Every finding on record at Clark County Nursing Home

Based on interview and record review, the facility failed to document in one resident's record (Resident #5), or notify the physician, when the resident had a large fecal impaction digitally removed by staff on 1/11/26 of seven sampled residents. The resident had a history of constipation and hemorrhoids with medication to treat. On 1/13/26, the resident experienced bleeding from his/her hemorrhoids. On 1/14/26, the Director of Nursing notified the physician of the resident's bleeding hemorrhoids. The physician ordered a complete blood count (CBC, a blood test used to look at overall health including the number of red blood cells to carry oxygen throughout the body). On 1/16/26 the resident passed a large amount of blood from his/her/rectum, began vomiting and was pale, tired and weak. Staff did not obtain the ordered blood work until 1/17/26. On 1/17/26, the laboratory notified the facility the resident's hemoglobin (a vital protein that gives the blood its red color and meets the body's need for oxygen) level was 5.5 grams/deciliter (normal range was 12-16 grams/deciliter). Staff sent the resident to the hospital for a blood transfusion, and the resident was then sent to a higher level of care hospital to treat the cause of the blood loss. The facility census was 56.Review of the facility's Change in a Resident's Condition or Status, revised on 4/2011, showed the following:-The facility shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's medical/mental condition and/or status;-The nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there has been:- need to alter the resident's medical treatment significantly;-instructions to notify the physician of changes in the resident's condition;-Except in medical emergencies, notifications will be made within 24 hours of a change occurring in the resident's medical/mental condition or status;-The nurse supervisor/charge nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. 1. Review of the resident's Significant Change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/10/25, showed the following:-Moderately impaired cognition;-Maximum assistance from staff for toileting hygiene and transfers;-Always continent of bladder and bowel, no constipation;-Received scheduled pain medication;-He/She received an opioid medication (a powerful class of prescription drugs used to relieve severe pain by binding to brain receptors, blocking pain signals, and releasing dopamine, which can also induce euphoria, but carries a high risk of drowsiness, constipation, slowed breathing, and addiction) during the seven day assessment. Review of Resident #5's physician orders, dated January 2026, showed the following: -May remove fecal impactions as needed (started 7/19/18);-Sodium phosphate enema, give rectally once a day as needed for constipation (started 7/19/18);-Aspirin low dose (reduces pain, fever, and inflammation) 81 milligrams (mg) give one tablet orally once a day for heart failure (started on 4/16/19);-Dulcolax (laxative) 10 mg give one suppository rectally daily as needed for constipation (started 10/15/19);-Milk of Magnesia (laxative) 400 mg/5 milliliter (ml) give 30 ml orally daily as needed for constipation (started 10/15/19);-Anusol-HC (steroid) 25 mg suppository insert on suppository rectally twice a day as needed for hemorrhoids (started 1/11/20);-Tucks medicated pads apply topically to external hemorrhoids every four hours as needed for hemorrhoids (started 5/5/20);-Witch hazel liquid (used in alternative medicine as a possibly effective aid in treating hemorrhoids, minor bleeding, and skin irritation) apply topically to external hemorrhoids three times a day as needed (started 6/30/20);-Hemorrhoidal cream apply topically to external hemorrhoids every four hours as needed for inflammation (started 6/30/20);- Citrucel powder (laxative) give one tablespoon with 8-12 ounces of juice or water daily for constipation (started 9/20/21);-Ferrous sulfate (iron supplement) 325 mg give one tablet twice a day for iron deficiency anemia (started 7/13/22);-Tramadol (opioid pain medication) 50 mg give one tablet orally every six hours (started on 12/10/25). Review of the resident's nurse's notes for 1/11/26 showed no documentation the resident complained of difficulty having a bowel movement, was uncomfortable due to the inability to have a bowel movement or received treatment including digital removal of feces. Review of the resident's Nurse's Note, dated 1/13/26 at 6:24 A.M., showed the following:-Rectal bleeding continued even without bearing down;-Hemorrhoidal suppository given in hopes to decrease hemorrhoids. Review of the resident's Nurse's Note, dated 1/14/26 at 12:02 P.M., showed the following:-Spoke with the physician regarding the resident's hemorrhoids and loss of blood;-Order received to obtain a CBC;-Attempted but was unsuccessful, will attempt again on Friday, 1/16/26 with lab draws. There was no documentation staff notified the physician of the inability to obtain the ordered lab. Review of the resident's Nurse's Note, dated 1/16/26 at 4:11 P.M., showed the following:-During a shower, the resident passed a bright red, rectal clot larger than a quarter in size;-On the toilet, the resident passed a large amount of dark colored blood, notified the Director of Nursing;-Administered a rectal suppository for hemorrhoids;-The Director of Nursing attempted to retrieve a blood sample three times;-The resident started vomiting back in the room;-Blood pressure was 117/61 mmHg (normal range was below 130/80 and above 90/60), heart rate was 82 beats per minute (normal range was 66-90 beats per minute), oxygen saturation was 97% (normal range was 95% to 100% on two liters of oxygen per nasal cannula;-The nurse called the power of attorney regarding the facility was out of Tucks pads (pre-moistened, medicated pads containing 50% witch hazel designed to provide immediate, soothing relief from burning, itching, and irritation caused by hemorrhoids) and of the recent episode, the power of attorney said, he/she would bring the pads as soon as possible. Review of the resident's Nurse's Note, dated 1/16/26 at 9:48 P.M., showed the following:-The resident's skin color was very pale as well as her conjunctiva (thin, transparent mucous membrane that lines the inner eyelids and covers the white part of the eyeball);-The resident said, he/she was very tired and felt weak;-Temperature of 97.6 degrees Fahrenheit (normal range of 97 degrees Fahrenheit to 99 degrees Fahrenheit), heart rate of 77 beats per minute, respirations of 18 breaths per minute (normal range was 12 to 20 breaths per minute, blood pressure was 106/51 mmHg, and oxygen saturation was 99% on three liters per nasal cannula. There was no documentation in the resident' record staff notified the resident's physician of his/her change of condition or inability to obtain ordered labs. Review of the resident's Nurse's Notes, dated 1/17/26 at 8:59 A.M., showed staff obtained the ordered CBC. Review of the resident's Nurse's Note, dated 1/17/26 at 1:00 P.M, showed the following:-The hospital lab tech called at 12:55 P.M. to report a critical low hemoglobin of 5.5 grams/deciliter;-The nurse notified the physician and the resident's power of attorney;-The facility sent to the resident to the hospital via ambulance. Review of the resident's Clinical Laboratory Report, dated 1/17/26, showed the following:-The lab tech called the facility and reported the critically high white blood cell count (measures the number of infection-fighting cells in the blood) of 33. 5 x 10 to the 9th/liter (normal range 3.5 x 10 to the 9th/liter to 10.5x 10 to the 9th/liter) to the charge nurse;-The lab tech called the facility and reported the critically low hemoglobin level of 5.5 grams/deciliter to the charge nurse;-The lab tech called the facility and reported the low red blood cell count of 2.145 x 10 to the 6th/liter (normal range 4.3 to 5.7 x 10 to the 6th/liter to the charge nurse. During an interview on 2/3/26 at 11:40 A.M., Resident #5 said the following:-The resident remembered having difficulty having a bowel movement because the fecal material was stuck, and he/she needed help;-A nurse helped get the fecal material out, but the resident still felt like there was more to go so he/she kept trying;-He/She remembered the hemorrhoids were bleeding and painful;-He/She was not feeling well and the next thing he/she knew, the facility sent the resident to the hospital;-At the hospital, the surgeon removed the hemorrhoids;-He/She continued to have pain for a few days, but the pain was gone now. During an interview on 2/3/26 at 1:38 P.M., Certified Nurse Aide (CNA) E said the following:-On 1/11/26, Resident #5 begged staff to help him/her have a bowel movement;-The resident was miserable because he/she could feel the fecal material, but it was stuck and caused pain;-CNA E reported the situation to Registered Nurse (RN) F;-RN F asked CNA E for stand by assistance;-RN F had gloves on and used lubricant to feel what was going on with the resident;-RN F told the resident, there was a large mass of fecal material so RN F put lubricant around the mass to see if the mass would pass;-The resident was bearing down, even after RN F said not to;-The resident was not bleeding when CNA E left the shift;-On 1/13/26, the resident was bleeding from the rectal area and the resident was complaining about his/her bottom being sore;-CNA E reported what she found to the charge nurse, but did not know if anything was done at the time;-The next day, the resident continued to bleed from the rectal area and the resident looked pale, so CNA E reported it to RN F. During an interview on 2/3/26 at 2:27 P.M. and 2:48 P.M., RN F said the following:-At about 9:30 A.M., a CNA reported Resident #5 was asking the staff to do something because he/she couldn't have a bowel movement;-RN F grabbed a pair of gloves and lubricant to assess the resident, because the resident was adamant there was feces stuck inside him/her, caused pain, and the resident could not push it out;-The resident's rectum was dilated and RN F felt a firm mass of fecal material;-The resident continued to strain and bear down;-RN F inserted one finger approximately one inch into the resident's rectum to feel the mass and put lubricant around the mass of fecal material that was the size of a softball;-The hope was the lubricant spread around the fecal mass would help it go down and out of the resident's rectum;-Around 11:00 A.M., staff said the resident was begging for help again;-The resident was bearing down with all his/her might without success;-The resident was not bleeding;-RN F put on gloves and used lubricant to assess the resident again finding the rectum was still dilated;-RN F was able to barely hook onto the fecal mass with one finger and pulled it down and some of the fecal material went out, which was fibrous and hard;-RN F did it two more times to remove more fecal material, this allowed the remainder of the fecal material to exit the resident's rectum, but the fecal material became liquid afterwards;-The resident did not complain anymore during the shift, but had loose stools that must have been trapped behind the mass;-The resident was not bleeding and did not start the remainder of the shift;-The resident was also taking an iron supplement that caused the resident's feces to be black and it could also cause constipation;-The next time RN F worked on approximately 1/14/26, staff said the resident was bleeding from his/her hemorrhoids and was still straining to have a hard bowel movement;-RN F contacted the physician about the resident's condition and the physician ordered Colace (a stool softener) for the resident;-RN F did not document the resident having a hard bowel movement or assisting the resident to remove the fecal mass on 1/11/26 in the resident's medical record;-He/She should have documented the situation, but did not;-He/She did not call the physician regarding the hard fecal mass because it was not necessary. The resident was not bleeding, and the resident was able to have a bowel movement after the mass was removed. During an interview on 2/3/26 at 1:43 P.M., the Director of Nursing said the following:-The resident had a history of bleeding hemorrhoids several times and the staff monitored the resident's CBC each time; in those instances, the resident's hemoglobin never made a significant drop;-Staff did not report the resident had any issues with constipation to her until 1/14/26;-RN F found a softball sized fecal mass in the resident's rectum and worked with the resident to get it out, but did not report it to the Director of Nursing;-The resident developed bleeding a couple of days later;-When she found out about the bleeding hemorrhoids, she discussed the situation with the physician during rounds, and the physician ordered a CBC;-The CBC was ordered on 1/14/26, but she was not able to obtain the blood sample until 1/17/26;-She did not notify the physician about not obtaining the sample until 1/17/26;-The resident was no worse than the last time he/she had bleeding hemorrhoids;-She contacted the resident's family member who was a nurse, about drawing the resident's blood because she was unable to get it, and she thought it would give the family member an opportunity to become involved. Family did not draw the ordered lab. During an interview on 2/3/26 at 3:15 P.M., the Administrator said it was her expectation staff follow physician orders and facility policies and procedures. During an interview on 2/4/26 at 11:34 A.M., the resident's physician said the following:-His expectation was if a nurse had to manually remove hard fecal material from a resident that he needed to be notified;-He ordered the CBC because the resident was having bleeding hemorrhoids;-His expectation was if the nurse was unable to obtain a blood sample for lab to notify the physician because he/she needed to determine if the resident needed to be seen in the emergency department or wait for the sample to be obtained. #2719682

Based on interview and record review, the facility failed to provide for the rights of one resident (Resident #1), in a review of five sampled residents, when the facility performed a urinary catheterization (a procedure that involves inserting a flexible tube called a catheter into the bladder to drain urine) and obtained a urine drug screen (used to detect illegal and some prescription drugs in the urine) without notification and permission from the resident or his/her emergency contact. The facility census was 54. Review of the facility policy, Resident Rights, undated, showed the following: -It is the goal of the facility to promote and protect the rights as a resident in the facility. The resident has a right to a dignified existence, self-determination and communication with and access to persons and services inside and outside the facility. Therefore, as a resident, you have: -The right to be fully informed, orally and in writing, of your rights; -The right to be fully informed or your total health status, including your medical condition; -The right to refuse your nursing care and medical treatment and to refuse to participate in any experimental research; -The right to have your family and physician promptly notified of significant changes in your medical condition and/or status; -The right to be fully informed in advance of your medical care and treatment and any changes in such care and treatment. 1. Review of Resident #1's face sheet showed the following: -The resident was his/her own person; -Three emergency contacts were listed; -Diagnoses included chronic pain, post-traumatic stress disorder (PTSD, a mental health condition that can develop after experiencing or witnessing a traumatic event), and chronic kidney disease (CKD, a longstanding disease of the kidneys which can lead to kidney failure). Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 01/27/25, showed facility staff documented the following: -Cognitively intact; -Required substantial to maximal assistance with mobility and toileting; -Continent of bladder most of the time; -Did not have a urinary catheter. Review of the resident's February 2025 physician order sheet (POS), showed an order allowing staff to straight cath (a procedure that involves inserting a flexible tube called a catheter, or cath, into the bladder to drain the urine) the resident PRN (as needed) for urinary retention (inability to empty the bladder), start date 08/08/22, open ended (no stop date). There was no order for urine collection for any type of testing. Review of the resident's care plan, updated on 02/06/25, showed the following: -The resident will have positive experiences in daily routine without overly demanding tasks and without becoming overly stressed; -Respect resident's rights to make decisions. Review of the resident's nursing progress notes, dated 02/08/25 at 10:10 A.M., showed staff documented the resident was alert and oriented times three (cognitively aware of person, place and time). Review of the resident's nursing progress notes, dated 02/14/25 at 3:10 A.M., showed the DON documented the following: -Resident's urine in urinal is dark yellow, has sediment (particles that settle in the urine and creates a cloudiness to the appearance) and foul odor. Urine specimen obtained by straight catheter per clean technique. Dipped here (a urine dipstick test, a quick and simple test using a thin, plastic stick with chemical strips that change color when dipped into a urine sample to detect various substances and potential problems in the urinary tract). Also due to resident's behaviors tested resident's urine for drugs. The results seen show positive results for opioids, tetrahydrocannabinol (THC, the substance that is primarily responsible for the effects of marijuana on a person's mental state) and benzodiazepines (a class of depressant drugs that treat anxiety, insomnia, and seizures). Resident is currently on opioids. Will update the resident's primary care physician (PCP) before the courier is here to pick up the labs. The record showed no documentation the resident had urinary retention or documentation to show staff notified the physician prior to the urine specimen collection per strait catheterization. There was no documentation to show the DON obtained consent from the resident prior to the catheter procedure and/or testing. Review of the resident's nursing progress notes for 02/14/25 showed no documentation that the facility staff called the PCP for an order to perform a straight catheterization of the bladder on the resident, or that staff received an order to perform a urine drug screen. Review of the resident's nursing progress notes for 02/14/25 showed no documentation that the staff obtained permission to perform a urine drug screen from the resident or his/her first emergency contact. During an interview on 03/03/25 at 11:30 A.M., the resident said he/she remembered he/she got really sick a few weeks ago and had to go to the hospital, he/she did not recall any details about that time. During an interview on 03/03/25 at 5:35 P.M. and 03/04/25 at 1:32 P.M., the DON said the following: -She obtained a urine sample by a straight catheterization (cath) method from the resident due to his/her changes in his/her condition; -She did not get an order for a straight cath urine drug screen on the resident from the resident's physician; -She checked the resident's urine sample for drugs because the resident acted high, his/her demeanor was different, and he/she was joking and smiling even though he/she had changes in his/her physical condition and was possibly getting ill; -There had been reports that the resident's family had brought in marijuana gummies to the resident in the past, so that was also why she did a urine drug screen; -She did not get the resident's permission for a urine drug screen, and she did not notify his first emergency contact for permission either; -She should have asked the resident's permission before doing a urine drug screen, or contact his first emergency contact if the resident was unable to respond; -The facility did not have a policy for obtaining a drug screen on a resident or following physician orders. During an interview on 03/04/25 at 1:32 P.M., the facility Administrator said the following: -She would expect facility staff to get a physician order and a resident's permission, or the resident's first emergency contact's permission if the resident is unable to speak for themselves, before obtaining a urine drug screen; -The facility did not have a policy for obtaining a urine drug screen on a resident or following physician orders. During an interview on 03/03/25 at 4:30 P.M., the resident's physician said the following: -The facility had the capability to test a urine sample for drugs, including marijuana; -Facility staff should probably get the resident's or family's permission to perform a urine drug screen. MO00249915

Based on observation, interview, and record review, the facility failed to label food items, discard food that was past the expiration/remove by date in dry storage, and discard prepared food after the labeled use by date in the walk-in cooler. The facility also failed to ensure food service equipment and surfaces were appropriately cleaned and maintained. The facility census was 59. Review of the facility's policy, Food Storage (Dry, Refrigerated, and Frozen), dated 2020, showed the following: -Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety; -Discard food that has passed the expiration date, and discard food that has been prepared in the facility after seven days of storing under proper refrigeration; -Date marking for dry storage food items - once a case is opened, the individual food items from the case are dated with the date the item was received into the facility and placed in/on the proper storage unit utilizing the first in-first out method of rotation. Expiration dates on commercially prepared, dry storage food items will be followed; -Date marking for refrigerated storage food items - once opened, all ready to eat, potentially hazardous food will be re-dated with a use by date according to current safe food storage guidelines or by the manufacturer's expiration date; -Prepared food or opened food items should be discarded when the food item does not have a specific manufacturer expiration date and has been refrigerated for seven days, the food item is leftover for more than 72 hours, or the food item was older than the expiration date. 1. Observations on [DATE] between 10:30 A.M. and 5:00 P.M., in the dry food storage room showed the following: -An opened/resealed plastic bag of cornflakes unlabeled with an opened date and did not have an expiration date; -An opened/resealed 11.3-ounce package of pork gravy mix unlabeled with opened date and did not have an expiration date; -An opened/resealed 24-ounce package of cheddar cheese sauce mix, unlabeled with opened date and did not have an expiration date. Observations on [DATE] between 10:30 A.M. and 5:00 P.M., in the walk-in cooler, showed the following: -An approximate 10-inch by 8-inch stainless steel container of egg salad labeled 'Saturday supper, use by ,d+[DATE]'; -An approximate 6-inch by 6-inch glass container of tomato sauce labeled 'Saturday supper, use by ,d+[DATE]'. During an interview on [DATE] at 9:15 A.M., the Dietary Manager said the following: -Dietary staff should ensure food items were labeled correctly and removed when required from the walk-in cooler/freezer and the dry food storage room; -Dietary staff should monitor the walk-in cooler/freezer and dry food storage room daily to identify products to ensure they were labeled and not expired; -She expected food items to be labeled correctly and to be removed after the use by/expiration dates. During an interview on [DATE] at 11:00 A.M., the Dietary Supervisor said the following: -All dietary staff were responsible for ensuring food items were labeled properly and any outdated items were removed from the dry storage and walk-in cooler/freezer areas. -She expected dietary staff to monitor the food items in the dry storage and walk-in cooler/freezer daily correct labeling, rotation of stock and removal of products past the use by/expiration dates. During an interview on [DATE] at 3:00 P.M., the Administrator said the following: -All dietary staff and the dietary supervisor were responsible in making sure food items were labeled correctly in the dry storage room and walk-in cooler and freezer; -Staff should monitor these areas on an ongoing basis; -She expected staff to label the food items when opened. Any items with past use by dates were to be removed. 2. Observations on [DATE] between 10:30 A.M. and 5:00 P.M., of the ice machine in the kitchen, showed the following: -An approximate 4-foot long by 0.25-inch-wide white scaly material on the outside of the machine at the top front and around both corners above the door; -White scaly and rust-colored run marks on both left and right sides of the front corners; -A buildup of a white, scaly material was on the inside of the machine at the right side of the stainless-steel panel to the ice dump; -A crack around the circumference of the plastic underside of the door; -The crack was filled with a sealant, and the sealant was separating from the repaired area. Observations on [DATE] between 10:30 A.M. and 5:00 P.M., of the dishwasher in the kitchen, showed the following: -A buildup of debris on the top surface of the dishwasher and around the temperature box area; -A buildup of debris behind the temperature box area and the piping below; -A buildup of debris located below the power/motor switches and wash/rinse temperature gauge area; -A buildup of a blackened material located below the dirty dish entrance side (right side of dishwasher), plastic piping, and baseboard. During an interview on [DATE] at 9:15 A.M., the Dietary Manager said the following: -Dietary staff were responsible for cleaning the ice machine, the dish washing machine and the areas around them; -She was not sure how often staff cleaned the machines; -She expected staff to clean the outside surfaces of the ice machine weekly and to clean inside the machine monthly; -She expected staff to clean the surfaces of the dishwasher daily. During an interview on [DATE] at 11:00 A.M., the Dietary Supervisor said the following: -The dietary department was responsible for cleaning the outside surface of the ice machine daily, and the maintenance department was responsible for cleaning inside the ice machine; -Dietary staff were responsible for cleaning the surfaces of the dishwasher daily and should clean the piping weekly; -She expected the outside/inside areas of the ice machine and the dishwasher surfaces, piping, and area to be clean and sanitized. During an interview on [DATE] at 12:20 P.M., the Maintenance Technician said the maintenance department was responsible for cleaning inside the ice machine. He was not aware of the white scaly material inside the machine. Maintenance cleaned the ice machine bi-annually, and it was due to be cleaned this month. During an interview on [DATE] at 3:00 P.M., the Administrator said the following: -The dietary department was responsible for cleaning the outside surfaces of the ice machine and the dishwasher weekly; -The maintenance department was responsible for cleaning/deep cleaning the interior of the ice machine and the dishwasher monthly; -She expected the ice machine, dishwasher, and equipment areas to be cleaned and sanitized.

