Every finding on record at Delmar Gardens of Chesterfield

Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 25 opportunities, two errors occurred, resulting in an 8% medication error rate (Residents #45, and #145). The census was 171 with 166 with certified bed.Review of the facility's Medication Administration-General Guidelines Policy, revised 1/2021, showed: Policy: Only a Registered Nurse (RN), License Practical Nurse (LPN), Certified Medication Aide, or Certified Medication Technician (CMT) are assigned responsibility for preparing, administering and/or record the administration of medications. Medications must be administered in accordance with a physician's order (i.e., the right resident, the right medication, the right dosage, the right route and the right time). Review of the facility's Administration Insulin policy, dated 5/2021, showed:-Remove the pen cap and cleanse the rubber stopper with an alcohol wipe. Attach pen to needle to device;-Prime the pen immediately before injections. Priming is dialing up 2 units (U) of insulin and pressing the button on the pen to shoot some insulin into the air. You should see a drop of insulin at the tip of the needle. More than one prime may be required for new pens;-[NAME] up the dose on the pen as indicated on the order. 1. Review of Residents #45 quarterly MDS, dated [DATE], showed:-Cognitively intact;-Diagnoses included diabetes, neuropathy (decrease in nerves sensation) and chronic kidney disease. Review of the resident's ePOS showed an order dated 7/17/25, for insulin aspart (fast acting insulin) sliding scale before meals and at night. Administer 2 units for a blood sugar of 131 through 180. During a Medication administration observation on 8/4/25 at 11:36 A.M., LPN G administered and verified the resident's electronic medical record (eMar) prior to administration. The resident's blood sugar measured at 217. LPN G administered 3U to the resident. He/She did not prime the insulin pen prior to administration. 2. Review of Resident #145's quarterly [NAME] Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 07/23/25, showed:-Cognitively intact;-Diagnoses included diabetes with chronic kidney disease. Review of the resident's electronic physician order sheet (ePOS), showed an order dated 4/1/25 for: -Lispro (fast acting insulin) 3U three times a day (TID) standard order;-Sliding scale 2U for blood sugars between 200-250. During observation and interview on 8/4/25 at approximately 11:24 A.M., showed LPN G entered the resident's room and explained to the resident the need for an accucheck (blood sugar check). The resident's glucose (blood sugar) measured 200 which required the standing order of 3U plus the sliding of additional 2U making the total of 5U that Resident #145 required. LPN G dialed the insulin pen to 6U, one unit over the physician's order/recommendation. LPN G did not prime the insulin pen prior to administration. 3. During an interview on 8/4/25 at 11:26 A.M., LPN G said he/she adds an extra unit when administering insulin for priming the pen prior to each dose. 4. During an interview on 8/4/25 at 12:28 P.M., the DON said she would expect staff to follow protocol for insulin administration. He/She acknowledge that LPN G failed to follow policy by not placing a needle on the device then priming with 2U of insulin prior to physicians ordered dose. DON said, resident may not have received the ordered dose.

Based on observation, interview, and record review the facility failed to ensure proper storage and labels on medications. For three out of four certified medical technician (CMT) carts checked and one of four medication storage rooms checked. The census was 171 with 166 with certified bed. 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;-No discontinued, outdated, or deteriorated drugs or medications are stored in the facility over the 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 area included drawers, cabinets, rooms, refrigerators, carts and boxes. 1. Observation of the 100-hall medication CMT cart on 8/4/25 at 7:15 A.M., showed a small white pill with markings of 11/x in the far back of the second draw and second column. 2. Observation on the 700-hall CMT cart on 8/4/25 at 10:08 A.M., showed a mini refrigerator that had personal items in a gallon Ziplock bag, to include a 12 ounce can of Mountain Dew and a 20 ounce disposable bottled water.During an interview on 8/4/25 at 6:35 A.M., License Practical Nurse (LPN) J said the Ziplock bag with Mountain Dew and disposable plastic water bottle was his/hers. Staff do not really have a place to put their things. 3. Observation of the 700-hall medication storage room on 8/4/25 at 10:08 A.M., showed:-Five pre-pulled tums in the top drawer without a resident identifier;-A blister pack of vancomycin hydrochloride (antibiotic) 125 milligram (mg) capsule without a resident identifier;-The third drawer on the far-right side had a 20-ounce disposable plastic water bottle.During an interview on 8/4/25 at 6:32 A.M., CMT D said the cart should not have any medications loose in it. He/She did not understand why the pills were there since the blister pack is antibiotics. CMT said, CMT carts should not have any antibiotics. Nurses are only allowed to pass those. He/She was off for the weekend and grabbed the pre-pulled medicine cup in the top drawer to discard the five tums. CMT D grabbed the plastic water bottle and said, that is mine, I will remove it. 4. Observation on the 600 hall CMT cart on 8/4/25 at 9:57 A.M., showed the second drawer contained 26 whole pills of varied sizes, colors and shapes, 14 partial pills of varies sizes, shapes and colors not in pharmacy labeled medication containers. During an interview on 8/4/25 at 9:57 A.M., LPN I nurse said medication carts should be cleaned, and they would not dispense any of the unlabeled pills. 5. During an interview on 8/6/25 at 9:45 A.M., the Director of Nursing said, it is up to the CMT, LPN, and Registered Nurse (RN) to clean the carts as needed. They should clean the carts at the beginning and end of every shift. If loose pills are found on the carts, staff should notify the charge nurse or DON to have the pills discarded immediately. There should be no personal items on medication carts or in the medication storage rooms and refrigerators. This could lead to cross contamination.

Based on observation, interview and record review, the facility failed to ensure staff maintained safe resident transfer techniques during a Hoyer (used for persons who are non-weight bearing) lift (Resident #12) and during a gait belt transfer (Resident #157). The sample was 33. The census was 177 with 166 in certified beds.Review of the transfer and lift policy, reviewed 5/2021, showed:-Purpose: to provide communication to staff regarding the resident's transfer abilities and to assure all precautions are taken to maintain safety of the resident. -Policy: -Upon admission each resident will be assessed by the inter-disciplinary team on the capabilities of how the resident transfers. This will be re-assessed with changes in condition; -A butterfly magnet will be placed inside the resident room on the overhead light or the door frame of the room indicating how the resident transfers. The butterfly will be coded to inform the staff of the resident's transfer ability; -The resident's transfer ability will be indicated in the resident's orders and included on the profile and care plan; -All staff involved in the transfer of residents will be trained on each lift including return demonstration; -When using a mechanical lift to transfer residents, two employees are required to assist in the transfer; -All assisted transfers and ambulation of a resident require the use of a gait belt. Proper placement of the gait belt should be ensured before assisting the resident. 1.Review of Resident #12's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated 6/11/25, showed:-Cognitively intact;-Used a wheelchair for mobility;-Dependent on staff for transfers;-Diagnoses included Alzheimer's disease, bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), heart disease, vascular disease and kidney failure. Review of the resident's care plan, updated 7/18/25, showed:-Problem: the resident had a deficit with mobility;-Goal: the resident will participate in care activities;-Approach: the resident requires a two person Hoyer lift. Review of the physician order sheet (ePOS), showed:-An order, dated 7/28/25: Hoyer lift. During observation and interview on 8/1/25 8:32 A.M., Certified Nurse Aide (CNA) O and CNA P greeted the resident and explained the transfer to the resident. CNA O placed the Hoyer pad under the resident and applied a sling to the lift. CNA O held the back of the chair as CNA P operated the lift. The resident swung freely over bed. CNA P pulled on the lift and maneuvered the resident over the reclining Geri chair (a reclining wheeled chair). No support was given to the resident's legs. As the resident neared the chair, the staff switched places, and for approximately 10 seconds, no staff held onto the Hoyer lift. CNA P pulled on the back of the sling and CNA O operated the lift. As the resident was lowered into the chair, his/her right leg struck the main support post of the lift. The staff did not provide physical support to the resident during the Hoyer transfer and the resident was left with no staff touching the resident as another aide held onto the reclining Geri chair. CNA O and P said they did not preform the transfer correctly. They wanted to conduct the transfer timely. The staff who did not operate the lift, should always have a hand on the resident. The aides switched places for resident positioning. The resident swung unattended as the staff switched places. During an interview on 8/6/25 at 9:45 A.M., the Director of Nursing (DON) said when staff conduct a Hoyer lift, the staff not operating the lift should keep hands on the resident to ensure resident legs or arms do not hit the lift. Staff should not switch places during the transfer. 2. Review of Resident #157's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment;-Required partial to moderate staff assistance;-Diagnoses included neurocognitive disorder with Lewy bodies (progressive brain disorder that affects thinking, movement, behavior, and sleep), muscle weakness (generalized), seizures, and Parkinson's disease without dyskinesia (uncontrolled, involuntary muscle movement). Observation on 7/31/2025 at 12:18 P.M., showed CNA Q and CNA R placed a gait belt around the resident's abdomen. CNA Q and CNA R grabbed the resident under his/her arm and lifted the resident to his/her feet. The resident did not appear to be fully alert as the CNAs walked the resident to his/her seat in the dining room. Review of the resident's care plan, showed: -An updated entry on 8/1/2025: updated to transferring x1 assist. During an interview on 8/5/2025 at 9:54 A.M., CNA Q said, staff are made aware of how a resident is transferred by the butterfly system. Each resident has a butterfly outside their door, or staff can find the information in the binder located at the nurse's desk. CNA Q said a gait-belt is positioned above the naval and placed snugly around the waist. CNA Q said staff should not grab a resident underneath the arms or wing lifting. Lifting a resident under the arms could cause bruising, soreness or injury. During an interview on 8/5/2025 at 10:06 A.M., CNA R said he/she is made aware of how someone ambulates and transfers by the butterfly system. The butterfly is placed on the outside of the doorframe. CNA R said residents should not be transferred under the arms. The gait belt should be used in the transfer. During an interview on 8/5/2025 at 12:00 P.M., Physical Therapy Manager (PTM) said the resident experienced some decline. PTM said staff should not pull on or underneath arms to lift a resident. Incorrect transfer techniques could cause physical damage to the shoulder or nerves. If a resident became more difficult to transfer, the staff are expected to communicate the change to therapy. During an interview on 8/6/25 at 9:45 A.M., the DON said gait belts should be applied snugly around the resident's waist. There should be enough room for one finger to slip between the belt and the resident. Residents who require a gait belt transfer, should not be lifted under the arms. Staff should use the gait belt to support the resident's weight.

Based on observation, interview and record review, the facility failed to ensure one resident (Resident #6) received gastrostomy tube (g-tube, a tube surgically inserted into the abdomen used for liquid nutrition, fluids and medications) feedings at the specified times as ordered by the physician and to ensure the resident's head of bed (HOB) was elevated to prevent aspiration (choking). The sample was 33. The census was 171 with 166 in certified beds.Review of the facility's Tube Feeding policy, revised June, 2021, showed:-Purpose: to deliver a continuous, regulated drip feeding to gastrostomy tube-fed residents using an enteral (delivering nutrition and medications through the gastrointestinal system) 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 with 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. Review of the facility's Aspiration Precautions policy, reviewed June, 2021, showed:-Purpose: To ensure that precautions are taken in order to prevent aspiration of a resident;-Definition: Aspiration is defined as the inhalation of food, saliva, medication or other foreign material int the trachea (windpipe) and lungs; Any material can be aspirated on the way to the stomach or as stomach contents are refluxed (return) back into the throat;-Guidelines on how to minimize the risk of aspiration: Keep the resident's HOB elevated 30-45 degrees. Review of Resident #6's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/11/25, showed:-Cognitively intact;-Coughs or chokes during meals and taking medications;-Complaints of difficulty or pain with swallowing;-The resident has a feeding tube;-Proportion of total calories the resident receives through tube feeding: 51%;-Diagnoses included malnutrition (poor nutritional status), muscle weakness and dysphagia (difficulty swallowing). Review of the resident's care plan, in use during survey, showed:-Problem: The resident requires a feeding tube related to his/her dysphagia and recurrent aspiration;-Approach: The resident receives Jevity 1.5 calorie (cal), a type of liquid nutrition, at 80 milliliters (mls) an hour for 18 hours, 4:00 P.M. through 10:00 A.M.; Administer medications through the feeding tube; Elevate HOB to thirty degrees while tube feeding, medications, and water flushes are being administered. Review of the resident's physician order sheets (POS), dated July, 2025, showed:-An order, dated 7/18/25, Jevity 1.5 cal at 80 mls per hour for 18 hours; On at 4:00 P.M. and off at 10:00 A.M.;-An order dated, 7/8/25, elevate HOB 30 degrees; For your information (FYI) only. Review of the resident's Medication Administration Record (MAR), dated July, 2025, showed:-An order, dated, 7/18/25, Jevity 1.5 cal. at 80 mls per hour for 18 hours; On at 4:00 P.M. and off at 10:00 A.M.;-Time: Days 7:00 A.M. through 3:00 P.M.; -On 7/19 through 7/31/25, day shift documented tube feeding: Off;-Time: Evenings 3:00 P.M. through 11:00 P.M.;-On 7/18 through 7/31/25, evening shift documented tube feeding: On;-Time: Nights: 11:00 P.M. through 7:00 A.M., -On 7/18 through 7/31/25 night shift documented tube feeding: On;-No specific time was listed on the MAR for staff to start the tube feeding or to stop the tube feeding. -No order for the resident's HOB to be 30 degrees was noted. Review of the resident's POS, dated August, 2025, showed:-An order, dated 7/18/25, Jevity 1.5 cal at 80 mls and hour for 18 hours; On at 4:00 P.M. and off at 10:00 A.M.; Discontinue date, 8/4/25;-An order, dated 7/8/25, elevated HOB 30 degrees; For your information (FYI) only. Review of the resident's MAR, dated August, 2025, showed:-An order, dated, 7/18/25, Jevity 1.5 cal at 80 mls per hour for 18 hours; On at 4:00 P.M. and off at 10:00 A.M.; Discontinued date, 8/4/25;-Time: Days 7:00 A.M. through 3:00 P.M.; -On 8/1 through 8/3/25, day shift documented tube feeding: Off;-Time: Evenings 3:00 P.M. through 11:00 P.M.;-On 8/1 through 8/3/25, evening shift documented tube feeding: On;-Time: Nights: 11:00 P.M. through 7:00 A.M., -On 8/1 through 8/3/25 night shift documented tube feeding: On;-No specific time was listed on the MAR for staff to start the tube feeding or to stop the tube feeding. -No order for the resident's HOB to be 30 degrees was noted. During observation and interview on 7/31/25 at 5:40 P.M., the resident lay in bed on his/her back and his/her HOB was approximately 10 degrees. The resident had a gastrostomy tube located in his/her abdomen. The resident had a tube feeding pump positioned on a pole, turned off and no tube feeding attached to the resident. The resident said his/her tube feeding is frequently hung late. It concerns him/her because the tube feeding is the only nutrition he/she received At 5:45 P.M., the resident placed his/her call light on and Licensed Practical Nurse (LPN) M entered the resident's room. The resident informed LPN M his/her tube feeding should have been started at 4:00 P.M. LPN M said he/she would check. LPN M returned to the resident room at approximately 6:00 P.M. and prepared the resident's tube feeding for administration.During observation and interview on 8/1/25 at 9:20 A.M., the resident lay in bed. The resident's HOB was elevated approximately 10 degrees. The resident said he/she has a pocket in his/her throat, and it makes it difficult for him/her to swallow. The resident said while at home, he/she had a choking episode and aspirated, and the stomach contents went into his/her lungs causing pneumonia. Observation showed the tube feeding bag was connected to the resident. The tube feeding pump alarmed and the resident's tube feeding bag was empty. The resident said it had been alarming for about 10 minutes. Certified Nursing Assistant (CNA) L entered the resident's room and said he/she would tell the nurse. At 9:30 A.M., the resident's tube feeding pump was turned off and remained attached to the resident. The resident's HOB remained at approximately 10 degrees. The tube feeding was stopped before 10:00 A.M. During an interview on 8/5/25 at 1:55 P.M., LPN K said the resident's orders on the MAR did not address the specific time the resident's tube feeding was to be started or stopped. Having the orders days, evenings and nights was too broad. The orders on the MAR should reflect the tube feeding is to be placed on at 4:00 P.M. and off at 10:00 A.M. The resident is not confused, and he/she will tell the staff if something is not done. It is important for the resident to receive all his/her tube feeding as ordered because that is his/her only nutrition he/she received. LPN K said the resident's HOB should always be at 30 degrees because he/she has a history of aspiration. During an interview on 8/6/25 at 8:51 A.M., Certified Medication Technician (CMT) D said residents who require tube feeding should have their HOB elevated 30 degrees so the stomach contents do not come back up. If the resident can use the bed controller by themselves, then more education needs to be given to the resident related to the HOB. During an interview on 8/6/25 at 10:25 A.M., CNA N said the resident's HOB should be at 30 degrees or higher since he/she is on tube feeding and has a history of aspiration. During an interview on 8/4/25 at 11:15 A.M. and on 8/6/25 at 9:50 A.M., the Director of Nursing (DON) said the resident's tube feeding orders needed to be clarified to reflect an actual time the tube feeding needed to be started and when it needed to be stopped to ensure there is no delay in the resident receiving his/her nutrition. The DON could not produce a report showing the actual times of the resident's tube feeding being started or stopped when requested. She expected staff to follow the physician orders and not delay in starting the tube feedings. She also expected staff to have enough tube feeding in the bag to complete the entire cycle of tube feeding. She expected staff to ensure the resident's HOB was at 30 degrees to prevent aspiration.

