Every finding on record at Delmar Gardens North

Based on observation, interview and record review, the facility failed to ensure all residents were treated with dignity and respect, ensuring their comfort, privacy, and personal rights are always upheld, when staff did not knock or announce their presence before entering the rooms of Residents #36, #50, #72, and #84, violating their right to privacy, when Residents #1, #2 and #28 were not provided with call lights within reach, limiting their ability to communicate their needs promptly and when staff failed to adjust the dining room temperature to a comfortable level, compromising their comfort for Residents #26, #72, #145, and #164. This affected the dignity standards to guarantee residents' physical comfort, autonomy, and respect in daily care for nine of 36 sampled residents. The census was 171. Review of the facility's undated Resident Right policy, showed:-Dignity and Respect: Resident has the right to expect the surroundings are safe, clean, and comfortable;-Privacy and Confidentiality: Resident has the right to privacy and confidentiality during persona visits; - Visitors and Communications: Staff respect the personal character of visits and correspondence. Review of the facility's Call Light - Answering policy, dated June 2021, showed:-Purpose: To get the resident when he/she calls for assistance and to assist the nurse in meeting resident's requests.-Procedures: Check to see if he/she call light is within reach. Review of the facility's Resident Council Minutes, dated June 30, 2025, showed the residents voiced concerns that call lights were not answered in a timely manner. 1.During observation and interview on 9/18/25, showed: -At 8:10 A.M., Resident #72 sat at a bedside table eating breakfast. The bedroom door was to the right side of the resident and closed. The resident was startled when the door opened without notice. Housekeeper (HSKP) O walked in carrying a vacuum while talking on a cell phone. HSKP O said, I need to vacuum, it will only take a minute. HSKP O started to vacuum as he/she continued to talk on his/her phone. HSKP O vacuumed around the resident and surveyor. The resident was unable to hear over the vacuuming and HSKP O's phone conversation. Resident rolled his/her eyes and said I get so frustrated; they do this all the time. They never knock and always on their phones. The resident and surveyor resumed their visit after HSKP O left the room;-At 11:08 A.M., Resident #36 closed his/her bedroom door to visit with a surveyor in private. Certified Nurse Aide (CNA) L entered resident's room without knocking or explaining why he/she was in the room. CNA L walk between the resident and surveyor and started gathering supplies. CNA P remained in the doorway. The resident sat in a wheelchair with his/her left shoulder facing the doorway. The surveyor sat on the bed and faced the resident. CNA L spoke to CNA P across the room about what personal care supplies were needed and did not acknowledge the resident or surveyor. CNA L told the surveyor the resident needed to be changed if he/she would step out;- At 11:28 A.M., Resident #36 said the staff never knock before they come in his/her room. There was no use to complain because the staff do not care. During an interview on 9/23/25 at 9:30 A.M., Resident #84 said his/her only complaint is when the staff come into his/her room and do not knock or announce themselves. Resident said last week he/she was in bed on his/her side with his/her back to the door when he/she rolled over and was scared half to death to see a CNA there next to his/her bed. During interview on 9/23/25 at 1:15 P.M., Resident #50 said last week, a man came into his/her room and did not knock or introduce himself and went straight into the bathroom. The resident said, I normally don't cuss but it scared me to death that I yelled, what the hell are you doing! The resident said the man said, I am just checking things out. The resident said he/she was so upset he/she told his/her roommate who went to the nurses' station and was told the man was from nursing. The resident said the staff should knock before coming in their room. During an interview on 9/23/25 at 9:05 A.M., Housekeeper (HSKP) N said before entering a resident's room, staff need to knock and announce who they are and wait for a response. If the resident has a visitor, they should be asked when they would like staff to return. Review of Resident #2's quarterly MDS, dated [DATE], showed:-Moderately impaired cognition;-Diagnoses included left side paralysis, chronic kidney disease, legal blindness, and urine retention. Observation on 9/23/25, showed Resident #2 in his/her room and the following:-At 7:24 A.M., Resident was awake lying on his/her back in bed. The resident winced and said he/she wanted to be repositioned. He/She pushed his/her call light;-At 7:28 A.M., the resident called out, Nurse please help me; -At 7:28 A.M., CNA R walked into the resident's room without announcing who he/was, while hanging up a phone call on his/her cell phone, turned off the call light, and told the resident he/she is going to go get some help and walked back out of the room;-At 7:29 A.M., the resident turned the call light back on;-At 7:35 A.M., the resident called out, please can I be turned; -At 7:37 A.M., the resident called out, help me please. He/She winced in pain while he/she attempted to reposition him/herself;-At 7:39 A.M., the resident called out, please help me.; -At 7:41 A.M., the resident called out, please somebody help me, Nurse please. The resident started crying; -At 7:45 A.M., CNA R came back to the resident's room. During an interview on 9/25/25 at 12:04 P.M., the Director of Nursing (DON) and Administrator said they expected staff to introduce themselves and what they are doing when speaking to all residents, but especially residents with visual impairment. They expected CNA R to assist the resident in a timely manner if the resident was visibly in pain. 2. Observation on 9/18/25 through 9/25/25, showed:-9/18/25 at 8:30 A.M., Resident #28 sat in his/her recliner. The call-light lay at the foot of the bed out of reach. The resident yelled for someone to get him/her more coffee;-9/18/25 at 8:35 A.M., CNA L entered Resident #8's room, placed coffee on the bedside table and exited the room. The call-light remained out of reach;-9/18/25 at 10:15 A.M., Resident #1's call-light at the foot of bed by his/her feet;-9/19/25 at 6:49 A.M., Resident #1's call light out of sight;-9/19/25 at 12:45 P.M., Resident #28 yelled out for more coffee to staff as they passed his/her room. The call-light lay at foot of the bed out of resident's reach;-09/19/25 at 1:05 P.M., Resident #1's call-light was out of reach, at the foot of the bed;-9/22/25 at 9:15 A.M., Resident #28 yelled out to two staff members Hey you, I want more coffee. Both staff members continued to walk down the hall. The call light laid at the foot of the bed and out of the resident's reach;-9/23/25 at 6:25 A.M., Resident #1's call-light lay at the foot of the bed;-9/25/25 at 08:18 A.M., Resident #1's call-light was coiled up by his/her feet at the end of the bed. During an interview on 9/22/25 at 6:20 A.M., Resident #1 said the call-light does not work. CNA B lifted the bottom of the mattress to reach his/her call-light that was stuck. CNA B draped the call-light across the resident's body. During an interview on 9/22/25 at 10:30 A.M., two of the resident's family members said the resident's call light is frequently out of reach, which has been brought up to the nursing staff. One of the family members said recently during a visit he/she observed Resident #28 yell out to staff, who stopped and looked at the resident but kept going. The family member said this was reported to the Director of Nursing (DON) that day, who said it would be addressed, but they felt it has not improved. During interview on 9/23/25 at 06:25 A.M., Licensed Practical Nurse (LPN) A said when Resident #1 is rolled, he/she can get the call light stuck. 3. Observation of the 400 hall dining room temperatures on 9/19, 9/22 and 9/23/25, showed:-9/19/25 at 7:50 A.M., Residents #72, #145 and #164 were in the dining room at a table that was placed approximately two feet under ceiling supply vents that blew cold air. The residents said it was cold. The thermostat setting was 73 degrees Fahrenheit (F);-9/19/25 at 8:56 A.M., showed the ceiling supply vents in front of the dining room windows blew cold air at 69.87 F; air flow was taken with electric Eray Humidity meter. The air flow was directly felt by all three table occupants who were seated along the vents. The wall thermostat showed a setting of 73 degrees F.-9/22/25 at 7:55 A.M., Residents #26, #72, #145 and #164 said the dining room was too cold and they wished staff would put something over the vents;-9/22/25 between 7:55 A.M. and 11:49 A.M., Resident #26 sat in unit 400 hall's dining room at a table that was placed approximately two feet under a ceiling supply vent which blew cold air. At 7:58 A.M., the resident asked CNA K to adjust the temperature because he/she was too cold. CNA K yelled out to Licensed Practical Nurse (LPN) G to call maintenance to adjust the temperature. The thermostat setting was 73 degrees F. From 8:15 A.M. until 11:49 A.M., the dining room temperature had not been adjusted.-9/22/25 at 9:13 A.M., Maintenance K approached the unit 400 hall nursing desk located in front of the unit 400 hall dining room, stopped briefly then continued down another hallway, away from 400 hall dining room. He/She did not adjust thermostat as previously requested by the resident. During an interview on 9/18/25 at 9:45 A.M., Resident #26 said the dining room is too cold for him/her to enjoy the food because the food gets cold too quickly. The resident said it is because the ceiling supply vent blows directly down on him/her. He/She said all the residents who sit under the vents often complain and ask staff to adjust the temperature during meals, but no one listens or cares. During an interview on 9/23/25 at 9:05 A.M., Maintenance A said residents are known to complain the dining rooms are too cold. When the nursing staff let maintenance know, they will adjust the temperature. Maintenance A said he/she was not made aware residents on the 400 hall were complaining the dining room was cold but it is hard to control the temperature since the vents blow directly down on a few of the tables. 4. During an interview on 9/22/25 at 9:35 A.M., CNA K said he/she was aware it gets cold in the dining room, but it is the vents that blow down on the residents. When the residents complain, they will tell maintenance to come and adjust the temperature. CNA K said it would be helpful if they could move the tables so they would not be directly under the vent. CNA K said before anyone enters a resident's room, they need to knock and announce themselves. If a resident has a visitor, staff should ask if they want staff to come back. CNA K said before he/she leaves a resident's room, he/she makes sure the resident has their call light within reach. 5. During an interview on 9/22/25 at 10:05 A.M., LPN G said ultimately, it is the CNA's job to ensure resident's call lights are within reach, but all staff should be looking before they leave a resident's room to ensure the call light is within the resident's reach. LPN G said staff should knock before entering a resident's room and if they have a visitor, they should ask the resident when a good time would be to come back. If a resident or staff have a concern with maintenance issues, staff will call maintenance. LPN G said the maintenance is good about addressing any issues quickly. 6. During an interview on 9/25/25 at 10:30 A.M., the Administrator said the facility does not have a policy on reporting maintenance issues. All maintenance issues are reported to maintenance immediately by calling overhead or reporting to the receptionist who fills out a work order slip. The work order slips are kept at the receptionist desks. The Administrator said she expected staff to follow the Call Light - Answering policy by ensuring resident call lights are within reach. The Administrator expected all staff to knock and announce who they are before entering a resident's room. If the resident has a visitor, staff should ask the resident if they should come back.

Based on observation, interview and record review, the facility failed to maintain a clean or organized medication cart and storage rooms within the facility. Four out of seven carts were checked. Staff failed to ensure proper storage and labels on medications on four Certified Medication Technician (CMT) medication carts. The census was 171. Review of the facility's Medication Storage Policy, dated December 2021, showed:-Drugs and medications are to be stored in the original container in which they were received;-Only the charge nurse or medication nurse has access to the narcotics keys,-Now discontinued, outdated, or deteriorated drugs or medications will be stored in the facility over thirty (30) days.-Medications which require refrigeration are kept in the refrigerator in the locked medication room. Drugs stored under the refrigeration are stored separately from food, -Compartments and areas containing drugs are locked when not in use or when left unattended. Such areas included drawers, cabinets, rooms, refrigerators, carts and boxes. 1. Observation of the 100-hall medication CMT F cart on 9/19/25 at 6:30 A.M., showed:-A total of 40 pills with various colors, shapes and sizes under the white pull-out tray;-The second drawer had 13 pills of various colors, sizes and shapes;-Thirty pills at the back of columns;-Metamucil 4-1 fiber canister open without a date;-Polyethylene glycol without an open date;-The narcotics drawer had an herbal supplement jar with loose change and dollar bills inside of it. Observation of the 100-hall storage room on 9/19/25 at 6:30 A.M., showed vitamin C 500 was open, and 12 pills were left in the bottle without an open date. The bottle was in the overstock cabinet. During an interview on 9/19/25 at 6:32 A.M., CMT D said he/she tried to clean out their cart. There are 2-3 times weekly checks, with the pharmacy coming out monthly. CMT D said sometimes staff pop out medications, and they attempt to locate the medicine but cannot always find the pill in the cart. 2. Observation on the 200 hall CMT E cart on 9/19/25 at 7:40 A.M., showed: -The top drawer has 4 double D batteries, and several double A batteries;-A personal fan located in the third drawer;-Three aerosols with floral smells. During an interview on 9/19/25 at approximately 8:00 A.M., CMT E said staff used the batteries for the weight scale in the halls. He/She removed them from the cart. The CMT grabbed the plastic fan and said, That is mine, I will remove it. 3. Observation on the 300-hall nurse cart on 9/19/25 at 8:20 A.M., showed:-Polythene Glycol without an open date;-Two pills with markings of O25 white circular score (easily cut in half), one long yellow marked 100/ GG 335, one grey/brown pill, 894/5 peach/pink long pills;-A phone charger in the third drawer. During an interview on 9/19/25 at 8:20 A.M., Licensed Practical Nurse (LPN) F said the pills must have fallen out when they were popped into the medicine cup. The nurse in charge of their cart should clean out the cart. 4. Observation on the 400 hall CMT cart on 9/19/25 at 8:41 A.M., showed:-The third drawer has three long white pills, one blue pill and one peach pill;-Fourth drawer: seven pills in total, in various sizes and colors. During an interview on 9/19/25 at 8:41 A.M., LPN G said he/she believed CMTs or management cleaned out the medication carts but was unsure. LPN G said he/she believes whoever is on the cart would be responsible for cleaning the cart. 5. Observation on the 500 hall CMT cart on 9/19/25 at 9:08 A.M., showed:-The top drawer had three loose white pills;-The second drawer, the fourth column, had over 50 pills in various sizes, colors, shapes, and capsules;-Third drawer had 13 loose pills of various sizes and colors;-The fourth drawer had four loose pills in total, in various sizes and colors. During an interview on 9/19/25 at 9:13 A.M., LPN I said CMTs, LPNs and Registered Nurses (RNs) are responsible for cleaning the carts. During an interview on 9/19/25 at approximately 9:15 A.M., the Unit Manager said medications carts are cleaned on a regular basis but was unable to define what regular meant. He/She expected no pills to be found on the cart. However, this second drawer, with over 50 pills, was less than satisfactory. He/She said the third drawer should have no pills. During an interview on 9/19/25 at 11:50 A.M., the Director of Nursing (DON) said he/she expected staff to follow policies and procedures, and it is up to the CMT, LPN, and RNs to clean the carts as needed or daily if they see medication laying out. The DON's expectations are no personal items are to be found on medication carts.

Based on interview and record review, the facility failed to ensure a resident's Against Medical Advice (AMA) discharge was documented in the medical record and appropriate information was communicated to the resident and/or responsible party. The facility also failed to maintain a copy of a signed AMA discharge form for one of three residents reviewed for voluntary and involuntary discharge procedures (Resident #178). The census was 171. Review of facility's admission Agreement, showed: -You may voluntarily end this admission Agreement and leave our facility at any time by giving us seven days advance written notice. If you leave against the advice of your physician, you agree to assume full responsibility of all results that follow. You also agree to pay all outstanding charges before you leave. If you die while in our facility, we will honor your wishes and provide assistance to your Resident Representative or to whomever is responsible for making all funeral arrangements.Review of Resident #178's medical record, showed:-admitted on [DATE];-discharged on 7/24/25 at 8:25 A.M., left against medical advice.Review of the resident's progress notes, showed:-On 7/23/25 at 9:42 A.M., patient arrived to facility via Emergency Medical Services (EMS) transport from hospital into bed by EMS staff. Admitting diagnoses abdominal abscess (localized collection of pus that forms in the body's tissues or organs) with history of pancreatic cancer, liver cancer, diabetes, acidosis (too much acid in the body), low hemoglobin (a protein found in red cells that carries oxygen throughout the body), and hypoglycemic (low blood sugar). Alert and oriented x 3-4 (person, place, time and situation), able to express needs but can be forgetful at times. Patient is a regular diet and continent of bladder and bowel. Patient is a full code. All medications verified with physician and faxed to company; -On 7/24/25 at 1010 A.M., for 7/23/25 11:00 P.M.-7:00 A.M. shift, alert and oriented and able to make needs known. Rested in bed during shift. Was incontinent of bowel and bladder and good peri care given; -No documentation of the resident's AMA discharge.Review of the resident's medical record, showed no documentation of the resident's signed AMA form or other documentation of the resident's and/or responsible party's decision to discharge AMA.During an interview on 9/25/25 at 11:27 A.M., the Administrator said she was not familiar with the resident, but the facility has an AMA policy and the resident signs the AMA form. She would expect the resident to sign the discharge AMA form. She would expect staff to document the resident's decision to discharge AMA in the progress notes.On 9/25/25 at 3:00 P.M., at the time of exit, the facility's discharge policy and Resident #178's signed AMA form was not received.

Based on observation, interview and record review, the facility failed to document assessments and failed to contact the resident's physician regarding a change of condition for one sampled resident (Resident #11). The sample was 36. The census was 171. Review of the facility's policy, Following Physician's Orders, dated 6/29/21, showed:-Purpose: It is the policy of the community to ensure that all Licensed Professional Nurses (LPNs) Registered Nurses (RNs) and other healthcare professionals, follow physicians in accordance with State, Federal regulations and their respective practice acts.-Procedure: All physicians orders will be followed as prescribed and if not followed, the reason shall be recorded on the resident's medical record;--If an order is questionable according to the seven Rights of Medications Administration, a clarification order will be obtained;--All physician or other health care professional's verbal, telephone or written orders will be immediately entered by the nurse obtaining the order. Review of the facility's policy, Wound Management for the Palliative/Hospice Resident, revised date 7/23, showed:-Skin Care and Maintenance of Skin Integrity: --Handle and treat the skin with extreme care;--Cleanse with mild cleanser; avoid the use of soap;--Pay particular attention to high-risk areas sacrum, elbows, and the heels. Review of Resident #11's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/11/25, showed:-Cognitively intact;-Diagnoses included stroke, localized swelling, mass and lump in the left upper limb, polyneuropathy (simultaneous malfunction of many peripheral nerves throughout the body). Review of the resident's care plan, in use during the survey, showed:-Problem: Pressure injury at risk of developing alterations in skin integrity and pressure;-Goal: Maintain and improve skin integrity related to risk factors and healing potential;-Approach: Complete bath and skin reports on shower days, communicate with the charge nurse about concerns noted on the skin, floating heels, utilize pressure-reducing devices in bed or wheelchair. Review of the resident's Physician Order Sheets (POS), dated 9/11/25, showed: -Evaluate for left elbow bursitis with a draining abscess per orthopedic follow-up. Wound care initiated and site assessed for drainage and dressing needs. The resident was instructed to use the use of an elbow pad, to be worn at all times except during bathing. Review of the resident's shower sheet, dated 9/13/25, showed left forearm dark purple bruising, elbow pad on, elbow bursitis (a sac of fluid near/by a joint) abscess, right butt cheek small, discolored area. Review of the resident's Medication Administration Record (MAR), showed no assessments during the period of 9/11/25 and 9/24/25. During an interview on 9/18/25 at 10:33 A.M., LPN C said the resident is only monitored for pain and if he/she has their protective elbow brace on daily. LPN C said the resident has a follow-up appointment on 9/24/25. LPN C said nurses are not required to chart color, size or monitor the abscess in any way. LPN C said he/she is unaware if the resident is being followed by wound management at this time. During an interview on 9/22/25 at approximately 11:00 A.M., the Assistant Director of Nursing (ADON) reviewed the specialist orders: Diagnosis of left elbow bursitis with draining abscess. Wound care to evaluate for dressing changes, elbow pad to be worn except baths. The ADON said staff should monitor the site noted on 9/13. The ADON said the order showed for wound management to evaluate the abscess for drainage. Observation on 9/22/25 at 11:07 A.M., showed the ADON and LPN C went to assess the elbow. An adhesive brown bandage was on the site without a date. A small amount of brown dried drainage was present on the bandage. The ADON said he/she couldn't stage the wound due to no prior knowledge of the wound. The wound had a light center and a discolored purple outer center. There is swelling around the site. The ADON said he/she would call the provider to clarify the prior orders. The ADON would put daily monitoring in place and have the wound management provider review the abscess next time they are in. Review of the resident's MAR, showed:-9/22/25 Wound management orders for the left elbow to evaluate and treat. During an interview on 9/25/25 at 11:50 A.M., the Director of Nursing (DON) said all staff members are expected to follow correct policies and procedures when it involves caring for residents. The DON said when wounds are found, staff should report them to wound management. The DON was unaware why LPN C did not clarify the order when the resident came in with an unclear order. The DON said a resident going 11 days without a nurse's care could lead to infection risk. The DON said staff should have charted the wound sooner than 11 days.