42592 Based on observation, interview, and record review, the facility failed to follow current infection control standards for three residents (Residents #25, #17, and #21), in a review of 22 sampled residents, and for two additional residents (Resident #20 and #55). The facility failed to follow infection control practices while performing blood glucose monitoring (a procedure where a drop of blood is obtained to test the amount of sugar in the blood) for three residents (Resident #25, #20, and #17) when staff failed to appropriately sanitize the glucometer (a machine that tests a drop of blood for the amount of sugar it contains) after use and use a barrier to protect against contamination. The facility failed to store oxygen tubing and nebulizer equipment (equipment used to give aerosol breathing treatments) when not in use in a way to prevent potential contamination for three residents (Resident #25, #21 and #55). The facility failed to develop a policy to address Legionella (a bacterium that can cause a serious type of pneumonia called Legionnaires' Disease (a bacterial disease commonly associated with water-based aerosols) in persons at risk) control that included specific control parameters based on Center for Disease Control and Prevention (CDC) and American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) standards, and failed to complete a facility water assessment to identify potential sources of Legionella growth. The facility's policy did not include a water management team, a water flow map, parameters for findings related to water monitoring, and did not include how staff were to monitor residents for Legionnaire's Disease. The facility census was 59. Review of the Centers for Disease Control (CDC), Considerations for Blood Glucose Monitoring, showed the following: -Assign blood glucose meters to a person unless the device is designed for use in professional settings and is cleaned and disinfected after every use; -Clean and disinfect blood glucose meters after every use per the manufacturer's instructions, to prevent the spread of blood and infectious agents. Review of the Easy Touch Glucose Monitoring System User Manual, revised 12/2011, showed the following: -When cleaning meter, gently wipe the exterior surface using a damp soft cloth; -For healthcare professionals using this system on multiple residents, please be aware that all items that come in contact with human blood should be handled as potential biohazards. Users should follow the guidelines for prevention of blood-borne transmittable diseases in a healthcare setting for potentially infectious human blood specimens as recommended in the National Committee for Clinical Laboratory Standards, Protection of Laboratory Workers from Instrument Biohazards and Infectious Disease Transmitted by Blood, Body Fluids and Tissue: Approved Guideline. Review of the National Committee for Clinical Laboratory Standards, Protection of Laboratory Workers from Instrument Biohazards and Infectious Disease Transmitted by Blood, Body Fluids and Tissue: Approved Guideline website, that provides guidance on how to protect workers from bloodborne infections, instructs for safety, appropriate disinfectants should be used. Review of the website for Clorox Healthcare Hydrogen Peroxide Cleaner Disinfectant Wipes (green top) showed the following: -Wipe surface until completely wet; -30 seconds to 1 minute contact times on most bacteria and viruses. -The product protects against hepatitis B (virus commonly spread by exposure to infected bodily fluids), hepatitis C (virus that is spread by contact with contaminated blood) and human immunodeficiency virus (HIV) (virus that is transmitted by contact with infected blood. Review of the National Heart, Lung, and Blood Institute, National Institute of Health: How to Use a Nebulizer, dated October 2021, showed the following: -After each treatment wash the medicine cup and mouthpiece or mask with warm water and mild soap, rinse well and shake off excess water, air dry parts on a paper towel; -Between uses store nebulizer parts in a dry, clean plastic storage bag. 1. Review of Resident #25's undated Face Sheet, showed the resident's diagnoses included chronic obstructive pulmonary disease (COPD; a lung disease that blocks airflow and makes it difficult to breath), chronic respiratory failure with hypoxia (a long-term condition that occurs when there is not enough oxygen in the blood), dependence on supplemental oxygen, asthma, and diabetes mellitus with diabetic chronic kidney disease (too much sugar in the blood stream and affects the ability of the kidney's for function correctly). Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument, dated 11/15/24, showed the following: -Cognitively intact; -Received oxygen therapy. Review of the resident's Care Plan, revised 11/15/24, showed the following: -The resident had a potential for impaired air exchange related to COPD and chronic respiratory failure; -Administer oxygen as ordered; -The resident used oxygen at 2 liters via nasal cannula (a medical device that provides supplemental oxygen to a patient through their nose) as needed. The resident will remove oxygen for shower, activities, and meals. Review of the resident's Physician Orders, dated 12/23/24 through 1/23/24, showed orders for the following: -Continuous oxygen at 2 to 4 liter via nasal cannula. May be off for meals, activities, shower, and transportation; -Blood glucose (level of sugar in the blood stream) checks for times a day as needed for signs and symptoms of hyperglycemia (high blood sugar); -Fasting blood sugar check weekly on Mondays. Observation on 1/21/25 at 1:25 P.M. showed the resident lay in bed. The resident received oxygen via nasal cannula. The oxygen tubing was dated 12/2/24. There was no bag in the resident's room for the oxygen nasal cannula and tubing when not in use. During an interview on 1/21/25 at 1:25 P.M., the resident said the following: -He/She wore continuous oxygen and only took it off when he/she was out of bed or left the room; -When he/she took off the oxygen, he/she laid the oxygen tubing on his/her bed and did not put it in a bag; -The staff did not change the tubing very often, maybe a couple times each year. Observation on 1/22/25 at 9:00 A.M. showed the resident lay in bed and received oxygen via nasal cannula. The oxygen tubing was dated 1/21/25. Observation on 1/22/25 at 11:03 A.M. showed the resident was not in his/her room. The resident's oxygen nasal cannula and tubing lay on the resident's bed and was not stored in a bag. There was no storage bag for the oxygen tubing available in the resident's room. Observation on 1/23/25 at 6:31 A.M. and 2:49 P.M. showed the resident was not in his/her room. The resident's oxygen nasal cannula and tubing lay on the bed and was not stored in a bag. There was no storage bag for the oxygen tubing available in the resident's room. Observation on 01/23/24 at 8:25 A.M., showed the following: -Registered Nurse (RN) B prepared to obtain a blood sugar sample for the resident; -A container of Clorox Healthcare Hydrogen Peroxide Cleaner Disinfectant Wipes (green top) sat on top of the treatment cart, available for use (an approved disinfectant wipe); -RN B took an Easy Touch glucometer (used for multiple residents) out of the treatment cart and placed it directly on top of the treatment cart without a barrier; -RN B went into the resident's room and placed the glucometer directly on the resident's bedside table without a barrier; -RN B obtained the blood sample from the resident's finger, performed the blood glucose check procedure by placing a blood filled test strip in the glucometer, obtaining the result and then removing the blood filled test strip; -RN B returned the glucometer to the treatment cart, cleaned the glucometer with an alcohol swab and placed the glucometer back into the treatment cart drawer; -RN B did not use the Clorox Healthcare Hydrogen Peroxide Cleaner Disinfectant Wipes to disinfect the glucometer. During an interview on 01/24/25 at 11:56 A.M. and 1:16 P.M., RN B said on 01/23/24, he/she cleaned the glucometer with alcohol wipes after taking the resident's blood sugar because that was how the nurse managers told him/her to clean the glucometer. 2. Observation on 01/23/25 on 6:08 A.M., showed the following: -Certified Medication Technician (CMT) N placed the glucometer (used for multiple residents) on the medication cart without a barrier; -CMT N put a test strip in the glucometer, entered Resident #20's room, obtained a blood sample from the resident's finger an placed it on the test strip; -CMT N returned to the medication cart, placed the glucometer on the cart without a barrier, removed his/her gloves and washed his/her hands; -CMT N quickly cleaned the glucometer (less than 30 seconds) with a Clorox Healthcare Hydrogen Peroxide Cleaner Disinfectant wipe and placed the glucometer directly on top of the medication cart without a barrier; -CMT N sanitized his/her hands and placed the glucometer back into the drawer. Observation on 01/23/25 6:15 A.M., showed the following: -CMT N put gloves on, took the glucometer (he/she used to check Resident #20's blood sugar) and placed the glucometer on the medication cart without a barrier; -CMT N put the test strip in the monitor, entered Resident 17's room, and obtained a blood sample from the resident's finger onto the test strip; -CMT N returned to the medication cart, placed the glucometer directly on the cart without a barrier, removed his/her gloves and washed his/her hands; -CMT N quickly cleaned the glucometer (less than 30 seconds) with a Clorox Healthcare Hydrogen Peroxide Cleaner Disinfectant wipe and placed the glucometer directly on top of the medication cart without a barrier; -CMT N sanitized his/her hands and placed the glucometer back into the drawer. During an interview on 01/28/25 at 03:33 P.M., the Director of Nurses (DON) said the following: -Staff should clean the glucometers using the manufacturer's directions; - 70% alcohol is not recommended for multi-use glucometers; -There was some discrepancy with the information that was given from the manufacturer when they called; -She educated staff on how to clean glucometers using Clorox Healthcare Hydrogen Peroxide Cleaner Disinfectant wipes. During an interview on 01/28/25 at 4:45 P.M., the Administrator said the manufacturer said to clean the glucometers with alcohol. 3. Review of Resident #21's undated Face Sheet showed he/she had a diagnoses of COPD. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -No rejection of cares; -Received oxygen therapy. Review of the resident's Care Plan, revised 11/04/24, showed the following: -The resident had the potential for impaired air exchange related to COPD and chronic respiratory failure; -Monitor the resident's oxygen saturations due to him/her removing his/her oxygen. He/She removes the oxygen and throws it on the floor at times; -Administer oxygen as ordered by the physician. Review of the resident's January 2025 POS showed the following: -An order for continuous oxygen at 2 to 5 liters per nasal cannula. May be off for meals, activities, showers and transporting between; -An order for ipratropium-albuterol (an inhaled solution administered by nebulizer for treatment of COPD symptoms) 0.5 milligrams (mg) -3 mg/3 milliters (ml) 1 vial by inhalation three times a day between 6:00 A.M. to 10:00 A.M., 11:00 A.M. to 2:00 P.M. and 4:00 P.M. to 7:30 P.M. Observation on 1/21/25 at 11:55 A.M., showed the following: -An oxygen concentrator was against the wall in the dining room; -Undated oxygen tubing was connected to the concentrator. The oxygen tubing and the nasal cannula lay on the floor; -There was no storage bag attached to the concentrator; -Certified Nursing Assistant (CNA) E pushed the resident into the dining room and sat him/her at the table closest to the oxygen concentrator; -CNA E placed the nasal cannula, that had been on the floor, inside the resident's nares and turned on the oxygen at 2 liters. Observation on 01/21/25 at 12:40 P.M. showed CNA E removed the nasal cannula from the resident's nares, gathered the oxygen tubing and tucked it in the handle of the oxygen concentrator and took the resident from the dining room. CNA E did not store the oxygen tubing in a bag. During an interview on 01/24/25 at 1:35 P.M., CNA E said the following: -Oxygen tubing should be stored in the blue bag when not in use; -Oxygen tubing that touched the floor should never be used for a resident; -He/She was unaware on 01/21/25 that the oxygen tubing for the resident touched the floor prior to him/her putting it on the resident. Observation on 01/21/25 at 2:12 P.M. showed a nebulizer (a machine used to administer inhaled breathing treatments) machine was at the resident's bedside. The nebulizer tubing was connected and uncovered. A nebulizer set-up (the mechanism to administer the breathing treatment) was disassembled and sat on a washcloth by the handwashing sink. The set-up was uncovered and no storage bag was present in the room. Observation on 01/22/25 at 10:22 A.M., showed a nebulizer machine was at the resident's bedside. The nebulizer tubing was connected and uncovered. The nebulizer set-up was disassembled and sat on a paper towel turned upside down by the handwashing sink. The nebulizer set-up was uncovered and no storage bag was present in the room. Observation on 01/23/25 at 6:05 A.M., showed a nebulizer machine was at the resident's bedside. The nebulizer set-up was connected to the machine and lay uncovered on the resident's bedside table. Observation on 01/23/25 at 6:25 A.M., showed Certified Medication Technician (CMT) C removed the nebulizer treatment mask from the resident's face after administering a breathing treatment. He/She rinsed the nebulizer set up and placed it open side down on a clean washcloth on the counter by the handwashing sink. CMT C did not cover the set up with a drape or towel and did not place the set-up in a bag. Observation on 01/23/25 at 10:43 A.M. showed the resident's nebulizer treatment equipment was dry and continued to sit open side down on a clean washcloth on the counter by the handwashing sink. The equipment sat uncovered and was not placed in the equipment bag. During an interview on 01/24/25, at 1:28 P.M., CMT C said the following: -Oxygen supplies such as nasal cannulas and nebulizer treatments should be stored in the bag when not in use; -If the nebulizer treatment has been used and was drying after washing, it should be covered with a paper towel or clean washcloth so germs from the sink do not get splashed on it. During an interview on 01/24/25 at 11:56 A.M. and 1:16 P.M., Registered Nurse (RN) B said the following: -When oxygen supplies are not being used, such as tubing and nebulizer treatments, they need to be stored in the blue bag; -If a nasal cannula touches the floor, it needs to be thrown away and a new one obtained; -Nebulizer treatment equipment should not be left uncovered on the counter or on the bedside table. During an interview on 1/28/24 at 3:33 P.M. the DON said the following: -When oxygen tubing is not in use, it should be stored in the blue bags; -Staff should change oxygen tubing monthly and as needed; -Nebulizer tubing, reservoir and mask are to be cleaned and put on a clean surface to dry; -Placing the nebulizer parts in a clean area, on a clean surface, uncovered, would be appropriate, next to the sink would not be appropriate. 4. Review of Resident #55's undated Face Sheet showed the resident's diagnoses included aortic valve stenosis (narrowing of the valve in the large blood vessel branching off the heart, can cause chest pain, fatigue, and shortness of breath) and dependence on supplemental oxygen. Review of resident's annual MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Received oxygen therapy. Review of resident's care plan, revised 12/27/24, showed no documentation the resident used supplemental oxygen. Review of the resident's Physician Orders, dated January 2025, showed an order for continuous oxygen at 3 liter via nasal cannula at bedtime. May be off for meals, activities, showers and transportation. Observation on 1/21/25 at 1:39 P.M. showed the resident sat in a chair in his/her room. The resident's oxygen nasal cannula and tubing lay on the floor and were not stored in a bag. A storage bag hung on the oxygen concentrator. The oxygen tubing was labeled with the date 12/2/24. During an interview on 1/21/25 at 1:39 P.M., the resident said he/she only wore oxygen at night and not during the day. Observation on 1/22/25 at 8:47 A.M. showed the resident sat in a chair in his/her room. The resident's oxygen nasal cannula and tubing lay on the floor and were not stored in a bag. A clear bag hung on the oxygen concentrator in the room. The oxygen tubing was labeled with the date 1/21/25. Observation on 1/23/25 at 7:39 A.M. and 2:42 P.M. showed the resident sat in a chair in his/her room. The resident's oxygen nasal cannula and tubing lay on the floor and were not stored in a bag. Observation on 1/24/25 at 1:09 P.M. showed the resident sat in a chair in his/her room. The resident's oxygen nasal cannula and tubing lay on the floor and were not stored in a bag. 5. Review of the Centers for Medicare and Medicaid Services (CMS) Survey and Certification (S&C) letter 17-30, dated 06/02/17 and revised on 06/09/17, showed the following: -The bacterium Legionella can cause a serious type of pneumonia called Legionnaires' Disease (LD) (a bacterial disease commonly associated with water-based aerosols and often a result of poorly maintained air conditioning cooling towers and potable water systems) in persons at risk. Those at risk include persons who are at least [AGE] years old, smokers, or those with underlying medical conditions such as chronic lung disease or immunosuppression. Outbreaks have been linked to poorly maintained water systems in buildings with large or complex water systems including hospitals and long-term care facilities. Transmission can occur via aerosols from devices such as shower heads, cooking towers, hot tubs and decorative fountains; -Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water; -CMS expects Medicare certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. An industry standard calling for the development and implementation of water management programs in large or complex building water systems to reduce the risk of legionellosis was published in 2015 by American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE). In 2016, the CDC and its partners developed a toolkit to facilitate implementation of this ASHRAE Standard (https://www.cdc.gov/Legionella/maintenance/wmp-toolkit.html). Environmental, clinical, and epidemiological considerations for healthcare facilities are described in this toolkit; -Surveyors will review policies, procedures, and reports documenting water management implementation results to verify that facilities: -Conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system; -Implement a water management program that considers the ASHRAE industry standard and the CDC toolkit, and includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens; -Specify testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained. Review of the Centers for Disease Control and Prevention Legionella Environmental Assessment Form, undated, showed Legionella generally grows well between 77 degrees Fahrenheit (F) and 113 degrees F. The optimal growth range for Legionella is between 85 degrees F and 108 degrees F. Growth slows between 113 degrees F and 120 degrees F, and Legionella begin to die above 120 degrees F. Growth also slows between 68 degrees F and 77 degrees F, and Legionella become dormant below 68 degrees F. Review of the undated facility policy, titled Legionella Prevention, showed the following: -Employee and resident exposure to Legionnaires' Disease; -It (Legionnaires' Disease) can occur where water, contaminated with the legionella organism, is aerosolized and then breathed in by workers or residents; -Legionnaires' Disease is not contagious, but is of environmental origin. Consequently, only those who are directly exposed to the contaminated aerosolized water source can get the disease; -Exposure to the legionella bacteria could occur in the shower or whirlpool area, or areas that use spray nozzles. Cooling towers, evaporative condensers, fluid coolers, and domestic hot-water systems are water sources that frequently provide optimal conditions for growth of the legionella organism; -Exposure to the legionella bacteria can cause a mild respiratory illness (that may not require treatment), or severe pneumonia-like symptoms two to 10 days after exposure; -If not detected and treated promptly with appropriate antibiotics, can lead to death; -The risk for the facility is deemed low, as the infrastructure affected by potential Legionella outbreaks is modern, up to date and well maintained; -The water supply for the facility enters from the south end of the facility via a 3 PVC main from the city municipal water supply; -Backflow protection is in place at the entrance to the facility and after the water softening system; -Cold water is distributed directly to appropriate end-user locations; -Hot water is constantly circulated throughout the building via circulating pumps in each mechanical room; -Indirect water boilers supply two, 119 gallon holding tanks, that are a part of the circulating system; -On the [NAME] End, two, 80 gallon water heaters, distribute to all areas in this portion of the building, also constantly circulating; -Detection: a. Multiple commercial devices are available to detect legionella contamination; b. These devices include a validation line to ensure the test sample was adequate; c. While no brand is endorsed by this plan, options include: 1. Accepta Legionella Detection Kit; 2. Hydrosense Legionella Test Kit; 3. Nova-Tech Legionella Detection Kit; 4. Orbeco Legionella Test Kit; 5. And other; -Testing, in accordance with the selected test kit will be done when a possible outbreak is being investigated; -Prevention Solutions: a. Maintenance of water systems - specific recommendations: 1. Water will be stored at 140 degrees F and delivered at a minimum of 122 degrees F to all outlets; 2. To prevent scalding problems, scald protection equipment, such as preset thermostatic mixing valves may be installed if outlet temperature exceeds 130 degrees F.; 3. Where building cannot be retrofitted, consider periodically increasing the temperature to at least 158 degrees for chlorination followed by flushing; 4. Inspect systems annually to ensure equipment functions properly; b. Domestic cold-water systems: 1. Eliminate water tanks that allow water to remain uncirculated for long periods or design them to reduce storage time to a day or less. They should also be covered and protected from temperature extremes; 2. Prevent cross-contamination of the domestic cold-water system with other systems; 3. Use hyperchlorination to eradicate legionella if the cold-water lines have significant contamination; -References: a. OSHA Technical Manual, also provides Controls, and Source Identification; b. Appendix Ill: 7-5. OSHA Technical Manual, Water Treatment Protocols for Facilities that have experienced a Legionnaires' Outbreak; c. Appendix Ill: 7-1. Employee Awareness Program, to inform employees of any potential outbreaks, and to educate about the disease, and provide early recognition of the disease. Sample forms and questions and answers about Legionnaires' disease are provided; VI. Medical Awareness of Physicians and Health Care Workers (HCWs): a. HCWs need to be aware that the bacteria can be present in water systems and promptly test vulnerable and/or symptomatic residents and use appropriate antibiotics quickly; b. Legionnaires' Disease most frequently attacks individuals who have an underlying illness or weakened immune system. The most susceptible include persons who are elderly, smokers and immunosuppressed; c. Symptoms include: i. dry cough, high fever, chills, muscle aches, diarrhea, fatigue, headache, and abdominal pain; d. Treatment: i. Usually treated with erythrornycin or a combination of erythromycin and Rifampin (antibiotics). VII. Additional Information: a. Legionnaires' Disease. OSHA eTool. This tool was designed to assist industrial hygienists in the assessment of worksites for potential legionnaires' disease. It provides information on disease recognition, investigation procedures to identify probable water sources, and control strategies; b. Environmental Care; Utility System and Acquired Illness. Joint Commission, Environment of Care Standards, (2008, November 24). Address issues of improperly designed and maintained aerosolizing water systems (controlling pathogenic biological agents such as legionella in cooling towers, domestic hot water systems, etc); c. Patient Facts: Learn More about Legionnaires' disease. Centers for Disease Controland Prevention (CDC), (2008, June 27). -The facility did not reference the ASHRAE standards developed in 2015, including a facility water management team, it's required members, meetings or a facility water flow map, or the CDC toolkit developed in 2016 as directed in the 2017 S&C letter in their policy, they referenced resources from 2008; -The policy states water will be delivered at a minimum of 122 degrees F to all outlets, but temperatures over 120 degrees F contradicts state regulation for temperature. Review of the facility's water temperature log, dated 10/28/24, showed the following: -Men's east shower room, 106.5 degrees F; -Women's east shower room, 104.2 degrees F; -room [ROOM NUMBER], 107.8 degrees F; -room [ROOM NUMBER], 108.1 degrees F.; -The specific location that the water temperature was taken from was not specified; -The log did not include cold water temperatures or any actions taken for low hot water temperatures. Review of the facility's water temperature log, dated 11/08/24, showed the following: -East shower room, 106.7 degrees F; -Chapel, 107.1 degrees F; -room [ROOM NUMBER], 109.6 degrees F. -West spa/shower, 109.7 degrees F; -400 hall shower, 107.9 degrees F; -room [ROOM NUMBER], 107.7 degrees F.; -The specific location that the water temperature was taken from was not specified; -The log did not include cold water temperatures or any actions taken for low hot water temperatures. Review of the facility's water temperature log, dated 11/11/24, showed the following: -East shower room, 108.9 degrees F; -The specific location that the water temperature was taken from was not specified; -The log did not include cold water temperatures or any actions taken for low hot water temperatures. Review of the facility's water temperature log, dated 12/02/24, showed the following: -East shower room, 108.9 degrees F; -East spa, 108.7 degrees F; -room [ROOM NUMBER], 108.3 degrees F; -The specific location that the water temperature was taken from was not specified; -The log did not include cold water temperatures or any actions taken for low hot water temperatures. Review of the facility's water temperature log, dated 12/23/24, showed the following: -East spa, 106.8 degrees F; -The specific location that the water temperature was taken from was not specified; -The log did not include cold water temperatures or any actions taken for low hot water temperatures. Review of the facility's water temperature log, dated 12/31/24, showed the following: -room [ROOM NUMBER], 108.9 degrees F; -West spa/shower, 109.6 degrees F; -400 hall shower, 106.7 degrees F; -room [ROOM NUMBER], 108.7 degrees F; -The specific location that the water temperature was taken from was not specified; -The log did not include cold water temperatures or any actions taken for low hot water temperatures. The facility did not provide water temperature logs from 01/01/25 to 01/24/25. During an interview on 01/24/25 at 11:02 A.M. and 12:28 P.M., the Environmental Services Supervisor, said the following: -The facility does not test for legionella; -Every open or closed loop was moving; -The facility did not have stagnant water; -He flushed empty rooms by turning on the water for a couple minutes once a month, sometimes every two weeks; -The facility has not completed a CDC tool kit that he knew of and he had not heard of the ASHRAE guidelines; -He made sure there were no breaks in the water lines; -The facility tested for hard water but does not test for legionella; -The facility does not have a water flow map; -The facility does not have a water management team; -He monitored hot water temperatures weekly to make sure they were above 120 degrees Fahrenheit. If they were below, he turned the water heater temperature up; -He does not monitor cold water temperatures, chlorine levels, water sediment or biofilm; -The hard water test has a pH (measure of alkalinity/acidity) component but they do not have any actions or specifications of what the pH needed to be so they do not do anything with that value. During an interview on 01/24/25 at 11:02 A.M., the Infection Preventionist (IP), said the following: -She does not serve on a water management committee or any committee that discussed water or Legionella; -The facility does chest x-rays for people with pneumonia; -She does not screen anyone for legionella, she thought the hospital would have to do that if the resident was sick enough to go to the hospital; -She does not know the signs or symptoms of legionella, or Legionnaire's disease or how to check for legionella. During an interview on 01/23/25 at 1:45 P.M., the Administrator said the following: -The facility tests the water for legionella; -She did not have documentation of a facility water assessment; -She did not know what a water flow map was; -The Maintenance Director monitored water temperatures and can get the water management program and any testing completed; -The Maintenance Director was expected to follow the policy and guidelines for monitoring water; -The facility did not have a water management team. 50189 51988