Based on interview and record review, the facility failed to ensure the attending physician documented actions taken to address irregularities noted by the pharmacist for one of three residents sampled for medication regimen reviews (Resident #7). The sample was 33. The census was 171 with 166 in certified beds.Review of the facility's Pharmacist Consultant Duties and Responsibilities policy, reviewed May 2021, showed:-Purpose: To ensure that drug regimen reviews, medication pass observations, and medication audits are performed in accordance with state and federal regulations;-Drug regimen review (DRR):-Policy: The consultant pharmacist reviews the medications for each resident for any irregularities and to: verify appropriateness of the medications involved; evaluate disease state management; ensure appropriate medication monitoring to maximize safety and efficacy; and prioritize patient goals, safety, and quality of life;-Procedures: --The consultant pharmacist reviews each resident chart to identify and address any irregularities;--The consultant pharmacist will review the chart of every resident at every facility each month;--All recommendations (including no recommendations) will be printed each month (within 72 hours of completing the all of the DRR's in the facility) and sent to the corresponding Director of Nursing (DON) to distribute appropriately and get completed; -Individual recommendations (one page per recommendation) directed to physicians and nursing staff will be sent to the DON to distribute to individual charts and get completed; -Pharmacy consults should be signed, completed, and acted on within 30 days of being sent to the facility; -The facility should write a description of their attempts to get the consult completed on the actual consult (or in response to the observation in the electronic medical record (EMR). For example, faxed to physician on these dates: put in physician mailbox on this date, etc.; -Each month the consultant pharmacist will follow up on previous consults; -Physician consults will be repeated two months later if not completed. Review of Resident #7's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/4/25, showed:-Resident rarely/never understood;-Short and long-term memory problem;-Diagnoses included non-traumatic brain dysfunction, Alzheimer's disease, dementia, seizure disorder, traumatic brain injury (TBI), anxiety disorder;-Antipsychotic medication received on a routine basis;-Has a physician documented gradual dose reduction as clinically contraindicated: No. Review of the resident's medical record, showed:-Primary Care Physician listed as Physician U;-Psychiatrist listed as Physician V;-A physician order, dated 4/8/24, for quetiapine (antipsychotic medication) 50 milligrams (mg), three times a day. Diagnoses: dementia in other diseases classified elsewhere with behavioral disturbance. Note: TBI and Alzheimer's disease. Ordered by Physician U. Review of the resident's Pharmacist's Recommendations to Prescriber, dated 1/20/25, showed:-Resident is on hospice and has received the antipsychotic quetiapine 50 mg, take one tablet by mouth every morning, every evening, and at bedtime since 4/8/24 for the indication of dementia in other diseases classified elsewhere, severe, with other behavioral disturbance;-Based on information in the chart, resident does not appear to be a candidate for possible dose reduction. However, the required physician documentation of a clinical contraindication to a dose reduction is not present;-Please select a response below: Blank;-Prescriber's response: Box checked for Other, with a handwritten note, Refer to psychiatrist. Signed by Physician U. Review of the resident's Pharmacist's Recommendations to Prescriber, dated 2/28/25, showed:-Attention psych: please see the consult below (PCP referred consult to psych);-Resident is on hospice and has received the antipsychotic quetiapine 50 mg, take one tablet by mouth every morning, every evening, and at bedtime since 4/8/24 for the indication of dementia in other diseases classified elsewhere, severe, with other behavioral disturbance;-Based on information in the chart, resident does not appear to be a candidate for possible dose reduction. However, the required physician documentation of a clinical contraindication to a dose reduction is not present;-Please select a response below: Blank;-Prescriber's response: Box checked for Other, with a handwritten note, Patient under hospice care, may refer to psych. Signed by Physician U. Review of the resident's Pharmacist's Recommendations to Prescriber, dated 4/15/25, showed:-Attention psych: please see the consult below (PCP referred consult to psych);-Resident is on hospice and has received the antipsychotic quetiapine 50 mg, take one tablet by mouth every morning, every evening, and at bedtime since 4/8/24 for the indication of dementia in other diseases classified elsewhere, severe, with other behavioral disturbance;-Based on information in the chart, resident does not appear to be a candidate for possible dose reduction. However, the required physician documentation of a clinical contraindication to a dose reduction is not present;-Please select a response below: Blank;-Prescriber's response: Blank. Review of the resident's Pharmacist's Recommendations to Prescriber, dated 6/7/25, showed:-Attention psych: please see the consult below (PCP referred consult to psych);-Resident is on hospice and has received the antipsychotic quetiapine 50 mg, take one tablet by mouth every morning, every evening, and at bedtime since 4/8/24 for the indication of dementia in other diseases classified elsewhere, severe, with other behavioral disturbance;-Based on information in the chart, resident does not appear to be a candidate for possible dose reduction. However, the required physician documentation of a clinical contraindication to a dose reduction is not present;-Please select a response below: Box checked for Other;-Prescriber's response: Box checked for Other, with a handwritten note, Refer to psych. Signed by Physician U. During an interview on 8/6/25 at 9:45 A.M., the DON said the pharmacist conducts medication regimen reviews monthly. The pharmacist enters their recommendations in the resident's EMR and a paper copy is given to the DON. The DON gives the pharmacist's recommendation to the appropriate physician. The physician reviews the recommendation, documents their response, and gives the form back to the DON. If the primary care physician (PCP) says to refer to psychiatry, the DON puts the resident on the list of residents to be seen during the psychiatrist's next visit to the facility. The PCP is the one who documents the response on the pharmacist's recommendation form. Resident #7's pharmacist recommendations go to his/her PCP, Physician U, and his/her psychiatrist, Physician V. The physician responding to the pharmacist recommendations should document a specific response to address the pharmacist's recommendation. During an interview with the Assistant Administrator and Administrator on 8/6/25 at 10:24 A.M., they said when the pharmacist notes irregularities during a medication regimen review, the prescribing physician should document their response to address irregularities, including documentation of a clinical contraindication to a dose reduction. if recommended. The physician's response should be completed within timeframes outlined in regulatory requirements and in accordance with facility policy.

Based on observation, interview and record review, staff failed to following policies and procedures regarding hand hygiene and enhanced barrier precautions (EBP) prior to applying protective personal equipment (PPE) and touching the resident (Resident #12). The sample was 33. The census was 177 with 166 in certified beds.Review of the enhanced barrier precautions (EBP) policy, revised 8/2024, showed:-Purpose: to reduce the spread of multi-drug resistant organisms (MDRO, various bacteria that are resistant to various antibiotic therapies);-Definitions: -EBPs are indicated for residents with any of the following: -Infection or colonization with a MDRO when contact precautions do not apply; -Wounds even if the resident is not known to be infected or colonized with a MDRO;-Procedure: -Residents with colonization of MDRO and/or with indwelling medical devices (intravenous lines) will be placed on EBP; -Signage placed outside the room to alert staff that personal protective equipment (PPE) including gowns and gloves, will be available in an area accessible to use when high contact resident care activities are anticipated; -PPE should be worn with during high-contact resident care activities: dressing, transferring, and changing briefs. Review of the handwashing policy, revised 1/2021, showed:-Purpose: provide guidelines to employees for proper and appropriate hand washing techniques that will aid in the prevention of the transmission of infection;-When to wash hands: -Before and after each resident contact; -After contact with body fluids; -After handling any contaminated items (linens, soiled briefs, etc). Review of Resident #12's medical record, showed:-re-admitted from the hospital: 7/28/25;-Full staff assistance needed for daily care and hygiene needs. Review of the hospital Discharge summary, dated [DATE], showed:-Admitting diagnosis: Monoarthritis (inflammation and pain in a single joint) of the right knee;-Surgical irrigation and debridement to the right knee;-Hospital cultures grew: Escherichia coli (E.coli);-Orders: Ceftriaxone (Rocephin, antibiotic) 2,000 milligrams (mg) for infusion. Administer one dose by IV every 24 hours for 36 days. Review of the progress notes, showed:-On 7/28/25 at 5:07 P.M., a nurse note: the resident re-admitted with orders for IV antibiotics for 36 days. Noted a peripherally inserted central catheter (PICC, used for long term antibiotics) line to the left upper arm. Multiple small surgical incisions noted to the right knee;-On 7/29/25 at 8:11 P.M., a nurse note: received new orders for laboratory blood work to be completed and faxed to infectious disease physician;-On 7/29/25 at 9:51 P.M., a nurse antibiotic note: -Medication in use for infection: ceftriaxone; -Type of infection: right knee; -Adverse reactions from antibiotic: no; -Current signs and symptoms: IV antibiotic therapy; -Are vitals within normal limits: yes. Observation on 7/31/25 at 10:48 A.M., showed the resident's outer bedroom door frame had an EBP magnet noted on the door frame. Inside the room, over the bathroom door hung PPE supplies, which included yellow gowns, gloves and masks. Observation on 8/1/2025 at 8:32 A.M., showed Certified Nurse Aide (CNA) O and CNA P entered the resident's room, and explained care to the resident. Neither aide performed hand washing, and both applied gloves. The aides did not apply gowns before placing the sling pad under the resident. The aides completed the transfer and verified the resident's comfort. The aides removed their gloves and performed hand hygiene. CNA O and CNA P said they were unaware the resident's care required EBP. Neither aide observed the EBP PPE on the bathroom doorway. The aides did not observe the EBP magnet on the outside of the doorway. Observation on 8/4/2025 6:35 AM, showed CNA S and CNA T entered the resident's room. Neither aide performed hand hygiene and applied a gown and mask. CNA T applied gloves. CNA S did not. CNA T unfastened a wet brief and tucked the brief under the resident's hips and between the legs. CNA S placed his/her bare hands on the resident's hip, stopped, then applied gloves and assisted the resident to turn onto his/her side. The aides removed the gowns and gloves in the room, held used PPE in their bare hands, exited the resident's room walked across the hallway to the soiled utility room and disposed of the used PPE in the soiled utility room. During an interview on 8/5/2025 at 10:41 A.M., the Director of Nursing said staff should wash their hands when entering a resident's room. Gloves should be applied before starting care tasks. Staff should don full PPE for residents identified as needing EBP. All used PPE should be disposed of in the resident's room and not carried outside of the room. Failure to perform hand hygiene and apply required PPE prior to care could spread infection.

Based on interview and record review, the facility failed to ensure one discharged resident's (Resident #131) Oxycodone (narcotic used to treat pain) and one resident's (Resident #185) discontinued Ativan (used to treat anxiety) were appropriately destroyed in accordance with the facility's policy and free from medication misappropriation. The facility started the investigation when the Assistant Director of Nursing (ADON) questionably destroyed a resident's discontinued Hydrocodone (Resident #113). The ADON admitted to taking the discontinued medications of Resident #131 and Resident #185 for personal use. She provided the card of Oxycodone and the bottle of Ativan at the time of questioning. The census was 177 with 166 in certified beds. The Administrator was notified on 8/6/25, of the past non-compliance. Upon notification of the misappropriation allegation on 6/25/25, the facility immediately suspended staff, investigated and implemented abuse/neglect in-servicing to all facility staff. The training also included training on narcotic medication destruction. During the onsite investigation, interviewed staff verified in-servicing and verbalized education. The deficiency was corrected on 6/29/25.Review of the Abuse, Neglect and Misappropriation policy, revised 9/22, showed:-Policy: to maintain a work and living environment that is professional and residents are free from threat of abuse or misappropriation of property;-Residents must not be subjected to abuse;-Definitions: -Misappropriation of property: means the deliberate misplacement, exploitation or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent;-Procedure: -On going education: annually, in-service programs shall be presented which encompass: -Identifying, intervening and reporting situations in which occurrences of unexplained misappropriation of resident property may occur;-Procedure for investigation: -Any employee suspected of violation of safety policies may be suspended pending investigation; -Staff found to be in violation of the resident safety policies may be reported to local law enforcement as appropriate; -Summaries of the investigation will be reviewed during quality assurance and assessment committee meeting for re-evaluation of policies and procedures, if warranted, to prevent further occurrences. Review of the controlled substance medication policy, showed:-Purpose: to outline procedures to accurately maintain records of controlled substance medications;-Procedure: Destruction of controlled substance medications: -Only two licensed nurses or a licensed nurse and pharmacist may destroy controlled substances. 1. Review of Resident #113's medical record, showed: -Diagnoses included lower back fracture, hip arthritis, heart failure, diabetes, depression and anxiety. Review of the June Medication Administration Record (MAR), showed:-An order, Hydrocodone 10-325 mg, administer one tablet four times a day for pain. Thirty documented refusals. Review of the physician order sheet (POS), showed:-An order, dated 6/19/25 to discontinue Hydrocodone 10-325 milligrams (mg) four times a day. Review of the progress notes, dated 6/19/25 at 5:17 P.M., showed a nurse note: new orders to discontinue Hydrocodone 10-325 mg. 2. Review of Resident #185's progress notes, dated 5/30/25 at 1:10 P.M., showed a nurse note: the resident admitted to the facility following a left femur fracture and surgical repair. Alert and oriented, able to make needs and wants known. Weight bearing as tolerated and stand by assist with transfers. Review of the POS, showed an order, dated 5/30/25: Oxycodone 5 mg, take 2.5 mg tablet as needed (PRN) for pain. Review of the progress notes, dated 5/31/2025 at 4:42 A.M., showed a nurse note: the resident ambulates with one assist and the walker. He/She denied pain. Review of the May 2025 MAR, showed:-An order, dated 5/30/25, to monitor of pain during the day and medication passes. On 5/30/25 and 5/31/25, showed a 0 or no pain reported;-On 5/31/25 at 6:27 P.M., a documented administration of oxycodone and the administration was effective. Review of the admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/6/25, showed:-Received rehabilitation services;-Able to make needs and wants known;-Diagnoses included heart failure, renal failure, hip fracture and dementia;-Received routine and as needed pain medications;-Surgical repair to the left hip. Review of the care plan, revised 6/12/25, showed:-Problem: Pain: the resident is at risk for discomfort related to surgical left hip pain;-Goal: the resident will remain pain free;-Approach: assess pain level, provide medication and document effectiveness and identify the source of the pain. Review of the June 2025 MAR, showed:-Monitor for pain during A.M and P.M. med passes twice a day. Pain ratings noted at 0;-On 6/7/25 at 3:25 P.M., an administration of oxycodone, documented as effective;-On 6/11/25 at 8:14 P.M., an administration of oxycodone, documented as effective. Review of the progress notes, dated 6/17/25 at 2:00 P.M., showed a nurse note: the resident discharged to assisted living. No complaints of pain. Review of the resident's June POS, showed an order, dated 6/18/25: discontinue oxycodone 5 mg, take 2.5 mg PRN for pain. 3. Review of Resident #131's quarterly MDS, dated [DATE], showed:-Moderate cognitive impairment:-Diagnoses included high blood pressure, Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), and anxiety;-Received hospice services. Review of the current care plan, showed:-Problem: behaviors during care;-Goal: no behaviors and accept care from staff;-Approach: approach with acceptance, administer medications as ordered. Review of the May 2025 POS, showed:-An order: 5/30/25 for Ativan 0.5 mg every eight hours for anxiety.-An order: 6/6/25 to discontinue oral Ativan, and begin liquid Ativan 0.25 ml every two hours PRN for anxiety. Review of the June 2025 MAR, showed an order for Lorazepam (Ativan, used for anxiety) , administer 0.25 ml every two hours, PRN for anxiety. Documented as administered and effective on 6/6/25 at 4:10 A.M., and 6/26/25 at 11:13 A.M. 4. Review of the facility's investigation, dated 7/1/25, showed:-The facility DON reported to management concerns of medication misappropriation by the ADON. The ADON did not follow the policy regarding medication destruction. The ADON admitted to taking controlled substances. Upon further investigation, the ADON produced Resident #185's discontinued Oxycodone and a bottle which contained Resident #131's discontinued Lorazepam; -The police department was notified and responded to the facility. The ADON was suspended;-The facility implemented immediate in-servicing regarding the facility policy and procedures regarding controlled medication handling and destruction. 5. During an interview on 8/5/25 at 12:13 P.M., Licensed Practical Nurse (LPN) A said he/she was in-serviced regarding the facility policy to account and destroy discontinued narcotics. Narcotics should be destroyed with two nurses present. 6. During an interview on 8/5/25 at 12:51 P.M., LPN B said when he/she reported to work on 6/19/25, the ADON asked him/her for the nurse cart keys. The ADON asked where the narcotics were located in the medication cart. The ADON said he/she was going to remove Resident #113's discontinued card of Hydrocodone (Norco, used to treat moderate pain) and destroy the narcotics. There was one card of 60 and one card of 6. The ADON removed the card of 60 and left the card of 6 in the medication cart. LPN B entered the ADON's office later in the afternoon to destroy the card of 6 pills and the card of 60 Hydrocodone was not noted. He/She did not know where the card of 60 was located. The ADON said she threw away the card that contained the 60 pills. LPN B reported the concern to the facility Director of Nursing (DON). He/She had been in-serviced on policies and procedures to destroy narcotic medications with two nurses. 7. During an interview on 8/5/25 at 1:22 P.M., LPN C said he/she had been in-serviced on the appropriate way to destroy narcotic medications. The in-servicing included the requirement to have two nurses present to destroy all medications. 8. During an interview on 8/5/25 at 2:41 P.M., the DON said she was made aware by LPN B the ADON had asked for the nurse cart keys to remove discontinued narcotics from the cart for destruction. The DON notified upper management and started the investigation. Upon further investigation, LPN B informed him/her regarding the discontinued Hydrocodone pills. Mediprocity (a secure, patient confidential compliant communication and medication management system) showed 6 of the 60 Hydrocodone pills were destroyed by LPN B and the ADON, however, the system did not reflect destruction of 60 of the pills. When the ADON was interviewed, she stated she threw the card of 60 away. The ADON was suspended, and management requested drug testing. The drug test was negative. The ADON was questioned several times in person. During the questioning, she produced an unlabeled and unidentified medication card of 24 tablets and a bottle of 20 discontinued Ativan tablets for personal use. The police were called. The facility did not press charges on taking the discontinued medications and is supporting the ADON in therapy options. All Certified Medication Technicians (CMT) and nurses have been in-serviced on the facility policy regarding medication destruction. 9. During an interview on 8/11/25 at 11:45 A.M., the DON said when LPN B reported to her the ADON had asked for the medication cart keys and then removed Resident #113's 60 tablets of Hydrocodone for destruction, it set of red flags. LPN B told the DON said that he/she and the ADON later destroyed the remaining card of 6 Hydrocodone but LPN B did not see the card of 60 in the ADON's office. The Hydrocodone had been discontinued due to not being used by Resident #113. The order to discontinue Resident #113's Hydrocodone medication was obtained by the ADON from the resident's physician. Management interviewed the ADON several times and during the questioning, she produced a card of 24 tablets of unidentified medications. She identified the medication as Resident #185's discontinued oxycodone. The ADON said she had torn the label off the medication card so it could not be identified. In addition, she produced a bottle of Ativan, which contained 20 tablets. She identified the Ativan as Resident #131's. The order had changed, and the ADON had the discontinued bottle on her person. The Ativan bottle had the ADON's name on it. The ADON said she poured the resident's discontinued Ativan into her own old Ativan bottle, so that it appeared the Ativan was her own. The concerns regarding the ADON started with LPN B's concern of Resident #113's Hydrocodone. It was during her interview she produced the discontinued medications that belonged to Residents #131 and #185. 1632884

