p.m., indicated R150 returned to facility by hospital transport at this time. R150's Hospital After visit summary dated 2/3/25, at 6:16 p.m., indicated R150 was at the emergency room from 1428 (2:28 p.m.) until discharge at 1700 (5:00 p.m.). In the emergency department, the hospital looked at the doses of medications you accidentally took, and spoke to poison control. No additional monitoring needs to be performed. When interviewed via telephone on 2/5/25 at 11:36 a.m., Licensed Practical Nurse (LPN)-A stated she was working on 2/3/25 on the 3000 floor. They indicated it was their first shift at the facility. They came in early for training, and started doing medication administration by going room to room. They indicated R150 and R149's room were next to each other. They indicated they dished up 149's medication, and were distracted, and went into R150's room and administered R149's medications. They went to the medication cart and immediately realized they had given the wrong resident the wrong medication and immediately reported it to the Registered Nurse (RN) on the floor When interviewed on 2/5/25 at 9:20 p.m.,NP-A was aware R150 had been given R149's medications in error. NP-A further stated she was here when the medication error occurred, as was R149's doctor. NP-A indicated they discussed the medications R150 had received and were concerned that the gabapentin might interact with the other medications. NP-A indicated they were notified later in the afternoon that the resident was restless and to send them to the emergency room . When interviewed on 2/5/25 at 2:35 p.m., clinical pharmacist (CP) was aware of R150's medication error. CP stated R150 had received R149 's metformin and might cause R150 stomach issues. CP indicated the medication was nothing really dangerous, and the emergency department sent her back without further orders When interviewed on 2/6/25 at 8:57 a.m., the administrator acknowledged R150's medication error and need for emergency room visit. The administrator further stated she had not yet spoke to LPN-B, but would get her statement. The administrator had been leading the facility investigation into the error as it was the second one in two days. The administrator stated education was ongoing for all nurses and TMAs before the start of their shift about resident identification, and following the seven rights of medication administration. When interviewed on 2/6/25 at 11:49 a.m., the Director of Nursing (DON) expected all staff to utilize the 7 rights of medication administration. DON further stated there were names on the doors, pictures on file, or staff who were nor familiar with the unit were expected to verify with other staff who normally worked on the unit. A facility policy titled Medication Administration revised 8/31/23, directed staff to administer medications by ensuring the right resident, right medication, right dose, right time, right route, and right documentation.

Based on observation, interview and record review the facility failed to ensure dishwasher temperatures were within range to ensure resident dishes were sanitized for 3 of 3 kitchenettes located on resident units. Furthermore, the facility failed to ensure expired milk was removed from 1 of 3 kitchenettes (3rd floor) and clean resident dishes were stored to prevent contamination from dust/debris for 1 of 3 kitchenettes located on resident units (4th floor). This had the potential to impact all residents who reside in the facility. Findings include: A facility document titled 3rd and 4th floor Dish Machine from Ecolab dated 2024, indicated the operating temperatures were a minimum wash temperature of 155 degrees Fahrenheit (F) and a minimum rinse temperature of 180 degrees F. A facility document titled 5th floor Dish Machine from Ecolab dated 2018, indicated the operating temperatures were a minimum wash temperature of 150 degrees F and a minimum rinse temperature of 180 degrees F. 4th floor Kitchenette A facility document titled Dish Machine Temperature Log 4th floor dated ,d+[DATE], indicated 5 of 5 days had final rinse temperatures at 180 degrees F or above, however, 0 of 5 days had wash temperatures documented at 155 degrees F or above. A facility document titled Dish Machine Temperature Log dated ,d+[DATE], indicated 17 of the 31 days had final rinse temperatures of 180 degrees F or above. The log further indicated 0 of the 31 days, had wash temperatures were documented at 155 degrees F or above. On [DATE] at 2:01 p.m., the 4th floor kitchenette was reviewed. An Ecolab dishwasher was used to cleaning resident plates from lunch. Dishwasher temperatures were observed to be 109 degrees for a wash cycle and 185 degrees for the rinse cycle. Culinary aide (CA)-A unloaded clean plates from the dishwasher and stacked them onto a plate storage container. The plates were not covered. Above the clean plates was an air grate that was visibly dirty with gray dust and dirt. There were strands of dust hanging down from the grate. When interviewed on [DATE] at 2:10 p.m., CA-A stated the dishwasher used chemicals to sanitize resident dishes. CA-A further stated dishwasher temperatures were monitored at mealtimes and documented on a temperature log, but litmus strips to ensure the appropriate chemical sanitizing was not completed on the resident units. CA-A verified the dust/debris in the grate above the clean dishes and was not sure how often or who was responsible to clean them. When interviewed on [DATE] at 2:16 p.m., maintenance (M)-A verified the dust and debris in the grate. M-A was not sure who cleaned those vents and would check with their supervisor. 5th floor Kitchenette A facility document titled Dish Machine Temperature Log 5th floor dated ,d+[DATE], indicated the 1 of 5 days had final rinse temperatures of 180 degrees F or above. The log further indicated 2 of the 5 days had wash temperatures documented at 150 degrees F or above. A facility document titled Dish Machine Temperature Log 5th floor dated ,d+[DATE], indicated 13 of the 31 days had final rinse temperatures of 180 degrees F or above. The log further indicated 6 of the 31 days, had wash temperatures were documented at 150 degrees F or above. On [DATE] at 8:14 a.m., the 5th floor kitchenette was reviewed. An ecolab dishwasher was in use washing resident dishes. The wash temperature was 159 degrees, and the rinse temperature was 182 degrees. When interviewed on [DATE] at 8:18 a.m., CA-B stated the dishwasher was a high temperature dishwasher and temperatures were monitored and documented on the temperature log. CA-B stated twice a day temperatures were monitored usually at lunch and dinner. CA-B verified the last temperatures documented were 124 degrees for washing and 165 for rinse on [DATE] at 6:16 p.m. 3rd floor kitchenette A facility document titled Dish Machine Temperature Log 3rd floor dated ,d+[DATE], indicated the 0 of 5 days had final rinse temperatures of 180 degrees F or above. The log further indicated 0 of the 5 days had wash temperatures documented at 150 degrees F or above. A facility document titled Dish Machine Temperature Log 3rd floor dated ,d+[DATE], indicated 6 of the 31 days had final rinse temperatures of 180 degrees F or above. The log further indicated 6 of the 31 days, had wash temperatures were documented at 150 degrees F or above. On [DATE] at 8:23 a.m., the 3rd floor kitchenette was observed. In the refrigerator were 5 individual containers of prairie farms 1% chocolate milk with best by dates of [DATE]. Next to the chocolate milk were stacks of individual Glenview Farms skim milk. Two of the skim milk containers had no best by dates on them. The rest of the skim milk containers had a best by date of [DATE]. An Ecolab dishwasher was started, and a wash temp was 155 degrees and a rinse temp was 165 degrees. When interviewed on [DATE] at 8:52 a.m., CA-C verified the chocolate milk's best by date was 2 days ago and stated they should not be in here. CA-C removed them and threw them away. CA-C further stated sometimes the milk does not have a best by date stamped on but all of the milks come out of the same box. If a milk didn't have a date and the other milks around it had a date, it was ok to go by that one as they would all be the same. CA-C verified the dishwasher rinse temperature did not reach 180 degrees and further stated it usually did. CA-C stated if the temperatures were not high enough, the dishes would be washed a second time. CA-C then started the dishwasher again. When interviewed on [DATE] at 11:15 p.m., the culinary director (CD) stated the dishwashers on the resident floors used chemicals to sanitize dishes. CD verified litmus strips were not used on the floor to ensure the effectiveness of chemicals and only the temperatures were monitored. CD wasn't sure what the temperatures should be and would follow up. CD stated the CA's stocked the unit kitchenettes daily and expected any outdated items to be removed and expected staff to have removed the chocolate milk. CD was not aware of missing best by dates on the individual cartons of milk however expected a process to ensure the dates were known. CD stated there had been issues with dirty vents on the 4th floor and stated when dirty vents were noticed, maintenance should be notified so they can be cleaned. When interviewed on [DATE] at 12:48 p.m., the Administrator stated the CD would know what kind of dishwashers were used on the resident units and expected the guidelines to be followed to ensure resident dishes were clean and sanitized. Furthermore, the Administrator expected any dust or dirty vents/grates to be cleaned and items removed from stock that were outdated. A follow up interview on [DATE] at 2:32 p.m., the CD verified the dishwashers on the units were all high temperature sanitizing and did not use chemicals to sanitize. CD verified the temperature logs did not always indicate the dishwashers were getting to the correct temperatures and expected staff to notify her so follow up with Ecolab could be completed. A facility policy titled Dishwashing Procedures no date, directed staff to operate in accordance to the manufactures instructions and the final sanitizing rinse will be 180 degrees F. A facility policy titled Food Storage- Perishable revised 2019, did not direct staff on a process for review of best by dates on items stored in the refrigerators.

