Every finding on record at Concordia Village Care Center

Based on observation, interview, and record review, the facility failed to perform hand hygiene prior to donning gloves and in between glove changes, failed to wear gloves while touching resident food, and failed to change gloves and perform hand hygiene when providing incontinent care for 6 of 8 (R1, R2, R17, R33, R37, R41) residents, reviewed for infection control in a sample of 34. Findings include:1.On 01/05/2026 at 11:45 AM, V6, (Certified Nurse Assistant) CNA, donned gloves, without benefit of hand hygiene, served lunch meal to a resident, then she removed her gloves, opened the refrigerator with her bare hands, took out ketchup, closed the refrigerator door and returned to the table, dispensed ketchup, and returned it to the counter. She then took another pair of gloves and donned them without benefit of hand hygiene. She then delivered a meal tray to R37 and set up her meal tray for her. 2.On 01/05/2026 at11:56 AM, V7, CNA, donned a pair of gloves without benefit of hand hygiene, and delivered meal tray to R33. She then removed her gloves and sat with R33 to assist her with her meal. V7, with her bare left hand, fed R33 her hamburger. Then, with her right hand she tucked her hair behind her ear while providing bites of food to R33. Then at 12:07 PM, she was feeding R33 french fries with her bare right hand. R33's. Minimum Data Set (MDS), dated [DATE], documented she was unable to complete the Brief Interview for Mental Status and that she was dependent upon staff for eating. On 01/08/2026 at 10:30 AM, V28, CNA, stated if she was assisting R33 with eating a hamburger and french fries, she would wear gloves and not assist with her bare hands. V28 also stated she would wash her hands before putting on gloves and after she takes them off. On 01/08/2026 at 10: 35 AM, V12, Licensed Practical Nurse (LPN), stated if a resident needed to be hand fed, she would wear gloves. She also stated she would wash her hands before donning gloves, after doffing them, or changing her gloves. 3. R41's Facesheet documented she was admitted to the facility on [DATE] with diagnoses of muscle weakness and Parkinsons's disease. On 1/5/26 at 12:07 PM, V5 (CNA) applied gloves without hand hygiene, then touched the chair arms to sit down with her gloved hands. V5 grabbed french fries with her same left gloved hand and fed them to R41. On 1/8/26 at 9:10 AM, V23 (CNA) stated hand hygiene is done before and after glove use; before and after serving a resident food and before and after feeding a resident with gloves. On 1/8/26 at 9:12 AM, V24 (CNA) stated hand hygiene is done before and after glove use; before and after serving a resident food and before and after feeding a resident with gloves. 4. R2's Face Sheet, print date of 1/7/26, documented R2 has diagnoses including urinary tract infection, Parkinson's disease, aphasia following cerebral infarction, and hypertensive heart disease with heart failure. R2's MDS (Minimum Data Set), dated 11/17/25, documented R2 is severely cognitively impaired. R2's Care Plan Report, print date of 1/8/26, documented R2 has ADL (activities of daily living) selfcare deficit related to decreased mobility and muscle weakness. R2's Care Plan also documented R2 is occasionally incontinent. On 1/6/26 at 11:35 AM, V15, CNA (Certified Nurse Assistant), donned gloves without completing hand hygiene prior. V15 then removed R2's adult diaper that was soiled with a small amount of feces. V15 then cleansed R2's in thighs on both sides then turned R2 onto her right side and began cleansing R2's buttock. V15 did not cleanse R2's inner labia/urethra region. R2 continued to have a bowel movement as V15 was cleansing R2's inner buttock. V15 finished cleansing R2's buttock region. V15 then reached into R2's nightstand drawer and obtained a skin cream tube with the same gloves on as was used to cleanse the feces from R2's buttock. V15 then applied the cream and placed an adult diaper on R2. On 1/8/26 at 10:27 AM, V2, DON (Director of Nursing), stated she would expect the CNAs to perform hand hygiene and change gloves before, during, and after providing incontinent care. 5. On 1/5/26 at 12:00 PM during lunch observation in the kitchenette on the Reach Hall, V11, Cook, was seen putting a pair of blue gloves on after bringing up the warming cart, no hand hygiene seen. V11 kept the same pair of gloves on during the following: getting plates of food from warmer, removing lids and plastic wrap from food, had tongs in one hand and then with the other, grabbed some lettuce, onions, and tomato slices with his hand instead of using the tongs. V11 was seen opening cabinets, the fridge, running the mixer/blender, and touching everything in the kitchenette. V11 was also seen rinsing dishes in the sink, wrapping and putting away food items in the fridge, wiping the counters off, then would get another resident's plate ready, including touching top of the cups. V11 was seen pulling his pants up all with the same pair of gloves used throughout the lunch service. On 1/5/26 at 12:25 PM, V10, Dietary Manager, was seen using a scoop that was inside a container of peas and cauliflower, scooping up some and placing in a small bowl, and delivering the bowl to R17 without any hand hygiene or gloves on. V11 then used the same scoop to scoop up further dishes. On 1/5/26 at 12:30 PM, V8, Certified Nursing Assistant (CNA), was seen delivering lunch plates and drinks to R1 at the table, was seen cutting up R1's hamburger, removing plastic wrap from drinks and dishes, placing straws in cups, delivering to residents at table with no hand hygiene seen done before, between, or after. The Facility's Hand Hygiene Policy, dated 2/25/25, documents, 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 7. Use an alcohol-based hand rub containing at least 60% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: b. Before and after direct contact with residents; c. Before preparing or handling medications; g. Before handling clean or soiled dressings, gauze pads, etc.; h. Before moving from a contaminated body site to a clean body site during resident care; i. After contact with a resident's intact skin; k. After handling used dressings, contaminated equipment, etc; m. After removing gloves; n. Before entering isolation precaution settings and after leaving isolation precaution settings; o. Before and after eating or handling food; and p. Before and after assisting a resident with meals.8. Hand hygiene in the final step after removing and disposing of personal protective equipment. The Facility's Preventing Foodborne Illness - Hygiene & Sanitary Practices Policy, dated 3/6/25, documents, 5. Employees must wash their hands: a. After personal body functions; c. Whenever entering or re-entering the kitchen; d. Before coming in contact with any food surfaces; f. After handling soiled equipment or utensils.

Based on interview and record review, the facility failed to ensure residents were free from verbal abuse from staff for 1 of 3 residents (R31) reviewed for abuse in the sample of 34. Findings Include:R31's Face Sheet, print date of 1/5/26, documented R31 has diagnoses including Parkinson's disease, dementia, visual hallucinations, aphasia, and dysphagia.R31's MDS (Minimum Data Set) documented R31 is severely cognitively impaired and is dependent on staff for mobility. R31's care plan, print date of 1/5/26, documented R31 has a diagnosis of anxiety disorder with physical manifestations of hallucinations with interventions including touch hands/shoulder to show caring or provide comfort. Provide 1-1 interaction. The Facility's IDPH (Illinois Department of Public Health) Notification form, dated 11/21/25, documented date of alleged incident: 11/8/25 and 11/11/25, General Category: Resident verbal abuse, Name of Resident: (R31), Mental Status: Alert and oriented X1. It continues, during the process of investigation, medical record review and interview of witnesses, etc., the following conclusions have been determined about the alleged incident: Residents room has electronic monitoring in place with signage at the entrance of her room to indicate this. The residents spouse reviewed camera footage from 11/8/25 and 11/11/25 and showed this footage to the DON (Director of Nursing) on 11/17/25. In the video footage from 11/8/25, the staff member, (V18, CNA/ Certified Nurse Assistant) is getting the resident ready for a shower. The resident is naked, and the staff member (V18) is putting the (mechanical lift) sling underneath the resident. The resident has a urinary incontinent episode. The staff member (V18) responds to resident, Girl, of course you would pee right now. Right now, of all the times in the world! In the footage from 11/11/25, the staff member (V18) is providing care for the resident and is also on her personal cell phone using the speaker mode talking to someone. She uses explicit language during the call as the resident is present. The staff member (V18) states, 'It is so f*****g the bomb. Oh, my f*****g God. I'm trying to make all this shit make sense.' Immediately after viewing this video, administrator was notified, and the staff member was suspending pending investigation. Based on the regulation, this is verbal abuse. The staff member (V18) was suspending during the investigation. Residents and staff were interviewed with no further findings of abuse. The facility's Corrective Action form for employee V18, dated 11/20/25, documented V18 was terminated on 11/20/25 via phone with Administrator and DON present for verbal abuse. On 1/6/25 at 2:35 PM, V2, DON (Director of Nursing), stated she reviewed the video footage of the verbal abuse by a CNA to R31. V2 stated, It was definitely abuse; we immediately suspended the CNA and then terminated her.On 1/8/25 at 9:20 AM, V1, Administrator, stated her abuse investigation did substantiate verbal abuse occurred to R31 by V18, CNA. The facility's Abuse/Neglect Prevention and Response policy, revision date of 7/29/21, documented residents and clients of facility campuses and programs will live and be served in an environment that promotes dignity, respect and strives to be free from abuse, neglect, and exploitation. Allegation of potential or actual abuse, neglect or exploitation will be immediately reported to the appropriate leadership and government agency, the resident protected, and the allegation investigated. Definitions: Abuse the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish as well as the deprivation of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. It continues, verbal abuse is defined as any use of oral, written, or gestured language that includes disparaging and derogatory remarks to residents/clients or their families within their sign or hearing, regardless of the resident or client's ability to comprehend the language.

Based on interview, observation, and record review, the facility failed to implement fall interventions for 2 out of 6 residents (R4, R46) in a sample of 34 reviewed for Quality of Care. Findings include:1.R4's Facesheet documented she was admitted to the facility on [DATE] with diagnoses of dysphasia, drug induced Parkinsonism, and chronic obstructive pulmonary disease.R4's Minimum Data Set (MDS), dated [DATE], documented she was severely cognitively impaired and was dependent on staff to roll in bed and for chair/bed to chair transfers. The MDS also documented they could not complete transfers involving sit to lying, lying to sitting, sit to standing, toilet, or shower due to R4's current illness, exacerbation or injury.R4's Care Plan, dated 1/24/22, documented she is a risk for falls with interventions of: on 1/28/22 provide body pillow while in bed; on 10/19/23 fall mat in place next to bed; on 8/21/25 fall body pillow (already implemented on 1/28/22) to assist resident comfortably on her side to help with pressure reducing to coccyx/wound area; Fall 10/26/25 continue current interventions, ensure bear is in reach of resident while in bed; on 1/24/22 fall risk assessment to be completed on admission, quarterly, if significant changes, and with falls.The facility's Adverse Event Documentation, dated 8/21/25, documented R4 fell due to contributing factors of improper positioning in bed and R4 stated she was rolling over in bed. The document continued to report R4 was found next to her bed. The facility's Adverse Event Documentation, dated 10/26/25, documented, (R4) slid out of bed to the floor. Did not call for help prior to fall. Stated she did hit her head. No obvious injuries noted. No bumps, swelling, abrasions or bleeding noted on head or on any extremity. The document continued to report the contributing factors to R4's fall were form incontinence, disease process, and prior left sided cerebral vascular accident (CVA) routinely leaning to right and R4 stated she was attempting to grab her bear that had fallen off the bed. R4's Fall Risk Assessments, dated 6/5/25, 6/20/25, 8/13/25, 9/9/25 and 12/5/25, all documented R4 is a low fall risk and documented she has not had any falls. No Fall Risk Assessment was completed for R4's falls on 8/21/25 or 10/26/25. On 1/8/26 at 8:30 AM, V12 (Licensed Practical Nurse/LPN) was assisting with transferring R4 in from her bed to her wheelchair and stated she honestly does not know where her body pillow is right now or why it isn't in her room and nodded in agreement it should be. No body pillow was observed in R4's room, besides the one her roommate had in her bed, as she was lying in bed preparing to be transferred. 2.R46's Facesheet documented he was admitted to the facility on [DATE] with diagnoses of hemiplegia, heart failure, and muscle weakness.R46's MDS dated [DATE] documented he was severely cognitively impaired and required substantial/maximal assistance from staff to roll left and right in bed, and for all transfers. R46's Care Plan, dated 11/3/25, documented he is at risk for falls with interventions of, in part, on 11/3/25 side rail(s) as an enabler to assist with transfers and bed mobility- grab bars; remind and reinforce safety awareness, lock brakes on bed, chair, etc. before transferring; educate/remind Rich and/or family to request assistance for all ambulation and transfers; non-skid socks; appropriate footwear; fall risk assessment to be completed on admission, quarterly, and with significant changes. On 11/25/25 interventions of; in part, were to place R46 where visible to staff, encourage activity participation; on 1/1/26 to check on R46 beginning at 8:30a (AM) to see if he is ready to get out of bed; use of body pillow for positioning while in bed; continue will all current fall interventions, including ensuring call light is in reach, encourage activities, personal items are in reach and provide toileting assistance every 1-2 hours. The facility's Adverse Event Documentation, dated 11/23/25, documented R46 was sitting near the edge of his wheelchair and lowered down to the floor by staff but did not include an interview of what R46 was attempting to do. The document continued to report the fall was due to contributing factors of confusion/memory deficit, change in mental status, and impaired communication. The facility's Adverse Event Documentation, dated 1/1/26, documented R46 fell and was found hanging out of bed with his knees on the floor mat but did not provide an interview of what the R46 was attempting to do. The documentation continued to report the contributing factors of the fall were due to confusion/memory deficit and alerted gait/balance/tripped. The facility's Adverse Event Documentation, dated 1/1/26, documented R46 fell and was found on the floor after hearing a loud noise. R46 had two skin tears found after the fall. The document continued to report R46's fall was due to contributing factors of (again) confusion/memory deficit and disease process improper/self-transfer. R46's Fall Risk Assessment, dated 11/18/25, documented he is a low fall risk with no new evaluation completed. On 1/6/26 at 1:30 PM, V16, Licensed Practical Nurse (LPN), took R46's socks (with no grips) off to show his foot wounds and reapplied them, put his blanket back over his feet and left him the same way he was found (wearing socks without grips and no body pillow in bed).On 1/6/26 at 1:30 PM, V16 (LPN) stated R46 has a skin tear on his left forearm from his last fall. V16 stated R46 doesn't always use his call light and will get up by himself. V16 stated R46 is very unsteady on his feet.On 1/8/26 at 9:08 AM, V22, Certified Nursing Assistant (CNA), stated fall prevention interventions include gait belts, proper footwear, proper use of walkers and looking at the resident's sheets for detailed interventions. V22 stated she is new and doesn't know a lot, but can ask co-workers for information on the residents. On 1/8/26 at 9:10 AM, V23 (CNA) stated, For (R46's) fall preventions, we have a body pillow for him in bed, frequent checks, and a fall mat. V23 stated she thinks his falls are due to them not being able to get to him in time; he gets up on his own sometimes. V23 stated R46 is always incontinent. V23 stated R4's fall interventions also include a body pillow and is not sure what else or why she has fallen in the past. V23 stated for all residents she likes to make sure the beds are low, and body pillows are in place. V23 (CNA) stated hand hygiene is done before and after glove use; before and after serving a resident food and before and after feeding a resident with gloves.On 1/8/26 at 9:12 AM, V24 (CNA) stated R46's fall preventions include a long pillow in bed, a fall mat, a call light in reach. V24 stated she wasn't sure why he has fallen in the past, but he is with it enough to answer simple questions such as what he was doing before the fall. V24 (CNA) stated hand hygiene is done before and after glove use; before and after serving a resident food and before and after feeding a resident with gloves.On 1/8/26 at 12:15 PM, V1 (Administrator) stated risk assessments are completed quarterly, and upon admission, also after each fall the nurse completes a mini root cause assessment to determine new interventions and after that a deeper investigation is done; care plans are updated with new interventions. V1 stated any resident that has fallen in the last 6 months would not be considered a low fall risk. V1 stated R4's body pillow intervention added 8/21/25 she considered to be new just utilizing the same tool in a different way. On 1/8/26 at 1:09 PM, V2, Director of Nursing (DON), stated she expects the staff to be following fall interventions. The facility's Management of Falls policy last revised 9/14/22, documented, 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 policy continued to document staff will identify and implement relevant interventions to try to minimize serious consequences of falling.