Based on observation, interview and record review, the facility failed to complete a significant change status assessment (SCSA) Minimum Data Set (MDS), a federally mandated assessment, required to be completed by facility staff, for four residents (Residents #18, #8, #13 and #28), in a review of 22 sampled residents. This assessment should have been completed within 14 days after the facility determined, or should have determined, there had been a significant change (major decline or improvement in the resident's status) in the resident's physical or mental condition which had an impact on more than one area of the resident's health status and required interdisciplinary review and/or revision of the care plan. The facility census was 59. Review of the Long Term Care Facility RAI User's Manual, version 3.0 showed a significant change is a decline or improvement in a resident's status that: -Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, is not self-limiting; -Impacts more than one area of the resident's health status; -Requires interdisciplinary review and/or revision the care plan. -Significant Change in Status Assessment (SCSA) was appropriate if there was a consistent pattern of changes, with either two or more areas of decline, or two or more areas of improvement. This may include two changes within a particular domain (e.g., two areas of Activity of daily living (ADL) decline or improvement). -significant change is a major decline or improvement in a resident's status that: -Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self limiting; -Impacts more than one area of the resident's health status; and -Requires interdisciplinary review and/or revision of the care plan. 1. Review of Resident #18's quarterly MDS, dated [DATE], showed the following: -Supervision required for oral hygiene; -Supervision assistance with upper body dressing; -Independent when moving from sitting on the side of the bed to lying flat in bed and when moving from lying on his/her back to sitting on the side of the bed; -Supervision required to move from a sitting to a standing position, for chair to bed transfers and for toilet transfers; -Independent to walk 50 and 150 feet; -Always continent of bowel; -Pain rarely interferes with day to day activities. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Maximum assistance required for oral hygiene and upper body dressing; -Moderate assistance required when moving from sitting on the side of the bed to lying flat in bed and when moving from lying on his/her back to sitting on the side of the bed; -Moderate assistance required for chair to bed transfers and toilet transfers; -Maximum assistance when moving from a sitting to a standing position; -Did not complete walking up 50 or 150 feet; -Occasionally incontinent of bowel; -Pain occasionally interferes with day to day activities. Review of the resident's medical record showed no documentation staff completed a significant change assessment when the resident had a decline in two or more activities of daily living (ADL). During an interview on 1/22/25 at 9:58 A.M., the resident's family member said the resident had a major decline in his/her ADL function in the last three months. 2. Review of Resident #8's annual MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Diagnoses included arthritis, stroke, seizure, and mild cognitive impairment; -Independent with eating, oral hygiene, roll left and right, sit to lying, lying to sitting on side of bed and wheel 150 feet; -Required set up assistance from staff for upper body dressing and personal hygiene; -Required supervision/touch assistance from staff for toileting hygiene, lower body dressing, sit to stand, chair/bed-to-chair transfer, and toilet transfer; -Required partial/moderate assistance from staff for putting on/taking off footwear, and tub/shower transfer; -Required substantial/maximal assistance from staff to shower/bathe; -Frequently incontinent of bladder, continent of bowel; -Scheduled pain medication regimen and non-medication interventions for pain; -Pain occasionally at a three (on a scale of one to ten, with ten being the worst pain possible); -Resident weighed 287 pounds (lbs); -Therapeutic diet; -Edentulous. Review of the resident's quarterly MDS, dated [DATE], showed the resident weighed 283 lbs. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Required partial/moderate assistance from staff for eating, and toilet transfer; (a change from eating independently and supervision/touch assist for toileting transfer); -Required substantial/maximal assistance from staff for toileting hygiene, upper body dressing, lower body dressing, putting on/taking off footwear, sit to lying, lying to sitting on side of bed, and personal hygiene, sit to stand, chair/bed-to-chair transfer, and tub/shower transfer; (all changes from either independent, set up assistance, supervision/touch assistance or partial/moderate assistance); -Dependent on staff for oral hygiene, shower/bathe, roll left and right, and wheel 150 feet; (all changes from either independent or substantial/maximal assistance); -Occasional bowel incontinence; (change from continent of bowel); -New as needed (PRN) pain medication; -One fall since prior assessment; -New swallowing disorder; -252 lbs (31 lb weight loss since August), significant wt loss not on a program. Review of the resident's medical record showed no documentation staff completed a significant change assessment within 14 days when the resident had a decline in two or more ADL areas. 4. Review of Resident #13's annual MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Diagnosis of dementia, post traumatic stress disorder, (PTSD - a mental health condition triggered by a terrifying event, either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event) and Parkinson's (a progressive brain disorder that causes movement problems and is characterized by tremors, stiffness and difficulty with balance and coordination); -No difficulties hearing; -No functional range of motion (ROM) limitations; -Required setup or clean up assistance from staff for personal hygiene; -Required partial/moderate assistance from staff for roll left and right; -Required substantial/maximal assistance from staff for toilet hygiene and upper body dressing; -Dependent on staff for shower/bathing and to put on/take off footwear. Review of the resident's quarterly MDS, dated [DATE], showed the following: -New moderate hearing difficulty, speaker has to increase the volume and speak distinctly; -Limits to functional ROM in both lower extremities; (change from no functional range of motion); -Required partial/moderate assistance from staff for toilet hygiene and upper body dressing; (change from either set up or substantial/maximal assistance); -Required substantial/maximal assistance from staff for shower/bathing, put on/take off footwear, personal hygiene, roll right and left; (all changes from either dependent, set up assistance or partial/moderate assistance); -New swallowing disorder, loss of liquids/solids from mouth, when eating or drinking; -New mechanically altered diet. Review of the resident's medical record showed no documentation staff completed a significant change assessment within 14 days when the resident had a status change in two or more ADL areas. 3. Review of Resident #28's significant change in status MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Diagnoses included dementia and contracture (tightening of muscles) of right knee and left knee; -New limitation in ROM both lower extremities; -Independent with roll left and right, sit to lying, lying to sitting; -Required partial/moderate assistance from staff for eating, upper body dressing; -Required substantial/maximal assistance from staff for oral hygiene, toilet hygiene, lower body dressing, shower/bathe, and putting on/taking off footwear; -Dependent on wheelchair for mobility; -Weighed 160 lbs., significant weight loss (not planned); -No mechanically altered diet; -No signs or symptoms or pain management medications or interventions; -No antidepressant medication. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Required supervision/touching assistance from staff members for eating; (change from partial/moderate assistance); -Weighed 164 lbs.; -New antidepressant medication. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Independent with wheelchair mobility; (change from dependent status); -Required partial/moderate assistance from staff for roll left and right; (change from independent status); -Required substantial/maximal assistance from staff for upper body dressing; (change from partial/moderate assistance); -Dependent on staff for oral hygiene, toilet hygiene, shower/bathe, lower body dressing and putting on/taking off footwear; (all changes from substantial/maximal assistance); -New pain medication and non-pharmacological interventions for pain; -Weighed 147 lbs (10% significant weight loss since 09/04/24 assessment); -New mechanically altered diet; -Continued on antidepressant medication since the 09/04/24 assessment. Review of the resident's medical record showed no documentation staff completed a significant change assessment within 14 days when the resident had a status change in two or more ADL areas. During an interview on 01/24/25 at 11:04 A.M., the MDS coordinator (MDSC) said the following: -When completing the MDS, staff used residents' charts and Certified Nurse Assistants (CNA's) chart on specific areas during the look back period; -The facility had an interdisciplinary team (IDT) meeting and reviewed the results of the residents' assessments; -A SCSA was completed if a resident had two or more changes to the resident's condition; -Staff compared the MDS to the last MDS if it was a quarterly or a comprehensive; --A significant change occurred when there were two changes, for example a resident goes from one assist to two assist. She goes back to last quarterly assessment and did not know to go back to last comprehensive assessment; -She did not use the Resident Assessment Manual (RAI) manual much, as she thought the manual was for ICD10 codes. During an interview on 01/24/25 at 3:33 P.M., the Director of Nursing said the following: -She expected staff to complete a SCSA when the resident has had a change and demonstrated they would not return to their previous level of function; -She expected the SCSA to be initiated within two to three days of a change in condition; -Staff are expected to complete the SCSA as defined by the MDS criteria in the RAI manual; -The MDSC was responsible to complete the SCSA MDS. 50189

Based on observation, interview and record review, the facility failed to complete a side rail assessment for one resident, (Resident #17) or assess three residents' (Resident #17, #54 and #18) risk for entrapment prior to use of side rails, in a review of 22 sampled residents. The facility failed to obtain consent from one resident (Resident #54) or his/her family for use of the side rails prior to use. The facility census was 59. Review of the undated facility policy, Quarter Side Rail Policy, showed the following: -The purpose is to ensure the appropriate use of quarter bed rails and to ensure the safety for a resident who requests quarter bed rails. -Any resident who is admitted to the facility, that has a history of using bed rails, fall risks and compromised mobility, shall be reassessed for appropriate use; -Bed rails are used for: transferring, enhancing mobility, assisting with turning/reposition, and emotion support per request after nursing assessment and agreement by the Quality Assurance (QA) committee; -A resident who uses bed rails shall be screened or assessed monthly according to the monthly assessment scheduled; -The care plan shall reflect the use of bed rails; -A resident who requests to have bed rails shall be educated on risks and benefits; -The QA committee shall assess and decide for the continuity of use; -The procedure is to assess the residents mobility level, assess the residents emotional comfort, send the communication regarding this to the QA committee, QA committee meets briefly in the morning to discuss and approve side rail use after assessment, explain risk for use to resident and family members, obtain signed consent, monitor for entrapment, risk of injury, footboards and headboards, and documentation for risk assessment and evaluation monthly and as needed (especially with change of condition, mobility levels and fall risks). 1. Review of Resident #17's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, dated 11/18/24, showed the following: -Severe cognitive impairment; -Independent when rolling left and right; -Required partial to moderate assistance to move from sitting on the side of the bed to lying flat on the bed; -Required partial to moderate assistance lying on his/her back to sitting on the side of the bed with feet flat on the floor; -Required partial to moderate assistance to stand from a sitting position on the bed. Review of the resident's Care Plan, last reviewed 11/21/24, showed the following: -The resident had the potential for falls related to weakness, decrease mobility, poor safety judgement, and history of falls; -On 12/4/24, the resident slid out of bed; -On 12/19/24, the resident rolled out of bed. Staff provided safety awareness education about being aware of where he/she is in bed; -Transfer with assist of one staff at times. He/She transferred himself/herself between the chair and bed; -On 1/3/25, the resident liked side rails up on his/her bed so he/she was able to reposition himself/herself while in bed. Review of the resident's Physician's Orders, dated 12/23/24 through 1/23/25, showed the following: -The resident's diagnoses included history of repeated falls, altered mental status, muscle weakness, need for assistance with personal care, and lack of coordination; -An order dated 1/3/25 for one-fourth side rails for assistance with bed positioning. Review of the resident's medical record showed no documentation staff completed a side rail assessment or assessed the resident's risk for entrapment prior to use of the side rails on 1/3/25. Observation on 01/22/25 at 3:51 P.M., showed the resident lay in bed. The resident had a one-fourth side rail in the raised position on the left side of his/her bed. During interview on 01/23/25 at 1:05 P.M., the Director of Nursing (DON) said she completed a side rail assessment for the resident, but did not fill out a form with the assessment. She made a mental note to complete the assessment form at the end of the month. 2. Review of Resident #54's Side Rails Monthly Assessment, dated 12/5/23, showed the following: -Type of side rails: One-fourth side rails up times two; -Reason for side rail usage: Assist with bed mobility (turning side to side) and boundary limitations; -The side rail was an enabler; -The resident was alert and oriented and requests (side rails); -Risks and benefits were explained to the resident/family. Review of the resident's medical record showed no evidence staff assessed the resident's risk for entrapment prior to use of the bed rails. Review showed no evidence staff obtained consent from the resident/family for use of the side rails. Review of the resident's annual MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Required substantial/maximal assistance to roll left and right in bed, to change position from sitting to lying in bed and from lying to sitting on the side of the bed, and to stand from a sitting position on the bed. Review of the resident's Care Plan, last reviewed 11/26/24, showed the following: -The resident required maximum assistance to dependent on staff of cares. He/She used one to two staff assist with Sara Steady (a transfer aide used to assist an individual from a sitting to a standing position) for transfers; -The resident was alert with moments of confusion. He/She had episodes of hallucinations at times. He/She required orientation to his/her surroundings. -The resident liked to have bed rails so he/she was able to reposition himself/herself while in bed. Review of the resident's Physician's Orders, dated 12/23/24 through 01/23/24, showed the following: -The resident's diagnoses included Parkinson's disease, dementia with behavioral disturbances, hallucinations, and muscle weakness; -One-fourth side rails for positioning. Observation on 01/21/25 at 2:15 P.M., showed the resident lay in bed. The right side of the resident's bed was against the wall. The resident had a one-fourth side rail in the raised position on the left side of his/her bed. During interview on 01/23/25 at 1:10 P.M., the DON said the following: -She could not find a side rail consent form for the resident; -The resident used the side rail to know where the edges of the bed were located and to sit on the side of the bed. 3. Review of Resident #18's undated Face Sheet showed the following: -Diagnoses of history of falls, muscle weakness, hypertension (elevated blood pressure), gout (a form of arthritis that causes pain and swelling of the joints), chronic fatigue (tiredness), pain, osteoarthritis, and macular degeneration (a progress eye disease that causes vision loss); -Did not identify a responsible party, power of attorney, or health care proxy. Review of the resident's Resident Quarter Bed Rail Consent Form, dated 7/6/23, showed the resident's family member signed and gave consent for side rails on 7/6/23. Review of the resident's medical record showed no documentation staff assessed the resident's risk for entrapment prior to use of the side rails. Review of the resident's Physician Orders, dated 7/1/24 through 1/23/25 showed an order dated 7/11/23 for one-fourth side rail for positioning. Review of resident's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Impairment of bilateral lower extremities; -Independent in rolling left to right in bed; -Required partial to moderate assistance to move from sitting on the side of the bed to lying flat on the bed; -Required partial to moderate assistance to move from lying on his/her back to sitting on the side of the bed; -Required substantial to maximum assistance to move from sitting on the side of the bed to standing. Review of the resident's care plan, last reviewed 10/25/24, showed the following: -The resident required limited to extensive assist with activities of daily living (ADLs); -The resident transferred with one or two assist but did not always remember to ask for help; -The resident had the potential for falls related to weakness, decreased mobility, poor safety judgement and history of falls; -One-fourth side rails applied to the resident's bed for assistance and to help the resident determine the edge of the bed (implemented on 7/6/23); -The resident liked to have side rails up so he/she was able to reposition self while in bed (implemented 7/7/23). Review of the resident's Side Rails Monthly Assessment, dated 12/30/24, showed the following: -Type of side rails: one-fourth side rails up times two; -Reason for side rail usage: boundary limitations; -The side rail was an enabler; -The resident was alert and oriented and requests side rails; -The risks and benefits were explained to the resident/family on 7/6/23; -There was no change in condition; -Appropriate and continue use of side rails. Review of the resident's medical record showed no evidence staff assessed the resident's risk for entrapment from the bed rails. Observation on 1/22/25 at 8:49 A.M. showed quarter side rails in the raised position on both sides of the resident's bed. Observation on 1/24/25 at 1:07 P.M. showed quarter side rails in the raised position on both sides of the resident's bed. During an interview on 1/24/25 at 1:07 P.M., the resident said he/she used the side rails to roll over and get up out of bed. During interview on 01/23/25 at 1:10 P.M., the DON said the following: -Staff should obtain consent prior to initiating the bed rails; -She was responsible for completing the bed rail assessments. The assessments should be completed prior to using the side rails. 50189 51988

Based on observation and interview, the facility failed to ensure insulin (a medication used to treat diabetes) vials/pens for two residents (Residents #2 and #58), were dated when opened or discarded within the designated time frame after opening. The facility failed to secure a schedule IV controlled substance (a medication subject to abuse) in a separately locked compartment, failed to timely destroy expired medications, and failed to destroy one expired resident's (Resident #300's) medications. The facility census was 59. 1. Review of the Drugs.com showed the following: -Use Humalog (a rapid acting injectable insulin used to treat diabetes) within 28 days of opening; -Use Basaglar (a long-acting injectable insulin used to treat diabetes) within 28 days of opening. Observation of the east hall medication room and east hall nurse's medication and treatment cart on 01/23/25 at 5:16 A.M., showed the following: -One bottle containing 29 milliliters (ml) of liquid Ativan (a medication used to treat anxiety), labeled for Resident #1, was located in the unlocked refrigerator in the medication room; -One Basaglar Kwikpen, in use and labeled for Resident #2, was 1/2 full and was not labeled with an open date; -One vial of Humalog insulin, in use and labeled for Resident #58, was 3/4 full and was dated as opened 12/01/24 (opened 54 days, the medication was not discarded within 28 days after opening); -One card containing ten tablets of Xanax (a medication used to treat anxiety) 0.25 milligrams was in the locked emergency narcotic box and had an expiration date of 12/20/24. 2. Observation of the west medication room on 01/23/25 at 10:41 A.M., showed the following: -Two unopened boxes of albuterol sulfate (medication used to treat wheezing and shortness of breath) inhalation solution 0.5 mg/3 mg per 3 ml labeled with Resident #300's name. (Resident #300 expired on 10/20/24); -One opened bottle of nystatin topical powder (antifungal medication) expired 02/24; -One opened box of albuterol sulfate inhalation solution 0.083% 2.5 mg/3 ml expired 09/24. During an interview on 01/23/25 at 10:50 A.M., the Infection Preventionist/MDS Coordinator said certified medication technicians (CMTs) were to notify a nurse as soon as possible after a resident expired so the medication could be destroyed. 3. During an interview on 01/23/25, at 5:41 A.M., Licensed Practical Nurse (LPN) F said the following: -He/She was usually responsible for checking the medication rooms and carts for expired medications when he/she had time; -Ultimately, every nurse and certified medication technician (CMT), was responsible to check the medication room and carts for expired medications; -Staff should date insulin vials and pens when opened; -Insulin was good for 28 days once opened; -Two nurses should destroy expired medications; -Resident #1's Ativan was stored in the refrigerator in the medication room, and the refrigerator did not lock. During an interview on 01/28/25, at 3:29 P.M., the Director of Nursing (DON) said the following: -All licensed nursing staff had access to the medication rooms and carts and should check for expired medications; -The pharmacist also checked for expired medications on their monthly reviews; -Staff should check the emergency kits for expired medications; -Liquid Ativan should be stored in the refrigerator. The refrigerator did not lock; -Liquid Ativan should be under double lock.

Based on observation, interview, and record review, the facility failed to propel three residents (Resident 28, #17, and #11), in wheelchairs equipped with foot pedals, in a review of 22 sampled residents. The facility census was 59. 1. Review of Resident #28's significant change in status Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/14/24, showed the following: -Severe cognitive impairment; -Diagnoses included new dementia and contractures (muscle tightening restricting range of motion due to non use) right knee and left knee, -Dependent on wheelchair mobility; -Two or more non injury falls. Review of the resident's Social Services progress note, dated 12/03/2024, at 8:24 A.M., shoed the Social Services Director documented when up in his/her wheelchair, the resident will at times propel himself/herself. Observation on 01/23/25, 6:30 A.M., showed Certified Nurse Assistant (CNA)/Certified Medication Technician M propelled the resident in his/her wheelchair from his/her bedside, out of his/her room and approximately 20 feet down the hall. The resident's feet slid on the floor, making a sliding sound. The resident did not have foot pedals on his/her wheelchair. The staff did not apply foot pedals, cue the resident, or ensure the resident's feet were safe when there was audible sliding sounds while CNA/CMT M propelled the resident. During an interview on 01/23/25, at 8:05 A.M., CNA/CMT M said staff have been instructed to always make sure residents in wheelchairs have foot pedals before propelling their wheelchairs. Propelling a resident without foot pedals could cause injury to the resident's feet, or if the resident puts his/her feet down while the chair was moving it could eject them from their wheelchair. 2. Review of Resident #17's Care Plan, dated 06/08/23, showed the following: -Resident has potential for falls related to weakness, decreased mobility, poor safety judgment, and history of falls; -Resident uses wheelchair for long distances propelled by the resident. Review of the resident's, quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Dependent on staff for putting on/taking off footwear, to wheel his/her wheelchair 50 feet and make two turns, and dependent on staff to wheel his//her wheelchair 150 feet. The resident's care plan did not show evidence staff identified the resident required staff to propel his/her wheelchair long distances as reflected on his/her MDS 11/18/24. Observation on 01/22/25, at 09:45 A.M., showed the resident sat in his/her wheelchair. The wheelchair did not have foot pedals. Observation on 01/23/25, at 11:58 A.M., showed CMT N propelled Resident #17 from his/her room down the hall and into the dining room. The resident tried to hold his/her feet up. His/Her feet were barely off of the ground. Two times the resident could not hold his/her feet up and the wheelchair stopped when the resident's feet hit the floor. CMT N asked the resident to hold up his/her feet and continued down the hall. Observation on 01/23/25, at 03:19 P.M., showed the following: -The Wound Nurse and CNA/CMT M assisted the resident to the bathroom with a wheeled walker; -While in the bathroom the resident became unsteady; -CNA/CMT M assisted the resident to his/her wheelchair while in the bathroom; -CNA/CMT M propelled the resident from the bathroom back to his/her bed with no foot pedals on the wheelchair. The resident's feet touched the floor while CNA/CMT M pushed the resident's wheelchair. During an interview on 01/25/25, at 1:35 P.M., CMT N said he/she propelled residents without foot pedals in their wheelchair slowly while she walked behind the wheelchair. All residents have foot pedals for their wheelchairs, and staff should use foot pedals when propelling residents in the wheelchair to prevent injuries. Staff get busy and do not get the wheelchair foot pedals. 3. Review of Resident #11's face sheet showed the resident had a diagnosis of rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein into the blood and can cause muscle weakness and muscle aches). Review of the resident's quarterly MDS, dated [DATE], showed the following: -Used a wheelchair for mobility; -Independently with wheelchair mobility. Review of the resident's care plan, revised 11/18/24, showed the following: -Potential for falls related to weakness, decreased mobility, poor safety judgment and history of falls; -Propels self in wheelchair. Will ask for assistance as needed. Observation on 01/22/25, at 12:09 P.M., showed the Social Services Director (SSD) pushed the resident from his/her room down the hallway, approximately the distance of ten rooms. The resident did not have foot pedals on his/her wheelchair. The resident's right foot was crossed over his/her left foot and drug the floor approximately half the distance as staff pushed the resident in the chair During an interview on 1/24/25 at 4:14 P.M., the Social Services Director said the following: -If a resident was able to self-propel in a wheelchair, staff do not put foot pedals on the wheelchair; -Resident #11 typically self-propelled himself/herself in the wheelchair; -On 1/22/25, he/she thought the resident held his/her feet up and did not realize the resident's foot dragged on the floor. 4. During an interview on 01/28/25, at 3:29 P.M., the Director of Nursing (DON) said the following: -If staff pushed a resident a short distance in a wheelchair, staff could tell the resident to hold up their feet and staff could safely push them; -If staff pushed a resident in a wheelchair a long distance, the wheelchair should have foot pedals; -If staff pushed a resident and the resident's feet dragged on the floor, staff should no longer push the resident to avoid injury. During an interview on 01/28/25, at 4:45 P.M., the Administrator said the following: -Staff should not propel the residents in a wheelchair without foot pedals on the chair; -At times, it can be hard for staff to determine who should have foot pedals because some residents can propel themselves; -There were bags on the wheelchairs for the foot pedals. 42592