Based on observation, interview, and document review the facility failed to provide safe transfers according to the care plan, to prevent or mitigate risk of falls and/or falls with major injury, for 4 of 4 residents (R1, R2, R3, R4) who required staff assistance to transfer. This resulted in an immediate jeopardy (IJ) for R1 when she suffered an ankle fracture during a transfer. The IJ began on 7/29/24 when NA-A did not follow R1's care plan to use a standing lift (EZ-Stand) for transfers, R1 became weak and was assisted to the floor resulting in R1's ankle fracture and probable posterior malleolar fracture. The Administrator and director of nursing (DON) were notified of the immediate jeopardy on 8/15/24 at 3:19 p.m. The immediate jeopardy was removed on 8/15/24 but noncompliance remained at a lower scope and severity of a D with no actual harm with potential for more than minimal harm that was not immediate jeopardy. Findings include: R1's Face Sheet dated 8/24/22, identified R1 had diagnoses that included unspecified polyneuropathy, repeated falls, weakness, other specified disorders of bone density and structure with multiple sites of osteopenia. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 did not have cognitive impairment. R1 had moderate difficulty with hearing in which she required the use of a hearing aids. R1 also had highly impaired vision. R1 required substantial/maximal assist to don/doff foot wear. Tub/shower transfer was not assessed (N/A) but the quarterly MDS dated [DATE], identified R1 was totally dependent on staff for tub/shower transfer. R1's care plan dated 8/25/22, identified R1 had self-deficits with activities of daily living (ADL) with bathing, grooming, oral cares, ambulation, transferring, mobility, vision, and bowel/bladder. R1 required assist of one staff to assist with bathing and required assist of one with a mechanical standing lift (EZ-Stand) for transfers. R1's care plan dated 8/25/22, indicated R1 was at risk for falls related to history of falls, weakness, R1 did not wait/remember to ask for assistance, polyneuropathy, anxiety, and had visual impairment. Interventions included staff were to provide proper, well-maintained footwear. Facility reported incident (FRI) submitted to the State Agency (SA) on 7/30/24, indicated on 7/29/24, at 7:00 p.m. R1 reported to nursing home staff she was pivot transferred with assist of one staff person (instead of the standing mechanical lift). R1 could not remember details, but remembered having a hard time reaching the grab bar, she stood up to hold onto the back of the chair and landed on her ankle wrong. R1's progress note dated 7/29/24 at 1:18 a.m., identified R1 had a shower during the shift. R1's record did not include any documentation of the incident that was reported to the SA and did not identify any nursing care or treatment was provided to R1 following the fall until 7/30/24. R1's progress note dated 7/30/24 at 10:07 a.m., included nursing assistant reported resident had a bruise on right ankle. It measured 8.5 centimeters (cm) by 4.4 cm. R1 stated she could not bear weight on her right ankle. Painful to touch. Also has bruising on anterior side of right foot. R1's x-ray report titled final report dated 7/30/24 at 5:18 p.m., identified R1 sustained a displaced oblique fracture of the distal fibula (ankle fracture) at the level or the ankle joint and probably a minimally displaced avulsion of the posterior malleolus as well. R1's fall report indicated on 7/29/24. R1 had a fall in the shower room (time of fall was not identified) Interdisciplinary team (IDT) met to review R1's fall in which she was transferred inappropriately. R2 sustained a fracture to her right ankle. Pain is being managed with Tramadol, Tylenol, and elevation. Intervention: staff education. Resident is non-weight bearing to the right leg. She is now a Hoyer lift (full body mechanical lift). The facility's investigative file included R1's nursing assistant (NA) care sheet (abbreviated care plan used by NA's) used on the date of the fall indicated: R1 required assist of one staff with EZ-Stand with transfers. Vision impaired. Blind in Right, blustery in left. Hearing: hearing aids prefers to wear left hearing aid. R1 was a fall risk and staff were to encourage to wear nonslip socks at all times. During interview on 8/14/24 at 1:29 p.m., R1 stated staff were supposed to use the EZ-stand every time they transferred her, but that did not happen all the time. They [staff] think they can transfer me by myself [without the lift], I am just too heavy. R1 remembered the night she fell in the shower room very well. R1 recalled sitting on the shower chair, NA-A did not provide her with her hearing aids so she could hear and did not put anything on her feet. NA-A did not even put a gait belt on prior to telling her to stand up and hold onto the wheelchair that was not stable. R1 stated at the time, she was very worried and scared she was going to fall. R1 was standing up when she fell on to her leg which slid underneath her bottom so that she was partially lying and sitting on the floor. R1 screamed out in pain and knew something was wrong right away. She then was transferred by multiple staff with the Hoyer lift to her wheelchair that was in the shower room. R1 was pushed to her room, then transferred to the bed with the standing lift by one staff member but she was not sure which one. R1 stated she was not sure if a nurse was in the shower room or her room after the fall because she was blind and could not see the staff's faces or name tags. R1 explained it took a whole day for someone to look at her ankle even though she was reporting pain to nursing staff. R1 expressed safety concerns with staff not knowing what's going on or what I need. During interview on 8/14/24 at 12:39 p.m. NA-A stated she had worked the evening of 7/29/24 when R1 fell . NA-A stated R1 was supposed to use the EZ-Stand but transferred R1 by a standing pivot during her shifts for the last 11 months because that's the way I did it. NA-A indicated R1 was in the shower room sitting on the shower chair with her pants down around her upper legs. Once NA-A helped R1 to stand, R1 did not use the grab bar because NA-A told R1 to hold onto her wheelchair that was facing her. While R1 was arched over her chair, NA-A started pulling up R1's pants but R1 could not stand anymore because she became weak and started sliding down so NA-A assisted her to the floor. NA-A asked R1 if she was in pain and R1 said her leg was hurting. R1 had not reported pain in her leg before, during or after her shower until after she went down to the floor. NA-A indicated she called for help in the shower room. NA-B and NA-C responded they used a Hoyer to get R1 back to the wheelchair. Then pushed R1 to her room where NA-A used the EZ-stand to get R1 back into bed because her leg was hurting. NA-A explained she used the EZ-Stand instead of the Hoyer so R1 would not have to put so much weight on her leg. NA-A was not aware easing someone down to the floor was considered a fall. The reason NA-A did not report R1's fall and new onset of pain was because registered nurse (RN)-A was busy and had a bad attitude. NA-A did not report to oncoming RN or nursing assistants because she was not thinking of it. During interview on 8/15/24 at 10:15 a.m., NA-B stated she worked on 7/29/24, the evening R1 fell . NA-B was called on the walkie talkie by NA-A around 7:30 p.m. or 8:00 p.m. When NA-B entered the shower room, R1 was partially sitting and laying on her side, one of R1's legs was backwards and one was forward, and she was barefoot. NA-B reported R1 was not wearing a gait belt and there was no gait belt in the shower room. NA-B stated, NA-A had told her she had guided R1 to the ground. NA-C arrived to the shower room shortly after NA-B, at which point NA-A directed NA-C to go get the Hoyer (brand name of full body mechanical lift). After the three of them transferred R1 to her wheelchair NA-B and NA-C left the shower room. NA-B reported R1 stated she was fine and did not display or report pain. NA-A explained a nurse was not present during the transfers and had assumed NA-A had notified the nurse of the fall. NA-B was unaware if lowering a resident to the floor was considered a fall. During return call on 8/16/24 at 3:34 p.m., NA-C reported hearing someone needed help in the shower room on 7/29/24. Upon entering the shower room R1 was clothed, barefoot, and was laying on the ground without a gait belt on. NA-C was directed by NA-A to go get a Hoyer. NA-C stated R1 was then transferred off the floor to wheelchair. NA-C was unaware why R1 was on the floor and left the room after R1 was transferred to the chair. NA-C did not have any other contact with R1 that evening. NA-C stated R1 did not report pain or notice non-verbal signs of pain. NA-C indicated a nurse was not present and she had not notified a nurse of the incident. NA-C was unaware if lowering a resident to the floor was considered a fall. During an interview on 8/14/24 at 2:22 p.m., trained medication aid (TMA)-A stated she worked the evening of 7/29/24. NA-A did not report anything to her about a fall. NA-A mentioned a rough transfer and no further information. TMA-A reported witnessing NA-A transfer R1 with the EZ-Stand from wheelchair to bed on 7/29/24 following the shower and R1 did not appear to be in discomfort at that time. About half hour after R1 was in bed she complained of pain in her foot and leg so she applied the muscle rub that she could have when she needed it. TMA-A applied the muscle rub again that evening but could not recall the time. TMA-A did not see any swelling or bruising and R1 had not reported she was having excessive pain. During interview on 8/15/24 at 11:40 p.m., registered nurse (RN)-A reported to be the nurse for R1 on the nightshift of 7/29/24. RN-A was not notified of any falls for R1. RN-A stated NA-A never gave report before leaving for break or the end of her shift. RN-A stated she had completed a skin check on R1's body after the shower while R1 was in bed but did not find any concerns and R1 did not mention any pain. RN-A was notified by the director of nursing (DON) of R1's fall the next day when facility staff went to get R1 up and R1 reported pain. During interview on 8/16/24 at 9:56 a.m., clinical manager (CM)-A reported through her investigation R1 was not wearing a gait belt at the time of the fall. R1's fracture was identified on the morning of 7/30/24, after R1 reported pain to a NA who then reported to a licensed practical nurse (LPN). CM-A explained staff were not to stand R1 up without the use of an EZ-Stand. R1 should have been assessed by a nurse prior to getting her up from the floor. NAs were not trained to complete assessments to determine if there were injuries that were not obvious. CM-A indicated since the fall was not reported to a nurse timely it did cause a delay in necessary care and treatment of R1's fracture. CM-A indicated all falls should be reported immediately so a delay in services could be avoided. CM-A reported all three nursing assistants NA-A, NA-B and NA-C should have reported the fall after it happened. R1's fall was preventable if the care plan was followed. During interview on 8/15/24 at 11:14 a.m., physical therapist (PT)-A recalled being notified R1 had fallen during a transfer with a nursing assistant who did not use an assistive device or gait belt. R1 did not have adequate standing tolerance and would not be able to stand long enough to pull up her pants and transfer simultaneously. PT-A expected R1's legs would give out and should not have transferred without the use of an EZ-Stand due to risk of falling. Since the fall, R1 was now no weightbearing on the right leg and was in an immobilizer. During interview on 8/16/24 at 10:14 a.m., Administrator and director of nursing (DON) reported the causal factor for why R1 fell was due to an improper transfer due to staff not following the care plan and R1's fall was preventable. When staff do not follow the care plans there is a risk of causing harm to the residents. All staff should be aware of need to report a fall immediately; unintentionally coming to the ground was considered a fall. There was a delay in response to R1's pain because of the late reporting which could have caused increased pain. Additionally, oncoming staff members could have caused more damage when attempting to transfer without awareness of a previous fall. R4's Face Sheet dated 7/9/24, identified diagnoses which included other abnormalities of gait and mobility, lack of coordination, repeated falls, cognitive communication deficit, weakness, syncope and collapse and bilateral sensorineural hearing loss. R4's quarterly MDS dated [DATE], identified R4 had severe cognitive impairment. R4 required assist substantial/maximal assist to go from lying to sitting at the edge of the bed. R4 required substantial/maximal assist for sitting to standing and partial moderate assist for chair to bed transfer. R4's care plan dated 8/28/23, identified R4 required assist with bed mobility, transfers, ambulation, and locomotion due to rheumatoid arthritis. R4 required stand by assist with gait belt for all transfers. R4's undated care sheet identified R4 required A1 [assist of one] bed and transfers independently W/C [wheelchair]. R4's undated nurse report sheet identified R4 transferred independently. During observation on 8/15/24 at 9:20 a.m., NA-F was transferring R4 from the edge of the bed to the wheelchair that was directly in front of R4. Although NA-F had a gait belt around R4, NA-F laced her arms under R4's under arms and lifted R4 to standing position. R4's shoulders were above R4's ears during the lifting process. R4 yelled Ouch! Ouch! Ouch! at which point the surveyor directed NA-F to stop the transfer and allow R4 to sit back on the edge of the bed. Second attempt NA-F used R4's transfer belt to lift R4 to a standing position however R4's knees bent and was not standing in a straight up. While R4 was in that position, R4 leaned forward to hold onto the wheelchair in front of her for support. R4 was unable to lift her feet to start the 180-degree pivot after several attempts. Surveyor again directed NA-F to stop the transfer a second time. A second nursing assistant NA-E arrived. NA-E raised the bed and moved R4's wheelchair for a 90-degree pivot transfer. NA-E used physical assistance and a gait belt help R4 to a straight up standing position and completed the 90-degree pivot to R4's wheelchair with no instability noted. During interview on 8/15/24 at 9:42 a.m., nursing assistant (NA)-F indicated the difficult part of R4's transfer was lifting R4 up to stand. NA-F explained knew R4 was having trouble with the transfer because she was breathing heavy, had difficulty standing and moving her feet. NA-F stated the purpose of the gait belt was to prevent the resident from falling and explained she was trained by other staff to not use under the arms or clothing for lifting. NA-F admitted when residents needed assistance with a transfer, NA-F would assist them by holding under their arm pits, have them stand up, and give verbal ques to turn slowly. NA-F reported next time she plans on using the gait belt for lifting. Raising the bed by NA-E really helped. During interview on 8/14/23 at 1:56 a.m., NA-E reported staff should never go against the transfer status in the care plan for residents or go against resident care sheets. Assist of one means one staff to physically assist with the use of a gait belt. If there was weakness or any other concerns with a resident's ability to transfer, then the transfer should be stopped, and the nurse notified. R2's Face Sheet dated 11/30/2023, identified R2 had diagnoses that included Alzheimer's disease, cognitive communication deficit, unspecified dementia, weakness, other abnormalities of gait and mobility, repeated falls, left shoulder- rotator cuff insufficiency, other disorders of bone density and structure and left lower leg-subchondral sclerosis (thickening of bone). R2's annual MDS dated [DATE], identified R2 had severe cognitive impairment. R2 was independent to go from lying to sitting on the side of the bed, supervision or touching assistance for the ability to go from sit to stand and was independent for chair to bed transfer. R2 required partial/moderate assistance for toilet transfers. R2's care plan dated 7/13/23, identified R2 had activity of daily living (ADL) deficits and needs assist with bed mobility, transfers, ambulation, locomotion bathing, AM/HS (morning/night) cares, toileting, and meal set up due to Alzheimer's disease and other comorbidities. R2 required staff assist of 1 contact guard assist (CGA) for all transfers using a gait belt for support. R2's undated care sheet identified R2 required Bed: A1 Transfers: A1 R2 was noted to be a fall risk. R2's nurse report sheet undated, identified R2 transfer: A1 WC; use gait belt while on transfer. During observation on 8/14/24 at 2:54 p.m., R2 was noted to be laying perpendicular in bed. NA-C grabbed R2's right arm and pulled him forward and then pushed on R2's back so that R2 was sitting upright on the edge of the bed. NA-C placed wheelchair directly in front of R2. NA-C then laced her left arm under R2's under arm and pulled on R2's pants to bring R2 to a standing position without the use of a gait belt or walker. Once in the standing position, R2 was unsteady so he grabbed onto the wheelchair arm rest for support while NA-C held onto R2's pants to complete a 180-degree turn. During interview on 8/14/24 at 3:02 p.m., NA-C reported R2 sometimes needed a transfer belt, but this time he did not; NA-C did not offer a reason as to why R2 did not need a transfer belt. NA-C stated she was able to assist R2 to the chair by using her body to lift and help guide R2 upright into the chair. NA-C would use a transfer belt with R2 if he was fatigued. R2 had a walker that was in the bathroom, but she did not need it because he wasn't walking anywhere, just turning and did not need it. NA-C knew how to transfer R2 by the care sheets which listed R2 needed assist of one staff but did not identify R2 required a gait belt for transfers. NA-C stated if a resident needed a gait belt it would say on the care sheet. During interview on 8/14/24 at 3:12 p.m., registered nurse RN-(C) stated R2 was an assist of one with gait belt. RN-C knew R2 needed the gait belt because it was on the nurse report sheets. RN-C explained nurses and nursing assistants have different care sheets which were worded differently. RN-C was unsure why they were worded differently, and CM-A would make the changes when necessary. RN-C indicated the nurse report sheets and the care sheets should match what was in the care plan. R3's Face Sheet dated 10/20/23, identified R3 had diagnoses that included lack of coordination, unspecified dementia, other abnormalities of gait and mobility, age related osteoporosis without current pathological fracture, other specified disorders of bone density and structure multiple sites- osteopenia, repeated falls, cognitive communication deficit and weakness. R3's quarterly MDS dated [DATE], identified R3 had severe cognitive impairment. R3 required patrial to moderate assistance lying to sitting at the edge of the bed, substantial/maximal assist to complete sit to stand and supervision or touching assist for chair to bed transfer. R3 required supervision or touching assistance for toilet transfers. R3's care plan dated 12/19/23, identified R3 required assist of one to get on and off the toilet. Required assist to toilet upon rising, after meals, HS (night) and as requested. Staff should stay with R3 while seated on the toilet to prevent falls. R3's care plan dated 11/1/23, identified R3 had impaired mobility related to weakness. R3 was to maintain ability to transfer with assist x1, FWW (four wheeled walker) and wheelchair to follow with gait belt. R3's care sheet undated, identified R3 required Bed: Ax1 Transfers Ax1 and was noted to be a fall risk. R3's nurse report sheet undated, identified R3 transferred with A1 WC. During observation on 8/14/24 at 3:27 p.m., R3 was sitting on the toilet and being assisted by NA-C. R3 stood up off the toilet without a gait belt on. NA-C grabbed and pulled on the back of R3's pants while R3 completed the pivot to her wheelchair. Licensed practical nurse (LPN)-A observed this and instructed NA-C to use a gait belt. During interview on 8/14/24 at 3:36 p.m., licensed practical nurse (LPN)-A reported R3 did need a gait belt and a gait belt should be used with all residents. During interview on 8/14/24 at 3:40 p.m., NA-C reported R3 did not need a gait belt because R3 was able to stand independently. During interview on 8/15/24 at 9:29 a.m., nursing assistant (NA)-D stated she knew how to care for residents by looking at the care sheets. During interview on 8/15/24 at 10:13 a.m., occupational therapist (OT)-A reported all staff were to use a gait belt for all transfers except when a resident used an EZ-Stand and Hoyer. Contact guard assist (CGA) required a care givers hand on the resident. Whereas standby assist and/or supervision a hand may or may not be needed. The purpose of the gait belt was to keep the resident stable and stationery. The only time a staff member did not need a transfer belt was if they were fully independent in the room. During interview on 8/16/24 at 9:56 a.m., clinical manager (CM)-A reported facility expectation was for all nursing staff to give a thorough shift report on what needs to be done and inform of any changes. Nursing assistants were supposed to relay any information about changes, pain and any concerns with transfer status. An assessment by a nurse needed to be done for all falls which would include lowering residents to the ground. Staff were expected to always follow and understand the care plan. During interview on 8/16/24 at 10:14 a.m. director of nursing (DON) and administrator reported all staff should be aware when to report, how to follow their care plans, and use gait belts and appropriate devices for lifting and transferring residents. Staff should not be using resident's extremities, body parts or clothing to lift or move people this could result in injury and/or falls. All staff should be aware of the policies and procedures and follow them. During interview on 8/15/24 at 11:49 a.m., Medical director (MD)-A reported when the care plan identifies assist of one, staff should be using a gait belt. The expectation for contact guard is also for staff to hold onto the gait belt. Staff should not be using part of a resident's body or clothing to lift residents. Policy titled integrated fall management undated. Identified definition of a fall: Unintentional change in position coming to rest on the ground, floor or onto the next lower surface (e.g, onto bed, chair or bedside mat.) The fall may be witnessed, reported by the resident or an observer or identified when a resident is found on the floor or ground. Falls include any fall, no matter whether it occurred at home, while out in the community, in an acute hospital or nursing home. Falls are not a result of an overwhelming external force (e.g., a resident pushes another resident). Fall refers to unintentionally coming to rest on the ground, floor or other lower level, but not as a result of overwhelming external force. An episode where a resident lost his/her balance and would have fallen, if not for staff interventions, is considered a fall. A fall fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. Post fall procedure step (7) identified when a resident falls the licensed nurse is notified. The nurse completes and assessment of the resident's condition including an interview, if possible, completion of vial signs and a body assessment. A fall defined as an unintentional change in position coming to rest on the ground, floor or onto the next lower surface. Policy titled Safe Patient/Resident Handling and Movement policy dated 4/1/05 directed staff, o patient Handling and Movement Requirements: -The manual lifting or moving of residents is a hazardous task and should be avoided whenever possible. If unavoidable, assess them carefully prior to completion. -Use mechanical lifting devices and other approved patient handling aids for high-risk patient handling and movement tasks except when absolutely necessary, such as in a medical emergency. -Use mechanical lifting devices and other approved patient handling aids in accordance with instructions and training Employees shall: Comply with parameters of this policy. -Use proper techniques, mechanical lifting devices, and other approved equipment/aids during performance of high-risk patient handling tasks per facility policy and manufacturer's guidelines. -Notify supervisor of any injury sustained while performing patient handling tasks. -Notify supervisor of need for re-training in use of mechanical lifting devices, other equipment/aids and lifting/moving techniques. -Notify supervisor of mechanical lifting devices in need of repair and remove equipment from use. -Supply feedback to Supervisor on Safe Patient Handling and movement components, including but not limited to; resident refusal or non-compliance to use equipment and change in resident status that would limit success of the patient handling task. The immediate jeopardy that began on 7/29/24, was removed on 8/15/24, when it was verified the facility implemented the following: The facility reviewed and revised the policies and procedures related to safe patient handling, fall management, and reporting falls. The facility educated licensed staff and nursing assistant's on following the care plans and how to safely transfer residents using a gait belt. The facility developed and implemented competency for staff to demonstrate understanding of safe transfer technique and following the care plan. The facility identified residents who were at risk and review and revised care plans and care guides based as applicable. The facility ensured care sheets reflect the care planned directions for transfers. The facility ensured staff are able to communicate level of care for transfers/articulated the type of transfer and if gait belt is not expected to be used for some reason.

Based on interview and document review the facility failed to report an incident involving a fall was immediately reported to the supervisor according to the facility abuse policy for 1 of 4 residents (R1) who suffered a fracture during an unsafe transfer that caused a delay in care and treatment for over 12 hours. Finding include: During interview on 8/14/24 at 1:29 p.m., R1 reported being transferred incorrectly on 7/29/24 in the shower causing her to fall; she landed on her butt with her right leg and ankle underneath herself. R1 screamed in pain and told staff she was hurt. R1 was unable to identify staff as she reported being legally blind and was not provided her hearing aids prior to the transfer. R1 reported it took a whole other day to get anyone to look at it. R1's quarterly MDS (minimum data set) dated 6/20/24, identified R1 as cognitively intact, moderate difficulty with hearing and requires the use of a hearing aids. R1 had highly impaired vision. Tub/shower transfer was not assessed (N/A). R1 required substantial/maximal assistants taking off and putting on footwear. R1's progress note dated 7/30/24 at 10:07 a.m., included nursing assistant (NA) reported resident had a bruise on right ankle. It measured 8.50 centimeters (cm) by 4.40 cm R1 stated she cannot bear weight on right ankle. Painful to touch. Also has bruising on anterior side of right foot. R1's x-ray report titled final report dated 7/30/24 at 5:18 p.m., identified R1 sustained a displaced oblique fracture of the distal fibula (ankle fracture) at the level or the ankle joint and probably a minimally displaced avulsion of the posterior malleolus as well. Facility reported incident (FRI) submitted to the State Agency (SA) on 7/30/24, indicated on 7/29/24, at 7:00 p.m. R1 reported to nursing home staff she was pivot transferred with assist of one staff person (instead of the standing mechanical lift). R1 could not remember details, but remembered having a hard time reaching the grab bar, she stood up to hold onto the back of the chair and landed on her ankle wrong. During interview on 8/14/24 at 12:39 p.m. NA-A stated she had worked the evening of 7/29/24 when R1 was assisted to the floor in the shower room. NA-A stated R1 was supposed to use the EZ-stand but transferred R1 by a standing pivot. R1 became weak during the transfer and so NA-A assisted R1 to the floor. When R1 got to the floor she reported pain in her leg. NA-B called for help over the walkie talkie. NA-B and NA-C helped get R1 off the floor and back in her wheelchair using a full body mechanical lift. The reason NA-A did not report R1's fall and new onset of pain was due to registered nurse (RN)-A being busy and having a bad attitude. NA-A did not report to oncoming RN or nursing assistants due to not thinking of it. During interview on 8/15/24 at 10:15 a.m., NA-B stated she worked on 7/29/24, the evening R1 fell . NA-B was called on the walkie talkie by NA-A around 7:30 p.m. or 8:00 p.m. When NA-B entered the shower room, R1 was partially sitting and laying on her side, one of R1's legs was backwards and one was forward, and she was barefoot. NA-B stated, NA-A had told her she had guided R1 to the ground. NA-C arrived to the shower room shortly after NA-B and they transferred R1 to her wheelchair. NA-A explained a nurse was not present during the transfers and had assumed NA-A had notified the nurse of the fall. During return call on 8/16/24 at 3:34 p.m., NA-C reported hearing someone needed help in the shower room on 7/29/24. Upon entering the shower room R1 was clothed, barefoot, and was laying on the ground without a gait belt on. NA-C was unaware why R1 was on the floor. NA-C indicated a nurse was not present and she had not notified a nurse of the incident. During interview on 8/15/24 at 11:40 a.m., registered nurse (RN)-A reported to be R1's nurse the night of 7/29/24 and was unaware R1 had a fell . RN-A reported NA-A never provided report that night and left her shift without notifying anyone. Additionally, there was no communication of a floor transfer by NA-B or NA-C with knowledge who had knowledge R1 had been on the floor. RN-A did give the oncoming shift report, but due to not knowing reported R1 was fine. During interview on 8/16/24 at 9:56 a.m., clinical manager (CM)-A reported employees are to follow care plans and care guides and transfer as directed. Nursing assistants are expected to notify a nurse immediately if there was a fall and/or increases in pain so the nurse could fully assess. A delay of care could happen and cause further concerns if not reported. Nurses are the only ones to be able to assess following a fall. All staff are to follow policy and procedures related to this. During interview on 8/16/24 at 10:14 a.m., Administrator and director of nursing (DON) reported R1's fall as preventable and a delay in response to R1's pain due to a lack of reporting. Administrator and DON reported R1 was at risk due to the lack of reporting as R1 could have been further injured if oncoming staff attempted to transfer R1 or had R1 stand. All staff are expected to follow the policy and procedure related to reporting. Policy titled Abuse Prevention Plan with last review date of 7/21/22, identified : Willful: the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. 1.Prevention of Abuse, Neglect, Misappropriation of Resident Property, and Financial Exploitation In order to prevent abuse, neglect, misappropriation of resident property, and financial exploitation, the facility shall do the following: a. Require staff to report concerns, incidents, and grievances immediately to their supervisor. Ensure concerns, incidents, and grievances are promptly investigated and appropriate steps are taken to minimize the likelihood of re-occurrence. b. Supervisors or managers shall provide daily supervision of direct care staff to identify inappropriate behaviors, communication quality, physical contact, and/or burn out. b. Report within the timelines of the guidance: cStaff will notify the facility Charge of Building immediately of any reports of possible abuse, neglect, misappropriation of resident property, and/or financial exploitation. The Charge of Building will immediately notify the Administrator, Director of Nursing, and Director of Social Services. cIf the event that caused the suspicion involves abuse or results in serious bodily injury, the individual is required to report the suspicion to the state immediately, but not later than 2 hours after forming the suspicion. If the event does not involve abuse and does not result in bodily injury, the individual is required to report to the state no later than 24 hours after forming the suspicion.