Based on observation, interview, and record review the facility failed to provide complete incontinent care for 1 of 2 (R2) residents reviewed for incontinent care in a sample of 34. Findings Include:R2's Face Sheet, print date of 1/7/26, documented R2 has diagnoses including urinary tract infection, Parkinson's disease, aphasia following cerebral infarction, and hypertensive heart disease with heart failure.R2's MDS (Minimum Data Set), dated 11/17/25, documented R2 is severely cognitively impaired.R2's Care Plan Report, print date of 1/8/26, documented R2 has ADL (activities of daily living) selfcare deficit related to decreased mobility and muscle weakness. R2's Care Plan also documented R2 is occasionally incontinent. On 1/6/26 at 11:35 AM, V15, CNA (Certified Nurse Assistant), donned gloves without completing hand hygiene prior to donning the gloves. V15 removed R2's adult diaper that was soiled with a small amount of feces. V15 then cleansed R2's inner thighs on both sides then turned R2 onto her right side and began cleansing R2's buttock. V15 did not cleanse R2's inner labia/urethra region. R2 continued to have a bowel movement as V15 was cleansing R2's inner buttock. V15 finished cleansing R2's buttock region. V15 then reached into R2's nightstand drawer and obtained a skin cream tube with the same gloves on as was used to cleanse the feces from R2's buttock. V15 then applied the cream and placed an adult diaper on R2. On 1/8/26 at 10:27 AM, V2, DON (Director of Nursing), stated she would expect the CNAs to cleanse female residents' inner labia region after an incontinent episode. V2 also stated she would expect the CNAs to perform hand hygiene and change gloves before, during, and after providing incontinent care. The facility's Perineal Care policy, dated 10/4/23, documented the purposes of this procedure to provide cleanliness and comfort to the resident to prevent infections and skin irritation, and to observe the resident's skin condition. Steps in the Procedure: 1. Perform hand hygiene. 2. Fill the wash basin one-half (1/2) full of warm water, if used. If not used, place perineal wipes within reach. 3. Put on gloves. 4. For a female resident: a. Wet washcloth and apply soap or skin cleansing agent or use a perineal wipe. b. Wash perineal area, wiping from front to back. Continue to wash the perineum moving from inside outward to and including thighs, alternating from side to side, and using downward strokes. Do not reuse the same area of the washcloth and/or perineal wipe to clean the urethra or labia. c. Wash the rectal area thoroughly, using a washcloth or a perineal wipe, wiping from front to back to the buttocks.

Based on interview and record review, the facility failed to transcribe and follow the physician's orders for 1 of 5 (R1) reviewed for physician orders in the sample of 34. The findings include:R1's Facesheet, dated 1/6/26, documents R1 was admitted on [DATE] with diagnoses of Aortic Valve replacement, Pulmonary emboli and fibrosis, Atrial Fibrillation, Atherosclerotic heart disease, Diabetes Mellitus Type 2, Malignant neoplasm of bronchus or lung, Benign Prostatic Hyperplasia (BPH), Depression, and Chronic Obstructive Pulmonary Disease. R1's Care Plan, dated 12/24/25, documents R1 is on an anticoagulant and is at risk for bleeding. R1 is at risk for falls/injury as evidenced by history of falls, cognitive status/behavior, vision status, continence, mobility, balance. R1 has Activities of Daily Living (ADL) selfcare deficit related to decreased mobility and muscle weakness. R1's Minimum Data Set (MDS), dated [DATE], documents R1 is cognitively intact and requires partial/moderate assistance from staff for ADLs.R1's Physician Order (PO), dated 12/20/25, documents, Warfarin 10 MG (milligram) tablet 1 Time Daily for 1 Day. First scheduled time is 12/20/25 at 8:00 PM. There was no Warfarin order entered prior to this order.R1's Nursing Event Note, dated 12/20/25 at 8:50 PM, documents, Writer doing chart audit check and noticed that Coumadin was on all discharge instructions. Writer contacted supervisor and went over orders with her. LPN (Licensed Practical Nurse) called on call doctor to obtain new orders for INR of 1.1. Residents coumadin was found in medication room with multiple different doses. R1's Nursing Progress Note, dated 12/20/25 at 9:15 PM, documents, Call returned from Dr. Following new orders received. Coumadin 10 MG now. Coumadin 5 MG 10/21/25 and repeat INR (International Normalized Ratio) 12/22/25.V1, Administrator's, Investigation for R1's Medication Event, dated 12/21/25, documents, Resident admitted to the facility on [DATE]. On 12/20/25 a chart audit was performed and was found that resident had orders for Warfarin (Coumadin) upon admission that were not entered. Resident went 5 days without receiving Warfarin. INR obtained and was 1.1. Physician advised and new Warfarin orders and INR orders obtained. Resident and family aware. During risk analysis, it was determined that resident's medication list was faxed over prior to admission on 12/15. This list was used to create resident's medication list. Resident arrived at the facility on 12/15 with an updated set of orders in hand. The two list were not reconciled. The facility has taken the following actions based on the facts and conclusions of the investigation: admission audits will be completed within 24 hours of admission to include a reconciliation of medications, review of MARs (Medication Administration Records) from discharging facility.R1's Nursing Note, dated 12/23/25 at 3:40 PM, documents, Resident INR 2.2 left message with (V28, Physician) Nurse (V30, Certified Medical Assistant). (V30) called back and (V28) wants to stay with 5 MG of Warfarin and recheck INR in 1 week.R1's INR (International Normalized Ratio) results, dated 12/20/25 as 1.1, on 12/22/25 as 1.7, on 12/23/25 as 2.2, on 12/30/25 as 4.0, and on 1/2/26 as 1.9. According to the Cleveland Clinic website (https;//my.clevelandclinic.org/health/diagnostics/prothrombin-time-test), the normal ranges for INR results are 0.8 to 1.1 and an INR of 2.0 to 3.0 if you're taking Warfarin.R1's Medication Administration Record (MAR), dated December 2025, documents Warfarin was entered on 12/20/25. On 1/8/26 at 11:15 AM, V2, Director of Nursing (DON), stated, When a resident is admitted , we do an admission Audit within 24 hours of the resident's arrival. This audit looks to see if all physician orders and resident assessments have been completed. When (R1) was admitted , apparently the audit was not done for 5 days after his arrival. I think if it was originally done, they were looking at the faxed orders instead of the orders that came with him. I would expect the 24-hour admission Audit to be completed within the first 24 hours after admission. On 1/8/26 at 11:20 AM, V20, Registered Nurse (RN), stated, When a resident is admitted , the nurse should fax all physician orders to the pharmacy, who will then enter each medication into the EMR (electronic medical record). We then will do a double check by acknowledging each med in the system to get them going. The nurse will then complete all resident assessments. Us nurses (sic) don't do the 24-hour audit; that is done by a supervisor.On 1/8/26 at 9:55 AM, attempted to contact V28, Medical Director, regarding R1's Coumadin Medication Event. V30, V28's Certified Medical Assistant (CMA), stated V28 is out of the country and will not be back until 1/21/26. V30 stated V29, Nurse Practitioner (NP), is covering for V28. V30 stated her notes show R1 was put back on Coumadin 5 MG daily on 12/22/25 and she is unable to tell surveyor anything further.On 1/8/26 at 12:55 PM, V29, NP, stated, It is not ideal for anyone on Warfarin to not get their Warfarin. There is no way to know the risk of not taking the Warfarin for 5 days. I don't believe (R1) had any harm from missing his Warfarin. I would expect any nurse to follow the physician orders.The facility's Reconciliation of Medication Policy, dated 2/19/25, documents, The purpose of this procedure is to ensure medication safety by accurately accounting for the resident's medication, route, and dosage upon admission or readmission to the community and transfers between levels of care. Preparation: 1. Gather the information needed to reconcile the medication list: a. Discharge summary from referring hospital, MAR from other transferring facility. b. admission order sheet. c. All prescription and supplement information obtained from the resident/family during the medication history. d. Most recent medication administration record (MAR) if there is a readmission. Steps in the Procedure: 1. Obtain a medication history from the resident and/or representative. 2. The information from the medication history should include a. Prescription medications, including those taken only as needed; b. Non-prescription/over the counter medications, including those taken only as needed, c. Herbal or dietary supplements, including vitamins and minerals; d. Patches, eye drops, creams, inhalers, shots, sample medication; e. Dosage, route, frequency and last dose taken for all items; and f. Reason(s) for taking each medication/supplement. 3. Review the list carefully to determine if there are discrepancies/conflicts. 4. If there is a discrepancy or conflict in medication, dosage, route or frequency, contact the physician within 24 hours and document. 5. When a resident is transferred to another facility, or within the organization, send the reconciled medication list to the receiving physician.The facility's admission Assessment and Follow Up: Role of the Nurse Policy, dated 2/19/25, documents, The purpose of this procedure is to gather information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission for the purposes of managing the resident, initiating the care plan or Individualized Service Plan (AL/ALMC), and completing required assessments. Steps in the Procedure: 5. Reconcile the list of medications from the medication history, admitting orders, the previous MAR (if available), and the discharge summary from the previous institution, according to established procedures. 6. Contact the physician and review the findings of the initial assessment and any other pertinent information and either obtain admission orders or reconcile orders that arrive with the resident that are based on these findings.

Based on interview, observation, and record review, the facility failed to serve food at a safe and appetizing temperature for 1 out of 1 resident (R37) reviewed for Food and Nutrition Services in a sample size of 34.Findings include:R37's Facesheet documented she was admitted to the facility on [DATE], with diagnoses of quadriplegia, anxiety disorder, and malaise. R37's Minimum Data Set (MDS), dated [DATE], documented R37 was cognitively intact.On 1/6/26 at 10:30 AM, R37 stated, I live in one of the last rooms on the hall and the food is not the warmest; isn't cold but could be warmer.On 1/6/26 at 11:34 AM, lunch temperatures off the steam table were recorded in degrees Fahrenheit go as follows: seafood crepe: 185 degrees, quiche: 145 degrees, potato wedges: 145 degrees.On 1/6/26 at 12:15 PM, the test tray after all residents were served was temperature checked and the following food was recorded in degrees Fahrenheit: seafood crepe:129.5 degrees, quiche was 131 degrees, and the potato wedges were 123.4 degrees. On 1/7/26 at 12:24 PM, V1 (Administrator) stated her expectation is that all hot food should be held at 135 degrees or above and all cold food should be held at 41 degrees or below.On 1/8/26 at 8:33 AM, V21 (Cook) stated holding temperatures are supposed to be at 135 degrees for hot foods and 41 degrees for cold foods.On 1/8/26 at 9:21 AM, V25 (Dietary Manager) stated holding temperatures are supposed to be at 135 degrees for hot foods and 41 degrees for cold foods.The facility's Food Handling policy, revised on 2/14/20, documented, Food will be stored, prepared, handled, and served so that the risk of foodborne illness is minimized.

Based on interview, observation, and record review, the facility failed to prepare and serve food in accordance with professional standards for food service safety by not performing hand hygiene and glove changes while serving food to 2 of 10 residents (R1, R17) reviewed for serving food sanitarily in the sample of 34.The findings include: On 1/5/26 at 12:00 PM during lunch observation in the kitchenette on the hall, V11, Cook, was seen putting a pair of blue gloves on after bringing up the warming cart; no hand hygiene seen. V11 kept the same pair of gloves on during the following: getting plates of food from warmer, removing lids and plastic wrap from food, had tongs in one hand and then with the other, grabbed some lettuce, onions, and tomato slices with his hand instead of using the tongs. V11 was seen opening cabinets, the fridge, running the mixer/blender, and touching everything in the kitchenette. V11 was also seen rinsing dishes in the sink, wrapping and putting away food items in the fridge, wiping the counters off, then would get another resident's plate ready, including touching top of the cups. V11 was seen pulling his pants up all with the same pair of gloves used throughout the lunch service. On 1/5/26 at 12:25 PM, V10, Dietary Manager, was seen using a scoop that was inside a container of peas and cauliflower, scooping up some and placing in a small bowl, and delivering the bowl to R17 without any hand hygiene or gloves on.On 1/5/26 at 12:28 PM, V11 then used the same scoop to scoop up further dishes.On 1/5/26 at 12:30 PM, V8, Certified Nursing Assistant (CNA), was seen delivering lunch plates and drinks to residents at the table, was seen cutting up R1's hamburger, removing plastic wrap from drinks and dishes, placing straws in cups, delivering to R1 at table with no hand hygiene seen done before, between, or after.On 01/08/2026 at 10:30 AM, V28, CNA, stated if she was assisting R33 with eating a hamburger and French fries she would wear gloves and not with her bare hands. V28 also stated she would wash her hands before putting on gloves and after she takes them off. On 01/08/2026 at 10: 35 AM V12, Licensed Practical Nurse (LPN), stated that if a resident needed hand fed, she would wear gloves. She also stated that she would wash her hands before donning gloves and after doffing them. On 01/08/2026 at 10:40 AM, V23, CNA, stated she would wash her hands before donning gloves and after doffing gloves. She also stated she would don gloves prior to touching the residents' food.On 1/8/26 at 10:27 AM, V2, DON (Director of Nursing), stated she would expect the CNAs to perform hand hygiene and change gloves as needed.The Facility's Hand Hygiene Policy, dated 2/25/25, documents, 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 7. Use an alcohol-based hand rub containing at least 60% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: b. Before and after direct contact with residents; c. Before preparing or handling medications; g. Before handling clean or soiled dressings, gauze pads, etc.; h. Before moving from a contaminated body site to a clean body site during resident care; i. After contact with a resident's intact skin; k. After handling used dressings, contaminated equipment, etc., m. After removing gloves; n. Before entering isolation precaution settings and after leaving isolation precaution settings; o. Before and after eating or handling food; and p. Before and after assisting a resident with meals.8. Hand hygiene in the final step after removing and disposing of personal protective equipment.The Facility's Preventing Foodborne Illness - Hygiene & Sanitary Practices Policy, dated 3/6/25, documents, 5. Employees must wash their hands: a. After personal body functions; c. Whenever entering or re-entering the kitchen; d. Before coming in contact with any food surfaces; f. After handling soiled equipment or utensils.