Based on observation, interview, and record review, the facility failed to ensure 2 of 6 sampled residents the facility identified with a catheter (medical device to allow for voiding) received appropriate catheter care. The facility failed to ensure one resident's catheter was stored properly while the resident was in bed (Resident #2) and failed to ensure one resident received proper catheter care (Resident #55). The sample was 36. The census was 171. Review of the facility's catheter care policy, dated 3/2021, showed:-Purpose: To keep indwelling catheter free of discharge and/or crusting which can cause infections;-Procedure: Check tubing for positioning. Coil on bed. Attach catheter bag to bed frame only.-Male catheter procedure: Apply gloves. Place protective pad or towel under the resident. Avoid unnecessary exposure. Moisten wash cloth with soap and water. Clean the catheter from the opening of the urethra outward four (4) inches, or farther if needed. Do not pull on the catheter. If the male is uncircumcised, the foreskin must be retracted and cleaned. Pat dry with towel. Cover resident. Remove gloves. Wash hands.1. Review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/24/25, showed:-Moderately impaired cognition;-Diagnoses included left side paralysis, chronic kidney disease, legal blindness, and urine retention. Review of the resident's care plan, in use at the time of the survey, showed the resident's catheter was not identified. Review of the resident's Physician's Order Sheet (POS), dated 9/2025, showed:-An order, dated 5/3/2025, Foley catheter. Observation on 9/18/25 at 8:31 A.M. and at 10:13 A.M., showed the resident lay in his/her bed, asleep. The resident's catheter bag was on the floor next to the resident's bed. Observation on 9/22/25 at 10:20 A.M., showed the resident lay in his/her bed, awake. The resident's catheter bag was on the floor next to the resident's bed. Observation on 9/23/25 at 7: 24 A.M., showed the resident lay in bed, awake. His/Her catheter bag was on the ground next to his/her bed. During an interview on 9/25/25 at 9:19 A.M., Licensed Practical Nurse (LPN) S said when a resident is in bed, their catheter should be placed on the bed frame. He/She expected the catheter to be off the floor to prevent infection and contamination. During an interview on 9/25/25 at 10:10 A.M., Certified Nursing Assistant (CNA) T said when a resident is in bed, their catheter should be placed on the bed frame. He/She expected the catheter to be off the floor to prevent bacteria from getting in the resident's catheter. During an interview on 9/25/25 at 11:58 A.M., the Director of Nursing (DON) and Administrator said they expected catheters to be hung on the bed frame and off the floor when a resident is lying in bed. They expected staff to ensure the catheter placement is correct before leaving the resident's room. 2. Review of Resident #55's admission MDS, dated [DATE], showed:-Cognitively intact;-Indwelling catheter -Diagnoses included cerebral palsy (lifelong impairment caused by brain damage or impairment of development), cognitive communication deficit (impaired thinking or problem-solving), dysphagia (difficulty swallowing), gastrostomy status (surgical site for a tube or other medical device) and aphasia (inability to communicate effectively). Review of the resident's care plan, in use during the survey, showed:-Problem: Urinary tract infection (UTIs) related to blood in catheter,-Goal: The resident will be resolved without complication by the next review date,-Approach: Report and documented to provider regarding signs and symptoms to UTIs like blood in urine, cloudy or sediment (buildup of white substance), encourage resident to pee on first urge rather than holding, given antibiotics as ordered while documenting the side effect and effectiveness, Provie incontinence care after each incontinent episode, teach care givers to provide good hygiene. Females to wipe and cleanse from front to back. Clean peri area well after the bowel movement (BM) in order to help prevent bacteria in the urinary tract. Review of the resident's current POS, showed: -3/5/25, Diagnosis for indwelling catheter: benign prostatic hyperplasia with lower urinary tract (enlargement of the prostate gland).-9/15/25, Bactrim (antibiotic) 1 tablet orally take twice a day for 10 days for UTI.-Catheter care per shift 7:00 A.M. to 3:00 P.M., 3:00 P.M. to 11:00 P.M., 11:00 P.M. to 7:00 A.M. Observation on 9/18/25 at 8:34 A.M., showed CNA Q entered the resident's room to perform care. He/She washed his/her hands and applied gloves. CNA Q wiped the left side and then the right side. CNA Q continued to wipe the genitals. CNA Q touched the indwelling catheter and wiped the middle of the tube in a downward motion. He/She left 2-3 inches of the drain coming from the glans (tip of the penis) untouched. CNA Q put an incontinence brief on the resident. The indwelling catheter was pulled from the left side of the brief draped across exterior of the brief under the right thigh of resident and hung on the right side of the bed. During an interview on 9/25/25 at 9:04 A.M., CNA Q said he/she knows the proper technique to cleanse residents with an indwelling catheter, however he/she did not follow the technique during the care of the resident. During an interview on 9/25/25 at 11:50 A.M., the DON said he/she expected all staff members to follow correct policy and procedures when it involves care for a resident. The DON said residents can be prone to reoccurring UTIs. The DON said there are different techniques for catheter care from men verses women. The DON expected any staff member who provides peri care to a resident to clean the glans and the medical device that is inserted into the urethra. To avoid cleaning the tube, it puts the resident in a situation for bacteria to build up and enter the urethra, which leads to a UTI.

Based on observation, interview and record review, the facility failed to ensure two residents received gastrostomy tube (a tube surgically inserted into the abdomen, used for liquid nutrition, fluids and medications) feedings at the specified times ordered by the physician (Residents #1 and #55). The sample was 36. The census was 171. Review of the facility's Tube Feeding policy, revised June 2021, showed:-Purpose: to deliver a continuous, regulated drip feeding to gastrostomy tube (g-tube) fed residents using an enteral pump;-Procedure: -Equipment: Enteral pump, enteral feeding bag and administration set; prescribed feeding; and a pole; -Review the physician's orders; The order should specify the amount and type of formula, and the flow rate. Review of the facility's Following Physician Orders policy, dated 6/29/21, showed:-Purpose: It is the policy of the community to ensure that all licensed professional nurses and other healthcare professionals, follow physician orders in accordance to state and federal regulations and their respective practice acts;-Procedure: All physician orders will be followed as prescribed and if not followed, the reason shall be recorded on the resident's medical record; If an order is questionable according to the seven rights of medication administration (right resident, right medication, right dose, right time, right route, right documentation, and right reason), a clarification order will be obtained. 1.Review of Resident's #1's admission Minimum Data Sheet (MDS), a federally mandated assessment instrument completed by the facility staff, dated 5/06/25, showed:-Cognitively intact;-The resident has a feeding tube;-Diagnoses include diabetes, venous thrombosis and embolism (a blood clot in the vein or blockage from the clot), hemiplegia and hemiparesis from cerebral infarction (inability to move half of their body from a stroke) and dysphagia (difficulty swallowing). Review of the resident's care plan, in use during the survey, showed:-Problem: Utilizes feeding tube for supplemental nutritional and hydration needs, receives mechanical soft diet as well;-Goal: Maintains current nutritional status and weight through the next review date;-Approach: Administer tube feeding as ordered, flush the g-tube as ordered, allow extra time to eat, assist with mealtime to ensure adequate meal intake. Review of the resident's Physician Order Sheets (POS), dated 5/3/25, showed:-An order, dated 5/3/25, check placement of g-tube placement before feedings and medications administrating by aspirating (pulling back content) stomach before meals at 6:00 A.M., 11:00 A.M., and 4:00 P.M.; -An order, dated 7/8/25, elevated head of bed (HOB) by 30 degrees; -Flush tube with 200 milliliters (ml) of water every six hours and at least 30 ml of water before and after each medication: 7:00 A.M., 1:00 P.M., 7:00 P.M. and 1:00 A.M.;-Glucerna (diabetes specific formula) 1.5 runs at 70 ml per hour daily between 7:00 P.M. and 7:00 A.M.;-Osmolite (calorically dense tube-feeding formula)1.5 in substitute for Glucerna feeding solution;-Formula intake per shift. During an interview on 9/19/25 at 6:49 A.M., the resident said he/she did not get any tube feeding last night. He/She received it the night before but none this morning. The resident was unsure why this happened. Observation on 9/23/25 at 6:25 A.M., showed the resident lay in bed, with the HOB at 30 degrees with no tube feeding running. During an interview on 9/23/25 at 6:31 A.M., Licensed Practical Nurse (LPN) A said the resident's tummy was hurting, and LPN A gave his/her stomach a rest sometimes. There are no orders for symptoms of bloating or distention to follow. Review of the resident's Medication Administration Record (MAR), dated 9/25, showed an order, dated 9/23/25 Glucerna 1.5 ran at 70 ml per hour from 7:00 P.M., to 7:00 A.M.; intake was 840 ml. During an interview on 9/23/25 at approximately 2:00 P.M., the Director of Nursing (DON) said LPN A called the medical provider about the missed tube feeding but was unable to speak directly to the provider or leave a message. The resident complained about distended abdomen and pain, which led LPN A to hold the nocturnal tube feeding. The resident's oral intake for 9/22/25 was 25% at breakfast, 50% at lunch and 75% during dinner. Another nurse attempted to contact the nurse practitioner but was unable to get in direct contact with him/her. The facility's assessment showed the resident had a patent (open) g-tube, bowel sounds and stable vitals. 2. Review of Resident #55's MDS, dated [DATE], showed:-Cognitively intact;-The resident has a feeding tube;-Diagnoses include cerebral palsy (lifelong impairment caused by brain damage or impairment of development), cognitive communication deficit (impaired thinking or problem-solving), dysphagia and gastrostomy status. Review of the resident's care plan, in use during the survey, showed:-Problem: The resident receives all nutrition and hydration via a g-tube. The resident may receive clear liquids as tolerated;-Goal: Will maintain current nutritional status and stable weight;-Approach: Ability to feed yourself, provide a diet as ordered. Review of the resident's POS, dated 2/18/25, showed: -G-tube placement by aspirating the stomach contents every shift day, evenings and nights date 2/18/2025;-Enteral feed: HOB 30;-Enteral Two Cal at 85 ml per hour continuous from 7:00 P.M. - 7:00 A.M., overnight. Observation, showed:-9/19/25 at 6:45 A.M., No tube feeding running and the HOB was at a 45 degree angle. The resident was slumped in bed.-9/22/25 at 6:18 A.M., Osmolite was running 85 mL per hour, volume was 827 mL.-9/23/25 at 6:22 A.M., No tube feeding was running. During an interview on 9/25/25 at 9:02 A.M., the resident said they did not hang his/her feeding tube last night. During an interview on 9/23/25 at 6:31 A.M., LPN A said he/she took the resident off the nocturnal feeding early due to him/her receiving care. LPN A said he/she will remove the tube feeding due to Certified Nurses Assistants (CNAs) in the past pulling the g-tube out. He/She said the resident was hospitalized for the g-tube being displaced in the past. LPN A said the resident received 750 ml of his/her nocturnal feeding. LPN A said the feeding ordered was 1,000 ml. During an interview on 8/25/25 at approximately 2:00 P.M., the DON said she would not expect nurses to discontinue nocturnal tube feeding for care alone. The DON expected staff to pause the pump and resume the nocturnal feeding post-care.