Based on observation, interview, and document review, the facility failed to provide sufficient staffing to ensure residents received care and assistance they needed. This had the potential to affect all 82 residents who resided in the facility. Findings include: The 2023 Annual Facility Assessment updated October 2, 2023, indicated the facility could serve 90 residents and had an average census of 73 residents. The service and care offered based upon the needs of those served included activities of daily living (ADL) support, bowel and bladder care and toileting support, coordination of care with physician and other health care providers, end of life care, fall prevention, infection prevention, medication administration, mobility assistance, nutrition support and pain management. Additionally, had an average of 24 FTE (full time equivalent) nursing staff at full census/pay period including the director of nursing (DON), assistant DON (ADON), clinical managers, Minimum Data Set (MDS) nurse, licensed nurses, infection preventionist, and wound certified nurse; and had 28 FTE nursing assistants, trained medication aide (TMA), and restorative aides. Under the heading, Staffing Plan staffing was planned in advance and altered based upon census in all departments. In addition staffing in nursing and therapy were altered based upon resident need and the number of admission and discharges and agency staff was utilized on an as needed basis. A Daily Census Report dated 4/15/24, indicated the total in house census was 82 residents with one resident on hospital leave. Forms, NAR Group Sheet 1, NAR Group Sheet 2, NAR Group Sheet 3, indicated the following, mealtime reminder: must count the meal tickets to make sure all residents have eaten, please reapproach three times and notify the nurse if a resident refuses cares. The NAR Group Sheets were reviewed and indicated on NAR Group Sheet 1 on the fourth floor there were a total of 10 residents; 4 residents who required an EZ stand, 2 residents who required a Hoyer lift with two assist. On NAR Group Sheet 2 on the fourth floor, there were a total of 10 residents; 3 residents required an EZ stand, one of those residents required two assist to transfer with the EZ stand, and 1 resident who required a Hoyer lift with two assist. NAR Group Sheet 3 on the fourth floor indicated there were 10 residents; 1 resident required an EZ stand for transfers and one residents required assist of two for transfers. A color coded Daily Nursing Schedule form was provided for 4/15/24 through 4/19/24. At the top of the form indicated the following, Going forward all floors will be taking turns on being short on a.m. shift due to call ins. 3rd>4th>5th Today's turn: COB {charge of building} to assign based on previous shift over wknds/holiday. A copy of Daily Nursing Schedule forms were provided from 3/17/24 through 4/17/24. The schedules indicated it was the 4th floor's turn to be short on the a.m. shift due to call ins on the following dates: 3/18/24 3/19/24 3/20/24 3/21/24 3/23/24 3/25/24 3/26/24 3/27/24 4/5/24 4/6/24 4/9/24 4/15/24 4/16/24 4/17/24 A color coded Daily Nursing Schedule form dated 4/15/24, indicated the following: 3rd floor had one 6:30 to 2:30 nursing assistant (NA) shift open. Additionally, the 3rd floor had one agency staff registered nurse (RN) scheduled on the day shift and two agency staff, an RN and licensed practical nurse (LPN) scheduled on the p.m. shift. 4th floor did not have an open shift and had 1 agency RN scheduled on the a.m. shift and one agency trained medication aide (TMA) scheduled on the p.m. shift, and one agency NA scheduled on the night shift. 5th floor did not have an open shift and had two agency nursing assistants scheduled on the a.m. shift, one agency TMA scheduled on the p.m. shift, and one agency RN on the night shift. 5 staff picked up a shift on the 4/15/24 schedule. A color coded Daily Nursing Schedule form dated 4/16/24, indicated the following: 3rd floor had one agency RN scheduled on a.m. shift. 4th floor had one agency LPN scheduled on the a.m. shift, one agency RN and one agency LPN scheduled on the p.m. shift. 5th floor had one agency NA scheduled on the a.m. shift, one agency TMA scheduled on the p.m. shift and one agency NA scheduled on the p.m. shift, and one agency RN scheduled on the night shift. 7 staff picked up a shift on the 4/16/24 schedule. A color coded Daily Nursing Schedule form dated 4/17/24, indicated the following: 3rd floor had one open NA shift on the a.m. shift. 4th floor had one agency TMA scheduled on the a.m. shift. 5th floor had one agency NA on the a.m. shift, one agency TMA scheduled on the p.m. shift. 9 staff picked up a shift on the 4/17/24 schedule. A color coded Daily Nursing Schedule form dated 4/18/24, indicated the following: 3rd floor had one open NA shift on the a.m. shift, one open NA shift on the p.m. shift, and one agency nurse scheduled on the p.m. shift. 4th floor had one open NA shift, one open NA shift on the p.m. shift, and had one agency TMA scheduled on the p.m. shift. 5th floor had one agency TMA on the p.m. shift. 4 staff picked up a shift on the 4/18/24 schedule. A color coded Daily Nursing Schedule form dated 4/19/24, indicated the following: 3rd floor had one open NA shift on the a.m. shift and one open NA shift on the p.m. shift. Additionally, one agency nurse scheduled on the a.m. shift, and two agency nurses scheduled on the p.m. shift. 4th floor had one open NA shift on the p.m. shift and had one agency nurse on the a.m. shift and two agency NA's scheduled on the a.m. shift. 5th floor had one open shift on the a.m. shift and had one agency nurse scheduled on the a.m. shift, and one agency nurse scheduled on the night shift. 2 staff picked up a shift on the 4/19/24 schedule. Refer to F677: the facility failed to provide timely activity of daily living (ADL) assistance for 2 of 2 residents (R9, R38) who required staff assistance to make it out to meals. Refer to F804: the facility failed to ensure food was served at warm, palatable temperatures for 3 of 3 residents (R9, R64, R50). R38's progress notes dated 1/19/24 at 9:39 p.m., indicated R38 did not receive a shower due to staffing problems. During interview on 4/15/24 at 1:34 p.m., family member (FM)-I stated the facility was short on staff and did not think care was good because staff rushed in order to get on to the next person. During interview on 4/17/24 at 7:24 a.m., dietary aide (DA)-A stated breakfast started at 7:30 a.m., and serving went until 9:00 a.m. During interview on 4/17/24 at 10:29 a.m., DA-A stated R9 had to come out to the dining room to eat and was normally out by 9:30 a.m., and stated R9 did not receive breakfast because he did not come out to the dining room. During interview on 4/17/24 at 10:47 a.m., NA-C stated R9 did not receive any breakfast and R9 liked oatmeal and scrambled eggs however, they were really running behind, but stated she would ask R9 if he wanted toast. During interview on 4/17/24 at 12:58 p.m., NA-C stated when they started the shift, NA-C was working as a trained medication aide (TMA) and there was only two aides, NA-C began working as an NA after an agency nurse came in and R9 did not eat breakfast because they were behind and R9 did not eat meals in his room, nor did he take medications in his room. During interview on 4/18/24 at 8:21 a.m., NA-C stated R9 required assist with peri care, dressing, and stated they completed most of R9's activities of daily living (ADLs). During interview on 4/18/24 at 9:35 a.m., DA-A stated he was finished serving and did not know why R9 and R38 had not received a meal tray. During interview on 4/18/24 at 8:53 a.m., nursing assistant (NA)-N stated if there was a call in, they worked with only two aides and if you worked with an agency staff it was chaotic and difficult to get work completed. NA-N stated if there was a call in, one week the 4th floor would work short and the next week another floor would work short and so on. During interview on 4/18/24 at 9:35 a.m., dietary aide (DA)-A stated he was finished serving and did not know why R9 and R38 did not receive a meal. During interview on 4/18/24 at 9:41 a.m., NA-L stated they would benefit having a float staff to help with showers because there were new residents and times were getting scrambled and residents wanted to get up at the same time. NA-L further stated NA-M was a new staff person. NA-L further stated she wanted residents to eat by 9:00 a.m., because lunch came at 11:30 and would ask a resident if it was past 10:30 a.m., if they wanted a snack and tried to make sure they received lunch first. NA-L further stated at times, some residents were eating breakfast when lunch was being served. NA-L stated she did not know what the process was if there was a call in and further stated they had been short a week straight and further stated they had a call in this morning, but it wasn't on the 4th floor and they received text messages to get people to move around. During interview on 4/18/24 at 9:54 a.m., NA-C stated NA-M's group had a lot of residents who required a mechanical lift and if you were not a regular staff person; it was difficult to get the residents up in a timely manner. NA-C further stated it was not ok to miss breakfast. During interview on 4/18/24 at 10:00 a.m., NA-C stated now that she was finished passing medications, she was going to offer her help. During interview on 4/18/24 at 10:03 a.m., NA-M stated she was going to finish R9 and further stated R38 did not refuse to get up; she had just not had the chance to go in to assist R38 yet. During interview on 4/18/24 at 11:23 a.m., the registered dietician (RD)-H stated R38 should have three meals a day and sometimes skipped breakfast per his choice depending on what time he got up. RD-H further stated if a resident wanted to get out of bed and was not getting help, it was not acceptable to miss breakfast. RD-H further stated their culinary staff relied on nursing staff to get residents out of bed and their staff had to wait until the resident was out in the dining room. During interview on 4/18/24 at 12:27 p.m., licensed practical nurse (LPN)-A stated she had 29 to 30 residents and there were 3 NA's on the 4th floor along with two nurses or one nurse and a trained medication aide (TMA) and LPN-A who was the clinical manager. Every day the director of nursing, administrator and the staffing coordinator met and if the staffing coordinator is on site would manage who was moving around. LPN-A stated they had a sick call in today and were able to move people quickly. During interview on 4/18/24 at 1:30 p.m., the director of nursing (DON) stated they looked at case mix and how many two person lifts and what the acuity was to determine staffing levels. DON further stated normal staffing was 3 nursing assistants and either a nurse and a TMA, or two nurses plus the clinical manager. DON stated they cut back on agency staffing and stated they had 2 to 4 aide positions open and for nurses maybe 6 positions opened. The DON stated they planned to add a 4th aide on the day and p.m. shift on the 4th and 5th floor. The DON further stated they were short in the morning due to a call in and got people to come in, however it was later in the morning and stated it was important residents receive their activities of daily living (ADLs) to maintain healthy nutrition and hydration and expected residents to get up for meals or if there was a working challenge to eat in their room. During interview on 4/18/24 at 2:29 p.m., the culinary director (CD) stated the facility provided three meals, breakfast, lunch, and dinner and a meal consisted of a protein, a starch, a dessert and a vegetable and toast was not considered a meal. 42580 R1 R1's annual Minimum Data Set (MDS) dated [DATE], indicated R1 had moderate cognitive impairment, required substantial/maximal assistance with eating, and dependent on staff for toileting hygiene. R1 was always incontinent of bowel and bladder. R1 did not have any swallowing issues and the care area assessment triggered for nutritional status. R1's care plan updated 3/27/24, indicated R1 had no natural teeth and had no dentures. Nursing staff were to bring tray to room and assist R1 with feeding. R1's nursing assistant care (NA) sheet undated included soft bit sized, consistent carbohydrate, thin liquids. Cut meat. Assist with meals and as needed when family is not available at supper, cut up food for resident to pick up and place tray on right side within reach. R1's physician order dated 1/2/24, indicated diet included soft and bite size texture, breads okay; consistent carbohydrate. thin liquid. R1 face sheet printed 4/18/24, indicated diagnosis generalized anxiety disorder, dependence on supplemental oxygen, and nutritional deficiency. During observation on 4/17/24 from 8:45 a.m., to 9:09 a.m., R1 was in bed asleep and in same position, lying on back, from previous observation at 7:51 a.m. During observation on 4/17/24 at 9:14 a.m., NA-K and licensed practical nurse (LPN)- E were observed completing R1's morning cares. After the completion of morning cares R1 was asked if had breakfast but could not recall if she had eaten breakfast. During interview on 4/17/24 at 10:09 a.m., NA-K stated they had filled out R1's diet slip and handed to dietary staff however had not seen R1's tray yet but had not gone to dietary to follow up on R1's breakfast tray. NA-K stated R1 required staff assist with meal set up and limited assist with feeding. NA-K verified R1 was assigned to her group but had not brought R1's breakfast to her and she had not had any breakfast at the time and R1 had not refused breakfast. During observation and interview on 4/17/24 at 2:00 p.m., R1 was lying in bed and when asked about breakfast stated, she was not sure if she had breakfast or lunch, but was hungry and asked surveyor to get her something to eat. Surveyor notified nurse manager LPN-B regarding R1's request. During interview on 4/17/24 at 2:06 p.m., nurse manager LPN-B stated was unsure if R1 had had breakfast or lunch but but would verify with NA-K. LPN-B stated thought R1 had refused breakfast at 7:30 a.m., when NA-K had asked but was unaware if R1 was reapproached after initial refusal or if she had had breakfast or lunch. A policy, Staffing and Daily Work Assignments, dated 2/2019, indicated sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. All nursing service personnel shall follow daily work assignments and perform assigned duties in accordance with professional standards of practice. Licensed nurses and certified nursing assistants are available 24 hours a day to provide direct resident cares services. Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care. Changes in work assignments must be approved by the supervisor.

