Every finding on record at Citadel of Bourbonnais,The

Based on observation, interview, and record review, the facility failed to ensure that a resident who requires maximum assistance with bed mobility was turned safely during provision of care. This failure resulted in R1 rolling out of bed and landing with his face on the floor, sustaining a laceration to his left forehead. R1 was sent to the emergency room and received 12 stitches on his forehead. This applies to 1 of 3 residents (R1) reviewed for fall incidents in the sample of 3.The findings include: R1 had multiple diagnoses including, atherosclerotic heart disease of native coronary artery without angina pectoris, unspecified anxiety disorder and personal history of traumatic brain injury, based on the face sheet.R1's annual MDS (Minimum Data Set) dated September 30, 2025, showed R1 was severely impaired with cognitive skills for daily decision making. The MDS showed that R1 had functional limitation to both lower extremities. The same MDS showed that R1 required total assistance from the staff with toileting hygiene and lower body dressing and required substantial/maximum assistance from the staff with bed mobility- from lying on his back to rolling to the left and right sides and returning to back lying position in bed.R1's progress notes dated October 3, 2025, at 6:26 PM, created by V3 (Licensed Practical Nurse/LPN) showed, At [1:20 PM] notified by [CNA/Certified Nursing Assistant) that resident was on the floor. Upon entering room, observed resident lying face down between bed and wall. Blood observed on floor under head. Applied pressure to laceration noted on forehead. Immediately called 911. Resident was unable to state what happened. CNA stated that during brief change [patient] suddenly swung his legs over the side and rolled out of bed. She was unable to catch him. NP (Nurse Practitioner) notified. The same progress notes showed that R1 was sent to the hospital at 1:25 PM.R1's progress notes dated October 3, 2025, at 11:23 PM, showed that the resident returned from the hospital at 8:40 PM. It was documented that, He is alert and oriented x 2, disoriented to time per usual. He was c/o (complaining of) a headache. PRN (as needed) pain medication administered. The same progress notes showed that R1 received 12 stiches to his forehead laceration while in the emergency department and R1's head was wrapped in gauze.R1's hospital notes dated October 3, 2025, showed, [Patient] to [emergency department] after suicidal attempt. [Patient] deliberately threw himself to ground striking his forehead. [Patient] arrived with laceration to left forehead.On October 4, 2025, at 12:38 PM, R1 was in bed, awake and verbally responsive. R1 had a bandage around his head. R1 was asked why he had a bandage on his head and the resident responded that he rolled out of bed, fell on the floor and sustained an open wound on his head. R1 was asked how he rolled out of bed, the resident stated, I don't know I slipped out of bed. When asked if anyone was present when he fell out of the bed, R1 responded that he was in the room by himself.On October 4, 2025, at 1:23 PM, V3 (LPN) stated that on October 3, 2025, between 12:00 and 1:00 PM, while on her break she was informed by V4 (CNA) that R1 fell out of bed. She was informed by V4 that while turning R1 towards the left side to change the resident's disposable brief, R1 swung his leg over the bed and rolled out of bed. V3 stated that when she went to R1's room to assess the resident, R1 was on the floor, on the left side of the bed, between the bed and the wall, away from the door. V3 stated that R1 was lying on his stomach with his head turned to his (R1) left side, facing towards the door. According to V3, there was a pool of blood on the floor, by the resident's head area and she was not able to assess where the bleeding was coming from. V3 stated that the staff did not move R1 due to fear of further injury and that 911 was immediately called because the resident was on anticoagulant medication. V3 stated that while R1 was on the floor, the resident remained alert and when asked how he was doing, R1 moaned and responded that his face hurt. V3 stated that after calling 911, the emergency personnel came to the facility within five minutes, transferred R1 from the floor to the stretcher and transported the resident to the hospital.On October 4, 2025, at 1:54 PM, V4 (CNA) stated that on October 3, 2025, between 12:00 and 1:00 PM, she was changing R1's disposable brief while the resident was in bed. V4 stated that she was providing the care by herself and that R1 was able to assist with turning, by moving/turning his leg towards the direction of where he was being turned. According to V4, while R1 was in the middle of the bed, she turned the resident on his (R1) left side, towards the wall, away from her (V4). V4 stated that while turning R1 on his left side, away from her (V4), the resident swung his right leg over the edge of the bed and R1 rolled out, then fell on his face on the floor. V4 stated that R1 was bleeding somewhere on the head, but she was not sure of the exact site, because there was so much blood on the floor. V4 stated that she immediately called V3 (LPN) to inform of the fall. V4 stated that R1 was not moved while on the floor until 911 personnel came and transported the resident to the hospital. According to V4, before providing care to R1 on October 3, 2025, she raised the height of the resident's bed for easy access. R1 was calm and cooperative during the care. R1 was using an air mattress that was plugged on the wall's electrical socket. V4 stated that R1's air mattress was flat (not scooped and/or no side bolsters) and there were no bedrails attached to the bedframe, nor was there any other device to prevent R1 from rolling out of bed away from her during the turning procedure. V4 stated that because R1 was naked during the provision of care, she (V4) had no other means to grab on to R1 and prevent the fall either.R1's care plan last revised on July 12, 2025, showed that the resident has an ADL (activities of daily living) self-care performance deficit. The said ADL care plan showed multiple interventions including, Bed mobility: The resident required extensive assistance by staff to turn and reposition in bed and Side rails: Resident uses 2 quarter side rails in bed for turning and repositioning. Instruct resident to grab onto side rail and gently pull self to side lying position. Two quarter bed rails up to aide in mobility. Both above-mentioned interventions were initiated on December 28, 2024, and were the active plan of care when R1 had the fall incident on October 3, 2025. On October 7, 2025, at 9:32 AM, V2 (Director of Nursing) stated that all residents at the facility are expected to be safe during provision of their care by the staff and that no resident should roll out of bed and fall, sustaining injury while being turned by the staff. V2 stated that two quarter side rails should be present in R1's bed for turning and repositioning of the resident to aide in bed mobility as part of R1's plan of care. According to V2, I do agree that if the bilateral quarter side rails were present, it would have potentially stopped the resident from rolling out of bed and sustaining the injury.On October 7, 2025, at 9:56 AM, V5 (Nurse Practitioner) stated she was aware that R1 was sent to the hospital via 911 after a fall with injury on October 3, 2025. V5 stated that she had read the emergency department notes dated October 3, 2025, documenting that R1 had suicidal attempt by deliberately throwing himself to the ground. According to V5, she sees R1 at the facility once a month. R1 was cognitively impaired and not a reliable historian. R1 had history of traumatic brain injury which she believes leads to some form of probable dementia. V5 stated that he had seen resident at the facility after the fall incident, and he denied suicidal attempt/ideation. V5 further stated that there was no psychiatric evaluation done at the hospital on October 3, 2025, which is a routine evaluation at the emergency department. This led her (V5) to believe that the emergency department does not believe the suicidal attempt was true. During the same interview, V5 stated that residents at the facility should be safe during the provision of their care by the staff. V5 stated that she expects the staff to provide all necessary safety measures to ensure that resident does not roll out of bed and sustain injury during provision of care. According to V5, the facility should implement their own plan of care for R1, including providing the two quarter side rails for turning and/or repositioning the resident to aide in bed mobility. Additionally, V5 stated that if the plan of care to have the two quarter side rails was implemented, it could have potentially prevented R1 from rolling out of bed and sustaining lacerations on his forehead requiring 12 stitches.

Based on observation, interview, and record review, the facility failed to maintain the facility's kitchen in a manner to prevent foodborne illness. This applies to all 90 residents in the facility receiving dietary services. Findings include: On [DATE] at 03:14 PM, V20 (Culinary Director) confirmed all 90 residents residing in the facility receive meals form dietary services. 1. On [DATE] at 11:01 AM, one red sanitization bucket in use tested at 100 ppm (Parts Per Million). On [DATE] at 10:23 AM, V20 (Culinary Director) stated the quat sanitizer for the red sanitization bucket should test between 300 and 400 ppm. On [DATE] at 11:15 AM, V20 stated the red sanitization bucket use quat for sanitization concentration range should be between 150 to 400 ppm. V20 states they don't document the actual reading; they just place a check mark that the sanitizer concentration is in range. On [DATE] at 03:14 PM, V20 stated the pots and pans log is where they document the testing for the red sanitization buckets. The facility did not provide a policy specific to the red sanitization buckets. 2. On [DATE] at 11:01 AM, The dishwasher rinse water tested the sanitizer at 10 ppm. V20 stated the dishwasher disinfects by chemical. V20 stated the temperature booster broke down, so the chemical use has been a new process for approximately three weeks. V20 also stated the facility tests the dishwasher and logs for the temperature. There were no logs documenting the sanitizer ppm. On [DATE] at 11:15 AM, V20 stated the dishwasher uses chlorine to disinfect the dishes and the sanitization concentration should the between 50 to 100 ppm. V20 stated maintenance checks the dishwasher and discovered there was a leak in the supply tubing for the sanitizer. V20 stated it important to make sure the disinfectants are in range to make sure the dishes are sanitized. V20 stated if they aren't disinfected the residents can develop a food borne illness. V20 stated the Dishwasher is responsible for making sure it the sanitization is in range. The Dish machine low temperature log states record wash temperature and sanitizer ppm. The acceptable range of sanitizer is 50 to 100 ppm. 3. On [DATE] at 10:23 AM, the dry storage contained: Two cans of mandarin oranges 6lb (pound) 10oz (ounce) which were dented. One can of pork & beans 7lb, dented. One can of refried beans 7lb dented. Buttermilk biscuit mix 5lbs that expired on ,d+[DATE]. Chicken flavor base 9lb with a written expiration date of ,d+[DATE]. One box of Vanilla wafer cookies 11 oz, open to air. On [DATE] at 11:15 AM, V20 stated using dented cans can led to food borne illness or botulism. We want to make sure they are intact, so they are safe for consumption. The facility Food Safety and Sanitization policy date 2014 states dented cans should be stored away from other foods to prevent being served. Label foods with delivery date and discard date. Monitor logs that include dishwasher temperatures and monitor chemical sanitizers on a regular basis. The undated facility Food Storage: Dry Goods policy states all packaged food items will be kept properly sealed. 4. On [DATE] at 10:45 AM, the walk-in freezer contained: One 20 lb. box of French bread sticks, open to air. On 10 lb. box of turkey franks, open to air. A tray of apple slices with partially uncovered plastic wrap with freezer burn with a written expiration date of ,d+[DATE]. On [DATE] at 10:54 AM, the reach-in cooler contained: A bag of shredded yellow cheese with no label or expiration date. Three 24 oz bottles of chocolate syrup with best by date of [DATE]. On [DATE] at 11:14 AM, the central nourishment room contained: Thickened lemon-flavored drink 216 oz carton that expired on ,d+[DATE]. Whole milk 236 ml (Milliliters) carton expired on [DATE]. A crusty foil take-out pan with spaghetti and meatballs without a name or date. A small brown bag with two hard cornbread muffins without a name or date. Open Imitation crab 8oz in a zippered bag without a name or date. On [DATE] at 11:15 AM, V20 stated Food should be discarded after it is expired because eating outdated food can cause illness. Food that is open to air can get dust and is susceptible to pest if there is an issue or anything could get in it to contaminate the ingredients. The undated facility Food Storage: Cold Foods policy states a written record of daily temperatures will be recorded. All food will be stored wrapped or in covered containers, labeled and dated arranged in a manner to prevent cross contamination. 5. On [DATE] at 11:30AM, a unit refrigerator contained excessive ice build-up in the freezer. Ice was built up inside the refrigerator on the back. The inside of the refrigerator had brown spills and splatters coating the inside. Three drinking mugs had a thick orange gel like substance with no label, name, or date. The September refrigerator temperature log had temperature logged for four days ,d+[DATE], ,d+[DATE], ,d+[DATE] and ,d+[DATE]. On [DATE] at 11:40 AM, the refrigerator in the main dining kitchenette had a bag with an expiration date of ,d+[DATE]. The bag contained three 23.9 oz open bottles of pizza sauce and an opened 5lb bag of mozzarella. V23 (Short Order Cook's) bun and mustache were not covered by his hair nets. On [DATE] at 11:24 AM, V3 (Assistant Director of Nursing) stated housekeeping is responsible for the temperature logs and making sure outdated expired foods are tossed out. Whoever puts the food in the refrigerator is responsible for making sure it is labeled with the resident's name and the date. On [DATE] at 09:58 AM, V1 (Administrator) stated housekeeping is responsible for cleaning out the refrigerator. Staff should know if they put food in the refrigerator, it should be labeled with a name and date. The facility policy Foods Brought by Family/Visitors dated [DATE] states containers will be labeled with the resident's name, the item, and the use by date. The Nursing staff will discard perishable foods on or before the use by date. 6. On [DATE] at 11:34 AM, V21 (Licensed Practical Nurse) was in the main kitchen without hair covering. On [DATE] at 11:36 AM, V22 (Kitchen Staff) was in the kitchen with a hairnet on the top of her head and long lengths of hair to her shoulders, uncovered. The facility Food Safety and Sanitization policy date 2014 showed Hair restraints must be worn at all times while around food production areas.

Based on observation, interview, and record review, the facility failed to provide ADL (Activities of Daily Living) care to residents. This applies to 5 residents (R7, R18, R47, R50, & R66) who were reviewed for activities of daily living in a sample of 22. Findings include: 1. On 09/24/24 at 12:27 PM, R18 had long jagged nails with brown substances under the nails and dry flaking skin on her legs. R18 said it had been over a month since she had been provided nail care. R18's 7/30/24 MDS (Minimum Data Set) showed that R18's cognition is intact, and personal hygiene showed that R18 needs partial/moderate assistance. R18's 7/16/24 care plan showed that R18 has an ADL self-care performance deficit related to diabetes, depression, and anti-depression medication, with interventions including staff assistance with personal hygiene. 2. On 09/24/24 at 12:15 PM, R50 was in her bed and her toenails were long and jagged, and her fingernails were long and jagged and with brown substances under the nails. R50's scalp had an excessive amount of dry flaking skin. R50 said that she would like more showers when she was asked about her personal hygiene. On 09/26/24 at 10:15 AM, R50's right hand fingernails were observed long and with brown substances under the nails. R50's 9/23/24 care plan showed that R50 has an ADL self-care performance deficit related to diagnoses including hemiparesis, anxiety, and weakness. The care plan showed interventions including R50 requires extensive assistance by staff with showering and extensive assistance from staff for personal hygiene. R50's 12/18/23 MDS showed that R50's cognition is moderately impaired, and section GG showed that R50 needs substantial/maximal assistance with personal hygiene. 3. On 09/24/24 at 12:40 PM, R66 was observed with long jagged fingernails and with brown substances under nails. R66's 8/15/24 MDS section GG showed that R66 needs substantial/maximal assistance with personal hygiene. R66's 6/14/23 care plan showed R66 has ADL self-care performance deficit related to impaired mobility due to quadriplegia with interventions including R66 requiring extensive assistance by staff with personal hygiene. On 09/26/24 at 12:35 PM V2 (Director of Nursing/DON) said that nailcare should be provided for safety, residents could scratch themselves and or others, and for infection control. V2 said that staff should provide skin care daily or as needed for dignity issues, cleanliness, skin integrity and skin balance. 48526 4. On 09/24/24 at 2:25 PM, R47 was sitting in a wheelchair reading a newspaper. R47 had long chin hairs and hairs above her lip. R47 stated she wanted the facial hair removed. On 09/25/24 at 4:19 PM R47 was in the hallway going to church services. She continued to have facial hair above her lip and under her chin. On 09/26/24 at 12:00 PM, V2 (DON) stated female residents should not have facial hair above their lips or below their chin. Facial hair should be removed on shower days, when visible, or when the resident requests. The CNAs (Certified Nursing Assistants) are responsible for removing the residents' facial hair. R47 does not refuse care. My expectation is that the staff do ADL care in a timely manner. It is a dignity issue for female residents to have facial hair. R47's Face Sheet showed R47 had diagnoses of congestive heart failure, dementia, anxiety disorder, adjustment disorder with depressed mood, polyarthritis, right shoulder dislocation, and weakness. R47's MDS dated [DATE] showed R47 had cognitive impairment. The same MDS showed R47 required partial/moderate assistance with personal hygiene. R47's ADL Self-Care performance care plan showed R47 required extensive assistance by staff with personal hygiene. 45906 5. R7's Face sheet shows an admitted [DATE] and diagnoses of dementia and weakness. R7's MDS dated [DATE] shows severe cognitive impairment and she requires moderate assistance for personal hygiene. R7's Care Plan dated 8/26/24 shows resident has an ADL self-care performance deficit. Intervention shows the resident requires partial assistance by staff with personal hygiene. On 9/24/24 at 2:24 PM, R7's fingernails were noted to be long, about a quarter inch past the tip of her finger and there was a brown/gray substance under every nail. On 9/26/24 at 1:43 PM, V19 (R7's daughter) said she noticed on 9/24/24 that R7's fingernails looked dirty and long, and they still need to be cleaned and trimmed. On 9/26/24 at 12:59 PM, V2 (DON) said resident nail care should be done by CNAs as needed, upon request, and twice a week during bathing. V2 said long, dirty nails are an infection control issue and a harm risk if the resident were to scratch themselves. The facility's policy titled, Activities of Daily Living (ADLs), Supporting last revised March 2022 states, Policy Statement: .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Policy Interpretation and Implementation: .2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care) .