Based on observation, interview, and record review, the facility failed to follow proper technique for medication administration of insulin pens and eye drops for three residents (Resident #2, #58, and #21), in a review of 22 sampled residents. The facility census was 59. 1. Review of resident #58's Continuity of Care Document (CCD) showed a diagnosis of diabetes mellitus (too much sugar in the blood stream). Review of the resident's care plan, dated 12/26/24, showed the following: -The resident had diabetes; -Administer insulin as ordered. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 01/22/25, showed the resident received seven insulin injections in the last seven days. Observation on 01/23/25 at 7:00 A.M., showed the following: -Registered Nurse (RN) B administered 40 units of Tresiba (an injectable long-acting insulin used to treat diabetes mellitus) insulin via pen to Resident #58; -Immediately after administering the dose, RN B removed the needle and did not wait for a count of five or six after administration. Review of the Tresiba administration instructions for use on Tresiba.com showed to give an injection, wipe the skin with an alcohol swab and let dry, insert the needle in desired spot, press and hold the dose button, after the dose counter reaches zero, slowly count to six. 2. Review of Resident #2's CCD showed a diagnosis of diabetes mellitus. Review of the resident's quarterly MDS, dated [DATE], showed the resident has a diagnosis of diabetes mellitus and received seven insulin injections in the last seven days. Observation on 01/23/25 at 6:50 A.M., showed the following: -RN B administered eight units of Humalog (an injectable fast-acting insulin used to treat diabetes) insulin via Kwikpen to Resident #2 ; -Immediately after administering the dose, RN B removed the needle and did not wait for a count of five after administration. Review of the Humalog KwikPen administration instructions, for use on [NAME] Lilly and Company website (maker of Humalog KwikPen), showed to give an injection, wipe the skin with alcohol swab and let dry, insert the needle into the skin, push the dose knob in and slowly count to five before removing the needle. During an interview on 01/24/25 at 11:56 A.M., RN B said he/she usually held the insulin pen for a count of five or six and thought he/she did with both of the injections. 3. Review of Resident #21's CCD showed an order for ketotifen/an eye drop used to treat itchy eyes and discomfort caused by allergies) 0.025% drops, instill one drop into both eyes two times a day for allergic conjunctivitis (eye inflammation caused by allergies). Observation on 01/23/25 at 6:07 A.M. showed the following: -Certified Medication Technician (CMT) C explained to the resident he/she had the resident's eye drops to administer; -CMT C pulled the resident's lower eye lid down and administered one drop of ketotifen to the left eye and then repeated the process with the right eye; -CMT C then wiped the excess from the resident's face with a tissue and walked away from the resident; -CMT C did not hold any pressure to the lacrimal gland or encourage the resident to keep his/her eyes closed for any period of time. Review of administration of Ketotifen ophthalmic eye drops, on Medlineplus.gov, showed to instill the eye drops, pull down the lower lid of the eye to form a pocket, instill the ordered about of drops, close the eye for two to three minutes, place a finger on the tear duct and apply gentle pressure and wipe any excess liquid from they face with a tissue. During an interview on 01/24/25 at 1:28 P.M., CMT C said the following: -When administering eye drops, pressure should be held for a couple of seconds to make sure the medication gets into the eye appropriately; -He/She did not hold pressure when administering the resident's eye drops and should have. During an interview on 01/24/25 at 3:30 P.M., the Director of Nurses (DON) said she would expect medication to be administered following professional standards of practice. 42592

Based on observation, interview, and record review, the facility failed to provide restorative nursing services to assist one resident (Resident #28), in a review of 22 sampled residents to attain or maintain his/her their highest level of functioning. The resident admitted to the facility free of contractures and had no limits in range of motion. The facility did not have a system to identify residents at risk for a decrease in range of motion or prevent development of contractures (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). The facility failed to develop restorative nursing plans with goals to prevent the development of contractures, improve or maintain functional range of motion, or direction to staff to meet the resident's needs. Resident #28 had a decrease in her range of motion abilities. The facility census was 59. During an interview on 01/24/25, the Director of Nursing (DON) said the facility does not have a policy for range of motion, contractures, or prevention/improvement of contractures. Review of the list of resident's on a restorative nursing program in the facility did not include Resident #28. Review of Resident #28's admission Minimum Data Set (MDS's), federally mandated assessment instruments to be completed by facility staff, from 10/22/18 (first admission to facility) to 03/18/24, showed the facility assessed the resident with no limits in range of motion. Review of the resident's Nurses Progress Notes, dated 03/07/24, at 7:05 P.M., showed the resident was found on the floor leaning towards his/her left side. Staff assisted the resident to a partial standing stance (due to contracted knees). Review of the resident's annual MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Diagnoses included heart dysrhythmia (abnormal heart beat), and diabetes mellitus (inability to control blood sugar); -Independent with eating, oral hygiene, toilet hygiene, putting on/taking off footwear, personal hygiene, roll left and right, sit to lying, lying to sitting, sit to stand, chair/bed to chair transfer, and toilet transfer; -Set up or clean up assistance from staff for upper and lower body dressing; -Required partial/moderate assistance from staff for tub/shower transfer; -Required substantial/maximal assistance from staff for shower/bathe; -Used a wheelchair independently; -Two or more no injury falls and one injury fall; -No limitation in functional range of motion (ROM); -Restorative range of motion and walking one day. Review of the resident's Nurses Progress Notes, dated 3/25/24, at 4:00 P.M. showed the resident had a lack of safety awareness and still believed at times he/she can walk. Resident's knees were contracted, but was still able to transfer self. Review of the resident's significant change in status MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Diagnoses included new dementia, and contractures of the right knee and left knees; -No behavior or rejection of care; -Independent with roll left and right, sit to lying, lying to sitting; -New limited ROM to both lower extremities; -Requires substantial/maximal assistance from staff for toilet hygiene, lower body dressing, putting on/taking off footwear; -Dependent on staff for sit to stand, chair/bed to chair transfer, toilet transfer, tub/shower transfer, and wheelchair mobility; -Two or more non injury falls; -No therapy or restorative nursing services; -Bed alarm and chair alarm used daily. Review of the resident's Physician's Orders, dated 12/24/23 to 01/24/25, showed the resident did not have an order for physical therapy to evaluate or treat. Review of the resident's quarterly MDS, dated [DATE], showed limited range of motion both lower extremities. Review of the resident's MDS's showed he/she admitted without contractures at the facility. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Independent with wheelchair mobility; -Limited ROM in both lower extremities; -Required partial/moderate assistance from staff for roll left and right -Dependent on staff for toilet hygiene, shower/bathe, lower body dressing, putting on/taking off footwear, -New pain medication and non pharmacological interventions for pain. Observation on 01/22/25, at 10:23 A.M., showed the following: -The resident lay in a low bed; -The resident wore no pants and was partially covered with a sheet; -The resident's legs were drawn up in a fetal position with his/her head leaning to the right side; -The resident had contractures at the knee and hip; -Staff came into the resident's room and assisted him/her to move, the resident was unable to straighten his/her legs. During an interview on 01/23/25, at 8:00 A.M., Certified Nurse Assistant (CNA)/Certified Medication Technician (CMT) M said the resident was contracted at the knees and hips. During an interview on 01/24/25, at 12:08 P.M., the Director of Nursing (DON) said the following: -The facility does not have a policy for range of motion, contractures or prevention/improvement of contractures; -She ensured residents who have a restorative program are appropriate, re-evaluated their programs and oversees the restorative aide; -Therapy can refer residents to restorative when they discontinue therapy services; -Residents get some range of motion with daily cares, getting dressed and taking showers; -The facility did not put residents on a restorative program because of limits with range of motion; -There was nospecific care program for residents with or at risk for contractures; -Resident #28 was not on a restorative program and had contractures. 50189

Based on observation, interview and record review, the facility failed to ensure two residents (Resident #42 and #1), a review of 22 sampled residents, received care and treatment to promote healing and prevent new pressure ulcers (a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) from developing. Facility staff failed to update Resident #42's care plan, implement identified interventions needed to promote healing and prevent worsening of a wound, prevent direct pressure to a pressure wound, or provide pressure reducing surfaces to promote healing of his/her unstageable pressure ulcer to his/her right heel. The facility failed to implement a system to ensure low air loss mattresses, utilized for one resident with pressure ulcers (Resident #1) was maintained on the correct weight setting to promote healing. The facility census was 59. Review of the facility's policy, Pressure Ulcers/Skin Breakdown Clinical Protocol, last revised 2007, showed the following: -The nurse shall assess and document/report a full assessment of pressure ulcers including location, stage, length, width and depth, presence of exudates or necrotic tissue. The nurse shall document a pain assessment and the resident's current treatments, including support surfaces; -The physician will authorize pertinent orders related to wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.) and application of topical agents; -The physician will help identify medical interventions related to wound management; for example, treating soft tissue infection surrounding an ulcer, removing necrotic tissue, addressing comorbid medical conditions, managing pain related to the wound or to wound treatment, etc.; -During resident visits, the physician will evaluate and document the progress of wound healing-especially for those with complicated, extensive or non-healing wounds; -The physician will help the staff review and modify the care plan as appropriate, especially when wounds are not healing as anticipated, or new wounds develop, despite existing interventions. Review of the facility's policy, Prevention of Pressure Ulcers, last revised March 2005, showed the following: -Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area and subsequent destruction of tissue; -The most common site of a pressure ulcer is where the bone is near the surface of the body, including the back of the head, around the ears, elbows, shoulder blades, backbone, hips, knees, heels, ankles and toes; -Pressure ulcers are often made worse by continual pressure, heat, moisture, irritating substances on the resident's skin (i.e., perspiration, feces, urine, wound discharge, soap residue, etc.), decline in nutrition and hydration status, acute illness and/or decline in the resident's physical and/or mental condition; -The facility should have a system/procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician and family and addressed; -Identify risk factors for pressure ulcer development; -For a person in bed, determine if the resident needs a special mattress. If a special mattress is needed, use one that contains foam, air, gel, or water as indicated; -Ensure the resident drinks plenty of fluids and eats a well-balanced diet; -Routinely assess and document the condition of the resident's skin, per facility wound and skin care program, for any signs and symptoms of irritation or breakdown; -Immediately report any signs of a developing pressure ulcer to the supervisor; -The care process should include efforts to stabilize, reduce or remove underlying risk factors; to monitor the impact of the interventions; and to modify the interventions as appropriate; -Use pillows or wedges to keep bony prominences, such as knees or ankles, from touching each other; -When in bed, every attempt should be made to float heels (keep heels off of the bed) by placing a pillow from knee to ankle or with other devices as recommended by therapist and prescribed by the physician; -Dietitian will assess nutrition and hydration and make recommendations based on the individual resident's assessment. Monitor nutrition and hydration status. Monitor laboratory values notify physician when appropriate. Encourage proper dietary and fluid intake. If a normal diet is not possible, talk to physician about supplements. Administer vitamins, mineral and protein supplements in accordance with physician orders and dietitian recommendations; 38016 1. Review of Resident #42's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 02/02/24, showed the following: -Severe cognitive impairment; -Diagnosis of diabetes mellitus (inability to regulate blood sugar), osteoporosis (decrease in bone mass causing bones to be fragile) and dementia; -Independent with roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed to chair transfer, toilet transfer, tub/shower transfer and ambulation with a walker; -Requires partial/moderate assistance from staff for lower body dressing and putting on/taking off footwear; -Requires substantial/maximal assistance from staff for to shower/bathe self, -Receives insulin (medication to treat diabetes); -No pressure ulcers present. Review of the resident's care plan, dated 02/05/24, showed the following: -The resident will be free from skin breakdown with good skin integrity; -Assist resident out of bed three to four times a day; -Encourage and assist resident with turning and repositioning every two hours and as needed; -Inspect skin at least weekly during showers and as needed; -Report any reddened or open areas to the physician. (The care plan did not include any identified wounds.) Review of the resident's care plan, updated on 03/01/24, added feather tic mattress (a mattress made of strong, stiff, tightly woven material (ticking) that was filled to make a mattress. Typically then laid over a firmer, non-feather mattress) on bed. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Required supervision/touching assistance from staff members for sit to lying, lying to sitting on side of bed, sit to stand and tub/shower transfer; -Required substantial/maximal assistance from staff for lower body dressing; -Dependent on staff for putting on/taking off footwear. -No pressure ulcers present. Review of the resident's Nurses Progress Notes, dated 12/23/24 at 9:30 A.M., documented by the Wound Care Nurse, showed the following: -Skin inspection during a shower showed an open area noted to the resident's right heel; -The open area measured 2 centimeters (cm) in length by 1.5 cm in width, with a depth of 0.2 cm; -The tissue was 100% dark, soft tissue; the wound margins were not attached to the wound bed; -The resident's heel was soft and boggy to touch; -Peri-wound (area around the wound) is white in coloration (also known as macerated skin (macerated skin appears soft, wrinkled, white or gray and may feel soggy or spongy. The skin may also be translucent or waterlogged, and is caused by too much moisture to the skin.) that extends out 0.5 cm around the wound with heel being tender to touch; -Physician notified and requested a treatment order; -Nursing intervention will be in place to float the resident's heels while in bed; -Power of attorney notified of resident's skin condition. Review of the resident's Nurses Progress Notes, dated 12/23/24 at 3:11 P.M., documented by the Wound Care Nurse, showed physician's office notified of right heel; new order received to startbetadinee (germicide used to prevent infection in wounds) paint to the resident's right heel two times daily until healed, ordered by the nurse practitioner. Review of the resident's Physician's orders, dated 12/23/24, showed Betadine paint to the resident's right heel two times daily until healed. Review of the resident's care plan did not show an update that a wound was found or of the intervention to float the resident's heels. Review of the resident's Nurses Progress Notes, dated 12/31/24 at 12:03 P.M., documented by the Wound Care Nurse, showed the following: -Wound Assessment, measurements obtained on 12/30/24; -Resident lay in bed with his/her bilateral heels floating on a pillow; -Assessment completed to bilateral heels with no open areas noted to left heel with tissue being pink-blanchable and non-tender to touch; -The right heel open area measured 1 cm in length, 1.8 cm in width, with wound bed being 100% soft, dark-black eschar, with periwound being white in coloration (unstageable), tender to touch; -Goal will be to continue to relieve site of pressure with floating heels when in bed; -Resident has not been wearing his/her shoes to ambulate, instead, slip socks worn due to his/her shoes causing him/her discomfort and rubbing at site; -Treatment remains appropriate, slight improvement noted. Review of the resident's Nurses Progress Notes, dated 01/08/25 at 4:42 P.M., documented by the Wound Care Nurse, showed the following: -Wound Assessment: Resident lay in bed with bilateral heels floating on a pillow; -Area to right heel measures 1.2 cm in length, and 1.7 cm in width with wound margins well defined and attached to wound bed; -Resident yelled ouch upon the slightest touch; -No depth present; wound bed is 100% black eschar (unstageable; obscured full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar); -Peri wound is dry, no longer macerated to surrounding site; -Continuing all pressure relieving interventions which are heels floating when in bed, feather tic mattress in place; -Resident no longer wearing his/her shoes as the back was rubbing, causing resident to have sore feet; the resident prefers slip socks at this time; -Treatment remains appropriate as improvement was noted; -(The assessment showed a new finding of the left heel being soft and boggy.) Review of the resident's Nurses Progress Notes, dated 01/15/25 at 3:30 P.M., documented by the Wound Care Nurse, showed the following: -Wound Assessment: resident lay in bed with bilateral heels floating on a pillow; -Right heel has an area that measures 2.5 cm in length, and 2.3 cm in width, the tissue is dry with all aspects of wound margins lifting; -Resident denies tenderness; -Surrounding tissue pink, healthy and blanches upon touch. -(The assessment showed an increase in the size of the right heel wound, and no documentation to evaluate what caused the increase in dimensions.) Review of the resident's annual MDS, dated [DATE], showed the following: -Required supervision/touching assistance from staff members to roll left and right; -Required substantial/maximal assistance from staff for tub/shower transfer, (worsening activities of daily living (ADL)'s); -New, as needed pain medication and non-pharmacological interventions for pain; -Vocal complaints of pain, one to two days in the last five days; -New pressure ulcer, unstageable and new pressure ulcer care. Observation on 01/23/25 at 2:05 P.M., showed the following: -The Wound Care Nurse entered the resident's room; -The resident lay in his/her bed; -When the Wound Care Nurse pulled the resident's covers back, the resident's heels were pressed against a pillow and not floated on the pillow as the Nurses Progress Notes, dated 12/23/24, directed (pressing against the pillow would cause increased pressure); -The resident's bed did not have a pressure reducing mattress or the feather tic mattress as documented on the resident's updated, 03/01/24, care plan as being added; -The resident grimaced and moaned in pain when the Wound Care Nurse moved his/her leg; -The resident said his/her heels really hurt bad; -The Wound Care Nurse measured the area to the resident's right heel as 1.2 cm in length, 1.5 cm in width total area of the skin alteration; -The eschar dark area measured 0.5 cm in length, and 0.8 cm in depth, without being able to visualize if any depth was present, obscured view because eschar intact; -The resident's wound was not stained with Betadine; the resident's surrounding wound was normal skin color and no area had discoloration or the color of Betadine painting was present. 2. Review of Resident #1's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Diagnoses of Alzheimer's disease, dementia and anxiety disorder; -Lower extremity impairment on both sides; -Always incontinent of bowel and bladder; -Two Stage I pressure ulcers; -Application of ointments/medications other than to feet. Review of the resident's care plan, revised 11/14/24, showed the following: -Resident has periods of confusion/forgetfulness, which causes him/her to have difficulty thinking and making decisions; -Potential for skin breakdown related to decreased mobility, bowel and bladder incontinence; -Feather tick mattress on bed. Review of the resident's physician's orders, dated January 2025, showed the following: -Left buttocks: apply barrier cream twice daily and upon cares to protect tissue from urinary incontinence; -No treatment order for the right buttocks. Review of the resident's weight record, dated 01/01/25, showed the resident's weight was 159 pounds (72 kilograms). Review of the resident's wound assessment, dated 01/05/25 at 3:11 P.M., showed the following: -No open areas are noted on left buttocks; -Right buttocks at upper aspect of cleft, open area measures 2.4 cm by 1.5 cm with area having a depth of 0.1 cm with wound margins attached to wound bed (depth now noted - a new finding); -Wound is 100% pink, shiny tissue, with no drainage noted at this time-open area not directly attached to wound as tissue between is pink and healthy measures 0.6 cm by 0.5 cm that is circular in shape with wound bed being 100% pink healthy tissue with wound margins attached to wound bed. Review of the resident's wound assessment, dated 01/06/25 at 11:43 A.M., showed the following: -Areas reported at this time that were not present on yesterdays (01/05/25) assessment to right elbow, outer aspect; -Resident has two open areas proximal (nearer to the center or point of attachment to the body) site measures 1.3 cm by 0.8 cm that has no depth-wound bed is pink, shiny and moist with wound margins attached at the wound bed-distal area measures 0.4 cm by 0.5 cm with no depth, circular in shape and wound margins attached to wound bed-wound bed is 100% pink, shiny tissue; -Resident lays on a feather tick mattress with lamb's wool between arms; -Intervention: feather tick mattress will be removed from bed and air mattress (an alternating pressure mattress system used for the treatment of developed pressure ulcers as well as prevention of them) will be provided. Review of the resident's care plan showed no documentation regarding the development of open areas on the resident's right outer elbow and right buttock or the discontinuation of the feather tick mattress or the addition of an air mattress. Review of the resident's physician's orders, dated 01/06/25, showed no evidence of an order for an air mattress. Review of the resident's wound assessment, dated 01/16/25 at 7:14 P.M., showed the following: -Inner aspect of left elbow to anterior (front) aspect of the forearm tissue is pink and shiny, measures 6.5 cm by 2.5 cm that has an appearance of superficial tissue loss, surrounding tissue is pink and blanchable; -Posterior aspect of elbow to bony prominence site that is scabbing over, measuring 3.7 cm by 1.5 cm; (a noted worsening in measurements of the elbow areas); -Left buttocks dark pink tissue that blanches slowly to touch measures 8.5 cm by 3 cm and to right buttocks dark pink tissue that blanches slowly measuring 4.8 cm by 5.6 cm; -Open area to right buttocks measures 0.5 cm by 0.5 cm with wound bed being pink shiny epithelial tissue with wound margins attached to wound bed; -Noted that upon touch, wound bed is 100% firm with surrounding tissue being firm to touch-tender to touch; -All interventions will remain in place as resident has an air mattress in place and wedge pillow in place for positioning. Observation on 01/21/25 at 12:23 P.M., in the resident's room, showed the following: -The resident lay in bed on his/her back with his/her eyes closed; -A lowaire loss mattress was present on the resident's bed; -The mattress was set at 110-130 kg (242-286 pounds) (over inflated and too firm for the resident's weight). Review of the resident's weight record, dated 01/22/25, showed the resident's weight was 147 pounds (67 kg). Observation on 01/22/25 at 8:46 A.M., in the resident's room, showed the following: -The resident lay on his/her left side in bed with his/her eyes closed; -A low air loss mattress was present on the resident's bed; -The mattress was set at 110-130 kg (242-286 pounds) and overinflated Observation on 01/22/25 at 12:04 P.M., in the resident's room, showed the following: -The resident lay on his/her back in bed; -The resident was awake; -A low air loss mattress was present on the resident's bed; -The mattress was set at 110-130 kg (242-286 pounds) and over inflated. Observation on 01/23/25 at 12:26 P.M., in the resident's room, showed the following: -The resident lay in bed; -Staff provided pericare and changed the resident's gown; -A low air loss mattress was present on the resident's bed; -The mattress was set at 110-130 kg (242-286 pounds) and over inflated. Review of the resident's wound assessment, dated 01/24/25 at 9:58 A.M., showed the following: -Right great toe at distal end with a small blackened circular area that has appearance of a blood blister, measurements are 0.5 cm by 0.8 cm with peri wound being pink and blanchable and non-tender; -Wound bed is 100% soft, not boggy, black eschar with wound margins well defined and area being circular in shape; -Left elbow tissue overall is dry. Medially (towards the middle) is a scabbed area that measures 0.5 cm by 0.5 cm that is circular in shape and firm to touch. Wound bed is 100%, dull, rust coloration with peri-wound being pink and blanchable surrounding the site-no warmth noted, non-tender; -Right buttocks tissue does blanch, measures 4.4 cm by 5.0 cm and left buttocks is pink, blanchable tissue that measured 5.0 cm by 3.0 cm. During an interview on 01/23/25 at 8:40 A.M., Certified Nurse Aide (CNA) P said the following: -He/She did not know who monitored the settings on the low air loss mattresses; -CNA staff do not adjust the settings on the low air loss mattresses. During an interview on 01/23/25 at 3:12 P.M., the Wound Care Nurse said low air loss mattresses were set when first placed on the resident's bed. During an interview on 01/23/25 at 12:26 P.M. and 3:15 P.M., the DON said the following: -The resident weighs approximately 140 pounds; -The low air loss mattress was set too high for the resident's weight; -Staff should set the mattress by the resident's weight. During an interview on 01/23/25 at 2:20 P.M. the Wound Care Nurse said the following: -She oversees wound care, quality measures and various other areas; -If a resident has a pink area, she will add interventions, then place the resident on her list to monitor; -She notifies the MDS Coordinator, so the MDS Coordinator can update the care plan with all the interventions that added; -She implements a feather tick mattress if the resident needs one; -If a resident had chronic wounds, or many wounds, the resident will get a low air loss mattress; -She expected the CNAs or nursing staff to do the interventions that have been added; -Resident #42's heels were against the pillow during the observed assessment on 01/23/25; -She thought she had asked for a feather tic mattress for Resident #42, but she may have missed asking them to put one on; -If the feather tic mattress was on Resident #42's bed, and staff removed it, staff are expected put it back on; -She expects staff to let her know if they took off an intervention for any reason; -If a resident is getting a betadine paint to a wound, the skin was usually yellow, and Resident #42's was not; -Resident #42 should have had a feather tick mattress and his/her heels floated, not against the pillow. During an interview on 01/23/24 at 3:15 P.M. and 01/28/24, at 3:33 P.M., the Director of Nursing said the following: -Any resident with a pressure ulcer should have a feather tic mattress; she did not have information on the brand or where they purchased the feather tic mattress overlays; -She expected low are loss mattresses to be set to a resident's weight; -She expected staff to ensure a resident's heels do not have direct pressure with a pillow under the heels; the heels should be off the pillow and mattress if heels are to be floated. 50189