Based on observation, interview, and document review, the facility failed to ensure proper hand hygiene was completed for 2 of 2 residents (R42, R1) and failed to ensure proper personal protective equipment (PPE) for 2 of 2 residents (R18, R1) observed for contact precautions and enhanced barrier precautions and failed to ensure proper cleaning of a mechanical lift following use was completed for 1 of 1 resident (R42) Findings include: R18's quarterly Minimum Data Set (MDS) dated [DATE], indicated moderate cognitive impairment, did not have behaviors and did not reject care, required substantial assistance with toileting and hygiene, partial to moderate assist with bathing, dressing, substantial assist for standing and transfering, was not on a toileting program, and was frequently incontinent of bowel and bladder. R18's Face Sheet form dated 4/15/24, indicated the following diagnoses: viral intestinal infection, repeated falls, gastro esophageal reflux disease with esophagitis without bleeding. A form provided by the facility indicated resident names, any medical devices or wounds and under the heading Notes indicated R18 had suspected norovirus. R18's physician orders indicated the following orders: 4/14/24, collect stool sample for fecal testing (Norovirus) special instructions: discontinue order after results obtained and called to the provider. 4/15/24, contact enteric precautions due to signs and symptoms of Norovirus. 4/15/24, strict contact enteric precautions due to signs and symptoms of Norovirus, isolate to room. R18's nursing progress notes dated 4/15/24, indicated a stool sample was sent due to symptoms of vomiting and loose stools times. Further, the note indicated, This writer put resident on enhanced barrier protections until test results are returned. R18's care plan dated 4/15/24, indicated R18 was on contact isolation precautions due to signs and symptoms of norovirus and interventions indicated an isolation care would be placed outside resident's room, R18 would remain in the room at all times, staff would perform proper handwashing, PPE placement and removal per facility policy prior to entering and when exiting room, staff will wear appropriate PPE related to R18's precautions. R18's care plan dated 3/20/24, indicated R18 had a urinary tract infection was was on an antibiotic. R18's care plan dated 8/28/23, indicated R18 was incontinent and required a bedpan and bedside commode. During interview and observation on 4/15/24 at 6:52 p.m., R18 was in her room in bed and a sign was located on the door for contact enteric precautions. The signage indicated everyone must clean hands with sanitizer when entering room and wash with soap and water upon leaving the room. Doctors and staff must gown and glove at the door and use patient dedicated or disposable equipment and clean and disinfect shared equipment. R18 had finished eating her meal in her room and asked if her bedside table could be moved closer to the bed. R18 activated her call light at 7:01 p.m. and at 7:02 p.m., nursing assistant (NA)-D entered R18's room without gloves or a gown. NA-D grabbed R18's meal tray and brought it into the bathroom then moved the bedside table to the resident's bedside without gloves or gown on and then picked up R18's meal tray and left the room. NA-D stated she did not wear a gown or gloves because NA-D did not provide personal cares on R18. During interview on 4/15/24 at 7:04 p.m., registered nurse (RN)-E stated R18 was on contact precautions due to suspected Norovirus and expected staff to wear PPE at all times and wash their hands when leaving the room. During interview on 4/17/24 at 9:03 a.m., licensed practical nurse (LPN)-A stated R18 was on enteric precautions and expected staff to donn PPE before going into the room and disposing of PPE when leaving and stated PPE included a mask, gown, and gloves. LPN-A further stated it was important to donn PPE because Norovirus can be on surfaces NA-D touched and could be carried to other residents. During interview on 4/18/24 at 11:51 a.m., the infection preventionist, (IP) and the director of nursing stated they expected staff to perform hand hygiene and donn gloves, gown to enter the room and when going to touch anything in the room. R42's admission assessment dated [DATE], indicated R42 was incontinent of bowel and bladder, required assist of 2 staff with toileting, bed mobility and repositioning. Additionally, R42 required continuous oxygen via nasal cannula. During observation on 4/15/24, at 01:13 p.m., signage posted outside of R42's door, and directly above a three-drawer plastic cart containing personal protection equipment, indicated need for standard precautions (a basic level of infection control that should be used in the care o all patients all of the time). Review of R42's medical record indicated this was required for staff providing cares related to R42's gastrostomy tube (G-tube: a tube inserted through the belly that brings nutrition or medications directly to the patient's stomach). During observation of cares for R42 on 4/15/24, at 02:09 p.m., certified nursing assistant (CNA)-H, with the assistance CNA-B, provided peri care to R42 after using the bedpan. R42 was transferred to bed using a mechanical lift. While wearing gloves CNA-H used a wet washcloth to clean the resident's peri area. CNA-H did not remove soiled gloves, or complete hand hygiene after providing peri care and immediately grabbed R42's oxygen nasal cannula, and assisted R42 to put it on her face. CNA-B removed her soiled gloves, did not complete hand hygiene, and took the mechanical lift out of R42's room without wiping down the mechanical lift. During interview on 4/15/24 at 02:28 p.m., CNA-B stated all mechanical lifts are supposed to be wiped down in between residents. During interview on 4/15/24, at 0:600 p.m., CNA-G stated mechanical lifts should technically be cleaned before leaving a resident's room. Additionally, CNA-G reported she wasn't sure what wipes were to be used to clean the lift, then removed a white container with a blue top from the bag attached to the mechanical lift and indicated this was what is used to clean the lift. The label on the container read PDI sani hands. During interview on 4/15/24, at 07:18 p.m., with licensed practical nurse (LPN)-B unit manager, LPN-B stated staff should clean mechanical lifts before exiting a resident's room using either bleach or hydrogen peroxide wipes, and staff should never remove a lift from a room without first wiping it down. LPN-B stated this practice will reduce the risk of cross contamination between residents. Furthermore, hand hygiene should be completed after all contact encounters with residents, after removing soiled gloves, and any time hands are visibly dirty. 42580 R1's annual Minimum Data Set (MDS) dated [DATE], indicated R1 had moderate cognitive impairment, was dependent for toileting hygiene. R1 was always incontinent of bowel and bladder. R1 care area assessment triggered for pressure ulcer. R1's care plan updated 3/26/24, indicated at risk for infection on Enhanced Barrier Precaution (EBP)related to extended-spectrum beta-lactamases (ESBL-enzymes that conferred resistance to most beta-lactam antibiotics, including penicillins, cephalosporins, and the monobactam aztreonam. Infections with ESBL-producing organisms have been associated with poor outcomes) and methicillin-resistant staphylococcus aureus (MRSA- infection caused by a type of staph bacteria that's become resistant to many of the antibiotics) in urine and R1 had active wounds. Care plan interventions included monitor signs and symptoms of infections. Access for EBP need and implement precautions according to facility protocol. R1's nursing assistant care sheet undated included EBP, incontinent, calmoseptine only. Check and change every 2-3 hours. R1's physician order dated 4/12/24, indicated calmoseptine ointment 0.44-20.6% topical for non-pressure chronic ulcer of buttock. R1 face sheet printed 4/18/24, indicated diagnosis generalized anxiety disorder, dependence on supplemental oxygen, hypertensive chronic kidney disease, and chronic pain syndrome. During observation on 4/17/24 at 9:12 a.m., R1 had EBP signage near door with personal protective equipment (PPE) supplies near door. Nursing assistant (NA-K) and licensed practical nurse (LPN)-E donned gown, mask and gloves and entered R1's room to complete morning cares. NA-K filled a bath basin with water and placed on R1's bedside table with other supplies. During pericares, NA-K cleaned R1's frontal area in a down to up motion from dirtiest to cleanliest. NA-K used a washcloth to dry R1's frontal area from down to up as well. R1 was turned to right side and NA-K used same glove to perform perineal care with and cleaned buttocks area, also using the same washcloth to clean skin area where R1 had an opened non-pressure related opened wound. NA-K then used the same glove after perineal care took R1's calmoseptine ointment 0.44-20.6% topical, and applied to non-pressure wound and surrounding skin. NA-K then changed gloves and donned new gloves to completed R1's morning cares. During continuous observation on 4/18/24 10:05 a.m., to 10:25 a.m., NA-K and NA-O entered R1's room and did not don gown, or gloves, with personal protective supplies stationed outside of R1's door. When surveyor knocked on R1's door and opened door NA-K and NA-O were observed without gown, completing morning cares for R1 and were repositioning R1 in bed. During interview on 4/18/24 at 10:31 a.m., NA-O stated they had completed morning cares for R1 including perineal cares and stated staff only needed to wear gloves even though they had direct contact with R1's non-pressure wound to buttocks. NA-K also stated was confused about when gowns should be worn for R1 and did not think gowns were needed in addition to glove use when providing perineal care fro R1 although had exposure to R1's buttock wound during perineal cares. During interview on 4/18/24 at 11:02 a.m., director of nursing (DON) stated it was the facility policy and an expectation that staff would wear gown, and gloves when performing a high contact activity such as providing morning cares with perineal cares for a resident with a non-pressure wound to buttock for EBP implementation. A policy, Contact Precautions, dated June 2017, indicated contact precautions were used when diseases were transmitted by contact with the resident or the resident's environment. Residents with disease caused by organisms that have been demonstrated to cause heavy environmental contamination will be placed on contact precautions. Diseases transmitted through contact transmission include, but are not limited to: acute infection with Methicillin Resistant Staphylococcus Aureus (MRSA), or Vancomycin Resistant Enterococcus (VRE), Clostridium difficile associated diarrhea, diarrhea and fecal incontinence or other organisms as determined by the facility's infection preventionist and medical director. Associates will change protective attire and perform hand hygiene between contacts with residents in the same room, regardless of whether one or both are on contact precautions. Hand hygiene is done prior to donning PPE, PPE is donned prior to entering room. A gown and gloves are needed upon entering room. Change gown and gloves between residents even if only one resident is on contact precautions. Use of masks, eye protection and face shields is not routinely a part of contact precautions, however, just as with standard precautions, these items are worn during resident care activities that are likely to create splashes or sprays of blood, body fluid, secretions, and excretions. Hand hygiene is performed between glove changes and when removing gloves.

Based on observation, interview, and document review, the facility failed to ensure use of a bed pan and urinal were offered and in place for 1 of 2 residents (R38) in accordance with the individualized care plan. Findings include: R38's quarterly Minimum Data Set (MDS) dated [DATE], indicated mild cognitive impairment, did not have behaviors, did not reject cares, had upper and lower extremity impairment on one side, required supervision or touching assistance for toileting hygiene, partial to moderate assistance with upper and lower body dressing, personal hygiene, was not on a toileting program for bowels or bladder, and was frequently incontinent of bladder and bowel. R38's Face Sheet form dated 4/17/24, indicated R38 had the following diagnoses: hemiplegia (paralysis on one side of the body) and hemiparesis (weakness) following cerebral infarction (stroke) affecting the left non dominant side, unspecified dementia, ataxia (lack of muscle coordination) following cerebral infarction, dysphagia (difficulty swallowing) following cerebral infarction, constipation, weakness, epilepsy, and diarrhea. R38's care plan dated 4/4/24, indicated R38 had functional urinary incontinence and interventions included: check and change incontinent products every three hours, ensure adequate bowel elimination per facility, have urinal within reach at the bedside, use incontinent products as needed. R38's care plan dated 4/4/24, indicated R38 had a self care deficit and required assist of 1 for bathing, assist of 2 with bed mobility, assist of 2 for transfers using a full body mechanical lift, was incontinent of bowel and bladder, and had a bowel and bladder plan that will help remain free of skin breakdown and respect R38's dignity, required assist of two for toileting needs. R38's care sheet indicated R38 was incontinent of bowel and bladder and intervention under bladder indicated offer the bed pan if preferred, check and change every three hours while awake and at night, document all bowel movements. The care sheet lacked information having a urinal at the bedside. During interview and observation on 4/15/24 at 12:59 p.m., R38 stated he went into the bathroom when he had to use the bathroom. A bed pan was located in the bathroom sitting on the toilet riser. During interview on 4/15/24 at 5:15 p.m., family member (FM)-G stated because of R38's stroke, staff told R38 to go in his depends. During interview and observation on 4/16/24, at 1:33 p.m., R38 was in bed and a urinal was located on the back of the toilet and stated staff did not help R38 in the bathroom, they provide a bedpan to use. During interview on 4/16/24 at 1:39 p.m., nursing assistant (NA)-I stated they looked at care sheets to know what kind of a cares a resident required, however did not have her care sheet on her and stated she could grab a care sheet. NA-I viewed R38's care sheet that indicated offer bed pan if preferred and stated R38 had been continent and asked for the urinal and bed pan and further stated she had R38 ask for the urinal instead of keeping it at the bedside and assisted R38 and stated R38 could take the bed pan out from underneath him and had not had any episodes of incontinence that day. During observation on 4/17/24 at 7:10 a.m., R38 was in bed and there was no urinal located at the bedside. A brief was located on the floor next to the bed. During interview and observation on 4/17/24 between 7:53 a.m., and 8:12 a.m., NA-J picked up the brief off the floor and placed it in the garbage and grabbed a new brief. The urinal was located on top of the toilet. R38 was in bed. NA-J told R38 she was going to get him dressed and assisted in applying a brief. At 7:56 a.m., NA-J had R38 turn to the side and R38 had a smear of stool and NA-J wiped R38's bottom. NA-J did not offer R38 a bedpan or urinal. NA-J continued to wipe R38's bottom that had smears of stool and applied the new brief. At 7:59 a.m., NA-J assisted in donning R38's pants and placed a sling under R38. At 8:04 a.m., NA-C came into the room to assist with a full body mechanical lift transfer and at 8:08 a.m., R38 was transferred into his wheelchair. At 8:12 a.m., R38 was wheeled out to the dining room. The bedpan and urinal were not offered. During interview on 4/17/24 at 8:55 a.m., licensed practical nurse (LPN)-A stated staff looked at care sheets to know what cares a resident required and the care sheets were updated where there was a change in the plan of care. LPN-A viewed R38's care sheet and stated R38 was incontinent and used a bed pan and required a check and change every three hours. LPN-A stated she expected staff to offer a bed pan if preferred. LPN-A further verified the care sheet did not indicate the urinal was to be at the bedside and stated it should have been on the care sheet and further stated staff would not know to place the urinal at the bedside because it was not indicated on the care sheet. During interview on 4/17/24 at 10:22 a.m., NA-J stated she usually looked at the care sheet, and finds an NA who worked regularly and asks them to go through every person. NA-J stated R38's care sheet indicated to offer the bed pan and verified she did not offer the bed pan to R38 and stated R38 took his own brief off and she should have offered the bed pan and did not know R38 required the urinal at the bedside. During interview on 4/18/24 at 1:23 p.m., the director of nursing stated she expected the urinal be at R38's bedside. A policy was requested related to bowel and bladder care.

Based on interview, observation, and document review, the facility failed to ensure a self administration of medication assessment (SAM) was completed to allow residents to safely administer their own medications for 3 of 3 residents (R70, R11, R52). Findings include: R70's admission Minimum Data Set (MDS) dated [DATE], indicated intact cognition, required set up or clean up assist for eating, oral hygiene, and required supervision for upper body dressing, partial assist for lower body dressing and supervision for personal hygiene. R70's Face Sheet form dated [DATE], indicated R70 had the following current diagnoses: metabolic encephalopathy, hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease, cognitive communication deficit. R70's physician orders were reviewed and lacked an order to self administer medications. An order was later added on [DATE], Ok for daily medications to be left with resident to take independently after set up. R70's care plan was reviewed and lacked interventions to self administer medications. R70's nursing progress notes dated [DATE], indicated R70 was admitted to the facility and was alert and oriented times four. R70's care conference note dated [DATE] at 12:39 p.m., indicated occupational therapy (OT) would complete a med box set up for comprehension of the task. R70's social services note dated [DATE], indicated R70 had intact cognition. R70's Occupational Therapy Progress Report form dated [DATE], through [DATE], indicated R70's goal was to safely and efficiently manage medications with supervision or touching assistance in order to facilitate improved ability to care for self. The report indicated the goal was not attempted due to environmental limitations. R70's Occupational Therapy Treatment Encounter Notes form dated [DATE], indicated CPT (cognitive performance test) was initiated and indicated for Medbox scored ,d+[DATE]. R70's Occupational Therapy Treatment Encounter Notes form dated [DATE], indicated R70's average CPT score was 5.2. R70's Observation Assessment screen reviewed on [DATE] at 9:26 a.m., from [DATE], to [DATE], lacked a SAM assessment. R70's SAM assessment dated [DATE] at 11:25 a.m., indicated a No next to the question, Does the resident want to self administer medications including, but not limited to oral, creams/ointments, eye drops, nebulized meds? A No response indicated no further assessment was needed, therefore, cognitive status, whether R70 was appropriate to self administer medications, whether R70 would become confused due to frequent changes in drug regimen, whether R70 could name the dosage, frequency, and reason for use of each medication, whether R70 could identify the time and state the time each medication was due, whether R70 could read the prescription label and identify each medication, whether R70 could swallow medications without altering the dispensed form, whether R70 had a history of non compliance, was unanswered. Additionally, questions were unanswered under the heading, Interdisciplinary team (IDT) Evaluation which included whether it was appropriate for R70 to self administer medications, what medications R70 could self administer, and whether to enter a nursing order for self administration. Under the heading, Notes indicated, R70 requested to have medications set up by the facility, however wanted daily medications left on the tray with meals to take independently and the provider was contacted for an order. During interview on [DATE] at 2:10 p.m., R70 stated the facility would not leave his medications for him to take, and did not like staff standing over him to take his medications. R70 stated, I'm not 5 years old. R70 further stated, It's demoralizing. R70 stated he will take his medications and has done so every time they are provided. During interview on [DATE] at 8:28 a.m., registered nurse (RN)-C stated she observes residents until they took their medications and when a resident was admitted to the facility, a SAM assessment was completed. RN-C verified R70 did not have a SAM assessment completed and thought if a resident had episodes of confusion a SAM assessment would not be completed. RN-C viewed R70's progress notes from admission and stated R70 was alert and oriented times four and was coherent. RN-C further stated R70 was capable of making his own decisions and should have had a SAM assessment completed. During interview on [DATE] at 8:44 a.m., licensed practical nurse (LPN)-A stated SAM assessments were completed if a resident felt strongly about self administering medications and SAM assessments were also completed upon admission. LPN-A stated R70 was capable of making his own decisions and verified a SAM assessment had not been completed and should have had one completed. LPN-A stated it was important to complete a SAM because it was a resident's right to do as much as they feel they a capable and further stated a diagnosis of encephalopathy would not disclude a resident from having a SAM assessment. LPN-A further stated they complete a SAM assessment and then get the provider involved and the SAM assessment included information on cognition and once the assessment was completed they had a discussion. During interview on [DATE] at 12:40 p.m., occupational therapist (OT)-B stated R70 was going to stay long term and since nursing took care of R70's medications, R70's goal to safely and efficiently manage his medications was no longer appropriate. OT-B clarified a score of 5.2 on a cognitive performance test (CPT) indicated a resident could live alone with someone checking in weekly. OT-B further stated Medbox was a mock set up of medications and R70 was able to follow instructions and got at least one of the medications correct and was cued on others. OT-B stated you wouldn't use the test to see if a resident can administer their medications, you would look at the overall score and R70's recommendation was monitoring and partial assist for managing medications and stated she thought R70 would be able take medications without staff hovering unless there were notes that indicated R70 could not do that. During interview on [DATE] at 1:16 p.m., the director of nursing, (DON) stated SAM assessments were completed upon admission and with significant changes and additionally worked with OT to get residents set up to go home. DON further stated if a resident had disorientation they would not complete a SAM assessment, however if a resident was alert and oriented times four would be assessed for a SAM. DON further stated she expected R70 to have a SAM and the SAM assessment should have been completed entirely because R70 would still be self administering medications if left at the bedside. 42580 R11 R11's admission Minimum Data Set (MDS) dated [DATE], indicated R11 was cognitively impaired, received antidepressants, opioids, hypoglycemic medications and received hospice cares. R11's care area assessments triggered areas included cognitive loss dementia, visual function, and communication. R11's care plan updated [DATE], lacked a Self Administration of Medication (SAM) assessment documentation. R11's face sheet printed [DATE], included diagnosis of anxiety disorder, restlessness and agitation, attention and concentration deficit. R11's SAM assessment dated [DATE], indicated R11 did not want to self-administer her medications and no further action was needed. R11's physician orders from [DATE], to [DATE], lacked indication for a SAM order. During observation on [DATE] at 2:10 p.m., R11 had two bottles of nystatin 100,000 unit/gram topical powder for candidiasis noted in bathroom sink. One bottle did not belong to R11. R17's nystatin powder was in R11's bathroom sink. There was also a bottle of unlabeled expired aspirin 81 milligrams (mg) in top cabinet bottom shelf in R11's bathroom. During observation and interview on [DATE] at 11:01 a.m., registered nurse (RN)-G stated nystatin powdered and creams were okay to be kept in resident's rooms so that nursing assistants could apply to resident during provision of care. During observation the following medications were noted in R11's bath basin in cupboard: unlabeled aspirin 81mg, expired on ,d+[DATE], found on top shelf in cupboard; pramoxine-menthol 1.0 .5% lotion, apply topically four times daily for itching, found in bath basin on middle shelf in cupboard; and nystop 100,000 unit per gram, topically two times a day. RN-G verified the medications were in R11's room and left the nystop and pramoxine-menthol lotion in room, then removed the unlabeled expired aspirin 81mg from R11's room, then stated perhaps R11 was admitted with medication or family had brought into facility. During interview on [DATE] at 11:02 a.m., DON stated nystatin powder was to be administered by nurses and were not to be kept in residents' rooms for nursing assistants to administer. DON further clarified all medications should be kept in medication and treatment carts and not in residents rooms. R52 R52's significant change MDS dated [DATE], indicated R52 was cognitively impaired and diagnosis included anxiety disorder, and depression and was given antipsychotics, antianxiety and antidepressants during the assessment period. R52 was also on hospice care. R52's care plan revised [DATE], indicated R52 displayed difficulty in making decisions, declining memory, disorientation and exhaustion. R52's care plan lacked a SAM documentation. R52's diagnosis list printed [DATE], indicated unspecified dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), hemiplegia (paralysis of one side of the body), and hemiparesis (weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating or dressing) following unspecified cerebrovascular disease (interruption in the flow of blood to cells in the brain). R52's self-administration of medication assessment dated [DATE], indicated R52 did not want to SAM, with no further assessment needed. R52's physician orders printed [DATE], lacked a SAM order. During observation on [DATE] at 4:55 p.m., R52 was was sitting at the dining table with a medication cup left sitting in front of her with two round white pills noted in cup. R52 stated she thought the medications were Tylenol but did not want to take the medication. The white pills were slightly melted and R52 stated had placed in mouth but did not want to take the medication so had spit them out into the medication cup left at the table. During interview on [DATE] at 5:04 p.m., trained medication assistant (TMA)-B stated had given R52 medications and R52 placed in mouth with water and may have spit out the pills. TMA-B further explained R52 refused cares and medications. During interview on [DATE] at 11:02 a.m., director of nursing (DON) stated when nursing staff administered medications to residents, staff were expected to observe and ensure the resident had taken the medications before leaving resident if resident did not have a SAM assessment which would indicate they could do so independently. A policy, Self Administration of Medications dated [DATE], indicated residents had the right to self administer medications if the interdisciplinary team has determined it is clinically appropriate and safe. The nursing associates will assess each resident's mental and physical abilities to determine whether self administering medications is clinically appropriate for the resident. Assessment is documented in the electronic health record (EHR). The resident has the right to self administer medications if the interdisciplinary team has determined that this practice is clinically appropriate. The IDT considers the following: the medications appropriate and safe for administration, the resident's physical capacity to swallow and open bottles, the resident's cognitive status, including their ability to correctly name their medications and know what conditions they are taken for, the residents capability to follow directions and tell time to know when medications are needed, the resident's comprehension of instructions for the medications they are taking, including the dose, timing, and signs of side effects, and when to report to nursing associates, the resident's ability to understand what refusal of medication is and appropriate steps taken by associates to educate when this occurs, the resident's ability to ensure that medication is stored safely and securely.