Based on interview and record review, the facility failed to ensure a discharge summary was completed, including a recapitulation of the resident's stay and final summary of the resident's status at the time of discharge (Resident #7). The sample was 14. The census was 168. Review of the discharge or transfer policy, dated January 2021, showed: -Purpose: -To provide prompt and safe discharge/transfer of a resident from the facility and to ensure continuity of care through provisions of pertinent resident information; -To provide orientation for a resident being discharged /transferred to ensure a safe and orderly transition home or to a new living environment; -Procedure: -A discharge summary observation will be completed for all residents who: -Discharge to a private residence/home or independent retirement community; -Transferred to another facility; -The nurse will obtain an order from the physician for transfer/discharge or a resident as well as release of medications; -discharged to residence/home or independent retirement community: -Discharge summary; -Any prescriptions; -Follow up physician appointments or labs; -If home care is ordered, fax, scan or email the following to the home care of choice: -Discharge summary observation, Physician Order Sheet (POS), face sheet, advance directives/living will, nurse notes, therapy notes, lab/x-ray reports, most recent Minimum Data Set and Care Plan, physician progress notes, list of medications and copy of the Medication Administration Record (MAR), skin testing; -Reconcile the pre-admission and post discharge medications and review the medication regimen with the resident and/or representative. Call the resident's pharmacy of choice if medications need to be ordered; -If being discharged home or to an independent retirement community and the meds are bubble packaged, refer to the discharge plan for med set-up policy; -If transportation is being provided by an emergency transportation complaint, the notification to Emergency Medical Services (EMS) personnel if the resident is an at risk behavioral health patient; -Prepare the resident for transfer/discharge. Pack all personal items and document on the inventory form; -The nurse will complete a progress note in the medical record, that includes: -Physician; -Physician discharge order, including time and date the order was obtained; -List of medications sent with the resident/family member; -Disposal/returned medications; -Location resident was discharged /transferred to; -Who transported the resident (ambulance, family etc); -Diagnoses of resident and reason for discharge/transfer; -Signature of nurse completing the summary; -Resident and/or resident representative must sign the discharge summary observation and the POS; -Copy of signed discharge summary and POS will be scanned into the electronic health record (EHR). Review of Resident #7's medical record, showed: -admitted to the facility: 11/14/24; -discharged : 3/18/25; -Diagnoses included vascular disease, heart failure, left shoulder cuff tear, long term use of diuretics and anticoagulants and stroke. Review of the POS, showed: -An order dated 3/18/25: discharge home with medications, home health, and therapy; -Atorvastatin (used for heart disease) 20 milligram (mg). Take one tablet daily; -Bumetanide (used for edema) take one tablet daily; -Cyclobenzaprine (used for muscle relaxant) 5 mg. Take one tablet three times a day; -Dilitazem (used for blood pressure) 30 mg. Take one tablet every six hours; -Eliquis (used to thin the blood) 5 mg. Take one tablet twice a day; -Furosemide (used for edema) 40 mg. Take one tablet once a day; -Levofloxacin (antibiotic) 500 mg. Take once tablet twice a day; -Lidocaine patch (used to treat pain) 4 percent (%). Apply once patch twice a day to left shoulder; -Mirtazapine (used for depression) 7.5 mg. Take once daily at bedtime; -Simbrinza (used to treat eye dryness) 0.2%. Apply one drop in both eyes twice daily; -Vancomycin (antibiotic) powder 900 micrograms (mcg)/mg. Apply daily to clean right toe, cover with dry dressing; -Warfarin (blood thinner) 4 mg. Take one tablet daily at bedtime. Review of the resident's care plan, dated 11/18/24, showed: -Problem: discharge plans: the resident has a goal of returning to prior living arrangements at home with family support; -Goal: the resident will transition into the community; -Approach: referrals as needed, nursing to provide teaching and evaluations, provide frequent feedback to resident/family on progress. Review of the progress notes, showed: -On 11/18/24 at 2:41 P.M., a social worker (SW) note: care conference held today with family, therapy and nursing. The resident had been living independently prior to the hospital. The resident may not be able to return home due to several health concerns at present time. He/She has some current skin conditions the facility is managing. SW will follow for discharge planning; -On 11/27/24 at 12:22 P.M., a social service note: care plan meeting held with resident, family and therapy. The resident and family agreed to remain at the facility while a space at an assisted living (AL) level II is pursued. The family was notified the resident will not be able to return home alone, as he/she needs a level of supervision. Referrals sent to agreeable facilities; -On 12/16/25 at 11:03 A.M., a social service note: the resident's family continued to be referred to an assisted living facility. However, most decline due to wound care needs, and AL facilities are recommending resident remain in house until the wounds resolve; -On 3/7/25 at 3:17 P.M., a nurse note: the resident's prothrombin ratio and international normalized ratio (PT/INR, measures how long it takes blood to clot) reported to the physician. New order received to continue 4 mg daily; -No further progress notes in the resident's medical record. Review of the physician's Discharge summary, dated [DATE], showed: -admission date: 11/14/24; -discharge date : [DATE]; -Diagnoses: peripheral vascular disease, heart failure, atrial fibrillation (a-fib, is an irregular heart rhythm), malnutrition; -discharged home with home health, therapy, nursing, meds and belongings; -Signed: 3/21/25. During an interview on 4/10/25 at 11:04 A.M., the Director of Nursing said when a resident discharges home or to another care facility, the electronic medical record should have a discharge summary from all departments. The summary should include the medications, recapitulation of stay, if home health is ordered and what company, list of medications and how many were sent with the resident, and any follow up appointments.

Based on observation, interview and record review, the facility failed to follow their policy to provide the necessary care to prevent pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) for one resident who was at high risk for pressure ulcers and developed a new pressure ulcer (Resident #10) and for a resident who was at risk for pressure ulcers and had an existing pressure ulcer (Resident #11). The sample size was three. The census was 168. Review of the Long Term Care Facility Resident Assessment Instrument User's Manual, Version 3.0, Chapter 3, Section M, defines the different stages of pressure as follows: -Stage I: an observable, pressure related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in skin temperature, tissue consistency, sensation, and/or a defined area of persistent redness; -Stage II: Partial thickness loss of dermis (the inner layer that makes up skin) presenting as a shallow open ulcer with a red-pink wound bed, without slough (non-viable yellow, tan, gray, green or brown tissue). May also present as an intact or open/ruptured blister; -Stage III: full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining (destruction of tissue or ulceration extending under the skin edges) or tunneling (a passage way of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound); -Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color) may be present on some parts of the wound bed. Often includes undermining and tunneling. Review of the facility's Wound Care Protocol, dated 7/23, showed: -Prevention and early interventions goals: To identify residents at risk for pressure ulcers and to create an environment to promote the prevention of pressure ulcers; -Prevention: Turn and reposition; Manage moisture and shear (a horizontal force that causes the bony prominence to move across skin causing it to tear); Charge nurse responsible for reviewing each risk factor and potential causes individually and provide interventions written on the care plan; -Treatment: Offer routine toileting; -For residents with Stage I or Stage IV pressure ulcers: adjust turning schedule to eliminate turning to compromised area; reduce shearing forces; use positioning devices to avoid placing resident on an ulcer; turn and reposition, offer routine toileting. 1. Review of Resident #10's care plan, dated 1/30/25, showed: -Problem: Incontinent of bowel and bladder related to history of incontinence, reduced cognition, mobility deficits and need for assistance with all transfers and lower body clothing management and hygiene. Interventions included: check for incontinence frequently and provide prompt perineal care (peri-care, washing the front and back of the hips, genitals, anal area and buttocks) to prevent skin damage; -Problem: Deficit in activities of daily living (ADLs) functioning and mobility and required assistance. Interventions included: Assist with repositioning in bed and in wheelchair frequently; -Problem; At risk for pressure ulcers. Interventions included: history of Stage II pressure ulcer to coccyx (tailbone); Monitor skin for any redness, bruises or open areas. Review of the resident's Braden scale assessment (for predicting pressure ulcer risk) dated 2/8/25, showed the resident was at high risk. Review of the resident's Continuity of Care Document, dated 4/8/25, showed: -Diagnoses included atrial fibrillation (irregular heart rhythm), dementia, chronic kidney disease (CKD, impaired kidney function) and stroke; -Received hospice (end of life care) services. Review of the resident's Medication Administration Record (MAR), dated 3/9/25 through 4/8/25, showed: -An order dated 2/6/24, complete weekly skin assessment once a day on Tuesday, was completed as ordered. On 4/1/25, there was no skin issues reported; -An order, dated 1/30/25, for Calmoseptine ointment (a skin barrier treatment containing zinc oxide), apply to left and right buttock after each incontinence episode, every shift. Documentation showed the treatment was completed as ordered. Observation on 4/8/25 at 7:27 A.M., showed: -The resident lay on his/her bed on top of an alternating pressure mattress (APM, specialty mattress used to reduce, eliminate and help treat pressure ulcers); -Licensed Practical Nurse (LPN) A and Certified Nursing Assistant (CNA) B performed perineal care on the resident, removing a urine soaked brief; -The resident had an area of red skin located on his/her lower right gluteal (buttock) which had an open area located within the boundaries of the red skin; -LPN A applied Calmoseptine on the resident's right and left buttocks; -LPN A and CNA B finished dressing the resident and transferred the resident to his/her wheelchair; -The wheelchair had a special pressure relieving cushion in the seat of the chair. During an interview on 4/8/25 at 7:39 A./M., LPN A said: -The area on the resident's right lower gluteal measured 4.9 centimeters (cm) by 2.6 cm with a small area measuring 1.1 cm by 0.6 cm which had the first layer of skin gone, exposing a red wound bed; -He/She was not allowed to stage pressure ulcers per facility directions but per his/her nursing knowledge, the wound on the resident's right lower gluteal was a Stage II pressure ulcer; -It was a new wound; -The Wound Nurse was responsible for completing wound treatments every Monday, Wednesday and Friday, and the nurses were responsible for completing wound treatments on Tuesday, Thursday, the weekends and any time the Wound Nurse was not able to complete treatments; -The Wound Nurse was responsible for completing wound assessments on all residents every Tuesday; -Nurses were responsible for completing all skin assessments; -He/She expected CNAs to alert any new skin issues to the nurses so they could get assess, inform the Primary Care Physician (PCP) and family, as well as get new orders. Observation on 4/8/25 at 8:55 A.M., showed the resident sat flat on his/her buttocks in his/her wheelchair, in the dining room eating breakfast. Review of the Hospice Visit Documentation, dated 4/8/25, showed: -Hospice CNA arrived at 9:24 A.M. and left at 10:47 A.M.; -There was no other documentation of the visit found. Observation on 4/8/25 at 11:37 A.M., at 12:05 P.M., at 12:20 P.M., at 12:57 P.M. and at 1:13 P.M., showed the resident in the dining room, sitting flat on his/her buttocks in his/her wheelchair. The resident was eating lunch. Observation on 4/8/25 at 1:19 P.M., showed the resident was in his/her bedroom, sitting flat on his/her buttocks in his/her wheelchair with a visitor. During an interview on 4/8/25 at 1:34 P.M., CNA B said: -The CNA from Hospice came to give the resident a bed bath that morning around 9:00 A.M. and finished at roughly 10:45 A.M.; -The resident had been sitting flat on his/her buttocks in his/her wheelchair since the Hospice Aide left that morning; -He/She had not provided any incontinence care or repositioned the resident since 7:27 A.M.; -He/She should have asked the visitor if it was okay to perform incontinence care after the resident finished with lunch; -The resident was at greater risk of skin breakdown if not repositioned or checked for incontinent episodes at least every two hours. During an interview on 4/8/25 at 1:47 P.M., LPN A said: -He/She expected CNAs to reposition and check residents for incontinent episodes at least every two hours to prevent skin breakdown; -Residents needed to be kept clean and dry to decrease the risk of skin breakdown, prevent pressure ulcers and prevent the risk infection of existing pressure ulcers; -He/She expected CNAs to alert him/her if the resident had not received incontinent care before a visitor arrived as he/she would have intervened and asked the resident and their visitor if they could perform care first; -The Hospice CNA came and gave the resident a bed bath that morning at approximately 10:30 A.M. During an interview on 4/8/25 at 2:05 P.M., the Hospice Registered Nurse (RN) said: -The resident refused the Surveyor's request to watch the Hospice RN and CNA B provide incontinent care to the resident; -They laid the resident down in the bed from his/her wheelchair and removed a moderately to heavily urine soaked brief before perineal care; -The resident had a Stage II pressure ulcer located on his/her right buttock which measured 0.5 cm by 0.5 cm.; -The Hospice RN saw the resident earlier that day but wanted to come back to assess the resident's buttocks as she was informed by a nurse there was an area of concern. Review of the resident's progress notes, showed: -On 4/8/25 at 2:05 P.M., a nurse wrote he/she assessed the resident and noted an area was found on the resident's right buttock, non-blanchable, with the first layer of skin gone. It measured 2.6 centimeters by 0.6 centimeters. The nurse reported the new skin alteration to the Hospice Nurse, the Wound Nurse, the PCP and family; -On 4/8/25 at 5:26 P.M., the Hospice RN wrote she assessed the resident's right buttock and noted a small opened Stage II pressure ulcer was present on the inner part of the buttock measuring 0.5 cm by 0.5 cm with no depth. The PCP was informed with orders to apply ointment with zinc oxide on the open area every brief change until healed. Observation on 4/9/25 at 7:15 A.M. and at 8:12 A.M., showed the resident sat in his/her wheelchair, on a pressure relieving pad, in front of the nurses station. Observation on 4/9/25 at 9:06 A.M., showed the resident in the dining room, eating breakfast. The resident's position was unchanged; He/She sat in his/her wheelchair. There were no positioning pillows or wedges present. At 9:24 A.M., 9:36 A.M., 9:55 A.M., 10:10 A.M., 10:17 A.M., 10:32 A.M., 10:40 A.M., 10:45 A.M., 10:55 A.M., 11:05 A.M., and at 11:14 A.M., the resident sat in his/her wheelchair in his/her bedroom. There were no positioning pillows or wedges present. During an interview on 4/9/25 at 11:28 A.M., the Hospice RN said: -She expected nursing staff to reposition the resident while he/she was in his/her wheelchair with pillows or offer to lay the resident down at least every two hours to prevent pressure ulcers; -She expected nursing staff to check the resident at least every two hours for incontinence episodes and provide perineal care to prevent pressure ulcers; -Hospice services were extra care for the resident and the facility staff were still responsible for providing care to the resident as per their policies and per nursing professional standards; -The lack of repositioning and lack of incontinence care could have contributed to the resident's new Stage II pressure ulcer found on his/her right buttock on 4/8/25. Review of the Wound Management note, dated 4/11/25, showed: -Seen for evaluation of an ulcer on his/her buttock discovered on 4/8/25. The ulcer is being treated topically with barrier cream. Healing complicated by incontinence and immobility; -Right buttock: Type: Pressure Ulcer/Injury: Stage 1 Intact (Skin Reddened with no Blanch) (no open ulcers). Measurements: 5.5 x 6.5 cm; -Left buttock: Type: Pressure Ulcer/Injury: Stage 1 Intact (Skin Reddened with no Blanch) (no open ulcers). Measurements: 5.5 x 4.0 cm; -Goal: Adequate offloading to alleviate pressure for optimal wound healing and Comfort Care to maintain quality of life and dignity; -Plan: Will continue to treat his/her buttocks topically with Remedy Protect Zinc Oxide Paste every shift and as needed (PRN). Staff is going to be sure to lie him/her down in bed periodically throughout the day and provide incontinent care as needed. Caregivers educated on skin care, positioning and wound care. 2. Review of Resident #11's Braden Score, dated 10/9/24, showed the resident was at high risk for pressure ulcers. Review of the resident's care plan, dated 11/29/24, showed: -Problem: Pressure Ulcer; The resident had an alteration in skin integrity and required wound monitoring. Interventions included: The resident preferred to be on his/her back and was educated on the importance of repositioning for better wound healing; Apply treatments per physician orders; Keep clean and dry as possible, minimize skin exposure to moisture; Offer and assist resident to turn and reposition frequently. Review of the resident's quarterly MDS, dated [DATE], showed: -Cognitively intact; -No behaviors present; -Dependent on assistance from staff for toileting, dressing, personal hygiene, bed mobility and transfers; -At risk for pressure ulcers; -One unhealed Stage IV pressure ulcer present; -Diagnoses included kidney disease, chronic obstructive pulmonary disease (COPD, lung disease), heart disease and respiratory failure. Review of the resident's progress notes, showed: -On 3/31/25 at 12:25 P.M., the resident was seen by outside wound company and no new orders were given; -On 4/7/25 at 2:42 P.M., the resident was seen by an outside wound company and new orders were given; -There was no documentation the resident was offered repositioning or educated on increased risk of pressure ulcers without repositioning. Review of the resident's outside wound company wound report, dated 4/7/25, showed a Stage IV pressure ulcer was located at the resident's sacrum (triangular bone located above the coccyx (tailbone)), 100% pink granulation tissue (new tissue) present in wound bed, measuring proximal area (located closer to trunk of body) 0.6 cm by 0.7 cm by 0.1 cm deep and distal area (away from trunk of body) measuring 1.0 cm by 1.0 cm by 0.2 cm with moderate amount of sero-sanguinous (composed of serum and blood) exudate (drainage) present. Review of the resident's MAR, dated 3/9/25 through 4/8/25, showed: -An order, dated 7/21/23, to complete weekly skin assessments once a day on Tuesdays, was completed as ordered; -An order, dated 2/24/25 through 4/7/25, to cleanse sacral ulcer with normal saline, apply Sorbagon silver (AG, a calcium alginate dressing used to manage moderately to heavily exudating (drainage) wounds) to proximal ulcer, apply Triad (ointment for wound care) to ulcer at the six o'clock position and cover with foam dressing twice a day and as needed. Documentation showed the treatment was administered as ordered; -An order, dated 4/7/25, to cleanse sacral ulcer with normal saline, apply Sorbagon AG, cover with bandage twice a day and as needed. Documentation showed the treatment was administered as ordered. Observation on 4/8/25 at 8:05 A.M., showed the resident asleep, flat on his/her back, on top of an APM. Observation on 4/8/25 at 8:26 A.M., showed: -The Wound Nurse and CNA B gave perineal care to the resident after removing a visibly heavily soaked with urine brief; -The Wound Nurse and CNA B turned the resident to his/her left side, exposing a bandage located on the resident's sacrum, dated 4/7/25; -The resident had bowel movement located on his/her anus and right and left buttocks; -The Wound Nurse instructed the CNA to remove the bandage from the resident's sacrum; -The bandage had dried brown matter on the outside edges of the dressing; -CNA B used a wet cleansing cloth and wiped the bowel movement from the resident's anus up towards the open wound; -The Wound Nurse administered the wound treatment to the sacral wound after CNA B completed perineal care; -They put a clean brief on the resident and covered him/her with a blanket, leaving the resident lying on his/her bed, flat on his/her back. During an interview on 4/8/25 at 8:35 A.M., the Wound Nurse said: -He was not allowed to stage pressure ulcers until he completed his Wound Nurse certification per facility directions but per his nursing knowledge, the resident had a Stage IV pressure ulcer located at his/her sacrum; -The outside wound company evaluated and treated the resident's Stage IV pressure ulcer every Monday; -He described the resident's Stage IV pressure ulcer as having a 100% pink wound bed, with one area of depth, with a scant amount of sero-sanguineous exudate; -The resident was admitted with the Stage IV pressure ulcer located on his/her sacrum and it had improved greatly since admittance. Observation on 4/8/25 at 1136 A.M., at 11:56 A.M., showed the resident asleep in his/her bed, flat on his/her back. Observation on 4/8/25 at 12:20 P.M. through 12:40 P.M., showed CNA B in the dining room assisting residents with lunch. Observation on 4/8/25 at 12:43 P.M., showed the resident sat up in his/her bed, with the head of the bed elevated approximately 45 degrees, listening to his/her phone. The resident did not have any wedges or positioning pillows underneath him/her and sat flat on his/her buttocks. Observation on 4/8/25 at 1:15 P.M., showed the resident sat up in his/her bed, flat on his/her buttocks, with the head of the bed elevated approximately 90 degrees. The resident's bed tray was positioned over him/her and the resident was eating lunch. During an interview on 4/8/25 at 1:16 P.M., the resident said: -He/She did not think staff had changed his/her brief since the morning when the Wound Nurse was present and changed his/her treatment; -He/She did not have any pillows or wedges underneath him/her to reposition him/her off of his/her buttocks; -He/She could change his/her position in the bed by using the bed remote; -He/She required assistance to move/roll in the bed. Observation on 4/8/25 at 1:40 P.M., showed the resident lying in bed, flat on his/her back. CNA B removed the resident's blankets and pulled back his/her gown to expose the resident's brief. The brief was visibly soaked with urine, with the material bunching up in clumps underneath the outermost layer of the brief. There was a strong odor of urine present. During an interview on 4/8/25 at 1:42. P.M., CNA B said he/she had not provided incontinence care since 8:00 A.M. that morning and had not repositioned the resident during his/her shift. He/She should have checked the resident frequently for incontinence and repositioned the resident every two hours to prevent further skin breakdown and deterioration of the resident's existing pressure ulcer. He/She would get help from another CNA and provide incontinence care to the resident. Review of a documented interview, dated 4/16/25, submitted by the facility and with CNA B, showed he/she assisted Resident #11 with peri care, brief change and repositioning before lunch and after lunch. At 2-2:30 the resident was given a full bed bath with the assistance of a fellow CNA and CNA B. CNA B states the resident does not use the call light when he/she is incontinent, but has full control over the bed remote and often repositions the head and foot of the bed. CNA B states although resident prefers his/her back, the resident allows CNA B to place pillows under hips to reposition. Observation on 4/9/25 at 7:14 A.M., showed the resident asleep, lying on his/her APM, positioned flat on his/her back. Observation on 4/9/25 at 8:13 A.M., showed: -The resident sat up in his/her bed, positioned flat on his/her buttocks; -LPN C administered medications to the resident; -There was a strong odor of urine emitting from the resident. Observation on 4/9/25 at 8:22 A.M., showed: -The resident lay flat on his/her back in his/her bed; -LPN C removed the covers from the resident and pulled back the resident's gown, exposing his/her brief; -The resident's brief was visibly soaked with urine, bulging between the resident's thighs; -There was a strong odor of urine emitting from the resident; -LPN C covered the resident back up with his/her gown and covers. During an interview on 4/9/25 at 8:24 A.M., LPN C said: -The resident's brief was wet with urine; -LPN C could not say he/she smelled any urine from the resident but he/she smelled pee all day long. During an interview on 4/9/25 at 8:39 A.M., the resident said: -He/She could feel the brief was wet, and could feel the wetness against his/her skin; -He/She was not sure if the wetness was bothering him/her but preferred to get changed. Observation on 4/9/25 at 8:42 A.M., showed: -The resident received incontinence care from LPN C and CNA D; -The nursing staff removed the resident's visibly urine soaked brief from the resident and performed perineal care; -The resident was then rolled to his/her left side with assistance from the nursing staff, exposing his/her buttocks which had dried brown matter stuck to them; -The resident was laying on an absorbent pad which was visibly dirty with brown matter; -The resident's sacral Stage IV pressure ulcer had a treatment on it, dated 4/8/25; -The bottom and left sides of the treatment were not secured to the resident's skin and were yellow in color with brown matter visible at the edges; -LPN C confirmed the brown matter on the edges of the treatment and on the resident's buttocks was bowel movement; -LPN C removed the treatment from the sacral Stage IV pressure ulcer and showed there was fecal matter on the inside of the treatment as well; -LPN C performed perineal care on the resident, cleaning him/her of the bowel movement; -LPN C cleaned the sacral Stage IV pressure ulcer wound and applied the treatment as ordered; -LPN C failed to adhere the bottom edge of treatment to the resident's skin, leaving the bandage open; -The LPN and CNA put a new, clean brief on the resident and positioned the resident on his/her back; -LPN C and CNA D failed to remove the absorbent pad from underneath the resident, which was visibly dirty with brown matter; -LPN C and CNA D left the room. Observations on 4/9/25 at 9:04 A.M., 9:25 A.M., 9:36 A.M., 9:55 A.M., 10:10 A.M., 10:17 A.M., 10:32 A.M., 10:40 A.M., 10:45 A.M., 10:55 A.M., 11:05 A.M., and at 11:24 A.M., showed the resident lay in his/her bed, flat on his/her back. Review of a documented interview, dated 4/16/25, submitted by the facility and with CNA E, showed he/she was the assigned CNA for Resident #11 on 4/9/2025. CNA E was pulled from Division 700 at approximately 0730. He/She received report and began preparing for breakfast. CNA E stated he/she changed and performed peri care after breakfast, before lunch and after lunch. CNA E's shift ends at 1:30 P.M. CNA E stated the resident verbalized preferring to lay on his/her back. CNA E encouraged resident to offload and allowed a pillow to be placed under resident's hip, alternating each hip with each ADL care. During an interview on 4/10/25 at 9:56 A.M., the Wound Nurse said: -He expected nurses to ensure treatments were sealed/adhered to the resident's skin to prevent the risk of bowel movement or urine, or any other bacteria, from entering into the pressure ulcer, which could lead to infection and risk delay of the healing process; -He expected nursing staff to wipe bowel movement away from the resident's sacral Stage IV pressure ulcer to avoid getting bowel movement into the pressure ulcer; -He expected nursing staff to lay the resident on clean absorbent pads which were free from urine or bowel movement to prevent the risk of infection or delay the healing process of the resident's pressure ulcer. 3. During an interview on 4/8/25 at 1:34 P.M., CNA B said: -He/She was assigned to both Residents #10's and #11's care today from 7:00 A.M. through 3:00 P.M.; -Residents who were dependent on staff for care needed to get repositioned and checked for incontinent episodes every two hours in order to prevent pressure ulcers. During an interview on 4/8/25 at 1:47 P.M., LPN A said: -He/She expected CNAs to reposition and check residents for incontinent episodes at least every two hours to prevent skin breakdown; -Residents needed to be kept clean and dry to decrease the risk of skin breakdown, prevent pressure ulcers and prevent the risk infection of existing pressure ulcers. During an interview on 4/9/25 at 11:07 A.M., and on 4/10/25 at 9:56 A.M., the Wound Nurse said: -He expected nursing staff to check residents for incontinent episodes at least every two hours to ensure they were kept clean and dry, and more often if the residents had heavy urine incontinence; -It was important to keep residents clean and dry to prevent skin breakdown and to decrease the risk of deterioration and infection of existing pressure ulcers; -He expected nursing staff to reposition residents off of bony prominences at least every two hours to prevent skin breakdown and to improve blood flow throughout residents' tissues; -He expected nursing staff to get residents up and out of their wheelchairs to prevent pressure ulcers and to help heal existing pressure ulcers, even if the resident was on hospice, as the goal was to prevent any harm to the resident; -He expected nursing staff to continue to offer repositioning to residents, even if they refuse and if their refusals were care planned; -Nursing staff had a responsibility to continue to educate residents on the importance of repositioning to prevent pressure ulcers and to try to figure out why the resident was refusing repositioning in order to put appropriate interventions in place; -He expected nursing staff to write progress notes showing they continued to offer repositioning and educated the residents on importance of repositioning so nursing staff could see the pattern of refusals and what interventions were tried. During an interview on 4/9/25 at 11:52 A.M. and at 1:20 P.M., the Director of Nursing (DON) said: -She expected staff to have knowledge of and to follow facility policies; -She expected staff to prevent pressure ulcers and promote healing of existing pressure ulcers by repositioning residents, checking them for incontinence episodes and performing perineal care if needed at least every two hours; -She expected nursing staff to offer to lay residents down or reposition them while they were in a wheelchair at least every two hours to help prevent pressure ulcers and promote healing of existing pressure ulcers; -She expected staff to offer residents repositioning and continued education on the importance of repositioning for pressure ulcer prevention and healing throughout their shift and to include their refusal in a care plan with appropriate interventions; -She expected nursing staff to keep residents' treatments free of any bowel movement to prevent the risk of infection and delayed healing of existing pressure ulcers. MO00243017 MO00243255 MO00248943