Based on observation, interview, and record review, the facility failed to assess the use of pressure alarms used in a resident's bed and chair as a restraint for one resident (Resident #48), in a review of 22 sampled residents. The facility implemented the pressure alarms upon the resident's admission to the facility as an intervention to prevent falls. Staff documented the alarms caused the resident to become agitated. The resident expressed he/she hated the alarms and felt restrained to his/her chair and trapped. The facility census was 59. 1. Review of Resident #48's undated Continuity of Care Document (CCD), showed the following: -Diagnoses included dementia with behavioral disturbances, Parkinsonism (a clinical syndrome characterized by tremors (involuntary shaking), bradykinesia (slowness of movement), rigidity (stiffness), difficulty maintaining balance), delusional disorders, need for assistance with personal care, weakness, abnormalities of gait and mobility, repeated falls, muscle weakness, major depressive disorder, and restless leg syndrome; -The resident has a durable power of attorney for healthcare decisions. Review of the resident's Progress Notes, dated 6/8/24 at 10:10 A.M., showed the resident required two staff with a gait belt and walker to transfer. He/She did not remember to use the call light, so a pressure alarm was in place on both his/her bed and chair. It was noted that when the pressure alarm was going off, the resident was found up and walking without assistance. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 6/13/24, showed the following: -Severe cognitive impairment; -No inattention, disorganized thinking, or altered level of consciousness; -No behaviors, rejection of care, or wandering; -Utilized a walker and wheelchair for mobility; -Dependent on staff for ambulation and wheelchair mobility; -Had one fall within a month of admission; -Bed alarm and chair alarm used daily. Review of the resident's Progress Notes, dated 6/25/24 at 6:05 P.M., showed the resident was found standing and going through his/her closet without assistance. His/Her pressure alarm was sounding. Staff redirected the resident back to his/her recliner and put the pressure alarm back in place for safety. Review of the resident's Progress Notes, dated 7/2/24 at 12:43 P.M., showed the resident had behaviors of moodiness. Reported behaviors included shutting off his/her pressure alarm and throwing it onto the other bed in the room. Staff replaced the pressure alarm in his/her chair resulting in the resident becoming agitated and saying his/her spouse said he/she did not need that. Staff explained to the resident that his/her spouse wanted the pressure alarm for safety due to being a fall risk, his/her lack of safety awareness, and not using the call light. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -No inattention, disorganized thinking, or altered level of consciousness; -No behaviors, rejection of care, or wandering; -Utilized a walker and wheelchair for mobility; -Supervision or touching assistance for ambulation; -Independent for wheelchair mobility; -Bed alarm and chair alarm used daily. Review of the resident's care plan, updated on 12/6/24, showed the following: -He/She required limited to extensive assistance with activities of daily living; -He/She walked with a walker and assist of one or two staff with a gait belt; -Pressure alarm at all times; -Potential for falls related to weakness, decreased mobility, poor safety judgement, antidepressant therapy and history of falls; -Encourage the resident to wait for assistance and answer call light promptly; -The resident had periods of confusion/forgetfulness, which caused difficulty thinking and decision making. Review of the resident's medical record showed no evidence staff evaluated the use of the bed alarm and chair alarm as a restraint prior to implementing the alarms or after the resident became agitated and upset after the alarms were utilized. Observation on 1/21/25 at 12:57 P.M. showed the resident sat on a pressure alarm in his/her recliner in his/her room. During an interview on 1/21/25 at 12:57 P.M., the resident and his/her spouse said the following: -The resident admitted to the facility due to falls at home; -He/She had not had any falls since admission; -He/She had a bed and chair alarm due to a history of falling. Observation on 1/22/25 at 1:07 P.M. showed the resident sat in his/her recliner chair in his/her room with a pressure alarm in place in the recliner. Observation on 1/23/25 at 5:26 A.M. showed the resident lay on a pressure alarm in bed. Observation on 1/23/25 at 6:17 A.M. and 2:52 P.M. showed the resident sat in his/her recliner chair in his/her room with a pressure alarm in place in the recliner. During an interview on 1/24/25 at 1:12 P.M., the resident's spouse said the following: -The resident had the bed and chair alarms since he/she was admitted ; -The resident did not like the alarms; -The resident had a lot of falls at home and didn't remember to use the call light, which was why he/she needed the alarms. During interviews on 1/24/25 at 1:12 P.M. and 4:46 P.M., the resident said the following: -He/She hates the alarms; -The alarm made him/her afraid to get up, because when it goes off, everyone came running; -He/She felt restrained to the chair; he/she just wanted to be able to get up and use the bathroom; -He/She thought it was ridiculous to be trapped in the chair and almost pee yourself, because sometimes it took staff a while to answer the call lights; -He/She felt trapped, which made him/her mad because all he/she wanted was some freedom; -He/She wanted to do better and be safe, but did not want to be trapped in the same spot all day. During an interview on 1/28/25 at 3:29 P.M. the Director of Nursing (DON) said the following: -The facility did not currently have any restraints in use; -A restraint was something that prevented a resident from doing something. She did not feel the chair or bed alarms prevented residents' movement. During an interview on 1/28/25 at 4:45 P.M. the Administrator said she did not consider an alarm to be a restraint. 50189

Based on observation, interview, and record review, the facility failed to have a system in place to ensure residents, including one resident (Resident #13), with diagnosis of post traumatic stress disorder (PTSD - a mental health condition triggered by a terrifying event, either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event), were assessed and received trauma informed care to mitigate or eliminate triggers that may cause retraumatization of the resident. The facility's census was 59. Review of email communication, dated 02/05/25 at 4:52 P.M., showed the Director of Nursing (DON) wrote the facility did not have a policy for trauma informed care or care for residents with PTSD. 1. Review of the resident's face sheet showed the following: -Current admitted [DATE]; -Diagnoses of PTSD and major depressive disorder. Review of the resident's care plan, updated 08/15/23, showed the following: -Resident has verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others); -Resident will not threaten, scream at, or curse at other residents, visitors, and/or staff; -Avoid power struggles with resident. Leave the room. Do not argue with resident; -Inform the Charge Nurse and Management of resident's behaviors. Set expectations and limits for resident; -Investigate the reasoning for the behavior; -Maintain a calm environment and approach to the resident. Review of the resident's care plan, last reviewed/updated 11/6/24, did not include information about the resident's PTSD triggers or interventions to prevent the resident from experiencing further re-traumatization related to his/her diagnosis of PTSD. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 01/26/24, showed the following: -Moderate cognitive impairment; -Diagnosis of PTSD, anxiety, and depression; -The resident did not have a PASARR screening completed; -No difficulties hearing; -No behaviors or rejection of care; -Very important to the resident to have activities involving pets and keeping up with the news; -Somewhat important to the resident to have activities and to go outside when the weather was nice. Review of the resident's medical record, including physician notes and social service notes, showed no documentation regarding the resident's PTSD. The resident's record contained no trauma informed care assessment, and did not address how to care for the resident related to the resident's PTSD. Review of the resident's electronic medical record, under the document tab labeled social services, a document was saved as the DA124C (the states Level I screening form), when the document opened it showed a face sheet and hand written at the top of the face sheet a staff member wrote not needed a VA resident. During an interview on 01/21/25 at 1:43 P.M. and 01/24/25 at 2:00 P.M., the resident said the following: -He/She was in the military during the war and laid on the battle field for four hours with 14 holes in him/her from shrapnel. The shrapnel hit the artery behind his/her knee and he/she thought he/she was would die. The resident shared how much this experience had affected him/her. His/Her spouse was a retired nurse and had helped him/her deal with the PTSD. The resident said he/she did not receive counseling at the facility, his/her spouse was a retired nurse and helped him/her deal with the PTSD; -He/She cannot take the commotion in the dining room, just stays in his/her room and eats all meals in his/her room. If there was too much going on, he/she felt overwhelmed. He/She did not want to go to group activities and the facility did not offer any in room activities so he/she watched television with his/her spouse. Observations throughout survey, from 01/21/25 to 01/24/25, showed the resident did not leave his/her room for activities or meals. During an interview on 01/28/25 at 12:59 P.M., the MDS Coordinator said the following: -The resident did not have a Level I screening that she could find; -She was not sure if the resident had triggers with his/her PTSD; -The care plan should include any special care needs for behaviors or triggers for PTSD for staff to follow; -She was not sure if the care plan included those behavioral issues or if the resident's PTSD was included in the resident's care plans. During an interview on 01/28/25 at 3:33 P.M., the DON said the following: -There were no specific interventions related to residents with PTSD: -Triggers that might cause the resident to remember or have flash backs of their trauma were probably not in the care plan, but staff knew these by word of mouth; -Staff were still learning some of the residents' triggers; -The facility only knew what a resident's triggers were when family shared these with facility staff; -Once staff knew the residents, this would be added to information on the report sheet; -New staff would be told by current staff; -Triggers and behaviors would be good to have on the care plan, but they may not be on the care plan; -The facility did not monitor triggers or specific behaviors as much as the staff were monitoring for side effects of medications. During an interview on 01/28/25 at 3:33 P.M., the Administrator said the facility took care of veterans. Every resident was treated as if they had PTSD.

Based on interview and record review, the facility failed to provide a written notice of bed hold policy with required information to the resident and/or resident representative for three residents (Resident #13, #61, and #48), in a review of 22 sampled residents, when the residents were transferred to the hospital for medical evaluation and treatment. The facility census was 59. 1. Review of Resident #13's undated Face Sheet showed the resident had emergency contacts that were his/her family members. Review of the resident's annual Minimum Data Set (MDS), a federally required assessment completed by staff, dated 1/26/24, showed the resident had moderate cognitive impairment. Review of the resident's Nursing Progress Notes, dated 04/05/24 at 8:00 P.M., showed the resident had a temperature of 101-102 degrees Fahrenheit (normal 98.6 degrees) and was sent to the hospital for evaluation. The resident was admitted with Coronavirus 2019 (COVID-19, respiratory infection) and hip pain. Review of the resident's medical record showed no documentation the facility provided the resident or the resident's representative with a bed hold policy when he/she admitted to the hospital on 4/5/24. 2. Review of Resident #61's face sheet showed the resident had a durable power of attorney (DPOA) for health care. Review of the resident's Progress Notes, dated 1/15/25 at 11:06 A.M., showed the resident was working with therapy and became very short of breath and had to be put on his/her oxygen at 3.5 liters per nasal cannula. The resident's family member was present and insisted the resident be seen at the emergency room . The resident was sent to the hospital via private car due to family choice of emergency room . Review of the resident's Progress Notes, dated 01/17/25 at 4:01 P.M., showed the resident returned to the facility (from the hospital) at 2:00 P.M. Review of the resident's medical record showed no documentation the facility provided the resident or the resident's representative with a bed hold policy when he/she admitted to the hospital on 1/15/25. 3. Review of Resident #48's Face Sheet, showed the resident had a durable power of attorney for healthcare decisions. Review of the resident's Progress Notes, dated 7/16/24 at 8:55 A.M., showed the resident was unable to ambulate or sit up right, continually leaning to the left and coughing, non-productively. Ambulance called for transport to hospital for evaluation. Review of the resident's Progress Notes, dated 7/16/24 at 3:28 P.M. showed the resident was admitted to the hospital. Review of the resident's Progress notes, dated 7/30/24 at 1:15 P.M. showed the resident returned to the facility (from the hospital). Review of the resident's Progress Notes, dated 9/17/24 at 2:32 P.M. showed the resident's family member reported the resident had an episode where his/her head, neck, and arms hyperextended and he/she quit breathing for a moment. Vital signs showed a pulse of 47. Review of the resident's Progress Notes, dated 9/17/24 at 3:29 P.M., showed the decision was made to send the resident to the hospital for further evaluation. Review of the resident's Progress Notes, dated 9/17/24 at 3:46 P.M. showed the ambulance arrived and the resident was transferred to the hospital. Review of the resident's Progress Notes, dated 9/23/24 at 2:17 P.M. showed the resident was being discharged from the hospital after being admitted for a cardiac dysrhythmia (irregular heartbeat) and syncopal episodes (sudden and temporary loss of consciousness that typically resolves quickly), and having a pace maker inserted. Review of the resident's Progress Notes, dated 9/23/24 at 4:00 P.M. showed the resident returned to the facility. Review of the resident's medical record showed no documentation the facility provided the resident's representative with a bed hold policy when he/she admitted to the hospital on 7/16/24 and 9/17/24. 4. During an interview on 01/23/25 at 9:06 A.M., the Director of Nursing (DON) said the facility did not give bed hold information to residents or representatives because they do not do bed holds. The facility takes all residents back. During an interview on 01/28/25, at 4:45 P.M., the Administrator said the facility did not issue a bed hold policy with transfers/discharges and was unaware of a requirement a bed hold notice had to be issued with transfers/discharges. 42592 50189

Based on interview and record review, the facility failed to provide a written notice of discharge with required information to the resident and/or resident representative for two residents (Residents #13 and #48), in a review of 22 sampled residents, when the facility initiated a transfer to the hospital. The facility did not provide any other written documentation to the resident or resident representative of the reason and date for transfer/discharge, where the resident was transferred/discharged , ombudsman contact information, information on how to appeal a transfer/discharge, or how to contact the mental health advocacy group for residents with intellectual disabilities or mental illness. The facility census was 59. Review of the undated facility policy, Discharges, showed the following: -Social services will ensure that when the facility anticipates discharging a resident, that the resident is able to make their own choices regarding discharge plans; -Family/Power of Attorney will be involved in the discharge plan and given information; -Their attending physician will also be notified; -Information regarding their right to appeal the discharge will be given to the resident, family or responsible party. 1. Review of Resident #13's face sheet, showed the resident had emergency contacts who were his/her family members. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 01/26/24, showed the resident had moderate cognitive impairment. Review of the resident's Nursing Progress Notes, dated 04/05/24 at 8:00 P.M., showed the resident had a temperature of 101-102 degrees Fahrenheit (normal 98.6 degrees) and was sent to the hospital for evaluation. The resident was admitted with Coronavirus Disease 2019 (COVID-19) (respiratory virus) and hip pain. Review of the resident's medical record showed no documentation the facility issued the resident a written notice of transfer to the hospital. 2. Review of Resident #48's Face Sheet, showed the resident had a durable power of attorney for healthcare decisions. Review of the resident's Progress Notes, dated 7/16/24 at 8:55 A.M., showed the resident was unable to ambulate or sit up right, continually leaning to the left and coughing, non-productively. Ambulance called for transport to hospital for evaluation. Review of the resident's Progress Notes, dated 7/16/24 at 3:28 P.M. showed the resident was admitted to the hospital. Review of the resident's Progress notes, dated 7/30/24 at 1:15 P.M. showed the resident returned to the facility (from the hospital). Review of the resident's Progress Notes, dated 9/17/24 at 2:32 P.M. showed the resident's family member reported the resident had an episode where his/her head, neck, and arms hyperextended and he/she quit breathing for a moment. Vital signs showed a pulse of 47. Review of the resident's Progress Notes, dated 9/17/24 at 3:29 P.M., showed the decision was made to send the resident to the hospital for further evaluation. Review of the resident's Progress Notes, dated 9/17/24 at 3:46 P.M. showed the ambulance arrived and the resident was transferred to the hospital. Review of the resident's Progress Notes, dated 9/23/24 at 2:17 P.M. showed the resident was being discharged from the hospital after being admitted for a cardiac dysrhythmia (irregular heartbeat) and syncopal episodes (sudden and temporary loss of consciousness that typically resolves quickly), and having a pace maker inserted. Review of the resident's Progress Notes, dated 9/23/24 at 4:00 P.M. showed the resident returned to the facility. Review of the resident's medical record showed no documentation the facility provided the resident's representative with a written notice of transfer when the resident was transferred to the hospital on 7/16/24 and 9/17/24. 3. During an interview on 01/23/25 at 9:06 A.M., the Director of Nursing (DON) said the following: -The facility did not provide a written notice of transfer for facility-initiated transfers; -She did not know they were supposed to issue a written notice of transfer; -Staff calls the family and verbally lets them know when a resident is going to the hospital; -She did not think the families get information on how to appeal, ombudsman contact information, or information on mental health advocacy on facility initiated transfers. During an interview on 01/28/25 at 4:45 P.M., the Administrator said the facility did not issue a written notice of transfer (when a resident was transferred to the hospital) and was unaware there was a requirement written transfer notices had to be issued. 42592 50189

Based on observation, interview, and record review, the facility failed ensure food items were labeled, dated, covered or discarded when expired; failed to ensure staff utilized sanitary practices when handling ready to eat food items; and failed to ensure staff wore hair restraints to cover exposed hair. The facility census was 59. 1. Review of the undated facility policy, Food Labeling and Dating and Closure, showed the following: -All foods placed in dry storage, refrigerated and freezer units must be dated with date opened/placed, use by date (UBD) and initials and sealed with an approved tie; -Dietary staff and/or any staff member placing items for dietary or resident must follow this procedure; -Dietary staff and/or any staff member receiving food from family for a resident must follow this procedure and inform the family that the item will only be kept for three days; -Any item placed in dry storage, refrigerated and freezer units that has been opened must be sealed (not just folded over) to ensure freshness and have a label (you may write with marker if packaging allows) with the date opened/placed, UBD and your initials. Day 1 is the day opened or made-add six days. Example: ,d+[DATE] you opened pears UBD would be ,d+[DATE]; - Items will be discarded the day after the UBD or label is not properly filled out. Observation on [DATE] at 10:31 A.M. of the walk-in cooler showed the following: -A plastic container appeared to contain shredded carrots and was dated ,d+[DATE], and labeled Friday supper; -An open package of raisins was undated. The open edge of the package was folded over but unsealed; -A large plastic bag containing two bagels was sealed and undated; -A container of pancake batter was dated ,d+[DATE]. Observation on [DATE] at 10:34 A.M. of the dry storage room in the kitchen showed an individual plastic bag of white cheddar popcorn was open to air and sat on the bottom shelf of a silver cart. The popcorn was not dated or sealed. Observation on [DATE] on 10:40 A.M. of the refrigerator located in the east dining room showed two clear round containers sat in the refrigerator door and were labeled Fr bar (fruit bar) and were dated ,d+[DATE]. Observation on [DATE] at 9:57 A.M. in the refrigerator and on counter tops located in the west dining room kitchenette, showed the following: -A clear plastic container held meat, green beans and potatoes and was labeled with a resident's name and was undated; -A large pizza box contained half of a pizza and was labeled with a first name and was undated; -A large plastic container with a label that read Baby Spinach contained five chocolate chip cookies. The container was labeled with a resident name and was undated; -A pink rectangular box of almond macaroon cookies contained three cookies inside and was open to air and unsealed. The box was undated; -One hot dog bun sat inside a zippered plastic bag on top of a container of chocolate chip cookies. The hot dog bun was undated. 2. Review of the undated facility policy, Read to Eat Food, showed the following: -Guideline: To ensure ready to eat food is handled properly to avoid cross contamination; -Definition: Ready to eat food is defined as food that will not be cooked or reheated before serving; -Examples: bread items, cookies, donuts, fresh vegetables, and many more; -Dietary staff preparing, serving or delivering food to residents must use utensils, tongs, deli paper or sanitary gloves when dealing with a ready to eat food item. -Nursing staff or any other person helping to prepare, serve, deliver, or assist with feeding must use utensils, tongs, deli paper or sanitary gloves when dealing with a ready to eat food item; -All staff assisting a resident with cutting their food must use utensils, tongs, deli paper or sanitary gloves. No bare hands may touch the food a resident will be eating. Observation in the kitchen on [DATE] at 6:15 A.M., showed the following: -Dietary Staff O did not wear gloves while preparing the donuts for breakfast; -As he/she put icing on the donuts, three of the donuts slid towards the end of the plate. He/She touched and moved the donuts back onto the plate with this/her bare fingers. Observation on [DATE], at 7:40 A.M., showed the following: -Nursing Assistant (NA) L fed Resident #44 his/her breakfast; -NA L picked up half the donut with his/her bare hand, and gave it to the resident to eat; -NA L coughed into his/her left hand and he/she assisted the resident to eat. He/She did not perform hand hygiene; -NA L picked up the other half of the donut with his/her bare hand, and gave it to the resident to eat. -NA L did not perform hand hygiene as he/she fed the resident. Observation on [DATE], at 12:24 P.M., showed the following: -Activity Aide M fed Resident #44 his/her lunch; -Activity Aide M touched the resident's biscuit with his/her bare hand as he/she put butter and jelly on the biscuit; - Activity Aide M did not perform hand hygiene prior to or during assisting the resident to eat. During interview on [DATE], at 1:45 P.M., NA L said the following: -He/She fed the resident breakfast on [DATE]; -He/She was not wearing gloves when feeding the resident; -He/She did not perform hand hygiene when feeding the resident; -He/She should not touch resident's food with bare hands. During interview on [DATE], at 6:12 P.M., Activity Aide M said he/she should not touch resident's food with a bare hand. During an interview on [DATE] at 10:08 A.M., Dietary Staff O said he/she would use tongs when handling ready to eat food and denied touching the donuts with his/her bare hands. 3. Review of the undated facility policy, Hair Restraints, showed the following: -Guideline: Hair restraints shall be worn by all dietary staff when in food production areas, dishwashing areas or when serving food; -Procedure: -1. Dietary staff shall wear hair restraints in all food production areas, dishwashing areas or when serving food; -2. Hair restraints, hats, and/or beard guards shall be used to prevent hair from contacting exposed food. Facial hair is discourage. Any facial hair that is longer than the eyebrow shall require coverage with a beard guard in the food production areas, dishwashing areas or when serving food; -3. Non-dietary staff must follow guidelines and red lines when entering the kitchen. Observation on [DATE] between 11:54 A.M. and 1:03 P.M. during the lunch meal service showed Dietary Staff P stood over the steam table and plated desserts and a biscuit on residents' meal trays. His/Her hair bangs were not covered with a hair restraint and were on the outside of the hair net. During an interview on [DATE] at 8:55 A.M., the dietary manager said the following: -The date on the item was the use by date. The item should be discarded by the following day; -The food items prepared for the next day should have been discarded if not used; -The bag of raisins should have been sealed and dated when opened; -The opened popcorn bag on the cart shouldn't have been stored there and most likely belonged to staff and should have been discarded; -The container labeled fruit bar should have been discarded on ,d+[DATE]; -The pizza in the west dining room refrigerator had been there since ,d+[DATE]; -Staff go through the kitchen refrigerators and refrigerators outside of the kitchen either weekly or biweekly; -Any dietary staff member that handled ready to eat food should wear gloves or use a utensil; -He/She was unaware there were items that needed to be discarded in these areas; -Hair nets should cover all hair on a person's head. Dietary Staff P tended to leave his/her bangs outside the hair net and his/her bangs needed to be covered with a hair net. 34536 46506