Based on observation, interview and document review, the facility failed to provide timely activity of daily living (ADL) assistance for 2 of 2 residents (R9, R38) who required staff assistance to make it out to meals. Findings include: A form, Meal Times, indicated an open breakfast from 7:30 a.m., until 9:00 a.m., and lunch was served at 11:30 a.m., on the 4th and 5th floors and at 12:00 p.m., on the 3rd floor. Dinner was served at 4:30 p.m., on the 4th and 5th floors and at 5:00 p.m., on the 3rd floor. Forms, NAR Group Sheet 1, NAR Group Sheet 2, NAR Group Sheet 3, indicated the following, mealtime reminder: must count the meal tickets to make sure that all residents have eaten, please reapproach three times and notify the nurse if a resident refuses cares. R9's quarterly Minimum Data Set (MDS) dated [DATE], indicated R9 had intact cognition, did not have physical, verbal, or other behaviors, and did not reject cares, required set up or clean up assistance with eating, substantial to maximum assistance with showering/bathing, partial to moderate assistance with upper body dressing, personal hygiene, and was dependent on staff for lower body dressing, chair to bed and bed to chair transfers, and required substantial to maximum assistance with sitting to standing. R9's physician orders indicated the following order: 12/18/23, RG7 (normal everyday foods of various textures that are developmentally and age appropriate. Biting and chewing ability needed.) regular texture cardiac less than 2400 milligrams (MG) of sodium diet and thin liquids. R9's Face Sheet form dated 4/17/24, indicated R9 had morbid obesity due to excess calories, had chronic kidney disease stage 3, prediabetes, muscle weakness, anxiety, and depression. R9's care plan dated 4/16/24, indicated R9 had a potential for alteration in nutrition and was able to feed himself with meal set up and interventions included: small meal portions to support weight loss per resident wishes, staff to offer salads and saltine crackers with soups at lunch and dinner meals per resident preference. Likes egg, cheese, cucumber and tomato, likes apples, sandwiches, oatmeal, juice, coffee, celery, raspberry vinaigrette dressing, dislikes carrots, provide meal set up. Diet per physician orders, encourage adherence to therapeutic diet per physician orders, encourage good food and fluid intakes at and between meals as needed. R9's care plan dated 4/16/24, indicated R9 had a mobility deficit as evidenced by R9 required assist with mobility and transfers due to increased weakness, deconditioning secondary to congestive heart failure, bilateral lower extremity weakness, obesity and interventions included: provide assistance for mobility while encouraging as much independence as able. R9's care plan dated 4/16/24, indicated R9 had a self care deficit in ADLs due to congestive heart failure (CHF), interventions included: assist of one with grooming as needed, extensive assist of one with dressing, and extensive assist with transfers. R9's care sheet indicated R9 was on an RG7, 2200 milliliter (ML) fluid restriction, and preferred hot meals and ice in cold drinks. Additionally, R9 required a mechanical stand lift for transfers, and assist of one for dressing and grooming. During interview on 4/17/24 at 7:24 a.m., dietary aide (DA)-A stated breakfast started at 7:30 a.m., and serving went until 9:00 a.m. During interview on 4/17/24 between 9:32 a.m., and 9:46 a.m., dietary aide (DA)-A verified there were still residents who had not eaten including R9, R50, and R64. During observation on 4/17/24 at 9:54 a.m., R9 was in his room and had not had breakfast. During interview on 4/17/24 at 10:29 a.m., DA-A stated R9 had to come out to the dining room to eat and was normally out by 9:30 a.m., and stated R9 did not receive breakfast because he did not come out to the dining room. During observation on 4/17/24 at 10:32 a.m., R9's door was closed. During observation on 4/17/24 at 10:34 a.m., nursing assistant (NA)-C brought R9 out of his room and wheeled resident down towards the dining room. During interview on 4/17/24 at 10:47 a.m., NA-C stated R9 did not receive any breakfast and R9 liked oatmeal and scrambled eggs however, they were really running behind, but stated she would ask R9 if he wanted toast. During observation on 4/17/24 at 10:52 a.m., NA-C offered toast and R9 stated he did not eat bread and said he would wait until lunch. R9 did not get oatmeal and was not offered oatmeal. During interview on 4/17/24 at 12:58 p.m., NA-C stated when they started the shift, NA-C was working as a trained medication aide (TMA) and there was only two aides, NA-C began working as an NA after an agency nurse came in and R9 did not eat breakfast because they were behind and R9 did not eat meals in his room, nor did he take medications in his room. During interview on 4/17/24 at 1:19 p.m., R9 stated staff got him up about 10:30 a.m., and R9 had to wait until lunch to get something to eat. R9 stated that has happened 3 or 4 times and stated he was hungry and further stated he lived on oatmeal with brown sugar and scrambled eggs, but because it was too late, could not get it and when it waits too long, it is cold and then stated he did not want cold food. R9 stated he liked to be up around 9:00 a.m. During interview on 4/18/24 at 8:21 a.m., NA-C stated R9 required assist with peri care, dressing, and stated they completed most of R9's activities of daily living (ADLs). During observation on 4/18/24 at 9:17 a.m., R9's call light was on and at 9:22 a.m., NA-C went in to R9's room and answered the call light. During interview on 4/18/24 at 9:35 a.m., DA-A stated he was finished serving and did not know why R9 and R38 had not received a meal tray. During observation on 4/18/24 at 9:40 a.m., R9 was in bed. During interview on 4/18/24 at 9:41 a.m., NA-L stated she went in to show NA-M R9 and R9 stated he did not want to get up until 9:00 a.m., and NA-M was giving showers and did not know why R9 was still in bed. NA-L further stated at times, some residents were eating breakfast when lunch was being served. During interview on 4/18/24 at 9:54 a.m., NA-C stated she answered R9's light at 9:22 a.m., and asked R9 if he was ready to get up as he told his NA he needed 20 more minutes, and told R9 his aide was finishing a shower. NA-C further stated this group had a lot of residents who required lift transfers and if you were not the regular aide on the group, it was difficult to get the residents up in a timely manner. NA-C further stated R9 mentioned he missed breakfast the day prior and stated she told the dietary aide today that R9 needed scrambled eggs and oatmeal when he got up. During interview on 4/18/24 at 10:03 a.m., NA-M stated she planned to get R9 up, but did not have the care sheet. During interview and observation on 4/18/24 between 10:11 a.m., and 10:13 a.m., R9 was out in the dining room and stated he had just gotten out of bed and was waiting for breakfast. R9 stated he did not like to get up before 9:00 a.m., and at 9:00 a.m., NA-M was giving someone a shower so he had to wait. At 10:13 a.m., NA-M delivered R9 oatmeal and scrambled eggs. R38: R38's quarterly MDS dated [DATE], indicated moderate cognitive impairment, did not have physical, verbal, or other behaviors, and did not reject care, had impairment on one side for upper and lower extremity range of motion, required set up or clean up assistance with eating, partial to moderate assistance with dressing, personal hygiene, and transferring. R38's State Optional Assessment (SOA) dated 2/29/24, indicated R38 ate independently, required extensive assistance with toileting, bed mobility, and transfers. R38's Face Sheet form dated 4/16/24 at 2:48 p.m., indicated the following diagnoses: hemiplegia (one sided paralysis) and hemiparesis (one sided muscle weakness) following cerebral infarction (stroke), dementia, ataxia (poor muscle control) following cerebral infarction, dysphagia (difficulty swallowing) following cerebral infarction, alcohol abuse, other abnormalities of gait and mobility, muscle weakness, other lack of coordination, cerebrovascular disease, and major depressive disorder. R38's care plan dated 4/4/24, indicated R38 had a self care deficit and required assist of two for bed mobility, assist of two for transfers with a hoyer lift, and assist of two with toileting needs. R38's care plan dated 4/11/24, indicated R38 was at risk for falling and a new intervention implemented on 4/11/24, indicated to bring R38 to the dining room at least 30 minutes prior to a meal. R38's care plan dated 4/4/24, indicated R38 was non compliant with care needs and refused to donn clothing, eat meals, or change incontinent products. Interventions included: accept R38's right to refuse and show respect for decisions, offer as many alternatives as possible for me to choose from, R38's care plan dated 4/16/24, indicated R38 was potentially at risk for nutrition and hydration needs related to cerebral vascular accident (CVA, stroke), dementia, depression, and alcohol abuse and interventions included: provide three meals per day and offer snacks. R38's care sheet indicated R38 required assist of two for transfers using a hoyer lift, was incontinent of bowel and bladder, required assist of 1 for dressing and grooming and report changes in mood and behavior to the nurse. R38's progress notes dated 11/30/23 at 1:11 p.m., indicated R38 preferred three meals a day and had his meals in the dining room. R38's progress notes dated 12/13/23 at 7:22 a.m., indicated R38 ate three meals a day in the dining room and his appetite was good. R38's progress notes dated 12/29/23 at 3:18 p.m., indicated R38 had non significant weight loss since admission and R38 occasionally would skip one meal per day. R38's progress notes dated 1/19/24 at 1:51 p.m., indicated R38 had a gradual weight loss and encourage resident to be up for breakfast meal in the dining room. R38's progress notes dated 1/19/24 at 9:39 p.m., indicated R38 did not receive a shower due to staff problems. R38's progress notes dated 4/11/24 at 1:23 p.m., indicated R38 had fallen on 4/9/24. R38 stated he was trying to go to the dining room and a new intervention was added that R38 would be brought to the dining room a half hour before meal time. During interview on 4/17/24 at 8:55 a.m., licensed practical nurse (LPN)-A stated staff looked at the care sheets to know what cares a resident required. During observation on 4/18/24 at 8:51 a.m., R38 was in bed. During observation on 4/18/24 at 9:02 a.m., there were eight meal tickets on the counter on the fourth floor including R9, and R38. During observation on 4/18/24 at 9:16 a.m., R38 was in bed. During observation on 4/18/24 at 9:23 a.m., there were 6 meal tickets located on the counter on the fourth floor including R9, and R38. During observation on 4/18/24 between 9:31 a.m., and 9:35 a.m., two meal tickets were located on the counter on the fourth floor for R9, and R38. At 9:32 a.m., DA-A took both tickets into the kitchen. At 9:35 a.m., DA-A stated he was done serving and did not know why R9 or R38 had not received a meal tray. During observation on 4/18/24 at 9:40 a.m., R38 was in bed. During interview on 4/18/24 at 9:41 a.m., NA-L stated there were new residents on the floor and as a result their times were getting scrambled and residents want to get up at the same time and stated it was full on this floor. NA-L further stated the aide on R38's group was newer and was learning. NA-L further stated she wanted residents to eat by 9 because lunch came at 11:30 a.m. NA-L stated if it was past 10:30 a.m., she would ask a resident if they wanted a snack and would try to make sure they received lunch first. During interview on 4/18/24 at 9:54 a.m., NA-C stated she did not know if NA-M had gone into R38's room or if she offered to get R38 up. NA-C further stated NA-M's group had a lot of resident's who required a mechanical lift and if you were not the regular person on the group, it was difficult to get the residents up in a timely manner. NA-C further stated it was not ok to miss breakfast. During interview on 4/18/24 at 10:00 a.m., NA-C stated now that she was finished with a.m., medications she would offer her help with R38. During interview on 4/18/24 at 10:03 a.m., NA-M stated R38 was not refusing to get up, she had just not gotten to him. During observation on 4/18/24 from 10:14 a.m., to 10:17 a.m., NA-N took the full body mechanical lift out of R38's room and at 10:17 a.m., NA-C pushed R38 out to the dining room. During interview and observation on 4/18/24 between 10:23 a.m., and 10:31 a.m., at 10:24 a.m., NA-C brought R38 [NAME] toast and R38 stated he was hungry. NA-C stated she brought R38 toast with butter and strawberry kiwi juice. At 10:25 a.m., R38 began eating his toast. R38 had two pieces of toast cut in half and was finished eating his toast by 10:31`a.m. During interview on 4/18/24 at 11:23 a.m., the registered dietician (RD)-H stated R38 should have three meals a day and sometimes skipped breakfast per his choice depending on what time he got up. RD-H further stated if a resident wanted to get out of bed and was not getting help, it was not acceptable to miss breakfast. RD-H further stated their culinary staff relied on nursing staff to get residents out of bed and their staff had to wait until the resident was out in the dining room. During interview on 4/18/24 at 12:27 p.m., licensed practical nurse (LPN)-A stated R9 liked to get up at 9:00 a.m., but with the amount of people that have to care for R9 sometimes R9 was not up at a perfect time which was a terrible fact and stated it was not acceptable. LPN-A further stated normally NA-I was R9's aide and if R9 wanted to be up at 9:00 they should have made sure it got done. LPN-A further stated they wanted residents up and eating breakfast with their peers and needed to come up with better time management and further stated R38 should not have just received toast. During interview on 4/18/24 at 1:30 p.m., the director of nursing stated on 4/17/24, they were short staffed due to a call in and got people to come in, however it was later in the morning and further stated it was important to get ADLs in order to maintain healthy nutrition and hydration and expected residents get up for meals or could have brought meals to residents in their room. During interview on 4/18/24 at 2:29 p.m., the culinary director (CD) stated the facility provided three meals, breakfast, lunch, and dinner and a meal consisted of a protein, a starch, a dessert and a vegetable and toast was not considered a meal. A policy, Activities of Daily Living (ADL) dated June 2021, indicated the purpose of the policy was to provide residents with care, treatment and services appropriate to maintain or improve their ability to carry out ADLs. Residents unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming, personal hygiene, elimination, communication and mobility. If residents with cognitive impairment or dementia exhibit behavioral expressions of resistance to cares, associates will attempt to identify the underlying cause of the problem and not assume the resident is declining or refusing care. Approaching the resident in a different way, or at a different time, or having another associate speak with the resident may be appropriate.