Based on interview, observation, and record review, the facility failed to label and date food products, restrain hair, and ensure resident use refrigerators are only used for residents to prevent foodborne illness. This failure has the potential to affect all 51 residents residing at the facility. Findings include: On 8/19/24 at 10:30 AM, the main kitchen was observed. The walk in refrigerator had a container of meat (which appeared to be tuna). The container was not labeled or dated. The main kitchen freezer had a metal sheet pan lying on the floor. There was a frozen bag with red pasta sauce on the sheet pan. At 10:40 AM, the Summer hall kitchen refrigerators were observed. The was an employee lunch box, 3 premade salads, a storage container of cottage cheese, a storage container of what appears to be tartar sauce. None were labeled or dated with made on and expires on dates. There were 9 fruit cups and 9 applesauce cups that were not covered, labeled or dated. The freezer section had frozen meat that was not labeled or dated, an open storage bag of frozen waffles, and breakfast sausage that was undated. In the cabinet, there were 2 squeeze bottles- one has liquid butter and one has syrup, neither was labeled or dated. There was a box of cream of wheat that was open and not sealed. At 10:55 AM, the Reach hall kitchen refrigerators were observed. There was a block of cheese that is not labeled or dated. The freezer had a bag of unknown meat that was undated and not labeled that had freezer burn, and an employee's frozen meal. In the cabinet, there were 2 squeeze bottles- one has liquid butter and one has syrup, neither were labeled or dated. There was a box of cream of wheat that was open and not sealed. At 10:55 AM, V5, Cook, stated employees should not keep food in the refrigerator, all food should be labeled and dated, and all foods should be sealed properly. V5 stated, Unfortunately, I can not be here around the clock and things get missed. At 11:05 AM, the Spring hall kitchen refrigerators were observed. There was a a tray of cheese and pepperoni roll ups and a jar of minced garlic jar. V6, Cook, was questioned if the items were for residents or employees. V6 stated both of those are employees. There was a storage container of cottage cheese and fruit salad both are undated and are not labeled. There was 2 bags of frozen cookies that were open and not sealed properly. In the cabinet, there were 2 squeeze bottles one has liquid butter and one has syrup, neither were labeled or dated. There was a box of cream of wheat that was open and not sealed. On 8/21/24 at 11:25 AM, the noon meal was observed on the steam table, being plated, covered and placed in hot boxes to be taken to the halls. V18, Cook, was serving from the steam table and handing the plates to V17, Cook, who was covering the plates and putting the plates into the hot box. Neither V17 or V18 were wearing a beard net. On 8/19/24 at 10:30 AM, V4, Dietary Manager, stated, All food products should be labeled with the name, date prepared, and expiration date. On 8/21/24 at 11:30 AM, V4 stated he would order some beard nets. On 8/22/24 at 9:37 AM, V4 stated employees should not use refrigerators for residents for their personal food. The policy Food Storage, dated 10/1/20, documents, 6. Items that arrive in their original packaging with a manufacturer's expiration date will utilize that date for discard. a. Should an item be opened and stored in a different container, it will be labeled with an open date and a discard date. The policy Preventing Foodborne Illness - Hygiene & Sanitary Practices, dated 9/ 2013, documents, 11. Hair nets or caps and / or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils and linens. The Long Term Care Facility Application for Medicare and Medicaid, dated 8/19/24, documents that the facility has 51 residents residing in the facility.

Based on interview, observation, and record review, the facility failed to dispose of medications for 2 of 51 residents (R42, R115) reviewed for medication storage in the sample of 29. Findings include: 1. On 8/20/24 at 8:55 AM, reviewed medication storage room with V7, Licensed Practical Nurse (LPN). In the medication refrigerator there were 3 Lantus Pens and a vial of 100 units for R155. V7 stated R155 has not been in the facility for awhile. V7 stated, Old medications are destroyed. Our pharmacy never accepts medications for refund. R155's Face Sheet, print date of 8/22/24, documents R155 was discharged on [DATE]. On 8/20/24 at 9:08 AM, the (hall name) medication storage room was observed. R42 had 5 prescription cards stored; Potassium Chloride 20 meq (milliequivalent) ER (extended release) dispense date of 4/18/24, Ocuvite tablets dispense date of 4/15/24, Rosuvastatin 40 mg (milligrams) dispense date of 4/24/24, Acetaminophen 325 mg (milligrams), dispense date 2/22/24, and Losartan 25 mg dispense date of 4/26/24. R42's Census Record, undated, documents R42 was moved from (hall name) on 6/6/24. On 8/20/24 at 12:35 PM, V2, Director of Nursing, stated, Old medications should be destroyed. (R42's) prescription cards must have come from home because we don't have prescription cards . They should have been used first or sent home with her family. (R42) doesn't even live on (hall name) anymore she is on (hall name). The policy Discarding and Destroying Medication, dated 8/17/22, documents, Medication will be disposed of in accordance with federal, stated, and local regulations governing management of expired medications, non-hazardous pharmaceuticals, hazardous waste and controlled substances. Discontinued medications should be either destroyed or returned.

Based on interview, observation, and record review, the facility failed to perform hand hygiene, post a needed isolation sign, and use Personal Protective Equipment (PPE) for 2 of 24 residents (R40, R255) reviewed for infection control in sample of 29. Findings include: 1. On 8/20/24 at 8:37 AM, V7, Licensed Practical Nurse, LPN, gave R40 his pill medication to take. R40 took all the medications. V7 donned gloves with no hand hygiene before, and then administered eye drops in R40's eyes. On 8/22/24 at 11:15 PM, V2, Director of Nursing, DON, stated hand hygiene should be done before donning gloves. The policy Hand Hygiene, dated 1/30/24, documents, 1. Perform hand hygiene before applying non - sterile gloves. 2. On 8/20/24 at 1:00 PM, V2 stated, (R255) just turned positive with COVID. On 8/21/24 at 8:45 AM, R255's door does not have an isolation and needed PPE sign on the door. On 8/21/24 at 8:50 AM, V2 stated ]R255 should have a signage indicating what personal protective equipment is need. R255's Clinical Note, dated 8/20/24, documents, Resident was tested for COVID via POC (Point of Care) test. COVID test was positive. The policy Covid - 19 Infection Prevention Control Measures, dated 4/1/24, documents, d. Post visual alerts at the entrance and in strategic places. These alerts should include instructions about current IPC (Infection Prevention Control) recommendations.

Based on interview and record review, the facility failed to provide timely assessment and treatment of humeral fracture in 1 of 3 residents (R2) reviewed for abuse in the sample of 3. This failure resulted in a delay of care for R2's humeral fracture from, at a minimum, 5:30 PM on 6/12/24 to 12:34 PM on 6/13/24. Findings include: R2's Face Sheet documents, R2 was admitted to the facility on [DATE], with diagnoses including dementia, depression, muscle weakness, osteoporosis, and history of falling. R2's, undated, Minimum Data Set/MDS documented R2 was severely cognitively impaired with inattention, disorganized thinking, and altered level of consciousness. The MDS documented R2 ambulated via wheelchair, required substantial assistance with rolling, and was dependent with transfer. R2's Care Plan, starting 3/29/24, documents R2 is at risk for falls, injury, and pain. On 6/25/24 at 1:43 PM, V7, Certified Nursing Assistant (CNA), stated, (R2) complained of right arm pain before getting up on the morning of 6/12/24 and was not using her right arm at lunch time, which she usually uses to feed herself. On 6/25/24 at 2:58 PM, V8, Registered Nurse, (RN) stated several people commented to her that R2 was not her usual perky self on 6/12/24. She stated V7, CNA, mentioned to her in the afternoon that R2 had complained of right arm pain earlier in the day, but when V8 checked in on R2, she was sleeping peacefully in her bed. On 6/25/24 at 3:15 PM, V9, CNA, stated he cared for R2 on the evening of 6/12/24, and noticed R2 was not using her right arm during dinner. He stated, (R2's) right arm was hanging in an unusual way, then I noticed bruising while getting her ready for bed. V9 stated he informed V20, Licensed Practical Nurse, (LPN), and she stated she would let the other nurses know. On 6/26/24 at 8:35 AM, V20, Licensed Practical Nurse, (LPN), stated she was walking out the door to leave work, around 5:30 PM on 6/12/24 when V9, CNA, came and asked her if she knew anything about a bruise on R2. She stated she was unaware of any bruising, but told V9 he should check with the other nurses and see if there was any documentation in the Shift Change Report Notes. On 6/26/24 at 9:06 AM, V15, LPN, stated she cared for R2 on 6/13/24, and V9, CNA, did not report any bruising to her. She stated if she had been informed, she would have evaluated R2's arm and notified management. On 6/25/24 at 11:25 AM, V4, CNA, stated she was getting R2 dressed on the morning of 6/13/24, and R2 acted like she was in pain. V4 then noticed the bruising all over R2's right upper arm, her right armpit, and her right eye. She stated she immediately told V5, LPN. X-Rays were ordered and R2's arm was found to be broken. On 6/25/24, at 10:12 AM, V5, LPN, stated on the morning of 6/13/24, V4, CNA, alerted her that R2 had bruising from her shoulder to her mid arm. V5 stated she immediately notified V3, Assistant Director of Nursing (ADON), who notified V19, Physician, and R2's Family. She stated V19 ordered an X-Ray that showed R2 had a broken arm. The Facility's Shift Change Report Notes for Day Shift on 6/12/24 document R2 was less talkative and complained of arm pain. The Facility's Shift Change Report Notes for Evening Shift on 6/12/24 document, Ok next to R2's name. R2's Clinical Note by V5, LPN, on 6/13/24 at 12:34 PM, documents, CNA was getting resident up and dressed when she noticed bruising to her right arm and right side of her head just above her eyebrow. Writer called management to let them know. Writer noticed she was grimacing, not moving arm, and complaining of pain. She would not let writer move her arm. Family and (V19, Physician) aware. (V19) ordered X-Rays of shoulder, elbow, and ribs. R2's X-Ray of right shoulder on 6/13/24 documents, Acute comminuted, (broken in at least two places) fracture proximal right humerus, (upper arm bone), with deformity and inferior, (lower), subluxation, (partial dislocation), of the proximal right humerus. R2's Clinical Note by V3, Assistant Director of Nursing (ADON), on 6/13/24 at 12:37 PM documents X-ay results were received and R2 was transported to the emergency room (ER) at 12:34 PM for further evaluation. R2's Clinical Note by V15, LPN, on 6/13/24 at 10:20 PM, documents R2 returned to the Facility at 8:30 PM with arm in a sling due to a comminuted fracture of the right humerus. On 6/25/24 at 2:20 PM, V1, Administrator, stated the Facility completed an investigation and determined the injury likely happened between 6/10/24 and 6/12/24. On 6/26/24 at 11:23 AM, V19, Physician, stated she ordered R2's X-rays on 6/13/24 as soon as she was notified of the bruising and pain. She stated she would expect the Facility to contact her as soon as the bruising and pain were discovered, and if they were present the day before they contacted her, that would be a delay. She stated the treatment would not have changed, but pain is always something they consider, and if they had told her the day before about R2's bruising and pain, she would have automatically ordered the X-Ray, especially since R2 has dementia and is unable to communicate her needs. On 6/26/24 at 12:03 PM, V1, Administrator, stated she would have expected the facility to contact the Physician immediately about R2's bruising and pain. The Facility's Change in Resident Condition Policy reviewed 1/29/24 documents, The community will promptly notify the resident's physician and representative of changes in the resident's medical/mental condition. The Nurse will notify the resident's Physician or on-call Physician and representative when there has been: A discovery of injuries of an unknown source. A significant change in the resident's physical/emotional/mental condition. Except in Medical Emergencies, notification will be made no later than 12 hours of a change occurring in the resident's medical/mental condition.