Based on observation, interview, and record review, the facility failed to provide care with dignity to 2 residents (R38, R70) reviewed for dignity in a sample of 22. Findings include: 1. On 09/24/24 at 11:58 am V5 (Certified Nursing Assistant/CNA) was observed in the dining room during lunch time standing over R70 at the foot of R70's wheelchair, while assisting R70 to eat. At 12:05 pm V5 was observed still standing over R70 assisting her with eating, holding R70's bowl while R70 would feed herself and V5 also feeding R70. At 12:06 pm V3 (Assistant Director of Nursing/ADON) was observed taking over for V5. V3 was observed at the foot of R70's wheelchair, holding R70's bowls of food while R70 spoon-fed herself with V3 also spoon feeding R70. R70's 1/19/24 MDS (Minimum Data Set) showed that R70's cognition is severely impaired, and she requires supervision or touch assistance for eating. R70's 8/1/22 care plan showed that she has an ADL (Activity in Dailly Living) self-care performance deficit related to diagnoses including functional impairment and dementia with interventions including, R70 is able to feed herself with supervision with set up help from staff. R70's care plan also showed, provide set-up help with meals and fluids only, or Provide cues and supervision with all meals and fluids, or provide assistance as needed for meals and fluids, or requires total care with food and fluid intake. 2. On 9/24/24 at 12:02 pm, R38 was observed during lunch setting, at the table with her plate in front of her but she had not received any assistance with set up. R38's meat patty was not cut up and her utensils were wrapped in a napkin above her plate on the table. R38 was observed eating her mashed potatoes with her right-hand fingers and holding the whole meat patty with her left hand eating it whole. At 12:08 pm R38 was observed still eating with her hands, her fingers were in the mashed potatoes and the utensils still wrapped. At 12:09 pm V4 (CNA) was observed while assisting another resident at R38's table, looking at R38 eating with her hands. V4 did not assist R38 at that time, she just left the table after she was done assisting the other resident at the table. On 09/25/24 at 8:34 am during breakfast, V6 (CNA) was observed standing over R38, feeding her. R38's diagnoses include gastro-esophageal reflux disease, dementia, dysphagia oral, & encephalopathy. R38's 7/3/24 MDS indicated R38's cognition is severely impaired. R38's 7/12/24 MDS under eating showed that R38's ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident should be done with supervision or touching assistance. R38's 7/19/24 Care Plan showed R38 has cognitive impairment and dementia, with poor short-term memory, poor reasoning and/or poor judgment. R38 may lose or misplace items, forget how to get places, and may be easily distracted. The interventions include to monitor R38 for snack and hydration needs. Provide cues and prompting and demonstration as needed. R38's care plan also showed that R38 is on a general mechanical soft, thin liquid diet, and she has dysphagia. The interventions include provide set-up help with meals and fluids or provide cues and supervision with all meals and fluids, or provide assistance as needed for meals and fluids, or requires total care with food and fluid intake. On 9/26/24 at 12:35 pm V2 (Director of Nursing) said that staff should not be standing over residents while feeding them, for communication, eye contact, and dignity. V2 said that staff should have provided meal setup for R38. V2 said that if staff sets up R38's meal including cutting her food and setting up her utensils, she will eat with her utensils and not her hands. V2 said, If my loved ones were observed eating with their hands, I would consider it a dignity issue. The facility's Quality of Life - Dignity policy, dated February 2020, showed each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling of self-worth and self-esteem. Residents will be treated with dignity and respect at all times. The policy showed that staff are expected to treat cognitively impaired residents with dignity and sensitivity. The facility's Assistance with Meals policy, dated July 2017, showed that residents shall receive assistance with meals in a manner that meets the individuals needs. Residents who cannot feed themselves will be fed with attention for safety, comfort, and dignity. Assistance will be provided to ensure that residents can use and benefit from special eating equipment and utensils.

Based on observation, interview, and record review, the facility failed to properly position 1 resident to maximize her eating abilities. This applies to (R50) who was reviewed for quality of life in a sample of 22. Findings include: On 09/24/24 from 11:58 AM to 12:09 pm, R70 was observed in the dining room during lunch, laying on her back in her adaptive wheelchair. The chair was in an upright position but R70's back and buttocks were on the seat of the chair. At 11:58 AM V5 (Certified Nursing Assistant/CNA) was observed assisting and feeding R70 in this position, at 12:06 PM, V3 (Assistant Director of Nursing) was observed assisting and feeding R70 in this position. At 12:09 PM V6 (CNA) was observed assisting and feeding R70 in this position. R70's 1/19/24 MDS (Minimum Data Set) Section C showed that R70's cognition is severely impaired and Section GG eating, showed that R70 needs supervision or touch assistance while eating. R70's 8/1/22 care plan showed that R70 has an ADL (activities in daily living) self-care performance deficit related to functional impairment related to non-rheumatic aortic valve stenosis and dementia with interventions including Eating: R70 requires supervision help from staff. R70's 5/8/24 care plan showed R70 is on a general diet with puree consistency and thin liquids with interventions including provide set-up help with meals and fluids, provide cues and supervision with all meals and fluids, provide assistance as needed for meals and fluids, and or requires total care with food and fluid intake. On 09/26/24 at 12:35 PM, V2 (Director of Nursing) said that staff should have repositioned R70 for aspiration precaution. The facility's Assistance with Meals policy dated July 2017 showed that residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity.

Based on observation, interview, and record review, the facility failed to offer restorative strengthening exercises as recommended from physical therapy to a resident with weakness to both lower extremities who was discharged from skilled therapy. This applies to 1 of 1 resident (R88) reviewed for restorative nursing in a sample of 22. The findings include: On 09/24/24 at 12:18 PM, R88 was in bed. R88 stated he had been living in the facility for two months. R88 said he does not receive therapy, and no one comes in to help him exercise his legs. R88 stated I can't use my left leg. R88 stated he asked for help with exercises, and no one assisted him. R88 stated when he was admitted to the facility, her received therapy for his hands and arms, but not his lower extremities. On 09/26/24 at 4:00 PM, R88 stated he has never worked with restorative nursing for exercising. R88 stated no one has come in to work on arm exercises or riding a bike with me. I would not refuse restorative nursing. I want exercises for my leg. On 09/26/24 at 9:07 AM, V15 (Physical Therapy Aide/Director of Rehab) stated R88 received physical and occupational therapy from 06/17/24-07/09/24. V15 stated R88 told him he had deficits with his left leg. When R88 was discharged from skilled therapy on 07/09/24, V15 stated he gave a referral to V9 (Restorative Aide) for strengthening to both upper and lower extremities for range of motion as tolerated. V15 stated we give the restorative referrals to the restorative aide, and she communicates with the restorative nurse. This is the normal process where the restorative aide gives the referrals to the restorative nurse. On 09/26/24 at 9:24 AM, V17 (Licensed Practical Nurse/Restorative Nurse) stated R88 is receiving bed mobility and lower body dressing restorative programs that only the CNAs (CNA/Certified Nursing Assistant) provide. V17 stated she never received a referral from therapy. On 09/26/24 at 11:49 AM, V17 stated she does not remember receiving a therapy discharge notice restorative referral from the restorative aide. V17 stated prior to today, R88 was not receiving a strengthening program. V17 stated residents with weakness should be receiving restorative exercises. The referrals from therapy should be upheld and carried out. The resident could have a decline and get a contracture. It is my responsibility to make sure residents have the appropriate restorative programs and to follow up on therapy recommendations. I create the programs and do care plans for restorative programs. The resident does not have an active program for exercises. We did not follow through with the recommendations from therapy. On 09/26/24 at 11:41 AM V9 (Restorative Aide), stated when a resident is discharged from therapy and referred to restorative, we get a copy of the therapy discharge notice restorative referral. I keep a copy and I give one to V17. V9 stated she gave a copy of the referral to V17 in July. On 09/26/24 at 2:07 PM V2 (Director of Nursing) stated it is the responsibility of the restorative nurse to create the programs and care plans for all residents. It is the restorative nurse's responsibility to follow the recommendations received from the therapy department. On 09/26/24 at 4:20 PM, V2 verified R88 does not have a care plan for refusing care. R88's Face Sheet showed R88 had diagnoses of diabetes, acute respiratory failure with hypoxia, alcoholic cirrhosis of liver, peripheral vascular disease, acute kidney failure, and metabolic encephalopathy. R88's MDS (MDS/Minimum Data Set) dated 06/2024 showed R88 was cognitively intact. R88's Therapy Discharge Notice Restorative Referral dated 07/09/24 showed R88 was discharged from physical and occupational therapy on 07/09/24. The same form showed the equipment needed was two-pound dumbbells, and two-pound ankle weights. The form also showed: recommend strengthening to both upper and lower extremities in available pain free ROM (ROM/Range of Motion) as tolerated. R88's Physical Therapy Evaluation & Plan of Treatment assessment dated [DATE] showed R88's strength to his right and left lower extremities were impaired. R88's Physical Therapy Discharge Summary with discontinue date 07/09/24 showed R88 was referred to restorative for strengthening and mobility. R88's Restorative: Assessment/Side Rail/Restraint dated 06/18/24 was reviewed on 09/25/24, it showed R88 was high risk for developing contractures. The same assessment showed no active restorative program for ROM or exercises. 09/25/24 R88 had no active restorative nursing care plan for ROM or exercises. The facility's Restorative Nursing Services Policy revised 07/2021 showed: Policy Statement- Residents will receive restorative nursing care as needed to help promote optimal safety and independence. Policy Interpretation and Implementation 1. Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services (e.g., physical, occupational or speech therapies. 2. Residents may be started on a restorative nursing program upon admission, during stay or when discharged from rehabilitative care. 3. Restorative goals and objectives are individualized and resident-centered and are outlined in the resident's plan of care. 4. The resident or representative will be included in determining goals and the plan of care. 5. Restorative goals may include but are not limited to supporting and assisting the resident in: b) developing, maintaining, or strengthening his/her physiological and psychological resources.

Based on observation, interview and record review, the facility failed to implement dietary supplements recommended by the dietician. This applies to 1 of 2 residents (R31) reviewed for nutrition in a sample of 22. Findings include: R31 was readmitted to the facility on [DATE] with diagnoses that includes cerebral infarction, type 2 diabetes, muscle wasting and atrophy, hematuria, wedge compression fracture of lumbar vertebra, anemia, acute kidney failure, congestive heart failure, hypothyroidism, hypertension, and hyperlipidemia. R31's MDS (Minimum Data Set) dated 8/14/24 shows he is cognitively intact. R31 was assessed to have a greater than 5% weight loss in six months. The dietary oral /dehydration/nutritional assessment completed by V25 (Clinical Nurse Manager) states R31 was not on a therapeutic nutrition supplement. R31's care plan dated 8/26/24 states on 8/15/24 R31 to receive (nutritional supplement) cc (Cubic Centimeters) noon and PM meals. Registered dietician to evaluate and make recommendations as indicated. On 09/26/24 a11:20 AM, V20 (Culinary Director) stated she generates meal tickets form the communication she receives from the nursing department. Supplements that come from the kitchen will be included on the communication. On 09/26/24 at 12:44 PM, R31 stated he never got nutrition supplements. On 09/26/24 at 12:04 PM, V24 (Dietician) stated she made recommendations on 8/15/24 for R31's significant weight changes. V24 stated she recommended a high calorie no sugar supplement at noon and PM meals for 30 days. V24 stated she provided her recommendation form to the facility before she left on 8/15/24. On 09/26/24 at 01:50 PM, V25 (Clinical Nurse Manager) stated the dietician discontinued the previous order but did not reenter the new order with her recommended changes. The dietician recommended no sugar added (nutritional supplement) 120 cc for 30 days. V25 stated R31 had a 7.7% weight loss over a two-month period. The weight loss was a concern which is why R31 should have had the nutrition supplement. V25 stated she receives V24's recommendations and updates the care plan and dietary to send the supplements on the meal tray. On 09/25/24 at 03:38 PM, R31 did not have any physician ordered diet in the EMR (Electronic Medical Record). R31's EMR showed his diet orders were discontinued on 8/15/24. No nutritional supplement order was in place for R31 as of 8/15/24. The facility policy Diet and Nutrition dated December 2021 states each resident is provided with a nourishing palatable well-balanced diet that meets his or her daily nutritional and special dietary needs.

Based on observation, interview, and record review, the facility failed to follow infection control practices for enhanced barrier precautions, hand hygiene, and urinary drainage bag management. This applies to 3 residents (R7, R22, R65) reviewed for infection control in a sample of 22. The findings include: 45906 1. On 9/24/24 at 2:24 PM, an enhanced barrier precaution sign was seen on the door to R7's room. V7 (Certified Nursing Assistant/CNA) was then seen emptying R7's indwelling catheter drainage bag wearing only gloves, no gown. R7's urine was noted to be dark brown with thick sediment seen in the tubing. After V7 finished emptying R7's indwelling urinary catheter drainage bag, V7 clipped the urinary drainage bag onto R7's bed with the bottom of the drainage bag resting on the floor. The floor in the room was noted to be sticky by R7's bed when walking on it. R7's POS (Physician Order Sheet) shows an order for enhanced barrier precautions related to urinary catheter. The POS shows an order dated 8/26/24 for referral to Infectious Disease doctor for salmonella in the urine. R7's MDS (Minimum Data Set) dated 8/14/24 shows R7 has an indwelling urinary catheter. On 9/25/24 at 11:35 AM, V3 (Infection Preventionist/Assistant Director of Nursing) said gown and gloves are required in enhanced barrier precaution rooms for direct contact care, including emptying an indwelling urinary catheter drainage bag. V3 said the staff should be wearing gown and gloves to prevent the transmission of bacteria between the staff and the resident. V3 said if the resident has a history of an MDRO (Multi-Drug Resistant Organism) there is greater risk of bacteria transmission. V3 said enhanced barrier precautions are put in place to help protect both the staff member and resident from the spread of infection. On 9/26/24 at 12:59 PM, V2 said a urinary catheter drainage bag should never be resting on the floor because of the risk of contamination of the floor in the room and/or the resident's urine. V2 said there is risk for bacteria from the urine to be carried around the building on staff shoes and/or the risk of urinary tract infection for the resident if bacteria get inside the drainage bag from the floor. V2 said gown and gloves are required for enhanced barrier precautions when emptying a urinary catheter drainage bag to protect both the staff member and resident from contaminants. V2 said we have residents with histories of MDROs in the urine and the risk for those residents is greater because they already have a history of those infections. R7's Care Plan dated 8/26/24 shows the resident has risk for infection and is on enhanced barrier precautions related to urinary catheter. Interventions include wear gowns and gloves during direct high contact resident care such as urinary catheter care. Care Plan initiated on 8/26/24 shows resident has a urinary tract infection related to salmonella in urine and is on contact precautions and antibiotic treatment until 9/9/24. The facility's displayed Enhanced Barrier Precaution sign states, providers and staff must also wear gloves and gown for the following high contact resident care activities: .device care or use: .urinary catheter . The facility's policy titled, Enhanced Barrier Protection last revised 3/24 states, Introduction: This precaution is for use in long term care facilities to prevent the spread of novel or MDRO infections. Multidrug resistant organism (MDRO) transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. Facility will consider EBP (when contact precautions do not otherwise apply) for residents with any of the following: .indwelling medical devices .history of MDRO .Procedure: .Healthcare providers must don a gown and gloves prior to providing direct care .High contact activities include: .Device care or use such as: .urinary catheter . The facility's policy titled Indwelling Catheter, Urinary last reviewed July 2020 states, Purpose: The purpose of this procedure is to prevent catheter-associated urinary tract infections . Infection Control .2.b. Be sure the catheter tubing and drainage bag are kept off the floor . 2. On 09/24/24 at 11:47 AM, in the dining room during lunch, V4 (CNA) was observed placing R12's plate on the table and then went to R48, who was sitting at R12's table, and adjusted R48's legs, feet, and R48's footrests on her wheelchair. V4 then went back to the kitchen window, without cleaning her hands, and picked up R65's lunch plates. V4 setup R65's meal including opening up R65's napkin for his utensils and cut up his meat. V4 did this with ungloved, unclean hands. After providing meal setup for R65, V4 did not clean her hands and went back to the kitchen window and got R22's lunch plates and brought them to her, still with ungloved, uncleaned hands. On 09/26/24 at 12:35 PM, V2 (Director of Nursing) said that staff should clean their hands after touching a resident, after going from an area of dirty to clean and always before touching food, for infection control. The facility's Handwashing/Hand Hygiene policy dated August 2022 showed that the facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall be trained and regularly in serviced on the importance of hand hygiene in preventing the transmission of healthcare associated infections. All personnel shall follow the hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors.