Based on observation, interview and record review, the facility failed to maintain an environment as free of accident hazards as possible and to provide supervision and assistance to prevent falls for five of seven sampled residents (Residents #1, #3, #4, #5 and #6) by not implementing care planned fall interventions. On 12/31/24 Certified Nurse Aide (CNA) A failed to place Resident #1's bed in a low position. Resident #1 was found screaming and hanging off the bed holding onto the grab rail. A nurse assisted the resident to the floor. The resident sustained bilateral (both sides) fractured femurs (thighbones). The facility failed to complete post fall neurological (neuro) assessments (a series of questions and tests to check brain, spinal cord, and nerve function) as ordered by the physician and in accordance with the facility's policy for seven out of seven sampled residents (Residents #1, #3, #4, #5 #6 and #7), and failed to complete post fall follow-up documentation each shift for 72 hours after falls for six out of seven sampled residents (Residents #3, #4, #5, #6, #7, and #8). Additionally, the facility failed to update two of seven sampled residents' resident care plans (Residents #3 and #6) with interventions after falling. The census was 170. The Administrator was notified on 2/4/25 at 3:06 P.M., of an Immediate Jeopardy (IJ) which began on 12/31/24. The IJ was removed on 2/7/25, as confirmed by surveyor onsite verification. Review of the facility's Fall Risk/Fall Prevention Program, revised 7/24, showed: -Purpose: To identify residents at risk for falls and implement fall prevention interventions. To ensure appropriate and prompt follow up of resident falls; -Procedure: -1. The Morse Fall Scale Observation form will be completed electronically by the charge nurse on admission, re-admission, quarterly or when risk has changed from resident's previous risk score. When completing item #1 identify if the resident has had a fall in the last 3 months, regardless of when admitted ; -2. After completion, if the fall risk assessment is scored 25 or higher, the charge nurse may initiate the at risk fall care plan template in MatrixCare (electronic medical record). The CNA profile and/or assignment sheet will be updated; -3. If the resident scores 51 or higher, the resident will be identified as a High Fall Risk. The Fall Prevention Approaches order set in MatrixCare can be initiated if appropriate and resident specific fall interventions can be implemented based on the reason why the resident is at high risk on the care plan. Add this identification to the CNA Profile. The FALL RISK banner will populate on the resident's face sheet; -4. If the resident scores greater than 50, a Red bag tag may be placed on the resident's wheelchair and/or assistive devices to remind everyone of the high risk. Review of the facility's Post-Fall Assessment, revised 7/24, showed: -Purpose: All falls are investigated to determine the reasons for the fall and to develop interventions to minimize or eliminate future falls. Residents at risk for falls are identified on the Resident Banner in MatrixCare; -Procedure: -1. The nurse on duty will complete a Post-Fall Assessment Event for every fall; -2. Physician (PCP, primary care physician), and resident representative (RR) must be notified of all falls; -3. Neurological (neuro) Assessment should be initiated with all falls: Initiate Neurological Assessment Form for falls with head injuries. Initiate Neurological Assessment Form for unwitnessed falls without head involvement; -4. The charge nurse will implement any immediate interventions necessary to minimize risk of future fall. Be sure to note the date of the fall any injuries and any new/revised interventions; -5. Therapy will complete the Rehab Multidisciplinary Screening Form Observation within 24 to 72 hours, communicate any interventions to nursing staff, and document those interventions in the resident's care plan; -6. Nurses must assess the resident's condition following the fall and document every shift for 72 hours after a fall; -7. The Interdisciplinary (IDT) Fall Review Team will meet at least weekly and formally address every resident that has fallen during the previous week. Discussion will focus on interventions that have been implemented and other interventions that may be required to reduce falls and meet the resident's needs. Interventions are to be updated on the resident care plan. The Interdisciplinary Fall Review Checklist will be completed during fall rounds for Quality Assessment & Assurance (QAA) purposes; -Falls Definition Guidelines: -Current CMS policy regarding falls include: -a. An episode where a resident lost his/her balance and would have fallen, were it not for staff intervention, is a fall. In other words, an intercepted fall is still a fall; -b. The presence or absence of a resultant injury is not a factor in the definition of a fall. A fall without injury is still a fall; -c. When a resident is found on the floor, the facility is obligated to investigate and try to determine how he/she got there, and to put into place an intervention to prevent this from happening again. Unless there is evidence suggesting otherwise, the most logical conclusion is that a fall has occurred; -d. The distance to the next lower surface (in this case, the floor) is not a factor in determining whether or not a fall occurred. If a resident rolled off a bed or mattress that was close to the floor, this is a fall. 1. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/11/25, showed: -Moderate cognitive impairment; -Upper extremity: Impairment on one side; -Lower extremity: Impairment on both sides; -Dependent with eating, toileting, bathing, personal hygiene, dressing, rolling left and right, and transfers; -Fall in the last month prior to admission; -Fracture related to fall in the six months prior to admission; -Diagnoses included high blood pressure, heart failure, diabetes, hemiplegia and hemiparesis left sided, and fracture. Review of the resident's most recent Morse Fall Scale, dated 11/14/24, showed a score of 35, low risk for falls. Review of the resident's current care plan, showed: -Problem: Falls, resident is at risk of falls due to left side hemiplegia and hemiparesis, legally blind, problem start date, 6/27/23, edited 1/10/25; -Goal: Minimize the risk of falls and related injury through next review, edited 11/13/24; -Approach: -Resident had a fall on 12/31/24, low bed, fall mat and bed against wall, created 1/10/25; -On 7/29/23, resident slid from edge of bed after attempting to get out of bed without assistance, education received on use of call light, created 8/8/23; -Ensure call light is in reach and educate on use of call light if indicated, created 6/27/23; -Ensure environment is free of clutter, created 6/27/23; -Keep bed in lowest position when resident is in bed, created 6/27/23; -Keep personal items within reach of resident, created 6/27/23; -Physical Therapy (PT) and Occupational Therapy (OT) to screen and evaluation as indicated, created 6/27/23; -Problem: Activity of Daily Living (ADL) functional status/rehabilitation potential, resident requires total assist with ADL care, edited 1/9/25; -Approach: Transfer with Hoyer lift (mechanical lift) and assist of two; -Bed not against wall and one fall mat on the right side of the resident's bed. Review of the resident's event history, dated 11/1/24 through 2/3/25, showed: -Date/Time: 12/31/24 at 6:15 A.M., Short Description: Post fall. Review of the resident's post fall assessment, dated 12/31/24: -Event date: 12/31/24 at 6:15 A.M.; -Location of fall: Resident room; -What was resident doing just prior to fall: Sleeping in bed; -Was the fall witnessed: Yes; -Describe exactly what happened: Resident was hanging off the bed holding onto the grab rail; -Check all that apply: Other: rolled off the bed; -List immediate interventions taken to promote resident's safety: Pain management assessment, other: encouraged to call for help; -Was there an injury: No injury; -Did the resident hit their head: No; -Obtain resident statement of activity prior to fall if able: blank; -Behavioral characteristics that may have contributed to the fall: Afraid of falling, forgetful; -Describe the environment at the time of the fall: Call light in reach, lights on in room, assist rails/siderails up; -Pupils: Within normal limits; -Hand grips: Within normal limits; -Were any new medications started within the last month: No; -Notifications: -PCP: 12/31/24 at 7:45 A.M.; -RR: 12/31/24 at 7:26 A.M.; -Care Plan reviewed: Yes: Note: low bed, fall mat and bed against the wall; -Orders: Treatment: Fall: With suspected head trauma - Neuro checks per policy on paper neuro assessment form and compete nurses note every shift for 72 hours, order dated 12/31/24; -Notes: -12/31/24 at 7:57 A.M.: This morning at 6:15 A.M., Registered Nurse (RN) B was heading to the resident's room to give early morning medications and pain medication and heard the resident yelling for help. Resident was seen hanging off the bed and holding on to the grab rails with his/her legs on the floor wrapped with a blanket. The resident's bed was very high up. RN B called out to Certified Nurse Aide (CNA) A, but CNA A was in another resident room with the door closed and did not hear RN B calling out. The resident said he/she couldn't hold on anymore to the rail and that he/she needed to sit down. RN B had to lower the resident to the floor gently holding on to his/her hip and then went and got assistance. The resident was assisted back into bed by four staff on the hall using a blanket with the bed lowered all the way to the floor. The resident was assessed, no physical injuries noted. Resident complained of pain to right thigh. RN B massaged the resident's right thigh and bilateral legs and foot with diclofenac gel (used to relieve pain from arthritis). As needed (PRN) oxycodone (narcotic, used to treat moderate to severe pain) given for pain management. PCP aware order given to x-ray resident's right thigh and right hip, x-ray scheduled. RR made aware and stated would come and see resident this evening instead of tomorrow, as planned. Neuro checks initiated; -12/31/24 at 12:57 P.M.: Continues on observation related to being lowered to floor, awaiting x-ray. Resident resting in bed at this time remains alert and able to make needs known. Small emesis noted earlier, clear. Resident complained of upset stomach as needed (PRN) Mylanta (used to treat upset stomach, heartburn, and acid indigestion) given and effective. Vital signs stable, neuro checks within normal limits (WNL). No complains of pain or discomfort noted at this time. Review of the resident's Neurological Assessment for falls without head involvement, dated 12/31/24, showed: -Unusual verbalization, statements, or behaviors, YES/NO, document specific verbalization in nurse's notes: -12/31/24, 7:00 P.M. - 7:00 A.M., the entry was blank. Review of the nurses notes, showed: -1/1/25 at 2:59 A.M.: Incident follow up (IFU) fall, received x-ray results at 1:53 A.M. via fax. Right hip showing normal examination. Right femur shows acute fracture at distal (body part that is farther away from the center of the body than another part) femur. Call placed to PCP received new order to send to emergency room (ER) to evaluate and treat. Resident denied pain until transferred to gurney; -Evaluation: -Evaluation notes: Resident hanging off the bed holding onto side rail. Care plan: low bed fall mat and bed against wall: -Falls prevention program initiated: Yes; -Injury is resolved/healing without complications: Yes; -Care plan updated: Yes. Review of hospital medical records, dated 1/1/25, showed: -Resident presented from facility with complaint of distal right femur fracture, Facility staff reported resident was tangled in sheets and they tried to assist him/her back into bed. Family concerned resident may have fallen out of bed. X-ray obtained on 12/31/24 at facility showed periprosthetic (a fracture that occurs around or near a previously implanted femoral (thigh bone) prosthesis, such as a total hip or knee replacement) right distal femur fracture. Resident reports pain in bilateral lower extremities and neck pain; -Resident presents with bilateral lower extremity pain of possible ground level fall from bed. X-rays demonstrate bilateral distal femur fractures; -X-rays demonstrate obvious deformities of bilateral distal femurs. -Physical exam: Tender bilaterally in distal femurs, no pelvic tenderness to palpation (touch). Holds right leg in external rotation (movement of a body part away from the body's center). No tenderness in calves or ankles bilaterally. Review of the resident's electronic medical record, showed the facility readmitted the resident on 1/9/25. Review of a written statement and facility interview, dated 1/2/25, showed CNA A said he/she provided the resident's care on the morning of 12/31/24 around 6:00 A.M. CNA A stated he/she changed the resident, gave the resident his/her call light and raised the head of the bed slightly. The height of the bed was at waist height. CNA A stated he/she did not hear RN B yelling for help. During an interview on 2/6/25 at 7:24 A.M., CNA A said he/she worked with the resident on the morning of 12/31/24. CNA A said he/she was not aware the resident was a fall risk because the resident did not have any signs up, or a yellow wrist band that would indicate the resident was a fall risk. CNA A said after changing the resident, the resident fell about 10 - 15 minutes after receiving care. CNA A said he/she left the resident's bed a little bit over waist high. CNA A stood up and held his/her hand at waist level that measured approximately 44 inches high. CNA A said he/she was not aware the resident's bed was supposed to be at the lowest level when the resident was in bed and leaving the room. CNA A said RN B came and asked for assistance with transferring the resident back into bed. CNA A said one person got the resident's legs and one person got the top of the resident, and they lifted the resident into the bed. CNA A said to transfer the resident they are to use the Hoyer. CNA A said there was no reason they didn't use the Hoyer, they were just trying to hurry up and get the resident off the floor because it was cold. CNA A said the resident did not complain of pain when they transferred him/her off the floor and into the bed. CNA A said he/she did not stay in the room when RN B did the assessment on the resident after the resident was transferred into bed. CNA A said he/she did not work with the resident again before the resident went to the hospital. Review of a written statement, dated 1/3/25, showed RN B wrote, on 12/31/24 morning at 6:15 A.M., he/she was doing his/her medication pass. Getting to the hall RN B was about to get medications on that side of the hall when RN B heard the resident shouting for help. CNA A said he/she had already changed the resident and that he/she did not know why the resident was screaming for help. RN B told CNA A he/she should have gone to see why the resident was screaming. While RN B was saying that to CNA A, RN B started making his/her way down to the resident's room. RN B went straight into the resident's room and found the resident hanging off the bed holding onto the grab rail. The resident's back was towards the door and the resident was facing the wall beside the heater. RN B began shouting for CNA A to come help, but CNA A never came to the room. Meanwhile RN B held the resident on his/her hip with both hands so he/she wouldn't fall to the floor because the bed was up high in the air. The resident's legs were on the floor wrapped around his/her blanket. RN B did not see the resident's legs and how they were positioned, but the resident's legs were on the floor while he/she was holding on to the grab rail. The resident then stated he/she could not hold on anymore and RN B told the resident to hold onto the rails firmly so that RN B could lower him/her to the floor. RN B tried to grab the small chair by the heater but was unable to without help. RN B lowered the resident to the floor while holding onto the resident's hips and around his/her waist and gently lowered the resident onto the floor. RN B left the room to get help and found CNA A. RN B told CNA A to go to the resident's room and RN B went to get more help. RN B called two additional staff to come and assist with getting the resident up. On assessment when the resident's blanket was moved, he/she was in a sitting position with both legs to the left side close to the heater. RN B and staff used a big blanket and put it underneath the resident and lowered the bed to the floor and transferred the resident back to the bed. The resident has never been able to do range of motion (ROM) on his/her lower extremities. Resident has a history of bilateral knee replacement of which he/she has arthritis really bad on both legs. The resident complained of right thigh pain, so the nurse massaged it with diclofenac gel, including both legs and feet. RN B also gave PRN (as needed) oxycodone for pain management. RN B notified the PCP immediately and got an order to x-ray the right thigh and right hip. RN B entered the order and called and scheduled the x-ray before leaving for the day. When RN B returned to work, he/she was told the resident had an acute distal femur fracture. RN B thinks the way the resident fractured his/her femur was when he/she rolled off and his/her leg hit the floor. Meanwhile no one witnessed this, it could have been worse if RN B did not hold the resident and gently lower him/her to the floor. With the height of the bed the resident would have broken his/her hip as well. The way the resident was positioned and the bed it would be have been difficult to get the resident up with the Hoyer, so they used four persons with a big blanket to transfer. During an interview on 2/4/25 at 9:40 A.M., RN B said on 12/31/24 at approximately 6:15 A.M., he/she was passing morning medication and heard the resident screaming. RN B asked CNA A who was screaming and he/she said it was the resident. When RN B went into the resident's room, he/she saw the resident's lower body hanging off the left side of the bed with the resident's legs wrapped in the resident's blanket. The resident was hanging onto the grab rail with both arms and the resident's bed was positioned as high as it could go. The resident's legs were wrapped in blankets and he/she was yelling for help. RN B said he/she placed his/her arms around the resident's waist trying to support the resident and yelled out for help. Nobody arrived to assist RN B when he/she was yelling out for help. The resident then said he/she needed to sit down yelling, I can't take it, help me so RN B tried to grab a chair and could not reach the chair, so RN B gently lowered the resident to the floor while holding the resident in a bear hug. RN B left the room to get assistance from other staff. RN B said when the blankets were removed, the resident's legs were bent at the knees and turned to the resident's left side. RN B got assistance from other CNAs and they lifted the resident into bed with a blanket that was placed underneath him/her. RN B said the resident normally transfers with a Hoyer lift, but the way the resident was positioned they could not use the Hoyer lift and used the blanket instead. The resident complained of right thigh pain and rated the pain as a 9 out of 10 (0-3 mild pain, 4-6 moderate pain, 7-10 severe pain). RN B did not check ROM on the resident's legs due to the pain reported. RN B contacted the PCP and obtained an order for a stat (immediate) x-ray to right thigh and hip. RN B said he/she massaged the resident's right legs with diclofenac gel and gave the resident oxycodone for pain. RN B said he/she thought there was a fall mat on the right side of the resident's bed but there was no fall mat on the left side of the resident's bed at the time of the fall. RN B said when the resident's legs went over the edge of the bed and hit the floor from the high position, he/she believes that is when the resident fractured his/her legs. RN B said the resident's call light was not on when the resident was screaming for help, RN B said the resident normally uses his/her call light when he/she needs assistance, but sometimes the resident gets confused. RN B said the resident fell because he/she was trying to get out of bed to look for his/her family members. RN B said it is not the first time the resident had attempted to get out of bed to look for family. RN B said the resident attempted to get out of bed last year to look for his/her family, but staff redirected him/her before the resident fell . Observations on 2/3/25 at 8:50 A.M., 2/3/25 at 1:57 P.M., and 2/4/25 at 6:55 A.M., showed the resident lay in his/her bed in low position on a low air loss mattress. A fall mat was on the right side of the resident's bed, no fall mat was on the left side of the resident's bed. The resident's bed was not against the wall. During an interview on 2/4/25 at 11:54 A.M., agency RN C said nobody told him/her why the resident only had one mat. The physician order should be specific to one or two fall mats, and which side the fall mat goes on. There should be an order for a low bed. The resident is a high fall risk when he/she is in bed. The nurses on the floor can get the order from the doctor or therapy depending on what the interventions are. The nurse on the floor does not put interventions into the care plan. The nurse on the floor gets the order and puts the order in the computer. During an interview on 2/4/25 at 12:20 P.M., CNA D said fall interventions for the resident include to make sure his/her bed is as low as possible, fall mat in place, and rounds every two hours. Sometimes, the resident thinks he/she can walk. CNA D said the mat is on the left side. The right side is the side the resident turns to. That is the side when he/she feels that he/she can walk that he/she tries to get out of. CNA D said there should be one on each side. The bed has never been against the wall. Observation on 2/4/25 at 12:23 P.M., showed the resident lay in his/her bed in low position on a low air loss mattress. A fall mat was on the right side of the resident's bed. No fall mat was on the left side of the resident's bed. The resident's bed was not against the wall. During an interview on 2/4/25 at 12:52 P.M., the DON said she did not recall any specific fall interventions for the resident. The DON said she feels the resident is a high fall risk since the resident had his/her fall in December. Observation and interview on 2/4/25 at 1:29 P.M., showed the resident lay in bed. The bed was in a low position. There was a fall mat on the right side of the resident's bed and no fall mat on the left side of the bed. When the Assistant Administrator (AA) looked at the resident's room, she said there was only a fall mat on the right side of the resident's bed not a fall mat on the left side. The AA said there should be a fall mat on both sides of the bed. The AA was unsure why there was only one fall mat next to the resident's bed. If there is one fall mat, the resident's bed should be up against the wall. The AA said the resident fell off the left side of the bed where there was no fall mat. The AA verified the resident's bed was not against the wall as listed on his/her care plan. The AA expected interventions listed in the resident's care plan to be in place. The AA did not recall the resident's bed ever being against the wall. Without the fall interventions listed on the care plan in place, it puts the resident at risk for the same thing happening again; falling again and the possibility of the resident getting injured again. The concern she had was the fall mat not on being on the left side of the bed with the bed not being against the wall and the bed not being against the wall as care planned. The AA expected a fall intervention to be put in place after every fall. The CNAs find out what fall interventions are in place through the nurse. CNAs have a computer system, but the Internet connection is bad, so the CNAs need to get report from the nurses. 2. Review of Resident #3's admission MDS, dated [DATE], showed: -Moderate cognitive impairment; -Dependent with toileting, bathing, and lower body dressing; -Maximal assistance with bathing transfers; -Fall since admission or prior assessment, no; -Uses wheelchair for mobility; -Diagnoses included Parkinson's Disease (a progressive neurological disorder that affects movement, balance, and coordination), arthritis, dementia, unspecified fall and rhabdomyolysis (a rare muscle injury when the muscle tissue breaks down and releases damaging substances into the blood). Review of the resident's most recent Morse Fall Scale, dated 12/2/24, showed a score of 50, high risk for falls. Review of the resident's current care plan, showed: -Problem: Falls, the resident is at risk for falling due to decreased mobility, unsteady gait, unassisted attempts to stand/transfer/ambulate and poor safety awareness, edited 2/3/25; -Goal: Prevent manage possibility of falling, edited 12/4/25; -Approach: -Resident had a fall on 1/8/25, staff to ensure resident is up in a chair for all meals, created 1/10/25; -Resident had a fall on 12/12/24, staff to offer to sit in TV area or close to nurses station, edited 2/3/25; -Resident had a fall on 11/26/24, staff will encourage use of assistive device while walking in his/her room, edited 11/27/24; -Resident had a fall on 9/7/24, staff will provide frequent rounds, created 9/10/24; -Resident had a fall on 9/3/24, encourage to use call light to get things that are out of reach, created 9/4/24; -Follow facility protocol after any fall, created 6/1/24; -Keep call light in reach, encourage resident to use it and wait for staff when in need of assistance, created 6/1/24; -Keep resident in a supervised area as much as possible, created 6/1/24; -Monitor for decreased/loss of functional status, created 6/1/24; -PT/OT evaluate and treat as ordered and PRN, created 6/1/24; -Resident may utilize a low bed with fall mat and bed against the wall, created 6/1/24; -Resident may utilize a perimeter mattress (bolster mattress, mattress cover with built-in foam bolsters that create a raised rail around the bed's edges) to bed, created 6/1/24; -No intervention listed for fall on 1/31/25. Review of the resident's event history, dated 11/1/24 through 2/3/25, showed: -Date/Time: 11/26/24 at 4:07 A.M., Short Description: Post Fall assessment; -Date/Time: 12/12/24 at 12:47 P.M., Short Description: Fall no injuries; -Date/Time: 1/8/25 at 8:58 A.M., Short Description: Fall on floor in room rolled out of bed; -Date/Time: 1/31/25 at 2:30 A.M., Short Description: Fall. Review of the resident's post fall assessment, dated 11/26/24, showed: -Event date: 11/26/24 at 4:07 A.M.; -Description: Post fall assessment; -Location of fall: Resident room; -What was resident doing just prior to fall: Lying in bed; -Was the fall witnessed: No; -Describe exactly what happened: Resident stated he/she was walking around in room and his/her legs became weak; -Check all that apply: Walking; -List immediate interventions taken to promote resident's safety: Encourage assistive device use; -Was there an injury: Yes, describe below; -Describe injury and first aide, if provided: (this was not completed by facility staff); -Did the resident hit their head: Yes; -Obtain resident statement of activity prior to fall if able: Bilateral lower extremity weakness; -Behavioral characteristics that may have contributed to the fall: Does not use call light, poor safety awareness; -Describe the environment at the time of the fall: Call light in reach; -Pupils: Within normal limits; -Hand grips: Within normal limits; -Foot pushes: Within normal limits; -Were any new medications started within the last month: (this was not completed by facility staff); -Notifications: -PCP: 11/27/24 at 1:01 P.M.; -RR: 11/27/24 at 9:42 A.M.; -Care Plan reviewed: Yes, encouraged use of assistive devices even when walking in room; -Orders: -Chart every shift for 72 hours related to fall, order date 11/26/24 - 11/29/24; -Fall without head involvement: Complete paper neuro assessment form per policy per policy every shift and complete nurses note for 72 hours, order date 11/26/24 - 11/29/24; -Fall: With suspected head trauma - Neuro checks per policy on paper neuro assessment form, and complete nurses note every shift for 72 hours, order date 11/26/24 - 11/29/24; -Notes: 11/26/24 at 4:15 A.M., resident was observed on the right side of the bed facing the wall at 4:00 A.M. Resident stated that he/she was attempting to walk in his/her room when his/her legs gave out. [NAME] was not being used at time of fall. There is a bruise to the right cheek. Review of the resident's Neurological Assessment for falls without head involvement, dated 11/26/24, showed: -Unusual verbalization, statements, or behaviors, YES/NO, document specific verbalization in nurse's notes: -11/26/24, 7:00 P.M. - 7:00 A.M., (not completed by facility staff); -11/27/24, 7:00 P.M. - 7:00 A.M., (not completed by facility staff); -11/28/24, 7:00 A.M. - 7:00 P.M., (not completed by facility staff); -11/28/24, 7:00 P.M. - 7:00 A.M., (not completed by facility staff). Review of the resident's post fall assessment, dated 12/12/24, showed: -Event date: 12/12/24 at 12:47 P.M.; -Description: Fall no injuries; -Location of fall: Resident room; -What was resident doing just prior to fall: Sitting in wheelchair; -Was the fall witnessed: Yes; -Describe exactly what happened: Maintenance personnel was walking by residents room and informed this nurse that resident was falling. Maintenance personnel was able to catch resident before he hit the floor; -Check all that apply: Other: Unsteady gait, walking; -List immediate interventions taken to promote resident's safety: Close observation: Monitor every hour for needs; -Was there an injury: No injury; -Did the resident hit their head: No; -Obtain resident statement of activity prior to fall if able: (not completed by facility staff); -Behavioral characteristics that may have contributed to the fall: History of falls, does not use call light, refuses to ask for assistance; -Describe the environment at the time of the fall: Call light in reach, lights on in room, bed at lowest height, shoes and socks on, bed/wheelchair locks on; -Pupils: Within normal limits; -Hand grips: Within normal limits; -Foot pushes: Within normal limits; -Were any new medications started within the last month: No; -Notifications: -PCP: 12/12/24 at 12:47 P.M.; -RR: 12/13/24 at 12:29 P.M.; -Care Plan reviewed: Yes, staff to offer to sit in TV area or close to nurses station; -Orders: -Fall without head involvement: Complete paper neuro assessment form per policy per policy every shift and complete nurses note for 72 hours, order date 12/12/24 - 12/15/24; -Vitals every shift for 72 hours: Special instructions: Add to Point of Care (POC) for CNA vital task, order date 12/12/24 - 12/15/24; -Notes: 12/12/24 at 12:55 P.M., Maintenance personnel was walking by residents room and informed this nurse that resident was falling. Maintenance personnel was able to catch resident before the resident hit the floor. No visible injuries were noted, skin intact, vital signs within normal limits. PCP and RR notified; -Evaluation notes: Resident was walking around in room and his/her legs became weak. Care plan: use assistive device while in room; -Falls prevention program initiated: Yes; -Injury is res

Based on interview and record review, the facility failed to provide activities of daily living (ADL) care assistance for a dependent resident (Resident #1), during the evening shift on 12/3/24 and the overnight shift from 12/3/24 to 12/4/24. The sample was five. The census was 172. The Administrator was notified on 12/26/24, of the past non-compliance. The facility disciplined various staff members who failed to provide ADL care to the resident. The facility in-serviced current employees on the topics of rounding on residents, customer service, abuse and neglect, and grooming. The deficiency was corrected on 12/11/24. Review of Resident #1's Medical Record showed: -Diagnoses included Alzheimer's disease, diabetes and major depressive disorder; -Cognitively intact; -Resident required two staff members assistance with ADLs. Review of the resident's care plan, in use at the time of the investigation, showed: -Problem: The resident refuses to shower at times; -Goal: The resident will allow staff to assist him/her with showers until next review; -Approach: Reattempt to ask at a later time; -Problem: Resident is dependent with ADL care; -Goal: Resident will be well groomed and increase/be stable with current ADL status; -Approach: Assist with toileting needs per request, routine, and as needed. Give verbal cues for bathing, dressing, grooming. Use gentle, firm approach. Resident is noted to refuse showers. Resident educated on need for personal hygiene daily, staff will re-attempt offer of shower. Review of the resident's shower sheets, showed: -On 11/29/24, Certified Nursing Assistant (CNA) C documented that the resident refused a shower or bath; -On 12/3/24, CNA C documented that the resident refused a shower or bath. Review of the resident's progress notes, showed: -No progress notes showed staff re-attempted to provide the resident a shower between 11/29/24 and 12/3/24; -A note, dated 12/3/24 at 10:45 A.M., written by Licensed Practical Nurse (LPN) G, showed CNA C was working with this resident and came to this nurse and said the resident was full of fecal material, and his/her clothes were soiled. The resident needed to be cleaned up but would not allow CNA C and a fell ow CNA to assist to clean the resident. This nurse stepped into the room with the resident and observed him/her and a foul odor. The resident's bed was covered in fecal material. This nurse explained to the resident that staff could not leave him/her unclean with fecal material on him/her. The resident was persistent about refusing care and began to pull at his/her bed clothes and his/her brief, getting his/her hand into the fecal material. While speaking with the resident, CNA C explained that it was the resident's shower day, and that he/she has already said no to being taken to the shower. This nurse asked if he/she and the other two CNAs could give the resident a bed bath. At this time, the resident refused, but this nurse persuaded the resident to be cleaned up. He/She was given a bed bath by CNA C and a fell ow CNA with help from this nurse. This nurse spoke with the Nurse Practitioner (NP) about resident's body odor due to consistent refusal of showers. The NP went to the resident's room to speak with him/her, returned to this nurse and stated that the resident said he/she will take a shower when asked next time. Around the end of CNA C's shift, he/she returned to ask for assistance to clean this resident again. This nurse went in and spoke to resident and let him/her know that he/she has to be checked, dried and cleaned before CNA C could hand off report to the next shift. The resident, at that time, agreed to be cleaned up once more with the help of this nurse; -A note, dated 12/4/24 at 8:04 A.M., written by Registered Nurse (RN) F, said the resident was in his/her room, noted to be tachypneic (fast breathing) with labored breathing, not answering questions appropriately, Respiratory Rate (RR): 38 breaths per minute (normal 10-22), Heart Rate (HR) 133 beats per minute (normal 60-100), Oxygen Level (O2): 70 (normal 95-100), Temperature (T): 99.9 degrees Fahrenheit (F) (normal 98.6 F). A call was placed to (Emergency Medical Services) EMS; Emergency Contact (EC) was contacted and requested for the resident be taken to the emergency department for evaluation. EMS arrived and the resident was transferred to hospital. Review on 12/26/24, of CNA C's written statement, dated 12/4/24, showed: -On 12/3/24, he/she attempted to get the resident up for breakfast twice. By the third attempt, he/she informed LPN G that something may be wrong. That morning, on 12/4/24 around 7:00 A.M., CNA C did rounds on the residents on his/her own. He/She noticed the resident's door was closed. He/She opened it and noticed the resident appeared to be in the same condition as 12/3/24. He/She informed the night nurse, LPN B, who then stated he/she was not told anything was wrong. He/She proceeded back to check on the resident with another aide. He/She then noticed the resident had a pill laying on his/her shirt, so he/she informed LPN B and RN F who went to check on the resident. From there, the resident was sent out to the hospital; -Review of the Assistant Director of Nursing (ADON's) summary of an interview with CNA C on 12/5/24, showed CNA C said the resident had the same clothing on from 12/3/24. CNA C said he/she did not provide any care to the resident on 12/4/24. He/She said the last time he/she had given the resident a shower was on Thanksgiving. He/She said before a resident is sent out to the hospital, the resident should be taken to the bathroom and changed. CNA C said he/she had reported to the nurse that the resident was refusing ADL care. Review on 12/26/24, of the ADON's summary of an interview with CNA D, dated 12/4/24 showed: -CNA D said on 12/3/24, he/she worked the evening shift. The resident was in his/her bed for the duration of his/her shift. The resident refused to allow CNA D to change his/her brief and clothing. CNA D did not inform the nurse of the resident's refusal of care. Review on 12/26/24, of CNA E's written statement dated 12/5/24, showed: -CNA E said on 12/3/24, he/she took care of the resident from 10:45 P.M. to 7:15 A.M CNA E laid eyes on the resident around 11:20 P.M. and said the resident was awake in bed watching the television. CNA E returned to the resident's room around 12:40 A.M. with fresh water and the resident was still awake. The next round was around 2:00 A.M., and the resident was sleeping. CNA E emptied the resident's urinal at this time. The next round was at 4:30 A.M., and he/she observed the resident in bed with his/her urinal between his/her legs, under the covers. He/She left the resident's room and continued his/her rounds. He/She returned to the resident's room around 5:40 A.M. and emptied the resident's urinal; -Review of the ADON's summary of an interview on 12/5/24 with CNA E, showed CNA E was unable to say what clothing the resident was wearing on 12/4/24 as the resident was covered with a blanket. CNA E said when he/she did rounds on the resident, he/she should have pulled back the resident's blanket to make sure his/her clothes were not soiled. Review on 12/26/24, of LPN B's written statement dated 12/5/24, showed: -On 12/4/24 at 7: 30 A.M., he/she was finishing his/her work when the day shift aide, CNA C, approached the nurse's station and said the resident did not look good and that he/she needed to be checked on. The two nurses, RN F and LPN A, who were relieving his/her station, went to evaluate the resident and decided to send him/her out to the emergency room (ER). He/She made copies of the resident's Continuity of Care document, face sheet, and code status. He/She called 911 and notified the resident's family member of his/her condition and that he/she was being taken to the ER for evaluation and treatment; -Review of the ADON's summary of an interview on 12/5/24 with LPN B, showed LPN B popped by the resident's room to check on him/her during the night shift (12/3/24 to 12/4/24)but didn't want to wake the resident up. LPN B said no reports were made to him/her of the resident refusing care. Review on 12/26/24, of RN F's written statement, dated 12/5/24, showed: -On 12/4/24, upon arriving on shift, he/she got report from the day nurse and started making rounds. He/She overheard CNA C talking about a change in condition of the resident. Upon assessment, He/She noticed the resident had labored breathing and was breathing fast. He/She grabbed vitals. EMS arrived, he/she gave report, and then the resident was transported to the hospital. Review on 12/26/24, of LPN A's written statement, dated 12/4/24, showed: -CNA C asked me to come to the resident's room and said the resident does not look well. The resident's breathing was labored, eyes looked glassy, weak. LPN A called the second nurse, RN F, to the resident's room. Both nurses took vitals and assessed the resident while LPN B called 911, called the resident's family, and printed out paperwork. During an interview on 12/26/24 at 10:51 A.M., LPN A said he/she was working when the resident was sent to the hospital on 12/4/24. He/She said he/she was assigned to another hallway but went to assist the resident's nurse when it was decided that the resident was going to be sent out to the hospital. He/She said he/she did notice the resident appeared dirty and had fecal material on him/her. He/She did know the resident had not received a shower or ADL care before he/she was sent out to the hospital. During an interview on 12/26/24 at 1:03 P.M., the ADON said she along with the Administrator were informed that the facility was going to be hotlined to the Department of Heath and Senior Services (DHSS). She said a facility investigation was started on 12/4/24 into the resident's ADL care. She found multiple issues with staff not reporting the resident's refusal of care. She said the resident was not provided proper ADL care on 12/3/24 on day shift and evening shift and the overnight shift from 12/3/24 to 12/4/24. During an interview on 12/26/24 at 1:23 P.M., the Administrator and ADON said they would expect for staff to provide appropriate ADL care for residents and would expect any refusal of care to be reported and documented. MO00246140