Based on interview and record review, the facility failed to ensure medications were given as prescribed, as well as at the time frame as ordered, for 2 of 5 residents, (R32, R104) reviewed for medications, in the sample of 28. This failure caused R32's medication to be omitted for 5 doses/nights, causing R32 to experience wandering behaviors requiring intervention. Findings include: 1. R32's Face Sheet, dated 9/20/2023, documents R32 has Alzheimer's Disease, Dementia with Behavioral Disturbances, Insomnia, and Hallucinations. R32's Administration Record documents, Trazodone 100 mg, (Milligrams), tablet one time daily starting 12/23/2022. Indication: Insomnia. R32's Care Plan, dated 9/20/2023, documents, (R32) has a diagnosis of Insomnia- Alteration in sleep pattern related to insomnia. Medications should be given per the Medical Doctor's order. The Facility's Adverse Event Documentation, dated 3/27/2023, documents, Brief Description of Medication Event (describe medications involved and any immediate actions taken). On 3/26/2023 it was noted that Trazodone 100 mg was not in the medication strip. Call placed to Pharmacy who states the medication was not discontinued on 3/16/2023. Our records indicate that medication as not discontinued but was updated to add Physical monitors to the order. Pharmacy states, they did not receive the updated order. Pharmacy confirms that Trazodone was delivered on 3/15/2023 with enough meds to receive doses through 3/21/2023. Resident did not receive Trazodone as ordered from 3/21/2023-3/25/2023. Trazodone 50 mg 2 tabs were pulled from the state safe for 2100 (9 PM) dose on 3/26/2023. No adverse effects noted. R32's Administration History documents R32 had no behaviors requiring intervention 3/16/2023, 3/17/2023, 3/10/2023, 3/20/23. Its further documents on 3/21/2023, R32 exhibited wandering behaviors on 3/21/2023, 3/22/2023, and 3/24/2023 requiring redirection, and one to one staff with resident. On 9/19/2023 at 11:56 AM, V24, Certified Nursing Assistant, (CNA), stated she has worked at the Facility for approximately one year. V24 stated R32 does not currently have any behaviors, but he did previously. V24 stated, He (R32) wouldn't sleep. He was an 'all nighter' (implying R32 stayed up all night). On 9/20/2023 at 1:02 PM, V17, Assistant Director of Nursing, (ADON), stated, We added Physical monitors for adverse reactions or behaviors (to the Administration History). I faintly remember the Trazodone situation. The nurses should have noticed it wasn't there if they were following the MAR (Medication Administration Record). I do not know how they did not catch it for that many days. That's the problem. It (Trazodone) wasn't being given. On 9/20/2023 at 1:17 PM, V17 stated R32 could have experienced some adverse effects from missing the Trazodone doses. On 9/20/2023 at 1:59 PM V2, Director of Nursing, (DON), stated, The nurses obviously didn't check to make sure it was packaged in the (medication) strips. I would expect them to check every single time for medication accuracy. If a med (medication) was missing, I would expect them to notify Pharmacy and get it out of the stat safe (an emergency medication supply). V2 continued to state the Facility had implemented a new behavior tracking system and the medication order had to be discontinued and re-entered. V2 stated, The Pharmacy reports they did not get the new order entered, just to discontinue it. V2 stated, He (R32) did exhibit increased symptoms (restlessness) during that time frame (3/21/2023-3/25/2023). 40650 2. R104's Face Sheet, dated 09/20/2023, documented diagnoses of blindness one eye unspecified eye and unspecified glaucoma. R104's Physician order sheet, dated 09/2023, documents orders for Latanoprost 0.005% eye drops 1 drop both eyes. Indication was for glaucoma. Every evening starting 9/11/23 at 5:00 PM. R104's Minimum Data Set, (MDS), undated, documented R104's cognition was moderately impaired. On 09/19/2023 at 08:37 AM, V5, Registered Nurse, (RN), was at the medication cart; took out R104's Latanoprost eye drops. V5 administered R104's latanoprost eye drops, 1 drop in each eye. On 09/20/2023 at 10:43 AM, R104 stated he was ok with the nurse (V5, RN) giving him his eye drops at the breakfast table. He continued to state usually they do his eye drops in his room. On 09/20/2023 at 11:25 AM V14, RN stated she would give the right medication at the right time as ordered. On 09/20/2023 at 2:00 PM, V7, LPN stated she would give the right medication at the right time. On 09/20/2023 2:15 PM, V21, LPN stated would give the right medication at the right time and as the Doctor ordered it. The Facility's Administering Medication Policy, dated 9/22/2023, documents, Medication shall be administered in a safe and timely manner as prescribed.

Based on observation, interview, and record review, the facility failed to secure medications appropriately, and failed to label and date open bottles of medications. The facility also failed to ensure medications requiring refrigeration were monitored and documented per the Facility policy. This has the potential to affect all 49 residents living in the facility. Findings include: 1. R104's Face Sheet, dated 09/20/2023, documented diagnoses of blindness one eye unspecified eye and unspecified glaucoma. R104's Minimum Data Set, (MDS), undated, documented R104's cognition was moderately impaired. R104's Physician order sheet, dated 09/2023, documents orders for Latanoprost 0.005% eye drops 1 drop both eyes. indication glaucoma. every evening starting 9/11/23 at 5:00 PM. Dorzolamide 22.3 milligrams, (mg)-timolol 6.8 mg/milliliters, (ml) eye (1 drop) both eyes indication glaucoma two times daily. On 09/19/2023 at 08:37 AM, the rehabilitation hall medication cart was in the hallway and was unlocked. V5, Registered Nurse (RN), was in the dining area. On top of the cart was a box of Enoxaparin 40mg/0.4ml box with 5 filled syringes in it, belonging to R47. At 8:43 AM, V5 walked away from the medication cart, leaving it unlocked, to take R104's Blood Pressure. R104 was out in the dining room. V5, RN, returned to the medication cart, took out R104's medication: Dorzolamide 22.3 milligrams, (mg), -timolol 6.8 mg/milliliters, (ml), eye (1 drop) both eyes. This bottle was open and was not dated. V5, RN, then left the medication cart, out in the hallway, and walked away from it without locking it to give R104 his medication. On 09/20/2023 at 10:43 AM, R104 stated usually they give him his eye drops in his room. 2. R102's Face sheet, dated 9/20/2023, documented diagnoses of displaced spiral fracture of the left femur. R102's MDS, undated, documented her cognition was intact. R102's Physicians order sheet, dated 09/2023, documented an order for enoxaparin 40mg/0.4ml syringe subcutaneous one time daily. Docusate 100 mg capsule two times daily, Donepezil 10 mg tablet one time daily, Magnesium Oxide 400mg tablet one time daily, Oyster Shell Calcium-Vitamin D3 500mg- 5 micrograms (mcg) two times daily, [NAME] Colon Health 3 billion cell capsule 1 capsule one time daily, Sertraline 50mg tablet one time daily, Vitamin D3 25 mcg capsule one time daily and Multiple Vitamin- Minerals tablet one time daily. There was not an order documented for resident to self-administer medications. On 9/19/2023, V5, RN, returned to the medication cart, that was still unlocked, and removed R102's medications. V5, RN, left the medication cart unlocked and walked away. R102 was sitting at the dining room table with R47 and V6, R47's husband. V5, RN, handed R102 her pill cup with her medications in it, and walked away not observing her taking them. On 09/20/2023 at 1000 AM, R102 stated they do leave her medication with her at the table because she takes it with food. 3. R101's Face sheet, dated 9/20/23, documented diagnoses of Sepsis and Chronic Obstructive Pulmonary Disease, (COPD). R101 was admitted to the facility on [DATE]. R101's Physicians Order sheet, dated 9/2023, documented an order for Carboxymethylcellulose sodium 0.5% eye drops (Refresh Plus eye drops) 1 drop both eyes indication dry eyes as needed starting 09/12/2023. It did not document this medication could be left at the resident's bedside. On 9/19/2023 at 9:00 AM, V5, RN, took out the medication packages for R101. V5 stated she needed to take R101's blood pressure, and she put the medicine packages back in the medication cart, did not lock the cart, and went into R101's room. On R101's overbed table, was Refresh plus eye drops box with 10 disposable vials of eye drops. There was not a Pharmacy label, nor was it dated. V5 returned to the unlocked medication cart, took R101's medication out of the packages and placed them on top of the medication cart, and placed them in a medication cup. V5 then walked away from the unlocked medication cart, and entered R101's room. V5, RN, administered the Refresh plus eye drops that were on the overbed table to R101, and gave him his medication. On 09/20/2023 at 10:13 AM, R101 stated he did not know who brought the eye drops in that were on his overbed table. On 09/20/2023 at 11:25 AM, V14, RN stated she would lock the medication cart when she is giving medications or when it is not in use. V14 also stated she does not have any residents with orders to leave their medications at the bedside, and when she gives medications, she stays with the resident until all their pills are taken. On 09/20/2023 at 2:00 PM, V7, License Practical Nurse, (LPN), stated she would keep the medication cart locked at all times if she was not getting meds out of it, or when she leaves it unattended to go give a resident their medication. She stated the medication cart stays out in the hallway when not in use, and no medicines are left on top of it. The only medications that can be left at a resident's bedside are the ones that have a doctor's order to do so. On 09/20/2023 at 2:15 PM, V21, LPN stated her medication cart is always locked when she is not using it, and when it is out in the hallway. She stated it is also locked when she is giving a resident their medication. V21, LPN, stated she would wash her hands and don gloves when giving injections and eye drops. She does not have any residents that have orders to keep medications at the bedside, and medications cannot be left with the resident to be taken without her there. On 09/20/2023 at 3:10 PM, V3, Assistant Administrator, statedshe would expect staff to lock the medication cart and not leave medications at the bedside without an order. On 09/20/2023 at 3:15 PM, V2, Director of Nursing, stated she would expect staff to lock the medication cart and not leave medications at the bedside without an order. V2 also stated she would expect the nurses to stay with the resident to make sure they take their medicine. 40701 4. On 9/19/2023 at 10:09 AM, the medication storage room was inspected. There was a refrigerator containing medications. V8, Licensed Practical Nurse, (LPN), stated, The temperatures are only checked once a day and it's done on night shift. It is documented in this binder. The Facility's Refrigerator and Freezer Temp, (temperature)/Humidity Log, dated September 2023, was reviewed and contained several days without a temperature documented, including 9/4/2023, 9/8/2023, 9/9/2023, 9/13/2023, 9/17/2023, and 9/18/2023. V8 verified this information by stating, There are a couple night shift entries missing. On 9/19/2023 at 10:15 AM, V17, Assistant Director of Nursing, (ADON), stated, Refrigerator temperatures should be taken and recorded once a day. 5. On 9/19/2023 at 10:10 AM, the refrigerator in the Summer Breeze Household was inspected. At this time, a vial of Humalog with a small yellow paper taped to the vial that said, (105's name). There was no date opened sticker on the vial. The vial had been opened, and contained about half of the insulin remaining. At this time, V8 verified the vial had been opened and stated, (R105) isn't even on this hall. He is on (another household). On 9/20/2023 at 1:59 PM, V2, Director of Nursing, (DON), stated, Of course I would expect it (the insulin vial) to be dated (to indicate when it had been opened). On 9/21/2023 at 11:08 AM, V25, Pharmacist, stated Humalog should be discarded after 28 days of the vial being open. The Facility's Medication Storage in the Facility Policy, dated March 2021, documents, Policy: Medications and biologicals are stored safely, securely and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel or staff members lawfully authorized to administer medications. It continues to document, B. Only licensed nurses, pharmacy personnel and those lawfully authorized to administer medications (such as medication aides) are permitted to access medications. Medication rooms, carts and medication supplies are locked when not in use or in direct view of persons with authorized access. If further documents, Temperature: E. The Facility should maintain a temperature log in the storage area to record temperatures at least once a day. It further documents, Expiration Dating (Beyond-use dating): D. When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. 1) The nurse shall place a date opened sticker on the medication (if dedicated area not on label/container) and enter the date opened and the new expiration. The expiration date of the vial or container will be 30 days unless the manufacturer recommends another date of regulations/guidelines require different dating. The Facility's Administering Medication Policy, dated 9/22/2023, documents, Medication shall be administered in a safe and timely manner as prescribed. It continues to document, The expiration date/beyond use date on the medication label must be checked prior to administering. When opening a multi-dose injectable (i.e insulin), the date opened shall be recorded on the container. It further documents, During administration of medications, the medication cart will be kept closed and locked when out of sight of the individual administering medications. The Resident Census and Conditions of Residents, CMS 672, dated 09/19/2023, documents the facility has 49 residents living in the facility.

Based on observation, interview, and record review, the facility failed to provide complete incontinence care for 4 of 4 (R6, R19, R36, R41) residents reviewed for incontinent care in a sample of 13. Findings include: 1. R6's Care Plan, last evaluation date 9/19/23, documents R6 is always incontinent of urine and frequently incontinent of bowel. It also documents, check for incontinence; clean and dry skin if wet or soiled. R6's Minimum Data Set/MDS, dated [DATE], documents R6 is severely cognitively impaired, always incontinent of bowel and bladder, and is totally dependent on 2 staff for toileting. On 9/19/2023 at 1:40 PM, V11, V13, and V16, all CNAs (Certified Nursing Assistants), assisted R6 with incontinent care. V11, V13, and V16 transferred R6 into the bed using the full body lift. V11, V13, and V16 rolled R6 onto his left side and removed his pants, then assisted to R6 to R6's back. V16 opened R6's incontinent brief. V11, V13, and V16 turned R6 onto his right side, and V16 removed R6's incontinent brief which was soiled with stool. V13, using a wet wipe, cleansed R6's anal area x3. V16 then applied the clean incontinent brief behind R6. V11, V13, and V16 turned R6 onto his right side, and V11 pulled the clean brief onto R6's buttocks. V11, V13, and V16 rolled R6 onto his back. Using a wet wipe, V16 wiped R6 penis. V11, using a wipe, cleaned R6's right and left groin and penis. V16 closed R6's incontinent brief. V11, V13, and V16 stated they were finished with incontinent and peri care at that time. V13 did not cleanse R6 buttocks, and V11 and V16 did not cleanse R6's scrotum or shaft of R6's penis. 2. R19's Care Plan, last evaluation date 8/22/23, documents R19 has ADL (activity of daily living) selfcare deficit related to decreased mobility and muscle weakness. (R19) requires extensive assist with most ADLs. It also documents R19 is always incontinent. It continues, check for incontinence; change if wet/soiled. Clean skin with mild soap and water. Apply moisture barrier as appropriate. R19's MDS, dated [DATE], documents R19 is always incontinent of urine and requires extensive assist of 1 staff member for toileting. On 09/18/23 at 1:30 PM, V11, CNA, assisted R19 with toileting. R19 was incontinent of urine. V11 assisted R19 to the toilet using the standup lift. V11 removed R19's incontinent brief and heavily soiled incontinent insert. V11 sat R19 onto the toilet; R19 voided. V11 stood R19 up and cleansed R19 anal area, using a wipe. V11, standing behind R19, went between R19 legs from behind and wiped the vaginal area twice. V11 applied a new brief and assisted R19 back into her wheelchair. V11 did not cleanse R19's buttocks, groin area, inner thighs, or inner labia. 3. R31's Care Plan, last evaluation date 6/28/2023, documents R31 is frequently incontinent of bowel and bladder. It also documents, check for incontinence, change if wet/soiled. Clean with mild soap and water. Apply moisture barrier. R31's MDS, dated [DATE], documents R31 is frequently incontinent of urine and occasionally incontinent of bowel, and requires extensive assist of 1 person for toileting. On 9/20/23 at 1:24 PM, V11 and V13 assisted R31 with toileting. R31 was incontinent of urine. V11 and V13 assisted R31 into the bed using a mechanical lift. V11 and V13 removed R31's pants, revealing a heavily soiled brief and soiled pants. V11 and V13 rolled R31 onto her right side. V11, using a wet wipe, cleansed R31's left buttock, rolled the soiled brief under R31, and placed a clean brief behind R31. V11 and V13 rolled R31 onto her back and cleansed R36 right and left groin and outer labia. V11 and V13 rolled R31 onto her left side, removed soiled brief, and pulled a clean brief under R31. V11 and V13 rolled R31 onto her back and closed the brief. V11 and V13 failed to clean R31's entire left buttock or right buttock, inner labia, vaginal area, and inner thighs. On 9/20/2023 at 3:15 PM V2, Director of Nursing, stated the Perineal Care policy is the same as the incontinent care policy. On 9/20/2023 at 3:17 PM, V22, Registered Nurse, stated she expects the CNAs to clean all areas of incontinence when providing incontinent care. V22 stated, For a female, this includes the inner labia, vaginal area, both buttocks, and inner thigh. For a male, the penis, shaft, scrotum, beneath the scrotum, both buttocks, and inner thighs. If a resident is incontinent and then placed on the toilet, I expect the staff to perform incontinent care even if the resident then voids on the toilet. V22 stated she would expect the staff to wash their hand before putting on gloves, and when changing gloves to use hand sanitizer. On 9/20/23 at 3:19 PM V23, CNA, stated, When cleaning an incontinent resident, you clean all the areas that would come in contact with the urine. This would include the vaginal area, inner labia, groin, scrotum, both buttocks and inner thigh. If a resident is incontinent, they receive incontinent care regardless. V23 stated when putting on gloves, hand hygiene is performed first. V23 stated this could be soap and water or hand gel. 4. R36's Care Plan, last evaluation date 9/14/2023, documents R36 is frequently incontinent of bowel and bladder. It also documents, Check for incontinence, change if wet/soiled. Clean with mild soap and water. Apply moisture barrier. R36's Minimum Data Set, (MDS), dated [DATE], documents R36 is severely cognitively impaired, always incontinent of urine, frequently incontinent of bowel, and requires extensive assist of 1 staff for toileting. On 09/18/23 at 1:51 PM, V11 and V12, Certified Nursing Assistants, (CNAs), assisted R36 with toileting. R36 was incontinent of urine. V11 and V15 (Licensed Practical Nurse/LPN) used the standup lift to transfer R36 to the toilet. V12 removed R36's urine soiled brief. V11 and V12 stood R36, and V11, using a wipe, cleansed R36 anal area, with stool on wipe. V11 and V12 sat R36 on toilet. At 1:55 PM, V11 and V12 stood R36. V11, using a wipe, cleansed R36 anal area. V11 cleansed R36's right groin area from the back. V11 cleansed R36's penis. V11 did not cleanse R36's left groin, scrotum, or R36's right and left buttock. The facility's Perineal policy, dated 8/30/22, documents, The purpose of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. 4. For female b. wash perineal area wiping front to back. i. Separate and wash area downward from front to back. iii. Continue to wash the perineum moving from inside outward to and including thighs, alternating from side to side, and using downward strokes. C. Wash the rectal area thoroughly, using a washcloth or perineal wipe, wiping from the base of the labia towards and extending over the buttocks. 5. For male b. Wash the perineal area starting with urethra and working outward. Iii. Continue to wash the perineal area including the penis, scrotum, and inner thighs. e. Wash and rinse, or use perineal wipe, the rectal area thoroughly, including the area under the scrotum, the anus, and the buttocks.