Based on observation, interview, and record review, the facility failed to post the current date's staffing for the Daily Nursing Department Staffing Report. This applies to all 90 residents in the facility. The findings include: On 09/24/24 at 9:30 AM upon entrance for the annual licensure and certification survey, the Daily Nursing Department Staffing Report sheet was dated for 09/23/24. On 09/26/24 at 1:25 PM V1 (Administrator) stated the Scheduler is responsible for making sure the daily nursing staffing report is visible and up to date. The Scheduler changes the staffing sheet every day. V1 stated it needs to be visible to residents, visitors, and staff, so they will know the staffing for the day. On 09/26/24 at 1:29 PM, V18 (Scheduler) stated it is my responsibility to make sure the daily staffing is posted every day. It was not changed on Tuesday 09/24/24 because it was my first day back to work from vacation, and I got sidetracked. V18 stated it is important that the staffing is posted to make sure we are fully staffed, and if anything happens, we know how many staff is in the building. The facility's Posting Direct Care Daily Staffing Numbers Policy (revised 07/2022) showed: Policy Statement- Our facility will post on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents. Policy Interpretation and Implementation: 1. The number of Licensed Nurses (RNs, LPNs, and LVNs) and the number of unlicensed nursing personnel (CNAs) directly responsible for resident care will be posted in a prominent location (accessible to resident and visitors) and in a clear and readable format daily. 3. Shift staffing information shall be recorded on the Nursing Staff Directly Responsible for Resident Care form for each shift. The information recorded on the form shall include: b. The date for which the information is posted.

Based on observation, interview, and record review, the facility failed to transfer a resident safely from a shower chair. This failure resulted in R1 sustaining a left tibial fracture after a fall in the shower room. This applies to 1 of 3 residents (R1) reviewed for falls in a sample of 3. The findings include: R1's Face sheet shows diagnoses of diabetes with diabetic neuropathy, cerebral infarction, repeated falls, muscle weakness, and lack of coordination. R1's MDS (Minimum Data Set) dated 7/20/23 shows her cognition is intact. On 12/28/23 at 9:52 AM an observation was made of the main shower room where R1's fall occurred. There are 3 shower stalls on the right-side wall, and 1 shower stall on the left wall. The last/furthest shower stall on the right side has an approximately 4-foot-long horizontal grab bar, which is about 6 inches to the left of the shower, above the tile floor. On 12/27/23 at 11:15 AM, R1 said at the time of her 9/14/23 fall, there was a towel on the floor, and she told V7 (CNA/Certified Nurse Assistant) that she thought she was going to fall if she tried to stand up. R1 said the next thing she knew, she had fallen and landed on her butt with her legs out in front of her. R1 said she thinks she fell because the towel under her feet slipped out and her feet slipped too. On 12/28/23 at 9:36 AM, R1 said the fall took place in the main shower room, outside of the last/furthest shower on the right-hand side while she attempted to stand up using the grab bar outside of the shower stall. On 12/28/23 at 1:57 PM, R1 said at the time of her fall she had bare feet and was not wearing any non-skid socks or slippers. R1 said she did not fall because of her knee buckling or her hand slipping off the grab bar, she fell immediately and was never able to stand upright. On 12/28/23 at 10:25 AM, V7 (CNA) said she put a towel down on the floor before attempting to help R1 stand up. V7 said she was watching R1's hands on the bar when she fell and did not notice what happened with her feet. On 12/28/23 at 11:28 AM, V7 said R1 was not wearing non-skid socks or slippers at the time of her fall. V7 said R1 had bare feet, and a gait belt was not used. R1's nurse's note dated 9/14/23 at 21:55 (9:55 PM) shows that at 2100 (9 PM), resident was observed in shower room laying on her right side and complaining of pain to her left leg. When the nurse asked the resident what happened, R1 said, as she was beginning to stand holding the bar in shower room, her foot slipped, and she fell down. The CNA was unable to prevent the fall and placed a dry towel on the floor, but R1 still slipped. R1's hospital record documents left lower leg x-ray completed on 9/15/23 at 8:25 AM had finding of comminuted oblique fracture mid tibial diaphysis. On 12/27/23 at 2:03 PM, V5 (CNA), said when she gives a resident a shower in the shower room, she will dry the floor with towels and then remove all towels before the resident stands up. V5 said, I always remove the towels because I don't want the resident to slip, especially because they don't have any shoes on and are barefoot. I was trained to wipe the floor up and remove the towels before having the resident stand up. On 12/27/23 at 2:24 PM, V6 (CNA) said before transferring a just-showered resident from the shower chair into their wheelchair, I secure the area. I make sure the floor is dry and transfer her with gait belt and lift from shower chair to her wheelchair. I dry the floor and remove all of the towels, I don't leave a dry towel down for the resident to stand on. That would be a safety issue, the resident could slip on the towel. R1's Care Plan dated 11/8/23 shows R1 has a risk for falls related to weakness. Interventions include ensure R1 is wearing appropriate footwear (slip resistant socks and/or shoes) when ambulating or mobilizing in wheelchair and R1 needs a safe environment free of clutter. This same Care Plan shows R1 has had previous falls on 12/31/22, 3/26/23, 8/11/23, and 9/14/23. The 9/14/23 fall states, Resident was standing up from the shower chair when her foot slipped, and she fell . She sustained a left tibia fracture. R1's final incident report dated 9/22/23 at 10:00 AM shows that on 9/14/23 resident was observed on the floor lying on her right side. When asked what happened, resident stated as she was beginning to stand holding onto the bar, her foot slipped, and she fell . NP notified and resident sent out to ER. Report of a closed fracture to left tibia received and resident returned to the facility after left tibial nailing surgery.

Based on observation, interview, and record review, the facility failed to complete assessments for medication self-administration and failed to obtain orders to keep medications at the bedside. This applies to 2 of 3 residents (R8, R57) reviewed for medications in sample of 18. The findings include: 1. On 10/31/23 at 10:58 AM, during initial tour, surveyor went to R57's room. R57 and R60 are husband and wife and share a room together. Neither R57 nor R60 were in their room; per staff, they were in the hospital. There was a container of Triamcinolone Acetonide 0.1% ointment on R57's bedside table. On the label of the container of the Triamcinolone Acetonide, it showed it belonged to another resident (R68), who was in a different room. On 11/1/23 at 1:20 PM, surveyor went with V2 (Director of Nursing/DON) to R57's room. R57 had still not come back from the hospital. The container of the Triamcinolone Acetonide that belonged to R68 was inside his drawer. R60, (R57's wife) stated I just came back from the hospital. (R57) is my husband and he's still in the hospital. This ointment has always been here. I didn't know it belonged to another resident. R57 was putting it on himself for itching because he has a rash on his chest. Surveyor then went with V2 to the wound cart and could not find R57's Triamcinolone Acetonide cream. On 11/1/23 at 1:27 PM, V2 stated R68's medicated cream should not be in R57's room. The nurse should not be using another resident's cream on R57. There should be orders for all medication and an order to be at the bedside. There should be a self-administration of medication assessment for the resident as well. On 11/2/23 at 9:43 AM, surveyor went with V3 (Licensed Practical Nurse/LPN) to the wound cart on the unit. V3 found R57's Triamcinolone Acetonide in the treatment cart. The medicated ointment was not in a container, but rather in a tube with barely anything in it. V3 stated, It's running out. The nurse shouldn't have used another resident's Triamcinolone for R57. The nurse also should not have left it in the resident's room. It should have been stored in the medication cart. The nurse should have also ordered a new medication It wasn't me who was giving it to him when he was here. I'm only working on this unit today. This is not my regular unit. R57's face sheet documents an admitted [DATE]. R57's POS (Physician Order Sheet) documents the following order that started on 10/2/23: Triamcinolone Acetonide External Lotion 0.1%--Apply to both arms, chest/abdomen, and upper/lower back topically two times a day for skin condition. R57's (Nurse Practitioner) dated 8/9/23 documents: (R57) seen today for evaluation of rash. Nurse reported patient states he has a rash that started today. (R57) states when he woke up this am, his arms and trunk were itching and about lunch time, he noted a red rash. Skin: Scattered papules to top of arms, and trunk/chest area, with excoriation due to scratching. Assessment/Plan: Rash-Benadryl for itching today. Triamcinolone cream ordered for affected areas. R57's MAR (Medication Administration Record) from August 2023 to present show that R57 was receiving the Triamcinolone Acetonide ointment. R57's medical record did not have an assessment for self-administration of medications. 2. On 10/31/23 at 11:15 AM, R8 was sitting in her wheelchair in her room. On top of her bedside table, there was one 24-hour Nasal Spray. R8 stated she bought this from the store and uses it occasionally. R8 stated no one told her how to use it, but she knows how to use it. R8 stated it is always in her room. R8's POS for October 2023 does not have an order for the nasal spray. R8's POS had an order for Flonase Allergy Relief suspension 50 MCG (Micrograms)/ACT (Fluticasone Propionate)-1 spray in both nostrils one time a day for allergies, which is a different medication for the nasal spray that was found in R8's room. R8's medical record also did not contain an assessment for self-administration of medication, nor did she have a care plan regarding this. Facility's policy titled Self-Administration of Medications (2016) documents: 1. As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. 2. In addition to general evaluation of decision-making capacity, the staff and practitioner will perform a more specific skill assessment. 6. For self-administering residents, the nursing staff will determine who will be responsible (the resident or the nursing staff) for documenting that medications were taken. 8. Self-administered medications must be stored in a safe and secure place. Facility's policy titled Storage of Medications (2022) shows: 8. Drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications shall be assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents. Facility's policy titled Administering Topical Medications (2010) documents: Step in the Procedure: 6. Check the label on the medication and confirm the medication name and dose with the MAR.

Based on observation, interview, and record review, the facility failed to apply assistive devices to prevent contractures. This apples to 2 of 2 residents (R23, R34) reviewed for assistive devices in a sample of 18. The findings include: 1. R34's face sheet showed R34 had diagnoses including cerebral infarction, hemiplegia affecting left non-dominant side, abnormalities of gait and mobility, lack of coordination, congestive heart failure, and muscle weakness. R34's MDS (Minimum Data Set) dated 8/29/23 showed R34 was cognitively intact and required supervision for eating, substantial assistance for oral hygiene and upper body dressing, and was dependent on staff for toileting, showering/bathing, lower body dressing, and applying or removing footwear. R34's care plan showed left hemi arm sling to LUE (left upper extremity) for support when out of bed. R34's POS (Physician Order Sheet) showed an order for left hemi arm sling to LUE for support, when out of bed starting 5/24/23. The POS also showed an order for a left resting hand splint to prevent worsening contractures s/p (status post) CVA (Cerebral Vascular Accident) starting 9/21/23. On 11/1/23 at 01:59 PM, R34's left hand was closing into a fist. R34 did not have a brace on the left hand or a sling. R34 said the facility was supposed to get a brace for her left hand, but she hadn't received one yet. R34 stated the facility staff said they ordered the brace two weeks ago. R34 said she had pain in her left hand, and she would massage her hand. R34 said she had never had a brace applied to her left hand. At 10:36 AM, R34 was sleeping in her high back wheelchair and no sling or brace was observed on her left arm or hand. The next day on 11/2/23 at 12:11 PM, R34 was in the high back wheelchair in the dining room eating her lunch. R34 did not have a sling or brace on her left arm. On 11/2/23 at 12:13 PM, V7 (Licensed Practical Nurse/LPN) said she had been taking care of R34 since 6 AM. V7 said R34 had a stroke that affected her left side and caused weakness. V7 said R34 did not have a brace on her left hand when she started her shift. On 11/2/23 at 12:28 PM, V8 (Certified Nurse Assistant/CNA) said she had been taking care of R34 since 6 AM. V8 said R34 had a stroke which affected her left side and caused weakness. V8 said she had never seen a sling on R34 and had never seen a brace on R34. V8 said she was the aide who would wake R34 up in the morning and provide care and she had never seen R34 with a brace on in the morning. V8 said she was not aware R34 was supposed to have a brace or sling. On 11/2/23 at 12:15 PM, V6 (Restorative Aide) said she worked from 6 AM to 2 PM and tried to do range of motion with R34 when she could. V6 said R34 was not able to use her left hand but she was unaware if R34 was supposed to have anything on her left hand. V6 also said R34 should have a sling on her left arm every day. On 11/2/23 at 12:54 PM, V9 (Restorative Nurse) said she often works with the residents as the floor nurse and would work from 6 PM to 10 PM. V9 said R34 recently had a stroke and was on restorative for bed mobility. V9 said R34 usually goes to bed around 8 or 9 PM and she did not believe R34 needed a brace for her left hand and never applied one on her during bedtime. V9 said R34 should have a sling on her left arm when she is up in the chair. On 11/2/23 at 01:01 PM, V2 (Director of Nursing/DON) said if there was an order for a brace or sling, it should be on, unless they refuse. V2 said if they refuse, it should be documented in the care plan. The facility's Assistive Devices and Equipment policy revised on 12/2021 showed the facility provides, maintains, and trains and supervises the use of assistive devices and equipment for residents. Devices and equipment that assist with resident mobility, safety and independence are provided for residents. These include, but are not limited to splints, braces, immobilizers. 31327 2. On 11/1/23 at 10:56 AM, R23 was lying in bed. R23's left hand was observed to be severely contracted. R23 did not have her carrot splint inside her left hand. Surveyor asked R23 where her splint was. R23 pointed to the dresser. The carrot splint was next to her television (TV). R23 stated, They (CNAs) changed me a few minutes ago. They put my carrot by the TV. I need it. I have to tell them to put it back in my hand. Sometimes, they forget to put it in my hand, and I have to remind them. On 11/1/23 at 2:49 PM (almost four hours later), R23 was lying in bed and on the phone. Surveyor asked R23 if she received her splint yet. R23 stated, No, I still don't have it in my hand. The splint was still on top of the dresser. The next day on 11/2/23 at 9:50 AM, R23 was in bed and watching TV. R23 did not have her carrot in her hand. Surveyor asked R23 where her splint was. R23 stated that it was in her purse. R23 took the splint out of her purse and tried to put it in her left hand. R23 was unable to put inside because her left hand was severely contracted. R23 stated, I need someone to help me put it in my hand. I can't do it by myself. They never came by to put it my hand today. R23 pushed her call light. V6 (Restorative Aide) came inside to R23's room. V6 attempted to open R23's hand and put the splint in. When she finally put the splint in, R23 stated it was hurting her. Then, V6 removed the splint. On 11/2/23 at 9:57 AM, V6 stated, Yes, R23's carrot should be inside her left hand because her hand is contracted. It's one of the restorative interventions. It should be in her hand except during meals or as tolerated. R23's face sheet documents an admitted [DATE]. R23's face sheet shows the following diagnoses: morbid (severe) obesity due to excess calories, muscle weakness (generalized), lack of coordination, fatigue, contracture of left hand, functional quadriplegia, and personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits. R23's POS (Physician Order Sheet) shows an order that R23 is to wear a splint to her left upper extremity up to 4 hours as tolerated. Remove if there are signs of redness or break down. R23's care plan (12/31/20) shows the following: Focus-(R23) has an ADL (Activities of Daily Living) self-care, performance deficit related to quadriplegia. Restorative splinting program carrot to left hand on in am, off at bedtime, 6-7 times a week. Goal-(R2) will maintain or improve current level of function through the review date. Interventions-(R23) has contractures of the (left hand). Staff will provide skin and nail care to keep clean and prevent skin breakdown. (R23) uses a carrot.