Based on observation, interview, and document review, the facility failed to provide timely referral to an outside optometry service to resolve broken eyeglasses and provide a routine follow up appointment for 1 of 1 resident (R9) reviewed whose glasses were broken. Findings include: R9's quarterly Minimum Data Set (MDS) dated [DATE], indicated R9 had intact cognition, had adequate vision including fine detail, including regular print in newspapers and books with glasses or other visual appliances and did not wear corrective lenses. R9's annual MDS dated [DATE], indicated R9 had adequate vision and wore corrective lenses, and it was very important to have books, newspapers, and magazines to read. R9's state optional assessment dated [DATE], indicated R9 required extensive assist for bed mobility, transfers, and toileting and was independent with eating. R9's progress notes were reviewed on 4/17/24 at 2:59 p.m., and lacked documentation of any refusals of eye exams after 8/22/22. R9's care plan dated 4/16/24, indicated R9 wellness would provide R9 with reading materials and puzzles. R9's care plan dated 4/16/24, indicated R9 could read regular print with glasses and had a history of vitreous detachment (vitreous is the gel like fluid that fills your eye and contains fibers that attach to the retina. Fibers of the vitreous pull away and can cause symptoms that can affect vision) and saw a specialist. Interventions indicated to arrange eye appointments and rides as requested by resident and family, assure that the lenses of glasses were clean and in good repair, observe for signs or symptoms of decreased visual acuity like statements of vision changes, squinting at TV, not being able to identify objects and staff etc and update as needed. A form, Quality Healthcare Services Provided On-Site with Compassion and Care provided by the facility indicated Healthdrive's health professionals brought dental, optometry, podiatry and audiology services directly to residents of extended care facilities. Optometry provided glaucoma and overall eye health testing, vision testing using trial lenses specialized for the elderly, eyeglass fabrication, repair and engraving, and low vision aids for the partially sighted. R9's HealthDrive form dated 10/28/20, indicated R9 consented to be seen for audiology, eye care, and podiatry. R9's HealthDrive Eye Care Group form dated 10/3/22, indicated R9 had a macular scar on the right eye, pseudophakia (artificial lens implant), low vision on the right and normal vision on the left, and presbyopia (age related far sightedness). Under the heading, Plan indicated monitor, follow up comprehensive on 9/27/23, and new reading eyeglasses; new glasses improve vision, patient defers bifocal. Under the heading, Action indicated R9 required glasses and staff were to encourage part time use for reading. R9's HealthDrive Eye Care Group form dated 12/20/22, indicated R9's glasses were adjusted and under the heading, Plan indicated monitor; follow up comprehensive on 9/27/23. Further, glasses were required and staff were to encourage part time use for reading. During interview on 4/15/24 at 6:03 p.m., R9 stated the temple part of his eyeglasses had been broken for about a year and R9 wanted to get new glasses because he couldn't see to use his computer and stated the facility had not set up an appointment for him to be seen. During interview and observation on 4/17/24 at 10:43 a.m., nursing assistant (NA)-C brought R9 out of his room and R9 did not have any glasses on. NA-C stated R9 had glasses with him. During interview and observation on 4/17/24 at 1:19 p.m., R9 took out eyeglasses in a brown case and they were missing the temple and R9 further stated the eyeglasses he currently wore had a horizontal line across the lens and did not like to wear those because it made it difficult for him to see his puzzles. R9 stated he had an additional pair of glasses and observed the pair and the temple was pulled out all the way to the side. R9 stated he wasn't able to read the computer because he did not have glasses to see with. During interview on 4/17/24 at 11:05 a.m., the director of nursing stated HealthDrive came to the facility but was not sure if optometry came and added someone came for vision and the health information manager (HIM) handled appointments. During interview on 4/17/24 at 1:37 p.m., the HIM stated the facility used a service called HealthDrive that provided dental, audiology, optometry, and podiatry services. HIM further stated optometry usually came to the facility about three times a year. When a resident is admitted , residents are provided a form they complete before they are seen to indicate the services wanted. HIM verified R9 had requested eye care and stated R9's last appointment was on 12/21/22 and further added appointment refusals were documented in the progress notes and HIM verified there were no documented refusal in the progress notes. HIM further stated everyone received a HealthDrive form to sign or decline services but the social worker (SW) followed up. HIM further stated optometry was last at the facility January 4th or 5th 2024. During interview on 4/17/24 at 2:19 p.m., SW-A stated she had been working at the facility about two months and was starting to complete components of the MDS, but did not complete the vision or hearing section. SW-A further stated the previous SW quit working at the facility about two weeks prior. During interview on 4/17/24 at 2:24 p.m., registered nurse (RN)-D stated she completed section B of the MDS which contained information on vision based on clinical documentation and observations. RN-D further stated HealthDrive was discussed at care conferences and the SW would follow up with the resident and stated she expected R9 to have an eye appointment if a follow up appointment was ordered. During interview on 4/17/24 at 2:36 p.m., the director of nursing (DON) stated HIM managed HealthDrive and either the manager or SW asks if residents want the service and obtain consent and then the HIM manages the visits. DON further stated if a resident refused an appointment, HealthDrive would document the refusal and it would be scanned in the electronic medical record (EMR). DON further stated it sounded like R9 should have had an eye appointment if the form indicated a follow up and would look for a policy. During interview on 4/18/24 at 1:21 p.m., the DON stated R9 was not seen by optometry because the eye doctor was on maternity leave and they planned to talk with R9 to see if he wanted to be seen or have his glasses fixed. A policy was not provided.

Based on observation, interview, and document review, the facility failed to ensure interventions were in place for 1 of 3 residents reviewed for pressure ulcers. Findings include: R183's Brief Interview & Staff Assessment for Mental Status (BIMS) dated 4/9/24, indicated R183 had moderate cognitive impairment. R183's Continuity of Care document printed 4/18/24, indicated R183's diagnoses included pressure ulcer of right heel and lymphedema. R183's Functional Abilities assessment dated [DATE], indicated R183 required substantial/maximal assistance with putting on/taking off footwear and sit to stand performance. R183's admission body audit/skin condition assessment dated [DATE], indicated R183 had a right heel wound. R183's Skin Risk Observation with Braden Scale dated 4/8/24, indicated R183 had an unhealed pressure injury on right lower heal and at risk for further skin breakdown. The assessment identified interventions which included heel protectors. R183's provider orders included the following: 4/8/24-Out of bed-CAM boot on right foot anytime out of bed to offload wound and protect foot. In bed-heel protector boots on, place pillows under legs also to help offload heels. 4/10/24-Zflex offloading boots (heel protector boots) while in bed to fully offload heels. Z-Flex boot (CAM) on right foot while up in wheelchair. Goal to keep all pressure off heels and off the wound. 4/10/24-Tubi grips on BLE (bilateral lower extremities) daily. On in AM and off at HS (bedtime). R183's care plan (CP) dated 4/16/24, indicated R183 was at risk for alteration of skin status d/t (due to) lymphedema, and skin impairment to right heel. CP interventions included tubi grips and z-flex boots as ordered. R183's undated nurse aide care sheet indicated, Tubi grips on in AM & off @HS and Z-flex boots when in bed. CAM boot on for transfers. During observation and interview on 4/15/24, at 5:58 p.m., R183 was sitting in wheelchair in room. R183 did not have the tubi grips or the CAM boot on and had both feet resting flat on the floor. The CAM boot was on the floor next to the dresser and the Z-flex boots were on the windowsill. No tubi grips observed. R183 stated staff were not applying those boots when in bed but used the CAM boot to walk. During observation on 4/16/24 at 1:55 p.m., R183 was not in room. Z-flex boots sitting in windowsill in same position as previous day. During observation and interview on 4/17/24 at 6:57 a.m., R183 was up and dressed and sitting in wheelchair. The CAM boot was sitting on the floor by the dresser. During interview on 4/17/24 at 7:24 a.m., R183 stated she did not have the z-flex boots on overnight, legs were not elevated with pillows and heel rested directly on the bed. R183 stated she had not had the CAM boot on yet today and had transferred without it. R183 stated they typically did not put the CAM boot on until after wound care which was supposed to be in the morning but occasionally did not occur until after noon. The z-flex boots remained in the windowsill in the same previous position and the CAM boot was on the floor by the dresser. R183 did not have wraps or tubi grips and stated staff had never used any compression items on her legs since admission. R183's feet were resting directly on the floor. During interview on 4/17/24 at 7:42 a.m., registered nurse (RN)-A stated R183 should have pressure reducing boots on at all times while in bed and the CAM boot on when up in the wheelchair. RN-A further stated R183's heel should be protected from further breakdown with pillows or boots and should not be resting on the ground. During interview on 4/17/24 at 8:19 a.m., nursing assistant (NA)-B stated R183 did not have any boots on while in bed this morning nor when assisted into the wheelchair. During interview on 4/17/24 at 8:44 a.m., NA-A verified and stated R183 was sitting up in wheelchair and did not have the CAM boot on and was not wearing tubi grips. During interview on 4/17/24 on 11:17 a.m., RN-B stated R183's heel should always be protected either with soft z-flex boots while in bed or CAM boot when out of bed. RN-B stated R183 required the CAM boot for all transfers. RN-B further stated R183 should have tubi grips applied in the morning and removed at night and that the NAs could do it and nursing would verify and document completion. During interview on 4/17/24 at 11:21 a.m., wound doctor (WD) stated expected R183 would have offloading boots while in bed and a CAM boot for transfers. During interview on 4/18/24 at 9:25 a.m., occupational therapy assistant (OT)-A stated expectation for R183 to have CAM boot on for all transfers. During interview on 4/18/24 at 12:06 p.m., director of nursing (DON) stated expectation for pressure ulcer interventions to be implemented as ordered. Facility policy Prevention and Treatment of Skin Breakdown/Pressure Injury undated, indicated, residents at an increased risk for impaired skin integrity are provided preventative measures to reducing the potential for skin breakdown, Those residents who experience a break in skin integrity or wounds are provided care and service to heal the skin according to professional standards of care.

Based on observation, interview and document review, the facility failed to label, date and store food in a sanitary manner to prevent food borne illness for food brought into the facility by a resident, family or guest. In addition, the facility failed to properly label, date and store meal trays held after meal service for 2 of 2 meal trays. This deficient practice had the potential to affect 3 of 3 residents residing on the fifth floor. Findings include: During observations on 4/15/24, at 12:40 p.m., a small glass containing orange liquid was sitting on R3's bedside table. Additionally, an open jar of salsa was observed sitting on the windowsill. At 4:43 p.m., R3 was observed in his room, and the glass that had contained the orange liquid was empty and R3 stated it was from his breakfast that morning and he drank it when he came back from an appointment at approximately 4:00 p.m. During subsequent observations between 4/15/24 at 2:03 p.m., and 4/17/24 at 07:43 a.m., the jar of open salsa remained on R3's windowsill. During tour of fifth floor kitchenette, and interview with culinary director on 4/16/24, at 2:38 p.m., two meal trays were observed on the counter just outside and to the right of the kitchenette door. Plates were covered and had visible condensation on the inside of the plate covering. Culinary director stated meals held after a meal service should be labeled with resident name, time, and date. Furthermore, any meals without that information would need to be thrown out as there is no way to identify exactly how long the meal had been sitting out. Additionally, food brought into facility from an outside source would need to be labeled and stored in the kitchenette. During interview with CNA-E on 4/16/24, at 03:38 p.m., CNA stated food coming in from the outside needed to be labeled right away to avoid a resident getting sick from food not being stored correctly. During interview with certified nursing assistant (CNA- F) on 4/16/24, at 03:43 p.m., CNA-F stated all food brought to resident from an outside source needed to be labeled and dated for each individual resident and perishable items stored in the kitchenette fridge. During interview with licensed practical nurse (LPN-N) unit manager on 4/17/24, at 07:43 a.m., LPN-B stated staff should label all food with resident's name and date and store in the kitchenette. In addition, open perishable food that is found in a resident's room undated should be immediately thrown away to avoid any potential food borne illnesses or contamination. During interview with administrator on 4/17/24, at 09:00 a.m., administrator stated when food is brought into the facility for a resident from any outside source, the item must be labeled and dated and stored in the kitchenette where it can be held for up to three days. Furthermore, she stated her expectation of staff would be to discuss the risks of food borne illnesses with the resident and establish a plan for safe food storage to avoid any potential food borne illnesses caused by food not properly being stored. Facility policy titled Safe food storage and handling for food brought in by residents, families and visitors indicated all food brought into the facility should be labeled with the date the product was brought into the facility, the use by date (max of 3 days), name and room number of resident.

Based on observation, interview, and document review, the facility failed to ensure food was served at warm, palatable temperatures for 3 of 3 residents (R9, R64, R50). Findings include: R9's quarterly Minimum Data Sets (MDS) dated [DATE], indicated R9 had intact cognition, did not have physical, verbal, or other behaviors, and did not reject cares, required set up or clean up assistance with eating, substantial to maximum assistance with showering/bathing, partial to moderate assistance with upper body dressing, personal hygiene, and was dependent on staff for lower body dressing, chair to bed and bed to chair transfers, and required substantial to maximum assistance with sitting to standing. R9's physician orders indicated the following order: 12/18/23, RG7 (normal everyday foods of various textures that are developmentally and age appropriate. Biting and chewing ability needed.) regular texture cardiac less than 2400 milligrams (MG) of sodium diet and thin liquids. R9's Face Sheet form dated 4/17/24, indicated R9 had morbid obesity due to excess calories, had chronic kidney disease stage 3, prediabetes, muscle weakness, anxiety, and depression. R9's care plan dated 4/16/24 indicated R9 had a potential for alteration in nutrition and was able to feed himself with meal set up and interventions included: small meal portions to support weight loss per resident wishes, staff to offer salads and saltine crackers with soups at lunch and dinner meals per resident preference. Likes egg, cheese, cucumber and tomato, likes apples, sandwiches, oatmeal, juice, coffee, celery, raspberry vinaigrette dressing, dislikes carrots, provide meal set up. Diet per physician orders, encourage adherence to therapeutic diet per physician orders, encourage good food and fluid intakes at and between meals as needed. R9's care sheet indicated R9 was on an RG7, 2200 milliliter (ML) fluid restriction, and preferred hot meals and ice in cold drinks. During interview on 4/15/24 at 6:01 p.m., R9 stated carrots were not cooked properly and stated they were difficult to chew when you don't have teeth. R64's significant change in status MDS dated [DATE], indicated severe cognitive impairment, did not have physical, verbal, or other behaviors, and did not reject cares, required partial to moderate assist with eating, oral hygiene, dressing, and transferring. R64's care plan dated 3/27/24, indicated R64 was on hospice and the facility was to provide daily cares. R64's care plan dated 3/27/24, indicated R64 was potentially at risk for altered nutrition and was able to feed himself with some difficulties due to Parkinson's disease and interventions included: providing three meals a day and offer snacks. R64's care plan dated 4/16/24 indicated R64 had an alteration in skin integrity and interventions included providing a diet per physician's order. During interview on 4/15/24, at 1:35 p.m., R64's family member (FM)-I stated the food needed improvement and stated some nights the food was cold, not cooked enough, and sometimes the food was burned. R50's annual MDS dated [DATE], indicated intact cognition, did not have physical, verbal, or other behaviors, and did not reject cares and had weight loss of 5% or more in the last month or 10% or more in the last 6 months and was on a therapeutic diet. R50's care sheet indicated R50 required assist of two with a hoyer lift for transfers, was incontinent of bowel and bladder, preferred to get out of bed by 8:00 a.m. During interview on 4/17/24 at 7:24 a.m., dietary aide (DA)-A stated breakfast started at 7:30 a.m., and serving went until 9:00 a.m. During interview and observation on 4/17/24 between 9:32 a.m., and 9:46 a.m., the dietary aide checked food temperatures on the steam tables. The poached eggs were 110 degrees Fahrenheit (F), the Canadian bacon was also 110 degrees F, scrambled eggs were 130 degrees F, at 9:35 a.m., the eggs [NAME] sauce was 120 degrees, and the oatmeal was 125 degrees F at 9:36 a.m. DA-A stated eggs were supposed to be 160 degrees and meat was supposed to be 170 degrees when they came out of the oven. DA-A stated he did not know what the temperature was supposed to be on the steam tables, but stated the steam table was on the highest setting and was the best it could be. DA-A verified there were still residents who had not eaten including R9, R50, and R64. At 9:46 a.m., DA-A verified the steam table was on high and stated they had problems with the steam table on another floor however that was fixed and they had problems with the steam tables from time to time. During observation on 4/17/24 at 9:54 a.m., R9 was in his room and had not had breakfast. During interview on 4/17/24 at 9:59 a.m., the culinary director (CD) stated the holding temperature for foods on the steam table should be at 145 degrees and stated the temperatures DA-A obtained were low and stated they checked temperatures in the kitchen before food was brought up to the floors and had had a lot of turnover and temperatures were not consistently completed. CD further stated staff were probably running behind. CD further stated the dietary aides should know what the holding temps should be but it was still a training process and stated DA-A had been with the facility two years. CD further stated if resident's reported cold food, staff could contact the CD to resolve the concern. During interview on 4/17/24 at 10:29 a.m., DA-A stated R9 had to come out to the dining room to eat and was normally out by 9:30 a.m., and stated R9 did not receive breakfast because he did not come out to the dining room. During observation on 4/17/24 at 10:32 a.m., R9's door was closed. During observation on 4/17/24 at 10:34 a.m., nursing assistant (NA)-C brought R9 out of his room and wheeled resident down towards the dining room. During interview on 4/17/24 at 10:47 a.m., NA-C stated R9 did not receive any breakfast because R9 liked oatmeal and scrambled eggs and they were running behind, but stated she would ask R9 if he wanted toast. During observation on 4/17/24 at 10:52 a.m., NA-C offered toast and R9 stated he did not eat bread and said he would wait until lunch. R9 did not get oatmeal and was not offered oatmeal. During interview on 4/17/24 at 12:58 p.m., NA-C stated R9 did not eat breakfast because they were behind. During interview on 4/17/24 at 1:19 p.m., R9 stated staff got him up about 10:30 a.m., and R9 had to wait until lunch to get something to eat. R9 stated that has happened 3 or 4 times and stated he was hungry and further stated he lived on oatmeal with brown sugar and scrambled eggs, but because it was too late, could not get it and when it waits too long, it is cold and then stated he did not want cold food. R9 stated he liked to be up around 9:00 a.m. During interview on 4/18/24 at 8:21 a.m., NA-C stated R9 required assist with peri care, dressing, and stated they completed most of R9's activities of daily living (ADLs). A policy, Maintaining Proper Food Temp During Food Service, dated August 2019, indicated food would be maintained at proper hot and cold temperatures prior to and during meal service to assure food quality and tastiness/palatability as well as food safety. The temperature of TCS (time/temperature control) hot food will be 135 degrees F or higher during tray assembly. Temperatures will be taken and recorded for all hot and cold items at all meals. Temperatures will be recorded. Heating food in the steam table is prohibited. Heating food to the proper temperature is accomplished by direct heat i.e. stove, oven, and steamer and food is then transferred to the preheated steam table not more than 30 minutes before meal service.