Based on observation, interview, and record review, the facility failed to perform appropriate hand hygiene and donning gloves during medication administration and incontinent care and, and failed to perform appropriate cleaning of soiled surfaces for 4 of 6 (R31, R101, R102 R104) residents reviewed infection prevention, in a sample of 28. Findings include: 1.R104's Face Sheet, dated 09/20/2023, documented diagnoses of blindness one eye unspecified eye and unspecified glaucoma. R104's Minimum Data Set, (MDS), undated, documented his cognition was moderately impaired. R104's Physician Order sheet, dated 09/2023, documents orders for Latanoprost 0.005% eye drops 1 drop both eyes. indication glaucoma. every evening starting 9/11/23 at 5:00 PM. Dorzolamide 22.3 milligrams (mg)-timolol 6.8 mg/milliliters (ml) eye (1 drop) both eyes indication glaucoma two times daily. On 09/19/2023 at 08:37 AM, V5, Registered Nurse, (RN), statedshe spilled Metamucil granules on top of the medication cart. V5 retrieved a dry paper towel and wiped off the cart, leaving granules in the crevasses of the medication cart. V5, RN, took out R104's medication packages and opened them up onto the top of the medication cart where the Metamucil granules were. Then, without benefit of hand hygiene, V5 placed medications, with her bare hands, into a medication cup. V5, without benefit of hand hygiene or donning gloves, administered R104's latanoprost eye drops, administered R104's pills, and administered R104's Dorzolamide 22.3 milligrams (mg)-timolol 6.8 mg/milliliters (ml) 1 drop in each eye. 2. R102's Face sheet, dated 9/20/2023, documented diagnoses of displaced spiral fracture of the left femur. R102's MDS, undated, documented her cognition was intact. R102's Physicians Order Sheet, dated 09/2023, documented an order for enoxaparin (Lovenox) 40mg/0.4ml syringe subcutaneous one time daily. Docusate 100 mg capsule two times daily, Donepezil 10 mg tablet one time daily, Magnesium Oxide 400mg tablet one time daily, Oyster Shell Calcium-Vitamin D3 500mg- 5 micrograms (mcg) two times daily, [NAME] Colon Health 3 billion cell capsule 1 capsule one time daily, Sertraline 50mg tablet one time daily, Vitamin D3 25 mcg capsule one time daily and Multiple Vitamin- Minerals tablet one time daily. There was not an order documented, for resident to self-administer medications. On 9/19/2023, V5, RN, returned to the medication cart, that was still unlocked, and without benefit of hand hygiene, she took R102's medications, Lovenox 40mg/0.4ml injectable, Docusate, Donepezil, Magnesium Ox, Oyster Shell, [NAME] Colon Health, Sertraline, Vitamin D and Theran M + out of the packages with the pills landing on top of the medication cart. With her bare hands, she then placed the medications into a medication cup. R102 was sitting at the dining room table. V5, RN, used alcohol-based hand rub (ABHR), went to R102's dining room table, and without donning gloves, she lifted up R102's shirt to expose her right mid abdomen, used an alcohol wipe and cleansed her right abdomen, and injected R102 with her Lovenox 40mg/0.4 ml to that area. 3. R101's Face sheet, dated 9/20/23, documented diagnoses of Sepsis and Chronic Obstructive Pulmonary Disease. R101 was admitted to the facility on [DATE]. R101's Physicians Order Sheet, dated 9/2023, documented, an order for Carboxymethylcellulose sodium 0.5% eye drops (Refresh Plus eye drops) 1 drop both eyes indication dry eyes as needed starting 09/12/2023. It did not document that this medication could be left at the resident's bedside. On 09/20/2023 at 9:00 AM, V5, RN, took out the medication packages for R101's Fluoxetine, Lasix, healthy eyes cap, spironolactone, EC ASA, Carvedilol, Docusate, K+, Eliquis, Enestrol, and without benefit of hand hygiene, took the above medication out of the packages and placed them on top of the medication cart. Then with her bare hands and without benefit of hand hygiene, V5 picked up the medications and placed them in the med cup. V5, RN, entered R101's room, and without benefit of hand hygiene or without donning gloves, administered the Refresh plus eye drops to R101, and gave him his medication. On 09/20/2023 at 11:25 AM, V14, RN, stated she would never open the pill package and put the medicines on top of the cart if the cart had something spilled on it. V14 stated she would wash her hands and put on gloves when she is giving an injection or eye drops to a resident. On 09/20/2023 at 2:00 PM, V7, Licensed Practical Nurse, (LPN), stated she would wash her hands and put gloves on when giving a resident an injection, and if she spilled something on the medication cart, she would clean it up with Sani wipes or soap and water. She stated she does not open the resident's medication packets and put the pills on top of the medication cart. She would open the pill package and put them in the med cup. On 09/20/2023 at 2:15 PM V21, LPN, stated she if she spilled something on top of her medication cart, she would clean it up with the sanitizing cloths or soap and water, and she does not put open pills on top of the cart; she puts them in a medicine cup. V21, LPN stated she would wash her hands and don gloves when giving injections and eye drops. On 09/20/2023 at 3:10 PM, V3, Assistant Administrator stated she would expect the staff to wash their hands and wear gloves when giving injections and eye drops. V3 stated she would expect the staff to clean off the top of the med cart with the appropriate cleaner. On 09/20/2023 at 3:15 PM, V2, Director of Nursing, stated she would expect the staff to wash their hands and wear gloves when giving injections and eye drops. V2 stated she would expect the staff to clean off the top of the med cart with the appropriate cleaner. 42108 4. R31's MDS, dated [DATE], documents R31 is severely cognitively impaired, frequently incontinent of urine, and occasionally incontinent of bowel, and requires extensive assist of 1 person for toileting. On 9/20/23 at 1:24 PM, V11 and V13 assisted R31 with toileting. R31 was incontinent of urine. V11 and V13 assisted R31 into the bed using a mechanical lift. V11 applied gloves; no hand hygiene performed. V11 and V13 removed R31's pants revealing heavily soiled brief and soiled pants. V11 removed her gloves and applied new ones; no hand hygiene performed. V11 and V13 rolled R31 onto her right side. V11, using a wet wipe, cleansed R31's left buttock, rolled the soiled brief under R31, and placed a clean brief behind R31. V11 removed her gloves and applied new ones; no hand hygiene performed. V11 and V13 rolled R31 onto her back and cleansed R36 right and left groin and outer labia. V11 and V13 rolled R31 onto her left side. V13 removed the soiled brief and pulled the clean brief under R31. V11 removed her gloves. V11 and V13 rolled R31 onto her back and closed the brief. V13, using the same soiled gloves, pulled R31's linen over R31, and moved the bed against the wall. V13 removed her gloves and left the room. V11 gathered soiled linens and placed them in the soiled utility room. V11 and V13 did not perform hand hygiene up completion of incontinent care. On 9/20/2023 at 3:15 PM, V2, Director of Nursing, stated the Perineal Care policy is the same as the incontinent care policy. On 9/20/2023 at 3:17 PM, V22, Registered Nurse, V22 stated she would expect the staff to wash their hands before putting on the gloves, and when changing gloves to use hand sanitizer. On 9/20/23 at 3:19 PM, V23, CNA, stated V23 stated when putting on the gloves hand hygiene is performed first. V23 stated this could be soap and water or hand gel. The facility's Perineal policy, dated 8/30/22, documents, the purpose of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. 1. Perform hand hygiene. 3. Put on gloves. 6. Remove gloves. 7. Perform hand hygiene. The facility's Hand Hygiene policy, dated 9/23/22, documents, This organization considers hand hygiene the primary means to prevent the spread of infections. 7. Use and alcohol-based hand rub containing at least 60% alcohol; or, alternatively, soap and water for the following situations: b. Before and after direct contact with residents; h. Before moving from a contaminated body site to a clean body site during resident care; m. After removing gloves; 9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing health care associated infections.

Based on interview, observation, and record review, the facility failed to safely secure and store medications in a locked medication cart, failed to dispose of expired medications in the medication cart, and failed to properly label medications with a resident name and the open date. These failures have the potential to affect all 44 residents in the facility. Findings include: 1. On 10/17/22 at 11:20 AM, the medication cart located on the 6200 hall, (Reach), was seen unlocked with no nurse in sight. No residents were seen around the cart. V7, RN, (Registered Nurse), was working this hall and caring for residents. 2. On 10/18/22 at 2:45 PM, the medication cart located on the 6300 hall, (Summer Breeze), was seen unlocked with two unattended residents, R38 and R10, sitting in their wheelchairs about six to ten feet away from the cart. 3. On 10/18/22 at 9:00 AM, The medication cart on the 6200-hall had four expired cards of medications for R14. These include [MEDICATION(S)] 10 mg, (Milligram), expired 8/10/22 with 14 LTC, (Left to Count), [MEDICATION(S)] 112 mcg, (Microgram), expired 8/1/22 with 4 LTC, [MEDICATION(S)] 100 mg, expired 8/9/22 with 9 LTC, [MEDICATION(S)] 400 mg expired 8/9/22 with 11 LTC. On 10/18/22 at 9:10 AM, V11, RN, (Registered Nurse), stated (R14) came in with these medications and we don't use them, we use the roll packs from our pharmacy. They should have been discarded. 4. The Medication, (Nurse's), room with a locked refrigerator and medications inside had a stock vial of [MEDICATION(S)] opened with no open date, there was a vial of [MEDICATION(S)] R Insulin 100units/ml, (Milliliter), opened, not labeled with a resident's name or the date opened. There was a vial of [MEDICATION(S)] Insulin 100units/ml opened and not labeled with a resident's name or the date opened, along with, two [MEDICATION(S)] Insulin pens 100units/ml opened and not labeled with a resident's name, or the date opened, and a [MEDICATION(S)] Insulin pen 100units/ml opened and not labeled with a resident's name or date opened. On 10/18/22 at 9:20 AM, V11, RN, stated I know the insulins were (R193's), because he is the only one on Insulin. We have two residents who are Diabetic and only (R193) is on Insulin. Yes, they should have been labeled, but I can't control what other staff do. On 10/19/22 at 1:17 PM, V2, DON, (Director of Nursing), stated I would expect the nurses to keep the medication carts locked at all times, to dispose of or send back to pharmacy any expired medications, to label all open vials with the date it was opened, and to label all vials/medications with the resident's name. Then on 10/18/22 at 9:30 AM, V11 was then seen labeling each Insulin Pen with a yellow sticky note with R193's name written on it. The Facility's Labeling and Storage of Medications, dated 5/26/21, documents All medication maintained in the community will be properly labeled in accordance with current State and Federal regulations and stored in a safe, secure, and orderly manner. Labeling: 1. Medication labels must be legible at all times. 2. Labels for individual medication containers shall include all necessary information such as: a. The resident's name; b. The prescribing physician's name; c. The name, address, and telephone number of the issuing pharmacy; d. The name and strength and quantity of the medication; e. The prescription number (if applicable); f. The date the medication was dispensed; g. Appropriate accessory and cautionary statements; h. The expiration date, when applicable; and i. Directions for use. 3. Labels for each single unit dose package shall include all necessary information, such as: a. The name and strength of the medication; b. The lot and/or control number; c. Appropriate accessory and cautionary statements; d. The expiration date, when applicable; e. The name of the resident and physician (Note: The names of the resident and physician do not have to be on each unit package, but they must be identified with the package in such a manner as to ensure that the medication is administered to the right resident); f. The prescription number; g. The name, address, and telephone number of the pharmacy dispensing the medication; and h. Directions for use. It continues Storage: 3. Medication containers that have missing, incomplete, improper, or incorrect labels should be returned to the dispensing pharmacy or destroyed. 4. The community will not use discontinued, outdated, or deteriorated medications. All such medications will be returned to the dispensing pharmacy or destroyed. 6. Compartments (including but not limited to: drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications shall be locked when not in use, and trays or carts that transport such items should not be left unattended if open or otherwise potentially available to others. The Facility's CMS 672, dated 10/17/22, documents that there are 44 residents residing in this facility at this time.