Based on interview and record review, the facility failed to update interventions in the resident's care plan to reflect current care needs for six residents (Residents #9, #18, #34, #44, #57, and #162), in a review of 19 sampled residents. The facility census was 59. 1. During interview on 05/04/23, at 1:00 P.M., the Quality Assurance (QA) Nurse said the facility did not have a policy in place for care plans timing and revisions. Review of the Centers for Medicare and Medicaid Services (CMS), Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.17.1, Chapter 4, revised October 2019, showed the following: -The care plan is driven not only by identified resident issues and/or conditions but also by a resident's unique characteristics, strengths, and needs; -A care plan that is based on a thorough assessment, effective clinical decision making, and is compatible with current standards of clinical practice can provide a strong basis for optimal approaches to quality of care and quality of life needs of individual residents; -A well developed and executed assessment and care plan: 1. Looks at each resident as a whole human being with unique characteristics and strengths; 2. Views the resident in distinct functional areas for the purpose of gaining knowledge about the resident's functional status (MDS); 3. Gives the interdisciplinary team (IDT) a common understanding of the resident; 4. Re-groups the information gathered to identify possible issues and/or conditions that the resident may have (i.e., triggers); 5. Provides additional clarity of potential issues and/or conditions by looking at possible causes and risks (CAA process); 6. Develops and implements an interdisciplinary care plan based on the assessment information gathered throughout the RAI process, with necessary monitoring and follow- up; 7. Reflects the resident's/resident representative's input, goals, and desired outcomes; 8. Provides information regarding how the causes and risks associated with issues and/or conditions can be addressed to provide for a resident's highest practicable level of well- being (care planning); 9. Re-evaluates the resident's status at prescribed intervals (i.e., quarterly, annually, or if a significant change in status occurs) using the RAI and then modifies the individualized care plan as appropriate and necessary; 10. Reviews and revises the current care plan. 42592 1. Review of Resident #57's face sheet showed the resident's diagnoses included lobar pneumonia (infection of one lobe of a lung), chronic obstructed pulmonary disease (COPD) (chronic inflammatory lung disease that causes obstructed airflow from the lungs), and dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). Review of the resident's nurse note, dated 1/22/23 at 2:40 P.M., showed the following: -The resident had a wet congestive cough with audible congestion that clears with cough for short periods and lungs have rhonchi (continuous low-pitched, rattling lung sounds that often resemble snoring) throughout; -Upon conversation, the resident seemed paranoid (unreasonably or obsessively anxious, suspicious, or mistrustful); -The resident had edema to right hand and bilateral lower extremities up to knee-pitting edema (when a swollen part of your body has a dimple (or pit) after you press it for a few seconds) with plus 3 pitting edema present; -The resident said the edema was why he/she couldn't walk; his/her legs felt too heavy; -The resident became very emotional upon conversation and even began crying; -One-on-one was provided. Review of the resident's nurse note, dated 1/23/23 at 12:00 P.M., showed the resident continued to have plus 3 pitting edema to bilateral lower extremities and right hand had plus one pitting edema. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/26/23, showed the following: -The resident had moderately impaired cognition; -No delirium, mood issues, or behaviors; -He/She didn't reject care or wander. Review of the resident's nurse note, dated 2/5/23 at 2:10 P.M., showed the following: -The resident attempted to become combative, which is not like this resident; -The resident's family member said the resident had some personality changes; -Conversation held between the family member and the resident, then the family member said the resident has been emotional with the transition from residential care facility (RCF) to skilled nursing facility. Review of the resident's nurse note, dated 2/11/23 at 7:30 P.M., showed the resident tried to elope. He/She went through the doors going to the RCF (that was attached). He/She had the code for the door on his/her walker and used it. Review of the resident's nurse note, dated 2/14/23 at 5:45 A.M., showed the following: -The resident refused to sleep in his/her room; -The staff assisted the resident to his/her room and the resident stopped at the doorway, and said, I am not going in that room and if you make me I will call the police on you; -The staff offered the resident to sleep in a recliner across from the nurses station. He/She agreed and slept all night in the recliner. Review of the resident's nurse note, dated 2/14/23 at 10:29 A.M., showed the resident had a chest x-ray performed resulting in hyperinflated lungs compatible with COPD and possible infectious process. Review of the resident's nurse note, dated 2/15/23 at 3:13 P.M., showed the resident was prescribed Levaquin (an antibiotic) for an upper respiratory infection. Review of the resident's nurse note, dated 2/16/23 at 10:25 P.M., showed the resident was hallucinating. He/She saw men coming through the wall and blood coming out between his/her toes, so staff redirected the resident. Review of the resident's nurse note, dated 2/24/23 at 7:15 P.M., showed the following: -The resident finished antibiotic therapy; -The staff encouraged the resident to cough as he/she doesn't do so and will have audible congestion. Review of the resident's care plan, last updated 3/17/23, showed the following: -The resident may be confused at times, but still had a strong opinion; -He/She wanted to control some decision making and felt his/her opinion mattered; -Allow to express feelings of frustration and inadequacy; -The resident was not an elopement risk; -The care plan did not address resident specific non-pharmacological interventions for behaviors or problems with edema and lung infections/congestion. Review of the resident's nurse note, dated 4/21/23 at 3:43 P.M., showed the following: -The resident refused to sleep in his/her bed the previous night and removed the dressing on his/her buttocks; -The resident refused to go to the dining room for breakfast, said he/she was left in water, stubborn and argumentative and refused cares wanting to do all activities of daily living for himself/herself, and lacked safety awareness. A staff member stayed with the resident for safety. Review of the resident's nurse notes, dated 4/25/23 at 4:01 P.M., showed the following: -The resident complained of not feeling well; -Lungs have crackles (clicking, rattling, or crackling noises that may be made by one or both lungs of a human with a respiratory disease during inhalation) throughout; -The nurse asked the resident to cough to clear his/her airway and his/her cough was extremely congested but unable to clear. Review of the resident's nurse notes, dated 4/27/23 at 9:12 A.M., showed the following: -Increase Lasix (diuretic) 20 mg orally twice a day for two weeks; -Use DuoNeb (bronchodilator) per nebulizer machine as needed for shortness of breath. During an interview on 5/3/23 at 2:20 P.M., the Quality Assurance Nurse said the following: -The resident was confused at times and was stubborn regarding assistance with ADLs, interventions for pressure ulcers, and dietary interventions; -He/She thought the resident had negative behaviors when he/she was not feeling well or when something was not going the way he/she expected; -The staff were told not to argue with the resident when he/she had behaviors, but keep him/her safe; -The staff should remain calm and allow him/her to voice frustrations; -Sometimes the family talked to him/her before the resident would calm down; -The resident had edema and took Lasix (diuretic) to reduce it; -The resident was admitted from a hospital with pneumonia on 1/19/23; -He/She was susceptible to respiratory infections because of the COPD and being sedentary; -The resident had nebulizer medication as needed for shortness of breath, but didn't need oxygen. 2. Review of Resident #44's care plan, last updated 4/4/22, showed the following: -Provide toileting assist daily; -Remind the resident that he/she is unable to ambulate on his/her own any longer; -Provide incontinence care after each incontinence. Review of the resident's quarterly MDS, dated [DATE], showed the following: -The resident had severely impaired cognition; -He/She required extensive assistance from two staff for bed mobility, dressing, and toilet use; -He/She was dependent on two staff for transfers; -He/She was dependent on one staff for locomotion, eating, personal hygiene, and bathing; -He/She had limited range of motion on one side of the upper and lower extremities; -He/She was always incontinent of bladder and bowel. Observation on 5/1/23 at 8:03 A.M., showed the following: -The resident sat up in geri-chair (specialized wheelchair) at the dining room table and leaned to the right side of his/her chair; -The resident's right hand was in a closed, fist position; -Certified Nurse Aide (CNA) F assisted the resident to eat his/her breakfast; -CNA F attempted to reposition the resident in the geri-chair, but was unsuccessful so CNA F raised the feet on the geri-chair and took the resident back to his/her room. Observation on 5/1/23 at 8:35 A.M., showed the resident sat up in the geri-chair and continued to lean to the right. During an interview on 5/1/23 at 11:30 A.M., CNA F said the following: -The resident is unable to walk, and transfers with a mechanical lift and two staff; -He/She needed assistance with all the care provided. Observation on 5/3/23 at 7:20 A.M., showed CNA J and CNA K transferred the resident with the mechanical lift from the resident's bed to the geri-chair. During an interview on 5/4/23 at 8:50 A.M., CNA J said the following: -The resident required assistance with all of his/her activities of daily living; -The resident required assistance of two with transfers, bed mobility, incontinence care, but only one person with personal hygiene and eating. During an interview on 5/4/23 at 10:10 A.M., the Restorative Aide/CNA said she worked on the resident's hand that has limited movement and places a cushion in the resident's hand because it draws up, preventing use of the hand. Review of the resident's care plan showed it was not updated to show the resident's current needs of needing assistance with eating, need of two staff members with bed mobility and dressing, dependence of one staff member with personal hygiene and bathing, and transfers with mechanical lift. 3. Review of Resident #162's face sheet showed the resident's diagnoses included dementia with Lewy bodies (a type of progressive dementia that leads to a decline in thinking, reasoning and independent function. Review of the resident's fall event report, dated 03/29/23 at 2:43 A.M., showed the following: -The resident's bed alarm was sounding and staff found the resident sitting on his/her buttocks next to his/her bed; -No injuries noted; -Immediate intervention of floor mat placed; -Care plan was not reviewed. Review of the resident's care plan showed no evidence staff updated the care plan to include the floor mat. Review of the resident's fall event report, dated 04/9/23, at 1:30 A.M., showed the following: -The resident's bed alarm was sounding and staff found the resident sliding out of bed saying he/she was trying to clean up a spill; -No injuries noted; -No immediate interventions indicated; -Care Plan was not reviewed. Review of the resident's care plan, revised 05/01/23, showed the following: -Potential for falls related to weakness, decreased mobility, poor safety judgment and history of falls; -No indication of floor mat use; -No indication of bed alarm use; -No indication of side rail use; -No indication of 03/29/23 or 04/09/23 falls or interventions implemented following these falls. Observation on 05/01/23, at 6:17 A.M., showed the resident's bed alarm was sounding. The resident lay in bed sleeping with his/her feet hanging to the side. The half side rail located on the right side of the resident's bed was raised. A fall mat was on the floor at the resident's right side of bed. 4. Review of Resident #9's quarterly MDS, dated [DATE], showed the following: -Severely impaired cognition; -Require extensive assistance from one staff for transfers and bed mobility; -Bed rails not used; -Bed and chair alarm used daily. Review of the resident's care plan, revised on 03/22/23, showed the following: -Diagnoses include dementia with behavior disturbance (a group of thinking and social symptoms that interferes with daily functioning, exhibiting physical or verbal aggression), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with daily activities). -Potential for falls related to weakness, decreased mobility, poor safety judgement, anti-depressant therapy and history of falls; -No indication of side rail use or bed or chair alarm use. Observation on 05/01/23, at 7:08 A.M., showed the resident sat awake in his/her recliner. The resident sat on a pressure chair alarm that was not connected to the alarm box. Observation on 05/03/23, at 5:32 A.M., showed the resident lay awake in bed with the right side upper 1/2 side rail in the raised position. The resident had a bed alarm. 5. Review of Resident #18's annual MDS, dated [DATE], showed the following: -Severely impaired cognition; -Required extensive assistance from two staff for bed mobility and transfers; -No bed side rails used. Review of the resident's care plan, revised on 03/02/23, showed the following: -Diagnoses include cerebral infarction (also called ischemic stroke, occurs as a result of disrupted blood flow to the brain that can cause paralysis), Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), left sided hemiplegia (paralysis of left side) and left sided hemiparesis (muscle weakness of the left side). -The resident has potential for falls related to anti-depressant therapy, weakness, decreased mobility, poor safety judgment and history of falls; -He/She thinks he/she can transfer himself/herself. Remind the resident to use call light for help; -No indication of side rail use; -No indication of bed alarm use. Observations on 05/01/23 at 10:09 A.M., on 5/2/23 at 9:18 A.M., and on 5/3/23 at 5:30 A.M. showed the resident lay awake in bed. The resident had half side rails raised on both sides of his/her bed. The resident had a bed alarm. 6. Review of Resident #34's annual MDS, dated [DATE], showed the following: -Severely impaired cognition; -Total dependence on one staff for bed mobility; -Total dependence on two staff for transfers; -No bed side rails used. Review of the resident's care plan, revised on 03/10/23, showed no indication of side rail use. Observations on 05/01/23 at 10:12 A.M., 5/2/23 at 9:12 A.M., and on 5/3/23 at 5:28 A.M. showed the resident lay in bed. The resident had half side rails raised on both sides of his/her bed. 7. During interview on 05/04/23, at 1:15 P.M., the Quality Assurance (QA) Nurse said the following: -Nurses can update the care plans, but she has not asked them to do so since they are very busy; -Side rails and alarms have not been put on the care plans, but would probably be beneficial to do so; -Lack of staff and nurses, and too many things going on made it difficult to get the updates done. During interview on 05/04/23, at 2:30 P.M., the MDS Coordinator said the following: -She or the QA nurse were responsible for updating the care plans and they had gotten behind on updates; -Things like falls, infections, oxygen use, alarms and side rails should be updated on the care plans. During interview on 05/04/23, at 3:12 P.M., the Director of Nursing (DON) said the following: -She would expect oxygen use, falls, side rails and alarms to be included on the care plan; -She would expect interventions to be listed on the care plan; -The MDS coordinator is responsible for the care plans and updates.

Based on observation, interview, and record review, the facility failed to ensure nursing staff performed acceptable infection control practices to prevent contamination when staff failed to protect nebulizer masks while not in use for two residents (Residents #22 and #54), in a review of 19 sampled residents. The facility failed to follow the facility's policy for hand washing and gloving during perineal care for one sampled resident (Resident #13) and for three additional residents (Residents #11, #19 and #163). The facility census was 59. Review of facility's undated handwashing policy showed the following: -Handwashing remained the single most effective means of preventing disease transmission; -Washing hands often and well, paying particular attention to around and under fingernails and between the fingers; -Staff were expected to wash hands when they were soiled with body substances, before food preparation, before eating, after using the toilet, before performing invasive procedures, and upon completion of resident's care; -Waterless antiseptic hand cleaners or towelettes may be used if hands could not be washed right after being soiled, but soap and water must be used as soon as feasible; -The use of alcohol based rinses or foams with non-drying emollients were occasionally used as an adjunct to handwashing. During interview on 05/04/23, at 1:00 P.M., the Quality Assurance (QA) Nurse said the facility did not have a policy in place for oxygen or nebulizer equipment storage when not in use. 1. Review of Resident #54's care plan, last reviewed/revised on 3/23/23, showed the following: -He/She had potential for impaired air exchange related to chronic obstructive pulmonary disease (COPD, chronic lung disease characterized by shortness of breath) and chronic respiratory failure; -He/She would have minimal dyspnea (shortness of breath) and free from respiratory infection; -Administer medications and oxygen as ordered by his/her physician. Review of the resident's physician's orders, dated 4/1/23 to 5/3/23, showed the following: -His/Her diagnoses included COPD and hypoxemia (low levels of oxygen in the blood); -An order for ipratropium-albuterol (inhaled medication used to relax muscle and open air passages to the lungs to make breathing easier) to be administered per nebulizer (a small machine that turns liquid medicine into a mist that can be easily inhaled) four times a day. Observation on 5/1/23 at 10:00 A.M. showed the resident's nebulizer mask was uncovered on the resident's bedside table. Observation on 5/2/23 at 11:55 A.M. showed the resident's nebulizer mask was uncovered on the resident's bedside table. Observation on 5/2/23 at 3:36 P.M. showed Certified Medication Technician (CMT) C administered a nebulizer treatment to the resident via the nebulizer machine/mask. 2. Review of Resident #22's undated continuity of care document (CCD) showed the following: -His/Her diagnoses included COPD; -An order for ipratropium-albuterol to be administered via nebulizer four times a day. Review of resident's care plan, last reviewed on 3/14/23, showed the following: -He/She had the potential for impaired air exchange related to COPD and chronic respiratory failure; -Staff were to administer inhalers/medications per physician's orders. Observation on 5/1/23 at 6:30 A.M. showed the resident's nebulizer mask was uncovered on the resident's bedside table. Observation on 5/2/23 at 10:00 A.M. showed the resident's nebulizer mask was uncovered on the resident's bedside table. Review of resident's Treatment Administration Record (TAR), dated 5/2/23, showed staff administered ipratropium-albuterol on 5/2/23 at 12:08 P.M. Observation on 5/2/23 at 1:16 P.M. showed the resident's nebulizer mask was uncovered on the resident's bedside table. During an interview on 5/16/23 at 10:35 A.M., Certified Medication Technician (CMT) C said some of the residents' nebulizer masks were located on their night stands. Staff were to place the masks on the holder located on the nebulizer machine when not in use. He/She was not aware of ever covering nebulizer masks with any sort of bag. 46506 3. Review of Resident #13's care plan, last updated 1/30/22, showed the following: -The resident required limited to extensive assist with activities of daily living (ADLs) at times; -Assist with peri care as needed. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/5/23, showed the following: -The resident had severely impaired cognition; -He/She required extensive assistance of one staff member for toilet use; -He/She had occasional urinary incontinence. Observation on 5/1/23 at 8:19 A.M., showed the following: -Certified Nurse Aide (CNA) F and CNA G entered the resident's room, washed their hands and put on gloves; -CNA F assisted CNA G to transfer the resident from the wheelchair to the toilet; -CNA F pulled down the resident's wet incontinence brief; -CNA F and CNA G assisted the resident to stand, and CNA F provided perineal care for the resident with toilet paper; -CNA F did not remove his/her gloves or wash his/her hands after providing perineal care to the resident; -CNA F assisted to pull up the resident's clean incontinence brief and pants, transferred the resident to the wheelchair and then to bed, and placed a blanket on the resident. During an interview on 5/1/23 at 8:27 A.M., CNA F said the following: -He/She didn't wash hands or change gloves between handling dirty items, because he/she was the one who was performing the dirty tasks, while CNA G performed the clean tasks; -He/She didn't think about how he/she had to touch the resident with dirty gloves when transferring the resident back from the toilet to wheelchair and again from wheelchair to bed. 4. Review of Resident #11's annual MDS, dated [DATE], showed the following: -The resident had moderately impaired cognition; -He/She required limited assistance of one staff member for toilet use; -He/She was always incontinent of bladder. Review of the resident's care plan, last updated, 1/3/23, showed the resident required assistance with peri care. Observation on 5/3/23 at 6:23 A.M., showed the following: -Nurse Aide (NA) I washed his/her hands and put on gloves; -NA I removed the resident's urine soiled clothes and performed perineal care for the resident; -Without removing his/her gloves and washing his/her hands after providing perineal care, NA I assisted the resident to transfer from the bed to the wheelchair and then from the wheelchair to the toilet. During an interview on 5/3/23 at 6:42 A.M., NA I said the following: -He/She made a mistake when the resident was in the restroom, because he/she was assigned the clean tasks; -He/She performed the peri care, pulled up the resident's clean clothes, and assisted with the transfer without changing his/her gloves or washing his/her hands. 5. Review of Resident #19's care plan, revised on 12/20/22, showed the resident was incontinent of bowel and bladder and needed assistance with perineal care and toileting. Review of the resident's annual MDS, dated [DATE], showed the following: -Moderately impaired cognition; -Required extensive assistance from one staff for toileting and personal hygiene; -Always incontinent of bowel and bladder. Observation on 05/01/23, at 8:25 A.M., showed the following: -The resident was incontinent of urine and his/her pants were wet with urine; -NA L did not wash his/her hands or put on gloves; -NA L took the resident to the bathroom and removed the resident's pants and urine soaked incontinence brief; -CNA G entered the resident's room, and without washing his/her hands or performing hand hygiene, he/she put on gloves; -CNA G removed the resident's soiled pants and placed them directly on the floor; -Without washing his/her hands, NA L put on gloves and wiped the resident's buttocks with toilet paper; -Without removing their gloves, CNA G and NA L applied a new incontinence brief and pants on the resident; -CNA G placed the resident's soiled pants in a bag, removed one of his/her gloves, and left the resident's room. During interview on 05/04/23, at 1:45 P.M., NA L said the following: -Staff should wear gloves any time they are providing resident care, such as toileting; -Staff should change their gloves between dirty procedures and after providing peri-care; -He/She did not remember not using gloves while caring for Resident #19. During interview on 05/04/23 at 12:05 P.M., CNA G said the following: -Staff should wear gloves when providing care for the residents; -Staff should wash their hands or use hand sanitizer prior to putting on gloves and after removing gloves; -He/She used hand sanitizer outside Resident #19's room prior to coming into the room to assist NA L with the resident's care. 6. Review of Resident #163's care plan, revised 04/06/23, showed the resident needed moderate to extensive assist of one staff member with toileting. Observation on 05/02/23, at 1:26 P.M., showed the following: -The resident was incontinent of bladder and bowel; -CNA D washed his/her hands and put on gloves; -CNA D performed perineal care to the resident's buttocks and rectal area; -Without removing his/her gloves, CNA D picked up a basin from the sink counter, turned on the water, turned off the water, returned to the resident's bedside, and wet a clean washcloth and rinsed the soap from the resident's buttocks; -Without removing his/her gloves, CNA D assisted the resident to turn to his/her side. During interview on 05/11/23, at 6:00 P.M., CNA D said the following: -Staff should wash their hands before and after providing resident care and applying gloves; -Staff should changed gloves when they become soiled; -He/She provided peri-care for the resident and forgot to get a basin of clean water; -He/She did not remove his/her gloves when he/she got the basin of clean water; -He/She should have removed his/her gloves, washed his/her hands and applied new gloves before getting the clean basin. 7. During an interview on 5/4/23 at 3:12 P.M., the Director of Nursing said the following: -She expected staff to wash their hands before and after direct resident care, and after changing gloves; -She expected staff to wear gloves when providing resident care and helping the resident to the bathroom; -Nebulizer masks/oxygen equipment should be covered when not in use. During an interview on 5/4/23 at 3:12 P.M., the Administrator said the following: -She expected staff to wear gloves when providing resident care to wash their hands before putting on gloves and after removing gloves; -Hand sanitizer was located in the hallway for staff to use as needed prior to entering a resident's room.