Based on interview, observation, and document review, the facility failed to provide a therapeutic diet as prescribed and failed to ensure adequate hydration in accordance with the individualized care plan for 1 of 2 residents (R38). Findings include: R38's quarterly Minimum Data Set (MDS) dated [DATE], indicated mild cognitive impairment, did not have behaviors, did not reject cares, had upper and lower extremity impairment on one side, required supervision or touching assistance for toileting hygiene, partial to moderate assistance with upper and lower body dressing, personal hygiene, and required set up or clean up assistance for eating. The MDS further indicated R38 was on a therapeutic diet. R38's Face Sheet form dated 4/17/24, indicated R38 had the following diagnoses: hemiplegia (paralysis on one side of the body) and hemiparesis (weakness) following cerebral infarction (stroke) affecting the left non dominant side, unspecified dementia, ataxia (lack of muscle coordination) following cerebral infarction, dysphagia (difficulty swallowing) following cerebral infarction, weakness, and diarrhea, and hyperlipidemia (an excess of lipids or fats in the blood that can increase your risk of a heart attack or stroke) R38's physician's orders indicated the following orders: 11/24/23, low sodium, low fat RG7 (normal everyday foods of various textures that are developmentally and age appropriate. Biting and chewing ability is needed) regular texture diet. 11/24/23, thin liquids. 2/5/24, weekly weight on Mondays. 2/26/24, Readycare shake (chocolate) 4 ounces (oz) daily every a.m., document amount consumed for weight loss. 2/26/23, Offer snacks twice daily, document the amount consumed. R38 prefers: yogurt, chocolate pudding, cheese crackers, peanut butter crackers at 2:00 p.m., and 8:00 p.m. R38's care plan dated 4/4/24, indicated R38 required assist of two for bed mobility and transferred using a hoyer lift with two assist. R38's care plan dated 4/11/24, indicated R38 was at risk for falling and interventions included to bring R38 to the dining room at least 30 minutes prior to a meal. R38's care plan dated 4/16/24, indicated R38 was at risk for nutrition and hydration needs due to a diagnoses of cerebrovascular accident (CVA) (stroke), dementia, alcohol abuse and depression. R38 is able to feed himself and voice needs after set up assistance. R38's interventions included: offering Mrs Dash and pepper with meals, offer snacks twice a day (yogurt, chocolate pudding, cheese and crackers, peanut butter crackers), weights once a day on Wednesdays, offer 30 to 60 cubic centimeters (cc's) by mouth fluids with every contact, R38 prefers water and Ginger Ale, R38 is provided with three meals a day and snacks are offered. R38's care sheet indicated R38 was on a heart healthy RG7 diet, had an adaptive cup with a lid, and R38 required a bedtime snack and enjoyed peanut butter and jelly sandwiches, required assist of 1 to 2 for bed mobility and assist of two with a hoyer lift for transfers. A weekly menu for week 1 dated Monday 4/15/24, through Sunday 4/21/24, indicated the following meals: 4/16/24, 2% milk, oatmeal, diced peaches, scrambled eggs, bacon, strudel cherry stick or vanilla yogurt, cheerios, dry wheat toast. 4/16/24, chicken florentine herbed penne pasta, meadow blend vegetables, mint chocolate chip ice cream or salami sandwich, multigrain sunchips, meadow blend vegetables, bean and bacon soup. 4/17/24, eggs [NAME], chilled fruit cocktail, oatmeal, 2% milk, or vanilla yogurt, corn flakes, and dry wheat toast. R38's meal ticket for breakfast 4/16/24, indicated the following under the heading Diet cardiac 2 gram, regular texture, and thin liquids. Under the heading, Beverage indicated decaf coffee, and under the heading, Dairy indicated skim milk and vanilla yogurt. Under the heading, Juice indicated orange juice. Under the heading, Cereal indicated cheerios and oatmeal. Under the heading, fruit indicated diced peaches. Under the heading, Entree indicated scrambled egg. Under the heading, Breakfast sides indicated hard boiled egg, under the heading, Bread indicated dry wheat toast and buttered raisin toast, and under the heading, Condiment indicated Mrs Dash seasoning, pepper, and grape jelly. R38's meal ticket lacked bacon or strudel cherry stick as a meal option. R38's meal ticket for lunch on 4/16/24, indicated under the heading, Beverage decaf coffee, under the heading, Dairy indicated skim milk, under the heading, entree indicated chicken florentine or beef deli sandwich on wheat. Additionally, under the heading, Starch indicated multigrain sunchips or herbed penne pasta, under the heading, Vegetable indicated meadow blend vegetables, under the heading, Condiment indicated pepper or Mrs Dash seasoning, and under the heading, Dessert indicated vanilla ice cream and under the heading, Soup indicated chicken noodle soup. R38's meal ticket lacked a salami sandwich as a meal option. R38's meal ticket for breakfast on 4/17/24, indicated under the heading, Beverage decaf coffee, under the heading, Dairy indicated skim milk or vanilla yogurt. Under the heading, Juice indicated apple juice, under the heading, Cereal indicated corn flakes or oatmeal, under the heading, Fruit chilled fruit cocktail, under the heading, Entree indicated egg muffin sandwich, under the heading, Bread indicated dry wheat toast, and under the heading, :Condiment indicated pepper, grape jelly, and Mrs Dash seasoning. The meal ticket did not indicate eggs [NAME] as a meal option. R38's progress notes dated 11/25/23 at 4:27 p.m., indicated family member (FM)-G wanted R38 on a heart healthy diet. R38's progress note dated 11/30/23 at 1:11 p.m., indicated R38 preferred three meals a day, ate in the dining room and was able to feed himself and like a bedtime snack. R38's weight was 176.4 pounds on 11/27/24. R38's progress note dated 12/13/23 at 7:22 a.m., documented as a late entry on 12/14/23 at 7:22 a.m., indicated R38 at three times a day in the dining room and was offered a snack at night. R38's weight was 175 pounds and dietary reported R38 was on a heart healthy diet related to CVA. R38's progress note dated 12/28/23 at 8:31 a.m., indicated the snack order was updated to offer twice a day snacks per family preference. R38's progress note dated 1/3/24 at 2:04 p.m., indicated R38 required a cup with a lid or other adaptive cup for hot liquids. Additionally, the note indicated R38 had non significant weight loss since admission and occasionally skipped 1 meal per day. A new order for a Readycare Shake 4 oz daily was received to assist in meeting nutritional needs. R38's progress note dated 1/19/24 at 1:51 p.m., indicated R38 had gradual trending weight loss and R38's weight was 168.6 on 1/18/24. Additionally, the note indicated to encourage R38 to be up for breakfast and the previously offered snack twice daily p.m. and bedtime was changed to bedtime only as R38 would receive a supplement in the afternoon. R38's progress note dated 1/26/24, indicated R38 had a care conference and the dietary department reported R38 was on a heart healthy diet of low saturated fat, low salt, blander type diet, and needed assistance with options at meal time. R38's progress note dated 2/26/24 at 3:13 p.m., indicated R38 was offered Readycare shake twice a day due to a history of weight loss and a bedtime snack was offered daily. The supplement and snack order was updated to offer the Readycare shake once daily in the a.m., and a snack twice a day at 2:00 p.m., and at 8:00 p.m. per R38 and family request. R38's progress note dated 4/11/24 at 1:23 p.m., indicated R38 had fallen on 4/9/24, R38 stated he was trying to go to the dining room and a new intervention was added to bring R38 to the dining room half an hour before meal time. R38's vulnerable adult report dated 12/15/23 at 9:34 a.m., indicated the facility was not providing enough water for R38. FM-G was concerned R38 would have another stroke if he became too dehydrated. During observation on 4/15/24 at 12:57 p.m., R38 was in bed and a water pitcher was located on the left side of the window sill and on the opposite side of the window the bed was located, and was out of R38's reach. During interview on 4/15/24 at 5:20 p.m., family member (FM)-G stated R38 relied on staff to bring him out to the dining room and stated R38 was provided the wrong food and stated a heart healthy diet included not having salt. During interview and observation on 4/16/24 between 1:33 p.m., and 1:39 p.m., R38 was in bed and stated he asked someone for water but they left the room. R38 had a maroon pitcher with a black covered water pitcher with a straw on the left side of the window sill. R38 stated he had a sandwich for lunch and chips. At 1:39 p.m., a staff person came in and asked R38 if he wanted his sun chips and R38 said to leave the chips. During interview on 4/16/24 between 1:39 p.m., and 1:51 p.m., nursing assistant (NA)-I stated R38 did not get up for lunch because he was pushing himself out of the chair. NA-I stated R38 had toast, bacon, and a Danish cherry strudel for breakfast and did not want cheerios. NA-I further stated residents had menus and could pick what they wanted to eat. NA-I further stated they looked at care sheets to know what kind of cares a resident required, but did not have a care sheet with her. NA-I viewed R38's care sheet and stated R38 was on a heart healthy diet and stated she passed snacks and water at the end of the shift. NA-I further stated today was sandwich day and R38 received a salami sandwich for lunch because he didn't like chicken. NA-I further stated a heart healthy diet meant R38 used MRS Dash and stated R38's liquids should be at the bedside on the bedside table. At 1:51 p.m., NA-I stated R38's water pitcher should be at his bedside and verified the water pitcher was located out of R38's reach on the left side of the window sill and stated that the water pitcher was from yesterday. NA-I took the pitcher out of the room and replaced the water pitcher with a new pitcher and placed it on the bedside table. During interview and observation on 4/17/24 at 7:53 a.m., NA-J stated she worked for an agency staffing company and told R38 she was going to get him up. R38's water pitcher was located on the bedside table. At 8:02 a.m., NA-J asked R38 if he wanted eggs [NAME] and R38 stated oatmeal was better than a poached egg. At 8:04 a.m., NA-C came in to assist with a hoyer transfer and at 8:08 a.m., R38 was transferred into his wheelchair and at 8:12 a.m., R38 was brought out to the dining room and was not offered water. R38 was not offered a choice of meal in accordance with his meal ticket. During interview on 4/17/24 at 8:55 a.m., licensed practical nurse (LPN)-A stated NA's looked at care sheets to know what cares a resident required. During interview on 4/17/24 at 10:22 a.m., NA-J stated she usually looked at a care sheet and found an aide who worked regularly to know what cares a resident required and stated she worked with R38 before and stated it got hectic when they were busy. NA-J stated she did not offer R38 anything to drink during cares and stated she didn't know she was supposed to give R38 anything to drink. During interview on 4/17/24 at 10:55 a.m., LPN-A stated she expected the care sheet reflect the care plan and offering fluids should have been on the care sheet and stated staff knew to offer R38 water. LPN-A further stated it would be important to be on the care sheet because the facility staffed with agency staff who would need to know how to care for a resident and expected R38's water pitcher to be within reach especially when R38 can not get up and reach it himself and stated she would update the care sheet. During interview on 4/18/24 at 11:23 a.m., the registered dietician (RD)-H stated she managed the menus which were on a 5 week cycle and additionally had a fall/winter menu and had just switched to a spring/summer menu. RD-H stated a therapeutic diet consisted of a resident on a heart healthy or diabetic diet and made sure if a menu included for example lasagna, that there is a heart healthy option. If a resident was on a low salt and low fat diet, there was a spreadsheet for the cook if they needed an alternate option. RD-H stated if they had bacon for breakfast they would need to swap the bacon out for heart healthy options and would switch to another protein. RD-H also stated she would not give a resident salami if they were on a low salt and low fat diet. RD-H further stated she would not be as restrictive with therapeutic diets for a resident in long term care if they asked for a salami sandwich, however it would not be on their menu. RD-H further stated residents had a meal ticket every meal and had their diet order and all their meal options so nursing staff would not need to know their options because it was already changed for a resident on therapeutic diet. RD-H stated R38 was on a heart healthy diet because he had a stroke and his family wanted him to be on a heart healthy diet. RD-H further stated on 4/16/24, R38's menu did not indicate he should have salami and stated R38 did not like chicken. RD-H stated it would be important to follow a low sodium diet because R38 had a stroke and his family was adamant R38 receive a heart healthy diet and R38 came to the facility on a heart healthy diet. RD-H stated if it happened frequently where a resident deviated from their diet it would be documented and stated she told residents if they don't like the food they can look to liberalize the diet otherwise could offer Mrs Dash and pepper. RD-H further stated R38's menu indicated he received extra condiments which was done instead of changing R38's diet order. RD-H stated there was nothing in the care plan to deviate from the diet nor was there documentation that R38 was noncompliant with his diet orders and stated she had not heard this week R38 was not compliant with his diet. RD-H further stated R38's menu matched the heart healthy diet and staff should present R38's menu and ask R38 what he wanted and if R38 deviates from his ordered diet, expected a progress note documented. During interview on 4/18/24 at 12:09 p.m., LPN-A stated she expected staff follow orders for a low salt, low fat diet and if R38 was not following the ordered diet, it should be documented. LPN-A stated resident's have rights, but added they should be aware so they can talk to the resident and the physician to see what can be done for the residents and stated bacon was not heart healthy, nor was a salami sandwich. During interview on 4/18/24 at 1:23 p.m., the director of nursing stated she expected R38's water pitcher be next to him and stated she took off the care plan to offer fluids and if R38 was deviating from his diet, they could look at a waiver. A policy, Diet Orders, dated 2012, indicated based on a resident's comprehensive assessment, the facility must ensure that a resident receives a therapeutic diet, prepared in a form designed to meet individual needs, prescribed by the attending physician, when there is a nutritional problem. Each resident will receive and consume foods in the appropriate form and or the appropriate nutritive content as prescribed by a physician and or assessed by the interdisciplinary team to support the treatment and plan of care. Therapeutic diet is defined as a diet ordered by a physician as part of treatment for a disease or clinical condition, to eliminate or decrease certain substances in diet, e.g. sodium, or to increase certain substances in diet e.g. potassium or to provide food the resident is able to eat e.g. mechanically altered diet. Substitutes are offered of similar nutritive value to residents that refuse food served. When a diet order does not correspond with the facility's approved diet order terminology, the licensed nurse will be responsible for obtaining clarification from the physician. The diet order is communicated in writing from nursing to culinary services and must correspond with the physician's order as recorded in the medical record. A policy, Resident Noncompliance With Provider Ordered Diet, dated 2012, indicated the resident has the right to refuse treatment, including acceptance of prescribed diet. All foods provided by the community will be consistent with the resident's ordered diet. Resident rights in choice will be upheld. The nursing staff and dietitian or designee will manage noncompliance with the provider ordered diet. When a resident consistently requests food not included in their therapeutic diet, a licensed nurse and or dietitian will explain the potential risk of not adhering to the provider ordered diet. The dietitian or designee will attempt to offer food substitutes that are agreeable to the resident and consistent with their diet ordered. Nursing and dietitian will document in the medical record the foods that the resident chooses to eat, including a discussion of risk and the attempts made to find food acceptable to the resident. The provider physician will be notified to explain resident noncompliance and discuss liberalizing the diet order.

Based on observation, interview, and document review, the facility failed to ensure a resident (R17) was free from physical restraints when he had a wanderguard on his wheelchair and assessed as low risk for elopement. This had the potential to affect all 13 residents with a wanderguard residing in the facility. Findings include: R17's significant change Minimum Data Set (MDS) dated [DATE], indicated R17 was cognitively intact, required extensive assistance with transfers, supervision and one-person assistance with mobility and did not display wandering behavior. R17's MDS further indicated a wanderguard alarm restraint was used daily. R17's diagnoses included history of stroke, diabetes, anxiety, and depression. R17's care plan (CP) last reviewed/revised 9/5/23, indicated R17 was at risk for elopement with an intervention dated 3/3/22, A wandergurd [sic] has been added to residents WC [wheelchair]. R17's elopement risk assessment dated [DATE], indicated R17 was at low risk for elopement. R17's progress note (PN) dated 5/16/23 at 3:16 p.m., indicated R17 had a wanderguard related to past elopement attempts. R17's PN's dated 2/1/23 through 9/21/23, lacked any further evidence of actual elopement attempts. In addition, the PN lacked any evidence regarding alcohol, liquor or R17's recovering alcohol addiction. During observation and interview on 9/18/23 at 12:52 p.m., R17 was in his room in WC watching TV. A wanderguard was attached to the bottom of his WC. R17 stated disappointment he was not allowed to leave the building, go shopping, or even go outside to the facility grounds. During observation and interview on 9/19/23 at 1:14 p.m., R17 was in room sitting in WC watching TV. The wanderguard was attached to the bottom of the WC. R17 was able to self-propel in WC. R17 stated he wanted to go to Target to purchase a shaver and could arrange a ride with Metro Mobility to get there and back. During observation on 9/19/23 at 1:55 p.m., R17 wheeled self to licensed practical nurse (LPN)-A's office and asked if she would assist him downstairs tomorrow (9/20/23) if he made arrangements with Metro Mobility to go shopping. LPN-A responded she would talk to social service director (SSD). During interview on 9/19/23 at 2:08 p.m., registered nurse (RN)-A stated R17 was not at risk for elopement and his elopement risk was assessed regularly. During interview on 9/20/23 at 9:00 a.m., R17 stated he was not able to go out shopping per SSD. During interview on 9/20/23 at 2:07 p.m., LPN-A stated a person would be considered at risk for elopement if they made statements regarding wanting to leave the facility. LPN-A further stated R17 had previously attempted to leave and his safety awareness was gone. During interview on 9/21/23 at 11:33 a.m., SSD stated R17 was his own person and could make his own decisions regarding advanced directives. SSD could not recall the last time R17 attempted to elope. SSD stated R17 wanted to go to Target last winter, but he only wore shorts and SSD did not think he had proper insight into environmental factors. SSD further stated R17 probably wanted to buy liquor and was always trying to find a liquor store due to being a recovering addict. During interview on 9/21/23 at 12:37 p.m., director of nursing (DON) stated expectation was for elopement assessments be completed quarterly and as needed and the result of the assessment would drive the need for a wanderguard. DON further stated if a resident was their own person, they had the right to make their own decisions, even if they were poor decisions. Facility policy Wandering and/or Active Elopement dated 9/11/19, indicated wandering and/or elopement attempts should be documented in the resident's medical record. A facility policy on restraints was requested and not provided.