Based on observation, interview and record review, the facility failed to ensure the residents' environment remained free of accident hazards by keeping an un-secured plastic container filled with insulin (used to control high blood sugar) pens (a small lightweight pen that is prefilled with insulin to inject under a person's skin) of 13 residents (Residents #2, #4, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15 and #16) on un-attended, unsupervised treatment/medication carts. The facility also had an open plastic tray with auto shield duo pen needles (needles used to inject insulin from the insulin pen) and lancets (a small device with a needle used to prick the surface of the skin to obtain a blood sample) with a sharps container (used to discard used lancets and auto shield duo pen needles) which had an unsecured plastic lid on top of the un-attended, un-supervised treatment/medication carts. The sample size was 16. The census was 95. Review of the facility's Storage of Drugs policy, undated, showed: -Compartments and areas containing drugs are locked when not in use or when left unattended. Such areas include drawers, cabinets, rooms, refrigerators, carts and boxes. 1. Observation on 7/19/24, at 12:20 P.M., showed an un-attended, unsupervised treatment cart, labeled #2, on the 300 hall, with a red, plastic box with four rows of individual drawers which contained insulin pens; -The first row had one drawer labeled with Resident #7's name containing a Humalog (short acting insulin) pen and a Lantus (long acting insulin) pen; a separate drawer labeled with Resident #7's name which contained a Novolog (fast acting insulin) pen; a separate drawer labeled with Resident #8's name which contained a Lantus pen and a Lispro (fast acting insulin) pen, a separate drawer labeled with Resident #9's name containing two Fiasp (fast acting insulin) pens; a separate drawer labeled with Resident #2's name containing a Humalog pen and a Lantus pen; a separate drawer labeled with Resident #10's name containing a Lispro pen and a Lantus pen; -The second row had one drawer labeled with Resident #11's name containing one Soliqua (a long-acting insulin) and a Lispro pen; a separate drawer labeled with Resident #12's name containing one Lantus pen and a Humalog pen; -The third row had one drawer labeled with Resident #13's name containing one Lispro pen; a separate drawer labeled with Resident #14's name containing one Aspart (a fast-acting insulin) pen; a separate drawer labeled with Resident #15's name containing two Basaglar (a long-acting insulin) pens and one Humalog pen; a separate drawer labeled with Resident #4's name containing one Basaglar pen and a Lispro pen; a separate drawer labeled with Resident #16's name containing on Novolog pen; -The fourth row had separate drawers containing lancets and auto shield duo needles; -Each drawer was un-secured and pulled out of the red plastic box. They each were covered with a plastic cover which was also unsecured and easily opened; -There was also a plastic basket, that did not have a cover, sitting on top of the treatment cart, filled with lancets and auto shield duo needles; -A small sharps container, half filled with used lancets and duo needles, had an un-secured plastic lid that had a small round opening with an attached round lid. The round lid was not attached to the plastic lid and the opening was large enough for a small hand to reach in and take out the used, dirty sharps or shake dirty, used sharps out of the container. The plastic lid covering the top of the small sharps container was also easily removed completely off of the sharps container to gain access to the dirty, used sharps. The small sharps container was mobile and not secured to the cart in any way; -The large sharps container was not secured to the medication cart. There were residents walking around the area of the un-attended, un-supervised medication cart during the time of observation. During an interview on 7/19/24 at 12:28 P.M., the Wound Nurse confirmed the observation of the treatment cart, labeled #2, located in 300 hall, of the un-secured, un-attended red plastic box with rows of drawers labeled with residents' names and containing insulin pens, lancets and auto shield duo needles left on top of the cart. She also confirmed the observation of the small plastic tray which contained lancets and auto shield duo needles and the small sharp container which had an unsecured plastic lid with the hole on top of the lid also uncovered. The Wound Nurse confirmed the small sharps container was not secured to the treatment cart. The Wound Nurse said residents and/or visitors could easily taken any of the insulin pens, lancets or auto shield duo needles and inject insulin into themselves which could cause great bodily harm. She also said residents and/or visitors could easily get their hands into the sharps box or take the sharps box off of the cart. There was potential for a resident and/or visitor to prick themselves with the used, dirty sharps and infect themselves with whatever dried blood was on the sharps. The insulin pens and supplies should be locked up for safety. 2. Observation on 7/19/24 at 1:49 P.M., showed the same red plastic container with drawers labeled with residents' names and containing insulin pens, lancets and auto shield duo needles was left on top of a nurses medication cart located in the 300 hall, un-supervised and unattended. There was also the same yellow plastic tray containing lancets and auto-shield duo needles left on top of the red plastic box, There was a large sharps container that was slightly filled with dirty, used sharps. The lid was secure and attached to the top of the sharps container. The large sharps container was not secured to the medication cart. There were residents walking around the area of the un-attended, un-supervised medication cart during the time of observation. 3. Observation on 7/23/24 at 10:24 A.M., showed showed an un-attended, unsupervised medication cart, on the 300 hall, with a red, plastic box with four rows of individual drawers which contained insulin pens; -The first row had one drawer labeled with Resident #7's name containing a Humalog pen and a Lantus pen; a separate drawer labeled with Resident #7's name which contained a Novolog pen; a separate drawer labeled with Resident #8's name which contained a Lantus pen and a Lispro pen, a separate drawer labeled with Resident #9's name containing two Fiasp pens; a separate drawer labeled with Resident #2's name containing a Humalog pen and a Lantus pen; a separate drawer labeled with Resident #10's name containing a Lispro pen and a Lantus pen; -The second row had one drawer labeled with Resident #11's name containing one Soliqua and a Lispro pen; a separate drawer labeled with Resident #12's name containing one Lantus pen and a Humalog pen; -The third row had one drawer labeled with Resident #13's name containing one Lispro pen; a separate drawer labeled with Resident #14's name containing one Aspart pen; a separate drawer labeled with Resident #15's name containing two Basaglar pens and one Humalog pen; a separate drawer labeled with Resident #4's name containing one Basaglar pen and a Lispro pen; a separate drawer labeled with Resident #16's name containing on Novolog pen; -The fourth row had separate drawers containing lancets and auto shield duo needles; -Each drawer was un-secured and pulled out of the red plastic box. They each were covered with a plastic cover which was also unsecured and easily opened; -There was also a plastic basket, that did not have a cover, sitting on top of the treatment cart filled with lancets and auto shield duo needles; -There was a large sharps container that was slightly filled with dirty, used sharps. The lid was secure and attached to the top of the sharps container. The large sharps container was not secured to the medication cart; -There were residents walking around the area of the un-attended, un-supervised medication cart during the ten minutes of observation. 4. During an interview on 7/26/24 at 11:26 A.M., the Administrator, Director of Nursing (DON) and Assistant Director of Nursing (ADON), said: -They expected insulin pens be stored inside of a locked medication cart when not in use, as they were a medication and needed protection from direct sunlight; -There was a risk of residents and/or visitors to take un-attended, unsupervised insulin if they were left on top on a medication/treatment cart instead of locked inside of a medication/treatment cart; -It was not appropriate or safe to keep unsecured used sharp containers (in which the lid was not locked on, a hand could fit into it to retrieve used sharps, and used sharps could get poured out of the container) on top of an unattended medication cart because anyone could have access to the used sharp and get stuck by the dirty, used sharps. The residents and/or visitors were at risk of infection; - It was not safe or appropriate to keep lancets and duo needles unsecured and unattended on a medication cart as it posed a risk to residents' safety, they could take and then use the lancets and needles on themselves; -Residents were at risk of harm if insulin pens and auto shield duo needles were left un-attended, as they could inject the insulin into themselves which could cause them harm. 5. During an interview on 7/26/24 at 3:32 P.M., the Administrator said she expected staff to have knowledge of and follow the facility policies.

Based on observation, interview and record review, the facility failed to prevent further potential abuse, neglect or mistreatment by not investigating an injury of unknown origin for one of three sampled residents (Resident #1). The census was 95. Review of the facility's Injury of Unknown Source - Investigative Protocol policy, undated, showed: -Purpose: The following indicators of abuse/neglect are provided to help determine if abuse/neglect should be suspected. Staff are mandated to report suspected abuse; -Indicators of physical abuse may include injuries of an unknown source; -The attached worksheet and directions are offered to assist facilities in their internal investigation. If a logical/reasonable explanation of the source of the injury cannot be determined, notify your local state agency within 2 hours of discovery. Review of the facility's when to initiate an investigation document, undated, showed: -Contact Administrator and Nursing Administration immediately for the following events included for injury, actual or suspected. Examples included bruise of unknown origin/suspicious bruising or skin tear. Review of the facility's Abuse and Neglect Policy, revised January 2019, showed: -Providing a safe environment for the resident is one of the most basic and essential duties of the facility; -Injuries of unknown source: An injury should be classified as an injury of unknown source when both the source of the injury was not observed by any person or the source of injury could bot be explained by the resident and the injury is suspicious because of the extent or severity or the location of the injury (the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time; -The Administrator or designee will be responsible to ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property are reported immediately, not later than two hours after the allegation is made, to other officials in accordance with state law including to the state survey and certification agency; -Procedure for investigation: -Administrator or designee on duty will assess the resident (including the size, location, etc. of any injury), and assure proper documentation of the date, time, and location of the reported or suspected incident; -The supervisor will do everything possible to protect the resident's welfare and safety from harm during the investigations; -An incident report will be completed; -The physician and family will be notified as soon as possible; -The Administrator or Director of Nursing is responsible to notify their Regional Nursing Supervisor to report alleged violation of the resident safety policy to assure prompt investigation and corrective action are in place; -Any employee suspected of violation of these resident safety policies, may be suspended pending investigation; -If a family member or other visitor is suspected of violation of these policies, they may not be allowed to visit the resident or in any other way have access to the facility pending the investigation; -The Administrator or designee and/or supervisor on duty will interview the resident as well as any nursing, housekeeping, laundry, dietary, activity, social service staff, any visitors, volunteers or others who may have knowledge of the occurrence or who may have been in the vicinity at the time of the incident. The Administrator or designee on duty will prepare a written summary of each interview; -Summaries of these investigations will be reviewed during quality assurance and assessment committee meetings for re-evaluation of policies and procedures, if warranted to prevent further occurrences. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/6/24, showed: -Sometimes able to make self-understood; -Sometimes able to understand others; -Required max assistance for upper and lower body dressing, putting on/off footwear, showering, and transferring from chair/bed-to-chair; -Diagnoses included non-traumatic brain dysfunction, chronic kidney disease, Alzheimer's disease, epilepsy (seizure disorder) and chronic obstructive pulmonary disease (COPD, lung disease); -No open lesions, or skin tears noted. Review of the resident's progress notes, showed: -On 6/10/24, at 6:23 P.M., the resident slide out of his/her chair and sat on the floor. No injury or pain was noted. The resident was assisted back up with assistance with two staff members. The Medical Director (MD) and resident's responsible party (RP) were notified. Review of the facility's event summary report, dated 4/22/24 through 7/23/24, showed: -On 6/10/24, at 6:18 P.M., a post fall assessment was completed due to the resident sliding out of his/her chair and sat on the floor; -There was no injury or pain noted; -The care plan was not reviewed; -The evaluation was to ensure assistance in and out of recliner; -The event was closed on 6/14/24. Review of the resident's progress notes, showed: -On 6/18/24, at 9:55 P.M., the resident was noted with a dime size skin tear to his/her left inner arm. No pain or drainage was noted. The area was cleansed and covered with a dry dressing. The MD and the RP were notified. Review of the resident's event report, dated 6/18/24, at 9:51 P.M., showed: -Event details: A dime sized skin tear/laceration was located on the resident's left inner arm, with irregular wound edges with out any pain reported from the resident; -Activity during skin tear/laceration occurrence: Post fall; -MD and RP were notified; -Orders included: Apply non-adhering dressing, cover with foam dressing, change every three days; Skin tear: Apply antibiotic ointment, cover with dressing if needed to minor cuts or skin tears. Review of the facility's wound report, dated 4/01/24 through 7/23/24, showed: -There was no wound documentation found on the resident. Review of the facility's event summary report, dated 4/22/24 through 7/23/24, showed: -There was no documentation of a fall between 6/10/24 and 6/18/24; -There was no documentation of the injury of unknown origin, the skin tear found on 6/18/24, located on the resident's left inner arm. Review of the resident's Medication Administration Record (MAR), dated June 2024, showed: -An order dated 8/18/23, for a weekly skin assessment, once a day on Wednesdays. Documentation showed an assessment was completed on 6/26/24, noting the resident had impaired skin, a skin tear on the left elbow; -An order, dated 6/28/24 and discontinued on 6/28/24, for a skin tear; monitor for signs and symptoms of infection on each shift. Documentation showed the facility did not administer per order on the night shift on 6/26/24, due to no area.; -An order, dated 6/18/24 and discontinued on 6/28/24, for a skin tear, to apply antibiotic ointment, cover with dressing if needed, change day; Documentation showed the treatment was not administered on 6/27/24 due to healed. Review of the resident's MAR, dated July 2024, showed: -An order, dated 6/18/24, discontinued on 7/6/24, to apply non-adhering dressing, cover with foam dressing, change every three days was administered as ordered. Review of the resident's care plan, dated 7/17/24, showed: -Problem: The resident was at risk for falls; Interventions included: on 6/10/24, the resident had a fall. Ensure assistance in and out of recliner; -Problem: The resident requires maximum assistance with activities of daily living (ADLs); Interventions included monitor skin for redness and breakdown during ADL care and bathing. Report changes to nurse and MD. During an interview on 7/23/24, at 1:39 P.M., the Assistant Administrator said: -Nurses were expected to complete weekly skin assessments and document completion on the residents' MAR; -Nurses were expected to document any new skin issues in the residents' wound management detail. During an interview on 7/23/24, at 2:35 P.M., LPN D, said: -He/She was assigned to the resident's care; -He/She was not aware the resident had any wounds; -He/She would report any abuse, suspected or witnessed, including physical, verbal, mental, sexual or theft, to the Administrator, the Director of Nursing (DON), or Assistant Director of Nursing (ADON) so they could investigate the incident for the residents' safety; -He/She expected the facility to investigate any injury of unknown origin to ensure the cause was not due to abuse. Observation on 7/24/24, at 11:19 A.M., showed the Wound Nurse evaluated the resident's skin. The resident had a healed wound to his/her upper left arm. During an interview on 7/24/24 at 11:25 A.M., the Wound Nurse said: -She was not aware the resident had a healed skin tear located on his/her left inner arm and did not know there was a treatment order for the skin tear; -She expected the nurses who initially found the wounds to document the wounds in the wound management document so she could see them when she looked at residents' wound management detail report; -She would have followed up on the skin tear to ensure the appropriate treatments were ordered and the MD and RP were notified. During an interview on 7/24/24, at 10:45 A.M., the Assistant Administrator said the facility's event summary report would include injuries of unknown origin. During an interview on 7/26/24, at 11:26 A.M., the Administrator, Director of Nursing (DON) and Assistant Director of Nursing (ADON), said: -They expected nurses, after finding a new skin issue, to assess the wound and document their finding in the resident's wound management document, call the MD, get new orders if appropriate, and tell the Wound Nurse; -The nurses were not required to document new skin issues in progress notes; -The Wound Nurse was made aware of any new skin issues by nurses reporting the new wounds to her verbally or by reading residents' progress notes; -The DON and Night Supervisor also looked at daily notes to see if any new skin issues were noted and they would inform the Wound Nurse of their findings; -They expected the Wound Nurse to assess the residents' new skin issue, make sure there was an appropriate wound order and see if the outside wound management team needed to get involved. They also expected the Wound Nurse to put findings in a progress note and in wound management if not already there; -They expected the Wound Nurse to know if a resident had a treatment order for a wound; -They expected nurses to notify the Wound Nurse when they put in a treatment order for a new wound; -They expected nurses to create an unknown injury event, notify the MD, the Wound Nurse and RP of the injury, and document their assessment, what they did and how they followed up when they find an injury of unknown origin; -They expected staff to report any injury of unknown origin to their supervisors, so they could investigate how if might have occurred by talking to the staff, the resident and family members, do a root cause analysis, and put in proper interventions to try to keep it from happening again after reviewing the resident's care plan; -They would document the conclusion of the investigation in a miscellaneous event report and would notify the RP of their findings of the investigation; -They monitored for potential or actual reported allegations of abuse or neglect by depending on residents, family and especially staff to report any potential allegations of neglect; -Staff had not reported any concerns about the manner in which care was provided to the resident; -They were not aware of the resident's skin tear, found by staff on 6/18/24, located at his/her left upper arm; -They could not determine how the skin tear occurred or when as there were no notes in the resident's electronic medical record (EMR) so it was considered an injury of unknown origin; -There were no investigations found on the resident's skin tear located at his/her left upper arm, an injury of unknown origin; -When an injury of unknown origin was not reported to the administrative team, it put the resident at risk of infection and pain if the injury was left untreated; -The facility investigated all injuries of unknown origin to protect residents from possible abuse or neglect. During an interview on 7/26/24 at 3:32 P.M., the Administrator said: -The delivery of care at the bedside by the CNAs was monitored by the nurses on the floor. The care the nurses gave to residents was monitored by the nurse supervisors (Nurse Managers, ADON and DON); -She expected nursing staff to have knowledge of and follow facility policies. MO0023922