Based on observations, resident and staff interviews, record reviews, and review of the Administrator's Job Description, the facility failed to ensure good faith attempts were made to correct quality deficiencies through their Quality Assurance and Performance Improvement (QAPI) process. The Administration had not implemented any QAPI programs to address the ongoing COVID-19 and respiratory syncytial virus (RSV) outbreaks. Additionally, the administration failed to identify sufficient staffing as a possible quality deficiency. These failures placed all facility residents at risk for transmission of COVID-19 and RSV and accidents, unmet needs, and lack of incontinence care related to insufficient staffing. Findings include: Review of the undated Job Description - Administrator revealed, Assist with all aspects of Quality Assurance . [and] Ensure that each resident receives the necessary nursing, medical, and psychosocial services to attain and maintain the highest possible mental and physical functional status possible. Throughout the survey, the following deficient practices were identified: 1. The facility failed to ensure sufficient staffing to meet the needs of the 180 residents in the facility. Several residents and staff members voiced concerns regarding sufficient staffing, and the facility exhibited failures related to a lack of sufficient staffing throughout the survey. Observations on the night shift revealed staff asleep at the nurses' stations. Several staff members stated they had voiced concerns to administration related to the current staffing levels and extra duties, such as serving meals; however, no changes had been made. Cross-reference F725: Sufficient Nurse Staffing. During an interview with the Administrator, Director of Nursing (DON), and Director of Clinical Services on 02/09/24 at 6:40 PM, the Administrator confirmed she was aware of instances of staff sleeping during the night shift. However, the Administrator and DON both stated they did not visit the facility on the night shift to monitor the staff. The Administrator stated, I think our nursing staff ratio is really good . We have good staffing in building but also explained there were post-pandemic challenges with all departments and there were efforts to hire more staff and use less agency staff. The Administrator stated she had heard complaints from the nursing staff, especially about serving food at meals, but stated, This is the way it has always been done. During an interview with the Administrator, DON, and Director of Clinical Services on 02/09/24 at 7:42 PM, the Administrator stated the QAPI committee interviewed and listened to the concerns of the Certified Nursing Assistants (CNAs) and nurses and incorporated their concerns into the QAPI program. However, the Administrator stated the facility had not brought any of the staffing concerns to the QAPI committee for improvement activities, such as increased monitoring of night shift staff or auditing of resident care to determine appropriate staffing levels to meet the residents' needs. The Administrator stated, Personally, I don't think staffing is a problem. The Director of Clinical Services added the facility had implemented plans to decrease reliance on agency staffing to improve the continuity and quality of care; however, this was not included in the QAPI program. 2. The facility staff failed to wear appropriate personal protective equipment (PPE) when providing care to residents on transmission-based precautions, doff (take off) soiled PPE prior to exiting the room, complete resident testing upon new positive cases of COVID-19 in the building, complete contact tracing for staff that were in close contact with COVID-19 or exposed to RSV, ensure appropriate staff testing during an outbreak of COVID-19, and ensure appropriate cohorting of residents within close contact to COVID-19 and RSV. Cross-reference F880: Infection Control. During an interview with the Administrator, DON, and Director of Clinical Services on 02/09/24 at 7:42 PM, the Administrator stated the QAPI committee discussed the type of infections in the facility and antibiotic use; however, the committee had not identified the outbreak that began on 11/09/23 and affected 46 residents as an area for potential performance improvement. The Administrator stated the RSV outbreak was too recent to be discussed in the QAPI committee, and the recent COVID-19 outbreak was not too severe. The Director of Clinical Services stated the facility had an interdisciplinary team meeting when they started to see their numbers increasing; however, this was not documented or incorporated into the QAPI program. 3. The facility failed to ensure two (Resident (R) 100 and R147) of four residents reviewed for activities of daily living received assistance with incontinence care and/or using the toilet as needed. These failures created a potential for skin problems, urinary tract infections, or increased incontinence for these two residents. Cross-reference F677: Activities of Daily Living. During an interview on 02/09/24 at 6:40 PM with the Administrator and DON, the Administrator confirmed her expectation was that staff provided incontinence checks/care at least every two hours. The DON stated this was a problem and the staff had received frequent education to provided care every two hours. She stated, however, that she had not conducted audits to monitor staff compliance. During an interview with the Administrator, DON, and Director of Clinical Services on 02/09/24 at 7:42 PM, the Administrator stated there was no QAPI monitoring of toileting/incontinence care.

26006 Based on observations, interviews, record reviews, review of the Centers for Disease Control (CDC) guidelines, and facility policy review, the facility failed to: 1. Wear appropriate personal protective equipment (PPE) when providing care to residents on transmission-based precautions. 2. Doff (take off) soiled PPE prior to exiting the resident's room. 3. Complete resident testing upon new positive cases of COVID-19 in the building. 4. Complete contact tracing for staff that were in close contact with COVID-19 positive residents or exposed to Respiratory Syncytial Virus (RSV) positive residents 5. Provide evidence of staff testing done during an outbreak of COVID-19. 6. Ensure appropriate cohorting of residents within close contact to other COVID-19 and RSV positive residents. This affected 49 (Residents (R) 116, R46, R121, R65, R81, R72, R13, R157, R14, R96, R67, R172, R88, R92, R134, R221, R111, R173, R156, R174, R83, R130, R175, R158, R114, R176, R4, R177, R159, R131, R273, R272, R178, R28, R179, R108, R102, R87, R171, R155, R118, R55, R62, R13, R64, R139, R108, R106, R85, and had the potential to affect all 180 residents of the facility. Findings include: Review of the facility policy titled, Infection Control Policy and Procedure Manual revised 06/2020 revealed, It is the policy of this community to, when necessary; prevent the transmission of infections within the community through the use of Isolation Precautions. The 2007 Centers for Disease Control and Prevention (CDC) Guidelines for Isolation Precautions will be utilized in this community with some modifications .Droplet Precautions: In addition to Standard Precautions, use Droplet Precautions for a resident known or suspected to be infected with microorganisms transmitted by droplets .Contact Precautions: In addition to Standard Precautions, use Contact Precautions for residents known or suspected to be infected with microorganisms that can be easily transmitted by direct or indirect contact .All personal protective equipment (disposable isolation gowns, mask, gloves, etc.) should be used once and discarded in either the trash or used linen receptacle before you leave the room .Contact tracing will be completed for any staff who have had prolonged contact with a person with confirmed COVID-19 . Close contact is defined as being within six feet for a cumulative total of 15 minutes or for over a 24-hour period with someone with COVID-19 infection . test is recommended on day 1 (not earlier than 24 hours after the exposure, if known. If negative, test again on day three and day five. If additional positives are identified, repeat testing with antigen testing every three days until there are no new cases for 14 days on the affected unit(s). Review of the CDC Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated 06/08/23 and accessed at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, revealed, A single new case of SARS-CoV-2 infection in any HCP or resident should be evaluated to determine if others in the facility could have been exposed. The approach to an outbreak investigation could involve either contact tracing or a broad-based approach; however, a broad-based (e.g., unit, floor, or other specific area(s) of the facility) approach is preferred if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission. Perform testing for all residents and HCP [health care professionals] identified as close contacts or on the affected unit(s) if using a broad-based approach, regardless of vaccination status. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. Review of the CDC Viral Respiratory Pathogens Toolkit for Nursing Homes, dated 12/05/23 and accessed at https://www.cdc.gov/longtermcare/prevention/viral-respiratory-toolkit.html, revealed, Prepare for respiratory viruses (e.g., SARS-CoV-2, influenza, RSV) . Roommates of symptomatic residents - who have already been potentially exposed - should not be placed with new roommates, if possible. They should be considered exposed and wear a facemask for source control around others. Review of the CDC Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated 06/08/23 and accessed at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, revealed, Place a patient with suspected or confirmed SARS-CoV-2 infection in a single-person room. The door should be kept closed (if safe to do so). Ideally, the patient should have a dedicated bathroom. If cohorting, only patients with the same respiratory pathogen should be housed in the same room. Review of the CDC Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated 06/08/23 and accessed at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, revealed, HCP who enter the room of a patient with suspected or confirmed SARS-CoV-2 [COVID-19] infection should adhere to Standard Precautions and use a NIOSH Approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). Review of the CDC Transmission Based Precautions, dated 01/07/16 and accessed at https://www.cdc.gov/infectioncontrol/basics/transmission-based-precautions.html revealed, Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens. Review of the CDC's Respiratory Virus Toolkit (cdc.gov), revealed Residents: Apply appropriate Transmission-Based Precautions for symptomatic residents based on the suspected cause of their infection. Roommates of symptomatic residents - who have already been potentially exposed - should not be placed with new roommates, if possible. They should be considered exposed and wear a facemask for source control around others. 1. Review of the facility's ongoing Line Listing provided on paper revealed an outbreak of COVID-19 began in the facility on 11/09/23 with R116 and spread to 15 additional residents (R46, R121, R65, R81, R72, R13, R157, R14, R96, R67, R172, R88, R92, R134, and R221) during November 2023 through Divisions 100, 300, 400, and 600. In December 2023, an additional 22 residents (R111, R173, R156, R174, R83, R130, R175, R158, R114, R176, R4, R177, R159, R131, R273, R272, R178, R28, R179, R108, R102, and R87) tested positive for COVID-19 throughout all Divisions (100, 200, 300, 400, 500, and 600). In January 2024, an additional five residents (R171, R155, R118, R55, and R62) tested positive for COVID-19 in Divisions 200, 300, 400, and 700. From 02/01/24 to 02/05/24, three additional residents (R13, R108, R72) tested positive for COVID-19 in Divisions 200, 300, and 400. The facility did not provide any records of staff testing for November 2023 and did not provide tracking of staff COVID-19 infections from 11/09/23 to 02/05/24. There was no documentation of contact tracing for all positive cases to ensure testing of any residents or staff within close contact were tested as needed. 2. Review of the facility's ongoing Line Listing and resident testing records, provided on paper, revealed: -R273 was diagnosed with COVID-19 on 12/24/23. R273 resided on Division 200, but there was no record of any Division 200 resident testing until 12/27/23. -On 12/24/23, R272 was diagnosed with COVID-19. R272 resided on Division 300, but division 300 residents were not tested until 12/31/23. -On 01/19/24, R62 was diagnosed with COVID-19. There were no records of resident testing in January 2024. -On 01/23/24, R171 was diagnosed with COVID-19. There were no records of resident testing in January 2024. -On 01/30/24, R155 was diagnosed with COVID-19. There were no records of resident testing in January 2024. 3. Review of the facility's ongoing Line Listing and Roommate Tracking Record, provided on paper revealed: -R28 was diagnosed with COVID-19 on 12/27/23. His/Her roommate, R113, was moved to a room with R112, who was not exposed or positive, on 12/28/23. -R83 was diagnosed with RSV on 01/16/24. His/Her roommate, R75, was moved to a room with R92, who was not exposed or positive, on 01/17/24. -R85 was diagnosed with RSV on 01/19/24. His/Her roommate, R110, was moved to a room with R54, who was not exposed or positive, on 01/22/24. 4. Review of R118's Resident Face Sheet under the Resident tab in the electronic medical record (EMR) revealed he/she was admitted to the facility on [DATE]. Review of the facility's ongoing Line Listing, provided on paper, revealed R118 was diagnosed with COVID-19 on 01/31/24. During an observation and interview on 02/06/24 at 10:30 A.M., R118's room door had signage and PPE for contact and droplet precautions and the bin to dispose the PPE was outside the door in the hallway; there was no hand sanitizer available in the room or on the door. Certified Nursing Assistant (CNA) 3 exited the room while wearing his/her gloves, gown, face shield, and mask and carrying a dirty meal tray in one hand. He/She doffed his/her gloves, gown, mask, and shield in the hallway, put the tray on the cart, and walked down the hall to the hand sanitizer dispenser at least 20 feet away across from the soiled utility room. All other residents who resided on the hall where the CNA walked through were negative, and often passed by the room and the dirty PPE container in the hallway. 5. Review of R106's Significant Change of Status Minimum Data Set (MDS) assessment, dated 12/28/23 and located in the RAI (Resident Assessment Instrument) tab of the EMR, revealed he/she was admitted to the facility on [DATE]. Review of the facility's ongoing Line Listing, provided on paper, revealed R106 was diagnosed with RSV on 02/03/24. During an observation and interview on 02/06/24 at 2:06 PM, R106's room door had signage and PPE for contact and droplet precautions and the bin to dispose the PPE was outside the door in the hallway; there was no hand sanitizer available in the room or on the door. CNA2 entered R106's room wearing a gown, mask, and gloves; CNA2 did not wear any eye protection. CNA2 confirmed that eye protection was available, but did not think about putting it on. No trash bin was available inside the room to dispose of soiled PPE and CNA2 exited the room without doffing the PPE. 6. Review of R13's Significant Change of Status MDS assessment, dated 12/31/23 and located in the RAI tab of the EMR, revealed he/she was admitted to the facility on [DATE]. Review of the facility's ongoing Line Listing, provided on paper, revealed R13 was diagnosed with COVID-19 on 02/01/24. During observation on 02/06/24 from 2:45 PM to 3:30 PM, R13's room door had signage and PPE for contact and droplet precautions and the bin to dispose the PPE was outside the door in the hallway. The bin was overflowing with used PPE and uncovered; there was no hand sanitizer available in the room or on the door. There was a large bin in the room for linen that was empty. 7. Review of R72's Quarterly MDS assessment, dated 11/02/23 and located in the RAI tab of the EMR, revealed he/she was admitted to the facility on [DATE]. Review of the facility's ongoing Line Listing, provided on paper, revealed R72 was diagnosed with COVID-19 on 02/02/24. During observation on 02/06/24 at 3:45 PM, R72's room door had signage and PPE for contact and droplet precautions and the bin to dispose the PPE outside the door in the hallway; the bin was overflowing with used PPE and was uncovered. 8. Review of R64's Face Sheet located in the Electronic Medical Record (EMR) under the Resident tab revealed he/she was admitted to the facility on [DATE]. Review of the facility provided document titled, Line Listing R64 was diagnosed with RSV on 01/31/24. Review of R139's Minimum Data Set (MDS) located in the EMR under the RAI (Resident Assessment Instrument) tab revealed the resident was admitted to the facility on [DATE] with a primary diagnosis of non-traumatic brain dysfunction. Review of the facility provided document titled, Line Listing R139 was diagnosed with RSV on 01/28/24. During an observation and interview on 02/06/24 at 12:34 PM CNA1 entered R64 and R139's room who were both on droplet and contact precautions for RSV. Signs were posted on the door that all staff entering the room should wear full PPE for contact and droplet precautions, including gown, gloves, mask, and eye protection. CNA1 donned a gown and mask only and entered the room to deliver meal trays. CNA1 delivered R64's meal tray, moved R64's over-bed side table, raised the head of the bed, and emptied a beverage cup in the sink. He/She did not sanitize or wash his/her hands prior to serving R139. CNA1 confirmed that he/she should have worn eye protection and gloves. At 12:45 PM CNA1 exited the room while wearing his/her soiled PPE and proceeded to remove his/her PPE outside the R64's room and disposed of the PPE in a bin outside of the room in the hallway. At 1:00 PM the Director of Nursing (DON) entered the room wearing a mask, gown, and gloves. The DON confirmed that she and CNA1 should have been wearing full PPE including eye protection. There was a trash bin observed outside the residents' rooms with soiled PPE. There was no hand sanitizer in the room for staff to use prior to exiting. There was no bin for soiled linens inside the room. 9. During an interview on 02/06/24 at 2:04 PM, the Infection Preventionist (IP) stated the facility did not document tracing of staff who came in close contact with positive residents and employees were responsible for testing themselves and did not report their results to her. She did not document who needed a test, when they tested , or the results and expected the staff to report a positive test. The IP stated, we just believe our employees and expect them to be truthful. The IP stated she did not have a way of ensuring all employees with close contact were tested and did not have a way to trace whether additional facility staff assigned to other areas worked with the positive resident. Additionally, the IP revealed she was told by the DON that staff should doff soiled PPE outside of the infected resident's room and place the PPE in the trash bin just outside the door, and soiled linen should go in a trash can inside the room. The IP revealed she was not aware that staff were not wearing all necessary PPE for residents on transmission-based precautions. Her expectation was for the staff member to wear a mask, gloves, eye protection, and a gown when in the rooms of residents on contact and droplet precautions. The IP stated when a resident tested positive for COVID-19, their roommate would be moved to another room. Ideally, they would be moved to a private room; however, if none were available, they would be moved to a room with another resident who was not positive and had not been exposed, and there was no additional testing of the new roommate. During an interview on 02/06/24 at 3:30 PM with Licensed Practical Nurse (LPN) 2, he/she stated he/she did not know who was responsible to maintain and/or empty the bins with used PPE outside the rooms so they did not overflow. During an interview on 02/09/24 at 3:33 PM, the Medical Director stated the Administrator and DON had not reached out for guidance in handling the ongoing outbreak and he had not been involved in surveillance, contact tracing, outbreak testing, or cohorting decisions. The Medical Director stated he did not know what the current CDC recommendations were related to a COVID-19 outbreak.