Based on observation, interview, and record review, the facility failed to remove expired food items, clean residents' refrigerators, provide refrigerator thermometers, and monitor daily temperatures. This applies to 3 of 3 residents (R15, R50, R72) reviewed for refrigerators in a sample of 18. The findings include: 1. On [DATE], the following observations were made during the initial tour: At 10:53 AM, inside R50's refrigerator, there was no thermometer. The following items were noted: 1 unopened (,d+[DATE] pint) milk (2% reduced fat) that expired on [DATE] (25 days earlier). There was an opened carton of ,d+[DATE] pint milk (2% reduced fat) halfway full that expired on [DATE] (32 days earlier), 1 carton of whipped unsalted butter--best by [DATE], and 1 carton (8 oz--ounces) of cream cheese that expired on [DATE]. The refrigerator was cluttered and dirty with stains. R50 was not in her room. R50's face sheet documents an admitted [DATE] to the facility. 2. At 2:11 PM, R72's refrigerator was inspected. R50 and R72 are roommates. There was no thermometer inside R72's refrigerator. On [DATE] at 12:50 PM, V4 (Environmental Services Director) provided the binder for temperature logs of resident and unit refrigerators. R72 did not have a temperature log sheet for the month of June. There was only one refrigerator temperature log sheet for [DATE] for the room that R50 and R72 stayed in. V4 was unable to determine if it was for R50 or R72. There were no log sheets for both R50 and R72 for [DATE]. R72 was sleeping and was unable to be interviewed. R72's face sheet documents an admitted [DATE]. On [DATE] at 10:55 AM, V5 (Licensed Practical Nurse/Clinical Nurse Manager) said that it's housekeeping's job to check the refrigerators every day and remove expired items. On [DATE] at 12:59 PM, V4 (Environmental Services Director) stated refrigerators in residents' rooms are brought in by the residents' families. V4 stated, The facility provides the thermometers for the refrigerators and keeps the temperature logs. Any staff member in the facility can remove expired items from the refrigerator. Every refrigerator should have a thermometer and the temperature needs to be checked and logged on a daily basis. Housekeeping should be checking the refrigerators and making sure they are clean. Facility's policy titled Food Brought in by a Family or Visitors Personal Refrigerators documents the following: Personal refrigerator temperatures are maintained at 41 degrees F (Fahrenheit) or below. Refrigerators are cleaned regularly to maintain a safe and sanitary environment for food storage. Refrigerated foods that have been opened or left-over foods stored in the refrigerator will be marked with use-by date. The use-by date is 6 days from the day the food was opened or the day the left-over food was put in the refrigerator. The nursing staff will discard perishable foods on or before the use by date. The nursing and/or food service staff will discard any foods prepared for the resident that show obvious signs of potential foodborne danger (for example, mold growth, foul odor, past due package expirations dates). 48526 3. On [DATE] at 11:35 AM an expired mixed berry drinkable parfait dated [DATE] (41 days earlier) and an expired red gelatin dated [DATE] was found in R15's refrigerator. On [DATE] at 10:36 AM and [DATE] at 10:41 AM, the expired mixed berry drinkable parfait and expired red gelatin were still present in R15's refrigerator. On [DATE], [DATE], and [DATE] R15's refrigerator did not a have temperature log.

Based on observations, interviews, and record reviews, the facility failed to notify R1's physician and representative on 4/9/23 when R1 was found on the floor. On 4/14/23 R1 was diagnosed with comminuted fractures to her right tibia and fibula. This applies to 1 of 3 residents (R1) reviewed for injury of unknown origin. Findings include: R1 is a non-verbal, non-ambulatory, [AGE] year-old female admitted to the facility on [DATE] with diagnoses including heart failure, hypertension, peripheral vascular disease, profound intellectual disability, and other specified disorders of bone density and structure. On 4/14/23 R1 was diagnosed with comminuted fractures to her right tibia and fibula. 1. 4/9/23 On 4/19/23 at 5:27pm V1 (Administrator), on 4/19/23 at 4:46pm V2 (Director of Nursing), on 4/18/23 at 2:26pm V9 (Nurse), on 4/19/23 at 3:25pm V17 (Nurse), on 4/19/23 at 1:35pm V14 (Receptionist), and on 4/19/23 at 4:27pm V22 (Certified Nurse Assistant/CNA) said that on 4/9/23, R1 was found on the dining room floor after the facility's Easter Egg hunt. On 4/18/23 at 2:26pm V9 (Nurse) said that she did not report R1 being found on the floor to R1's Doctor or Nurse Practitioner. 2. 4/12/23 On 4/19/23 at 4:03 PM, V21 (CNA) said that on 4/12/23, while changing R1's adult brief, R1's right leg buckled, but she did not report the incident to anyone. 3. 4/13/23 On 4/18/23 at 12:52pm, V8 (CNA) said that on 4/13/23 she observed swelling and a bruise to R1's right ankle and she reported it to V9 (Nurse). On 4/18/23 at 2:26pm, V9 said that on 4/13/23 she observed a bruise and swelling to R1's right ankle around 6am but did not notify R1's doctor or document it. 4. 4/14/23 On 4/18/23 at 12:32pm, V7 (Nurse) said that on 4/14/23 she was informed by V8 (CNA) that R1 had swelling and a bruise to her right ankle. V7 (Nurse), said that she observed the swelling and bruise to R1's right ankle and notified V6 (Wound Nurse). On 4/18/23 at 12:15pm, V6 said that on 4/14/23 she was notified of a bruise and swelling to R1's right ankle by V7 and she notified V18 NP (Nurse Practitioner). On 4/19/23 at 3:05pm, V18 said that on 4/14/23 she was informed of bruising and swelling to R1's right ankle and gave orders for x-rays and to be sent to the hospital for evaluation. V18 said that she was never notified on 4/9/23 when R1 was found on the floor, on 4/12/23 when R1's right knee buckled or on 4/13/23 when R1's right ankle was observed with a bruise and swollen. V18 said she would have given at minimum orders for observation. On 4/19/23 at 3:55pm V20 (R1's Primary Care Physician) said he was not notified on 4/9/23 when R1 was found on the floor, on 4/12/23 when R1's right knee buckled or on 4/13/23 when R1's right ankle was observed with a bruise and swollen. On 4/18/23 V12 (R1's Orthopedic Doctor) said that R1's fracture was the result of a onetime acute injury resulting in a fracture. V12 said the injury was the result of trauma to R1. A review of R1's electronic record did not show any documentation for 4/12/23 or 4/13/23 regarding any buckling, bruising, or swelling to R1's right leg or right knee. R1's nursing progress note showed that on 4/17/23 at 9:51am, V9 made a late entry, showing that on 4/9/23 R1 was found on the floor in the dining room at 3:15pm. No progress notes showed any notifications were made to R1's doctor or guardian regarding R1 being found on the floor on 4/9/23. R1's 4/14/23 at 1:45pm progress note showed that V6 (Wound Nurse) noted bruising to right ankle, assessment noted with swelling, no expression of pain with palpitation, spoke with NP (Nurse Practitioner), received stat X-ray orders. R1's 4/14/23 10:55am Lab/Radiology progress note showed, 4/14/23 R- ankle reviewed by V18 (NP). New orders to send to emergency department. R1's 4/14/23 hospital records showed that R1's x-rays showed comminuted fractures to R1's right tibia and fibula. R1's 4/18/23 orthopedic office visit documentation showed R1's date of injury 4/9/23. The documentation showed a diagnosis of comminuted distal fractures of the right tibia and fibula. V14's (CNA) 4/15/23 statement showed that on 4/9/23, V14 saw R1 on the dining room floor. V9's (Nurse) 4/15/23 statement showed that on 4/9/23 V9 saw R1 on the dining room floor. V22's (CNA) 4/15/23 statement showed that on 4/9/23 she saw R1 on the dining room floor. V21's (CNA) 4/14/23 statement showed that on 4/12/23 R1's knee buckled. V8's (CNA) 4/14/23 Witness Statement showed, V8 noticed on Thursday (4/13/23) swelling to R1's right leg and reported to the nurse. The facility's Assessing Falls and Their Cause policy dated March 2018 showed, steps after a fall notify residents attending physician and family in an appropriate time frame and complete an incident report for resident files no later than 24 hours after file occurs. The incident report form should be completed by the Nursing Supervisor on duty at the time and submitted to the Director of Nursing Services. The policy showed under Reporting, the facility is to report the incident to the Attending Physician, the family, the Director of Nursing and Nursing Supervisor on duty. The facility's Incident Reporting policy dated December 2017 showed, as required by federal or state regulations, our facility reports unusual occurrences or other reportable events which affect the health, safety, or welfare of our residents. Our facility will report the following events to appropriate agencies, serious injuries related to fall confirmed by a diagnosis e.g., fracture, hematoma Incidents shall be reported via fax or e-mail to appropriate agencies as required by current law within 24 hours of such incident, a written report detailing the incident in action taken by the facility after the event shall be sent and delivered to the state agency within 48 hours of reporting the event or as required by federal state law.

Based on observation, interview, and record review, the facility failed to ensure that the dishes are washed in a clean and sanitary environment and failed to maintain sanitizing solutions in sanitation buckets within recommended sanitation concentrations. This applies to all 91 residents that receive oral diets from the facility kitchen. The findings include: Facility Resident Census and Conditions of Residents form (CMS Form 672) dated 12/19/22 showed that the census of the facility was 92. Facility provided documentation that there was only one resident on NPO (Nothing by mouth) status on 12/19/22. 1. On 12/19/22 at 09:44 AM, the initial tour of the facility kitchen was done in the presence of V11 (Culinary Director). At the dish machine, V12 (Dietary Server) was seen loading the used dishes on the left side of the dish machine and V13 (Dietary Server) was pulling the clean dishes off the racks from the right side. The clean side of the dish machine was noted to have marked food deposits and scum, and the back splash of this area had blackish/brownish spots/substance. When this backsplash was wiped with a paper towel, brownish black substance came off to the surface of the paper towel. V11 stated that this blackish brown substance is the dirt from the paint that is chipping off from the walls. When standing by the dish machine, water was noted to be dripping from the ceiling above the dish machine unto racks of newly washed dishes and the floor surrounding it. To catch these drips, there were two yellowish colored rags that were soaked with liquid placed on top of the dish machine. V11 stated that the leak in the ceiling started last Thursday when it was raining outside and that she notified V14 (Environmental Service Director) the same day. V11 continued, that the facility is only one storied and there is no bathroom above this ceiling. V11 was notified that the cleaned dishes that were pulled from the dish machine on to the soiled area and those dishes that were stored under the dripping from the ceiling cannot be used for the meal service. V11 was also notified that the use of this dish machine to wash dishes under the current conditions has to be with the direction of facility management. On 12/19/22 at 10:52 AM, the concern of leakage above the dish machine was reported to V1 (Administrator) who stated that she was not aware of the leak from the ceiling. V1 stated that V14 (Environmental Service Director) handles all work orders. On 12/19/22 at 10:59 AM, after the inspection of the dish machine area, V1 verified that there is no patient care area above the ceiling. V1 stated that the affected dishware will be rewashed, and the storage of dishes relocated, and the area will be cleaned and sanitized. V1 stated We have to investigate where the leak is. V11 was present during this interaction. On 12/19/22 at 11:42 AM, V14 stated that this has been a recurrent issue whenever there is heavy rain. V14 stated that the wind created by the rain tends to blow into the discharge vent of the dishwasher on the roof. V14 stated that the water drippings are from the condensation of the dish machine steam that is supposed to go out of the vent. V14 stated that he was notified on Thursday and put in a work order on Friday and the roofers said that they will come as soon as they can to replace the entire vent. On 12/20/22 at 09:42 AM, the facility kitchen was visited again and noted that the ceiling still had peeling paint with condensation and continued drips to the floor from the same. The yellow-colored water-soaked rags were still on top of the dish machine. V16 (Dietary Server) who was in the area stated, it's always been there. The clean side of the conveyor belt had food debris collecting at base of the rack that held clean dishes. The back splash was still covered in areas with blackish/brownish spots. This was again relayed to V11 who stated that she will ensure that this area is cleaned again prior to washing dishes. On 12/20/22 at 11:22 AM, V14 stated the roofing company came by and stated that there were no issues with the roof. V14 continued that he had the Plumbing and Piping company come in and they stated that the belt that makes the fan spin to remove the condensation was broken which is causing the steam to be trapped and causing the leak. V14 stated that once the belt is fixed, he will cut out the dry wall and put in a new one to fix all the leaks and also clean and repaint the blackened area of the backsplash on the conveyor belt of the dish machine. 2. On 12/19/22 at 9:51 AM, V15 (Cook) was seen wiping the counter tops of the steam table with a cloth from a sanitizing bucket. When the sanitizing strength of the sanitizer was checked with a test strip, it showed a light green color on the color chart registering at 50 ppm/parts per million. V11(Culinary Director) stated that the sanitizer used is a QUATS [Quaternary Ammonia Cation] should test between 150-200 ppm. Facility Sanitizer Test Strip labels/dish machine procedure dated 6/10/22 included as follows: Using sanitizer test strips are one way to confirm levels are achieved to protect against food borne illnesses. A quat disinfectant must be 150-300 PPM to be considered effective. It's no longer considered to be an effective disinfectant at levels below 100 ppm.