Based on observation, interview and record review, staff failed to demonstrate proper use of hand hygiene and proper infection control during wound care for two of three sampled residents (Residents #2 and #4). The census was 95. Review of the facility's Infection Control Policy, dated 12/2016, showed: -Purpose: The community has established and maintains an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections; -Develop prevention, surveillance, and control measures to protect residents and personnel from healthcare-associated infections; -Develop specific policies and procedures governing such activities as surveillance, standard and transmission based precautions, hand hygiene procedures to be followed by staff involved in direct resident contact, aseptic technique, outbreak investigation, wound care, catheter care, etc. to be followed to prevent the spread of infections; -Ensure compliance with state and federal regulations related to infection prevention and control. Review of the facility's check list for clean dressing change, undated, showed: -Purpose: To prevent/minimize the transmission of microorganisms in a wound; -Gather equipment; -Prepare a clean surface with equipment onto it; -Wash hands and apply gloves; -Remove soiled dressing and dispose in plastic bag; -Remove gloves and wash hands; -Apply clean gloves; -Clean wound with wound cleanser or prescribed cleanser; -Remove gloves and wash hands; -Apply clean gloves; -Apply ordered treatment to the wound. Cover with secondary dressing if ordered; -Secure with tape. Apply the tape with initials and date on the dressing; -Remove gloves and wash hands; -Apply clean gloves; -Position the resident for comfort with bed in lowest position and call light within reach; -Discard gloves and used supplies in trash bag; -Wash hands. 1. Review of Resident #2's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/2/24, showed: -Cognitively intact; -Impairment on one side of upper extremity; -Impairment on both sides of lower extremity; -Dependent on staff for toileting, upper and lower body dressing, bathing, personal hygiene, rolling left to right and transfers; -At risk for pressure ulcers (localized are of tissue damage or necrosis (dead tissue) caused pressure over a bony prominence); -One Stage IV pressure ulcer (Full thickness tissue loss (damage extends below all areas of the skin into the subcutaneous tissue or beyond with possible areas of slough (non-viable yellow, tan, gray, green or brown tissue) and/or necrosis) with exposed bone, tendon or muscle) that was present upon admission or re-entry; -Diagnoses included non-traumatic brain dysfunction, diabetes mellitus, Alzheimer's disease, dementia, acquired absence of left leg below knee and right below the knee. Review of the resident's Physician Order Sheet (POS), showed: -An order dated 7/3/24, discontinued on 7/17/24, to cleanse the resident's right buttock with soap and water pat dry and apply Triad (zinc oxide based wound paste for wound healing), twice a day; -An order dated 7/3/24 , discontinued on 7/17/24, to cleanse the resident's sacrum (triangular bone at the base of the spine) and left buttocks with soap and water, pat dry, apply collagen to open wound beds, cover with calcium alginate and a foam dressing daily and as needed. Review of the resident's outside wound management report, dated 7/16/24, showed: -Wound/Ulcer #1: A Stage IV pressure ulcer located at the resident's sacrum, with scattered open scratches to right and left buttocks. Treatment plan: Cleanse with foam cleanser and water, pat dry, apply sacral hydrocolloid (moisture-retentive dressing) dressing, change twice a week and as needed; -Wound/Ulcer #6: Self Induced scratches on left and right buttocks. Treatment plan: Cleanse with foam cleanser and water, pat dry, apply sacral hydrocolloid (moisture-retentive dressing) dressing, change twice a week and as needed Review of the resident's POS, showed: -An order dated 7/17/24, to cleanse buttocks with cleansing foam, wipe clean with a wet towel, apply two hydrocolloid sacral dressing twice a week on Tuesdays and Saturdays and as needed. Review of the resident's Medication Administration Record (MAR), dated 7/11/24 through 7/24/24, printed for staff to use while electronic medical record system was down, showed: -There were no orders found for the resident's Stage IV pressure ulcer wound located at his/her sacrum; -There were no orders found for the resident's scratches located at his/her left and right buttocks. Observation on 7/19/24 at 10:37 A.M., showed Licensed Practical Nurse (LPN) A performed wound care on the resident: -LPN A sanitized his/hands, donned gloves, pumped wound cleanser on a clean gauze pad and cleansed the resident's wound located on his/her sacrum; -LPN A threw the dirty gauze pad away, and without changing his/her dirty gloves, picked up a clean gauze pad and cleansed the wounds located on the resident's right buttock; -LPN A threw the dirty gauze pad away, and without changing his/her dirty gloves picked up a clean gauze pad and cleansed the wounds located on the resident's left buttock; -LPN A threw away the dirty gauze pad, and without changing his/her dirty gloves, opened a packet of skin prep and applied it to the resident's peri wound (area surrounding the wound) of his/her sacrum; -LPN A threw the dirty skin prep pad away, and without changing his/her dirty gloves, opened a new packet of skin prep and applied to the peri wound of the resident's right buttock; -LPN A threw the dirty skin prep pad away, and without changing his/her dirty gloves, opened a new packet of skin prep and applied to the peri wound of the resident's left buttock; -LPN A threw the dirty skin prep pad away, and without changing his/her gloves, opened a package containing a foam dressing and applied it to the wound on the resident's sacrum; -LPN A then doffed his/her dirty gloves, sanitized his/her hands, donned new clean gloves, picked up a tube of Triad cream, squirted some on a gauze pad and used the gauze pad to apply the ointment using an up and down, round and round motion, to the wounds located on the resident's right and left lower buttocks and the resident's perineum (area between the anus and genitals); -LPN A failed to treat each wound separately, using the same gauze pad to treat multiple wounds. -LPN A failed to sanitize his/her hands and don new, clean gloves between each task. During an interview on 7/19/24 at 12:45 P.M., LPN A said: -There were no orders for the resident's wounds on the printed MAR given to him/her to use while the facility's EMR was down; -The Wound Nurse told him/her what type of treatment to use on the resident's wounds; -He/She should have changed his/her gloves and sanitized his/her hands between each dirty to clean task for infection control; -He/She should have treated each wound separately for infection control; -He/She put the resident at risk of infection, cross contamination and delayed wound healing by failing to follow infection control measures. 2. Review of Resident #4's quarterly MDS, dated [DATE], showed: -admitted on [DATE]; -Cognitively intact; -Impairment on both sides of lower extremity; -Required maximal assistance from staff for toileting, bathing, lower body dressing, putting on and off footwear and transfers, -Required moderate assistance from staff to roll left to right, sit to lying and lying to sitting on side of bed; -At risk for pressure ulcers; -No unhealed pressure ulcers; -Diabetic foot ulcer present; -Diagnoses included heart failure, peripheral vascular disease (PVD, poor circulation), chronic kidney disease, diabetes mellitus and malnutrition. Review of the resident's POS, showed an order dated 7/9/24, to cleanse the back of the resident's left foot with wound cleanser, apply Iodosorb gel (treats wet ulcers and wounds) and collagen powder (helps maintain a moist wound environment for healing), cover with heel foam. Change daily and as needed. Review of the resident's outside wound management wound report, dated 7/16/24, showed: -Wound /Ulcer #1: Arterial ulcer (ulcer due to inadequate blood supply to the area) full thickness with bone exposed; Treatment plan: Cleanse with wound cleanser, apply Iodosorb and collagen, gauze, cover with adhesive heel foam, change daily and as needed. Observation on 7/19/24 at 11:08 A.M., showed LPN B performed wound care on the resident's wound located on his/her left heel: -LPN B removed wound solution, a plastic baggy containing gauze pads, a packet of Iodosorb gel, a packet of collagen pellets and a packet containing a foam dressing from his/her treatment cart and placed them on top of the cart; -LPN B failed to sanitize the top of the cart with visibly dirty and dried, unidentifiable substances before placing the resident's wound treatment supplies on top; -LPN B gathered the wound supplies, entered the resident's room and placed wound supplies on top of the resident's bare mattress, visibly dirty with debris and dried unidentifiable substances; -LPN B failed to put the wound supplies on a clean, sanitized surface and/or a barrier cloth; -LPN B sanitized his/her hands and donned gloves; -LPN B twisted the cap off of the Iodosorb tube, held it in his/her left hand and pressed his/her gloved second finger on his/her right hand to the top of the tube, and squirted the gel onto his/her gloved finger, then applied the gel to the perimeter of the resident's pressure ulcer on his/her left heel; -LPN B then took his/her dirty gloved second finger, located on his/her right hand, touched the top of the Iodosorb tube and squeezed more gel from the tube onto his/her dirty gloved second finger, then used that same dirty, gloved finger and applied the gel into the resident's wound base; -LPN B then took the Iodosorb tube, placed it centimeters away from the resident's open wound and squirted more gel into the wound base; -LPN B twisted the cap back on the Iodosorb tube and placed the tube back onto the resident's dirty mattress; -LPN B doffed his/her gloves, failed to sanitize his/her hands and donned new gloves; -LPN B opened the packet of collagen pellets, poured them onto a gauze pad and then pressed the gauze pad into the resident's wound; -LPN B used one hand to hold the gauze, pressed into the wound base, and took the foam dressing from its packet and adhered it to the resident's left heel, covering the gauze pad and wound; -LPN B doffed his/her gloves, failed to sanitize his/her hands, gathered up the wound supplies from the resident's dirty mattress and put them back into the treatment cart; -LPN B then sanitized his/her hands. During an interview on 7/19/24 at 11:30 A.M., LPN B said: -He/She should have changed his/her gloves and sanitized his/her hands between each dirty to clean task for infection control; -He/She should have put the resident's wound treatment supplies on a sanitized area or on a barrier cloth for infection control; -He/She should have squirted the Iodosorb gel to a clean applicator instead of his/her dirty gloved finger for infection control; -He/She potentially introduced germs or bacteria into the resident's Iodosorb tube by touching the top of the applicator with his/her dirty gloved finger and by placing the tip of the applicator so close to the resident's open wound base; -He/She should have discarded the Iodosorb tube as it was potentially contaminated with germs and bacteria for infection control; -He/She should not have put the dirty wound treatment supplies back into the treatment cart as the products had the potential to touch and contaminate other supplies for infection control; -He/She put the resident at risk of infection, cross contamination and delayed wound healing by failing to follow infection control measures. 3. During an interview on 7/19/24 at 11:53 A.M., the Wound Nurse said: -She expected nurses to sanitize their hand and don new gloves when going from a dirty to clean task for infection control; -She expected nurses to put wound treatment supplies on a clean surface or barrier cloth for infection control; -The risk of cross contamination and introduction of bacteria to other items increases when nurses put dirty supplies back into their supply cart; -She expected nurses to squeeze gels and ointments onto a sterile gauze to apply to a wound, to discard the dirty gauze pad and use a new gauze pad for a different area of the wound for infection control; -Touching the top of the application on a tube of medication with a dirty, gloved finger that had touched a wound could contaminate the entire tube of medication; -Squeezing medication straight out of a tube of medication into a open wound increases the risk of cross contamination and contaminating the entire tube of medication; -Failing to follow infection control measures increased the risk of cross contamination, infection of wounds and delayed wound healing. 4. During an interview on 7/26/24 at 11:26 A.M., the Administrator, Director of Nursing (DON) and Assistant Director of Nursing (ADON), said: -They expected nurses to sanitize hands and change gloves during wound care before starting the treatment, between dirty to clean tasks and after wound care is completed; -They expected nurses to put wound care supplies on a sanitized area or on a barrier cloth due to risk of contamination of clean supplies, risk of infection of the wounds, and cross contamination; -It was not appropriate for nurses to put medication on their gloved finger, touching the tip of the tube, smear it on the resident's wound, use same dirty gloved finger, touch the tip of the tube again squirting medication on the dirty gloved finger, then spread the medication into the resident's wound bed due to increased risk of cross contamination for wound, risk of contaminating the tube of medication, risk of infection of wound and delayed healing of wounds; -It was not appropriate for nurses take a tube of medication and take it up to the wound bed and squirt the ointment into the wound bed due to increased risks of cross contamination to the wound, and contamination of the tube of medication. They expected the nurse to discard the tube of medication for infection control; -They expected nurses to use one piece of gauze for each wound site due to increased risk of cross contamination of wounds, risk of infection and risk of delayed wound healing; -They expected nurses to clean a wound from the inside out to decrease the risk of cross contamination, risk of infection and risk of delayed wound healing. 5. During an interview on 7/26/24 at 3:32 P.M., the Administrator said: -The delivery of care at the bedside by the nurses was monitored by the nurse supervisors (nurse managers, ADON and DON); -She expected nursing staff to have knowledge of and follow facility policies.

Based on interview and record review, the facility failed to ensure staff followed their Condition Change, of the Resident policy. On the morning of 10/9/23, Nurse O (the day shift nurse) documented the night shift nurse reported at shift change one resident had a low blood pressure (BP), the physician was notified and gave orders to encourage fluids. The night shift nurse failed to document in the progress notes and/or on an SBAR (Situation, Background, Assessment, and Recommendation, assessment tool) communication form, the date or time the resident's BP was low, what the BP was, or the physician's order. In addition, Nurse O failed to document on-going assessments/monitoring of the resident throughout the day. On 10/9/23 at 5:00 P.M., the resident's family visited and requested the resident be sent to the hospital. The resident was admitted to the hospital on 10/9/23, with a temperature of 102.2 Fahrenheit (F) and a diagnoses of urosepsis (a blood infection caused by a urinary tract infection (UTI)) and hyponatremia (low concentration of sodium in the blood). The resident received intravenous (IV) antibiotics and was readmitted to the facility on [DATE]. Six residents were sampled and problems were found with one (Resident #6). The census was 145. Review of the facility's Condition Change, of the Resident policy, revised 7/2021, showed: -Purpose: To observe, record and report any condition change to the attending physician so proper treatment will be implemented; -Procedure, included the following: After all resident falls, injuries or changes in physical or mental function, monitor the following: -Observe and inquire if resident has headache or pain; -Observe for personality changes; -Observe for alterations in consciousness; -Observe for sensory weakness; -Observe for generalized weakness; -Observe for speech disorder; -Observe for gait (walking), posture, or balance disorder; -Take vital signs and include temperature; -Document the change in progress notes on respective event; -Notify resident's responsible party; -Monitor resident's condition frequently until stable. Review of the facility's SBAR (Situation, Background, Assessment, and Recommendation) Communication Tool policy, dated July 2016 and revised 7/2021 and 11/2023, showed: -Purpose: To ensure optimal communication between the community's nurse and practitioner when there is significant change in a resident's condition; -Equipment: SBAR Communication Tool; -Procedure: A SBAR Communication Tool found in the EHR (electronic health record) or progress note, is encouraged to be completed by the nurse on residents experiencing a significant change in condition; -Note the change in condition, the onset of symptoms; -Complete an evaluation of the resident pertaining to this current change in condition. Complete all ten sections on SBAR. If a section does not apply to the change in condition, check the no changes observed box; -Summarize your assessment/observation; -Contact practitioner of this change in condition; -Contact the resident's POA (power of attorney) and inform of changes in condition and practitioner's orders as soon as reasonable. Review of the resident's annual Minimum Data Set, (MDS) a mandated assessment completed by facility staff, dated 7/18/23, showed: -Makes Self Understood: Understood; -Ability to Understand Others: Understands, clear comprehension; -Cognitively intact; -Eating: Setup or clean-up assistance. Helper sets-up or cleans-up. Resident completes activity; -Diagnoses of high blood pressure and dementia. Review of the resident's care plan, located in the EHR, showed: -Problem Start Date 8/12/20: Deficit in activity of daily living functioning and mobility due to due to congestive heart failure (the heart does not pump blood as well as it should); -Approaches: Assist with morning and evening care per facility policy. Encourage activity of daily living participation to maximize independence. Give verbal bathing-dressing grooming cues. Transfer with assist of 2 persons and Hoyer lift (a machine used to transfer a resident unable to bear weight). Uses a wheelchair for locomotion, he/she requires total assistance; -Problem Start Date 12/8/21: Dehydration/Fluid Maintenance; -Approaches: Provide fluid preferences within dietary restrictions. Encourage fluid intake at each meal, between meals, and with medication pass; -Problem Start Date 10/21/22: Cognitive Loss/Dementia; -Approaches: Staff will encourage resident to participate in conversation and to ask questions related to tasks and activities. Staff will provide resident with simple explanations and ask yes/no questions when possible for optimal understanding. Review of the resident's progress notes, for 10/8/23 and 10/9/23, showed no vitals or assessments documented. Review of the resident's vitals result, located in the EHR, showed: -No vitals documented on 10/8/23; -10/9/23 at 7:55 A.M.: temperature 97.1 (T, normal range 97.8 - 99.0), pulse 60 (P, normal range 60-100 beats per minute), respirations 20 (R, normal range 12-16 breaths per minute), and BP, 164/87 (normal range - systolic of less than 120 and diastolic of less than 80); -No documented vitals after 10/9/23 at 7:55 A.M. Review of the resident's progress notes, showed: -10/9/23 at 9:30 A.M., Nurse O documented: Resident not usual self, confused. Was informed by the night nurse that resident's blood pressure (BP) was low and that the physician was notified with new order to encourage fluids. This nurse had Certified Nursing Assistant (CNA) to get vital signs and and all vital signs were normal. Will continue to monitor; -No other nurse's notes documented until: -10/9/23 at 5:00 P.M., Nurse O documented: Resident still not usual self. Family at bedside very upset due to the resident representative was not called. This nurse apologized, but family did not want to hear it. Physician notified with new order to send resident to hospital emergency room (ER) for evaluation and treatment; -10/9/23 at 5:54 P.M., Nurse O documented: Two attendants with ambulance arrived to transport resident to hospital ER; -10/10/23 at 7:28 P.M., Nurse O documented a late entry for 10/9/23: This nurse did resident's treatment and he/she was alert and oriented, was able to roll on his/her left side facing the wall without difficulty. This nurse had to clean up resident due to resident had a bowel movement and urinated. Didn't notice any foul smelling odor. Resident doesn't appear to be in any distress at this time. During an interview on 11/2/23 at 7:15 A.M., Nurse O said he/she worked 10/9/23 from 7:00 A.M.-7:00 P.M., and was in charge of the resident that day. When he/she came to work that morning, the night nurse said the resident's BP was low on his/her shift. The night nurse called the physician and was told to have the resident drink additional fluid. Nurse O did not know what time the night nurse obtained the low BP, what the resident's BP was or if the resident's family had been notified. He/She did not notify the resident's family. The night shift nurse did not document any of his/her assessments or findings in the progress notes. At the beginning of the shift, Nurse O told CNA N to take the resident's vitals which were within normal limits. At the beginning of his/her shift the resident was confused, but got better during the day. He/She did not obtain any more vitals that day. He/She did not ask the CNA to obtain vitals after the first set was taken at 7:55 A.M. He/She assessed the resident's lungs and bowels later that morning and everything seemed fine. He/She did not document his/her assessment. Around 1:00 P.M., he/she did the resident's treatment and the resident was talking at that time. Around 5:00 P.M., the resident was not his/her usual self. Resident was verbal, just not his/her normal self. In the afternoon, the resident's family came in and said the resident did not look right and wanted the resident to go to the hospital. He/She called the physician who said to send the resident to the hospital. He/She did not know the resident's temperature was 102.2 when he/she arrived at the hospital. The resident had a history of UTIs. During an interview on 11/2/23 at 10:19 A.M., CNA N said he/she worked a double shift (7:00 A.M. - 11:00 P.M.) on 10/9/23, and was assigned to take care of the resident on both shifts. Before 10/9/23, he/she had taken care of the resident several times including the day before, and was familiar with the resident's normal behaviors. Normally, he/she went into the resident's room, said good morning and the resident said good morning back. They would then begin talking to each other. At meal time, the resident normally required set-up assistance, and then could feed and drink independently. On the morning of 10/9/23, he/she went into the resident's room and said good morning, but the resident did not really respond. The resident just looked at him/her. He/She tried to get the resident to talk to him/her a couple more times, but the resident just looked confused and did not respond. He/She told Nurse O and the nurse asked him/her to take the residents vitals, which he/she did around 8:00 A.M. He/She never took the resident's vitals again that day. The nurse did not ask him/her to take the resident's vital again. During meals that day, he/she had to hold the resident's cup for him/her to drink which was not normal. The resident drank his/her supplement and some additional fluids, but Nurse O never told CNA N to give the resident additional fluids. He/She was present later that day when the resident's family came in and said the resident must have a UTI again. The resident went to the hospital a short time later. He/She did not think the resident's condition changed from that morning until the time he/she went to the hospital. Review of the resident's hospital records, showed: -admitted [DATE] at 6:38 P.M.; -History of Present Illness: Resident brought into ER room via emergency medical staff from his/her nursing facility for weakness, lethargy (weakness). Family went to visit resident at the facility and he/she could barely wake up. Family states resident was like this last time when he/she had a UTI; -Urinalysis positive (UTI). Started on IV Cefepime and IV Vancomycin (antibiotics) for urosepsis (UTI spread to the kidneys); -Temperatures: -10/9/23 at 7:16 P.M., 102.2 F; -10/9/23 at 9:46 P.M., 103 F; -10/10/23 at 1:06 A.M., 101 F; -10/10/23 at 7:45 A.M., 101.2 F; -discharge date : 10/25/23. Discharge diagnoses of UTI and hyponatremia (low concentration of sodium in the blood). Review of the resident's progress notes, showed: -10/25/23 at 6:43 P.M., Resident returned from hospital with diagnoses of UTI and hyponatremia; -10/29/23 at 12:31 P.M., and documented by the Registered Dietician: Resident in hospital for over two weeks and readmitted with diagnoses of UTI and hyponatremia. Resident on Hospice care upon readmission. During an interview on 11/2/23 at 12:06 P.M., the Assistant Administrator said when a resident had a change in condition, nurses were encouraged to fill out an SBAR, but they could document in the progress note as well. During an interview on 11/2/23 at 12:45 P.M., the Director of Clinical Services said she would have expected there to have been some documentation regarding the resident's low BP in the progress notes. During an interview on 12/2/23 at 12:55 A.M., the DON said the night nurse should have documented the resident's low BP in the progress notes or he/she should have completed an SBAR form. She would have expected staff to have followed the facility change in condition policy. She would have expected there to have been nursing assessments regarding the resident's condition and documentation about encouraging fluids. During a telephone interview on 11/13/23 at 8:45 A.M., the Medical Director said she expected staff to follow the facility's change in condition policy. She expected the night shift nurse to have documented the resident's BP and her orders in the progress notes. She recalled the night shift nurse calling her, but could not recall the resident's BP now. She would have expected there to have been monitoring and assessments of the resident, and if there was improvement she would have expected staff to have notified her. MO00226744