Based on observations, staff and resident interviews, record reviews, and review of monthly Resident Council meeting minutes, the facility failed to ensure sufficient staffing to meet the needs of the 180 residents in the facility. Several residents and staff members voiced concerns regarding sufficient staffing, and the facility exhibited failures related to a lack of sufficient staffing throughout the survey. Findings include: A policy on staffing was requested but was not provided prior to survey exit. Review of the monthly Resident Council meeting minutes, provided on paper, revealed concerns of call lights taking too long to be answered were brought up in January 2024, November 2023, October 2023, and June 2023. During Initial Pool interviews and observations, four residents voiced concerns related to a lack of sufficient staffing: -During an interview with a resident who wished to remain anonymous on 02/05/24 at 11:28 A.M., the resident stated there was not enough staff available to answer call lights, especially at night. -During an interview on 02/05/24 at 11:57 A.M., Resident (R)79 stated he/she waited up to an hour at times for his/her call light to be answered and felt like it was related to insufficient staffing. -During an interview on 02/06/24 at 11:41 A.M., R53 stated it could take a long time for call lights to be answered, especially at night. He/She felt there were insufficient staff available to answer call lights in a timely manner. -During an interview on 02/06/24 at 5:04 P.M., R69 stated the facility used a lot of agency staff who did not know the needs of the residents and did not always get the job done. During observations of the night shift on 02/08/24 at 4:45 A.M., Certified Nursing Assistant (CNA) 7 was observed at the 300 Division nurses' station seated in a chair with his/her head on the desk. He/She had a hood over his/her head and a blanket and appeared asleep. At 4:50 A.M., CNA7 awoke when spoken to. He/She stated he/she had just laid down to rest, but was not asleep and stated he/she was resting before he/she had to start getting residents up around 5:00 A.M. CNA7 stated he/she was tired, because he/she had worked two eight-hour shifts in a row. During observations of the night shift on 02/08/24 at 4:55 A.M., CNA16 was observed in a chair in the area around the nurses' station at the 500 Division. His/Her eyes were closed, his/her feet were up on another chair, and he/she was covered in a blanket. At 5:00 A.M., CNA16 awoke when spoken to. He/She stated he/she was resting before starting to make rounds and get residents out of bed. CNA16 stated he/she was tired because he/she had been working for 12 hours. Additional concerns related to short staffing were voiced by the staff during the survey: -During an interview on 02/09/24 at 11:53 A.M., CNA12 stated he/she felt like there was not enough staff to meet the residents' needs and the facility administration did not provide enough help. CNA12 stated agency staff were used to fill in for open shifts; however, the agency staff did not know the needs of the residents and often required help to complete their daily tasks. CNA12 stated when staff called in sick, sometimes the shifts went unfilled. He/She stated it was unfair to the residents and felt like a punishment to all the staff. CNA12 stated sometimes residents did not get their showers because of being short-staffed. He/She also stated the staff were required to check for incontinence at least every two hours for residents with incontinence, and it was difficult to complete those checks timely plus complete all other assigned duties, such as setting up the dining room, serving meals, and cleaning up the dining room. CNA12 stated he/she loved the residents he/she worked with and did not want to leave his/her job, but was considering leaving because of the staffing levels. CNA12 stated he/she had witnessed staff sleeping on the job, especially when arriving in the morning and relieving the night shift staff. He/She stated, I see call lights on not being answered. Last week on 300 [Division], . I walked in and the [night shift staff] was asleep and three call lights were on. The smell hit me before anything. You could tell no one had been changed . There is a resident who digs and eats his/her feces. He/She was supposed to be up, but wasn't, so we had to take care of all that. There were people covered in urine head to toe . I was devastated. During an interview on 02/09/24 at 2:21 P.M., CNA11 stated he/she felt like there were not enough staff and not enough hours in the day to meet the needs of the residents. He/She stated residents and family members were upset, because they did not see the care they were paying for. He/She stated there were not enough staff to provide incontinence checks every two hours. CNA12 added, We do our best . but we need extra staff to help with toileting. He/She stated it was especially hard to find another staff member to help with transfers via mechanical lift when two staff were required. CNA12 stated there were times when staff did not show up for their shift and the shift was not able to be filled. He/She stated this created an additional hardship to get everything done. CNA12 added it was difficult to complete all tasks during mealtime, as CNAs were also responsible for dining room setup and tear down, plating the food, serving the food, and assisting the residents. During an interview on 02/09/24 at 2:55 P.M., Licensed Practical Nurse (LPN) 5 stated he/she did not feel there was enough staff to meet the needs of the residents. He/She stated the nurses had to pick up extra duties, such as assistance with toileting, feeding, or answering call lights, when CNAs were short. He/She stated the nursing staff also had to complete extra dietary and housekeeping duties, as those departments were short-staffed as well. LPN5 stated the CNAs were responsible for setting up and serving food at all meals, and this took away from their resident care duties. He/She stated residents who used a mechanical lift suffered because two staff were required to assist with a transfer. LPN5 stated he/she brought up concerns about staffing to administration several times, but nothing had changed. During an interview on 02/09/24 at 3:21 P.M., CNA9 stated there were not enough staff on the floor to meet residents' needs. He/She stated one of the problems was having the nurse aide students working on the floor who had not yet been trained in all the care the residents required, so the CNAs had to fill in. He/She also stated there was not enough staff during mealtimes to assist the residents to eat, and he/she ended up having to feed two residents at the same time, then stop after a few bites and go to another table, so none of the residents were able to finish their whole meal. CNA9 stated he/she had witnessed night shift staff sleeping on the job upon arrival in the morning, and he/she had brought his/her concerns up to administration, but nothing was done. During the survey, the following deficient practices related to insufficient nurse staffing were identified: -The facility failed to provide checks for incontinence in a timely manner. Cross-reference F677: Activities of Daily Living. -The facility failed to implement interventions to aid in the prevention of falls. Cross-reference F689: Free of Accident Hazards/Supervision/Devices. -The facility failed to implement components of an effective infection control program. Cross-reference F880: Infection Prevention and Control. During an interview on 02/09/24 at 3:33 P.M., the Medical Director stated staffing had been a challenge since the COVID-19 pandemic; however, he had not been directly involved with staffing in building. During an interview on 02/09/24 at 6:40 P.M. with the Administrator, Director of Clinical Services, and Director of Nursing (DON), the Administrator stated he/she was aware of incidents in the last few months of staff sleeping on the job during the night shift. He/She stated staff were never supposed to be sleeping while at the nurses' station; they could sleep during their break in the break room. The Administrator stated he/she had not come in during the night shift to monitor the staff. He/She stated the Nurse Manager used to come in on night shift, but had not been doing that in the last few months. The DON stated he/she had not come in during the night shift at least for the last four months. The Administrator stated, I think our nursing staff ratio is really good. We have good staffing in building. The Administrator stated the facility experienced post-pandemic challenges with staffing in all departments, so all staff worked together to get the work done. The Administrator stated she understood the concerns the nursing staff has voiced regarding serving the meals in addition to other CNA duties; however, That's the way it has always been done. The Director of Clinical Services stated the facility was actively recruiting staff and implementing things like job fairs, wage increases, recruiting at nursing schools, and hiring bonuses. The Administrator added they had advertised positions on websites held job fairs every quarter.

Based on observation, interview, review of Resident Council Meeting notes, and policy review, the facility failed to serve hot foods at palatable temperatures for seven of 40 sampled residents (Resident (R) 6, R64, R57, R75, R123, R143, and R146). This failure had the potential to contribute to decreased intake by residents. Findings include: A review of the facility policy titled Enhancing the Dining Experience, from the Dining Services policy and procedures manual, dated 2014, number 11 of 12 listed tasks stated that the meals were to be served in an attractive manner; served at the appropriate temperature; served according to safe food handling practices, and meets the residents' individualized needs. Review of the Resident Council Meeting notes, provided by the facility, revealed two previous food temperature group complaints were recorded on 07/24/23 and 11/27/23. During observation of the lunch meal service on 02/06/24 at 12:30 P.M., R64 was served lunch and ate less than 25 percent of his/her meal. R64 stated his/her food did not look appetizing or taste good. Observation on 02/08/24 11:59 A.M., revealed resident meals being delivered to resident rooms were covered with clear thin plastic wrap. During the group Resident Council interview on 02/08/24 at 1:46 P.M., R6, R57, R75, R123, R143, and R146 stated the food was sometimes served cold. During observation of meals served to residents in their room on 02/09/24 at 2:22 P.M., a test tray was provided to the surveyor. The meal cart transported eight food trays that revealed a thin plastic wrap covering the plates of food, no heated base or other insulation, and a clear thin plastic film was draped over the cart. The measured temperature of food served on the test tray revealed the protein meat (polish sausage on a bun) measured at 115 degrees Fahrenheit (F) and the vegetable (sauerkraut) was served at a temperature measured at 116 degrees (F). The Dietary Manager (DM) was present and confirmed the temperature of the food on the test tray. The DM stated she was aware of the low temperature of the food served to residents in their room, but did not have serving equipment that would contain the heat of the food until received by the resident.

Based on interview and record review, the facility failed to ensure third party liability (TPL) forms were completed within 30 days for the final accounting for residents who expired. This affected 15 residents who expired and had money in their accounts (Residents #509, #505, #502, #503, #511, #504, #501, #508, #510, #506, #512, #517, #513, #516, #515). The sample size was 17. The census was 179. 1. Review of Resident #509's medical record showed the following: -Effective/Expired on [DATE]; -Ending balance of $927.44; -No documentation of a TPL. 2. Review of Resident #505's medical record showed the following: -Effective/Expired on [DATE]; -Ending balance of $150.07; -TPL completed on [DATE]. 3. Review of Resident #502's medical record showed the following: -Effective/Expired on [DATE]; -Ending balance of $4238.47; -TPL completed on [DATE]. 4. Review of Resident #503's medical record showed the following: -Effective/Expired on [DATE]; -Ending balance of $3768.40; -TPL completed on [DATE]. 5. Review of Resident #511's medical record showed the following: -Effective/Expired on [DATE]; -Ending balance of $4499.59; -TPL completed on [DATE]. 6. Review of Resident #504's medical record showed the following: -Effective/Expired on [DATE]; -Ending balance of $55.98; -TPL completed on [DATE]; -Ending balance of $15.00; -TPL completed on [DATE]. 7. Review of Resident #501's medical record showed the following: -Effective/Expired on [DATE]; -Ending balance of $1228.00 -TPL completed on [DATE]. 8. Review of Resident #508's medical record showed the following: -Effective/Expired on [DATE]; -Ending balance of $22.31; -TPL completed on [DATE]. 9. Review of Resident #510's medical record showed the following: -Effective/Expired on [DATE]; -Ending balance of $5667.29; -No documentation of a TPL. 10. Review of Resident #506's medical record showed the following: -Effective/Expired on [DATE]; -Ending balance of $382.15; -TPL completed on [DATE]. 11. Review of Resident #512's medical record showed the following: -Effective/Expired on [DATE]; -Ending balance of $2622.19; -TPL completed on [DATE]. 12. Review of Resident #517's medical record showed the following: -Effective/Expired on [DATE]; -Ending balance of $1666.41; -TPL completed on [DATE]. 13. Review of Resident #513's medical record showed the following: -Effective/Expired on [DATE]; -Ending balance of $626.74; -TPL completed on [DATE]. 14. Review of Resident #516's medical record showed the following: -Effective/Expired on [DATE]; -Ending balance of $1594.13; -TPL completed on [DATE]. 15. Review of Resident #515's medical record showed the following; -Effective/Expired on [DATE]; -Ending balance of $76.00; -TPL completed on [DATE]. During an interview on [DATE] at 1:05 P.M., the Business Office Manager (BOM) said she was aware the TPL was behind and thought the required time frame was 60 days and not 30 days. The BOM said she had fallen behind in the process. During an interview on [DATE] at 1:30 P.M., the Assistant Administrator said she was not aware the TPL was not completed in the required timeframe. The Assistant Administrator said she did not know why.