Based on observation, interview, and record review, the facility failed to assist residents identified as needing assistance with personal hygiene and toilet use. This applies to 5 of 6 residents (R3, R31, R32, R49 and R54) reviewed for ADL (activities of daily living) in the sample of 22. The findings include: 1. R54's face sheet diagnoses include chronic diastolic (congestive) heart failure, generalized muscle weakness, presbyopia, and profound intellectual disabilities. R54's quarterly MDS (minimum data set) dated December 5, 2022 showed that the resident has severely impaired cognitive skills for daily decision making. The MDS showed that R54 required extensive assistance from the staff with most of her ADLs including personal hygiene and toilet use. The same MDS showed that R54 is incontinent of both bowel and bladder functions. On December 19, 2022 at 1:20 PM, R54 was sitting in her wheelchair in front of the nursing station. R54 was eating her lunch meal. R54 was served pureed food and was observed leaking her fingers. R54's fingernails were long, jagged with brown/black substances underneath. V4 (Nurse) was informed of the observation. V4 went to R54 to check on the resident and acknowledged that R54's fingernails needs cleaning and trimming. On December 20, 2022 at 1:12 PM, R54 was eating in bed with the head of the bed elevated. R54's fingernails remained long, jagged with brown/black substances underneath. V4 was present during the observation. V4 stated, Yes, you are right, they did not provide nail care to her. On December 20, 2022 at 1:20 PM, V4 and V5 (Certified Nursing Assistant/CNA) came inside the room to reposition R54. V4 and V5 decided to assist R54 to sit in her wheelchair. According to V5 she is not the assigned staff for R54. V5 stated, She eats better when she is sitting in her wheelchair. Prior to transferring R54 to her wheelchair, V5 provided incontinence care to R54 because the resident's disposable brief was wet with urine. On December 20, 2022 at 1:23 PM, V6 (CNA) stated that she was the assigned staff for R54. According to V6 she last checked and changed R54's disposable brief when she started her shift at 9:00 AM. R54's active care plan last revised on November 6, 2022 showed that the resident has ADL self-care performance deficit related to intellectual disabilities. The care plan showed under intervention, Personal hygiene: The resident requires extensive assistance to perform personal hygiene. The same care plan showed under intervention, Toilet use: The resident requires extensive assistance by staff for toileting. R54's active care plan last revised on November 6, 2022 showed that the resident is incontinent of bladder function. The same care plan showed in-part under intervention, Incontinent: Check every room rounds, upon request, as needed for incontinence. On December 21, 2022 at 9:28 AM, V3 (Assistant Director of Nursing) stated that the residents should be checked and changed at least every 2 hours and as needed to ensure cleanliness and comfort especially for residents needing assistance from the staff. V3 also stated that it is part of the nursing care to ensure that resident's fingernails are clean and trimmed. V3 added that it is especially important for R54's fingernails to be trimmed and cleaned because the resident needs the assistance of the staff with regards to hygiene related to R54's mental disability. 2. R49's face sheet diagnoses include has multiple diagnoses which includes rhabdomyolysis, generalized muscle weakness, lack of coordination, abnormal posture, and macular degeneration. R49's quarterly MDS dated [DATE] showed that the resident is cognitively intact. The same MDS showed that the resident required limited assistance from the staff with regards to personal hygiene. On December 19, 2022 at 3:49 PM, R49 was sitting in her wheelchair in-front of the nursing station. R49 was alert, oriented and verbally responsive. R49 had accumulation of long facial hair on her chin and on her upper lip. R49 stated that she wanted the staff to shave her facial hair. V4 (Nurse) was present during the observation and was aware of R49's request to be shaven. R49's active care plan last revised on November 2, 2022 showed that the resident has ADL self-care performance deficit related to weakness. The same care plan showed under intervention, Personal hygiene: The resident requires extensive assistance by staff with personal hygiene and oral care. On December 20, 2022 at 1:04 PM, R49 was sitting in her wheelchair inside her room. R49 was alert, oriented and verbally responded. R49 stated, Thank you for telling the nurse about my facial hair. Now I look like a woman instead of a man. On December 21, 2022 at 9:28 AM, V3 (Assistant Director of Nursing) stated that it is part of the nursing care to ensure that unwanted facial hair of the residents especially the female resident be removed, to maintain personal hygiene and grooming. V3 stated that though R49 is able to do some ADLs on her own, shaving requires the assistance of the staff for safety. 29562 3. R3 has multiple medical diagnoses which include generalized muscle weakness and lack of coordination. R3's minimum data set (MDS) dated [DATE] shows that she is alert and oriented and requires extensive assistance for grooming and hygiene. On 12/19/22 at 12:46 PM, R3 was in the sitting on her wheelchair by the nurses' station. R3 displays facial hairs to upper lip and chin. R3 has long nails with polish, however, underneath some of her nails were accumulation of unidentified substances. On 12/20/22 at 1:04 PM, V5 and V10 (Both CNAs) provided care to R3. R3 remains with facial hair and long fingernails with substances underneath. When R3 was asked if she wants to be shaven, R3 agreed. When asked about her nails she said that it was just done yesterday (nail polish). The nails polish looked new, however, there were still the accumulated substances and/or debris underneath some of her nails. R3's care plan active shows that she has an ADL self-care performance deficit related to weakness. R3 requires extensive assistance from staff with personal hygiene and oral care. 4. R31 has multiple diagnoses which include hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, blindness on one eye, generalized muscle weakness, and abnormalities of gait and mobility. MDS shows dated 9/15/22 shows that R31 is cognitively impaired and requires extensive assistance for grooming and hygiene. On 12/20/22 at 2:05 PM, R31 was sitting on his bed, with facial hair growth but R31 refused to be shaven. His nails were somewhat long with black substance underneath, when asked if he wanted to clean and clipped his nails, R31 agreed. V23 (CNA) stated that R31 is diabetic so she can't do it, but someone usually comes to clean their nails. R31's care plan shows that R31 has an ADL self-care performance deficit and requires extensive assistance by staff with personal hygiene. On 12/21/22 at 3:05 PM, V24 (Clinical Resource Nurse Manager) stated that if a resident is diabetic the CNA and the nurses can clean their nails but it's only the nurses who can clip the nails. The CNA staff must notify the nurse if the nails need clipping. 36567 5. R32's EMR (electronic medical record) included diagnoses of personal history of traumatic brain injury, other abnormalities of gait and mobility, other lack of coordination, difficulty in walking, dysphagia, oral phase. R32's Quarterly MDS dated [DATE] included that R32 was severely impaired in cognition and required extensive two-person physical assistance for personal hygiene. On 12/19/22 at 11:29 AM, R32 was lying in bed and appeared disheveled and noted to have facial hair and his arms had very dry and scaly skin. R32 was alert and able to communicate clearly and stated that he is mostly blind with some vision in his right eye. R32 remarked I need a shave and haircut. It's been more than a week since I was shaved. They haven't put any lotion on. R32's fingernails were noted to be about half inch long with blackish substance underneath. R32 stated They have to cut and clean it. On 12/19/22 at 12:50 PM, this information was relayed to V9 (Licensed Practical Nurse) who stated He gets shaved on shower days and will let the barber know about haircut. He needs to be oiled up. On 12/19/22 at 12:34 PM, R32 received a bedside tray and noted to take a few bites of his peanut butter jelly sandwich and his fingernails were still long with blackish substance underneath it. V10 (Certified Nursing Assistant) who came into the room was notified that R32 would like to have his fingernails cleaned and cut. On 12/20/22 at 09:49 AM, R32 was seen seated at the nurses station in a reclining chair. R32 noted to still have facial hair and his fingernails remained long with blackish substance underneath them. R32 stated They still haven't done anything. V9 (Licensed Practical Nurse) who was in the vicinity was again reminded of R32's requests. R32's nursing care with target date of 1/1/2023 included that R32 has potential impairment to skin integrity due to decreased mobility and ADL (activities of daily living) self-care performance deficit. Interventions included that R32 requires extensive assistance by staff with personal hygiene and oral care and for R32 to avoid scratching and to keep fingernails short.

Based on observation, interview and record review, the facility failed to serve portion sizes for the mechanical soft diets as shown in the menu spread sheet for the lunch meal service. This applies to 4 of 5 residents (R10, R25, R39, R64) observed for dining in the sample of 22. The findings include: Facility daily menu spreadsheet (Week 1: Monday) showed that the main entree for the lunch meal was BBQ [Barbeque] meatloaf (2 oz/ounce protein=2-1/2 oz serving). The column for serving portion for mechanical soft diets included ground BBQ meat lf/sce (12 scoop + 1 oz sce). [lf/sce=loaf/sauce]. On 12/19/22 on 12:05 PM, V15 (Cook) was seen at the tray line platting the lunch meal which included meat loaf with gravy as the main entree. V15 used a #16 scoop to serve ground meat loaf to the residents on mechanical soft diet. R64's tray card showed mechanical soft, double portion protein and received two #16 scoops of ground meat loaf. R10's tray card included mechanical soft diet with double portions and received two #16 scoops of ground meat loaf. R25 and R39's tray cards showed mechanical soft, and each person received one #16 scoop of ground meat respectively. When V15 was asked why #16 scoop was used instead of the #12 scoop,V15 stated that they (facility) do not have a #12 scoop and therefore he is using a larger #16 scoop which is a 2 oz portion to serve the residents mechanical soft meat. V15 added that based on the spreadsheet the 12 scoop is only 1 oz. V15 was notified that the spreadsheet was showing to use #12 scoop for ground meat + 1 oz sauce. V15 stated that he was under the impression that the 1 oz that appeared near #12 scoop meant that #12 scoop = 1 oz. On 12/19/22 at 12:27 PM, V11 (Culinary Director) showed a scoop size chart posted on the wall and stated that according to this chart #16 scoop =2 oz, #12 scoop =2 and 2/3 oz. V11 stated that based on this chart, the #12 is a bigger portion. On 12/21/22 at 01:24 PM, V20 (Registered Dietitian) stated that the facility should follow the menu spreadsheets to serve portion sizes as indicated. Facility Diet Orders listed on Diet List Report printed on 12/19/22 included that R10, R25, R39, and R64's are on mechanical soft diets.

Based on observation, interview, and record review, the facility failed to follow standard infection control practices during provisions of care related to hand hygiene, gloving and proper use of mask. The facility also failed to ensure catheter tubing was not touching the floor. This applies to 4 of 5 residents (R19, R37, R44, R74) reviewed for infection control in the sample of 22. The findings include: 1. On 12/19/22 at 3:55 PM, V18 (Nurse) administered medication to R44 while her mask was covering only her mouth and her nose was totally exposed. V18 talked to R44 and was only an arm's length away from R44. 2. On 12/20/22 at 12:52 PM, V5 and V10 (Both Certified Nursing Assistants/CNAs) provided incontinence care to R74 who was wet with urine. V10 wiped R74's posterior perineum, applied clean incontinence brief, repositioned, and straightened R74's clothes and bedding while wearing same soiled gloves. 3. On 12/20/22 at 1:55 PM, V10 and V23 (Both CNAs) provided incontinence care to R37. V23 cleaned R37's peri-area from front to back, then she applied barrier cream and clean incontinence brief, and repositioned R37 while wearing same soiled gloves. On 12/21/22 02:11 PM, V19 (Clinical Nurse Manager) stated that the staff must wash hands before donning gloves, perform hand hygiene and change gloves between dirty to clean task, and perform hand hygiene after completing care to prevent spread of infection. 4. During this survey, the facility had residents with Covid-19. On 12/20/22 at 1:49 PM, V25 and V26 (Both Housekeepers) entered the facility without a mask. They walked through a unit corridor where resident bedrooms were, and they reached the nurses' station and asked a nurse for the mask. There were several residents sitting in wheelchairs parked around the nurses' station. These residents were not wearing mask. The nurse along with V25 and V26 went somewhere and came back to the nurses' station with a box of mask. V25 and V26 applied their mask at the nurses' station. The surveyor asked a staff the names of V25 and V26. A few minutes later V25 and V26 approached the surveyor. V26 was angry and in a loud (yelling) voice asked the surveyor why their name was asked. The surveyor informed them of the observation. V26 stated that it's not her fault that there was no mask available by the facility's door when they entered the facility. On 12/20/22 at 2:35 PM, V1 (Administrator) and V14 (Environmental Service Director) both stated that staff must put a mask on before they enter the facility and must always wear it inside the facility. They also added the staff must wear it appropriately as part of their infection prevention process. Facility's Policy and Procedure for Hand Hygiene shows: Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infection. Procedure: 7. Use alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap and water for the following situations: h. Before moving from a contaminated body site to a clean body site during resident care. j. After contact with blood and body fluids. 9. The use of gloves does not replace hand washing/hand hygiene. Integration of gloves use along with routine hand hygiene is recognized as the best practice for preventing healthcare associated infections. 36567 5. R19's diagnoses on EMR (electronic medical records) included unspecified intellectual disabilities, acute kidney failure, obstructive and reflux uropathy, kidney transplant status. R19's POS (Physician Order Sheet) included Suprapubic catheter #16FR [French] related to obstructive and reflux uropathy. On 12/19/22 at 11:36 AM, R19 was seen seated in a wheelchair in his room and noted to have catheter tubing on the floor under R19's wheelchair. One end of the tubing was tucked into the leg of R19's pants and the other end with the catheter bag in a privacy bag. R19 was not able to answer queries adequately and stated ya ya to all queries. R19 was seen wheeling himself back at forth in his room with the tubing dragging on the floor underneath the wheelchair. On 12/19/22 at 12:47 PM, V9 (Licensed Practical Nurse) was notified about R19's catheter tubing on the floor. V9 stated He [R19] has a suprapubic catheter. The catheter tubing should not be on the floor. On 12/21/22 at 03:30 PM, V3 (Assistant Director of Nursing) stated that the catheter tubing should not be on the floor because of cross contamination from things from the floor to patient. Facility policy and procedure titled Catheter Care, Urinary (revised September 2014) included as follows: Infection Control: b) Be sure the catheter tubing and drainage bag are kept off the floor.

Based on interview and record review, the facility failed to fasten a seat belt of a resident while providing transportation in facility's bus and failed to provide supervision resulting in the residents fall. This applies to 1 of 2 residents (R77) reviewed for fall incidents in the sample of 22. The findings include: R77's face sheet included diagnoses including acute respiratory failure with hypoxia, dependence on renal dialysis, chronic kidney disease, stage 4 (severe), unspecified abnormalities of gait and mobility, unsteadiness on feet, other lack of coordination, unspecified intellectual disabilities. Quarterly MDS (minimum data set) dated 9/23/22 included that R77 was moderately intact in cognition and required extensive one person assistance with transfers, and locomotion off unit. Fall incident report dated 12/01/22 included that R77 slid out of his wheelchair while he was taken to a doctor appointment in the facility's bus and slid unto his knees when the bus brakes were used. IDT (Interdisciplinary Team) note included that R77 did not hit his head and that no injuries were reported. Intervention include that the bus driver was educated on properly securing residents on the bus with seat belt with return demonstration. R77's Fall Risk Assessment post fall 12/01/22 included that R77 is High Risk with fall score of 75. (Morse Fall scoring: High risk if 45 or higher). This assessment also included that R77 has had previous falls and has impaired gait and inability to walk unassisted. On 12/20/22 at 11:07 AM, R77 stated The driver did not put the seat belt on me. I need help with putting it on. The driver slammed the brakes on, and I fell out of my wheelchair and fell forward on my knee. My knees hurt but did not break anything. The CNA (Certified Nursing Assistant) was sitting in front of me, and she helped me get up. On 12/20/22 at 10:56 AM, V7 (Bus Driver) stated I had strapped R77 in with 4 latches that holds the wheelchair in place and makes sure it doesn't move. I thought I had fastened the seat belt across R77. There was a section on the road where 3 cars ahead of me slammed on the brakes. So, I had to correct the bus to prevent it from moving forward and moved it over to the side (shoulder) of the road. I heard a sound and when I looked back, R77 was holding on to the top of the head rest in front of him. He did not have his seatbelt on. The other lady I was also transporting was strapped in. Usually, we have a CNA accompany us, unless I am dropping the resident off with a family member meeting us there (for the appointment). R77 had a CNA with him, and she was one seat ahead of him. On 12/20/22 at 11:26 AM, V8 (Certified Nursing Assistant) stated I was accompanying two residents for a doctor appointment. We had gotten on to the bus and I saw the driver hooking the safety belts and at that point I thought that all the safety belts were on. The driver came to an abrupt stop down the street, and I noticed R77 come forward and he landed on the floor because the bus driver [V7] had not put a strap across him. The bus driver is responsible for checking if all straps are on when the residents are on the bus. On 12/20/22 at 11:31 AM, V2 (Director of Nursing) stated that during R77's fall incident of 12/01/22, R77's seat belt was not on. V2 stated that it is the bus driver's responsibility for strapping residents on when in the bus and it's the CNA's role to accompany the resident to the appointment. V2 stated that CNAs are there to ensure that the residents are safe on route to the appointment. On 12/20/22 at 11:41 AM, V1 (Administrator) stated that the bus driver is employed by the facility. Facility policy titled Transportation Bus Procedure revised 12/1/22 included as follows: 1) Make sure all residents are secure in a seat or wheelchair. 3) Make sure all safety belts are applied and locked. 4) Make sure all safety belts are in proper working order. 5) Make sure all residents are secure and comfortable before the bus is moving. 6) Make sure to frequently look to assure all passengers are secure.

Based on observation, interview, and record review the facility failed to provide incontinence care and catheter care in a manner that would prevent infection and maintain hygiene. This applies to 3 of 3 residents (R37, R54 and R74) reviewed for incontinence care and urinary catheter care in the sample of 22. The findings include: 1. R54 diagnoses includes chronic diastolic (congestive) heart failure, generalized muscle weakness, presbyopia, and profound intellectual disabilities, based on the face sheet. R54's quarterly MDS (minimum data set) dated December 5, 2022 showed that the resident is severely impaired with cognitive skills for daily decision making. The MDS showed that R54 required extensive assistance from the staff with most of her ADLs (activities of daily living) including personal hygiene and toilet use. The same MDS showed that R54 is incontinent of both bowel and bladder functions. On December 20, 2022 at 1:20 PM, V5 (Certified Nursing Assistant/CNA) provided incontinence care to R54 with the assistance of V4 (Nurse). R54's disposable brief was wet with urine. V5 used three disposable cleansing wipes (at the same time) and wiped R54's right groin area, then from the pubic area down with one stroke and then the left groin area. V4 wiped R54 in this manner using the same cleansing wipes without changing side or folding the wipes. During the procedure, V5 did not separate the labial folds to clean the area. R54's active care plan last revised on November 6, 2022 showed that the resident has ADL self-care performance deficit related to intellectual disabilities. The same care plan showed that R54 requires extensive assistance from the staff for toileting. On December 21, 2022 at 9:28 AM, V3 (Assistant Director of Nursing) stated that when providing incontinence care, staff should use one disposable cleansing wipe every time they clean the different part of the perineum. The used cleansing wipe or part of the used cleansing wipe should not be re-used to clean the resident to prevent cross contamination and potential infection, as well as to maintain hygiene. The facility's policy and procedure regarding perineal care dated February 2018 showed, The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. The same policy and procedure showed in-part that for female resident, b. Wash perineal are, wiping from front to back. (1) Separate labia and wash area downward from front to back. (2) Continue to wash the perineum moving from inside outward to the thighs, Rinse perineum thoroughly in same direction, using fresh water and a clean washcloth. 29562 2. R74's medical diagnoses include muscle wasting and atrophy, weakness, and malaise. R74's minimum data set (MDS) dated [DATE] shows that she requires assistance with toileting. On 12/20/22 at 12:52 PM, R74 was resting in bed. R74 was observed with indwelling urinary catheter. V5 and V10 (Both CNA) rendered incontinence care to R74 who was wet with urine (urinary catheter leaked). V5 and V10 assisted R74 into a side-lying position, then V10 proceeded to clean R74's posterior perineum, applied clean incontinence brief and assisted R74 back on supine position. V10 did not clean the anterior portion of R74's peri-area (which is the vulva) and the urinary catheter. 3. R37's medical diagnoses include generalized muscle weakness and lack of coordination. R37's minimum data set (MDS) dated [DATE] shows that she requires extensive assistance for toileting. On 12/20/22 at 1:55 PM, V10 and V23 (Both CNA) provided incontinence care to R37. V23 cleaned R37's peri-area from front to back. However, during the process V23 did not separate the inner labia to clean the folds. On 12/21/22 at 2:08 PM, V19 (Clinical Nurse Manager) stated that when staff is providing incontinence care for a female resident the expectation is that they must follow the proper steps of cleaning the peri-area, such as cleaning from front to back, separate the labial folds and clean side to side. If the resident has a catheter treat it as part of the resident's body, which means include the catheter tube with the cleaning procedure. This is to prevent infection. Facility Policy and Procedure for Urinary Catheter Care shows: Purpose: The purpose of this procedure is to prevent catheter-associated urinary tract infections. Infection Control: 2. Maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag. a. Do not clean the peri-urethral area with antiseptics to prevent catheter-associated urinary tract infections (UTI) while the catheter is in place. Routine hygiene (e.g., cleansing of the meatal surface during daily bathing or showering) is appropriate. Steps in the Procedure: 15. For female: Use a washcloth with warm water and soap to cleanse around the labia. Use one area of the washcloth for each downward cleansing stroke. 17. Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site to approximately four inches outward.