Based on interview, observation, and record review, the Facility failed to provide timely and complete incontinent care for 5 of 6 residents (R2, R5, R14, R36, R27) reviewed for incontinent care in the sample of 22. Findings include: 1. On 10/17/22 at 9:30 AM, R27 was lying in bed when V4, CNA, (Certified Nursing Assistant), and V5, CNA, entered with a sit-to-stand device, to get R27 up to his wheelchair. The top sheets were pulled off R27, showing his incontinent brief and his sheets saturated in urine. R27 assisted, to the toilet using a sit-to-stand. After toileting, R27 was again stood up, using the sit-to-stand and a brief perineal care was performed, by V5. Using the same gloves, she originally had on, V5 used a couple disposable wipes, then wiped R27 once to the front perineal area. R27's penis, testicles, and buttocks were not cleansed, no moisture barrier cream applied and R27 was not dried before applying the new incontinence brief. R27's Care Plan, 10/14/22, documents (R27) is occasionally incontinent of bowel. Interventions: apply moisture barrier to buttocks, assist to toilet for BM, (bowel movement), and check for incontinence. (R27) is always incontinent of urine. Interventions: check for incontinence; change if wet/soiled. Clean skin with mild soap and water, apply moisture barrier, check skin for redness, use pads/briefs to manage incontinence, use positioning devices as needed. R27's Minimum Data Set, (MDS), dated [DATE], documents that R27 has a severe cognitive impairment and requires extensive assistance, from two people for bed mobility, transfers and dressing, requires extensive assistance from one person for toilet use, personal hygiene and bathing. R27 is always incontinent of urine and occasionally incontinent of bowel. 2. On 10/18/22 at 9:30 AM, V14, CNA, performed perineal care on R14 after raising R14 off the toilet using a sit-to-stand. While R14 was standing, V14 reached from behind R14 and wiped once in-between her legs. There was no cleansing of the right or left groin area in front, no moisture barrier cream applied, and no drying of R14 prior to putting a clean incontinence brief on. R14's Care Plan, dated 8/12/22, documents (R14) is frequently incontinent of urine. Interventions: Check for incontinence; change if wet/soiled. Clean skin with mild soap and water. Apply moisture barrier, Dress in clothing that is easily removed for toileting, implement safety measures, (keep path to bathroom clear and well lit, select clothing that is easily removed for toileting, answer call bell quickly), Remind (R14) to empty bladder before meals, at bedtime, and before activities. (R14) is frequently incontinent of bowel. Interventions: Apply moisture barrier to buttocks, check for incontinence; clean and dry skin if wet or soiled, Document when [NAME] is incontinent, Report areas of redness, Use pads/briefs to manage incontinence. R14's MDS, dated [DATE], documents that R14 is cognitively intact and requires extensive assistance from one staff member for bed mobility, transfers, dressing, toilet use, personal hygiene and bathing. R14 is frequently incontinent of both bowel and bladder. 3. On 10/17/22 at 1:40 PM, V4, CNA, and V5, CNA, performed perineal care on R36. His pants were pulled down and his saturated incontinence brief was removed and then was turned to his right side. V4 used two disposable wipes and wiped once downwards to his left groin and then once to his right groin. V4 then wiped around R36's uncircumcised penis and the underside of his penis but did not pull the foreskin back and cleanse and did not clean his testicles. R36's left buttock/hip was wiped once and then he was rolled to his back and a new incontinence brief was applied. There was no cleansing of R36's anal area, no cleansing of his right buttock/hip, and no drying of R36 before applying new incontinence brief. R36's Care Plan, dated 10/7/22, documents (R36) is always incontinent of bowel movement (no episodes of continent bowel movement). Interventions: Apply moisture barrier to buttocks, check for incontinence; clean and dry skin if wet or soiled, Document when (R36) is incontinent, Report areas of redness, Use pads/briefs to manage incontinence. (R36) is always incontinent of urine. Interventions: Check for incontinence; change if wet/soiled, clean skin with mild soap and water, apply moisture barrier, check skin for areas of redness, report any changes to the nurse, use pads/briefs to manage incontinence, use positioning devices as needed. It continues (R36) requires extensive assistance. Interventions: Provide hygiene after voiding/BMs (bowel movement) to prevent skin breakdown, apply moisture barriers, select clothing that is easily removed, change incontinence pad/brief. R36's MDS, dated [DATE], documents that R36 has a severe cognitive impairment and is dependent on two staff members for transfers, locomotion, dressing, toilet use, personal hygiene and bathing. R36 is always incontinent of both bowel and bladder. 10/19/22 at 12:45 PM, V13, CNA, stated, When we get a resident up in the morning, we will do their perineal care at that time. On 10/19/22 at 1:15 PM, V2, DON, stated, I would expect the staff to provide complete and timely incontinent care for all residents and follow the Care Plan for appropriate incontinent care needed. 4. On 10/18/2022 at 8:18 AM, V5, CNA, provided incontinent care while R2 in sit to stand, in R2's bathroom. V5 cleansed hands with hand sanitizer, and donned gloves. With R2 standing with the sit to stand, V5 took a disposable wipe, and wiped one side of groin, folded the wipe then did other side of groin. V5 then used a new disposable wipe and swiped from the front to the back of R2's perineal area. V5 did not separate labia or dry after cleaning. V5 took same disposable wipe and rubbed over buttocks, did not dry R2, or place moisture barrier cream on. R2's MDS, dated [DATE], documents that R2 requires extensive assistance and two plus person physical assistance for toileting. R2's Care Plan, dated 10/13/2022, documents that R2 is frequently incontinent of urine. R2's Care Plan documents the following interventions: check for incontinence, change if wet/soiled, cleanse with mild soap and water. Apply moisture barrier as appropriate. The facility's Perineal Care Policy, dated, 8/30/2022 documents Purpose: The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. Steps in the Procedure: 1. Perform hand hygiene. 2. Fill the wash basin one-half full of warm water, if used. If not used, place perineal wipes within reach. 3. Put on gloves. 4. For a female resident: a. Wet washcloth and apply soap or skin cleansing agent or use a perineal wipe. b. Wash perineal area, wiping from front to back. i. Separate labia and wash area downward from front to back. ii. If the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about three inches. If using soap and water, gently rinse and dry the area. iii. Continue to wash the perineum moving from inside outward to and including thighs, alternating from side to side, and using downward strokes. Do not reuse the same area of the washcloth and/or perineal wipe to clean the urethra or labia. iv. If using soap and water, rinse perineum thoroughly in the same direction, using fresh water and a clean washcloth, then dry perineum. 5. On 10/18/22 at 08:33 AM, during incontinent care R5 was on his back in bed. R5's incontinent brief was wet as verified by V5, CNA and V10, CNA. V5, CNA, cleansed hands and donned gloves. V5 then used disposable wipes to cleanse left side of groin, then right side of groin. V5 CNA then lifted penis and cleansed scrotum. R5's scrotum was red in color. V5 did not retract and cleanse R5's penis. V5 did not dry R5's area she just cleaned with wipes. V5 and V10 then turned R5 on left side. V5 CNA then took a wipe and wiped from front to back. V5 did not cleanse inner thighs. Did not dry resident, did remove gloves sanitize hands donned gloves and then applied barrier cream. R5's care plan dated 4/1/2022 documents R5 is occasionally incontinent with intervention to check for incontinence, change if wet/soiled. Clean skin with mild soap and water, Apply moisture barrier as appropriate, R5's MDS dated [DATE], documents R5 is always incontinent of urine. R5's MDS documents that R5 requires extensive assistance and two plus physical assistance for toileting. The facility's Perineal Care Policy, dated, 8/30/2022 documents Purpose: The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. Steps in the Procedure: 1. Perform hand hygiene. 2. Fill the wash basin one-half full of warm water, if used. If not used, place perineal wipes within reach. 3. Put on gloves. 5. For a male resident: a. Wet washcloth and apply soap or skin cleansing agent or use a perineal wipe. b. Wash perineal area starting with urethra and working outward. If the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about 3 inches. Gently rinse and dry the area. i. Retract foreskin of the uncircumcised male. ii. Wash using washcloth/soap or perineal wipe. Then rinse, if using a washcloth and soap, urethral area using a circular motion. iii. Continue to wash the perineal are including the penis, scrotum and inner thighs. Do not reuse the same area of the washcloth/wipe to clean the urethra. c. Gently dry perineum following same sequence.

A.Based on observation, interview and record review the facility failed to perform hand hygiene and maintain a sanitary environment to prevent the spread of infections for 1 of 6 residents (R35) reviewed for infection control in the sample of 28. Finding includes: R35's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R35's Infection Assessment, a confirmed date of 10/19/21, of a facility acquired, [CONDITION(S)] pneumonia, an organism within the urinary tract contributing to an infection. R35's Progress note, dated 10/22/21, documented that R35 was sent out to a local hospital for increased confusion and hallucination and a urine culture with laboratory results of a positive urinary tract infection. On 11/2/21 at 12:50 PM, R35 was sitting on the toilet. V12, Certified Nurse Aide (CNA), was standing beside R35, applied clean gloves, pulled out four moist wipes and laid across the toilet support handicap bar, then wearing the same gloves, open a cabinet door located in the bathroom to retrieve a clean garbage waste bag. V12, wearing the same gloves and using the cleansing wipes, cleansed R35's front then the back perineum, as R35 had a large bowel movement. V12 then pulled up R35's pants, removed gloves and transferred R35 to a recliner and returned to wash hands. 11/03/21 10:15 AM, V2, Director of Nursing, stated she would expect hand hygiene before applying gloves and after care and the cleansing wipes should not be placed on an unclean environmental surface. The facility's policy, entitled Infection Prevention, Handwashing/Hand Hygiene, dated 4/28/21, documented, this organization considers hand hygiene the primary means to prevent the spread of infections, use of an alcohol-based hand rub or alternatively soap and water before donning sterile gloves, after contact with bodily fluids, after contact with objects and after removing gloves. B. Based on observation, interview and record review the facility failed to wear required Personal Protective Equipment (PPE) to prevent the spread of COVID-19. This has the potential to affect all 49 residents in the facility. Findings include: 1. On 11/01/21 at 12:13 PM, V15, Activity Aide was sitting at table in dining room on the spring unit with her mask below nose and face shield on. 11/04/21 at 9:48 AM V1, Administrator, stated the facility has worked hard with training for COVID-19. V1 stated she expects staff to wear a mask covering the nose. 2. On 11/1/21 at 12:11 PM, during dining observation, V6 Cook is working in Summer Unit kitchen and has his facemask below his nose throughout the dining room observation. 3. On 11/4/21 at 9:08 AM, V19 Registered Nurse is at the medication cart on Summer Unit with her facemask below her nose. The Facility's Resident Census and Conditions of Residents Form, CMS 672, dated 11/1/21 documents the facility had a census of 49. The facility PPE standards dated 7/30/2021 documents disposable face mask is to be worn entirety of shift. Centers for Disease Control and Prevent guidance, Use of Personal Protective Equiment (PPE) when caring for Patients with confirmed or Suspected COVID-19, documents Respirator/facemasks should be extended under chin. both your moth and nose should be protected.

Based on observation, interview and record review the facility failed to assess, monitor and turn and reposition to reduce pressure to prevent the formation of/or worsening of pressure ulcers for 2 of 5 residents (R7, R17) reviewed for pressure ulcers in the sample of 28. Findings include: R17's Electronic Medical Record dated 11/3/21 documents diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/03/21 at 9:30 AM, V21 Certified Nurse Aide (CNA) and V22 CNA transferred R17 from her bed to the reclining geriatric chair. When asked how long R17 would be up, V21 stated, We will leave her up until after lunch. On 11/3/21 at 1:20 PM, V21 and V23 CNA, transferred R17 back to bed using the mechanical lift. The facility weekly wound report given to surveyors on 11/1/21 documents, the initial date of observation of R17's pressure ulcer was 7/12/21. The Wound Report documented R17 had a Facility acquired pressure ulcer to her right upper buttock measuring 1.5 centimeters (cm) X 0.7 cm X 0 cm, Stage 2. The Wound report documents R17 has scarred area over bottom and the open area was over a scar. The Wound Report documented No drainage or signs/symptoms (s/s) of infection. There was no documentation of R17's heel pressure ulcer weekly measurements since 9/30/21. R17's Braden score on 10/24/21 documents a score of 11 (10-12 indicates a high risk for developing pressure ulcers). R17's November 2021 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Cover with foam dressing. Change every 3 days and as needed (prn). Right Heel, cleanse with wound cleanser, apply Thera Honey to wound bed, cover with border gauze one time daily. R17's November 2021 POS documents a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order documents to cleanse with wound cleanser, apply Thera Honey to wound bed, cover with border gauze. The Treatment was for one time daily. On 11/3/21 at 1:25 PM, V7 Licensed Practical Nurse (LPN), changed the dressing to R17's buttock pressure ulcers. V7 removed R17's old dressing which was soiled with urine. V7 cleansed R17's pressure ulcer wound cleanser and dried with 4 X 4 gauze. V7 applied border dressing. V7 did not apply Thera honey although this was ordered. R17 had a pressure ulcer to her right heel. On 11/3/21 at 4:05 PM, V3 Registered Nurse (RN) stated, (R17)'s right heel wound was found on 3/15/21. The wound doctor took over the care of the wound on 5/1/21 and the facility stopped doing weekly wound assessments and measurement due to taking over, in this facility when the wound doctor follows. The nurses no longer do weekly measurements. The wound doctor quit following her on 7/22/21, and the facility started wound measurement back on 8/18/21. The last wound measurement was done on 9/30/21. I would expect wound measurements to be done weekly. On 11/4/21at 12:00 PM V3 stated, R17 should be changed and repositioned frequently. The facility Policy and Procedure for Prevention of Pressure Injuries dated 1/11/2018, last updated 5/28/21 documents, Purpose: The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. General Guidelines: 1. 1. Pressure injuries are usually formed when a resident remains in the same position for an extended period of time, causing increased pressure or decreased of circulation to that area and subsequent destruction of tissue. 6. The community should have a procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, and reported to the nursing staff and physician. b. Weekly skin assessment. Interventions and Preventative Measures: General, 2. For a person in bed, a. Change position at least every 2 hours or more frequently if needed. 3. For a person in a chair, a. Change position at least every 1 to 2 hours. 2. On 11/04/21 at 9:00 AM, V18, Licensed Practical Nurse (LPN) removed R7's incontinent brief. R7 did not have a dressing in place to pressure sore on R7's sacrum as verified by V18. There was not a dressing in R7's incontinent brief. V18 stated the Certified Nursing Assistants (CNA's) are to notify nurse if dressings are not in place. R7's incontinent brief had brown tannish drainage from pressure ulcer. V18 stated that R7 acquired the pressure ulcer while in the hospital. V18 stated R7 is seen by wound physician weekly and he does the measurements of R7's pressure ulcer. V18 stated R7's pressure ulcer is a stage 4. R7's sacral ulcer measured 3.4 CM X 2.0 CM X 0.5 CM. R7's pressure ulcer has white/pink tissue surrounding the ulcer. Inside R7's ulcer was yellow slough. V18 cleansed the wound with wound cleanser packed wound with calcium alginate and covered with gauze. R7's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R7's skin risk assessment for pressure ulcers dated 11/3/2021 documents a score 13 (moderate risk 13-14) On 11/4/2021 at 9:43 AM V1 Administrator stated she would expect dressings to be in place to pressure ulcers. The facility policy Stage Pressure Injury Treatment Protocol dated, revision 5/28/2021 documents Stage 4 protocol documents to protect by filling dead space including tunnels and undermining, manage drainage and promote moist wound healing. 2. On 11/04/21at 09:00 AM V18, Licensed Practical Nurse (LPN) removed R7's incontinent brief. R7 did not have a dressing in place to pressure sore on sacrum as verified by V18. There was not a dressing in R7's incontinent brief V18 stated the Certified Nursing Assistants (CNA's) are to notify nurse if dressings are not in place. R7's incontinent brief had brown tannish drainage from pressure ulcer. V18 stated that R7 acquired the pressure ulcer while in the hospital. V18 stated she is seen by wound physician weekly and he does the measurements of R7's pressure ulcer. V18 stated R7's pressure ulcer is a stage 4. Sacral ulcer diameter 3.4 Centimeter (CM) X 2.0 CMX 0.5 CM. R7's pressure ulcer has white/pink tissue surrounding the ulcer. inside the ulcer yellow slough. V18 cleansed the wound with wound cleanser packed wound with calcium alginate and covered with gauze. R7's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R7's skin risk assessment for pressure ulcers dated 11/3/2021 documents a score 13 ( moderate risk 13-14) On 11/4/2021 at 9:43 AM V 1 Administrator stated she would expect dressings to be in place to pressure ulcers. The facility policy Stage Pressure Injury Treatment Protocol dated, revision 5/28/2021 documents Stage 4 protocol documents to protect by filling dead space including tunnels and undermining, manage drainage and promote moist wound healing.