Based on observations, interviews, and record review, the facility failed to ensure two (Resident (R) 147 and R151) of five residents reviewed for activities were assessed for activity interests and needs and received a program of activities to meet their needs. These failures placed R147 and R151 at risk for increased feelings of depression, helplessness, and boredom. Findings include: A policy on provision of activities was requested from the facility; however, was not provided prior to survey exit. 1. Review of R147's Resident Face Sheet under the Resident tab in the electronic medical record (EMR) revealed he/she was admitted to the facility on [DATE] with diagnoses including: Alzheimer's disease with anxiety, depression, and repeated falls. Review of R147's Admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 12/13/23 and located in the RAI (Resident Assessment Instrument) tab of the EMR, revealed he/she was unable to answer the Brief Interview for Mental Status (BIMS) and staff assessed his/her with short- and long-term memory problems and severely impaired cognition. R147 was rarely/never able to make herself understood. He/She had severely impaired vision and did not exhibit any behavioral symptoms. R147's activity preferences had not been assessed as required (cross-reference F636: Comprehensive Assessment). Review of R147's EMR revealed there was no assessment of his/her activity interests or participation or activities progress notes. Review of R147's Care Plan, dated 12/05/23 and located in the RAI tab of the EMR, revealed it did not address his/her activity preferences or participation needs. His/Her Care Plan documented, [R147] is at risk for falls related to his/her poor safety awareness, history of repeated falls, Alzheimer's dementia, daily psychotropic medication use, and visual deficits and included the approach, dated 01/09/24: Staff encouraged to monitor in high-view areas. Activities to be involved in promoting participation in cognitive/physically stimulating activities. During continuous observations of R147 on the 500 Division on 02/06/24 from 9:33 A.M. to 12:03 P.M., there were no observations of provision of activities: -From 9:33 A.M. to 10:13 A.M., R147 was seated in the dining room in his/her wheelchair. There was nothing on the table in front of her. -At 10:13 A.M., R147 was taken in his/her wheelchair from the dining room to the area in front of the nurses' station. He/She remained seated in this spot without any interaction or activity. There was no TV or music in the area and he/she was not wearing his/her headphones. -At 10:42 A.M., no staff were present near the nurses' station. R147 began reaching his/her arms out in front of his/her and sitting forward in his/her chair. Certified Nursing Assistant (CNA)10 was walking through the area, approached R147 at 10:43 AM, and told his/her sit back in his/her chair. CNA10 then walked away, and no additional staff were in the area. -At 10:59 A.M., R147 began reaching out in front of his/her and mumbling to his/her self. There were no staff present in the area. -At 11:17 A.M., R147 stood up from his/her wheelchair. CNA14 was walking through the area and assisted R147 to sit back down in his/her wheelchair. No physically or cognitively stimulating activities were provided. CNA14 then left the area, and no additional staff were present. -At 11:17 A.M., R147 stood up from his/her wheelchair. CNA14 assisted R147 to sit back down in his/her wheelchair. No physically or cognitively stimulating activities were provided. -From 11:17 A.M. to 12:03 P.M., R147 remained seated in this spot, in the same position, until 12:03 P.M., without any interaction or activity. There was no TV or music in the area and he/she was not wearing his/her headphones. -At 12:03 P.M., R147 was taken in his/her wheelchair from the nurses' station to the dining room. During continuous observations of R147 on the 500 Division on 02/07/24 from 10:16 A.M. to 1:57 P.M., there were no observations of provision of activities: -At 10:16 A.M., R147 was seated in the area in front of the nurses' station in his/her wheelchair. He/She remained seated in this spot until 10:50 A.M. without any interaction activity. There was no TV or music in the area, and he/she was not wearing his/her headphones. -At 10:50 A.M., R147 stood up from his/her wheelchair and walked approximately 6 feet before CNA10 and LPN5 assisted his/her back to his/her wheelchair and told her to sit back down. He/She remained seated in this spot until 11:34 A.M. There was no TV or music in the area and he/she was not wearing his/her headphones. -At 11:34 A.M., R147 was taken in his/her wheelchair from the nurses' station to the dining room, where he/she remained until 1:17 P.M. -At 1:17 P.M., R147 was taken in his/her wheelchair from the dining room to the nurses' station, where he/she remained seated in the spot until 1:57 P.M. There was no TV or music in the area and he/she was not wearing his/her headphones. -At 1:57 P.M., R147 stood up from his/her wheelchair and CNA11 walked with R147 to the bathroom in the shower room near the nurses' station. During continuous observations of R147 on the 500 Division on 02/08/24 from 11:08 A.M. to 11:58 A.M., there were no observations of provision of activities: -At 11:08 A.M., R147 sat in his/her wheelchair in the area in front of the nurses' station. He/She was leaning forward and reaching out in front of him/her. There was no TV or music in the area and he/she was not wearing his/her headphones. -At 11:12 A.M., R147 was attempting to scoot his/her wheelchair forward, but was unable to move it. He/She then began leaning forward and reaching in front of him/her. -At 11:41 A.M., R147 scooted forward in his/her chair, bent forward, and reached his/her arms out in front of his/her. The Director of Nursing (DON) entered the area and stated, He/She needs his/her headphones on for some music, approached R147, and asked if he/she would like his/her headphones. The DON then left the area, but did not return with the headphones or any type of music for R147. -At 11:58 A.M., R147 was taken in his/her wheelchair to the dining room. During an interview on 02/07/24 at 2:21 P.M. with family member (F) 2, he/she stated R147 was blind and had dementia, and he/she loved music. F2 stated R147 had headphones to play the music he/she likes while out at the nurses' station; however, the staff did not put the music on for his/her. During an interview on 02/09/24 at 2:21 P.M., CNA11 stated R147 liked to listen to music and wore headphones tuned to his/her favorite music. CNA11 stated activities department staff did not work with R147 or provide him/her with any type of engagement or stimulation. The CNA stated, He/She loves the headphones . sometimes he/she sings along with it. CNA11 stated R147 never refused to wear the headphones when offered. During an interview on 02/09/24 at 4:51 P.M., with the Assistant Administrator and Activity Director (AD), the AD stated he/she had only been working in the facility for three days and the Assistant Administrator was more knowledgeable about the current activity programming and residents. During an interview on 02/09/24 at 5:19 P.M., the Assistant Administrator stated he/she was unable to find any activity participation records for February 2024 for R147, did not locate an activity assessment or Care Plan for R147 and was unable to describe the activity program for R147. During an interview on 02/09/24 at 6:40 P.M., with Administrator and DON, the DON stated he/she did not provide R147 with headphones on 02/08/24, because the headphones were not working and needed to be fixed. He/She stated music was soothing to R147 and should be provided to him/her for sensory stimulation and engagement. The Administrator stated he/she expected the staff to provide activities to cognitively impaired residents to meet their needs according to their likes and dislikes. 2. Review of the EMR Diagnosis tab for R151 revealed he/she was admitted to the facility on [DATE] with diagnoses to include dementia with other behavioral disturbances, generalized anxiety disorder, unspecified hearing loss, legal blindness with corrective glasses, and major depressive disorder. Review of R151's Admission MDS with an ARD of 05/22/23 and located in the RAI (Resident Assessment Instrument) tab of the EMR, revealed her BIMS score was 12 out of 15 which indicated moderately impaired cognition. Per the MDS staff had indicated the daily and activity preferences interview should be conducted, however the daily and activity preferences questions were not completed. Review of the EMR Care Plan tab for R151's care plan, dated 11/28/23, documented that R151 required monitoring for activities of daily living (ADLs) for all transfers and mobility. The care plan documented R151 had behavioral symptoms as evidenced by standing up without staff assistance, and frequent yelling out for help that was disturbing to other residents. The documentation for activities listed in the care plan documented that R151 has an activity deficit related to his/her cognitive impairment. Documentation in the care plan for R151 regarding customary routine or activity preferences or interventions was not identified. During observation in the common area near the nurses' station on 02/05/24 at 10:24 A.M., R151 was seated in a recliner positioned in recline. R151 was calling out for help and did not open her eyes. CNA5 responded to R151 and asked him/her how he/she could help him/her. R151 said he/she needed a hug, and CNA5 gave the resident a hug. R151 stopped calling out for help and continued to sit with his/her eyes closed. During an observation of R151 on 02/05/24 at 2:57 P.M. through 3:45 P.M., R151 was observed seated in his/her wheelchair at the nurses' station calling out for help and standing up from him/her wheelchair. Registered Nurse (RN) 4 was seated beside R151 and consistently tried to redirect the resident to sit down. During continued observation of R151 on 02/05/24 at 4:10 P.M., the resident was seated in his/her wheelchair at the nurses' station beside RN4. R151 was calling out for help standing up from his/her wheelchair. The RN4 tried to consistently redirect the resident to sit down in his/her wheelchair so he/she would not fall. During an interview on 02/08/24 at 2:20 P.M., the Activity Assistant (AA) stated he/she had been employed as the activity assistant for a few weeks and could not locate or identify progress notes to indicate activity interventions had been documented for R151. The AA stated the activity progress notes were not documented on paper, but could be viewed in the EMR under the tab for activity progress notes. On 02/08/24 at 10:30 AM, all documentation regarding an activity program assessment or care plan interventions for R151 was requested from the Administrator. The Administrator provided one activity calendar dated November 2023 with seven activity events highlighted to indicate attendance to the activity by R151. The highlighted calendars did not contain a signature of the staff member that highlighted the activities. 36917

Based on observations, interviews, record review, and policy review, the facility failed to ensure two (Resident (R) 100 and R147) of four residents reviewed for activities of daily living (ADLs) received assistance with incontinence care and/or using the toilet as needed. These failures created a potential for skin problems, urinary tract infections, or increased incontinence for these two residents. Findings include: Review of the Urinary Incontinence Management policy, dated June 2021, revealed, AII residents will receive perineal care, as needed, in the morning before breakfast. every evening with evening care at bedtime, as needed after bowel movement or urination, and each time the resident is incontinent. The policy failed to address the expectation for rounding to check for incontinence and change if needed at least every two hours. 1. Review of R100's Resident Face Sheet under the Resident tab in the electronic medical record (EMR) revealed he/she was admitted to the facility on [DATE] with diagnoses including: dementia, hemiplegia and hemiparesis following a stroke, dependence on wheelchair, and urinary incontinence. Review of R100's Annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 12/21/23 and located in the RAI [Resident Assessment Instrument] tab of the EMR, revealed he/she was unable to answer to the Brief Interview for Mental Status (BIMS) and staff assessed him/her with short- and long-term memory problems and severely impaired cognition. R100 was rarely/never able to make himself understood and did not exhibit behavioral symptoms. He/she had impaired range of motion in the upper and lower extremities on one side and was dependent on staff with toileting hygiene. He/she had not used the toilet during the review period. R100 was always incontinent of bladder and bowel and was not on a toileting program. Review of R100's Care Plan, dated 08/05/22 and located in the RAI tab of the EMR, revealed, [R100] has a deficit in ADL functioning and impaired mobility related to weakness caused by cerebral infarction affecting his/her right side and cognitive impairments. The approaches included, Toileting: Assist x2 [by two staff] and Transfer status: Mechanical lift assist x2. The Care Plan also documented, [R100] was incontinent of bowel and bladder related to his/her cognitive impairments caused by dementia, history of [stroke]. The goal was, Will be dry/free of odors and attain highest level of continence. The approaches included, Cleanse peri area after each incontinence episode. Apply protective barrier ointment/cream as ordered and Offer fluids frequently to prevent UTIs [urinary tract infections]. Review of R100's Incontinence Assessment Quarterly, dated 12/21/23 and located in the Observations tab of the EMR, revealed he/she was always incontinent, was cognitively impaired, had impaired mobility, and had an inability to recognize the need to void. The assessment documented, Continue current plan of care. During an interview with family member (F) 1 on 02/05/24 12:20 PM, he/she stated R100 was not provided with incontinence care often enough. He/She stated, He/She goes too long without being changed. He/She is wet most of the time. He/She drinks a lot of fluids in the morning. The family member stated the staff woke R100 up early and changed his/her incontinence brief at that time, but then he/her stayed up in his/her wheelchair until about 2:00 PM without being changed again, and R100 could not tell the staff when he/she was wet. The family member stated he/she brought these concerns to staff, but nothing had been done to improve the situation. At this time, R100 sat in a wheelchair in the area around the nurses' station. He/she was unable to answer screening questions verbally. During continuous observations of R100 on the 500 Division on 02/06/24 from 9:33 AM to 1:15 PM, there were no observations of incontinence checks or brief changes: -At 9:33 A.M., R100 sat in his/her wheelchair in the dining room finishing his/her breakfast. -At 10:09 A.M., R100 was taken in his/her wheelchair from the dining room to the area in front of the nurses' station. He/She remained seated in this spot, in the same position, until 12:02 P.M., without any interaction or checks from staff. -At 12:02 P.M., R100 was taken in his/her wheelchair from the nurses' station to the dining room. -From 12:03 P.M. to 1:15 P.M., R100 sat in his/her wheelchair in the dining room eating lunch. During continuous observations of R100 on the 500 Division on 02/07/24 from 10:16 A.M. to 1:39 P.M., there were no observations of incontinence checks or brief changes: -At 10:16 A.M., R100 sat in his/her wheelchair in the area in front of the nurses' station. -At 10:50 A.M., R100 propelled his wheelchair from the nurses' station to his/her room, where he/she sat in his/her wheelchair without any checks by staff until 11:39 AM. -At 11:39 AM, R100's family member arrived and propelled him/her in his/her wheelchair to the dining room, where he/she remained, seated in his/her wheelchair, until 1:21 PM. -At 1:21 PM, R100's family member propelled him/her in his/her wheelchair to his/her room and alerted Certified Nursing Assistant (CNA)11 he/she was ready for assistance. -At 1:39 PM, CNA11 and CNA14 began preparing to assist R100 to bed using a mechanical lift. During an interview on 02/07/24 at 1:45 P.M., R100's family member stated he/she had not been changed all morning and was wet. He/She stated the staff were changing his/her incontinence brief now, but it had not been done all morning. During an interview on 02/07/24 at 1:56 P.M., CNA11 stated he/she had just assisted R100 to bed and changed his/her brief. She stated his/her brief was very wet with urine, and added the resident would drink a lot of coffee in the morning. The CNA confirmed R100 had not been changed between breakfast and lunch. During an interview on 02/09/24 at 2:21 P.M., CNA11 stated R100 was always incontinent and did not use the toilet. She stated she was aware the resident's family member was concerned he did not get changed frequently enough. CNA11 stated R100 should be checked and changed if needed during the morning between breakfast and lunch, and then again after lunch, but that was not always done, because he/she required two staff members for assistance, and it was difficult to find a second CNA who could assist. 2. Review of R147's Resident Face Sheet under the Resident tab in the EMR revealed he/she was admitted to the facility on [DATE] with diagnoses including: Alzheimer's disease with anxiety, repeated falls, and traumatic subarachnoid hemorrhage. Review of R147's Admission MDS with an ARD of 12/13/23 and located in the RAI tab of the EMR, revealed he/she was unable to answer the BIMS and staff assessed his/her with short- and long-term memory problems and severely impaired cognition. R147 was rarely/never able to make herself understood. He/She had severely impaired vision and did not exhibit any behavioral symptoms. R147 was totally dependent on staff for toileting hygiene and required partial/moderate assistance with toilet transfers. He/She was occasionally incontinent of bowel and bladder and was not on a toileting program. Review of R147's Care Plan, dated 12/05/23 and located in the RAI tab of the EMR, revealed, [R147] is at risk for incontinence of bowel and bladder related to his/her decreased ability to alert others of toileting urgency and his/her need for assistance with lower body dressing/hygiene. The goals were, [R147] will remain clean, dry, and free from odors and Resident will attain or maintain highest level or current level of continence through next review. The approaches included, Assist with toileting and hygiene per resident routine and as needed/requested and Check me for incontinence frequently and provide prompt peri care to prevent skin damage. Cleanse peri care and apply protective barrier as indicated. The Care Plan also documented, [R147] has a deficit in ADL functioning/mobility and requires assistance related to his/her repeated falls, subarachnoid hemorrhage, Alzheimer's dementia, visual deficits, and decreased mobility. The approaches included, Assist with repositioning in bed and in wheelchair frequently and Encourage ADL participation and allow resident sufficient time to perform ADLs without being rushed. Provide assistance, as needed or requested. During continuous observations of R147 on the 500 Division on 02/06/24 from 9:33 A.M. to 1:15 P.M., there were no observations of incontinence checks or brief changes: -From 9:33 A.M. to 10:13 A.M., R147 was seated in the dining room in his/her wheelchair. -At 10:13 A.M., R147 was taken in her wheelchair from the dining room to the area in front of the nurses' station. He/She remained seated in this spot without any interaction or checks from staff. -At 10:42 A.M., no staff were present near the nurses' station. R147 began reaching his/her arms out in front of his/her and sitting forward in his/her chair. CNA10 was walking through the area, approached R147 at 10:43 A.M., and told him/her to sit back in his/her chair. CNA10 then walked away, and no additional staff were in the area. -At 10:59 A.M., R147 began reaching out in front of him/her and mumbling to himself/herself. There were no staff present in the area. -At 11:17 A.M., R147 stood up from his/her wheelchair. CNA14 assisted R147 to sit back down in his/her wheelchair. -From 11:17 A.M. to 12:03 P.M., R147 remained seated in this spot, in the same position, until 12:03 P.M., without any interaction or checks from staff. -At 12:03 P.M., R147 was taken in his/her wheelchair from the nurses' station to the dining room. -From 12:03 P.M. to 1:15 P.M., R147 was seated in his/her wheelchair in the dining room eating lunch. During continuous observations of R147 on the 500 Division on 02/07/24 from 10:16 A.M. to 1:57 P.M., there were no observations of incontinence checks or brief changes: -At 10:16 A.M., R147 was seated in the area in front of the nurses' station in his/her wheelchair. He/She remained seated in this spot without any checks or interaction until 10:50 A.M. -At 10:50 A.M., R147 stood up from his/her wheelchair and walked approximately 6 feet before CNA10 and Licensed Practical Nurse (LPN) 5 assisted him/her back to her wheelchair and told her to sit back down. He/She remained seated in this spot without any checks or interaction until 11:34 A.M. -At 11:34 A.M., R147 was taken in his/her wheelchair from the nurses' station to the dining room, where he/she remained until 1:17 PM. -At 1:17 P.M., R147 was taken in his/her wheelchair from the dining room to the nurses' station, where he/she remained seated in the spot without any checks or interaction until 1:57 P.M. -At 1:57 P.M., R147 stood up from his/her wheelchair. CNA11 walked with R147 to the bathroom in the shower room near the nurses' station. During an interview on 02/07/24 at 2:10 P.M., CNA11 stated R147 used the toilet in the shower room and his/her brief was a little wet at that time. He/She stated R147 was not always able to use the toilet and was frequently incontinent. The CNA stated R147 could not tell the staff when he/she was wet or when he/she needed to use the toilet. CNA11 stated R147 received a shower in the morning and used the toilet at that time and confirmed he/she had not used the toilet or been changed again until after lunch. During an interview on 02/07/24 at 2:21 P.M. with F2, he/she stated R147 was blind and had dementia, so he/she was not able to speak for his/her self. He/She stated before R147 was admitted to the facility, he/she was taken to the bathroom every two hours and was able to use the toilet and remain continent. The family member stated a sign that R147 needed to be changed or use the bathroom was frequent standing from his/her wheelchair. During an interview on 02/09/24 at 2:21 P.M., CNA11 stated R147 was frequently incontinent and should be checked and changed if needed every two hours. He/She stated R147 should be checked sometime between breakfast and lunch and then again after lunch; however, this did not always get done because of other duties pulling the CNA's away from resident care, like dining room setup and cleanup and serving meals. During an interview on 02/09/24 at 10:31 A.M., CNA13 stated every resident with incontinence should be checked and changed if needed at least every two hours, and those who were unable to communicate their needs should be checked on more frequently. CNA13 stated every two hours was the standard, but there were some residents who were unable to wait that long. During an interview on 02/09/24 at 11:22 A.M., CNA8 stated residents with incontinence should be checked and changed if needed at least every two hours. During an interview on 02/09/24 at 11:38 A.M., CNA6 stated residents with incontinence should be checked and changed if needed at least every two hours. During an interview on 02/09/24 11:53 A.M., CNA12 stated residents with incontinence should be checked and changed if needed at least every two hours and sometimes it was hard to get that done plus complete meal service and dining assistance at times. 3. During an interview on 02/09/24 at 2:21 P.M., CNA11 stated, We do our best . but we need extra staff to help with toileting. During an interview on 02/09/24 at 2:55 P.M., Licensed Practical Nurse (LPN)5 stated the expectation was that staff would make rounds to check for incontinence and change if needed every two hours: in the morning, after breakfast but before lunch, and after lunch. LPN5 stated CNAs did not document their rounding or episodes of incontinence. During an interview on 02/09/24 at 6:40 P.M., with the Administrator and Director of Nursing (DON), the Administrator stated staff were expected to check and change each resident with incontinence every two hours at the minimum. The DON stated staff had been educated frequently regarding the requirement to check and change at least every two hours. He/She stated he/she had not conducted recent monitoring of staff rounding or incontinence management and care.

Based on interview and record review, the facility failed to ensure an accurate Level 1 pre-screening of a resident for a mental disorder (MD) or intellectual disability (ID) prior to admission to the facility was completed for one of one resident (Resident (R) 23) reviewed for Level 1 (one) Pre-Admission Screening and Resident Review (PASARR). Findings include: Review of R23's ''Face Sheet'' located in the electronic medical record (EMR) under the ''Profile'' tab, revealed an admitted [DATE] and included the following diagnoses: anxiety disorder, major depressive disorder, and bipolar disorder. Review of R23's annual ''Minimum Data Set (MDS),'' located in the EMR under the ''MDS'' tab, with an Assessment Reference Date (ARD) of 11/06/23 revealed R23 had a ''Brief Interview for Mental Status (BIMS)'' score of eight out of 15, which indicated he was moderately cognitively impaired. The MDS indicated R23 had anxiety disorder and manic depression. Review of R23's EMR did not include a Level 1 PASARR. Review of R23's ''Care Plan'' located in the EMR under the ''Care Plan'' tab, dated 01/21/24, included R23 was at risk for adverse medication reactions related to taking psychotropic medication to assisting in managing his/her diagnosis of anxiety. R23 had behavioral symptoms as evidenced by refusing care and becoming agitated/combative with staff. R23 had cognitive decline and difficulties with memory/recall due to his/her disease progression. During an interview on 02/08/24 at 1:12 P.M., the Social Worker (SW) confirmed R23 was admitted to the facility on [DATE] and should have a PASARR level one on file. The SW stated the facility went electronic in 2017 and maybe the paper copy did not get scanned. Additionally, the SW stated R23 transferred from another facility on Medicaid and the facility would not have admitted him/her without having PASARR Level 1. Prior to the admission they would have had to do the paperwork to receive funding for his/her care. The SW deferred this matter to the Admissions Department who may have additional information. During an interview on 02/08/24 at 4:41 P.M., the Administrator confirmed R23 did not have a PASARR level one on file and that they follow Centers for Medicare and Medicaid Services (CMS) guidelines. The facility did not have a separate policy related to PASARR. During an interview on 02/09/24 at 4:32 P.M., the Admissions Coordinator (AC) stated R23 was approved for Medicaid prior to his/her admission to the facility in 2017. AC confirmed that the facility should have a PASARR on file, but were unable to locate it.