42592 Based on observation, interview, and record review, the facility failed to have a system in place to obtain informed consent and educate residents and their responsible parties about the risks of bed rail use prior to use, and failed to assess for continued safe use of bed rails for five residents (Resident #9, #13, #18, #34, #162), in a review of 19 sampled residents. The facility census was 59. 1. During interview on 05/04/23, at 1:00 P.M., the Quality Assurance (QA) Nurse said the facility did not have a policy in place for bed rail assessments or use. 2. Review of the Food and Drug Administration (FDA) Guide of Bed Safety, Bed Rails in Hospitals, Nursing Homes and Home Health Care: The Facts, revised April 2010, showed the following: -Patients who have problems with memory, sleeping, incontinence, pain, uncontrolled body movement, or who get out of bed and walk unsafely without assistance, must be carefully assessed for the best ways to keep them from harm, such as falling; -Assessment by the patient's health care team will help to determine how best to keep the patient safe; -Potential risks of bed rails may include strangling, suffocating, bodily injury or death when patients or part of their body are caught between rails or between the bed rails and mattress, more serious injuries from falls when patients climb over rails, skin bruising, cuts, and scrapes, feeling isolated or unnecessarily restricted, and preventing patients, who are able to get out of bed, from performing routine activities such as going to the bathroom or retrieving something from a closet; -When bed rails are used, perform an on-going assessment of the patient's physical and mental status and closely monitor high-risk patients; -Use a proper size mattress or mattress with raised foam edges to prevent patients from being trapped between the mattress and rail; -Reduce the gaps between the mattress and side rails; -A process that requires ongoing patient evaluation and monitoring will result in optimizing bed safety; -Reassess the need for using bed rails on a frequent, regular basis. 3. Review of Resident #9's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, dated 03/09/23, showed the following: -Severely impaired cognition; -Extensive assistance of one staff member for transfers and bed mobility; -Balance during transitions is unsteady and only able to stabilize with staff assistance; -No range of motion impairments; -No falls since last assessment; -Bed rails not used; -Bed and chair alarm used daily. Review of the resident's care plan, revised on 03/22/23, showed the following: -Potential for falls related to weakness, decreased mobility, poor safety judgement, anti-depressant therapy and history of falls; -Interventions included call light within easy reach at all times, keep bed at lowest level convenient to resident, transfer with manual sit to stand lift and or walker with assist of staff; -Wear proper footwear and or non-slippery socks; -No indication of bed rail use; -No indication of bed or chair alarm use. Review of the resident's May 2023 physician order sheet showed no orders for bed rails, bed alarm or chair alarm use. Review of the resident's electronic health record showed no initial or routine bed rail assessment, no informed consent for bed rail use, and no education of risks or benefits related to bed rail use or initial or routine measurement of entrapment zones. Observation on 05/03/23, at 5:32 A.M., showed the resident lay awake in bed with the right side upper 1/2 bed rail in the raised position. During interview on 05/01/23, at 7:08 A.M., the resident said he/she used the bed rail to help him/her turn in bed. He/She did not recall signing consent for bed rail use. 46506 4. Review of Resident #13's face sheet showed the resident was admitted to the facility on [DATE] with diagnosis of dementia and he/she had a responsible party for decision making. Review of the resident's medical record did not include informed consent or education of the responsible parties on the risk of bed rail use and failed to document attempted alternatives prior to installing the bed rails. Review of the resident's care plan, last updated on 1/30/22, showed the following: -The resident was at risk for falls related to weakness, decreased mobility, poor safety judgement and history of falls; -Increased staff supervision with intensity based on resident need; -Ambulates with walker and assist of one or two staff with gait belt, goes back and forth to the bathroom, at times; -Staff will assist the resident into wheelchair reminding of safe transfers, -The care plan did not include the use of bed rails. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/5/23, showed the following: -The resident had severely impaired cognition; -He/She required extensive assistance of one staff member for bed mobility; -He/She required limited assistance of one staff member for transfers; -Diagnosis of dementia; -He/She had a fall without injury; -He/she took an antianxiety, antidepressant, and diuretic medication. Observation on 5/1/23 at 8:15 A.M., showed the resident lay on his/her back in bed with quarter bed rails up on both sides of the bed. Observation on 5/3/23 at 5:20 A.M., showed the resident lay on his/her back in bed. The quarter bed rail on the left side of the resident's bed was raised. 5. Review of Resident #18's annual MDS, dated [DATE], showed the following: -Severely impaired cognition; -Extensive assistance of two staff members for bed mobility and transfers; -Limited range of motion one upper and lower extremity; -No falls since last assessment; -No bed bed rails used. Review of the resident's care plan, revised on 03/02/23, showed the following: -The resident has potential for falls related to anti-depressant therapy, weakness, decreased mobility, poor safety judgment and history of falls; -He/She thinks he/she can transfer himself/herself, remind to use call light for help; -Keep bed in lowest level; -No indication of bed rail use. Review of the resident's May 2023 physician orders showed no order for bed rail use. Review of the resident's electronic health record showed no initial or routine bed rail assessment, informed consent for bed rail use or initial or routine measurements of entrapment zones. Observation on 05/01/23, at 10:09 A.M., showed the resident lay awake in bed with bilateral 1/2 upper bed rails in the raised position. Observation on 05/02/23, at 9:18 A.M., showed the resident lay in bed with eyes closed and bilateral 1/2 upper bed rails in the raised position. During interview on 05/02/23, at 9:20 A.M. the resident said he/she uses the bed rails for bed mobility. He/She did not recall signing consent for use of bed rails. Observation on 05/03/23, at 5:30 A.M., showed the resident lay in bed awake. The bed was in a low position. Bilateral 1/2 upper bed rails in the raised position. 6. Review of Resident #34's annual MDS, dated [DATE], showed the following: -Severely impaired cognition; -Total dependence on one staff member for bed mobility; -Total dependence on two staff members for transfers; -Limited range of motion bilateral lower extremities; -No bed side rails used. Review of the resident's care plan, revised on 03/10/23, showed the following: -The resident has potential for falls related to weakness, poor safety judgment and falling asleep in wheelchair; -Keep bed in lowest level, convenient to resident; -Transfer with assist of two per mechanical lift; -No indication of bed rail use. Review of the resident's May 2023 physician orders showed no order for bed rail use. Review of the resident's electronic health record showed no initial or routine bed rail assessment, informed consent for bed rail use or initial or routine measurement of entrapment zones. Observation on 05/01/23, at 10:12 A.M., showed the resident lay in bed asleep with bilateral 1/2 upper bed rails in raised position. Observation on 05/02/23, at 9:12 A.M., showed the resident lay in bed awake with bilateral 1/2 upper bed rails in raised position. During interview on 05/02/23, at 9:12 A.M., the resident said he/she uses the bed rails to help him/her turn in bed. He/She did not recall signing consent for use of bed rails. Observation on 05/03/23, at 5:28 A.M., showed the resident lay in bed sleeping with bilateral 1/2 upper bed rails in the raised position. 7. Review if the Resident #162's face sheet showed the following: -Admission to the facility on [DATE]; -Diagnoses include malignant neoplasm of unspecified bronchus or lung (lung cancer) and dementia with Lewy bodies (a type of progressive dementia that leads to a decline in thinking, reasoning and independent function. Review of the resident's May 2023 physician orders noted no order for bed rail or bed alarm use. Review of the resident's care plan, revised 05/01/23, showed the following: -Potential for falls related to weakness, decreased mobility, poor safety judgment and history of falls; -Keep bed in lowest level, convenient to resident; -No indication of bed alarm use; -No indication of bed rail use. Review of the resident's electronic health record showed no initial or routine bed rail assessment, informed consent for bed rail use or initial or routine measurement of entrapment zones. Observation on 05/01/23, at 6:17 A.M., showed the resident's bed alarm was sounding. The resident lay in bed sleeping with his/her feet hanging to the side, bed in low position and right upper 1/2 bed rail in the raised position. Observation on 05/03/23, at 5:26 A.M., showed the resident lay in bed sleeping, bed in low position, right upper 1/2 bed rail in the raised position. During interview on 05/03/23, at 8:45 A.M., the administrator said the facility did not have bed rail assessments or consents for bed rail use.

Based on observation, interview, and record review, the facility failed to review and/or revise interventions to prevent falls for four residents (Residents #9, #25, #47, and #54), in a review of 19 sampled residents. The facility failed to use proper technique when transferring one resident (Resident #13) when staff lifted under the resident's armpits during transfer and did not use a gait belt (a canvas belt placed around the resident's waist to assist with ambulation and transfers). The facility failed to safely transport three residents (Residents #9, #13, and #34) in wheelchairs with footrests. The facility census was 59. During interview on 05/04/23, at 1:00 P.M., the Quality Assurance (QA) Nurse said the facility did not have a policy in place for transporting residents in wheelchairs. Review of facility's policy for management of falls, dated December 2007, showed the following: -Based on previous evaluations and current data, the staff would identify interventions related to resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling; -Staff with the input of the attending physician, would identify appropriate interventions to reduce the risk of falls. If a systematic evaluation of a resident's fall risk identified several possible interventions, the staff could choose to prioritize interventions; -Examples of initial approaches might include exercise and balance training or a rearrangement of room furniture. If a medication was suspected a a possible cause of a resident's falling, the initial intervention might be to taper or stop that medication; -If falling recurred despite initial interventions, staff would implement additional or different interventions, or indicate why the current approach remained relevant; -If underlying causes could not be readily identified or corrected, staff would try various interventions, based on assessment of the nature or category of falling, until falling was reduced or stopped, or until the reason for the continuation of the falling was identified as unavoidable; -In conjunction with the attending physician, staff would identify and implement relevant interventions to try to minimize serious consequences of falling. Review of the facility's undated policy for gait belt transfers showed the following: -Gait belts were required for all residents when performing transfers, ambulation, or repositioning in a chair; -The belt was to be applied snugly around the resident's waist over clothing below the ribs so that the nurse assistant fingers may grasp the belt securely; -The nurse assistant grasps the belt on both sides of the resident's wait. Palms should be inserted between the belt and resident with fingertips pointing upward; -The nurse assistant should not transfer or ambulate residents by grasping their upper arms or under their arms. Such a transfer could result in skin tears, damage to the nerves and arteries, and possible dislocation of the shoulder. The gait belt increased the comfort and safety of the resident during the transfer procedure and prevented injury to the resident that could be caused by pulling on his/her arms, shoulders, or wrist. 42592 1. Review of Resident #47's Morse Fall Scale (a rapid and simple method of assessing a patient's likelihood of falling), dated 1/5/22, showed the resident was at high risk for falls. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 1/12/22, showed the following: -His/Her cognition was severely impaired; -He/She was independent with transfers and ambulation on and off of the unit; -He/She required supervision with locomotion on and off of the unit; -He/She had fallen in the previous month prior to admission. Review of the resident's event report, dated 1/25/22, showed the following: -At 3:15 P.M., staff found the resident sitting on his/her buttocks near the end of his/her bed; -Care plan was not reviewed. (There was no documentation to show interventions were reviewed/revised to prevent further falls.) Review of the resident's care plan, dated 1/27/22, showed the following: -He/She was at risk for falls due to his/her cognitive status; -He/She required increased staff supervision with intensity based on his/her needs; -Staff were to provide individualized toileting interventions based on needs/patterns. Review of the resident's Morse Fall Scale, dated 4/11/22, showed the resident was at high risk for falls. Review of the resident's quarterly MDS, dated [DATE], showed the following: -His/Her cognition was severely impaired; -He/She was independent with transfers and ambulation; -His/Her balance was unsteady, but able to transfer without human assistance. Review of the resident's event report, dated 6/18/22, showed the following: -At approximately 10:40 A.M., the resident was walking out of his/her room while holding the hand rail when he/she appeared to have lost his/her balance and fell forward onto his/her knees; -A small skin tear was noted on the inner left thumb; -Care plan was not reviewed. Review of the resident's care plan showed no documentation of the resident's fall on 6/18/22 or evidence interventions were implemented after the resident fell . Review of the resident's Morse Fall Scale, dated 10/10/22, showed the resident was at high risk for falls. Review of the resident's annual MDS, dated ,d+[DATE]//22, showed the following: -His/Her cognition was severely impaired; -He/She was independent with transfers and ambulation; -His/Her balance was unsteady, but able to transfer without human assistance. Review of the resident's event report, dated 1/2/23 at 7:38 P.M., showed the following: -The resident was wandering around the facility per his/her normal gait and pacing pattern; -He/She ambulated into the dining room where upon a loud noise was heard. Upon entering the dining room, staff noted the resident's legs on the floor in the back of the dining room where a stack of folding chairs on a rack were located. Upon moving the rolling chair rack, a bright red pool of blood was noted which was determined coming from the resident's left hand. Pressure was applied with an ice pack. Staff positioned the resident on his/her left side and immediately stabilized his/her head because it was obvious he/she had hit his/her head as there was a hematoma to the left eyebrow and cheek. There was a copious amount of blood coming from the resident's left thumb. The ambulance was notified, and the resident was sent to the hospital for evaluation and treatment of injuries; -At 6:10 P.M., report was received that the resident was returning to facility without evidence of fractures. -Care plan was not reviewed. Review of resident's care plan showed no documentation of the resident's fall on 1/2/23 or evidence interventions were implemented to prevent additional falls. During an interview on 5/3/23 at 5:30 A.M., Certified Nurse Assistant (CNA) N said the resident didn't have any specific interventions in place to prevent him/her from falling. He/She knew to monitor the resident's location and perform a room check every two hours and as needed. Fall interventions utilized for residents were communicated on the resident's care plans, CNA worksheet, and with verbal report. Review of facility's CNA worksheet, dated 5/4/23, showed the following: -The resident wandered; -The resident was independent with ambulation, but required help with finding the bathroom frequently. (Review showed no documentation the resident was at risk for falls with interventions to prevent falls.) 2. Review of Resident #54's admission MDS, dated [DATE], showed the following: -Severely impaired cognition; -Required limited assistance from one staff for transfers and toilet use; -Required extensive assistance from one staff with locomotion on the unit; -Balance during transitions was unsteady and only was able to stabilize with staff assistance; -His/Her triggered care areas included falls which was to be addressed on the resident's care plan. Review of the resident's event report, dated 3/8/23, showed the following: -The resident's pressure alarm was sounding. Upon entering the resident's room, staff found the resident sitting on his/her buttocks; -The resident sustained a skin tear to the left forearm; -Staff documented the care plan was not reviewed after the fall. Review of the resident's Morse Fall Scale (scale used to determine resident's risk for falls), dated 3/9/23, showed he/she was at high risk for falls. Review of the resident's event report, dated 3/15/23, showed the following: -Certified nurse assistant (CNA) responded to the resident's alarm sounding. Upon entering the room, staff found the resident sitting on the floor between the bed and heat register by the window; -He/She sustained a skin tear to the right wrist; -Staff documented the care plan was not reviewed. Review of the resident's care plan, revised on 3/24/23, showed the following: -His/Her diagnoses included dementia with behavioral disturbances, anxiety disorder, and coronary obstructive pulmonary disease (chronic lung disease characterized by shortness of breath); -He/She ambulated with walker and assist of one staff; -He/She used a pressure alarm in his/her chair and on the bed due to he/she was forgetful that he/she needed assistance with ambulation because he/she would fall; -There were no documentation of resident's falls on 3/8/23 and 3/15/23. Review of the resident's event report, dated 4/5/23, showed the following: -At 6:01 P.M., the resident fell in his/her room while ambulating without his/her walker or assistance; -Staff documented the care plan was not reviewed after the fall. Review of the resident's care plan showed staff failed to address his/her fall on 4/5/23 with interventions to prevent future falls. Review of the resident's event report, dated 4/12/23, showed the following: -At 3:15 P.M., the resident was found on floor between his/her bed and heat register; -The resident stood up beside his/her bed and then sat down to the floor; -Staff documented the care plan was not reviewed after the fall. Review of the resident's progress notes, dated 4/12/23 at 3:29 P.M., showed the resident said he/she was too weak to walk to the bathroom by himself/herself. There was discussion about positioning the resident's bed against the wall. Review of the resident's nursing progress notes, dated 4/15/23 at 10:50 A.M., showed the following: -He/She remained on follow-up after he/she fell on [DATE]; -He/She had been on one-on-one observation all throughout the morning; -He/She repeatedly attempted to stand while his/her pressure alarm sounded, and attempted to walk; -He/She displayed a complete lack of safety awareness and impulsive behaviors of which staff were unable to redirect; -Offering food, fluids, toileting, and other distractions had been attempted and were successful for a very short interval. Review of the resident's nursing progress notes, dated 4/16/23 at 7:41 P.M., showed the following: -He/She required one-on-one observation and was brought to the nurse's desk; -He/She lacked safety awareness, would stand, and attempt to walk without assist; -He/She was impulsive and believed that he/she could do things that he/she was no longer able to do. Review of the resident's care plan showed no documentation of resident's impulsivity and lack of safety awareness or interventions to address this, increased risk for falls and/or any interventions, including one-on-one observation, need for redirection with food or fluids, change in position, and/or any other intervention pertinent to the resident's increased fall risk. During an interview on 5/3/23 at 5:30 AM., CNA N said the resident had a body alarm and was monitored every two hours and as needed. Staff were aware to get to the resident quickly when the alarm sounds because the resident was quick. 3. Review of Resident #25's annual MDS, dated [DATE], showed the following: -Severely impaired cognition; -Walked independently with a walker; -One fall without injury since last assessment; -Administered antipsychotic, anti-depressant, and anti-anxiety seven out of seven days during observation period. Review of the resident's fall event report, dated 02/07/23, at 3:03 P.M., showed the following: -The resident was walking down the hallway when staff heard a loud crash; -The resident had fallen on his/her left side in the doorway of a room. The resident's walker had tipped and lay on the floor; -The resident's left calf appeared darker in color and slightly swollen but not caused by the fall; -No immediate interventions indicated; -Care Plan was not reviewed. Review of the resident's fall event report, dated 02/17/23, at 3:50 A.M., showed the following: -The resident was found on the floor in the doorway across the hall from his/her room; -The resident had a blanket under part of him/her and no walker; -The resident complained of pain in the left lower extremity; -Staff noted swelling with purple bruising, and pain with weight/moving; -The resident was sent to the hospital for evaluation; -No immediate interventions indicated; -Care Plan was not reviewed. Review of the resident's fall event report, dated 03/12/23, at 5:50 A.M., showed the following: -The resident was walking back from the closet without his/her walker and fell by the front of the bed; -The resident received a skin tear to his/her left forearm, bruising below elbow, and abrasion on left lower back; -Immediate intervention of first aid; -Care Plan was not reviewed. Review of the resident's care plan, revised 04/24/23, showed the following: -Diagnoses include panic disorder (sudden episode of intense fear or anxiety), dementia (a group of thinking and social symptoms that interferes with daily functioning) and delusional disorders (a belief or altered reality that is persistently held despite evidence or agreement to the contrary). -The resident has a potential for falls related to poor safety judgement, anti-depressant therapy and cognitive decline; -Interventions included continue to remind the resident to use call light, ambulates with walker independently, answer call light promptly, remind resident to use his/her walker when he/she forgets, wear proper foot wear with non-slippery soles; -No indication fall or interventions evaluated after falls on 02/07/23, 02/17/23, and 03/12/23. 4. Review of Resident #9's quarterly MDS, dated [DATE], showed the following: -Severely impaired cognition; -Required extensive assistance from one staff for transfers; -Required extensive assistance from one staff for locomotion on the unit; -Total dependence on one staff for locomotion off the unit. -Balance during transitions was unsteady and only able to stabilize with staff assistance; -Bed and chair alarm used daily. Review of the resident's care plan, revised on 03/22/23, showed the following: -Diagnoses included dementia with behavior disturbance (a group of thinking and social symptoms that interferes with daily functioning, exhibiting physical or verbal aggression), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with daily activities). -Potential for falls related to weakness, decreased mobility, poor safety judgement, anti-depressant therapy and history of falls; -Interventions include call light within easy reach at all times, keep bed at lowest level convenient to resident, transfer with [NAME] steady (manual sit-to-stand lift) and/or walker with assist of staff; -Wear proper footwear and or non-slippery socks; -Wheelchair for long distances, propelled by staff and sometimes by resident. Review of the resident's fall event report, dated 03/23/23 at 5:18 A.M., showed the following: -The resident was found on the floor in front of his/her recliner with the recliner in the fully raised position. The chair alarm was sounding; -No injuries noted; -No immediate interventions indicated; -Care plan was not reviewed. Review of the resident's fall event report, dated 04/03/23 at 6:21 P.M., showed the following: -The resident was found on the floor in front of his/her recliner with the recliner in the fully raised position. The chair alarm was sounding; -No injuries noted; -No immediate interventions indicated; -Care Plan was not reviewed. Review of the resident's fall event report, dated 04/30/23 at 8:34 P.M., showed the following: -The resident was found on the floor in front of his/her recliner with the recliner in the fully raised position. The chair alarm was not sounding; -No injuries noted; -Immediate intervention of rest and moved to bed; -Care Plan was not reviewed. Review of the resident's care plan showed no indication of updating with the 03/23/23, 04/03/23, and 04/30/23 falls or interventions after falls. Observation on 05/01/23, at 7:08 A.M., showed the resident sat awake in his/her recliner. The resident sat on a pressure chair alarm that was not connected to the alarm box. Observation on 05/03/23, at 7:08 A.M., showed the following: -CNA G propelled the resident in a wheelchair out of his/her room and up the hall to the dining room. The resident's wheelchair did not have foot rests; -During transport, both of the resident's feet slid on the floor making a rubbing sound at least half the distance to the dining room. Observation on 05/01/23, at 7:44 A.M., showed the following: -CNA G propelled the resident in a wheelchair from the dining room table out of the dining room to provide personal care; -During transport from the table out of the dining room, the resident's feet slid on the floor making a rubbing sound. During interview on 05/04/23, at 12:05 P.M., CNA G said the following: -Foot rests were available for the residents and located in the storage room; -He/She had also seen some in resident rooms recently; -Foot rests should be used if the resident does not propel themselves; -Resident #9 will kick the foot rests out of the way and does not like them; -Foot rests should be used if residents are not propelling themselves to prevent jerking the feet back and causing injuries. 5. Review of Resident #13's care plan, last updated 1/30/22, showed the following: -The resident propelled himself/herself via wheelchair and will ask for assist if needed; -The staff will assist the resident into his/her wheelchair reminding of safe transfer and allowing the resident to do what he/she can. Review of the resident's annual MDS, dated [DATE], showed the following: -The resident had severely impaired cognition; -He/She required limited assistance of one staff for transfers; -He/She was independent with locomotion on the unit. Observation on 5/1/23 at 7:13 A.M., showed CNA F propelled the resident in a wheelchair into the dining room. The resident's wheelchair did not have foot rests. The resident's socked feet dragged along the floor during the transport. Observation on 5/1/23 at 8:15 A.M., showed CNA F propelled the resident in a wheelchair from the dining room to the resident's room. The resident's socked feet dragged along the floor during the transport. Observation on 5/1/23 at 8:19 A.M., showed the following: -CNA F and CNA G transferred the resident from his/her wheelchair to the toilet; -CNA F and CNA G lifted the resident under his/her armpits up from the wheelchair to the toilet; -CNA F and CNA G lifted the resident up from under his/her armpit to transfer him/her from the toilet back to the wheelchair; -CNA F and CNA G then lifted the resident up from under his/her armpits to transfer him/her from the wheelchair to the bed; -Both CNA F and CNA G had gait belts on their person, but did not put them on the resident or utilize them during the transfers. During an interview on 5/1/23 at 8:27 A.M., CNA F said the following: -The resident's feet did drag on the floor because the resident was too tired to assist with the transport; -The resident didn't have foot rests to put on his/her wheelchair; -He/She was in a hurry, so he/she forgot to put the gait belt on the resident during the transfer. During an interview on 5/4/23 at 8:43 A.M., CNA H said foot rests were supposed to be on wheelchairs unless the resident propelled themselves with their feet. During an interview on 5/4/23 at 8:50 A.M., CNA J said the following: -The resident was supposed to have foot rests on his/her wheelchair when the resident was lethargic and not able to lift his/her feet; -All residents with a wheelchair were supposed to have foot rests available; -If a resident was able to propel himself/herself, then the foot rests can be left off. 6. Review of Resident #34's annual MDS, dated [DATE], showed the following: -Severely impaired cognition; -Total dependence on one staff for locomotion on the unit; -Required extensive assistance from one staff for locomotion off the unit; -Used a wheelchair for mobility. Review of the resident's care plan, revised on 03/10/23, showed the following: -Diagnoses include dementia (a group of thinking and social symptoms that interferes with daily functioning), legal blindness, and generalized muscle weakness; -Staff propelled the resident when he/she was in a wheelchair for long distances. The resident can propel himself/herself in wheelchair for short distances; Observation on 05/01/23, at 8:04 A.M., showed the following: -CNA F propelled the resident in a wheelchair out of the dining room. The resident did not have foot rests on his/her wheelchair; -During transport, the resident's right foot slid on the floor making a rubbing sound. Observation on 05/01/23, at 12:28 P.M., showed the following: -CNA G propelled the resident in a wheelchair from his/her room to the dining room. The resident's wheelchair did not have foot rests; -During transport, the toes on the resident's right foot slid on the floor making a rubbing sound. 7. During interview on 05/03/23, at 3:09 P.M., Registered Nurse A said the following: -After a fall, staff complete an incident check list and slide it under the Director of Nursing's (DON's) door or administrator's door; -The check list indicates for the DON to add the fall to the care plan and adds interventions; -Nursing staff is probably able to update care plans, he/she just never has; -The interdisciplinary team identifies interventions for falls, but if there is an immediate concern, nursing addresses the concern and lets management know what was done. During interview on 05/04/23, at 1:15 P.M., the Quality Assurance (QA) Nurse said the following: -She is in charge of initiating interventions after falls on the care plans; -Nurses can update the care plans but she has not asked them to do so since they are very busy; -Lack of staff and nurses, and too many things going on has made it difficult to get the updates done. During interview on 05/04/23, at 2:30 P.M., the MDS Coordinator said the following: -She or the QA nurse were responsible for updating the care plans and they had gotten behind on updates; -Falls should be updated on the care plans. During interview on 05/04/23, at 3:12 P.M., the Director of Nursing (DON) said the following: -She expected intervention be reviewed and/or revised as needed after falls; -The MDS Coordinator was responsible for the review of care plans and updates as needed. -Staff should use foot rests when pushing a resident in a wheelchair if the resident is unable to hold up his/her feet; -If foot rests are not used, it could potentially cause the resident to drag their feet and go out of the wheelchair face first or could damage the resident's feet; -Foot rests should be used if a resident's feet drag on the floor; -Nursing staff should use a gait belt when transferring a resident and not lift under the resident's arms. During interview on 05/04/23, at 3:25 P.M., the administrator said the following: -The residents who can propel themselves do not have foot rests; -Residents #9 and #34 have self propelled themselves recently; -Staff should not propel a resident in a wheelchair without foot rests if the resident cannot hold up their feet. 46506