Based on observation, interview, and record review, the facility failed to ensure a resident's Activities of Daily Living (ADL) cares were provided in a timely manner. This failure resulted in R5 reporting anxiety, humiliation, experiencing foot and leg swelling, and pain. This applies to 1 out of 4 residents (R5) reviewed for ADLs in a sample of 4. The findings include: R5's Face Sheet showed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R5's 4/25/22 MDS (Minimum Data Set) showed her cognition is intact. The same MDS showed R5 requires extensive assistance for transfers and toileting. On 5/5/22 at 11:15 AM, R5 was sitting on the side of her bed. Dark purple bruising measuring approximately two inches long was present on R5's right arm. R5 said that on 4/26/22, she was left on the commode for an hour and 15 minutes. R5 stated the mechanical lift was left in place while she was on the commode and she blew the vein from holding on to the equipment while waiting for help. R5 stated V7 (Certified Nursing Assistant/CNA) assisted her to the commode with the mechanical lift at 6:35 PM, and then she turned on her call light at 6:45 PM for assistance off the commode. R5 stated her call light was not answered until 7:50 PM (over an hour later) by V9 (CNA in Training). R5 stated she was scared and felt like her butt had melted to the seat and started to cry. On 5/6/22 at 9:51 AM, V7 said she had assisted R5 onto the commode at 5:55 PM on 4/26/22. On 5/6/22 at 11:16AM, V9 said she went back to R5's room with V8 (Registered Nurse/RN) to get R5 off the commode around 6:50PM (meaning R5 sat on the commode for 55 minutes). V9 verified that when R5 finally was helped off the commode, R5's feet were swollen, her buttocks were reddened, and R5 said she had pain in her legs. On 5/6/22 at 10:40 AM, V8 RN (Registered Nurse) stated that after R5 was assisted to bed, R5's feet and legs were swollen, and they placed a pillow under them for her in the bed. V8 stated a resident's needs would not be met if it takes 40 minutes to answer a call light. On 5/5/22 at 11:15 AM, R5 said she had to stay in bed three days after the incident because of her swollen legs, and she felt despair from her panic, anxiety, and humiliation. R5 said the commode incident held me back three days . it hindered therapy and my discharge back home. On 5/5/22 at 4:22 PM, V3 (Therapy Director) verified that from 4/27-4/29, R5 had pain in both legs that she rated as 10 out of 10, and that R5's therapy was done in her bed. R5's physical therapy notes from 4/27-4/29 also showed that she had pain before therapy ranging from 9/10 to 10/10. On 5/5/22 at 1:50 PM, V4 (Nurse Practitioner), said R5 told her that the bruise to her right arm developed after holding on to the commode. V4 said R5 told her that she used her call light for help, and nobody was around. V4 said it should not take longer than 5-10 minutes for staff to answer a call light and 45 minutes to an hour is not an acceptable time frame for a call light to be answered. V4 stated that sitting on a commode for 40 minutes can lead to leg swelling. On 5/5/22 at 11:15 AM, R5 also said that on 5/4/22, she told V5 (Physical Therapist) that her incontinence brief was soiled when she came to get her for physical therapy. R5 said that V5 replied, we can waste time and change you, or you can come down to Physical Therapy and we can do work. R5 stated she just went to therapy and could feel pee running down my leg and felt humiliated . there were other people in the room, and she wanted me to walk with a walker and I did 11 steps, and I didn't want to do more because I was still peeing . On 5/5/22 at 2:09 PM, V5 (Physical Therapist) said she took R5 to physical therapy on 5/4/22. V5 said she asked R5 if she was ready for therapy and R5 said she was wet and needed to be changed. V5 said she told R5 that she would call the CNA so she could change R5. V5 said she did not call the CNA because R5 said just take me. V5 said she took R5 to therapy without being changed. On 5/5/22 at 4:22 PM, V3 (Therapy Director), said all Physical Therapists can change a resident's incontinence brief, and residents should always be changed before coming to therapy. R5's 4/20/22 care plan showed she has an ADL self-care deficit related to weakness with an intervention for two staff person assistance with transfers. R5's plan of care also showed a need for the prompt response to calls for assistance secondary to R5's history of falls. The facility's March 2018 Activities of Daily Living (ADLs) Policy showed .Residents who are unable to carry out ADLs independently will receive services necessary to maintain . personal .hygiene Under Policy Interpretation and Implementation, it showed 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently .In accordance with the plan of care, including appropriate support and assistance with: a. hygiene, b. mobility, c. elimination (toileting) The facility's undated Call Light Policy showed In order to ensure resident's needs are promptly identified and met . Procedure: 1. Answer light promptly

Based on interview and record review the facility failed to safely transport resident in wheelchair causing resident to fall forward to floor. This applies to 1 of 3 residents (R1) reviewed for falls in a sample of 3. This failure resulted in R1 incurring a laceration to the left eyebrow requiring four stitches. Findings include: R1's Resident Face Sheet dated 11/07/2019 documents [DIAGNOSES REDACTED]. R1's Minimal Data Set, dated 10/15/2019 documents moderately cognitively impaired and requiring staff assistance of one for locomotion from distant areas with a wheel chair. R1's Care Plan for Falls dated 05/26/2016 documents a fall risk related to confusion with [DIAGNOSES REDACTED]. R1's 10/22/2019 Post Fall Investigation Tool documents under 1.) What was the resident attempting to do at time of the fall? Answer-R1 attempt to help reposition self. 9.) What do you feel could prevent this resident from falling again. Answer- Watch resident more closely. The local hospital notes dated 10/22/2019 at 06:00 PM Facial status [REDACTED]. On 11/07/2019 at 09:28 AM, V2 Director of Nursing stated I read the fall investigation and it just didn't make sense. I watched the video recording of the incident. I saw careless, sudden movement by the CNA (Certified Nursing Assistant) moving the wheel chair which caused the resident to jar forward and fall out of the wheel chair. This situation could have been prevented. On 11/08/2019 at 10:24 AM V4 (Medical Doctor for R1) confirmed R1's dementia makes her more vulnerable for falling from the wheel chair and that R1 incurred the laceration and stitches as a result of this fall. V4 confirmed that R1's fall may have been prevented if staff had been more careful during the transport. V4, Medical Doctor expects staff to implement care planned interventions. The facility policy Falls dated (MONTH) (YEAR) documents direct care associates shall evaluate the area where the fall occurred for possible contributors.

Based on observation, interview and record review the facility failed to identify and implement measures timely to prevent falls. This applies to 1 of 3 residents (R1) in a sample of 4. This failure resulted in R1 incurring a laceration to the forehead which required closure with 4 staples. Findings include: R1's Face Sheet dated (MONTH) 6, (YEAR) documents R1 with Dementia. R1's Minimum Data Set, dated dated dated (MONTH) 26, (YEAR) documents R1 with moderately impaired abilities to make daily decision and requiring cues and supervision. R1's Hospice Meeting Note dated (MONTH) 14, (YEAR) documents R1 with poor trunkal support. On (MONTH) 19, (YEAR) at 8:25am, R1 sat in a high backed reclining adaptive wheelchair being fed breakfast by V14 (R1's Family). R1 had a bandage to the left side of the forehead with yellow discoloration to the mid forehead extending into the left side into R1's hairline. V14 stated R1 has fallen twice in the past 3 week time period and the facility reported they think R1 was leaning forward in wheelchair trying to adjust socks during the last fall. The facility Resident Incident Report dated (MONTH) 22, (YEAR) at 5:45am documents R1 was found on the floor next to the wheelchair with a laceration and swelling to the forehead area. This report documents R1 was sent to the emergency room for evaluation and returned with steri-strips to the forehead as well as bruising to the forehead, eyes and face. The intervention initiated after this fall was to change the time R1 gets up in the morning. The CNA (Certified Nursing Assistant) Post Fall Tool dated (MONTH) 22, (YEAR), completed by V9 (Nursing Assistant), documents R1 as sleeping in her wheelchair. On (MONTH) 19, (YEAR) at 7:29pm, V9 stated V9 did not witness R1 fall on (MONTH) 22, (YEAR). V9 stated 20 minutes earlier R1 had been up in wheelchair and awake when V9 had last seen R1 and V9 further stated, I didn't realize I wrote that (R1) sleeping. V9 stated R1 leans forward in the wheelchair a lot messing with shoes and socks. V9 stated R1 is not always steady when R1 leans forward. On (MONTH) 19, (YEAR) at 1:23pm, V7 (Nursing Assistant) stated R1 fell on (MONTH) 22, (YEAR) around 5:30am and V7 found R1 on the floor by the nurses station. V7 stated R1 had just been placed there by V9 shortly before R1 was found on the floor. V7 stated, I am guessing R1 was leaned over messing with shoes and socks. R1 had shoes off . The facility Resident Incident Report dated (MONTH) 13, (YEAR) at 9:00am documents R1 was found lying on the floor with a gaping laceration above the left eyebrow and a small skin tear to the left knee. R1 was sent to the emergency room for treatment and returned with four staples to the laceration. On (MONTH) 19, (YEAR) at 12:57pm, V5 (Nurse) stated on (MONTH) 13, (YEAR) R1 was observed on the floor with one sock on and one sock off. V5 further stated, R1 messes with R1's socks a lot. I suspect (R1) fell forward messing with socks (because) R1's wheelchair was locked. The Post Fall Investigation Tool dated (MONTH) 13, (YEAR) documents R4 as a witness and R1 sitting in a wheelchair immediately prior to the fall. This form documents an answer to the question, Why do you think you fell ? as poor abdominal strength and end state dementia. R4's Brief Interview of Mental Status dated (MONTH) 17, (YEAR) documents R4 as cognitively intact. On (MONTH) 19, (YEAR) R4 stated when R1 fell the prior week R4 was sitting next to R1 in a wheelchair. R4 stated R1 suddenly leaned forward and to the left in the wheelchair and fell out. The facilities Final Report of Incident dated (MONTH) 16, (YEAR) documents on (MONTH) 13, (YEAR) R1 leaned forward in R1's chair and fell to the floor. The investigation revealed R1 has a history of reaching down to touch R1's feet at times and has poor abdominal strength. The CNA (Certified Nursing Assistant) Post Fall Tool dated (MONTH) 13, (YEAR), completed by V15 (Nursing Assistant), documents R1 needs to be assessed for a new chair as a potential intervention which could prevent R1 from falling again. On (MONTH) 20, (YEAR) at 11:51am, V15 stated he was caring for R1 on (MONTH) 13, (YEAR) but did not witness R1 fall. V15 stated in the last 30-60 days R1 has been leaning forward in the wheelchair and V15 could not indicate if this information had been reported. V15 stated R1 has a history of leaning forward, is fidgety and has weak abdominal muscles which causes a problem when R1 tries to sit up. V15 stated R1 is a priority high risk resident due to a previous fall and exhibits high risk behaviors of leaning forward in the wheelchair, reaching for things on the floor and falling asleep in the wheelchair. V15 stated since R1 was provided the new high backed reclining adaptive wheelchair R1 is a lot safer, not leaning forward and can lift R1's foot up onto R1's lap to reach shoes and socks. On (MONTH) 19, (YEAR) at 11:20am V7 (Nursing Assistant) stated R1 is constantly reaching down to mess with socks and shoes. V7 stated R1 shakes sometimes when leaning forward and isn't always steady. V7 stated R1's new high backed reclining adaptive wheelchair reclines back enough to position R1 better. V7 stated if R1 falls asleep she is placed in bed for safety. On (MONTH) 20, (YEAR) at 9:30am, V11 (Nursing Assistant) stated R1 would lean forward and remove socks. V11 stated some days R1 was steady when leaning forward in the wheelchair and other times R1 was not. V11 stated R1 was frequently placed by the nurses station for increased supervision so R1 didn't fall. V11 stated R1 was at risk for falls due to being unsteady and leaning forward in the wheelchair. On (MONTH) 20, (YEAR) at 11:06am, V17 confirmed V17 was functioning as the Fall Coordinator at the time of R1's recent falls. V17 stated the facility assesses all residents for fall risk, implementing individualized interventions as appropriate to address residents risks. V15 stated R1 has had a small steady decline due to dementia. V15 stated due to dementia when R1 loses R1's balance R1 lacks the cognition to correct her posture. On (MONTH) 20, (YEAR) at 1:12pm, V17 stated R1's get up time was changed after the information gathered after the fall on (MONTH) 22, (YEAR) indicated R1 was sleeping in the wheelchair at the time of the fall. V15 stated she was not aware of R1's leaning forward in the wheelchair removing socks/shoes as a problem. On (MONTH) 20, (YEAR) at 12:19pm, V13 (Nurse Practitioner) confirmed the facility should have addressed R1 leaning forward in the wheelchair sooner to keep R1 safe from further falls due to leaning forward in the wheelchair. The facility policy Falls Prevention Program dated (MONTH) 22, (YEAR) documents it is the policy of the facility residents will be assessed for Fall Risk and that appropriate interventions will be put into place to prevent the risk of fall.