Based on record review, interviews, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to conduct a quarterly assessment including assessment of cognitive patterns and mood for one (Resident (R) 118) of 40 sampled residents. These failures created a potential for specific resident needs related to cognition and mood to go unidentified. Findings include: Review of the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, accessed at https://www.cms.gov/files/document/finalmds-30-rai-manual-v11811october2023.pdf, revealed, Cognitive Patterns: Intent: The items in this section are intended to determine the resident's attention, orientation, and ability to register and recall new information and whether the resident has signs and symptoms of delirium. These items are crucial factors in many care-planning decisions . Attempt to conduct the interview with ALL residents. This interview is conducted during the look-back period of the Assessment Reference Date (ARD) . Mood: Intent: The items in this section address mood distress and social isolation. Mood distress is a serious condition that is underdiagnosed and undertreated in the nursing home and is associated with significant morbidity. It is particularly important to identify signs and symptoms of mood distress among nursing home residents because these signs and symptoms can be treatable. Social isolation refers to an actual or perceived lack of contact with other people and tends to increase with age. It is a risk factor for physical and mental illness, is a predictor of mortality, and is important to assess in order to identify engagement strategies . If a resident cannot communicate, then Staff Mood Interview (D0500 A-J) should be conducted. Review of R118's Resident Face Sheet under the Resident tab in the electronic medical record (EMR) revealed he/she was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy, anxiety, hearing loss, and altered mental status. Review of R118's Quarterly Minimum Data Set (MDS) with an assessment reference date of 12/31/23 and located in the RAI (Resident Assessment Instrument) tab of the EMR, revealed R118 was usually able to make himself/herself understood and understand others. His/Her cognitive patterns and mood symptoms were not assessed. Though the assessment documented both the Brief Interview for Mental Status (BIMS) and the resident interview for mood should be completed; the questions were unanswered. During an interview with the MDS Coordinator (MDSC) on 02/09/24 at 4:06 P.M., she stated the social services staff was responsible for completion of the cognitive patterns and mood sections. She stated she provided a calendar of assessment due dates and expected staff to complete their assigned sections based off the calendar. She stated she was then responsible to sign off on completion of the MDS. During an interview on 02/09/24 at 4:40 P.M., the MDSC stated she could not find any evidence of an assessment of R118's cognitive patterns or mood and she did not know why the assessments had not been done. During an interview on 02/09/24 at 5:09 P.M., the MDSC stated there was no facility policy on MDS completion; they followed guidance in the RAI Manual.

Based on record review, interviews, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to conduct a comprehensive assessment including assessment of mood and daily activity preference for two (Resident (R) 100 and R147) of 40 sample residents. These failures created a potential for specific resident needs related to mood and/or daily and activity preference to go unidentified. Findings include: Review of the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, accessed at https://www.cms.gov/files/document/finalmds-30-rai-manual-v11811october2023.pdf, revealed, Mood: Intent: The items in this section address mood distress and social isolation. Mood distress is a serious condition that is underdiagnosed and undertreated in the nursing home and is associated with significant morbidity. It is particularly important to identify signs and symptoms of mood distress among nursing home residents because these signs and symptoms can be treatable. Social isolation refers to an actual or perceived lack of contact with other people and tends to increase with age. It is a risk factor for physical and mental illness, is a predictor of mortality, and is important to assess in order to identify engagement strategies . If a resident cannot communicate, then Staff Mood Interview (D0500 A-J) should be conducted . Preferences for Customary Routine and Activities: Intent: The intent of items in this section is to obtain information regarding the resident's preferences for their daily routine and activities. This is best accomplished when the information is obtained directly from the resident or through family or significant other, or staff interviews if the resident cannot report preferences . If a resident cannot communicate, then family or significant other who knows the resident well may be able to provide useful information about preferences . If the resident is unable to complete the resident interview, attempt to conduct the interview with a family member or significant other. If neither a family member nor significant other is available, skip to item F0800, Staff Assessment of Daily and Activity Preferences. 1. Review of R100's Resident Face Sheet under the Resident tab in the electronic medical record (EMR) revealed he/she was admitted to the facility on [DATE] with diagnoses including: dementia, hemiplegia, and hemiparesis following a stroke, and dependence on wheelchair. Review of R100's Annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 12/21/23 and located in the RAI [Resident Assessment Instrument] tab of the EMR, revealed he/she was unable to answer to the Brief Interview for Mental Status (BIMS) and staff assessed him/her with short- and long-term memory problems and severely impaired cognition. R100 was rarely/never able to make himself/herself understood and did not exhibit behavioral symptoms. The MDS areas to assess mood symptoms and daily activity preferences were not completed. The assessment documented the resident interviews for mood and for daily activity preferences should not be completed as the resident was rarely/never able to make himself/herself understood; however, the alternative staff assessments for mood and for daily activity preferences also were not completed. Additionally, the assessment did not indicate R100 used a wheelchair. During an interview with the MDS Coordinator (MDSC) on 02/09/24 at 4:06 PM, she stated the social services staff was responsible for completion of the mood section and the activities director was responsible for the daily and activity preferences section. She stated she provided a calendar of assessment due dates and expected staff to complete their assigned sections based off the calendar. She stated she was then responsible to sign off on completion of the MDS. The MDSC stated there was an interim staff person who had completed some nursing sections of the MDS assessments remotely from home and was reliant solely on documentation in the record for completion of the assessment, and this person would have assessed the resident's wheelchair use. During an interview on 02/09/24 at 4:40 P.M., the MDSC stated she could not find any evidence of an assessment of R100's mood or daily activity preferences and she did not know why the assessments had not been done. She stated the resident's record reflected use of a wheelchair in multiple areas and the use of a wheelchair should have been included on the MDS. 2. Review of R147's Resident Face Sheet under the Resident tab in the EMR revealed he/she was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease with anxiety, depression, and repeated falls. Review of R147's Admission MDS assessment, with an ARD of 12/13/23 and located in the RAI tab of the EMR, revealed he/she was unable to answer the BIMS and staff assessed her with short- and long-term memory problems and severely impaired cognition. R147 was rarely/never able to make himself/herself understood. R147's daily and activity preferences had not been assessed as required. The MDS documented yes, the resident interview for daily and activity preferences should be completed; however, the questions were unanswered. During an interview on 02/09/24 at 5:09 P.M., the MDSC stated she could not find any evidence of an assessment of R147's daily and activity preferences and she did not know why the assessment had not been done. The MDSC added there was no facility policy on MDS completion; they followed guidance in the RAI Manual.

Based on observations, interviews, record review, and policy review, the facility failed to ensure the advance health care directive of one (Resident (R) 147) of six residents reviewed for advance directives was honored. This failure had the potential to result in unwanted provision of cardio-pulmonary resuscitation (CPR) resulting in possible pain, injuries such as broken ribs, and altered mental status. Findings include: Review of the undated Advance Directives Policy revealed, Upon admission, identify if the resident has an advance directive and if not, determine if the resident wishes to formulate an advance directive . Resident wishes will be communicated to the staff via the care plan and (identify facility protocol for communication of advance directives either in written or oral format) and to the resident physician. Review of R147's Resident Face Sheet under the Resident tab in the electronic medical record (EMR) revealed he/she was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease with anxiety, depression, and repeated falls. Review of R147's Admission Minimum Data Set (MDS) with an assessment reference date (ARD) of [DATE] and located in the RAI (Resident Assessment Instrument) tab of the EMR, revealed he/she was unable to answer the Brief Interview for Mental Status (BIMS) and staff assessed him/her with short- and long-term memory problems and severely impaired cognition. R147 was rarely/never able to make himself/herself understood. Review of R147's Health Care Directive, dated [DATE] and located in the Documents tab of the EMR, revealed, I make this Health Care Directive (Directive) to exercise my right to determine the course of my health care and to provide clear and convincing proof of my wishes and instructions about my treatment. If I am persistently unconscious or there is no reasonable expectation of my recovery from a seriously incapacitating or terminal illness or condition, I direct that all of the life-prolonging procedures that I have initialed [sic] below be withheld or withdrawn . heart-lung resuscitation (CPR). The form designated family member (F) 2 as R147's durable power of attorney (POA). Review of R147's Orders tab of the EMR revealed a physician's order, dated [DATE], for full code status, meaning CPR would be provided. Review of R147's Care Plan, dated [DATE] and located in the RAI tab of the EMR, revealed, I or my responsible party for Health Care decisions has selected the following directive for Code Status: Administer CPR. The goal was, My wishes for my code status will be honored during my stay in this facility. The approaches included: In the event that I have no pulse or respirations, CPR will be administered with the notification of 911 . My code status will be discussed and updated quarterly with my care plan review . [and] My physician and family will be notified following notification of 911 emergency response. Review of R147's Care Conference Information summary, dated [DATE] and located in the RAI tab of the EMR, revealed, Admission care plan done over phone with [F2] and SW . [F2] stated Resident has had dx [diagnosis] of dementia for approximately 8 years. [F2] confirmed residents code status is to remain Full Code. Resident is unable to make needs known due to confusion. During an interview on [DATE] at 11:18 A.M., Licensed Practical Nurse (LPN) 5 stated typically, a report of each residents' code status was printed by the night shift each night and kept at the nurses' station for reference; however, he/she was unable to find the code status reference list at the 500 Division nurses' station. He/She stated in this instance, he/she would refer to the physician's orders in the Orders tab of the EMR. LPN5 reviewed R147's orders and stated he/she had a full code status and CPR would be provided. During an interview on [DATE] at 11:29 A.M., the Social Worker (SW) stated the admissions staff were responsible for uploading the POA document and the Health Care Directive into R147's medical record and she was not aware that R147 had a Health Care Directive electing a 'do not resuscitate (DNR)' status. The SW stated she reviewed the code status with F2 during the initial Care Conference, and stated F2 requested a Full Code status at that time. The SW stated since she was not aware of R147's Healthcare Directive, she did not address the discrepancy with F2. The SW stated she was not aware how to proceed in a situation where the POA's wishes went against the resident's advance directive. The SW stated she would contact F2 to discuss the situation. During an interview on [DATE] at 2:10 P.M., the SW stated she discussed R147's Healthcare Directive with F2; however, F2 wished for the resident to remain with full code status. She stated this situation needed to be escalated for further discussion related to honoring R147's wishes. During an interview on [DATE] at 4:20 P.M., the Admissions Coordinator (AC) stated he would typically upload an advance directive to the Documents tab of the EMR upon a resident's admission, and all staff would be able to access the directive in the EMR. He stated since F2 was the POA, the POA's wishes for full code status would be honored and added that if the POA wishes did not align with the Health Care Directive, the SW should discuss the issue with the POA. The AC stated the admitting nurse would enter the code status order in the EMR and the SW reviewed the code status during the initial Care Conference. During an interview on [DATE] at 2:21 P.M., with F2, he/she stated he/she was now aware R147 had elected DNR status in her Health Care Directive and stated this had not been discussed with him/her prior to today. F2 stated he/she would like R147 to remain with a full code status and did not believe R147 was able to understand the Health Care Directive he/she formulated in 2018 due to dementia. During an interview on [DATE] at 6:40 P.M., with the Administrator and Director of Nursing (DON), the Administrator stated if a POA's wishes did not align with a resident's advance directive, she would expect the SW to have a conversation with the POA and involve the Ombudsman or other agencies as needed. She stated there was no clear direction on how to proceed in this instance so other agencies could help navigate the issue.