Based on interview and record review, the facility failed to ensure staff followed their Abuse, Neglect and Exploitation, Freedom From policy by failing to immediately notify the Administrator/Designee or Director of Nurses (DON)/Designee and promptly begin an investigation regarding one resident's allegation on 10/24/23 around 4:30 P.M. to 5:00 P.M., of being slapped or hit in the face/mouth by Certified Nursing Assistant (CNA) A. In addition, the facility failed to ensure CNA A was immediately suspended from work pending the results of an investigation. CNA A continued to work on 10/24/23 until 10:38 P.M., returned to the facility on [DATE], and worked from 6:34 A.M. until 3:27 P.M., before being suspended from work. Six residents were sampled and problems were identified with one (Resident #3). The census was 145. Review of the facility's Abuse, Neglect and Exploitation, Freedom From policy dated 1/2019 and last revised 9/2022, showed: -Resident Safety Position Statement, included the following: -It is the policy of the facility to maintain a work and living environment that is professional and residents are free from threat or occurrence of harassment, or abuse (verbal, physical, mental or sexual); -Providing a safe environment for the resident is one of the most basic and essential duties of the facility. Employees and volunteers have a unique position of trust with vulnerable residents. Having access to private information, being in a physically intrusive position and having elevated status and special relationships with residents' makes ethical and professional behavior essential; -Residents must not be subjected to abuse by anyone, including facility staff; -Definitions: -Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish; -Physical abuse includes, but is not limited to, hitting, slapping, pinching, and kicking; -Covered individual means anyone who is an owner, operator, employee, manager, agent, or contractor of the facility. Each covered individual shall report allegations or suspicion of abuse, neglect, exploitation to the Administrator or supervisor. Failure to report abuse, neglect, and exploitation timely may result in disciplinary actions to include termination; Application/Prevention: -The policy regarding resident safety has application in: the manner in which prospective employees are screened, new employees are oriented, how on-going education is provided for all employees, the care and treatment of residents, the supervision of staff, information on reporting for residents, family, volunteers and staff and the prompt reporting, investigation and appropriate response to any violation which is suspected and/or substantiated; -Reporting Suspected Violations: The supervisor on duty shall immediately report any alleged violations of this resident safety policy to the Administrator/Designee or DON/Designee. -Procedure for Investigation, includes: -The supervisor will do everything possible to protect the resident's welfare and safety from harm during the investigation; -Any employee suspected of a violation of these resident safety policies, may be suspended pending investigation. Review of Resident #3's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/16/23, showed: -Makes Self Understood: Usually understood, difficulty communicating some words or finishing thoughts but is able if prompted or given time; -Ability to Understand Others: Usually understands, misses some part/intent of message but comprehends most conversation; -Moderately impaired cognition; -Mobility Device: Wheelchair; -Diagnosis of dementia; -Hallucinations/Delusions: Not indicated; -No physical, verbal or other behavioral symptoms. Review of the resident's care plan, located in the electronic medical record (EHR), showed: -Problem: Communication, hard of hearing; -Approaches: Clear simple directions. Face resident while speaking using eye contact; -Problem: Cognitive Loss/Dementia; -Approaches: Encourage to participate in conversation and ask questions related to tasks and activities. Provide explanations or instructions in simple understanding to resident needs and give positive feedback and praise for accomplishments. Provide simple explanations and ask yes/no questions when possible for optimal understanding; -Problem: Activity of Daily Living; -Approaches: Resident requires minimum to moderate assistance with bed mobility, transfers, and toileting. Review of the resident's progress note, recorded as a late entry on 10/25/23 at 9:25 A.M. for 10/24/23 at 9:16 P.M., showed CNA reported that resident's relative approached him/her at dinner time and asked the resident if this was the person who hit him/her (resident). Reported this to Supervisor Nurse L and did a full body assessment. Resident is confused and states he/she does not know what I'm asking about being hit. No bruises or redness noted at this time. Resident slept throughout the night without difficulty, No signs/symptoms of pain or discomfort. Nursing monitored him/her throughout the shift. Review of the facility self-report submitted to the Department of Health and Senior Services on 10/24/23 at 9:56 P.M., and concluded on 10/30/23, showed: -Conclusion to Investigation for Resident #3, completed by the Assistant Director of Nurses (ADON), and dated 10/30/23; -On 10/24/23 at approximately 9:00 P.M., Supervisor Nurse L was informed by CNA A the resident's family member asked CNA A to come with him/her, then stated the resident said the CNA had hit the resident. The family member began pointing at the CNA while asking the resident, Did (he/she) hit you? After no response from the resident, the family member told the resident it's ok to say if someone hit you. The resident turned and said yes. CNA A found the Supervisor, and reported the allegation. When the Supervisor was made aware he/she went to locate the family member to obtain information regarding the allegation, and the family member had left the building. CNA A was not the resident's assigned caregiver at the time of the allegation. The nurse working with the resident performed a skin assessment and obtained vital signs. Resident was afebrile (normal temperature) with no signs or symptoms of distress. Resident's physician was made aware of the allegation; -An investigation was initiated. CNA A was interviewed and suspended pending the investigation. During the investigation, the DON spoke to the resident and he/she said his/her care at the facility had been fine. DON then asked resident how his/her night was and he/she said good. The resident was in a pleasant mood during the time of the interview. Other statements were gathered from residents on CNA A's assignment and all stated no issues. Body assessments were completed on non-verbal residents on the assignment and no concerns were found. Staff that worked with the resident within the past 72 hours were interviewed and staff said the resident voiced no concerns regarding care. The resident's roommate, alert and oriented time four (person, place, time, and situation) said no one had mistreated him/her (roommate) and Resident #3 at all and said CNA A had been great to both of them. The roommate also said he/she and Resident #3 are well taken care of. A care plan meeting was held with the family member during which time the family member shared a recording that he/she had with the resident and CNA A; -Conclusion: We cannot substantiate the resident's allegation, however we do not suspect Abuse and Neglect. As a precaution, we will continue to provide staff education on the Abuse and Neglect policy as well as how to care for residents with dementia. The resident's care plan was reviewed and updated. Review of the written statements by staff from the facility investigation, included: -CNA A's written statement dated 10/24/23, no time indicated, showed: To whom it may concern. Resident #3's family stopped him/her in the hall and asked who CNA A was. He/She said yes, what's wrong? The family said just come with him/her. He/She said the resident said CNA A had hit him/her. So CNA A and the family both got to the dining room. The family looked at the resident and pointed to CNA A, asking if he/she hit you. The resident did not respond, then about five seconds later the family said to the resident, it's ok to say if someone hit you. Then the resident turned and said yes. CNA A walked out and found his/her supervisor; -CNA J's written statement dated 10/24/23, no time indicated, showed: He/She overheard the conversation between the family of Resident #3 and CNA A today (10/24/23) while in the dining room that referred to an incident that occurred the day before (10/23/23) about CNA A hitting the resident in the mouth; -CNA K's written statement dated 10/24/23, no time indicated, showed: On 10/24/23, He/She was setting the dining room up for dinner when he/she overheard a person that was visiting with the resident ask the resident if anyone had slapped the resident. The resident did not respond until the person said it's ok to say, that someone hit you. At that time the resident said yes and nothing further so a CNA had walked past and told the nurse; -Certified Medication Technician (CMT) I's written statement dated 10/214/23, no time indicated, showed: He/She was in the dining room with the resident and his/her family member. He/She asked the resident if the resident was going to eat dinner today and the resident said yes. He/She asked the resident why he/she did not eat dinner the day before and the resident said someone had hit him/her in the mouth. CMT I spoke to the family and told the family member he/she did not believe anyone hit the resident. CMT I said he/she just didn't think the resident wanted to eat; -Nurse L's written statement dated 10/24/23, no time indicated, showed: This nurse called the resident's family. The family member said he/she asked the resident what's wrong? The resident said I'm ok, but someone hit me in the mouth after the family member left yesterday. The family member got CNA A and brought him/her in front of the resident. The family member asked the resident, Is this the CNA who hit (him/her)? The resident responded yes. The family member then went home. During a telephone interview on 11/1/23 at 1:38 P.M., CNA A said he/she was scheduled to work a double shift on 10/24/23 (7:00 A.M. to 11:00 P.M.). Prior to 10/24/23, he/she had not worked with the resident for four or five days. He/She was not assigned to care for the resident on the day shift (7:00 A.M. - 3:00 P.M.), but he/she was assigned to provide care to the resident that evening. Around 5:00 P.M. on 10/24/23, the resident's family member called CNA A over and the resident said he/she had hit the resident. He/She went to the nurse's station and told Nurse M what had happened. Nurse M did not give him/her any directives, so he/she went back to work. Around 8:00 P.M., CNA A found Supervisor Nurse L and told him/her what had happened. Supervisor Nurse L asked why he/she did not say anything earlier. He/She told Supervisor Nurse L he/she could not find him/her earlier. About 9:00 P.M., he/she was laying the resident down for bed when Supervisor Nurse L found him/her and told him/her to come to his/her office and write a statement. He/She then sent CNA A home. He/She told Supervisor Nurse L that he/she was scheduled to work a double shift the next day, 10/25/23. Supervisor Nurse L told CNA A he/she could work the next day as scheduled. He/She reported to work the next morning and worked the entire day shift (7:00 A.M. - 3:00 P.M.) before being sent home. Review of CNA A's Employee Time Card, showed he/she clocked in and out for work on the following dates and times: -10/23/23: In at 7:00 A.M., Out at 10:42 P.M.; -10/24/23: In at 6:58 A.M., Out at 10:38 P.M.; -10/25/23: In at 6:34 A.M., Out at 3:27 P.M. During an interview on 11/1/23 at 2:45 P.M. CMT I said he/she had worked at the facility for [AGE] years and had received abuse and neglect inservices several times prior to 10/24/23, but not since then. He/She fed the resident dinner on 10/23/23, and the resident never said anything about being hit in the mouth. On 10/24/23 between 5:00 P.M. and 5:30 P.M., he/she asked the resident if the resident was going to eat dinner. He/She asked the resident why he/she did not eat dinner yesterday and the resident said because someone hit him/her in the mouth. He/She spoke to the resident's family member who was present and CMT I told the family member he/she did not believe anyone hit the resident. He/She never reported the allegation because he/she did not believe the resident was hit. He/She should have reported it. During an interview on 11/2/23 at 6:50 A.M., Nurse L said he/she had worked at the facility for about one year. He/She worked on 10/24/23, as the Night Supervisor. Nurses work 12 hour shifts, 7:00 A.M. to 7:00 P.M., and 7:00 P.M. to 7:00 A.M. Nurse M was working the unit where CNA A was scheduled that evening. Nurse M never said anything to him/her about the alleged incident. At about 8:00 P.M., CNA A told him/her about the alleged incident. He/She did not remove the CNA from the floor at that time, and the CNA went back to work. He/She was aware of the facility's abuse policy. Nurse L did not immediately send the CNA home because the resident said the CNA slapped him/her the day before on 10/23/23, and CNA A was not assigned to the resident that day. The resident was very confused so it was possible if the alleged abuse occurred it could have been another day he/she referred to. He/She called the ADON around 9:00 P.M. and she told Nurse L to begin the investigation by getting the resident's and staff statements and to send the CNA home. However, CNA A was in a resident's room providing care and wanted to finish. He/She could not recall the exact time he/she called CNA A into his/her office, received his/her written statement then sent CNA A home. He/She talked to Nurse M. Nurse M said since the alleged incident occurred the day before, Nurse M thought the incident had already been reported. He/She had received the facility abuse and neglect inservice prior to 10/24/23, but not since then. During a telephone interview on 11/2/23 at 10:55 A.M., CNA K said he/she had worked at the facility for 9 years and had received the facility abuse and neglect inservice several times, but none since 10/24/23. On 10/24/23 around 4:45 P.M. or 5:00 P.M., he/she was setting up the dining room for dinner. He/She overheard a person, he/she thought was a family member, ask the resident, Did someone hit or slap you? The resident said yeah. Another CNA, he/she did not know, went over and told the nurse. The nurse did not say anything. The nurse did not ask CNA K or anyone else he/she was aware of anything about the resident saying he/she had been slapped. During a telephone interview on 11/2/23 at 3:00 P.M., CNA J said he/she had worked at the facility for about 6 months and received abuse and neglect inservicing during his/her orientation, but nothing since. On 10/24/23 around 4:30 P.M. - 5:00 P.M., he/she was setting up the dining room for dinner. He/She overheard the resident's family member say something to a CNA about the CNA hitting the resident in the mouth the day before. He/She was not sure who the CNA was, but thought it was CNA A. He/She did not report it because the family member said it happened the day before. He/She thought it had been reported the day before. During a telephone interview on 11/2/23 at 11:22 A.M., Nurse M said he/she had worked at the facility for a couple of months and received the facility abuse and neglect inservice during orientation. He/She was the nurse on duty on 10/24/23 and CNA A told him/her the resident said someone had hit him/her the day before on 10/23/23. CNA A did not say it was him/her that was alleged to have hit the resident. Since the CNA said it was supposed to have occurred the day before, Nurse M did not report it to Supervisor Nurse L. He/She thought it had already been reported. Had Nurse M known it had not been reported he/she would have reported it immediately to Supervisor Nurse L. During an interview on 11/1/23 at 12:17 P.M., with the Administrator and ADON, the ADON said Supervisor Nurse L called her on 10/24/23 at 9:00 P.M. She returned his/her call at 9:16 P.M. She told Supervisor Nurse L to get statements from staff and then he called the Administrator. The Administrator said she told the ADON to follow the facility policy and told her to call Supervisor Nurse L back. The ADON said she called Supervisor Nurse L back at 9:26 P.M., but there was no answer. She finally reached Supervisor Nurse L at 9:47 P.M., and told him/her to send CNA A home and CNA A was not to return pending further investigation. The following day she had no idea CNA A was working. She thought Supervisor Nurse L told CNA A he/she was suspended pending further investigation. The Administrator said she was not aware CNA A was working on 10/25/23. Neither recalled how they learned CNA A was working or what time they found out. They thought it was around 1:30 P.M. or 2:00 P.M. As soon as they found out, they called CNA A to the office and told him/her not to finish his/her scheduled double shift and sent CNA A home. During an interview on 11/1/23 at 2:30 P.M., the Director of Clinical Services said she expected staff to follow regulations and the facility policy. Supervisor Nurse L should have gotten CNA A's written statement first then sent him/her home. Staff should never have told CNA A to work on 10/25/23. Review of the facility Nursing In-Service Sign In Sheet, dated 10/30/23, and presented by the ADON on 10/31/23, showed: -Education Title: Elder Abuse Neglect Teaching Plan; -The in-service sheet showed 104 names (101 were nursing staff) and 38 nursing staff signatures; -The in-service sign in sheet did not show staff signatures for: Supervisor Nurse L, Nurse M, CMT I, CNA A, CNA J, or CNA K. Review of the facility Nursing In-Service Sign In Sheet, dated 10/25/23, and 10/30/23, and presented on 11/2/23, showed: -10/25/23 - Education Title: Abuse, Neglect, 2 Hour Reporting; -The in-service sheet showed 64 staff signatures; -10/30/23 - Education Title: Elder Abuse Neglect Teaching Plan; -The in-service showed 54 staff signatures; -The in-service sheets did not show staff signatures for: CNA J and CNA K. On 11/2/23 at 3:00 P.M., the Director of Clinical Services and the ADON said Supervisor Nurse L, Nurse M, CMT I, CNA A, CNA J, and CNA K were all inserviced at the time they gave their statements. Staff in-services were still on-going and would include all facility staff. During a telephone interview on 11/13/23 at 8:45 A.M. the Medical Director said she would expect staff to have followed the abuse and neglect policy. She would have expected the investigation process to have begun when the resident and family made the allegation. She would have expected CNA A to have been sent home as soon as the resident and family member alleged the CNA slapped/hit the resident. The CNA should not have been allowed to have worked until the investigation was completed. MO00226411

Based on observations, interviews, record review, and policy review, the facility failed to ensure: 1. the high temperature dish machine met proper temperatures and 2. the staff maintained a clean kitchen including items in the storage areas for all 133 residents who received meals from the kitchen. These failures had the potential to lead to food-borne illness among all facility residents. Findings include: 1.Observations during the initial tour of the kitchen on 10/02/23 beginning at 9:31 AM with the Food Service Director (FSD) revealed: The hot water dishwasher temperatures of Wash was 152 Fahrenheit (F), the Rinse was 154 F, and the Final Rinse was 190F. At 9:35 AM, Dietary Aide (DA) 1 loaded another batch of dirty dishes onto the conveyor belt and dishwasher temperatures registered at Wash 130F, Rinse 156F, and Final Rinse of 190F. On 10/02/23 at 9:36 AM, DA1 placed another load of dirty bowls from breakfast onto the conveyor belt with the FSD observing. The dishwasher gauges measured the following temperatures: Wash 128F, Rinse 148F and Final Rinse of 191F. The FSD stated that she did not know why the dishwasher temperatures were low and said that she was leaving the kitchen to contact their dishwasher service technician. The plaque on the dishwasher displayed required temperatures of Wash 150F, Rinse 160F and Final Rinse of 180F. On 10/02/23 at 9:44 AM, the FSD returned to the kitchen and told DA1 not to wash any more dishes until the dishwasher reached the correct temperature. In an interview on 10/02/23 at 9:54 AM, the FSD stated that she were not aware that the dishwasher temperature for the Wash and Final Rinse were not reaching the proper temperatures. In an interview on 10/02/23 at 10:24 AM, DA2, who worked at the facility as a dishwasher for one year, stated that he talked to maintenance about a month ago about dishwater temperatures not being met. DA2 stated, One side of the knobs are not moving or the temps [temperatures] were not heating up. The Final Rinse was the only side that worked or heated up. In an interview on 10/02/23 at 10:29 AM, DA3, who worked at the facility as a dishwasher for three years, stated the dishwasher Wash cycle normally gets to 120F and that is the highest . the final rinse is normally fine. In an interview on 10/02/23 at 10:42 AM, the Registered Dietician (RD), facility's dietician for [AGE] years, stated that she was not aware of any dishwashing issues until that morning. The RD stated that the FSD called the dishwasher technician and industrial chemical company. The RD added that it was odd that the final rinse is meeting temps but not the wash and rinse were not. In an interview on 10/02/23 at 10:49 AM, the FSD stated that they do not audit the dishwasher machine temperatures because they depend on the staff to tell them if the dishwasher was malfunctioning. The FSD stated that staff had not informed maintenance of the low wash and rinse temperatures. The FSD said that the dishwasher should be running at proper temperatures to ensure all germs are killed and that the dishes are cleaned and sanitized. In an interview on 10/02/23 at 1:48 PM, the Maintenance Director (MD) stated that the dishwasher was serviced last week for a converter belt issue and not a temperature issue. The MD stated the dishwasher was a high temp dishwasher and this was the first time he heard that the required temperatures were not met. The MD stated that they do not conduct audits of the dishwasher because expect their staff to report problems to management or their supervisor. In an interview on 10/02/23 at 12:01 PM, the Service Technician (ST) stated the dishwasher was now working and he noticed the wash tank temperature was extremely low because there was no voltage. ST said that he simply turned on the breaker and everything was now working. ST confirmed the proper dishwashing temperatures were the following: 150F for Wash 160F for Rinse 180F for Final Rinse. Review of the owner's manual for the dishwasher machine entitled Maintenance; Dishwashing; Gleaning - [NAME] c44 Instruction Manual shows required dishwashing temperatures as the following: 150F for Wash, 160F for Rinse, and 180F for Final Rinse. 2. During the initial visit to the kitchen on 10/02/23 at 9:10 AM with the FSD observations revealed: The storage room floor contained dirty tiny pieces of paper, sticky-like substances, and a plastic bag on the floor. The debris and substances were embedded onto the floor and under the storage racks. Large white bins of brown sugar, white sugar, white flour, grits, and oats were unlabeled and undated. The corners of the bins contained a buildup of grease and tiny crumbs. Fruit flies were flying around the sticky areas. The recipe shelf above the cook's food preparation area contained greasy crumbs and sticky substances. During a subsequent visit to the kitchen on 10/03/23 at 8:19 AM, observations with FSD revealed: Garbage can at the right of the sink where employees wash their hands was covered with sticky black substances with patches of a white substance embedded. In the storage closet next to the dish machine area, dirty plates (15), large serving trays (4), large rectangular lids (10), bin of scoops and silverware, and metal oven racks were observed. The deep freezer in the storage room across the hall from the kitchen needed defrosting and contained two inches of old ice, Unlabeled traditional stuffing mix and a rice bin covered with what appeared to be dirt were observed in the storage area across from the kitchen Black substance that appeared to be mold covered the large surfaces of two large rectangular plastic cutting boards. The cutting boards were observed in the storage closet next to the dish machine area in the kitchen. In an interview on 10/04/23 at 3:03 PM, the Administrator stated, kitchen food safety is important and it is expected the staff to know proper temps. And if dishwasher temperatures are not working, it is expected for the staff to notify [FSD] or Maintenance. Also, the Administrator stated that the expectation for kitchen staff was to provide clean and sanitized dishes to the facility's residents and proper dishwasher temperatures at all cycles. Review of the facility's Sanitation/Infection Control policy, dated August 2010, revealed Monitor that the dishwashing machine is maintaining operating guidelines for wash, rinse, and final rinse temperatures. Check each item as it comes out of the dishwashing machine for soiled items. Run dirty items through again until they are clean. the Dining Services staff shall maintain the operation of the dishwashing machine according to established procedure and manufacturer guidelines posted or contained in this guideline to ensure effective cleaning and sanitizing of all tableware and equipment used in the preparation and service of food . In addition, all dishwashing machines should be operated according to manufacturer recommendation. Tableware, utensils, and pots and pans should be cleaned and sanitized in either a high temperature dishwashing machine that uses hot water, or a chemical-sanitizing dishwashing machine that uses a chemical sanitizing solution.

Based on observation, interviews, review of manufacturer's instructions, policy review, and review of Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to train and ensure staff, including agency nurses, disinfected multi-use glucometers with an EPA registered disinfectant and removed used gloves for one of one resident observed receiving a fingerstick (Resident (R) 22) out of 39 residents receiving blood sugar monitoring. This failure increased the likelihood of transmission of blood-borne pathogens to residents receiving blood sugar monitoring. Findings include: During an observation on 10/05/23 at 8:12 AM, Registered Nurse (RN)1 approached the medication cart stating that the cart surface was clean from previous use. RN1 donned gloves gathered supplies and a glucometer. RN1 approached the resident, cleaned the resident's finger with an alcohol prep, allowed it to dry, and performed the fingerstick. She then touched the test strip with a drop of blood and read the results. RN1 then gathered the supplies, alcohol prep, used lancet, glucometer, and the test strip bottle with her contaminated gloves. On 10/05/23 at 8:15 AM, immediately following the observation, when asked about disinfecting the glucometer prior to performing the fingerstick RN1 stated that the glucometer was clean. When asked how she could be sure it was clean she stated that she could not be sure. When asked about removing the supplies with her contaminated gloves and contaminating the test strip bottle, RN1 stated she should have removed her gloves. RN1 stated she had been trained to clean the glucometer before and after each use but acknowledged she failed to clean the glucometer before using on R22. In an interview with Licensed Practical Nurse (LPN) 2 on 10/05/23 at 4:05 PM, LPN2 stated that she cleans the glucometer with alcohol or Sani-wipes. LPN2 added she cleans the glucometer before, after, and in-between each resident. LPN2 stated that she uses Sani-wipes (EPA registered disinfectant) first then alcohol pads. LPN2 stated that she did not receive any training on how to perform glucometer disinfection at the facility. During an interview on 10/05/23 at 4:15 PM with LPN1, located on the 400/500 unit, LPN1 stated use alcohol prep pad [to disinfect the glucometer] . that might not be their policy because I don't know all of their policies because I'm agency; we go by what we've been taught at other facilities. When asked how many times she has worked in the facility, LPN1 stated I've worked here maybe five or six times; usually do day or night shift; they don't do that orientation [disinfecting the glucometer] with us, and they don't tell us before we start doing Accu-Checks what the policy is. In an interview on 10/05/23 at 5:00 PM, the Staff Development Nurse/Unit Manager stated she completes orientation for new and agency staff. She stated that there should be two glucometers on each unit for the nurses to alternate use while waiting for the glucometer to dry after disinfection She stated that she would cleanse a glucometer with a wipe from a purple top canister (Sani-Wipe) and wait two minutes. She stated she would disinfect the glucometer before and after use. The Staff Development Nurse/Unit Manager further stated that glucometer disinfection was not covered in orientation unless the staff members asked about it. Review of the Orientation for New and Contract Staff training packet, provided by the facility, revealed no training related to glucometer cleaning and disinfection. Review of the CDC guidelines, retrieved from https://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html, revealed The Centers for Disease Control and Prevention (CDC) has become increasingly concerned about the risks for transmitting hepatitis B virus (HBV) and other infectious diseases during assisted blood glucose (blood sugar) monitoring and insulin administration. CDC is alerting all persons who assist others with blood glucose monitoring and/or insulin administration of the following infection control requirements: Whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions. If the manufacturer does not specify how the device should be cleaned and disinfected then it should not be shared . Review of the facility policy titled, Blood Glucose Monitors (Equipment Cleaning), revised February 2021, revealed Purpose: To prevent the spread of blood borne pathogens. Policy: Equipment used to obtain blood glucose results (blood glucose monitoring devices) that are used for more than one resident will be cleansed before and after each use. Procedure: A container of Oxivir TB will be stored in each treatment cart. Before and after the testing procedure, the nurse will cleanse the monitor with the Oxivir TB. Review of the EVENCARE ProView Blood Glucose Monitoring System manufacturer's instructions, provided by the facility, revealed that The EVENCARE ProView Meter should be cleaned and disinfected between each patient .Disinfection Instructions . the meter must be disinfected between patient uses by wiping it with a CaviWipes towelette or EPA-registered disinfecting wipe in between tests and be cleaned prior to disinfecting. The Disinfection process reduces the risk of transmitting infectious diseases if it is performed properly. 36383