Based on observation, interview, and record review, the facility failed to ensure safety and adequate monitoring were provided to prevent falls and failed to consistently implement and modify interventions as necessary, in accordance with current standards of practice for six residents (Residents #3, #4, #5, #7, #11, and.#13), who had histories of falls, in a review of 14 sampled residents. The facility's census was 55. 1. Review of the facility's policy on Fall Risk Management, revised December 2007, showed the following: -Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks, and causes to try to prevent the resident from falling and to try to minimize complications from falling; -The staff, with the input of the Attending Physician, will identify appropriate interventions to reduce the risk of falls; -If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the continuation of the falling is identified as unavoidable; -If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant; -Staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling; -If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. 2. Review of the facility's policy on Investigating and Reporting Accidents and Incidents, revised April 2010, showed the following: -All accidents or incidents involving residents shall be investigated and reported to the Administrator; -The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident; -The following data, as applicable, shall be included on the Report of Incident/Accident form: date and time of the incident, nature of the injury, circumstances surrounding the incident, where the incident occurred, names of witnesses and their accounts, the injured person's account, time the physician was notified as well as his/her response, time the family was notified, the condition of the injured person, any corrective actions taken, follow up information, and the name of the person completing the report; -The Nurse Supervisor/Charge Nurse shall complete a Report of Incident/Accident form and submit the original to the Director of Nursing Services within 24 hours of the incident or Accident. 3. During an interview on 9/30/15 at 1:00 P.M. the Director of Nursing (DON) said the nurse on duty filled out the incident reports for falls and a copy of the report was given to the DON. The DON reviewed the incident reports and then discussed them with the fall committee to determine what interventions to try. These interventions were communicated to direct staff through the resident's care plan and a daily report sheet. The DON said she was working on a system to track and trend falls in the facility but for now falls were logged for each resident on a fall flow sheet. The DON said if a resident was able to remove a body alarm, a sensor alarm should be used. The DON said for cognitively impaired residents, staff should continue to remind them to use the call light because sometimes residents' cognition fluctuated and it was always a good idea to remind a resident to use the call light. 4. Review of Resident #5's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 12/9/14, showed the following: -[DIAGNOSES REDACTED]. -Cognition was moderately impaired; -Independent with transfers, walking in his/her room, toilet use, and personal hygiene; -Balance was steady; -Utilized a walker; -One fall with an injury since the previous assessment. Review of an incident report showed the following: -The resident fell on [DATE] at 2:00 P.M.; -The resident had gotten tangled in oxygen tubing and was found on the floor of his/her room; -The resident had a laceration to his/her head; -The resident was sent to the emergency room for evaluation and treatment. Review of the resident's fall flow sheet showed the resident fell on [DATE] at 2:00 P.M. and obtained a laceration to the head. An intervention was listed to send the resident to the emergency room . Review showed no documentation staff evaluated the current interventions in place to prevent falls or implemented new interventions to address the resident's fall. Review of an incident report showed the following: -The resident fell on [DATE] at 3:00 P.M.; -The resident attempted to get up and get a drink of water; -The resident's body alarm sounded, staff entered the room and found the resident on the floor; -The resident obtained a laceration to the left side of his/her head; -The resident was sent to the emergency room for evaluation and treatment. Review of the resident's fall flow sheet showed the resident fell on [DATE] at 3:00 P.M. and obtained a laceration to the head. An intervention was listed to send the resident to the emergency room . The resident fell on [DATE] and 1/21/15 and was sent to the hospital for evaluation following both falls. The resident sustained [REDACTED]. Review showed no documentation staff evaluated the current interventions in place to prevent falls or implemented new interventions to address the resident's fall. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognition was severely impaired; -Required limited assistance of one staff for transfers and walking; -Required extensive assistance of one staff for locomotion, dressing, toilet use, and hygiene; -Balance was steady; -Utilized a walker; -Two or more falls with injury since the previous assessment. Review of an incident report showed the following: -The resident fell on [DATE] at 4:50 P.M.; -The resident reached for an item, attempted to stand, and slid out of bed onto the floor; -The resident was not injured. Review of the resident's fall flow sheet showed the resident fell on [DATE] while reaching for an item. There was no injury. The space on the flow sheet for intervention was blank. Review showed no documentation staff evaluated the current interventions in place to prevent falls or implemented new interventions to address the resident's fall. Review of an incident report showed the following: -The resident fell on [DATE] at 5:55 P.M.; -Staff heard the resident's alarm sounding, entered the resident's room, and found him/her on the floor; -The resident was anxious and confused. Review of the resident's fall flow sheet showed the resident fell on [DATE] at 5:55 P.M. The resident was confused and found on the floor by the bed. The resident hit his/her head. The space on the flow sheet for intervention was blank. Review showed no documentation staff evaluated the current interventions in place to prevent falls or implemented new interventions to address the resident's fall. Review of an incident report showed the following: -The resident fell on [DATE] at 4:50 A.M.; -The resident rolled out of bed and hit his/her head on the oxygen concentrator; -The resident had a raised bump with bruising to the right side of his/her head. Review of the resident's fall flow sheet showed the resident fell on [DATE] at 4:50 A.M. The resident rolled out of bed and hit his/her head on the oxygen concentrator. The space on the flow sheet for intervention was blank. Review showed no documentation staff evaluated the current interventions in place to prevent falls or implemented new interventions to address the resident's fall. Review of the resident's annual MDS, dated [DATE], showed the following: -Cognition was severely impaired; -Required extensive assistance of one staff for transfers, walking, dressing, toilet use, and hygiene; -Balance was steady; -One fall without injury since the last assessment; -Two or more falls with injury since the last assessment. Review of the resident's care plan, dated 6/3/15, showed the following: -Problem: The resident required extensive assistance with most activities of daily living; -Approach: Walks with a walker and assist of one staff. Body alarm when in bed. Transfer with assist of one staff; -Problem: Falls. The resident had a history of [REDACTED]. -Approach: Walk with a walker and assist of one staff. Body alarm when in bed. Keep call light in reach. Keep the bed at the lowest level. Transfer with assist of one staff. Wear proper footwear with non-slippery soles. Review of the resident's fall assessment form, dated 7/6/15, showed the following: -The resident fell at 5:00 P.M. in his/her room; -Staff found the resident on the floor next to his/her bed without any injury; -The resident's body alarm was in place and sounded; -An intervention was added to check on the resident more often. Review of the resident's fall flow sheet showed the resident fell on [DATE] at 5:00 P.M. There was no injury. The space on the flow sheet for intervention was blank Review of the resident's care plan showed no update regarding the fall on 7/6/15. Review of the resident's fall assessment form, dated 8/16/15, showed the following: -The resident fell at 12:30 (A.M. or P.M. not listed); -The resident was anxious and up in his/her room making the bed; -Staff heard the resident's alarm sound and found the resident on the floor; -The resident had a bruise on the right hip and complained of pain in his/her leg; -The physician was notified and gave orders to send the resident to the emergency room for evaluation and treatment; -An intervention was added to put slipper socks on the resident (repeated intervention from the care plan, dated 6/3/15). Review of the resident's nurse's note, dated 8/16/15 at 1:25 A.M., showed at 12:00 A.M. the resident had increased anxiety. The nurse administered medications for pain and anxiety. At 12:15 A.M., while staff administered medications to the resident, he/she said he/she was making the bed. The nurse encouraged the resident to lie down and the resident refused. At 12:30 A.M. the certified nurse aide (CNA) called the nurse to the resident's room. The resident was on the floor with his/her walker tipped over near him/her. The resident was unable to move his/her legs fully. Staff assisted the resident off the floor. The resident complained of pain. The resident had a bruise on the right hip. The resident lay in bed. The resident complained of pain in the right leg with movement. The physician was notified and gave orders to send the resident to the emergency room . Review of the resident's nurse's note, dated 8/16/15 at 6:45 A.M., showed the hospital called the facility to inform that the resident was being transferred to another hospital for treatment of [REDACTED]. Review of the resident's fall flow sheet showed the resident fell on [DATE] at 12:30 A.M. The resident was confused and found on the floor beside the bed. The resident obtained a hip fracture. The space on the flow sheet for intervention was blank. Review of the resident's care plan showed no update regarding the fall on 8/16/15. During an interview on 9/30/15 at 1:25 P.M., the Director of Nursing (DON) said she would have expected staff to assist Resident #5 on 8/16/15 if he/she were up in his/her room. The resident required assistance and had a body alarm at that time so staff should not have left the resident up in his/her room unattended. 5. Review of Resident #4's admission MDS, dated [DATE], showed the following: -Cognition was moderately impaired for daily decision making; -Required extensive assist of two staff for bed mobility; -Required extensive assist of one staff for transfer, locomotion off unit, dressing, and toilet use; -Required limited assist of one staff for walk in room and corridor, locomotion on unit, and personal hygiene; -Balance for moving from seated to standing position, walking, moving on and off toilet, and surface-to-surface was unsteady, but able to stabilize without staff assistance; -Balance for turning around was unsteady, only able to stabilize with staff assistance; -No functional limitation in range of motion; -No mobility devices used; -Continent of bowel and bladder; -[DIAGNOSES REDACTED]. -Had a fall in the last month prior to admission; -Had a fall in the two to six months prior to admission; -Had a fall with a fracture within the last six months prior to admission; -Received antidepressant and anticoagulant during the look back period; -Received occupational and physical therapy. Review of the resident's care plan, dated 4/15/15, showed the following: -Problem: Potential for falls related to antidepressant therapy, weakness, decreased mobility, recent right hip fracture, and history of falls; -Goals: Prevent/manage future likelihood of falls; -Approaches: Able to propel self in wheelchair, asks for assist as needed. Accept fears, feelings, encourage to express them. Adequate lighting at all times. Ambulate with walker and assist of one. Call light within reach at all times. Document signs and symptoms of adverse effects of medication on the resident. Encourage the resident to wait for assistance. Answer the call light promptly. Keep bed in lowest level convenient for resident. Keep room uncluttered and clear paths to bathroom. Observe for decreased or loss of functional status, gait, and unsteadiness. Physical and occupational therapy to evaluate and treat. Teach the resident proper use of assistive devices (walker). Teach the resident to identify own physical limitations and request assist when feeling dizzy, weak, or unsteady. Transfer with assist of one. Wear proper footwear, with non-slippery soles. Review of the resident's nurse's notes, dated 5/13/15 at 2:00 P.M., showed the resident up independently in room, had fall on the floor and complains of pain in right lower extremity. Moves all extremities except for right lower extremity. Complains of pain in right hip. Notified physician and family, order received to send to emergency room for evaluation and treatment. Review of the resident's fall assessment form, dated 5/13/15, showed the following: -Time: 2:00 P.M.; -Chief complaint: Pain in right lower extremity, unable to move leg; -Lower Extremity Movement: Unable to move right lower extremity; -Treatment: Transfer to bed with slide board and sent to emergency room for evaluation and treatment; -Add intervention: Use walker at all times. Review of the resident's fall flow sheet, showed the following: -On 5/13/15 at 2:00 P.M., the resident was up ambulating in room without walker attempting to carry thing to trash can, his/her feet twisted and he/she fell landing on his/her right hip; -Injury: Refractured right hip; -Interventions: Blank. (Review of the resident's assessment and his/her care plan showed the resident was to use his/her walker with assistance from one staff when walking inside and outside his/her room. The resident was assessed with [REDACTED]. Staff identified the added intervention following the fall was to use a walker at all times, however, the intervention was already in place at the time of the fall. The fall resulted in a refracture of his/her right hip.) Review of the resident's nurse's notes, dated 5/20/15 at 3:00 P.M., showed the resident was readmitted to the facility from outlying hospital. The resident propelled to room in his/her wheelchair, where he/she moved his/her right foot from the right foot pedal and grimaced. Complained of pain in his/her right leg. Edema from hip to ankle two to three plus. The resident does not remember the fall at the facility. Transferred to bed and maximum assist of two and gait belt. The resident's family request body alarm due to the resident continued belief he/she is able to ambulate independently. Further review of the resident's care plan, showed staff did not update to include the fall on 5/13/15 and revise or add any new interventions to prevent future falls. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognition was moderately impaired for daily decision making; -Required extensive assist of two staff for bed mobility; -Required extensive assist of one staff for transfer, locomotion on and off the unit, dressing, and toilet use; -Balance for moving from seated to standing position, moving on and off toilet, and surface-to-surface was unsteady, only able to stabilize with staff assistance; -Functional limitation in range of motion in one of the lower extremity (hip, knee, ankle, foot); -Wheelchair mobility device used; -Continent of bowel and bladder; -[DIAGNOSES REDACTED]. -Had a fall in the last month prior to admission; -Had a fall in the two to six months prior to admission; -Had a fall with a fracture within the last six months prior to admission; -Had no falls since readmission or since last assessment (5/20/15); -Received antidepressant during the look back period; -Received no occupational and physical therapy during the look back period. Review of the resident's fall assessment form, showed the following: -Date: 7/10/15; -Time: 3:00 P.M.; -Resident verbal description (if unable to respond please notate): The resident was self-transferring without assistance to get up and help roommate; -Nurse description: The resident was self-transferring himself/herself without assistance to get up to help roommate. Alarm in place, the resident fell to the floor, no injury, landed on buttocks; -Skin: Small bruise to right hand; -Treatment: None needed; -Walker in reach: No; -Wheelchair in reach: No; -Body alarm: Yes; -Ringing: Yes; -What intervention added: Keep walker close to the resident; -Added to care plan: Blank. Review of the fall flow sheet, showed the following: -On 7/10/15 at 3:00 P.M., the resident, who is non-weight bearing to right lower extremity, forgot and got up to help roommate and fell to the floor; -Injury: Bruise to right hand; -Interventions: Blank. Further review of the resident's care plan, dated 7/15/15, showed the following: -Problem: Potential for falls related to antidepressant therapy, weakness, decreased mobility, recent right hip fracture, and history of falls. The resident recently fell and refractured his/her hip, continue treatment; -Goals: Prevent/manage future likelihood of falls; -Approaches: Able to propel self in wheelchair, asks for assist as needed. Accept fears, feelings, encourage to express them. Adequate lighting at all times. Call light within reach at all times. Document signs and symptoms of adverse effects of medication on the resident. Encourage the resident to wait for assistance. Answer the call light promptly. Keep bed in lowest level convenient for resident. Keep room uncluttered and clear paths to bathroom. Observe for decreased or loss of functional status, gait, and unsteadiness. Teach the resident proper use of assistive devices (walker). Transfer with assist of two. Wear proper footwear, with non-slippery soles. (The care plan did not address interventions identified following previous falls. The resident was to have an alarm to prevent falls, and was to have walker close to the resident.) Observation on 9/29/15 at 6:50 A.M., showed Certified Nurse Assistant (CNA) D assisted the resident up from the low bed by himself/herself. The bed alarm sounded when the resident stood up. The resident ambulated to the bathroom with the use of gait belt, walker, and one staff, then sat down on toilet. (The resident's care plan directed staff to provide assistance from two staff when transferring the resident.) During an interview on 9/30/15 at 10:30 A.M., CNA D said he/she referred to a resident's care plan as well as information received at change of shift report to find out about a resident's care needs, including interventions to prevent falls. CNA D said interventions in place to prevent falls for Resident #4 were to answer roommate's call light quickly, low bed, and bed alarm. The facility failed to consistently evaluate the cause of the resident's falls and implement fall interventions after the resident had experienced falls, and failed to update the care plan including interventions to prevent falls for the resident. 6. Review of Resident #7's quarterly MDS, dated [DATE], showed the following: -Cognition was moderately impaired; -Required limited assistance of one staff for transfers and walking; -Required extensive assistance of one staff for dressing, toilet use, and personal, hygiene; -Balance was not steady, but able to stabilize without human assistance; -Utilized a walker and a wheelchair; -One fall without injury since the previous assessment. Review of the resident's care plan, dated 12/24/14, showed the following: -Problem: The resident required limited to extensive assistance with activities of daily living; -Approaches: Walks with a walker and assist of one staff. Body alarm on while in bed and wheelchair. Transfer with assist of one staff. The resident's care plan, dated 12/24/14, did not address the resident's risk for falls. Review of the resident's incident report, dated 1/13/15, showed the following: -The resident fell at 4:10 P.M.; -Staff responded to the resident's pressure alarm sounding and found the resident on the floor; -The bed was in the low position; -The resident did not have on shoes; -The resident was not injured; -Non-skid socks were placed on the resident. Review of the resident's fall flow sheet showed the resident fell on [DATE] at 4:10 P.M. The resident's pressure alarm sounded. The resident was found on the floor beside the bed. The bed was in the lowest position. The resident was not injured. The space on the flow sheet for intervention was blank. Review of the resident's care plan showed an entry, dated 1/13/15, the resident fell with no injuries sustained. A pressure alarm was in place and non-slick socks were placed on the resident. Review of the resident's incident report, dated 1/23/15, showed the following: -The resident fell at 10:45 P.M.; -Staff found the resident sitting on the floor beside the bed; -The resident's alarm was disconnected from the wheelchair and not on the bed. Review of the resident's fall flow sheet showed the resident fell on [DATE] at 10:45 P.M. The resident was found on the floor beside the bed without injury. The space on the flow sheet for intervention was blank. Review of the resident's care plan showed an entry dated 1/23/15 that the resident took himself/herself to the bathroom and slid to the floor. There were no new interventions listed for this fall on the care plan. Review of the resident's incident report, dated 3/29/15, showed the following: -The resident fell at 6:30 P.M.; -A certified nurse aide (CNA) walked by the resident's room and found him/her on the floor with blood all over the floor and the resident; -The resident said he/she was trying to get stuff out of the closet and fell ; -The resident said he/she took off his/her alarm; -Monitor resident and remind him/her to use the call light; -The resident had multiple skin tears. Review of the resident's fall flow sheet showed the resident fell on [DATE] at 6:30 P.M. The resident removed his/her own body alarm, attempted to stand to get items out of the closet and fell . The resident obtained skin tears. The space on the flow sheet for intervention was blank. Review of the resident's care plan showed an entry, dated 3/29/15, that the resident had a fall with injuries. The resident unhooked his/her alarm. There were no interventions listed on the care plan for this fall. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognition was severely impaired; -Required extensive assistance with transfers, walking, dressing, toilet use, and personal hygiene; -Balance was not steady, but able to stabilize without human assistance; -Utilized a walker and a wheelchair; -One fall with injury since the last assessment. Review of the resident's fall assessment form dated 7/21/15 showed the following: -The resident fell at 9:25 P.M.; -Staff found the resident on the floor beside the bed; -The bed was in the low position; -There were no injuries; -A body alarm was in place but did not sound; -The space for interventions added was blank. Review of the resident's fall flow sheet did not list a fall for the resident on 7/21/15. Review of the resident's care plan showed an entry dated 7/21/15 that the resident fell without injury. There were no interventions added to the care plan for this fall. Review of the resident's fall assessment form, dated 7/26/15, showed the following: -The resident fell at 4:30 A.M.; -The resident slid out of bed attempting to get up and use the bathroom; -There were no injuries; -A body alarm was in place and sounded; -The space for interventions added was blank. Review of the resident's fall flow sheet showed the resident fell on [DATE] at 4:30 A.M. Staff found the resident on the floor with his/her pants down. The resident said he/she was going to the bathroom. The space on the flow sheet for intervention was blank. Review of the resident's care plan showed no entry for the fall on 7/26/15. Review of the resident's fall assessment form, dated 7/29/15, showed the following: -The resident fell at 6:05 P.M.; -The resident attempted to transfer himself/herself from the wheelchair to the bed and fell on the floor; -There were no injuries; -A body alarm was in place and sounded; -The space for interventions added was blank. Review of the resident's fall flow sheet showed the resident fell on [DATE] at 6:05 P.M. The resident attempted to self-transfer from the wheelchair to the bed and fell to the floor. The space on the flow sheet for intervention was blank. Review of the resident's care plan showed no entry for the fall on 7/29/15. Review of the resident's fall assessment form, dated 8/5/15, showed the following: -The resident fell at 6:15 P.M.; -The resident slid out of the wheelchair onto the floor; -There were no injuries; -A body alarm was in place and sounded; -The space for interventions added was blank. Review of the resident's fall flow sheet showed the resident fell on [DATE] at 6:15 P.M. The resident slid out of the wheelchair onto the floor. Review of the resident's care plan showed an entry, dated 8/5/15, that the resident slid out of the wheelchair. A non-skid pad was applied to the wheelchair seat. Review of the resident's fall assessment form dated 8/27/15 showed the following: -The resident fell at 9:45 A.M.; -Staff found the resident on the floor next to the bed; -There were no injuries; -A body alarm was in place but did not sound; -An intervention to toilet the resident every two hours was added. Review of the resident's fall flow sheet showed the resident fell on [DATE] at 9:45 A.M. Staff found the resident on the floor without socks or shoes. The resident refused to be toileted after breakfast. The space for interventions listed to toilet the resident every two hours, non-skid socks and a different alarm. Review of the resident's care plan showed no entry for the fall on 8/27/15 at 9:45 A.M. or the interventions listed on the fall assessment and flow sheet to prevent further falls. Review of the resident's fall assessment form, dated 8/27/15, showed the following: -The resident fell at 10:45 P.M.; -Staff found the resident on the floor at the foot of the bed; -There were no injuries; -A body alarm was in place but did not sound; -An intervention to be one-on-one with the resident was added. Review of the resident's fall flow sheet showed the resident fell on [DATE] at 10:45 P.M. The resident's alarm sounded and staff found him/her on the floor. The space for interventions listed the resident to be one-on-one for a time. Review of the resident's care plan showed no entry for the fall on 8/27/15 at 10:45 P.M. or the intervention listed on the fall assessment and flow sheet to prevent further falls. Review of the resident's annual MDS, dated [DATE], showed the following: -Cognition was severely impaired; -Required extensive assistance with transfers, walking, dressing, toilet use, and personal hygiene; -Balance was not steady, but able to stabilize without human assistance; -Utilized a walker and a wheelchair; -Two or more falls without injury since the last assessment. Review of the resident's care plan, dated 9/16/15, showed the following: -Problem: Potential for falls related to weakness, decreased mobility, poor safety judgement, and a history of falls; -Approaches: Walk with a walker and assist of one staff. Body alarm while in bed and wheelchair. Call light in reach at all times. Encourage resident to use call light and answer promptly. Keep bed level with the wheelchair. Keep room uncluttered. Keep non-skid socks on when in bed. Pressure alarm in bed and wheelchair. Transfer with assist of one. Wear proper footwear with non-slippery soles. Review of the resident's fall assessment form, dated 9/24/15, showed the following: -The resident fell at 9:20 P.M.; -The resident was in bed, got up, and slid to the floor; -There were no injuries; -A body alarm was in place but did not sound; -An intervention to be sure the resident's alarm was on was added. Review of the resident's post fall huddle form, dated 9/24/15, showed the following: -The resident fell at 9:30 P.M.; -The resident's bed alarm was not plugged in or on; -The fall was almost certainly preventable; -The fall could have been prevented by ensuring the resident's bed and wheelchair alarm was on; -Actions to prevent another fall from occurring were for staff to take the resident with them in the evening while doing treatments. Review of the resident's fall flow sheet showed the resident fell on [DATE] at 9:30 P.M. Staff found the resident on the floor beside the bed. The space for intervention listed to double check the alarms when going to bed. Review of the resident's care plan showed no entry for the fall on 9/24/15 or the interventions listed on the fall assessment and flow sheet to prevent further falls. During an interview on 9/29/15 at 5:54 A.M., Certified Nurse Assistant (CNA) B said interventions to prevent the resident from falling were to offer him/her assistance to the bathroom every two hours. The resident would sometimes refuse to go to the bathroom when staff offered. The resident had alarms on the bed and the wheelchair which he/she would sometimes remove. The resident's bed was kept at the same height as his/her wheelchair. Observation on 9/29/15 at 7:32 A.M. showed the resident propelled himself/herself into his/her room in a wheelchair. The resident had an alarm in place on the wheelchair. The resident propelled himself/herself into the bathroom and stood up. The resident's wheelchair alarm sounded. Staff responded to the resident's alarm after the resident had already transferred to the toilet unassisted. 7. Review of Resident #3's admission MDS, dated [DATE], showed the following: -Cognitively intac