1) Based on record review and interview the facility failed to ensure timely physician notification and follow up to abnormal X-ray result which resulted in a delay in further diagnostic testing and medical treatment for [REDACTED]. This failure resulted in an 11 day delay in medical evaluation and treatment of [REDACTED]. The findings include: R1 has a history of recurrent falls. R1 has had 8 falls in the last nine months, including a 6/30/13 fall resulting in an acute [MEDICAL CONDITION] distal radius. Facilities 6/30/13 incident report includes: R1 fell at 10:15 PM. R1 was observed on the floor between the bathroom and the bedroom doorway with no complaint of pain. R1's call light was sounding. R1's progress notes include: - 7/1/2013 at 7:00 AM stated: R1 complained of pain with swelling to her left wrist at 2:00 AM. R1 stated at that time she thought she had caught herself with that hand when she fell earlier. R1 had ice applied to the wrist for the swelling. R1 also received tylenol for the pain. R1 then went back to bed, sleeping the rest of the night. R1 did complain of pain again upon arising. - 7/1/2013 at 9:15 AM stated: R1 s physician was notified of the fall. The physician ordered an X-ray of R1's left wrist. - 7/1/2013 at 1:09 PM includes: a portable X-ray was completed. R1 received tylenol at that time for further complaints of pain. R1 ' s left wrist remained swollen and R1 was guarding the wrist for protection. The progress note dated 7/1/2013 at 1:57 PM indicates the X-ray results were received and faxed to R1 ' s physician. The X-ray report dated 7/1/2013 shows R1 has moderate to diffuse osteopenia. The impression is as follows: diffuse wrist soft tissue swelling, suspicion for old fracture deformities of the base of the ulnar styloid and distal radial metaphysis, concern now for acute nondisplaced oblique [MEDICAL CONDITION] of the radial styloid. The radiologist suggests a CT-scan to confirm the fracture. The progress notes of 7/1/2013 at 8:58 AM and 7/2/2013 at 4:11 AM state R1 ' s left wrist remains swollen, discolored and causes pain if moved. The progress note dated 7/2/2013 at 8:59 AM states that the physician has not called regarding the left wrist X-ray results. There was no indication the facility reattempted to notify the doctor for orders. The physician did not call the facility about the X-ray until 7/11/2013. At that time a CT- scan was ordered as well as an orthopedic appointment. R1 continued to complain of left wrist pain during the 11 days (6/30/2013-7/11/2013) after the fall, but the facility did not follow up with the physician for any new orders. R1 was only receiving tylenol for pain. The progress note dated 7/15/2013 shows R1 returned from an orthopedic appointment with a short arm cast due to a [MEDICAL CONDITION]/ulnar bone of the left wrist. On 8/16/2013 at 10:50 AM, Z1 (physician for R1) said he did not see R1's X-ray report until he found it on his desk on 7/10/2013. He called and ordered a CT-scan of the left wrist for the next morning. He didn't recall the facility calling to check if he received these X-ray results. He would have ordered the CT-scan of the left wrist for R1 as soon as he saw the report to confirm the fracture. R1 has poor healing ability due to [DIAGNOSES REDACTED]. There would be negative outcome in the delay in treatment since R1 was having pain. " On 8/16/2013 at 8:40 AM, E1 administrator said she thought R1 had an old fracture identified on the X-ray not a new one. " E1 also stated if the physician is notified the nurses document this in the progress notes. 2) Based on interview and record review the facility failed to effectively communicate a shift to shift report with the [MEDICAL TREATMENT] center, failed to implement an individualized care plan for [MEDICAL TREATMENT] residents and failed to have a policy and procedure for the care of [MEDICAL TREATMENT] patients. This applies to 1 of 1 residents (R1) reviewed for [MEDICAL TREATMENT] in a sample of 18 and 4 residents ( R20 - R23) in the supplemental sample. The findings include: On 8/15/2013 at 1:25 PM, E7 (AM shift nurse) stated they send a [MEDICAL TREATMENT] communication sheet with the resident when they go to the offsite [MEDICAL TREATMENT] center. E7 stated this form is then returned with the patient upon return to the facility. The form has information regarding pre and post weights completed at the [MEDICAL TREATMENT] center, patients condition, if patient was seen by the physician, had new physicians orders, oxygen given, medications given, laboratory draws completed and any additional information. E7 also stated these forms should be filed in the resident record. E7 then went to the record of R1 and R23 to locate the [MEDICAL TREATMENT] form. R1 had none filed in the record and R23 had one file in the record. On 8/15/2013 at 1:29 PM E8 (registered nurse) stated the [MEDICAL TREATMENT] form should be located on the individual resident records. E8 reviewed R1's chart and found no [MEDICAL TREATMENT] communication forms. E8 stated the ambulance staff hand the form to the PM nurse. E8 also stated sometimes the communication form is not returned from the [MEDICAL TREATMENT] center. The nurse on duty should call and have the communication form faxed back to the facility if it is forgotten. E8 then began shuffling through a stack of papers on the nurses desk and found one [MEDICAL TREATMENT] communication form mixed in with other papers. On 8/15/2013 at 2:35 PM E9 (PM nurse) stated when the [MEDICAL TREATMENT] communication form is returned to the facility it is placed on the nurses clip board then filed in the resident record. All care plans for [MEDICAL TREATMENT] patients (R1, R20 -R23) have identical problems, goals and approaches. The care plans are very generalized. On multiple occasions through-out survey process the facility administrator was asked for a [MEDICAL TREATMENT] policy. On 8/16/2013 at 10:00 AM E1 (administrator ) stated the only policy the facility has regarding [MEDICAL TREATMENT] communication process written on 8/15/2013. There is no policy with emergency bleeding procedures, fistula site checks, or any [MEDICAL TREATMENT] process.

Based on observation, interview and record review the facility failed to provide adequate supervision, monitor and analyze the effectiveness of fall interventions, communicate and train staff regarding fall interventions and failed to ensure safety alarms were maintained in working order to preventing recurrent falls. This applies to 1 of 6 residents (R1) reviewed for falls in the sample of 18. This failure resulted in R1 sustaining a fracture of the distal radius of the left wrist. The findings include: R1 has a [DIAGNOSES REDACTED]. R1's Minimum Data Sets ((MDS) dated [DATE] and 5/2/2013 include: requires limited assistance of one staff for all transfers, ambulation and toileting and has frequent incontinence episodes. R1 is on a prompted toileting program (taken to the toilet every 2 hours while awake), per facility tolieting program list. R1 knows when she needs to urinate and will self- initiate toileting by trying to get up out of bed or self transfer from the wheelchair. R1 had two falls related to toileting issues (6/30/2013 and 2/6/2013). R1's 6/30/13 fall incident report includes: at 10:15 PM, R1 told staff she was trying to get off the toilet unassisted when her wheelchair moved because one brake was not locked. R1 complained of pain in her left wrist at 2:00 AM 7/1/2013. R1 sustained a fracture of the distal radius of the left wrist. During 8/13/2013, 10:00 AM and 8/14/2013, 10:00AM interviews, R1 stated "I fell here and broke my wrist." R1 also indicated she took herself to the toilet because it took staff 45 minutes to come back and take her to the bathroom. R1 also said "my wheelchair rolled back because the brake didn't work, so I fell ." Facility incident reports document R1 has had 8 falls in the last 9 months (12/30/12 though 7/18/2013). R1 fell from the bed on 5 occasions , fell from her wheelchair on 2 occasions and off the toilet on one occasion. The 8 fall incidents all occurred between the hours of 10:00 PM- 1:45 AM. The PM shift ends at 10:30 PM and night shift starts at 10:00 PM per E1 (administrator). 6 of R1's 8 fall incidents occurred during the night shift. R1's 7/01 and 7/10/13 incident reports state; R1 is confused and impulsive with poor safety awareness, yet the fall follow-up interventions, after sustaining fractured wrist, include to educate R1 on safety . On 8/14/2013 at 1:10PM, R1 had two types of floor mats noted beside her bed. There was a maroon soft mat on the door side of the floor (open space in room). There was a black floor mat with an alarm mechanism attached on the window side of the bed. The alarmed mat is to sound when pressure is applied to the mat. On 8/14/13 at 1:10PM, when tested , the mat was stepped on and the alarm did not sound. On 8/14/2013 at 1:30 PM, E6 (restorative nurse), stated the alarm mat should be on the open side of the room ( door side) and the maroon mat should be on the window side of the room. E6 then stepped on the mat with no alarm going off. E6 then opened the battery pack attached to the alarming mat and stated there is a battery missing. E6 indicated the mat was not functional at that time. E6 also indicated the mat placement was not documented anywhere for direct care staff to know correct mat placement. R1 was observed on multiple occasions (8/14/2013 at 1:10 PM, 1:30 PM and 3:30 PM), sitting on the side of her bed ( in the low position) with her feet on the soft maroon floor mat, on the door side of the room. On 8/14/2013 at 2:00 PM, E14 certified nurse aide (CNA) stated "I am R1's CNA today. E14 stated "I placed the maroon mat towards the door. I'm not sure if there is a special way the maroon and alarm mats are to be placed. " Review of the facility "Fall Prevention Program" shows in section G: The facility determined identifier (un-described indicator), is directly outside of the residents rooms. Other means of communicating the fall risk may additionally include placement on the card index, medical record, care plan, physicians order sheet (POS) and medication administration record (MAR). Section III of the Fall Policy and Procedure: states staff are to be trained on the fall prevention program and is incorporated into the new employee orientation for all staff as well as annual competency regarding resident safety. On 8/16/2013 at 8:40 AM E1 (administrator) stated that the staff were instructed to check the alarms on seat cushions, bed and floor mats were functional before utilizing the equipment. E1 stated this was just initiated . E1 also indicated extra batteries are now available to staff at the nurses station. E1 also indicated the batteries were all stored in E6(restorative nurses) office prior to this. On 8/15/2013 at 2:17 PM E11 (CNA) stated to know if a resident is a fall risk, look in the restorative book for residents who have sensors on their wheelchairs or beds. E11 stated these are residents who are high risk for falls. E11 showed the restorative book, that R1 should have been in, with no alarm sensors listed for R1's use. On 8/15/2013 at 2:15 PM, E10 (CNA) stated if a resident has a red name tag they are a fall risk all other residents have a white name tag outside their bedroom door. On 8/15/2013 at 2:22 PM, E8 (RN) stated there is no indicator outside a residents door if they are a fall risk. E8 stated all the residents have red name tags outside the door. On 8/15/2013 at 2:30 PM, E9 (LPN) stated no the fall risk is not indicated anywhere on the MAR or the POS.

Based on record review, interview and observations facility failed to develop and implement individualized interventions to prevent recurrent falls for three of nine sampled residents for falls (R1, R13 and R17) in the total sample of 19. This failure resulted in: -R1 sustaining multiple falls and emergency room visits, a Lumbar Sacral Sprain with back pain, two separate head contusions and a hip fracture. -R13 sustaining head lacerations, skin tears, and abrasions. -R17 sustaining head lacerations. The findings include; 1. R1 has a [DIAGNOSES REDACTED]. R1's 01/26/12 through 9/20/12 Minimum Data Set Assessments (MDS), document moderate cognitive impairment and decreased memory. R1's 3/15, 4/3, 7/01 and 9/20/12 MDS document R1's assistance need from supervised up to total assistance with transfers and toileting activities. R1's MDS's 01/26, 4/03, 7/01 and 9/20/12 document occasional to frequent urinary incontinence but no toileting programs. R1's urinary incontinence assessments 01/24/12, 7/01/12 and 9/10/12 include R1 knows when she needs to urinate and will self initiate toileting by going into the bathroom. R1's Urinary Incontinence assessments and care plans 01/24 through 9/10/12 do not include development or initiating a toileting plan. R1's 8/2012 and 9/2012 physician orders, medication administration records (MAR) and nurses notes include use of antibiotics for urinary tract infections (UTI), 8/08 - 8/18/12 and 9/04 - 9/10/12. These UTI's were not included in R1's 9/10/12 urinary incontinence assessment or in the fall incident investigation reports. Facility Incident Investigation reports document R1 had five fall incidents between 01/31/12 and 8/05/12 while attempting self transfers. Three occurred attempting to self toilet. - 01/31/12 at 8:00 AM , R1 was found in her room lying on her back on the floor in front of her un-locked wheel chair. R1 complained of stomach pain and vomited twice. R1 was sent to the emergency room and was diagnosed with [REDACTED]. This incident report documents that R1 has a fall history and is confused / disoriented. Post fall interventions were to complete an observation log and alarm on wheel chair. - 3/04/12 at 7:20 AM, R1 found lying on the floor on her right side in front of her locked wheelchair. R1 sustained a contusion with swelling to the right side forehead. R1's initial temperature was recorded as 100.3 degrees Fahrenheit. This Incident report includes R1 said she slid off the gel cushion on her wheel chair seat and hit her head. R1 was sent to the ER and returned to the facility at 11:10 AM. No changes to care implemented. - 3/04/12 11:35 AM R1 was found lying on her left side on the floor, yelling for help in the A-wing common bathroom. R1 was complaining of left hip pain, was sent to the ER and diagnosed with [REDACTED]. R1 was hospitalized and required surgical interventions to repair the fracture. R1 required a Indwelling Urinary Catheter from 3/05 through 3/23/12 as a result of this fracture. - 6/02/12 12:40 AM R1 found lying on the floor next to her bed with urine on clothing and the floor. R1's body alarm was attached and sounding. No changes implemented to prevent further falls documented. Incident report states Resident will be assessed for incontinence with appropriate toileting plan implemented to assist resident with toileting to prevent incontinence episodes at night. R1's 6/07/12 nurses note by E4 (restorative nurse), includes R1 has no incontinence episodes at night, sensor alarm is used to alert staff at which times she needs to toilet. No toileting plan is needed, resident is aware of her toileting needs. - 8/05/12 10:35 AM R1 found in a fetal position on the floor in the A-wing common bathroom. R1 had loose bowel movement on herself and the toilet. R1 sustained a bruise to the side of her head. R1 started exhibiting "episodes of altered mental status, tilting her head to the right side with slight tremors. R1 did not respond to her name being called for approximately 45 seconds, then became some what alert with confusion, not remembering her falling episode." R1 was sent to the ER and admitted with [DIAGNOSES REDACTED]. No changes to care initiated as a result of this fall. R1's 9/04/12 falls care plan includes history of dementia with confusion, experiencing increased confusion with onset of UTI, making comments of leaving, and making attempt to get out of wheel chair. The plan also includes potential for elopement. There was no specific individualized approaches/interventions developed to prevent other potential falls/injuries. On 9/26/12 during interview, E4 said that as of 9/27/12 R1 was not on any type of toileting plan. On 9/25/12 during initial tour, R1 was observed alone in wheelchair sitting in the doorway of the A-wing woman's common bathroom. On 9/26, 9/27 and 9/28/12 R1 was observed up in wheel chair and alone in her room. On 9/27/12 at 2:00 PM, R1 observed alert and independently ambulating in wheel chair. R1 said that she independently transfers, dresses and toilets daily. On 9/28/12 at 11:00 AM E3 (Assistant Director of nurses), provided four fall risk assessments for R1. E4 said theses are the only fall assessments completed on R1 between 01/01/12 and 9/28/12. The fall assessments are dated 3/09/12, 7/02/12, 9/04/12 and 9/28/12. All of these fall assessments scored R1 at risk for falls. No fall re-assessment or care plan revision was completed after the 01/31/12, 6/02/12 and 8/05/12 falls. The facility's fall prevention program policy, Section "V", A. notes "Fall risk assessment to be completed quarterly and with changes to patients / residents condition. Reassessment and documentation of risk to fall status will be as warranted by patient / resident's condition and with any fall occurrence." On 9/28/12 at 11 AM, E3 provided a Urinary Incontinence Assessment, up-dated care plan and nursing note for R1 dated 9/28/12. These documents include initiating a prompted toileting plan. The 9/28/12 nurses note includes "per interviews with staff, she is aware of need to void but does not ask staff for assistance with toileting but will accept assistance when staff asks or approaches her." "R1's assessment reveals stress and urge incontinence. Due to impaired cognition and need for assistance with transfers and toileting, a prompted voiding plan will be implemented. " R1's 9/28/12 urinary incontinence assessment includes history of UTI's in August and September 2012. As noted above, many of R1's falls were due to R1 attempting to self transfer to the toilet. R1 was not placed on any type of toileting/monitoring program until 9/28/12. 2. Review of physician progress notes [REDACTED]. It also states R13 "has fallen a couple times at the nursing home in her room as she has tried to get up, states she is a little more confused the last few weeks." E4 (restorative nurse) stated on 9/27/12 at 3:10pm that R13 has been very confused since she was admitted to the facility (10/13/10, per record review) and has been incontinent of urine with recurrent UTIs since then. Per E4 , R13 has been incontinent of urine since admission but would attempt to take self to the bathroom even though she required assistance due to frequent falls. Review of fall log and incident reports details R13's multiple falls and incidents The fall log and incident report showed the following: 10/29/11- resident room - found R13 on floor after losing balance in attempt to self transfer. "prefers to keep door to room closed which impairs staff observations" 11/1/11 - on floor next to wheelchair. Small raised area present to same location where resident previously had sutures from fall. 11/5/11 - Found with skin tear to right shin. Sent to ER. 12/10/11 - Nurse's aide opened door and found R13 on floor in bathroom doorway. Wheel chair unlocked. R13 initiates toileting as necessary. Staff attempts to keep resident's door open but she will close it. 12/11/11 - Door to room closed. Upon entering found R13 on floor. 12/15/11 - Skin tear to left lower leg with bleeding. 12/17/11 - 8:40 am - Staff observed resident sitting on floor across from nurses station. Hematoma to right occipital area of head. "Staff members were in the dining room at the time of this occurrence. This resident receives meals in her room per her preference and had already finished eating when she propelled her wheelchair to the nurses station. She exhibits confusion and could not answer what she was attempting to do when she fell ." 12/17/11 - 10:20 pm -Found on floor next to nightstand. R13 unable to tell staff what happened due to confusion. Assisted to toilet. Slams door shut. 12/18/11 -3:10 pm Observed on floor in room. Skin tear to left shin. Staff tries to continue to observe R13 frequently but she does become upset and tells staff to leave and slams door shut. 12/28/11 - 10:50 pm Observed lying on floor by her door. Abrasion to lower back and red area to left scapula. Staff attempted to replace the sensor alarm on wheelchair but resident became upset and told everyone to get out of the room and slammed the door shut. It was a brief period after this that staff opened the door to find R13 on the floor. 12/30/011 - 9:15 pm -CNA (nurse's aide) observed R13 walking out of the bathroom when she fell hitting her head on the floor. (R13) had removed sensor alarm from wheelchair again. Staff has found alarms in closet, under bed and in both garbage cans. Unable to retain safety information due to dementia. Small laceration to back of head, complained of pain to left hip and shoulder. Sent to ER for eval. 1/9/12 - 9:50 am - Found on floor near bed with wheelchair tipped sideways. Bleeding noted to right occipital area of head. Sent to ER for eval. 2/25/12 - Found on floor in room. R13 had pulled the cord apart for the sensor pad causing it to no longer to work properly. Unable to retain safety education. The above documentation indicates R13 was not being supervised as stated on her fall care plan: "high traffic areas while in wheelchair." E2 (director of nursing) and E4 were asked on 9/27/12 and 9/28/12 during the morning meeting if there had been any assessments or behavior interventions regarding R13's refusals to keep the door to her room open. In addition, E4 stated that R13 was not on a toileting program other than prompted even though the facility was aware that R13 was often found after a fall, attempting to take herself to the bathroom. Other examples of falls and skin tears occurred on 4/25/12, 5/512, 5/19/12, 5/21/12, 5/26/12, 6/28/12, 7/30/12, 8/9/12, 8/11/12, 9/11/12. 3. Closed record review of R17's admission face sheet showed R17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R17 was also admitted to the facility for rehabilitation. Review of the facility's incident log showed R17 had 6 falls from 3/6/12 to 4/26/12. With 2 of the falls R17 sustained lacerations. Review of the incident dated 4/25/12 at 9:15 a.m. showed R17 was in the physical therapy room and not under direct observation of therapy staff. The incident showed two other residents observed R17 riding a therapy bike, leaning sideways and fell ing to the floor striking his head. During this time an occupational therapist was in the room but had his back turned sitting at a desk doing paperwork. R17 was noted with bleeding to his forehead with a 1 cm. irregular laceration to the center of his forehead. R17 was sent to the emergency room for evaluation and treatment. Hospital paper work dated 4/25/12 showed R17's forehead laceration had to be "glued" shut. Review of an incident report dated 4/26/12 for 5:00 a.m. showed R17 was observed on the floor in front of his wheel chair. A small amount of blood was noted to the previous laceration. There was no description of the laceration size, depth, surrounding redness, bruising etc.. Review of the interventions addressed after each fall showed 4 of the 6 interventions were the same (sensor alarm, observation log, skilled therapy). Interview with E4 (LPN - Restorative Nurse) on 9/27/12 at 4:30 p.m. noted E4 to say, "All of the interventions are the same. Maybe we should have looked at some other interventions for R17 to try and prevent him from having additional falls." Nursing note documentation showed R17 also sustained abrasions to the right elbow, right knee, and left lateral ankle with this fall.