Based on observation, interview, and record review, the facility failed to follow physician's orders and their policy by failing to ensure one resident's gastrostomy tube (g-tube, a tube inserted through the belly that brings nutrition directly to the stomach) feeding infused at the prescribed rate. In addition, the facility failed to ensure staff recorded a date/time on the package of a g-tube declogger (used to declog a g-tube) of when it was opened, and failed to ensure staff were aware of how long the g-tube declogger could be used prior to discarding it. The facility identified six residents with g-tubes. Four were sampled and problems were identified with one. (Resident # 1). The census was 138. Review of the facility Enteral Nutrition /Tube Feeding policy, dated 2014, showed: -Guideline: Enteral Nutrition (EN, a way of delivering nutrition directly to the stomach or small intestine) may be substituted for individuals who have an intact gastrointestinal tract but are unable or unwilling to take food by mouth in amounts that will support adequate nutrition. Examples are individuals with neurological disorders (strokes, head and neck trauma or surgery), cancer, and individuals with difficulty swallowing or ingesting adequate amounts of food, and gastrointestinal obstructions. Enteral feedings provide nutrients and fluids using the gastrointestinal tract. Enteral feedings can be used to supplement oral intake or can provide all of an individual's nutritional needs; -Procedure: -The choice of the EN depends on the medical and nutritional needs of the individual as assessed by the Registered Dietician (RD) and physician; -Enteral feedings supply nutrients directly to the stomach via a very small diameter, flexible feeding tube; -Continuous drip: Requires a pump and is appropriate for individuals who do not tolerate larger volumes of Tube Feeding (TF, a medical device used to provide nutrition ) infusions. The TF is usually infused for a total of 18 to 24 hours; -Open System: TF product must be opened and poured into a tube feeding bag prior to administration; -EN feeding orders should include: formula - brand and formula name, route of feeding, administration method, strength, number of calories per day and the amount of water flushes per 24 hours; -If the individual is to be a continuous feeding, divide the total milliliters (ml) of enteral feeding by 24. This will be the rate per hour that the enteral formula is to be administered; -Monitoring of the individual's actual intake and tolerance of tube feeding is important to ensure that nutritional goals are met and maintained. Monitoring of the individual with tube feedings is an interdisciplinary team effort and includes EN is being delivered as ordered by physician; -The RD should assist the health care community with the development of guidelines, procedures and/or protocols regarding EN. Review of Resident #1's, quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/9/23, showed: -Makes Self Understood: Rarely/never understood; -Ability to Understand Others: Rarely/never understood; -Total dependence of one person required for bed mobility, dressing, eating, toilet use, personal hygiene and bathing; -Total dependence of 2 (+) persons required for transfers; -Diagnoses of Alzheimer's disease, aphasia (inability to speak), stroke, dementia, and hemiplegia/hemiparesis (partial or total paralysis of one side of the body/weakness of one side of the body); -Feeding Tube: 51% or more of total calories received through a feeding tube. Review of the resident's care plan, located in the electronic health care record (EHR), showed: -Problem: Nutritional status. -Approach(s): Administer g-tube feeding as ordered. RD follow-up as needed. Maintain NPO (nothing by mouth) status. Review of the resident's physician's order sheet (POS), located in the EHR, showed: -Diet: NPO; -Enteral Feeding: Nepro (formula) 1.8 continuous feeding at 50 ml per hour (ml/hour) continuous; -G-Tube Flush: 125 ml of water every two hours; -G-Tube Size: 18 french; -No order regarding g-tube decloggers. Observation on 9/29/23 at 8:51 A.M., showed the resident lay in bed with Nepro TF infusing via a g-tube feeding pump at 60 ml/hour. Observation inside the resident's top drawer of his/her chest of drawers showed an opened, undated, g-tube declogger (used to unclog a g-tube). The inside of the package had small flecks of brown material indicating it had been used. The opened package containing the declogger was marked at that time by the surveyor. That was the only declogger observed in the drawer. Observation on 10/2/23 at 9:32 A.M., and 11:30 A.M., showed the resident lay in bed with Nepro TF infusing at 60 ml/hour. Observation of the resident's top drawer of his/her chest of drawers showed the same opened and marked package containing the g-tube declogger. This was the only declogger observed in the drawer. During an interview on 10/2/23 at 112:50 A.M., Licensed Practical Nurse (LPN) 6 said he/she is an agency nurse. He/She did not know if the facility had a policy as to how long a g-tube declogger could be used prior to being discarded. He/She thought it should be discarded within three to five days after being opened. The package should be dated and timed when opened so staff would know when to discard it. Observation on 10/2/23 at 2:05 P.M., showed the resident sat in a chair in his/her room after being transferred from the bed to the chair. Certified Nursing Assistant (CNA) 3 left the room to find the nurse to turn the resident's tube feeding back on. A few minutes later, LPN 7 entered the room, reconnected the tube feeding and turned the tube feeding pump back on. The tube feeding rate was still set at 60 ml/hour. During an interview, the nurse said nurses work 12 hour shifts. Nurses are responsible to ensure tube feeding rates are set per physician's orders. He/She left to check the physician orders. He/She returned and said 60 ml/hour was not the correct tube feeding rate, and he/she re-set the tube feeding rate to 50 ml/hour. The nurse observed the tube feeding declogger in the resident's top drawer. He/She confirmed the package had been opened, and was undated. He/She was an agency nurse so he/she did not know what the facility's policy was for discarding a g-tube declogger after being opened. He/She thought it would not be used for more than three days to a week after opening. If the package was not dated when opened, you would not know when to discard it. During an interview on 10/2/23 at 2:55 P.M., the Director of Nurses said nurses work 12 hour shifts. Both the day and night shift nurses were responsible to ensure tube feedings were infusing at the rate ordered by the physician. The facility did not have a policy for g-tube decloggers. Staff should write the date and time on the package when it was opened. She thought a g-tube declogger should be discarded no longer than 24 hours after the package was opened and the declogger had been used. MO00223682

Based on interviews, record review, and review of facility policy, the facility failed to provide a baseline care plan within 48 hours of admission for one resident (Resident (R)100) of one resident reviewed for base line care plans out of 31 sampled residents. Findings include: Review of R100's Face Sheet located in the resident's electronic medical record (EMR) in the section titled Face Sheet revealed the resident was admitted to the facility on [DATE] with diagnoses that included unspecified dementia, anxiety, psychotic disturbances, chronic pain, and generalized osteoarthritis. Review of R100's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/08/23 located in the resident's EMR section titled Resident Assessment Instrument (RAI) revealed the resident had a Brief Interview of Mental Status (BIMS) score 14 out of 15 indicating the resident's cognition was intact. The MDS documented the resident had an unsteady gait but could stabilize with assistance and utilized a walker and cane for mobility. The MDS documented the resident sustained a fall after admission to the facility. Review of R100's Care Plans located in the resident's EMR section titled Care Plans failed to reveal a baseline care plan for R100. During an interview on 10/03/23 at 4:00 PM R100 revealed the resident stated she did not remember receiving or signing a care plan that discussed her care issues with interventions within 48 hours of her admission to the facility. During an interview on 10/04/23 at 11:45 AM Licensed Practical Nurse (LPN) 3 revealed the base line care plans were completed by the unit nurses. LPN3 revealed care plans were revised/updated by the IDT teams. LPN3 was unable to provide a copy of the baseline care plan for R100. During an interview on 10/05/23 at 12:49 PM, the Unit Manager (UM) and the MDS nurse revealed the floor nurse was responsible for baseline care plans that should have been maintained in the EMR. They revealed the baseline care plan was not separated from regular care plans. Neither the UM nor MDS nurse were sure if the resident or resident's responsible party received a copy of baseline care plans within 48 hours of admission. The MDS nurse stated that she and social services worked together in handling the baseline care plans. The facility was unable to provide a copy of the baseline care for this resident. Review of facility policy titled Care Plan Conference, Interdisciplinary, with a revision date 05/21, read in part . The admission care plan is initiated by a nurse or interdisciplinary (IDT) member within 48 hours of admission .

Based on record review, interview, and review of facility policy, the facility failed to ensure that care plans for one (Resident (R)96) was revised to reflect palliative services from a sampled 31 residents. Finding include: Review of R96's Resident Face Sheet located in the resident electronic medical records (EMR) section titled Face Sheet revealed the resident was admitted to the facility 12/16/22 with diagnoses that included acute kidney failure, pressure ulcers of the sacrum, diabetes mellitus type II, cerebral infarct with hemiplegia, hemiparesis, and dysphagia. Review of R96's monthly Physicians Orders located in the resident's EMR section titled Orders revealed the resident started to receive palliative services on 07/20/23. Review of R96's Resident's Progress Notes located in the resident's EMR section titled Documents revealed a note dated 07/20/23 that the resident was evaluated and admitted to palliative services. During an interview on 10/04/23 at 12:00 PM Licensed Practical Nurse (LPN)5 revealed that palliative services provided the care plan for the resident. However, she was unsure if the facility's care plan included that the resident was receiving palliative services. During an interview on 10/05/23 at 1:14 PM the Unit Manager (UM) revealed the resident's palliative services should have been included in the resident's care plan; and this was the responsibility of the Minimum Data Set (MDS) nurse. The UM reviewed the resident's care plan and confirmed it did not include that the resident was on palliative services. Review of the facility's policy titled Care Plans, Interdisciplinary, with a revision date 05/22, read in part . The care plan coordinator or the appropriate discipline updates the resident's care plan using the proper procedure for entering and discontinuing items .

Based on observation, record review, interviews, and facility policy review, the facility failed to promptly intervene when a resident's respiratory equipment was missing for one (Resident (R) 34) of three residents reviewed for respiratory care/oxygen of 31 sample residents. Findings include: Review of R34's electronic Face Sheet located in the Face Sheet tab of the electronic medical record (EMR) revealed R34 was admitted to the facility on [DATE] with diagnoses that included obstructive sleep apnea. Review of R34's electronic Active Orders located in the Orders tab of the EMR revealed R34 had the following physician's order dated 08/05/23 for bilevel positive airway pressure (BiPAP), a respiratory treatment used during sleep to treat obstructive sleep apnea every evening and night shift. 08/05/23: Wash CPAP [Continuous Positive Airway Pressure]/BiPAP mask/tubing/humidifier chamber with warm soapy water. Air dry. Once a day on Sun. During observation and interview with R34 on 10/03/23 at 9:15 AM a BiPAP machine was observed on R34's bedside table. When asked if the BiPAP was currently being utilized the resident stated that the BiPAP equipment was cleaned on Sunday (10/01/23) and the mask had been missing since that time. The resident further stated that the BiPAP had not been used during sleep on 10/01/23 or 10/02/23. During an interview on 10/03/23 at 9:47 AM Licensed Practical Nurse (LPN) 3, who identified herself as the charge nurse on R34's unit, revealed that she was not aware that R34's BiPAP face mask had been missing since 10/01/23. Interview with the Director of Nursing (DON) on 10/04/23 at 8:48 AM confirmed that R34's BiPAP mask had been missing since 10/01/23, but she had not been notified. The DON stated that R34's daughter and primary care physician (PCP) were notified. The DON stated the PCP gave an order at that time to do oxygen saturation checks on R34 every 2 hours while sleeping until the resident's BIPAP mask was replaced. The DON confirmed that the company for the BiPAP machine had also been contacted for replacement of R34's BiPAP mask. Review of the Nursing Policy and Procedure Manual entitled CPAP/Bi-Level Respiratory Care, revised on 07/21, revealed procedures for cleaning that included: WEEKLY: Wash mask, tubing and humidifier chamber in mild soapy water, rinse and allow to air dry.

Based on record review, interview and review of facility policies and procedures, the facility failed to ensure that two (Resident (R)72 and R247) of 31 sampled residents were informed and provided written information to formulate an advance directive. Findings include: 1. Review of R72'a Face Sheet located in the electronic medical record (EMR) under the Face Sheet tab revealed R72 had diagnoses of type II diabetes, peripheral vascular disease, non-pressure chronic ulcer, gangrene, and moderate protein calorie malnutrition. The resident was admitted on [DATE]. Further review of the EMR revealed a Code Status Form under the Miscellaneous tab labeled Advance Directive dated [DATE]. Review of R72's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] in the electronic medical record (EMR) under the MDS tab indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R72 was cognitively intact. An interview with the Social Services Director (SSD) on [DATE] at 3:00 PM revealed that the facility did not have a signed advance directive or even a notice that an advance directive was offered. An interview with the Administrator on [DATE] at 3:45 PM indicated she was not aware of the problem with R72; however, the facility was working on a quality improvement plan for advance directives. Further review of the quality improvement plan on [DATE] at 4:30 PM revealed no documentation of a quality improvement plan related to advanced directives was available. An interview with R72 on [DATE] at 4:45 PM revealed that she had not been asked about an advance directive for two years or since she broke her leg and went to the hospital. 20243 2. Record review of R247's Code Status Form, found in the Advanced Directives tab under resident documents in the EMR, revealed the resident had an admitted [DATE] and had elected to receive cardiopulmonary resuscitation (CPR) and that 911 would be called. In an interview on [DATE] at 2:40 PM, the SSD stated that the facility gave paperwork to residents or family members on admission and that she would look for R 247's Advanced Directives documentation. In an interview on [DATE] at 12:15 PM, the Administrator stated that advanced directives paperwork could not be found for R247. Facility policy review of an undated facility document titled Advance Directives Policy provided by the facility on paper revealed the facility policy was: 1.Upon admission, identify the resident has an advance directive and if not determine if the resident wishes to formulate an advance directive. A resident has the option to execute an advance directive but will not be required to do so. The facility will not discriminate against a resident based on whether he or she has executed an advance directive. 2. At the resident's request, the facility will provide written examples of advance directives to include, but not limited to a Living will, a directive to the attending physician, a durable power of attorney or health care. a medical power of attorney, a pre-existing medical order for do not resuscitate (DNR), or other document directing the resident's health care. 3. Facility staff will provide the resident and/or resident representative with a copy of this policy to implement an advance directive. (Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements are met.). The facility will identify the primary decision-maker (e.g., assess the resident's decision-making capacity and identify or arrange for an appropriate legal representative for the resident assessed as unable to make relevant health care decisions) has not followed their procedure.

Based on observation, interview and record review, the facility failed to provide appropriate care and treatment to aide in healing and prevent deterioration of a pressure ulcer when a resident was observed with the ordered treatment not applied on two separate days. The resident remained up in a wheelchair for five hours and three minutes with no treatment applied to a stage III pressure ulcer. This resulted in the resident having pain and irritation to the pressure ulcer site, for one expanded sampled resident (Resident #29). The census was 221 with 184 residents in certified beds. 1. Review of Resident #29's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/4/17, showed: -Brief interview of mental status (BIMS) score of 5 out of a possible score of 15; -A BIMS score of 0-7, showed the resident had severe cognitive impairment; -Rejection of care: Behavior not exhibited; -Extensive assistance of two persons required for bed mobility and transfers; -Extensive assistance of one person required for toilet use and personal hygiene; -Frequently incontinent of bowel and bladder; -[DIAGNOSES REDACTED]. -Skin conditions showed the resident was at risk for pressure ulcers. For determining how the resident was at risk, it showed staff did not determine the risk by a clinical assessment or by using an assessment tool such as a Braden or Norton scale; -No pressure sores. Review of the resident's physician order [REDACTED]. -An order dated 2/9/13, for weekly skin assessments; -An order dated 12/19/16, for barrier cream to the buttocks, perineal area (peri-area, the surface area between the thighs, extending from the pubic bone to the tail bone) and coccyx (tailbone) as needed for redness; -An order dated 1/27/17, to cleanse the areas on the right inner thigh with wound cleanser. Apply [MEDICATION NAME] AG (wound drainage absorbent product) with duoderm (sterile occlusive dressing). Change every three days and as needed until healed. Review of the resident's care plan, reviewed on 1/15/17, showed: -Problem start date 3/31/16, activity of daily living (ADL's, bathing, toilet use, eating, etc.) functional/rehab potential: Requires extensive assistance with ADL's. [DIAGNOSES REDACTED]. Problem updated on 1/27/17, new open area. Treatment as ordered: -Goal: Be well groomed; -Approach: Assist with bathing and dressing. Incontinent products used for incontinent episodes. Observe and assess skin for redness and/or breakdown routinely with bathing/showers, ADL's and as needed. Report any changes to the physician. Creams/ointments as ordered; -Problem start date 3/31/16, skin: At risk for skin breakdown related to decreased mobility with [DIAGNOSES REDACTED]. -Goal: Skin will remain intact; -Approach: Assess for the presence of risk factors. Treat, reduce, eliminate risk factors to extent possible. Conduct a systematic skin inspection. Keep linen clean, dry and wrinkle free. Report any signs of skin breakdown (sore, tender, red or broken areas). Creams/ointments as ordered. Barrier cream to buttocks with incontinent episodes and as needed. Reposition every two hours and toilet. Review of the resident's treatment administration record (TAR), dated 12/1/16 though 12/31/16, 1/1/17 through 1/31/17 and 2/1/17 through 2/28/17 and reviewed on 2/16/17, showed barrier cream to the buttocks, peri-area and coccyx as needed for redness not documented as administered. Review of the resident's weekly wound assessments, reviewed on 2/16/17, showed: -On 1/27/17: -Location, right inner upper thigh. Wound etiology, pressure ulcer (any lesion caused by unrelieved pressure that results in damage to the underlying tissue) stage II (a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, may also present as an intact or open/ruptured blister). Size documented as 1.5 centimeter (cm) long and 1.5 cm wide. Irregular shaped with a scant amount of serosanguineous (thin, watery, clear) drainage. Wound bed with 100% granulation tissue (the pink-red moist tissue that fills an open wound, when it starts to heal). No tenderness or pain; -Location, right inner upper thigh. Wound etiology, pressure ulcer stage II. Size documented as 3.5 cm long by 1 cm wide. Irregular shaped with scant serosanguineous drainage. Wound bed with 100% granulation tissue. No tenderness or pain; -On 2/1/17: Date acquired, 1/27/17. Location, right upper inner thigh. Wound etiology, pressure ulcer stage II. Size documented as 5.5 cm long by 1 cm wide. Irregular shaped with scant drainage (type of drainage not specified). Necrotic (dead) tissue present. Yellow slough (dead tissue) soft on 75% of the wound. Wound bed with 25% granulation tissue. Wound bed moist. No tenderness or pain. Deteriorating date, 2/1/17; -No weekly wound assessment available or provided for any dates after 2/1/17. Review of the resident's nurses notes, showed: -On 1/27/17 at 2 (the rest of the time illegible), the resident has two open areas to his/her inner upper right thigh. Both areas with 100% granulated tissue. First area measured 3.5 by 1 cm. Second area measured 0.5 by 0.5 cm. Small amount of bloody drainage noted; -On 2/1/17 at 3 (A.M. or P.M. not specified), area on the right upper inner thigh has deteriorated. Review of the resident's bath skin report sheets, provided on 2/16/17, showed: -On 1/28/17, a diagram with an X drawn on the right posterior thigh/buttocks area. Normal checked. No further description of what the X on the diagram represented. The form signed by the charge nurse; -On 2/1/17, a diagram with an X drawn on the right posterior thigh/buttocks area. No further description of what the X on the diagram represented. The form not signed by the charge nurse; -On 2/7/17, a diagram with an X drawn on the right posterior thigh/buttocks area. Skin tears checked. No further description of what the X drawn on the diagram represented. The form signed by the charge nurse; -On 2/8/17, a diagram with an X drawn on the right posterior thigh/buttocks area. Decubitus checked. No further description of what the X on the diagram represented. The form signed by the charge nurse; -On 2/9/17, a diagram with an X drawn on the right posterior thigh/buttocks area. Skin tears checked. Skin color checked. No further description of what the X on the diagram represented or what skin color was identified. The form not signed by the charge nurse; -On 2/11/17, a diagram with an X drawn on the right posterior thigh/buttocks area. Decubitus checked. No further description of what the X on the diagram represented. The form signed by the charge nurse; -On 2/14/17, a diagram with an X drawn on the right posterior thigh/buttocks area. Decubitus checked. No further description of what the X on the diagram represented. The form signed by the charge nurse; -On 2/15/17, a diagram with an X drawn on the right posterior thigh/buttocks area. Decubitus checked. No further description of what the X on the diagram represented. The form signed by the charge nurse. Review of the resident's hand written physician order [REDACTED]. -An order dated 2/1/17, to discontinue current treatment to the upper inner right thigh. Change order to cleanse area with normal saline, apply Santyl (sterile enzymatic [MEDICATION NAME] ointment) with a dry dressing. Secure with [MEDICATION NAME] tape (water resistant tape) daily and as needed until healed; -An order dated 2/5/17, for specialized wound management to evaluate and treat the resident. Review of the resident's specialized wound management wound care documentation, showed: -Visit date, 2/7/17: -Chief complaint: Evaluation of right posterior thigh ulceration; -History: Recently noted pressure injury to the right posterior thigh just below the buttocks. The wound has been noted for approximately two weeks; -Wound #1: Pressure injury right posterior thigh, stage III (full thickness tissue loss, subcutaneous fat may be visible but the bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss and may include undermining or tunneling). Length 0.2 cm, width 0.5 cm and depth 0.2 cm. Wound base color, 10% yellow and 90% pink. No necrotic tissue. Scant serous (clear) drainage; -Plan: Cleanse wound with saline (salt water), apply Santyl nickel thick. Cover with a dry dressing. Dressing to be changed daily and as needed; -Visit date, 2/14/17: -Chief complaint: Evaluation of right posterior thigh ulceration; -Wound #1: Pressure injury right posterior thigh stage III. Status, not healed. Quality of tissue, deteriorated. Length 1 cm, width 2 cm and unable to determine depth. Wound base color, 20% yellow and 80% pink. Necrotic tissue, minimal. Scant serous drainage; -Plan: Cleanse wound with saline, apply Santyl nickel thick. Cover with a dry dressing. Dressing to be changed daily and as needed. During an interview on 2/15/17 at 3:00 P.M., the resident's family member said he/she arrived to the facility at 1:25 P.M. on 2/15/17 and the dressing was off. A few weeks ago he/she had told the facility that the resident's bottom was getting red and if they did not do something, it was going to break down. He/she told them that they needed to be using protective ointment on the resident, reposition the resident more often and make sure to keep him/her clean. The resident ended up getting a pressure ulcer due to the facility's lack of care. Staff told him/her that the wound was looking better, but he/she looked at it today and it looks worse. Observation on 2/15/17 at 2:44 P.M., showed the resident lay in bed on his/her back. A strong odor of urine was present in the room. Licensed Practical Nurse (LPN) J entered the resident's room, washed his/her hands, placed gloves on, unsecured the resident's urine soaked brief and exposed an open area to the resident's right lower buttocks/upper thigh area. The wound irregular shaped, wound bed reddened with an area of yellow discoloration in the center. The skin around the wound edges with a purple discoloration. No dressing present on the wound or visible in the resident's brief or bed linen. LPN J said the area should have a treatment over it. He/she then cleansed the wound with wound cleanser spray. LPN J identified two open areas connected with a thin sliver of intact skin. He/she measured the inner posterior thigh opened area as 4 cm long by 1.4 cm wide and the outer posterior thigh open area as 0.8 cm long by 0.9 cm wide. LPN J applied santyl and covered the area with a dressing. LPN J said the yellow tissue in the center of the larger wound is slough. He/she believed the wound was a stage II pressure ulcer. He/she had just come on shift and did not know if the day shift nurse knew if or when the dressing had come off. During an interview on 2/15/17 at 3:05 P.M., Nurse B said he/she was the day shift nurse for the resident. He/she had not been informed that the resident's dressing had come off. He/she should have been told. Observation on 2/16/17 at 10:25 A.M., showed Certified Nursing Assistant (CNA) N assisted the resident to bed. He/she pulled down the resident's pants and unsecured the resident's brief. The dressing to the resident's right lower buttock/upper thigh area approximately half off, and exposed approximately half of the wound. The dressing that remained hung off loosely and clumped together. Observation on 2/16/17 at 10:33 A.M., showed CNA N propelled the resident in his/her wheelchair from his/her room out to the 100 hall nurses station. No nurse or other staff person entered the resident's room between the time CNA N assisted the resident to bed and when he/she propelled the resident out of the room. At 11:54 A.M. staff propelled the resident into the 100 hall dining room. At 1:10 P.M., staff propelled the resident in his/her wheelchair to the 100 hall nurses station. At 1:32 P.M., staff propelled the resident into the therapy gym. At 2:25 P.M., staff propelled the resident to the main dining room for the Bingo activity. At this time the Director of Nursing said she would assist the resident with a skin assessment after he/she is done in the Bingo activity. At 3:23 P.M., staff propelled the resident down the hall and into his/her room. At 3:36 P.M., CNA L and CNA M entered the resident's room and assisted the resident into bed. They assisted the resident to remove his/her pants and then covered the resident with a blanket. CNA M said the DON was in a different room, but would return shortly to complete the skin assessment. Staff left the resident's room. At 3:50 P.M., CNA K and the DON entered the resident's room. CNA K unsecured the resident's brief. The brief was saturated with foul smelling urine. Observation of the resident's skin showed the dressing not on and the wound to the right lower buttocks/upper thigh exposed to the urine saturated brief. The DON searched the resident's bed linen and brief, but no dressing was found. The tissue surrounding the wound had a white clumpy substance over it and the wound bed appeared reddened and inflamed, with white clumps in it. The DON prepared to change the dressing. She sprayed the wound bed with wound cleanser and dabbed the wound with a gauze pad. The resident yelled ouch! ouch! It hurts! as he/she pushed him/her self over, onto his/her back, and lay on top of the exposed wound. CNA L assisted the resident back to his/her side and the DON applied a new dressing to the wound. During an interview on 2/16/17 at 4:11 P.M., the DON said the resident's wound should have a treatment in place. CNA's should notify the nurse if the dressing comes off or if it is loose, and then the nurse should replace it. Treatments should be completed as ordered. Nurses complete skin assessments weekly on the residents. During an interview on 2/17/17 at 8:07 A.M., Specialized Wound Management (SWM) Nurse O said he/she is the nurse who was consulted to treat the residents wound and he/she specializes in wound care and treatment. He/she typically visits residents weekly. He/she would expect facility staff to follow the treatment orders as prescribed. Not having the dressing on for an extended period of time could potentially be detrimental to the wound. During an interview on 2/17/17 at 12:37 P.M., Nurse B said he/she was the nurse assigned to care for the resident during the day of 2/16/17. He/she was never informed on 2/16/17 that the resident's dressing had come off. During an interview on 2/23/17 at 11:02 A.M., the DON said the bath/shower sheets are used by the CNA's and completed any time the residents get a bath or shower. They fill it out and then the nurses review them. The charge nurses sign off on the shower sheets in order to determine if there are any new areas. If new areas are identified, the charge nurse should assess the resident's skin. Weekly skin and wound assessment should be completed. She would check to see if there are any skin assessments had been competed since 2/1/17 and if any bath/shower sheets had been completed since 2/9/17 and provide them if available. Review of the facilities wound care protocol, last revised 8/2016, showed: -Goals of assessment: To provide uniform descriptions, facilitate communication among staff, adequate monitoring of progress or deterioration, assess for pain and implement interventions to relieve it; -Pressure injuries: Localized damage to the skin and/or underlying soft tissue, usually over a bony prominence, or related to a medial or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear: -Stage II pressure injury: Partial-thickness skin with exposed dermis: The wound bed is visible, pink or red, moist and may also present as an intact or ruptured blister. Granulation tissue, slough and eschar are not present: -Recommendations: Use moisture/lubricating ointments after cleansing every shift and as needed. Offer routine toileting. Offer hydration in conjunction with turning schedules; -Stage III pressure injury: Full-thickness skin loss: Adipose (fat) tissue is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. If slough or eschar obscures the extent of tissue loss, that is an unstageable pressure injury: -Pressure redistribution: Frequent turning or repositioning. MO 408 MO 161 MO 339 MO 358