Based on observation, interview, and document review, the facility failed to ensure insulin pens and an inhaler stored in the medication cart were labeled with an expiration date for 3 residents (R1, R3, R12). In addition, the facility failed to ensure an insulin pen stored in the medication cart was labeled with a legible resident name or an expiration date for 1 unidentified resident. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had moderate cognitive impairment, required extensive assistance with most activities of daily living (ADL) and had diagnosis of diabetes mellitus. R1's physician order dated 4/19/23, indicated Novolog Flexpen U-100 Insulin pen; 100 unit/mL (3mL). Administer subcutaneous (SQ) per sliding scale three times a day. R1's medication administration record (MAR) dated 8/1/23 through 8/31/23, indicated R1 received 34 units of insulin. R1's MAR dated 9/1/23 through 9/19/23, indicated R1 received 34 units of insulin. R3's admission MDS dated [DATE], indicated R3 had moderate cognitive impairment, required extensive assistance with most ADLs, and had diagnosis of chronic obstructive pulmonary disease (COPD). R3's physician order dated 6/23/23, indicated Arnuity Ellipta (fluticasone furoate) blister with device: 100 mcg/actuation; inhale 1 puff daily. R3's MAR dated 8/1/23 through 8/31/23 indicated R3 received Arnuity 31 times. R3's MAR dated 9/1/23 through 9/21/23 R3 received Arnuity 20 times in September through 9/20/21. R12's quarterly MDS dated [DATE], indicated R12 was cognitively intact, required extensive assistance with most ADLs, and had diagnosis of diabetes mellitus. R12's physician order dated 3/31/23, indicated Novolog Flexpen U-100 Insulin pen; 100 unit/mL (3mL). Administer SQ 4 units two times a day when blood glucose over 150. R12's MAR dated 8/1/23 through 8/31/23 indicated R12 received 192 units in August. R12's MAR dated 9/1/23 through 9/21/23, indicated R12 received 112 units on insulin in September through 9/20/21. During observation and interview on 9/20/23 at 11:33 a.m., registered nurse (RN)-A removed and reviewed the insulin pen for R1. The insulin pen had a sticker indicating open date; however, the sticker was blank and lacked evidence when it was opened. RN-A stated not knowing when the pen was opened and that it should have been dated. RN-A further stated believed the pens were good for 28 days after opening. During observation and interview on 9/20/23 at 12:01 p.m., RN-A removed and reviewed the insulin pen for R12. The insulin pen had a sticker indicated open date however, the sticker was blank and lacked evidence when it was opened. RN-A stated not knowing when the pen was opened and that it should have been dated. Licensed practical nurse (LPN)-A assisted with medication cart review and stated all insulin was stored in the refrigerator until opened and once opened was good for 28 days. LPN-A stated the insulin pens should be dated when opened. A third insulin pen was removed which had a sticker open date; however, the sticker was blank and lacked evidence when it was opened. The resident label on this pen has black smudges on it which made the resident name illegible. RN-A confirmed all three insulin pens had been used, but could not state who the third pen had been used on. During observation and interview on 9/20/23 at 1:48 p.m., trained medication aide (TMA)-A removed an Arnuity inhaler from a medication storage cart. The inhaler had a sticker indicating open date; however, it was blank and lacked evidence when it was opened. TMA-A stated it had been used and did not know when it was opened. TMA-A stated it should have been dated when opened but was not sure how long it was good for after opening. During interview on 9/20/23 at 2:52 p.m., director of nursing (DON) stated expectation was for medication such as insulin and inhaler be dated when opened and that insulin was typically good for 28 days after opening. During interview on 9/21/23 at 8:20 a.m., consultant pharmacist (CP) stated the Novolog Flexpen insulin pens should be dated when removed from refrigerator and opened and they were good for 28 days. After 28 days the efficacy decreased. CP further stated Arnuity inhalers were good for six weeks (42 days) after opening and should be dated when opened. CP stated there was a slight decrease in dose after the 6 weeks. Facility policy Medication Storage dated 11/2018, indicated medications and biologicals should be stored properly following manufacturer's or supplier's recommendations. The policy further indicated when the original seal of a manufacture's container was initially broken, it was recommended that a nurse write the date opened on the medication container.

Based on interview and document review, the facility failed to provide baths for 1 of 1 resident (R23), reviewed for bath preferences. Findings include: R23's admission Minimum Data Set (MDS) dated [DATE], indicated R23 had moderate cognitive impairment, with daily preference for bath, very important to choose between a tub bath, shower, bed bath and sponge bath. R23 required limited assist with personal hygiene and physical transfers for bathing. R23's activities of daily living care plan, edited 8/29/23, did not mention of R23's bath preference. R23's face sheet undated, included diagnosis of parkinson disease and injury of nerve root of lumbar spine. R23's progress notes from admission on 7/28/23 through 9/18/23, had no documentation of R23 refusing baths or showers. R23's general order dated 8/25/23, indicated bath documentation: body audit to be completed on shift of scheduled shower. If refuses bath/shower, body audit still needs to be completed with any skin impairments and faxed into Matrix. Bath frequency once a day on Monday. R23's bath documentation since admission on 7/28/23, showed R23 only had the following four skin bath audits completed: -08/6/23-shower checked for a pm shift bath with skin checks completed -8/20/23-shower checked for pm shift bath with skin checks completed -8/28/23 -bed bath checked for am bath, with skin checks completed -9/4/23- no bath method indicated with skin checks completed. R23 only had four total documentation of skin bath audit that included two showers, one bed bath and no bath method documented on 9/4/23. During interview on 9/18/23 at 4:33 p.m., R23 explained she had often requested to get baths, however the facility continued to only gave her showers. R23 further stated baths were her preference but was unsure if the facility had a tub to provide her baths and also explained her bath days are not stable and often changed from week to week to different days. During interview on 9/20/23 at 11:02 a.m., nurse manager, licensed practical nurse (LPN)-C stated was unaware resident preferred a bath instead of a shower. LPN-C stated if R23 had informed LPN-C, R23's care plan would have been updated to reflect bath preference. LPN-C stated would have to check in with activities to determine if R23 had mentioned to them her bath preferences. During interview on 9/21/23 at 11:02 a.m., interview with assistant wellness director (AWD)-B stated R23 had an assessment done on 7/28/23, and had mentioned she preferred a bath since did not like to sit and possibly slip, if she took a shower. AWD-B stated, when activities completed their assessments, they were entered into Matrix charting system so other departments could access. AWD-B further mentioned activities did not communicate with nursing the resident's preferences and that nursing had to find their assessment placed into Matrix then make any necessary changes to care plans. During interview on 9/21/23 at 12:25 p.m., nurse manager, LPN-C stated, R23 had only had the four showers since admission on 7/28/23, and verified it in Matrix. LPN-C also stated there was no documentation of R23 refusing showers since her admission. LPN-C did not know R23's bath preference was bath instead of showers, and did not update the care plan or nursing assistant care sheets. LPN-C stated the facility would have to look into the process of communicating between departments. During interview on 9/21/23 at 2:50 p.m., director of nursing (DON) stated there was no documentation R23 had refused showers or baths and had become aware R23 had only received four showers since admission into facility. The expectation was resident's preferences should be addressed and documented in resident's electronic records and scheduled showers should be completed with refusals documented. A bathing policy was requested and was not received.

Based on observation, interview and document review, the facility failed to ensure the call light was within reach for 1 of 1 resident (R22) reviewed for call light accessibility. Findings include: R22's quarterly Minimum Data Set (MDS) dated [DATE], indicated R22 had moderate cognitive impairment, required extensive assistance with transfers, toileting, and personal hygiene. R22's diagnoses included Alzheimer's, cancer, diabetes, and depression. R22's care plan (CP) dated 9/8/23, indicated R22 was at risk for falling due to increased weakness, cognitive impairments, and other diagnoses. The CP instructed staff to keep resident in a safe area or bed after meals and to ensure call light was in reach. R22's falls risk assessment dated [DATE], indicated R22 was at risk for falls and had three or more falls in the previous three months. During observation and interview on 9/19/23 at 1:24 p.m., R22 was in her room sitting in a wheelchair with a tray table in front of her. R22's pressure pad type call light was approximately two feet away under her bed and wrapped around her walker. R22 stated she could not reach the call light to activate it if she needed assistance. During interview on 9/19/23 at 1:41 p.m., activites personnel (A)-A confirmed R22's call light was on the floor wrapped around walker and under her bed. A-A stated R22 would not be able to reach it if she wanted to use it. During interview on 9/19/23 at 1:59 p.m., nursing assistant (NA)-A stated R22 was a falls risk and was capable of pressing her call light if she needed something. During interview on 9/19/23 at 2:04 p.m., registered nurse (RN)-A stated R22 was a falls risk and one of the falls prevention interventions was to have her call light within reach. During interview on 9/19/23 at 2:48 p.m., licensed practical nurse (LPN)-B stated R22 could use the call light and it should be within reach when she was in her room. During interview on 9/19/23 at 2:53 p.m., LPN-A stated expectation was all call lights should be within reach so a resident could use it when needed. During interview on 9/20/23 at 2:53 p.m., director of nursing (DON) stated expectation was staff should ensure call lights were within reach and working. A policy on call lights was requested but not received.

Based on observation, interview and document review, the facility failed to ensure indwelling catheter management and skin assessments were completed to prevent erosion (tearing) of the penile urethral (opening for urine to pass out of body) for 1 of 3 resident (R4), whom had an indwelling urinary catheter. This caused actual harm for R4. Findings include: R4's Face Sheet printed 6/8/21, indicated diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's admission Minimum Data Set, dated dated dated [DATE], indicated R4 was admitted in 4/21, had severe cognitive impairment, required extensive assist of two staff for toileting, bed mobility and transfers with Care Area Assessment triggered for urinary incontinence and indwelling catheter. R4's care plan dated 4/9/21, indicated R4 required an indwelling urinary catheter (a tube that goes into the bladder to empty it and remains in place) related to [CONDITION(S)] bladder (lack of bladder control due to a brain, spinal cord or nerve problem), with urinary retention and interventions included use of a catheter strap (used to keep indwelling urinary catheter secured), and to document urinary output every shift. Staff were to change the indwelling urinary catheter monthly and as needed (PRN). Staff were also to record the amount, type, color, odor and observe for leakage. R4's care plan dated 4/9/21, lacked documentation for monitoring R4's skin for irritation with the use of the indwelling urinary catheter. R4's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's Admission Body Audit: Skin Condition dated 4/8/21, lacked assessment of any penile skin irritation. R4's Admission Body Audit: Skin Condition dated 4/15/21, lacked assessment of any penile skin irritation. R4's Skin Risk Assessment with Braden Scale dated 4/27/21, lacked assessment of any penile skin irritation. R4's Progress notes dated 5/2/21, at 2:11 p.m. indicated R4's indwelling urinary catheter replaced, 16 French (Fr) 10 cubic centimeters (cc) balloon with light yellow urine return. Resident tolerated insertion with some discomfort but stated he was alright once catheter was in place. Declined pain medication. There was no mention of any penile skin irritation or erosion. R4's Skin Risk Assessment with Braden Scale dated 5/3/21, lacked assessment of any penile skin irritation. R4's progress notes dated 5/5/21, at 12:50 p.m. indicated updated nurse practitioner (NP) on appearance of meatus (a passage or opening leading to the interior of the body) and glans penis (tip of the penis). Order received for urology referral for indwelling urinary catheter erosion concerns and evaluation for placement of supra-pubic catheter. R4's NP progress notes dated 5/5/21, printed at 9:40 p.m. indicated: nursing staff also expressed concerns with the indwelling urinary catheter . They reported that part of the catheter could be seen farther down on his penis. There was concern for further opening or erosion around the insertion site of the indwelling urinary catheter. The note further indicated R4 was seen in his wheelchair on 5/5/21, and the NP was unable to examine his private areas. NP discussed with staff and was going to refer to urology for evaluation. R4's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's progress notes dated 5/25/21, indicated R4 returned from urology appointment with new orders for placement of a suprapubic (SP) catheter with follow up appointment with urology in a month. R4's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] R4's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Notes from R4's urology appointments were requested and not provided by the facility. Several attempts were made to interview the urologist were unsuccessful . During an observation on 6/4/21, at 11:20 a.m. R4 was in dining room sitting at a table with his indwelling urinary catheter drainage leg bag visible below his left pants leg. R4's foley catheter straps were hanging loose around his left ankle and not securing the tubing to his leg causing pulling/pressure of the catheter on his penile urethral meatus. During an observation on 6/7/21, at 3:31 p.m. registered nurse (RN)-B and nursing assistant (NA)-A entered R4's room to assist with getting R4 out of bed and into his wheelchair. RN-B lifted R4's penis and explained that the split under the penis was the erosion and R4 had some reddened irritation. R4 had an approximate one-to-two-inch split under his penis from his urethral down the meatus downward at the base of his penis. The catheter was visible inside the split area entering the urethral duct (transmits urine from the bladder to the exterior of the body during urination). During an observation on 6/8/21, at 9:25 a.m. R4 was in bed lying on his left side. R4's catheter drain bag was within the privacy pouch attached onto R4's bed frame. R4's lower indwelling urinary catheter leg strap was not attached to resident but was on the catheter tubing line, near the drainage bag. The second leg strap for the indwelling urinary catheter tubing was unattached to R4's body but under R4's left ankle area. The lack of a securely placed leg strap could result in pulling of the indwelling urinary catheter causing more pull on the urethra and could have further worsened any penile skin irritation or erosion. During interview on 6/7/21, at 1:02 p.m. nurse practitioner (NP)-A stated R4 had penile urethral erosion at the base of his penis was caused from catheter use and she was unaware of this until the facility staff notified her on 5/5/21. NP-A stated that she had been unable to visually assess R4's perineal area or catheter insertion site/penis as R4 was usually up in his wheelchair (W/C) or was asleep during rounds. NP-A stated she typically read progress notes when she completed routine visits and had not seen any mention in the progress notes about the urethral erosion prior to 5/5/21 by the facility staff. NP-A further stated R4 was admitted [DATE], and she saw each resident at least once a month but was on campus at the facility at least three times per week. NP-A stated the facility staff had access to contact the provider when not onsite, 24 hours per day. NP-A stated she had communicated to facility nurses and managers her expectation of notifying providers with change in condition in residents. NP-A stated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . NP-A stated had the facility assessed and monitored R4's catheter insertion site and updated NP-A timely of the penile urethral erosion, the penile urethral erosion may have been avoidable. During interview on 6/7/21, at 2:45 p.m. licensed practical nurse (LPN)-C stated she had changed R4's foley catheter on 5/2/21, and noted the penile urethral erosion. LPN-C stated she thought she had updated the NP but was unable to find the documentation. LPN-C stated, on 5/5/21, she documented she had informed the NP of the penile urethral erosion and had received referral orders for urology consult. During interview on 6/7/21, at 3:45 p.m. RN-B stated R4 was noted to have the penile urethral erosion when RN-B worked with R4 during peri cares, a few days after his admission. RN-B stated R4's penis definitely looked different and was unusual with the erosion beginning at the meatus into the base of R4's penis and it looked irritated. RN-B further stated she could not recall if she had charted on the penile urethral erosion and had assumed it was at baseline for the R4, since R4 had urology issues in the past and that there was no active bleeding. RN-B indicated she had verbally informed the night shift about the penile urethral erosion but was unable to remember who the night nurse was. RN-B also stated several nursing assistants had come and verbalized their concerns about the catheter to her on different days. RN-B also stated in retrospect she should have notified the nurse manager and the provider about the penile urethral erosion immediately and should have also updated the nursing assistant care sheets on cleaning the site properly. RN-B verified that she had not updated the provider and did not document in R4's progress notes or skin assessments concerning the penile urethral erosion. During interview on 6/7/21, at 4:28 p.m. family member (FM)-A stated he had not been updated regarding any issues with R4's penile urethral erosion, until sometime in May 2021 when he was informed that R4 was to be seen by a urologist due to penile urethral erosion. FM-A also stated the previous facility had not mentioned any issues with R4's prior to his discharge. Initially R4 went to the urologist while at a previous facility; but due to COVID-19, the nurses had been changing the catheter onsite while at the previous facility. FM-A stated, R4 had not had any concerns about erosions communicated to him by the previous facility prior to discharge. During interview on 6/7/21, at 4:40 p.m. FM-B stated she had come to visit R4 while residing at current facility and observed catheter straps (which prevented pulling of the foley catheter from the urethra) were not in place and the catheter tubing looked dirty. During telephone interview on 6/8/21, at 8:57 a.m. LPN-D, who worked at the facility where R4 previously resided, stated when R4 was discharged from the previous facility he had no skin issues with his foley catheter. LPN-D stated if resident had any skin conditions it would have been documented and stated R4 had no openings with his penis while at their facility. LPN-D also verified that she had changed R4's catheter several times and noted no skin issues or abnormalities. LPN-D further stated R4's catheter was last changed on 4/5/21, at the previous facility and there was no indication of skin issues that were identified in the documents. During interview on 6/8/21, at 11:15 a.m. trained medication aide (TMA)-A stated she had worked with R4 within several days after his admission to the facility and observed his penis was split at the bottom and looked different. TMA-A stated she immediately verbally informed the nurse on duty, and further stated only the nurses completed the skin assessments. During interview on 6/8/21, at 11:54 p.m. unit manager (RN)-G stated she had called the previous facility R4 resided at and was informed by the staff at previous facility that R4 did not have any skin concerns with his foley catheter. RN-G stated there was no indication on the current facility's admission skin assessment that identified penile urethral erosion. RN-G also verified the nursing progress notes and skin assessments from admission on 4/8/21 through 5/4/21, lacked documentation of R4's penile urethral irritation or erosion. During interview on 6/8/21, at 1:51 p.m. the director of nursing (DON) stated she was informed that R4 possibly had the penile urethral erosion upon admission; however, there was no documentation to show this was present on admission. DON stated it was the expectation that the admitting nurse did a thorough skin assessment and documented findings of abnormal skin conditions in the resident's chart. It was also the expectation that staff informed other nursing staff if a resident had a penile urethral erosion for continued monitoring and to also immediately notify the provider with this assessment finding. The facility Prevention of Catheter-Associated Urinary Tract Infections Policy updated 12/29/17 indicated when a resident was admitted to the facility with a catheter in place, a thorough physical assessment as well as history review was to be completed. Catheter were to be Secured to avoid pulling and trauma to the bladder and urethra. The peri-urethra was cleaned regularly with mild soap and water and then rinsed. Staff were to always wash from the area of least contamination to the area of greatest and wipe from front to the back. The facility Resident Examination and Assessment Policy undated, indicated a through resident examination and assessment was to capture any abnormalities in health status, physical function, or an acute change in condition. This assessment was to provide the basis for the initial care plan, as well as provide additional updates to care plan as indicated. Physical exam and or refusals were to be documented in the Electronic Health Record. The facility Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Skin was to be observed daily with cares. If any skin concerns were noted, they were to be reported to the licensed nurse. Weekly skin audits were to be performed by a licensed nurse.