Based on observation, interview and record review the facility failed to assess, plan and implement care/services for three residents to prevent significant weight loss. This is for three of six residents (R6, R15, and R16) sampled for weight loss in a total sample of 19. This failure resulted in a significant unplanned weight losses for all 3 residents. Findings include: 1. R6 is a [AGE] year old female admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. R6 is alert and oriented to person, place, and time. Review of the facility's significant weight losses/gains record showed R6 weighed 124.2 pounds on 3/15/2012. R6 's weight on 9/17/2012 was 109. This was a 15.2 pound weight loss in 6 months. R6 also had a 9 pound weight loss from 3/1/2012 - 3/15/2012 which makes a total of 24.2 pounds in 7 months. Review of nurses notes from 3/27/2012- 3/28/2012 indicate R6 had recurrent emesis after meals. The physician was notified on 3/28/2012 at 7:30 PM. R6 was transferred to the emergency room per physicians order for evaluation. R6 was admitted to the hospital with [REDACTED]. R6 was again nauseated and having emesis on 4/5 and 4/6/2012. On 6/14/2012 R6 had an episode of dysphasia in the main dining room. While eating a pork chop R6 choked. R6 was able to clear her own air way. R6 then stated she was having difficulty with swallowing meat lately. R6 stated, "It feels like there is something in my lungs." R6's physician was notified and ordered a chest X-ray and a bed side swallow study. On 6/14/2012 at 4:30 PM the chest X-ray was completed. The chest X-ray result showed a small patch in the right lower lobe compatible with pneumonia. R6 was placed on Z-pak. There was no documentation or report regarding the bed side swallow study. On 9/27/2012 at 3:10 PM, E2 (Director of Nursing) stated R6 refused the bedside swallow study. There was no documentation of the refusal or of the physician being notified R6 refused the bedside swallow study. On 7/13/2012 nursing notes indicate R6 was coughing during lunch. R6 had an emesis and complained of chest pain. R6's physician again ordered a portable chest X-ray. Chest X-ray showed right lower lobe mild patchy density compatible with pneumonia. R6 was then placed on antibiotic therapy for 10 days. R6 then began having emesis on 7/24/2012. R6 continued to have crackles to lower lung lobes. R6 received respiratory treatments thru 7/27/2012. On 8/17/2012 nursing notes state R6 continues to complain of difficulty swallowing. R6 states, " It feels like anything I eat gets stuck in my chest." The physician saw R6 on 8/17/12 at 8:45 PM ordering an appointment with a digestive disease consultant for dysphasia. Dietary down graded R6's diet to pureed consistency. On 8/23/2012 R6 saw a [MEDICATION NAME] for an [MEDICAL CONDITION] gastro- duodenoscopy (EGD). The dietitian note of 4/9/2012 indicates R6 had no chewing or swallowing problems. R6's most recent weight at this time was 126 pounds; which is significantly down. The dietary note indicates R6 would benefit from Glucerna at this time, however R6 had a strong history of refusal of supplements. R6 has a normal meal intake, therefore a supplement will not be started at this time despite weight loss. 5/7/2012 no change in weight. On 6/6/12 R6 weighed 121 pounds The significant weight change report ( greater than 7.5% in 3 months and greater than 10% in 6 months) indicates dietary recommendation to start supplement. The 7/24/2012 dietary note states R6 's current weight is 120.4, a 11.2 % weight loss over 6 months. There were no new recommendations, only to continue dietary supplement. Dietary note dated 8/28/2012 states R6's current weight is 118 pounds. The physician was notified with no new orders given. R6's weight continued to decrease. Weights were as follows: -8/22/2012 - 116.2 pounds -9/04/2012 - 113.8 pounds -9/17/2012 - 109.0 pounds On 8/29/2012 R6 went to the digestive disease office. The office called the facility and reported R6 has a 5 centimeter mass in the distal esophagus. Which was diagnosed as [MEDICAL CONDITION]. The consultant ordered a pureed/liquid diet for R6. R6 refused to eat the pureed diet. Review of the CT scan dated 9/5/2012 showed impression R6 has a distal mass projected near the level of [MEDICAL CONDITION] junction obscuring the lumen. On 9/13/2012 at 10:13 AM orders were received for a gastrostomy tube placement as well as an appointment with oncology was received for R 6. R6 began refusing all oral medication and oral food on 9/15/2012 - 9/21/2012. R6 was diagnosed with [REDACTED]. During this time R 6 continued to lose weight and was not able to swallow solid foods but no feeding tube was placed for over a month. On 9/28/2012 E2 (DON) stated there was a scheduling problem and R6 should have had the gastrostomy tube placed sooner. Further interview with E2 noted E2 to say R6 never refused insertion of the gastrostomy tube. On 9/27/12 at 3:15 PM the family of R6 stated they were not aware R6 had refused a bedside swallow evaluation on 6/14/2012. The family indicated the facility is to notify them when R6 refuses a procedure and they will talk to R6 about receiving the procedure. The family also indicated R6 is able to make R6's own medical decisions. The family stated R6 really began to lose weight about two months ago. 2. According to the medical record, R15 is a [AGE] year old female who was admitted to the facility in 2007 with [DIAGNOSES REDACTED]. R15's monthly weight records were reviewed for March, 2012 through September 2012. R15's weight on 03/05/12 was recorded as 120.6 lbs. R15's weight on 07/06/12 (4 months later) was documented as 100 lbs. On 07/24/12 E6, (Corp. Registered Dietician) documented R15 has a significant weight loss of 6.9% over 1 month, 16.7% over 3 months and 16.1% over 6 months. R15's current weight ([DATE]) is 100 lbs. BMI (Body Mass Index) 17.2 (underweight). E6 further documented R15 reports ill fitting dentures and mouth pain at times due to dentures. Dietary note documentation showed a nutritional supplement 120 ml 2 times/day was added 6/11/12 due to weight loss over 1 month but the supplement was discontinued on 7/24/12 due to R15's dislike of the supplement. Further dietary note documentation on 7/24/12 showed, "recommend dental consult." On 08/22/12 E6 documented, "R15 reports continued pain in mouth which resident reports telling son in law who is her dentist. No new recommendations, will continue to monitor and update MD of weight change. Encouraged resident to select softer foods at meals for for optimal oral intake." On 09/10/12 E13, (another RD) assessed R15 and documented R15 is at increased risk for future weight fluctuations, increased risk of dehydration and skin breakdown due to variable oral intake,[MEDICAL CONDITION], ill-fitting dentures and mouth pain. E13 documented, "Will recommend dental consult due to ill-fitting dentures per MD discretion as resident on comfort care. Improving fit of dentures may aid in mastication (chewing) and encourage oral intake." On 09/27/12 at approximately 2:00 PM upon request R15 was weighed by facility staff and was noted to be 98.2 lbs, a further loss of 5 lbs since 09/21/12 weight of 103 lbs and a total weight loss of approximately 22 lbs. since 04/05/12. E13 stated on 09/28/12 she did make another recommendation on 09/10/12 that R15 be seen by the dentist due to R15's mouth pain and ill-fitting dentures. E13 further stated the doctor signed off on the consultation but to her knowledge R15 has not yet seen a dentist. During interview with R15 on 09/28/12 at approximately 11:00 AM, R15 stated her mouth hurts when she tries to eat. R15 pointed to her lower set of dentures and stated that it hurts "here." R 15's lower plate was observed to be shifting side to side in her mouth. R15 further stated her son gave her some medicine in a bottle to rub on her gums. R15 produced a bottle of over the counter oral pain reliever from her night stand. R15 also stated it helps somewhat and she also uses salt to help relieve the pain. E13 later stated she was not aware R15 was using a liquid pain medication on her gums. E1 (Administrator) was asked on the morning of 09/28/12 if R15 had been to see the dentist and E1 stated she wasn't sure but R15's son is a dentist. Further review of the record produced no information that R15 has been scheduled to see a dentist. 3. According to the medical record R16 is an [AGE] year old female with [DIAGNOSES REDACTED]. R16's weight record was reviewed from May, 2012 to September, 2012. R16's weight on 05/04/12 was noted to be 137.8 lbs. and on 09/21/12 R16 weighed 119.4 lbs.; a weight loss of 18.4 lbs. in 4 months. R16's dietary notes were reviewed and it was noted R16 was assessed by E13 on 07/30/12. R16 was noted to weigh 133.8 lbs. E13 documented R16 lost 2.4 lbs for the month but this was not significant at the present time. R16's weight record notes on 08/01/12 R16 lost another 4 lbs and and on 09/04/12 R16 lost another 5.2 lbs. However, R16's continued weight loss was not addressed by the facility for approximately two more weeks when she was assessed again by E13 who noted R16 as having a significant weight loss of 8.5 % for three months. E13 recommended Hi Cal 120 ml 2 times per day and noted the need for an appetite stimulant. R16 was weighed again on 09/21/12 and had a further loss of 5.2 lbs. During interview with E13 on 09/28/12 E13 stated she was not notified by the facility R16 was having continued weight loss since the last time E13 assessed her on 07/30/12.

Based on record review and interview the facility failed to administer anti-[MEDICAL CONDITION] medication ([MEDICATION NAME]) as prescribed by the physician to one resident outside of the sample of 19 (R24). This failure resulted in R24 being hospitalized with [DIAGNOSES REDACTED]. The finding includes: Review of the facility's incident reports showed an incident for R24 dated 1/01/11 with incident type documented as "medication omission." Review of R24's closed record, the incident report, and incident investigation showed R24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R24's admission physician's orders included an order for [REDACTED]. Nursing documentation dated 1/01/11 at 9:30 p.m. showed R24 was discovered having having a [MEDICAL CONDITION] in her bed in her room. R24's physician was contacted and orders were received to sent R24 to the hospital. R24 24 was sent to the hospital and admitted with [DIAGNOSES REDACTED]. Review of R24's MAR (medication administration record) and physician's orders for 12/2010 and 1/2011 showed R24's [MEDICATION NAME] medication had been accidentally discontinued on the MAR. There was no physician's order found to discontinue the [MEDICATION NAME]. Five doses of [MEDICATION NAME] had been skipped from 12/30/11 to 1/01/11 due to a transcription error in discontinuing the [MEDICATION NAME]. R24 remained in the hospital until 1/07/11 when she was readmitted to the facility. Readmission orders [REDACTED]. Interview with E 2 (Director of Nurses) on 10/26/11 at 3:00 p.m. noted E 2 to say, "Yes, R24 did start having [MEDICAL CONDITION] on 1/01/11. She had missed five doses of [MEDICATION NAME]. The [MEDICATION NAME] was mistakenly d/c'd (discontinued) by one of the nurses and R24 started having [MEDICAL CONDITION] after that."

Based on observations, interviews and record review, the facility failed to enure one resident (R15 in a sample of 4 residents identified with pressure sore out of the sample of 20 residents.) received timely assessment and treatment for [REDACTED]. This failure resulted in staff identifying R15 had a change in skin condition of the left foot on 9/06/11, but provided no treatment until approximately 14 days later, when R15's left heel developed to an unstageable wound. This has the potential to effect all five residents identified in the facility with decubitus, because four of the resident's wounds were identified as facility acquired. Findings include: On 10/29/2011 at 11:15 AM, R15's wound care to the left heel was observed. R15 was observed to have a unstageable wound to the left heel. E8 reported R15 had acquired this wound (to the left heel) at the facility. When it was initial identified and treated, E8 said it was already unstageable. E8 stated: "When I started it was a black scab, like eschar... I just started in this position (treatment nurse) last month. At first her (R15's) wound was 100% eschar. Now its about 25% eschar, and 75% pale granulation." So, R15's wound improve with treatment. However, E8 could not explain when asked, why staff did not treat R15's pressure sore before it became a blackened and a unstageable wound. E8 said she did not know. E8 was also asked to present her comprehensive assessment of R15's left heel wound. E8 said, "When it developed, I did not have (written) a comprehensive note," or comprehensive assessment done. Review of R15's Admission Face Sheet documented R15 is a [AGE] year old female with [DIAGNOSES REDACTED]. Review of R15's care plan documented on 9/10/2011 staff identified R15 was at risk for impaired skin integrity. The goal was to prevent R15's skin from breaking down. The interventions identified to achieve this goals were: "Daily skin inspection; report any changes in skin or signs of possible skin breakdown... Report any breakdown to the feet or heels..." However, facility's staff did not implement these nursing interventions to prevent R15 left heel from developing into an unstageable wound. Review of R15's shower sheet had documented problems with the skin integrity of her (R15's) left heel several days before being assessed and treated. R15's Shower Sheets documented the following: "9/16/2011... Description of Skin Issues: Heel of left foot is hard and dark colored. Says her entire back hurts. 9/13/2011... Description of Skin Issues: Heels Dark and Dry. 9/20/2011... Description of Skin Issues: Heel of left foot has black sore..." But, review of R15's Pressure Ulcer Assessment Form documented R15's left heel wound was not identified until 9/20/2011. R15's Pressure Ulcer Assessment Form documented on 9/20/2011, R15's wound measure "3.5 cm x 1.2 cm", was "100% black eschar" and "unstageable". Review of R15's Nursing Notes were observed to not have documentation of R15's left heel wound until 9/20/2011 at 3:51 PM. This nursing notes documented R15's left heel wound was reported to R15 primary physician and treatment orders obtained. A comprehensive nursing assessment of R15's skin and general condition was not documented as done until 10/28/2011. Review of the facility's Pressure Ulcer Assessment/Evaluation and Treatment documents the following: "...that patients/residents with pressure ulcers will have appropriate assessment, intervention and evaluation of treatment implemented. Physicians will be notified of pressure ulcers. A physician order [REDACTED]." "When a pressure sore is present daily monitoring will be documented." However, staff failed to implement this policy for R15 until her pressure sore had developed to an unstageable wound. During the Daily Status Meeting on 11/29/2011 with the administrative staff (E1/administrator and E2/director of nursing), the survey team expressed concerns that R15's pressure sore was not assessed and treated in a timely manner. E1 reported that R15's shower sheet documented that a CNA (certified nurses aide) observed a change in R15's left heel. But, E1 said that nurse and treatment nurse given R15's shower sheet did not assess and treat the change in R15's skin condition on 9/16/2011. E1 also told surveyor that the nurse and treatment nurse no longer worked at the facility and were not available for interview. But, R15's shower sheet, physician orders [REDACTED].