Based on observation, interview, and record review, the facility failed to ensure staff provided safe transfers for residents according to current transfer orders/recommendations and failed to communicate current information to staff regarding the level of assistance needed, for two out of three sampled residents (Residents #1 and #2). Staff failed to follow physician's orders [REDACTED].#1 on two different occasions which resulted in fractures each time, and Resident #2 was transferred against the physician's orders [REDACTED]. 1. Review of Resident #1's care plan, dated 6/3/16, showed the following: -At risk for falls due to decreased mobility/unsteady gait, history of falls, decreased mental status with poor safety awareness, unassisted attempt to transfer/ambulate; -Manage/prevent future likelihood of falls included: assist of two with transfers, monitor for decrease/loss of functional status, monitor for unsteady gait; -Fall 6/8/16, tried to get from wheelchair to bed without assistance. No injuries. Stop sign applied. Advised and encouraged to use call light and wait for assist. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/15/16, showed the following: -Height, 70 inches; -Weight, 278 pounds; -Required extensive assistance for bed mobility with one person's physical assistance, total dependence for transfers with one person's physical assistance; -Balance during transitions and walking, unsteady moving from seated to standing position and only able to stabilize with human assistance, unsteady walking or turning around and facing the opposite direction while walking, but able to stabilize without human assistance. Further review of the resident's care plan for fall risk, showed on 6/16/16 the resident was lowered to the floor by certified nurse aides (CNAs), his/her legs got weak, he/she obtained a skin tear to his/her left wrist. Continue skilled therapies as ordered. Review of the nurse's notes, showed on 8/18/16 at 2:30 A.M., the resident was observed in his/her room sitting in an upright position in front of the bed on the floor. No injuries were noted. No complaint of pain or discomfort. The resident stated he/she slid off the side of the bed. Further review of the resident's care plan for fall risk, showed on 8/18/16, the resident fell , sitting in front of his/her bed. The resident stated he/she slid down. There was no injury. Review of the resident's physician's orders [REDACTED]. -admission date of [DATE]; -[DIAGNOSES REDACTED]. -Activity level: Full weight bearing; -Transfer needs: Two person assist with gait belt. Review of the facility's order report (a report of all residents' transfer status), provided on 9/20/16, showed from 6/24/16 through 9/4/16, the resident's transfer needs included a two person assist with a gait belt. Review of the resident's post-fall assessment, dated 9/2/16 at 8:50 P.M., showed the resident was standing with a walker while getting a dressing changed. The resident said he/she needed to sit down, the nurse told the resident to wait, and the resident sat down in his/her recliner/lift chair while the chair was still in the up position, slid down to the floor, and scraped his/her big toe (on 9/2/16). Review of the resident's nurse's notes, dated 9/2/16 at 11:20 P.M., completed by Nurse A, showed the resident was on incident follow up (IFU) due to a fall (on 9/2/16). The resident sustained [REDACTED]. Physician/family notified. No complaints of pain or distress. Vital signs were within normal limits (WNL). During an interview on 9/23/16 at 11:25 A.M., Nurse A said he/she normally did the resident's dressing changes while the resident stood up. Nurse A would put the resident's walker in front of him/her. He/she stood with assist of the walker. The nurse would remove his/her incontinence brief, and the nurse would proceed with a dressing change on the resident's buttocks. Nurse A had never had any problem with the resident falling before. The resident used to be in bed, and the dressing was changed while he/she was in bed. The resident's family member brought his/her recliner that he/she slept in at home, and the resident wanted to stay in the recliner. Nurse A and the resident had a routine. The resident was a one person assist for transfers and could pivot. The resident had a gait belt in his/her room, and Nurse A thought he/she used it. Nurse A knew the resident was a one person transfer when he/she was in rehab and it was in his/her chart. Nurse A did not check the care card in the resident's room. During an interview on 9/23/16 at 11:50 A.M., CNA C said the resident was a two person assist for transfers with a gait belt. The resident was big and tall, and couldn't stand for long periods of time. The resident was up for meals, then in bed after meals. Staff did his/her dressing changes in bed, and the resident was cooperative. During an interview on 9/26/16 at 9:20 A.M., the resident's physician said the resident should have had a two person assist for transfers. It didn't make sense to have the resident stand for a dressing change. The physician had never heard of that before. The resident was large and unsteady. During an interview on 9/22/16 at 11:05 A.M., the DON said the facility had no specific wound care policies/procedures that required dressing changes be done while residents were in bed. During an interview on 9/20/16 at 9:00 A.M., the Administrator, DON, and Assistant Director of Nursing (ADON), said the resident was a two person assist for transfers when on 9/2/16 Nurse A prepared to do his/her dressing change. The resident was in a standing position with a walker and said he/she needed to sit. The resident intended to sit in his/her recliner/lift chair, but the chair was in the up position, and he/she slid to the floor. Nurse A should have had a second staff member assist him/her. Further review of the nurse's notes, dated 9/4/16 at 5:30 A.M., showed swelling and bruising were noted to the resident's right lower extremity. A Doppler (an ultrasound exam of the arm or leg to look at blood flow in the large arteries and veins) and x-rays were to be performed in the morning. Review of x-rays completed on 9/4/16, showed the following: -Reason: Bruising/pain, witnessed fall during dressing change; -Procedure: Right tibia (shinbone, the second largest bone in the body) and fibula (calfbone, provides muscle attachment); -Findings: Acute non-displaced obliquely oriented fibular head fracture. No tibial fracture. Osteopenia; -Impression: Non-displaced acute fibular head fracture; no tibial fracture visualized. Further review of the nurse's notes, dated 9/4/16 at 1:05 P.M., showed labs were reported to the on call physician. New orders were received, see physician's orders [REDACTED]. Will inform on-coming shift. Resident weight bearing status changed to non-weight bearing/Hoyer (mechanical) lift. Further review of the physician's orders [REDACTED]. Review of the resident's care plan for fall risk, showed on 9/4/16 the resident was non-weight bearing and required a Hoyer lift for transfers. During an interview on 9/23/16 at 10:55 A.M., Nurse F said he/she read the x-ray results to the on call physician. Nurse F did not realize the resident had a fracture. The resident's family member was visiting and Nurse F informed them of the x-ray results, but did not report a fracture. The on call physician gave new orders for the resident to be transferred using a Hoyer lift. It was change of shift. Nurse F delegated the update of the resident's care card to CNA C. Nurse F said ultimately, it was the nurse's responsibility to update the care cards with changes. Nurse F did not check the resident's care card to ensure the change to the resident's transfer status was made. Nurse F reported the change to the oncoming nurse. Review of the facility's order report, provided on 9/20/16, showed from 9/4/16 through 9/19/16, the resident's transfer need was a full body lift. Starting on 9/15/16, the resident's transfer needs included a two person assist with a gait belt and a Hoyer lift. Further review of the nurse's notes, dated 9/11/16 at 7:30 P.M., showed at 5:15 P.M. the resident fell on to the floor during a transfer. Blood was noted on his/her right outer ankle. The wound was cleaned with normal saline, pressure was applied, but unable to stop the bleeding. The resident denied pain. At 5:30 P.M. a call was placed to his/her physician. At 5:40 P.M., the on call physician returned the call and new orders were received to send the resident to the emergency room for evaluation of his/her right ankle. At 5:45 P.M., the resident's family member was made aware of his/her fall and orders for him/her to be sent to the hospital for evaluation and treatment of [REDACTED]. At 5:59 P.M., a call was placed to the ambulance service for transport. During an interview on 9/20/16 at 2:55 P.M., CNA B said the evening of 9/11/16 was his/her first time working with the resident, and he/she had only worked at the facility for a couple weeks. CNA B started the shift on another hall, and was pulled to the resident's hall to work after all the day shift staff had already left. CNA B didn't get report on the resident's hall and didn't know transfer status information was posted in the resident room closets. He/she didn't see any transfer information/symbols posted over the resident's bed by the light. Another CNA, who had worked for the facility longer, said the resident could stand and pivot, but they usually left the resident in bed for dinner. The nurse had requested CNA B get the resident up for dinner. CNA B went by what the other CNA said because that CNA had worked at the facility longer than CNA B. CNA B lifted the head of the resident's bed up, moved his/her legs to the side, and placed a gait belt around him/her. The resident was awake, CNA B told the resident he/she was getting the resident up for dinner, and the resident replied okay. The resident stood up, took a step, then another. On the third step the resident said oh, my leg and fell towards CNA B, sliding to the floor. The resident's legs/feet were wrapped with ace bandages and CNA B saw blood coming from the bandaged area. CNA B got Nurse E. During an interview on 9/20/16 at 3:50 P.M., Nurse E said the evening of 9/11/16 was his/her first time working with the resident. CNA B came and got Nurse E. The resident was on the floor and had on a gait belt, ace wraps, and non-skid socks. Nurse E could see blood. It was a horrible sight. Nurse E applied pressure and could not stop the bleeding. Nurse E could not see an injury because the area kept bleeding. Nurse E called the resident's physician and received orders to send the resident to the hospital for evaluation. When Nurse E called the resident's family member, he/she wanted to know how the resident fell because staff were supposed to use a Hoyer lift for transfers. Nurse E checked the resident's care card in his/her room closet and it showed his/her transfer status as a two person assist. CNA B didn't know about the care card and the regular CNA said the resident could stand and pivot. There were two butterflies over the resident's bed, but Nurse E said he/she didn't know what they meant. Review of the resident's hospital records, dated 9/11/16, showed the resident had a fall the week before, resulting in a borderline fracture of the right lower leg. Subsequently, he/she had another fall and lacerated his/her right lower extremity as well as fractured both malleoli (the protuberance on both sides of the ankle joint) on his/her right lower ankle. His/her weight was recorded as 300 pounds. In the emergency room , his/her hemoglobin registered 6.4 (reference range, 14.0 - 18.0) and he/she received 3 units of blood. He/she was taken to the operating room for internal fixation. During an interview on 9/20/16 at 9:00 A.M., the Administrator, DON, and ADON, said on 9/11/16, CNA B (who was newly employed at the facility) was told by another staff member (who had just returned from vacation) the resident could stand and pivot. The CNA was alone and stood the resident up. The resident took a couple steps, his/her ankle fractured, and he/she fell . CNA B should have had another staff member assist him/her. The Administrator said the resident's transfer status was changed after his/her fall on 9/2/16. At the time of the resident's 9/11/16 fall, the resident should've been transferred with a Hoyer lift. During an interview on 9/26/16 at 9:20 A.M., the resident's physician said staff should have followed non-weight bearing orders and transferred the resident with a Hoyer lift. The resident sustained [REDACTED]. The trauma is sometimes accompanied by ligament damage and dislocation), had surgery, and required [DEVICE] treatment. 2. Review of Resident #2's quarterly MDS, dated [DATE], showed the following: -Required two person's assistance for bed mobility, transfers, and toileting; -Balance during transitions, not steady when moving from seated to standing position and only able to stabilize with human assistance, not steady for surface to surface transfers and only able to stabilize with human assistance; -Functional limitation in range of motion, upper extremity impairment on one side, no lower extremity impairment. Review of the resident's care plan, dated 7/27/16, showed the following: -Problem category: activities of daily living (ADLs) functional/rehabilitation potential, the resident required moderate assistance with ADLs. Approaches included transfer with assistance of two staff members with a gait belt; -Problem category: falls. resident had a history of [REDACTED]. A handwritten note, dated 8/30/16, showed the resident slid off his/her bed to the floor with CNAs present who were trying to transfer him/her with stand up lift, no injury, physical therapy (PT) evaluation for transfer training with resident and staff. Review of the resident's physician's orders [REDACTED]. -admission date of [DATE]; -[DIAGNOSES REDACTED]. -Activity level: Full weight bearing; -Up ad lib with assist of wheelchair/walker; -No transfer orders noted; -9/9/16, PT evaluation only; recommend Hoyer lift for transfers, two person transfer. During an interview on 9/22/16 at 11:15 P.M., Physical Therapist G said he/she recommended the resident be transferred with a Hoyer lift because the resident was weak. The resident had MS and weakness in his/her legs and left arm. The resident's right arm was flaccid (weak). The Hoyer lift was recommended for the resident's transfers because he/she could slide out of the stand up lift. The Hoyer lift was the safest for the resident because his/her sitting balance and strength was not good. The therapist wrote the Hoyer lift recommendation on 9/9/16 and expected staff to transfer the resident with the Hoyer lift. Further review of the care plan, updated 9/9/16, showed PT evaluation only; recommend Hoyer lift, two person assist. Review of the facility's order report, showed starting on 9/9/16, the resident's transfer needs included a two person assist with a gait belt and a Hoyer lift. Observation on 9/20/16 at 1:30 P.M., showed CNA C and CNA D prepared to transfer the resident from his/her wheelchair with a stand up lift. Staff placed the padded strap around the resident and hooked it onto the lift. Staff began to raise the resident up in the lift, then lowered him/her, and readjusted the colored loop on the end of the strap. Using the lift, staff raised the resident up again. The resident held onto the lift with his/her left hand, while his/her right hand dangled at his/her side. Staff pushed the resident in the lift into the bathroom for toileting. During an interview on 9/23/16 at 11:50 A.M., CNA C said he/she knew how to transfer the resident because of the care card on the resident's closet door and magnet on the overbed light. The aides updated the care cards. The nurses, DON, ADON, and supervisors check the resident rooms daily, including the care cards, during their rounds. During an interview on 9/23/16 at 3:35 P.M., the DON said the resident's care card showed he/she should be transferred with a stand up lift. The DON and ADON don't always know that a resident's transfer status changed, and that's part of the problem. During an interview on 9/23/16, at 3:45 P.M., the ADON said at one time, night shift thought the resident was inappropriate for the stand up lift and felt the resident's hand was slipping. A therapy evaluation was recommended. The resident's family member didn't want staff to use the Hoyer lift, the resident didn't want to use the Hoyer lift, and the ADON didn't know the order had been written. The resident wanted to keep his/her mobility and continue to use the toilet in his/her bathroom, as opposed to a bedside commode. The ADON was not aware of the Hoyer lift order or transfer status discrepancies and said staff needed to discuss those kinds of concerns with her and the DON. The facility had over 200 residents and the staff did not always communicate with the DON and ADON. 3. During an interview on 9/20/16 at 9:00 A.M., the Administrator, DON, and ADON, said staff are educated on the facility's transfer policies/procedures during orientation. During an interview on 9/20/16 at 4:55 P.M., the DON said ultimately it was the nurses' responsibility to update the care cards with new orders before leaving for the day. Unfortunately not all steps were followed through to make sure all staff were aware of the transfer status changes. During a subsequent interview on 9/22/16 at 11:05 A.M., the DON said the facility had no specific system of when staff were to check the residents' care cards to ensure updates had been made. With the long term care residents, changes were so infrequent. The CNAs and nurses were the frontline staff and knew when changes occur. 4. Review of the facility's transfer and lift policy, effective date blank, showed the resident's transfer ability would be indicated on the standard admission order sheet and added to the physician's orders [REDACTED]. Transaction analysis reports of resident's transfer ability would be run weekly and placed at each nurse's station. A butterfly system identified the transfer status of residents. A transfer butterfly magnet related to the resident's transfer should be above the bed and noted on the care card. Colored butterflies indicated the following: -Orange = one person transfer with a gait belt, -Purple = two person transfer with a gait belt, -Pink = two person transfer with sit to stand lift, -Blue = two person transfer with Hoyer lift. MO 054