Based on observation, interview and record review the facility failed to provide appropriate treatment and services for indwelling urinary catheters for 1 of 2 residents (R8) reviewed for indwelling catheters in the sample of 28. Findings include: On 11/1/21 at 11:04 AM, R8 was resting in a low bed. R8's urinary catheter drainage bag and tubing was resting on the floor in the resident's room with no covering. R8's Nurse's Notes, dated 10/30/21 at 7:07 PM documents, The resident wanted to go to bed after dinner, at about 6:30 PM. His urine was full of mucous and was dark and mal-odorous. He took his first dose of [MEDICATION(S)] and tolerated it well. Doctor stated that this medication will help with his urinary tract infection ([CONDITION(S)]) and his [MEDICATION(S)] infection. Family was contacted and advised. She stated understanding. He will continue to be monitored. R8's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/4/21 at 10:51 AM, V3, Registered Nurse/RN stated, The catheter bag and tubing should not be on the floor. The facility Policy and Procedure for Urinary Catheter Care dated 12/15/2017, last updated 5/28/21 documents Purpose: The purpose of this procedure is to prevent catheter-associated urinary tract infections. Infection Control 1. Maintain clean technique when handling or manipulating the catheter, tubing or drainage bag. a. Be sure the catheter tubing and drainage bag are kept off the floor.

Based on interview, observation and record review, the facility failed to identify and assess range of motion deficits and failed to ensure that services including Passive Range of Motion (PROM) are provided for 3 of 11 residents (R3, R12, R13) reviewed for range of motion (ROM) in the sample of 15. This failure resulted in a gradual decline in range of motion for R3. Findings include: 1. The Minimum Data Set (MDS), dated [DATE], documents R3 is cognitively intact and has no limitations in range of motion. The August 2016 physician's orders [REDACTED]. The POS also includes orders for palm protector, splint left hand on day and evening, off at bedtime (HS.) The Care Plan, dated 3/22/16, documents R3 needs limited to extensive assist with ADL's (activities of daily living.) The goal is to assist R3 with her ADL's as needed. Interventions include apply left arm and leg splint and adjust PRN (as needed), but does not include any interventions toward her ROM exercises. On 8/23/16 at 10:50 AM, R3 was in her wheelchair in her room at her bedside. R3 did not have a splint on either her left wrist or leg. R3 stated she was trying to exercise her right hand against the bed. R3's left arm was flaccid and her fingers appear contracted. R3 stated she was afraid she's not improving. R3 stated she sees therapy for one session a week and stated she receives no assistance from the nursing staff. R3 stated she doesn't think the one session a week is enough and thinks she is declining. On 8/24/16 at 2:40 PM, E1, Administrator, stated the facility does not do any restorative programs and that any services such as ambulation, range of motion, etc would be listed on the Certified Nurses Aide (CNA) care board on the unit if done for the residents. The board on Spring Unit where R3 resides was observed on 8/24/16 at 4:00 PM with no residents listed who receive services in ambulation, transfer, range of motion on the unit. R3 did not have her splints on at any time of observations during the survey 8/23/16 thru 8/25/16. On 8/28/16 at 9:40 AM, E6, CNA, confirmed that R3 does not wear her splints any longer and hasn't in probably 6 months. E6 stated whenever R3 wore the splints, she complained of pain and refuses to wear them now. On 8/25/16 at 10:00 AM, E5, Physical Therapist (PT), stated that therapies used to have a go to person for restoratives, but no longer has one. At 10:05 AM, E4, PT Assistant, stated R3 pays for 30 minutes a week for her to work with R3's wheelchair positioning and range of motion. E4 acknowledged that Passive Range of Motion (PROM) standard practice is for PROMs to be provided twice daily 7 days a week. E4 also stated R3 refused to wear her splints due to them being uncomfortable. E4 stated R3 does have a contracture or limitation in her left knee which makes transfers difficult at times and that R3 is very worried about her contractures worsening. E4 stated they have a specialized wheelchair on order to address her wheelchair positioning problems. On 8/25/16 at 2:17 PM, E4 stated she would expect nursing to provide range of motion twice daily 7 days a week and even though she and E10 (health fitness) are working with R3, she is still having a gradual decline in ROM. Physical Therapy notes, dated 1/11/16, document R3's analysis of Functional outcome as has demonstrated little to no progress with therapy. She has long standing history [MEDICAL CONDITION] and her left side limits her ability to straighten her knee thus impairing ability to stand. Patient unable to stand for more that 30-40 seconds due to right LE (lower extremity) weakness. R3 was discharged from PT. There is no evidence R3 was provided nursing services to address her range of motion deficits and implement range of motion. The PT notes also document R3 has left knee flexion contracture of approximately 70-80 degrees of flexion. The PT daily Treatment Note, dated 7/26/16, documents PROM to left knee to decrease continued loss of AROM (Active range of motion. The Note, dated 8/1/16, documents Proms to left knee to decrease increased contracture. The notes, dated 8/8/16, 8/15/16 and 8/23/16, also document this. On 8/25/16 at 11:45 AM, E1, Administrator, stated the facility does not really have a policy on ROM and provided a Daily Programming policy, dated 11/7/11, which documents under Procedure B. Physical Activities which assist residents with range of motion and stimulate the cardiovascular system will involve those residents who choose to participate and have a physician order [REDACTED]. Such activities include but are not limited to exercise, balloon volleyball and other physical games. The policy fails to address residents with documented limitations of range of motion and fails to provide procedural interventions addressing the needs of those individuals with limitations or those at risk for treatment and prevention of contractures. On 8/25/16 at 3:00 PM, E1 stated R3 rides her bicycle every evening which staff help her get on, does weigh herself every evening and participates in the health center fitness once weekly with E10, Health Fitness coordinator. 2. The MDS, dated [DATE] documents R13 has cognitive impairment. The MDS documents no limitation in range of motion for upper extremities, but has limitations in both lower extremities. The MDS does not identify R13 as receiving PROM services. R13's Care Plan does not include any interventions addressing the range of motion deficits identified on the MDS. According to E1, on 8/25/16 at 11:45 AM, the facility has no assessments of the degrees of limitations and they have no restorative assessment and/or programs. On 8/25/16 at 11:30 AM, R13 was transferred via a mechanical lift. R13's legs remained bent during the transfer. R13 moaned when pulled up into a standing position by the machine. No cueing/encouragement was given to stand straight from E6 or E9, CNA's as the transferred occurred. The Restorative Services Policy, dated 4/1/08, documents under policy that the community believes that each resident has the right to be provided with the opportunity to regain skills and abilities lost due to illness and disability. Therefore each resident will be evaluated at move in, return from another health care facility and after a significant change in condition for the potential benefit of participating in a restorative program. The nurse will collaborate with rehabilitation therapists as needed in developing a restorative program. Team members may recommend or a resident may request to participate in a restorative program to improve the residents ability or prevent a decline in ability. The policy documents Restorative Nurses are available to all residents based on need. 3. R12's August 2016 Physician order [REDACTED]. R12's MDS, dated [DATE], documents R12 has severe cognitive impairment, requires assistance for all Acts of Daily Living, and R12 has Range of Motion limitations to one side of her lower extremities. R12's Care Plan, updated 8/24/16, does not address R12's limited range of motion or give any interventions to prevent further decrease in range of motion.

Based on observation, record review and interview, the facility failed to recognize, assess and manage pain for 2 of 5 residents (R3 and R5) reviewed for pain management in the sample of 5. This failure resulted in R3 and R5 experiencing increased pain and discomfort without receiving adequate pain medication before therapies or providing care that required movement. Findings include: 1. The physician's orders [REDACTED]. The POS, dated 10/31/13, documented Pain Assessment every 72 hours. R5's physician's orders [REDACTED]. On 02/25/16, the POS documented [MEDICATION NAME] 100 mg/5 milliliters (ml), give 0.125 ml every four hours. R5's Minimum Data Set (MDS), dated [DATE], documented R5 was moderately cognitively impaired and required total assistance of two staff for bed mobility, transfers, dressing, hygiene, bathing and toileting. The MDS also documented R5 had scheduled pain medications and that a pain assessment should be conducted. There was no pain assessment documented in R5's medical record. R5's Care Plan, dated 02/13/16, documented Observe and monitor me (R5) for pain and offer me medication that I have ordered if needed. R5's Nurse's note, dated 12/19/15 at 4:05 PM, documented R5 sustained a left [MEDICAL CONDITION] from a fall at the facility. On 12/20/15, R5's Nurse's Note documented R5 returned from the hospital with an order for [REDACTED]. documented R5 rated pain at a 6 out of 10, however there was no documentation of R5 receiving any pain medication. This Nurse's note documented R5's family did not want surgical repair done due to R5's poor health condition. On 12/22/15 at 12:05 AM, R5's Nurse's Note documented R5 grimacing with movement. However, there was no documentation of the facility giving any pain medication until 12/22/15 at 9:00 PM. The EMAR (Electronic Medication Administration Record) Monthly Report for December, 2015 documented that the [MEDICATION NAME] ordered was never given to R5. It documented no pain medication given until 12/22/15. The EMAR For January, 2016, documented R5 was given [MEDICATION NAME] as ordered three times per day. The EMAR for February, 2016, documented R5 had only received one dose of [MEDICATION NAME] by mouth on 2/15, 2/16, 2/21, 2/24 and 2/25. It documented on 2/25 and 2/28 [MEDICATION NAME] 650 mg given rectally. The remainder of the days in February had no documentation of any pain medication given. There was no documentation of the assessment of pain level, causative factors of pain or a plan to manage further episodes of pain. A radiology report, dated 02/04/16, R5's [MEDICAL CONDITION] femoral neck demonstrated mild interval displacement and appears mildly impacted when compared with the previous study. Adding, the distal fracture part demonstrates slightly greater proximal and medial migration with the fracture site appearing mildly impacted. On 03/29/16 at 4:00 PM, E9, Licensed Practical Nurse (LPN), stated that R5 was routinely given pain medication, but was not sure of how often or when it began. E9 stated that R5 would grimace when moved or say Oh when she was in pain, and that whenever she was moved, R5 would show signs of being in pain. On 03/29/16 at 4:10 PM, E10, Certified Nursing Assistant (CNA) stated R5 would grimace as if she were in pain when moved for perineal care or transfers. 2. The Admission Sheet documents R3 is a [AGE] year old male admitted to the facility on [DATE] with a history of recent Intertrochanteric fracture with left hip surgery, dementia and back surgery in part. R3's Hospital Discharge Summary, dated 3/18/16, documents Postsurgical changes of the left proximal femur. Chronic [MEDICAL CONDITION] proximal femur. R3's Interim Care Plan has Pain Control crossed out with pain management plan checked but no interventions listed. Pain location is identified as tailbone. The March 2016 POS and admitting orders document R3 received [MEDICATION NAME] 5-325 one tab every 4 hours for 3 days following admission, discontinued on 3/20/16 and currently has Tylenol 650 mg every 4 hours PRN for mild pain. An order, dated 3/18/16, documents Ask and assess resident for pain and administer pain medication as indicated 2x/day and make appropriate progress note and record pain scale 0-10. R3's Progress notes dated from admission on 3/18/16 thru 3/20/16 have no entries regarding pain management although R3 was documented as receiving the [MEDICATION NAME] every 4 hours routinely. Following the discontinuation of the [MEDICATION NAME] on 3/20/16, the Medication Administration Record [REDACTED]resident reports pain. There is no documentation that includes a visual assessment given the progress notes document R3 has some confusion at times. On 3/21/16, at 9:47 AM, the progress notes documents pain controlled by current interventions but other than the PRN (As needed) Tylenol order, there is no interventions identified. At 9:52 AM the same morning (3/21/16), the progress notes document recent increase in pain with the MAR indicated [REDACTED]. There is indication in the progress notes that the nurse identified the discontinuation of the [MEDICATION NAME] and the increase in pain. At 2:39 PM, the progress notes document controlled by current interventions. There is no evidence the facility assessed R3's pain comprehensively that included possible nonverbal signs of pain and/or anticipatory pain with movement. On 3/27/16, at 8:25 AM, E4, Registered Nurse (RN), gave R3 Tylenol for back pain with a severity of 4/10. At 5:12 PM, 9 hours after administering the Tylenol, E4 documented denies any pain at this time. E4 did not document the effectiveness of the Tylenol after giving the medication to R3 at 8:25 AM. On 3/29/16 at 10:45 AM, R3 was at the dining room table with E6, Therapy Director/Speech Therapist. E6 told R3 she would have the nurse give him Tylenol for complaints of pain at the time. The MAR indicated [REDACTED]burning, throbbing, cancer pain, pain recent onset related to traumatic event with a history of pain but includes no location and no followup to the effectiveness of the Tylenol given at 10:45 AM. At 5:13 PM, 7 hours later, E3 Licensed Practical Nurse (LPN) documented R3's severity of pain 2/10 perceived as ache again with no location identified, and no Tylenol documented as given for mild pain. On 3/29/16 from 1:03 PM until 4:34 PM, R3 was sleeping soundly with no visual sign/symptoms of pain. At 4:34 PM, E5 and E7, Certified Nurses Aides (CNA) pivoted R3 to the side of his bed. R3 grimaced, moaned and groaned stating oh the pain, why is it so painful? After pivoting to the side of the bed, R3 attempted to redistribute his weight to be more comfortable as he moaned. E5 stated I know it's painful so we'll be quick and get you into the chair. R3 was slid to the edge of the bed and continued to moan. When asked by E5 where his pain was, R3 stated I don't know as he shook his head. Once in the wheelchair, R3 appeared more comfortable and when asked if he wanted a pain pill, told E5 no. E5 stated this is typical behavior for R3 in that he always moans/groans and complains of pain when moved but is okay when not being moved. There is no evidence in the progress notes that E5 reported R3's complaints of pain to the nurse. On 3/30/16 at 8:45 AM, E6 stated R3 typically complains of leg or back pain and yesterday, she made sure he had been given Tylenol before he went into therapy after breakfast. E6 stated the Physical therapist assistant (PTA) E8 stated he did well in therapy with the Tylenol. On 3/30/16 at 10:38 AM, E8 PTA stated R3 will deny pain one time and another complain of knee pain and/or back pain. E8 stated pain medication helps one perform better and he does think R3 does better with the pain medication. E8 stated R3 did well last week and reported being told R3 walked in his room but hasn't done so good this week suggesting some decline. E8 was surprised that R3 has had only 5 doses of Tylenol in the last 10 days and agrees that R3 has pain upon movement which should be anticipated and treated. Physical Therapy notes dated 3/19/16 document R3 as unable to rate pain numerically but indicates low back and right hip discomfort with bed mobility and transfer. A note dated 3/29/16 documents due to limited progress this week, max VI for safety, posture and gait with //(Parallel) bars or ww (wheelwalker.) On 3/30/16 at 9:37 AM, E2 Director of Nurses (DON) stated the facility does not do any pain assessment other than what is in the progress notes and provided a Nursing Observation/Assessments and Documentation policy dated 4/23/13. The policy documents Observations/Assessments will be conducted and documented in the medical record by members of the clinical care team in order to evaluate and monitor the resident's status related to their clinical and psychological needs. The frequency of the observation/assessment is based on the resident level of care and their individual health care and psychosocial status as well as the caregivers scope of practice and training. These will be done at a frequency and in a format that aids the care team in understanding the resident and provide guidance to the team as they work with the resident and their family/significant others in defining/individualizing care needs and goals. The observation and assessment is defined as to mean to provide baseline information and routine monitoring and oversight of a residents general condition. This information should be concise, accurate, objective, timely and entered by the individual who obtains the data/completes the observation and/or provides for the oversight. This policy has Pain listed under Additional Observations and documents Pain interview or observation as defined in the MDS (Minimum Data Set) 3.0 Users manual will be conducted a minimal of on admission and with each MDS assessment and as needed. If Pain is present, resident will be interviewed as appropriate and/or observation related to pain including intensity, frequency, location and alleviating interventions will be done with follow-up observations as needed until pain is managed per resident individual plan. The facility had no documented comprehensive assessment to determine if R3's pain is acute, chronic, when it most likely occurs and/or is predictable, treatment, and what interventions staff could use to ensure his comfort during movement and therapy. They had no documented assessment regarding the effectiveness of the Tylenol after giving it PRN (as needed) as is standard nursing practice. The facility had no documented assessment or monitoring tool to identify R3's pain as incident pain or pain upon movement and with therapy which is predictable given his [MEDICAL CONDITION] and surgery status. The facility has no documentation in the progress notes and/or in the interim care plan that includes interventions for staff to use to ensure comfort during these times his ultimate comfort when his acute pain may cause impaired mobility or diminished quality of life including prior to therapy. At 2:30 PM on 3/30/16, E1, Administrator provided a one page policy entitled Pain Management, undated, which documents the purpose as The resident has the right to have their pain assessed, managed, and re-evaluated in a timely manner using a team approach that includes input from the resident and their family. The policy documents all residents are assessed for pain at the time of admission, quarterly, and with any new report of pain and at regular intervals once pain has been identified. Documentation will be completed in the Pain Management section of Optimus and will include pain management progress notes. The policy includes a pain scale of 0-10 with 10 being the worse, route of medication and other comfort measures that can be offered such as music, pastoral care, ice, heat, massage, relaxation techniques, position changes, pillow, etc.

Based on interview and record review the facility failed to safely transfer 1 of 3 residents (R1) reviewed for falls in the sample of 10. This failure resulted in R1 sustaining a left femur fracture. Findings include: The Incident Details report for R1, dated 12/19/15, documents that E3,Licensed Practical Nurse (LPN), was called to R1's room due to a fall. The report also documents, under Details of the Incident, Upon entry to room, (E3) noted that (R1) and care companion were sitting on the floor between the bed and the wall with(R1's) back to the bed. The report also documents, under Details of Corrective Measures Taken by Facility, Staff re-educated on proper transfers for this resident. The report also documents on 12/22/15: Two sets of films were ordered, first were inconclusive, second showed that there was a fracture to the femur. On 1/14/16 at 1:35 PM, E3 stated that she worked the afternoon of 12/19/15 when E5, Certified Nurses Aide (CNA), did a single person transfer with R1 resulting with both E5 and R1 being on the floor. E3 further stated R1 used to be a two person transfer, but the past two months it was changed to a mechanical lift with 2 people. E3 stated the mechanical lift was not on the CNA's Care Cards that CNAs review to know what kind of care is needed for each resident. E3 stated a preliminary x-ray was done with results of a possible left femur fracture and a second x-ray confirmed it. Multiple attempts to contact E5 for interview were unsuccessful. On 1/19/16 at 11:45 AM, E2, Director of Nurses (DON), stated that R1 was not transferred with a mechanical lift as per physician's orders [REDACTED]. R1's Physician order [REDACTED]. R1's Minimum Data Set (MDS), dated [DATE], documents R1 requires extensive assistance of two for transfers. The facility's Using Mechanical Lift policy and procedure, date approved 04/01/2008, documents, in part, Use of a mechanical lift will be determined by the resident's individualized plan for care. Transfer of dependent resident using a mechanical lift will be done by two (2) caregivers.

Based on interviews and record review, the facility failed to identify pain location changes and a substantial increase in pain with a decline in functioning post fall in a timely manner for 1 of 4 residents (R4) reviewed for necessary care and timely treatment in the sample of 4. This failure resulted in a 48 hour delay in treatment for [REDACTED]. Findings include: 1. The Admission Record identifies R4 as an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R4's Minimum Data Set ((MDS) dated [DATE] identifies R4 to have cognitive impairment and requires the supervision/assist of one staff for transfer and minimal assist of one for ambulation. The balance section of the MDS indicates that R4 is not steady without the assistance of staff for ambulation. R4's current care plan includes a fall prevention plan due to history of falls. The Facility's Incident Details Report, dated 1/21/15, documents R4 was found on the floor at 3:19pm. The report documents R4 was sent to the emergency room due to complaints of pain to right lower extremity and being unable to perform full ROM (range of motion) to right lower extremity. Hospital Report dated 1/21/15 documents "1. No acute osseous abnormalities, 2. Unchanged chronic compression deformity of the L3 vertebrae, 3. Marked Osteopenia, and 4. Marked [MEDICAL CONDITION] disc disease and lumbar spondylosis most pronounced at L4-5. " The Facility's Progress notes do not document when R4 was returned to the facility. Facility Progress Note, dated 1/23/15, at 12:57 AM, written by E14, Registered Nurse (RN), documents "Resident confused to place and time, attempting to get out of bed. Resident screaming, hitting and kicking at staff..." On 1/23/15 at 7:38 AM, E6, Licensed Practical Nurse (LPN) documents in the Progress Notes R4's pain onset is gradual and "continuous." On 1/23/15 at 8:42 AM , E6 documents that the nurse Practitioner (Z3) was notified of residents recent discharge orders that include medication changes. E6 also documents "Resident insists on ambulating, complains of pain to right side pelvic area with needed pain medication given and since medication given, resident is ambulating at all times." On 1/24/15 at 9:15 AM and 12:57 PM, E6 again documents in the Progress Notes R4's pain is continuous with the location of the pain "lumbar." The Incident Report documents on 1/24/15 at 10:53 AM, R4 was again found on the floor in her room. Details of the Incident written by E6 documents "Care companions came to writer stating resident was on the floor. Writer went into resident's room and observed resident laying on the floor approximately 3 feet from the bed off the roll mat on her left side. Care Companions states they were in the room with roommate and did not hear resident getting out of bed. The Details document "Resident continues with ROM WNL (within normal limits) except right lower extremity. No visible injuries noted." The Incident Report documents Z1, R4's physician, and family were notified. Progress Notes written by E6 at 2:26 PM on 1/24/15 documents "Resident continues to complain of pain to right lower extremity, right pelvic area and lower back. Staff assisted resident up and writer applied (brace). Resident continues to bear minimal weight to right lower extremity." The note documents Resident ate approximately 2-3 bites of breakfast and stated she couldn't eat anymore because of pain. The Progress notes documents location of pain changed following the fall of 1/24/15 from lumbar to leg pain. On 1/24/15 at 4:31 PM , 9:33 PM, and 9:43 PM , E11, RN documents leg pain, pain continuous. On 1/25/15 at 9:30 AM, E6 documents in the Progress Notes "Pain is of recent onset related to traumatic pain, pain location - back, hip, pain in continuous, pain level varies." E6 documents pain is affecting following areas "Decreased food consumption, limits mobility, stops engagement in recreational activities, change in mood and behavior." Nonverbal signs of pain are documented as "restlessness, agitation, anxiety, grimacing, loss of appetite, moaning, guarding or protecting body parts." On 1/25/15 at 3:52pm, in the Progress Notes, E12, LPN, documents R4's pain location as hip and leg. At 8:17 PM and 9:40 PM , E12 documented pain location as hip. There is no evidence that either E6 or E12 identified the pain location as changing from lumbar to leg and hip following R4's fall on 1/24/15. On 1/25/15 at 10:41 PM , E12 documents in the Progress Notes "Pain medication given as ordered PRN (as needed) for complaints of severe pain in right hip and pelvis. Resident seems delirious, talking and mumbling things that do not make sense. Ate minimal amount of supper. Care assistant from home agency at bedside. Writer notes that even during intervals of sleep, lying in bed, resident moans and mumbles, she appears to have tremor type jerking movements and is not resting comfortable." On 1/26/15 at 12:16 PM, E10, LPN, documents R4 denied pain but documents at 3:59 AM, R4 complains of pain in hip/pelvic area. At 4:04 AM , E10 documents "Does not c/o (complain of) pain in the lumbar area. Does c/o of right hip pain. Not bearing weight well, transfers difficult. Requires watching closely while aware, very restless @ (at) these times pulling @ clothing et (and) bedding et repeating same phrases over et over." The note documents that R4 "Has no internal or external rotation of right leg et no shortening. PROM (Passive range of motion) per writer with no increased c/o pain in back or hip et no abnormalities noted." On 1/26/15 at 1:07 PM , E9, RN, documents in the Progress Note "message left with (Z1's) nurse regarding resident cognitive decline since she returned from the hospital on Thursday evening. Also notified nurse about resident's physical decline and increase in right hip, lower back and right groin pain since her fall on Saturday morning (bilateral pedal pulses strong, no redness/warmth noted on affected extremity) resident was walking when she returned from the hospital, but since her fall on Saturday she has been unable to get out of wheelchair/bed without an extensive assist of one staff member due to pain." At 5:31 PM on 1/26/15, E13, RN, documents in the Progress Note "Received return call from (Z1's) nurse and order received to obtain x-ray of right hip d/t (due to) pain with movement." At 5:50 PM , E13 documented "Moves upper extremities and left lower extremity without c/o pain. Continues to c/o pain right groin and hip however refused pain med (medication) when offered by writer at 1630. Remains up in chair in DR (dining room) at present." At 6:40 PM , E13 documented R4's pain as sharp/throbbing with pain medication given for c/o right hip and groin pain with movement of right leg." The mobile x-ray was documented as done at 8:50 PM with results showing a fracture. R4 's Hospital Records documents she was transferred to the hospital on [DATE] and was [DIAGNOSES REDACTED]. She underwent surgery for [REDACTED]. On 3/13/15 at 2:00 PM , E6 stated R4 was going through a lot of things at the time of the fall on 1/24/15 and that she didn't think the pain location differed. E6 stated she thought she faxed notification to Z1 that R4 had fallen on 1/24/15 when asked why it wasn't documented in the progress notes. On 3/13/15 at 3:10 PM, E9 stated that when she got report from E10, LPN on 1/26/15, she can remember thinking it's a new pain location after the fall on 1/24/15 and why wouldn't someone had picked up on that. She described R4 at that time as "different, having lots and lots of pain, lots and lots of confusion." adding that she realized some of it could be pain medication or other medications changes she had, but "her pain location had changed" and Z1 needed to be notified. E9 stated she called Z1 then and an order was received for a mobile x-ray. On 3/14/15 at 10:40 am, E2, Director of Nurses (DON) stated she talked with E6 after R4 was transferred to the hospital and was told by E6 that R4 was bearing some weight and that Z1 was called due to increase in pain. The progress notes do not support this nor do they document notification to Z1 on the fall. On 3/17/15 at 9:55 AM , Z1 stated that she has provided the facility nurses her cell phone number and have told them to call her anytime they need to. Z1 stated she did not recall getting notification on the fall but would have only documentation in the office if they did. Z1 stated if the facility faxed at a time when she wasn't in the office, she would not have seen it until the next office day. Z1 stated she is not in the office on Saturday or Sundays. When asked if R4 having a fall with a change in pain location is something she would have wanted them to call about stated "Yes, definitely I would have wanted to know. I always x-ray after falls if complaints of pain are made to rule out any fractures." The facility policy entitled "Notification of a Significant Change in Condition" dated 4/1/08 documents that "The resident, residents legal representative and/or designated family member and the resident's physician will be notified promptly when the resident experiences a significant change in condition. The facility's policy entitled "Nurse Notification of Physician" dated 4/1/08, documents "It is the responsibility of licensed nurses employed in this community to notify the resident's physician when the residents clinical condition may require or requires physician intervention. The policy documents nurses are to record the following in the resident's clinical record, all attempts to notified the physician or designated alternate; method of attempted contact, times and individuals contacted, assessment findings, additional information provided, physician's response, physician's orders [REDACTED]."