Based on interview and record review, the facility failed to ensure residents received their medications as ordered by failing to ensure admission medications were verified and ordered promptly, medications were reordered prior to running out, staff checked the facility starter kit (an in-facility supply of commonly used medications for immediate use) and/or the medication supply room when a new medication was ordered or a current medication was unavailable. Additionally, staff failed to notify physicians, and/or the resident, and/or the resident's representative when medications were not administered as ordered. Resident #2 had a diagnosis of thyroid cancer and an order for Nexavar (used to prevent the growth and spread of cancer) and cephalexin (antibiotic). From 5/15/23 through 5/26/23, the resident missed seven of 24 doses of Nexavar. From 6/9/23 through 6/12/23, the resident missed six of 15 doses of cephalexin before admission to the hospital with diagnoses of a left lower extremity wound infection and sepsis (blood poisoning) secondary to the wound infection. Resident #1 was admitted to the facility on [DATE], after a recent left adrenalectomy (surgical removal of one or both adrenal glands (small glands that sit above the kidneys)) and nephrectomy (surgical removal of a kidney), and an order for a tapered dose of hydrocortisone (a steroid used to treat inflammation). On the day of admission, the resident's physician requested staff contact the resident's endocrinologist to confirm a tapered dose of hydrocortisone. Staff failed to follow-up with the endocrinologist until 5/1/23, when the tapered dose of hydrocortisone was started. On 6/15/23, Resident #4 received an order for amoxicillin (antibiotic) for a dental infection/toothache. The resident did not receive four of 14 doses as ordered, and of the 10 doses the resident received, staff administered three doses of amoxicillin clavulanate (Augmentin, an antibiotic) which was not the same as amoxicillin. Three residents were sampled and problems were identified with two. An expanded sample of six residents were selected and problems were identified with one (Resident #4). The census was 191. Review of the facility Medication Administration policy, revised on 1/2021, included the following: -General: -Only licensed registered nurses (RNs), licensed practical nurses (LPNs) or Certified Medication Technicians (CMTs) are assigned responsibility for preparing, administering and recording of medications, or permitted access to drug storage areas on each nursing unit; -Medication and treatment errors and undesirable effects are to be immediately reported to the Director of Nursing (DON) or nursing designee and the attending physician, charted in detail on the progress notes, and described in a full incident report; -Personnel administering drugs are to refer to the physician's desk reference (PDR, a drug reference), or its equivalent, when unfamiliar with the pharmacology of the drug, its potential toxic effects or contraindications; -If a medication is not available from the pharmacy, the attending physician is to be notified for an alternative. Review of the Pharmacy Policy/Procedures, Emergency Drug Supply, undated, included the following: -Pharmacy Responsibility: -Emergency drug supply refers to medication kept at the facility for stat (immediate) medication doses. These medications will be kept in the StatSafe. An emergency drug kit is supplied by the pharmacy if appropriate for the facility; -Facility Responsibility: -An emergency drug kit is available at the facility. A list of contents of this kit is kept with the kit; -When a resident has an order for a medication that needs to be started prior to the next delivery from pharmacy, the medication can be pulled from the emergency kit to get them started; -Ensure that the correct medication/dose is taken from the emergency kit to match the resident's order. Review of the facility Charge Nurse job description, undated, included the following: -Reports To: -DON/Nursing Administration; -Purpose: To provide direct nursing care to the residents, and to supervise and lead the day-to-day nursing activities performed by nursing assistants. Such supervision must be in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be required by the DON to ensure that the highest degree or quality care is maintained at all times; -Duties Include: -Place phone calls to the physician to report patient's condition changes, need for medication changes, accident/incidents, behavior changes, etc.; -Enter orders in Matrix (electronic medical record, (EMR)) for all orders changed by the physician over the phone; -Notify family members of any changes, transfers out of the facility or any other significant or insignificant needs of the resident; -Prepare, administer and chart medication according to house policy; -Perform all skilled nursing procedures according to house policy; -Complete the admission process on all new admits received during your scheduled shift. If unable to complete the admission process on your shift, give the oncoming nurse a detailed report of what is completed/not completed; -Maintain frequent communication with the DON on the conditions existing on your assigned division; -See that all physician's orders are carried out or appropriate arrangements made; -Re-order medications as needed. Review of the facility CMT job description, undated, included the following: -Reports To: Charge Nurse and/or Nursing Administration; -Purpose: To assist in administering of medications to residents as ordered by the attending physician, under the direction of the attending physician, the nurse supervisor or charge nurse, and DON. The administration of medication shall be in accordance with established nursing standards, the policies, procedures, and practices of this facility and the requirement of this state; -Duties Include: -Complete and accurate charting in the medication administration record (MAR) according to facility policy and procedures; -Administer medications; -Prepare, administer and chart on all medication and report observation to charge nurse; -Pour and pass medications to all residents according to their medication sheets, crushing medications as ordered; -Add new medications and reordered medications to proper areas of the medication cart and storage areas; -Understands that errors in preparing or administering medication may have serious consequences for residents; -Can identify what constitutes a medication error and notifies charge nurse of error. 1. Review of Resident #2's admission Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated 5/2/23, showed: -admitted [DATE]; -Adequate hearing and vision; -Speech Clarity: Clear speech - distinct intelligible words; -Diagnoses of stroke and thyroid disorders; -Cancer not indicated; -Special Treatments: Chemotherapy while a resident. Review of the resident's undated care plan, showed: -Problems: -Activity of daily living functional status/rehabilitation potential; -Pressure Ulcer/Injury: Unspecified ulcer to the left lateral shin; -Approaches: -Transfer Status, Bed Mobility: Assist with one; -Staff to monitor skin during care. Nursing to complete weekly skin audits and document as required; -The care plan did not address the resident's chemotherapy, cancer or Nexavar. Review of the resident's physician's order sheet (POS), showed: -4/23/23: Nexavar 200 milligrams (mg) two tablets (400 mg) every 12 hours at 6:30 A.M. and 6:30 P.M.; -6/8/23: Cephalexin 500 mg four times a day for seven days at A.M. med pass (7:25 A.M.-11:30 A.M.), noon med pass (11:30 A.M.-2:45 P.M.), P.M. med pass (3:15 P.M.-6:45 P.M.) and hour of sleep med pass (7:15 P.M.-11:00 P.M.). Review of the resident's Medication Administration Record (MAR), dated 5/1/23 through 6/22/23, showed staff did not administer the resident's Nexavar and cephalexin due to the medication being unavailable on the following dates and times; -Nexavar: -6:30 A.M.: 5/15, 5/21, 5/23 and 5/26; -6:30 P.M.: 5/20, 5/21, and 5/22; -This accounts for seven of 24 missed doses between 5/15/23 and 5/26/23. -Cephalexin: -A.M. med pass (7:25 A.M.-11:30 A.M.): 6/11 and 6/12/23; -Noon med pass (11:30 A.M.-2:45 P.M.): 6/11 and 6/12/23; -P.M. med pass (3:15 P.M.-6:45 P.M.): 6/11/23; -Hour of sleep med pass (7:15 P.M.-11:00 P.M.): 6/11/23; -This accounts for 6 of 14 missed doses between 6/11/23 and 6/12/23. Review of the resident's progress notes, dated 5/15/23 through 6/12/23, showed no documentation staff contacted the pharmacy, physician or resident representative regarding the missed doses of Nexavar and cephalexin due to the medications being unavailable. During an interview on 6/28/23 at 10:45 A.M., a pharmacy representative said the pharmacy does not supply the resident's Nexavar. The facility sent the pharmacy an order for cephalexin on 6/8/23 at 6:14 P.M., and the pharmacy delivered one card of 28 tablets on 6/8/23 at 9:34 P.M. Review of the facility Starter Checklist (for the emergency drug kit), kept on the 400 division of the facility, showed it contained two cards of cephalexin 250 mg for immediate use. Each card contained eight tablets. Review of the resident's progress notes, showed: -6/8/23 at 4:08 P.M., and completed by the facility Wound Nurse (WN): Treatment nurse administered treatment (wound on left lower extremity). Resident noted to have large amount of yellow drainage to left leg ulcers, redness and edema noted. Treatment administered and call placed to physician. Voicemail left for physician to request order for antibiotic for cellulitis (a bacterial infection involving the inner layers of the skin and characterized by an area of redness). Awaiting call back, reported to division nurse; -6/9/23 at 11:13 A.M., Physician returned call related to resident's left lower extremity. New orders were noted to start cephalexin 500 mg four times a day for seven days; -6/12/23 at 5:08 P.M., and completed by the WN:. This nurse went to resident's room to do treatment, resident recently started on antibiotic for wounds. Resident's entire left lower extremity red, inflamed, skin full of slough (dead skin/tissue) and plenty of loose skin. Serous drainage (thin pale or yellow drainage) noted on bandage. Call paced to physician, gave description of wounds and physician agrees the resident needs to be sent to the hospital. Family notified; -6/20/23 at 4:23 A.M.: Resident admitted to hospital with left leg wound drainage. He/She returned with minocycline (antibiotic) two times a day for 10 days. Resident is alert and oriented and able to make needs known. Review of the resident's hospital progress notes, dated 6/12/23 through 6/19/23, showed: -History/Physical: Presents to hospital for complaints of leg infection. Patient notes he/she injured his/her leg on mattress/bed about three weeks ago and developed swelling, redness of his/her leg which has been worsening. He/She was started on cephalexin on 6/8 by nursing home physician without improvement; -Assessment/Plan included: -1. Left leg infected wound with surrounding cellulitis. Start intravenous doxycycline. Consult with wound care RN; -2. Sepsis secondary to left leg wound; -4. Thyroid cancer with metastasis (cancer that has spread beyond the point of origin to other, distant areas of the body) to the lung; -Hospital Course: Wound culture growing multi drug resistant (MDR) ancinetobacter (bacteria) and methacillin resistant staphylococcus (MRSA, infection is caused by a type of staph bacteria that's become resistant to many of the antibiotics used). He/She was on ceftazidime (antibiotic) and doxycycline while admitted . Can discharge on minocycline 100 mg twice a day for 10 days. Review of the resident's progress notes, dated 6/20/23 at 4:23 A.M., showed the resident admitted to the hospital with left leg wound drainage. He/She returned with minocycline (antibiotic) two times a day for 10 days. Resident is alert and oriented and able to make needs known. During an interview on 6/22/23 at 11:30 A.M., the resident said he/she got an abrasion on his/her left lower leg. As soon as the abrasion was noted, the facility WN started treating it. He/She thinks he/she is currently getting antibiotics for the wound. During an interview on 6/22/23 at 12:00 P.M., the facility WN said the resident started cephalexin on 6/8/23, for the wound on his/her left lower leg. When she returned on 6/12/23, it did not look better. The physician could not come in until 6/14/23, so she called the physician and got an order to send the resident to the hospital for an evaluation. She didn't know the resident had missed some of his/her doses of antibiotic. That could be why the wound did not improve. During an interview on 6/26/23 at 8:06 A.M., CMT A (documented on the MAR the Nexavar was unavailable on 5/23/23 at 6:30 A.M., and the cephalexin was unavailable on 6/11/23 and 6/12/23) said he/she thought Nexavar was a medication for blood sugar. It's ordered through a local hospital and the resident's family picks it up. The nurses are responsible to let the family know when it needs reordered. The cephalexin comes from the pharmacy. He/She was not sure what it was being administered for, but if was for the leg wound then it would be important for the resident to have. CMTs are supposed to let the nurses know if the medication is not available. There is a starter kit on the 400 division, but he/she did not check to see if cephalexin was available. He/She is supposed to reorder a medication when it is down to the last seven doses. If a medication is not available, you are supposed to let the charge nurse know. He/She thinks he/she told the charge nurses about the Nexavar and cephalexin not being available. During an interview on 6/26/23 at 8:06 A.M., CMT A said when a medication is down to the last seven doses, you are supposed to pull the label and order it from the pharmacy. He/She always informs the charge nurse when a medication is unavailable. During an interview on 6/26/23 at 8:25 A.M., Nurse B said he/she thought Nexavar was an antibiotic. He/She was not aware it was a cancer medication. It would be important for the resident to not miss a dose. He/She thinks the family is responsible to bring the medication to the facility. Cephalexin is an antibiotic and was for the resident's leg wound. It would be important the resident receive all of his/her doses. Cephalexin is in the starter kit. CMTs should pull the cephalexin from the kit if it's available, then call the pharmacy. He/She had not been told by the CMTs the resident had missed any doses of either medication. The CMTs should let the nurses know when a medication is getting low so the nurses can contact the family or pharmacy to reorder the medication. If the resident misses a dose of any medication, CMTs should let the nurses know so the resident's physician and responsible party can be notified. This should be documented in the resident's progress notes. During an interview with the Director of Clinical Services, Administrator and DON, on 6/26/23 at 9:50 A.M., the DON said if a medication is unavailable for any reason, CMTs should let the nurse know. The nurse or CMT should contact the pharmacy to find how long a medication will be unavailable. The nurse should update the resident's physician, the resident and the resident representative and document it in the progress notes. Staff should check the starter kit to see if a medication is available. If it is, they should give the medication. Cephalexin is a medication that is available in the starter kit. She did not know why staff did not check the starter kit. There is no way to know had the resident received all of his/her doses of the cephalexin, if the resident's wound would have gotten worse. She expected staff to know what a medication is for before administering it. If they don't know, they should look it up. The Director of Clinical Services said staff should reorder a medication when the medication is down to its last three days. If a medication cannot be obtained, staff should document whom they spoke to, what was discussed and any new orders they received in the progress notes. During an interview on 6/26/23 at 12:33 P.M., CMT C (documented on the MAR the Nexavar was unavailable on 5/20/23 and 5/21/23) said if a medication is unavailable, they are supposed to order it from the pharmacy. If the medication is an antibiotic, he/she would check the starter kit to see if it is available to give. He/She was not sure what Nexavar was used for. If it is a cancer medication, it would be important for the resident to receive all the doses as ordered. He/She is not sure if the Nexavar is reordered through the pharmacy or family. A medication should be reordered when there were seven days left, to ensure it is delivered before running out. During an interview on 6/26/23 at 1:05 P.M., CMT D (documented on the MAR the Nexavar was unavailable on 5/26/23) said he/she did not know what Nexavar was used for. If a medication is unavailable, he/she would tell the nurse. If the medication is reordered through the pharmacy, he/she would call the pharmacy and tell the nurse. During an interview on 6/27/23 at 8:22 A.M., the DON said the electronic MAR would not alert staff if a medication was unavailable on previous days unless staff click on the look-back tab, which would show the last 14 days. She was not aware the resident had not received the Nexavar or cephalexin as ordered. This past May, she realized there was a problem with residents missing their medications. At that time, she began to print off a daily missed medication report. She had been giving those reports to the Nurse Managers to follow up. She had not been checking with the Nurse Managers to ensure they were following up though. During an interview on 6/27/23 at 11:18 A.M., Nurse G (worked on 5/22/23, 5/23/23 and 6/11/23) said on 5/22/23, the CMT told him/her the resident was out of the Nexavar and he/she called the resident's family that day. That was the first time he/she was aware the medication was unavailable. The family brought in a new bottle of the medication that day. He/She recalls the CMT telling him/her about the cephalexin being unavailable on 6/11/23, and he/she recalls telling the CMT to check the starter kit. He/She assumed the CMT checked it and gave the cephalexin. Any time a medication is not administered for any reason, the CMT should notify the nurse. If a medication is not available in the starter kit or in the facility stock supply room, he/she will call the pharmacy to see how fast it can be delivered. Part of their protocol is to also call the physician and family if a dose is missed and document it in the progress notes. During an interview on 6/27/23 at 12:15 P.M., the resident said he/she is on Nexavar for thyroid cancer and was receiving cephalexin for his/her leg wound. He/She was not aware he/she missed doses of Nexavar and cephalexin. No one told him/her. He/She would have liked to have informed. During an interview on 6/27/23 at 3:25 P.M., the resident's oncologist said he sees the resident about one time a month or every other month. The resident receives Nexavar for thyroid cancer with metastasis to the lungs. Nexavar is used to keep the metastasis in check. The resident should receive every dose of the medication, and he should be notified if the resident misses any doses. He does not recall being told the resident missed seven doses. Missing seven doses in one month would have a minimal effect on the resident. Staff should call the resident's family before allowing the medication to run out. During an interview on 6/28/23 at 9:42 A.M., Nurse H (worked on 5/21/23 and 6/12/23) said he/she does not recall CMTs telling him/her the resident's Nexavar or cephalexin was unavailable or that the resident had missed multiple doses. Had they told him/her, he/she would have notified the physician, family, pharmacy and documented it in the resident's progress notes. During an interview on 6/28/23 at 2:10 P.M., the resident's family member said he/she was not notified about the resident being out of Nexavar until 5/23/23, when Nurse G called him/her. He/She brought in a new bottle of the Nexavar that day. He/She was not informed the resident missed doses of the cephalexin for his/her leg wound. During an interview on 6/29/23 at 2:22 P.M., the resident's physician said he was not made aware the resident had missed doses of the antibiotic, but he would have expected the facility to notify him. He expected staff to check the starter kit and if available, give the medication. Since the resident had MRSA in the wound, it is difficult to determine if the cephalexin would have worked or not. 2. Review of Resident #1's admission MDS, dated [DATE], showed: -Makes Self Understood: Understood; -Ability to Understand Others: Understands; -Diagnoses of cancer (with or without metastasis), thyroid disorder and respiratory failure. Review of the resident's undated care plan, showed: -Problem: -Activities of Daily Living Functional Status/Rehabilitation; -Approaches: -Assist resident with repositioning in bed and in wheelchair frequently; -Assistance of one with transfers and bed mobility. Review of the resident's hospital medical records, dated 4/4/23 through 4/28/23, showed: -Primary Discharge Diagnoses: Adrenal mass (adrenal gland, located on top of both kidneys) with left adrenalectomy and left nephrectomy; -Medications to continue included: -Week 3 that started on 4/25/23: Hydrocortisone 15 mg upon waking, 15 mg with dinner; -Week 4: Hydrocortisone 15 mg upon waking, 10 mg with dinner; -Week 5 and beyond: Hydrocortisone 10 mg upon waking and 10 mg with dinner. Resident should remain on this dose unless otherwise instructed. Review of the resident's admission progress note, dated 4/28/23 at 3:59 P.M. and documented by Nurse H, showed the resident arrived at the facility. His/Her medications were faxed to the resident's physician for verification. No documentation about the physician requesting the endocrinologist be notified to verify the tapered dose of hydrocortisone. During an interview on 6/28/23 at 10:45 A.M., a pharmacy representative said they received the order for hydrocortisone from the facility on 5/1/23 at 12:00 P.M., and it was delivered to the facility on [DATE] at 12:54 P.M. Review of the resident's POS, showed: -No order for hydrocortisone on 4/28/23, 4/29/23 and 4/30/23; -5/1/23: An order received to begin a tapered dose of hydrocortisone. Review of the resident's MAR, dated 4/28/23 through 5/14/23 (discharge date ), showed: -4/28/23 through 4/30/23: No order for hydrocortisone tablets; -5/1/21 at 1:00 P.M.: The first dose of hydrocortisone was administered. During an interview on 6/26/23 at 10:20 A.M., the DON said when she came in on 5/1/23, the resident's family told her and the ADON that the resident was not receiving his/her hydrocortisone. She and the ADON reviewed the resident's admission orders, noting the order for the tapered dose of hydrocortisone and confirmed the resident had not been receiving the medication. She and the ADON contacted the resident's endocrinologist who confirmed the resident was to receive the hydrocortisone and he gave a new order for the hydrocortisone which was started that same day. She was not sure why the medication was not started upon admission. The charge nurse who admitted the resident was responsible to ensure the medication was verified, ordered from the pharmacy and started. During an interview on 6/27/23 at 10:44 A.M., the ADON said she spoke to Nurse H, who admitted the resident. Nurse H told her he/she called the physician to confirm the admission orders. The physician told Nurse H to confirm the tapered dose of hydrocortisone with the endocrinologist. She is not sure if Nurse H called the endocrinologist as there are no progress notes showing he/she did. If Nurse H did contact the endocrinologist, she expected him/her to have documented it. During an interview on 6/28/23 at 9:42 A.M.,, Nurse H said he/she got most of the resident's admission medications ordered on 4/28/23. The physician wanted the resident's tapered dose of hydrocortisone verified with the endocrinologist. He/She asked another nurse to do that, but he/she could not recall what nurse. He/She did not document any of this, but he/she should have. During an interview on 6/28/23 at 8:10 A.M., the resident's family member said he/she was very alarmed when he/she learned the resident was not receiving his/her hydrocortisone. He/She spoke to the DON on 5/1/23, and the DON realized the importance of the resident receiving the medication. The DON got the medication ordered on 5/1/23. 3. Review of Resident #4's quarterly MDS, dated [DATE], showed: -Adequate hearing and vision; -Speech Clarity: Clear speech-distinct intelligible words; -Eating: Independent, setup assistance only; -Diagnoses of anemia (a deficiency of oxygen carrying blood), high blood pressure, diabetes mellitus (insufficient insulin production characterized by high blood sugar), anxiety and depression. Review of the resident's undated care plan, showed: -Problems: -Antibiotic for tooth infection; -Cognitive Loss/Dementia; -Activities of Daily Living Status/Rehabilitation Potential; -Approaches: -Administer medications as ordered;; -Monitor and record any pain or discomfort that may arise due to my infection; -Report any decline to my physician. Review of the resident's POS, showed: -6/15/23: May be seen by the facility dentist; -6/15/23: Amoxicillin 875 mg two times a day for seven days. Review of the facility Starter Checklist (emergency drug kit), showed it contained two cards of amoxicillin 250 mg. Each card contained eight tablets (three and a half tablets equal 875 mg). Review of the resident's progress notes, showed: -6/15/23 at 7:19 P.M.: Call to physician to report resident's complaint of a toothache. On assessment, lower left mouth has a couple of gray teeth with one tooth inward where the gum and tooth meet. New order for amoxicillin 875 mg two times a day for seven days; -6/21/23 at 8:48 P.M.: Pharmacy called to report Augmentin (amoxicillin/clavulanate, an antibiotic) 875-125 had been pulled from the starter kit for the resident. The resident does not have this order, but has an order for amoxicillin 875 mg. Starter card had been pulled and three doses have been given since pulled on 6/20/23; -6/21/23 at 8:56 P.M.: Physician called to report Augmentin 875-125 had been pulled from starter kit and resident does not have an order for Augmentin, but does have an order for amoxicillin. No new orders at this time; -6/21/23 at 9:11 P.M.: Resident's representative notified about receiving the three doses of the wrong antibiotic; -No progress notes informing the physician, resident or resident's representative about the resident missing any doses of his/her amoxicillin. Review of the facility Stat Drug Sign Out Sheet, showed: -6/20/23: One card of amoxicillin/clavulanate pulled by CMT D. During an interview on 6/28/23 at 10:45 A.M., a pharmacy representative said the facility ordered the resident's amoxicillin 875 mg on 6/15/23 at 7:52 P.M., and 14 tablets were delivered to the facility on [DATE] at 11:48 A.M. Review of the resident's MAR, showed staff documented the amoxicillin as unavailable on the following dates and times: -6/18/23 at 7:15 P.M.-11:00 P.M.; -6/19/23 at 7:15 A.M.-11:00 A.M.; -6/19/23 at 7:15 P.M.-11:00 P.M.; -6/20/23 at 7:15 A.M.-11:15 A.M.; -This represents four of 14 doses not administered as ordered. During an interview on 6/28/23 at 1:40 P.M., CMT D said he/she was the one who took the Augmentin (amoxicillin/clavulanate) from the starter kit. He/She saw amoxicillin in the name of the antibiotic so he/she thought it was the correct antibiotic. He/She gave the first dose of the Augmentin. He/She was not asked to complete a medication error report. During an interview on 6/27/23 at 10:13 A.M., the DON said CMTs should have checked the starter kit first for the amoxicillin and if it was not available, notified the nurse who should have notified the physician and family and documented it in the progress notes. When the pharmacy called and told the nurse staff had pulled the wrong medication, the nurse should have completed a medication error report and sent it to her or the ADON. Neither she nor the ADON received a medication error report and neither she nor the ADON were aware of the error until now. During an interview on 6/27/23 at 12:43 A.M., the resident said no one told him/her he/she missed four doses of his/her amoxicillin or that he/she received three doses of the wrong antibiotic. He/She would have have liked to have been told. He/She is supposed to have the tooth removed. His/Her mouth is still hurting a bit. During the interview, Nurse Practitioner (NP) J entered the room. He/She said he/she is in the facility every day Monday through Friday. He/She had not been told by staff the resident missed any doses of the antibiotic or received three doses of the wrong antibiotic. They should have told him/her. During an interview on 6/29/23 at 2:22 P.M., the resident's physician said the facility notified him about the resident receiving Augmentin instead of amoxicillin, but they did not notify him about missing four doses of the amoxicillin. He should have been notified. MO00219644 MO00220072

Based on observation, interview and record review, the facility failed to ensure staff followed physician orders and facility policies while transferring two residents, each of whom sustained a laceration during their transfer (Residents #3 and #8). Resident #3 had a transfer order for a two person transfer using a gait belt (a belt applied snuggly around the waist and used by staff to provide stability during a transfer) and dermasavers (cushioned sleeves worn to reduce the risk of skin tears) to be worn at all times to the upper/lower extremities. On 8/14/22, the resident sustained a left calf laceration when one agency certified nursing assistant (CNA) J transferred the resident without assistance, without using a gait belt, and without applying the dermasavers. The resident was admitted to the hospital where admission records showed the laceration measured 15.0 centimeters (cm) (length) by 6.0 cm (width). The resident required morphine for pain, intravenous (IV) antibiotics to prevent infection, and wound treatments that included a wound vacuum (gentle suction that removes drainage from a wound bed). In addition, staff said the resident had a habit of crossing his/her legs during transfers and that information was not provided to the therapy department. Resident #8 had a transfer order for a Hoyer lift (a machine used to transfer a resident unable to bear weight) and dermasavers. On 8/20/22, the resident sat in a wheelchair with no Hoyer pad underneath him/her (a Hoyer pad is necessary to complete a transfer using a Hoyer lift). Two CNAs, CNA Q and CNA R, transferred the resident without a gait belt or dermasavers. The resident sustained a 6.0 cm by 6.0 cm by 0.4 cm (depth) laceration on the right lower leg. The resident, who was already receiving oral antibiotics for a previous skin tear, had the order continued for an additional week to prevent infection. Failed to ensure nine of nine sampled new staff, hired since 7/1/22, received physical therapy orientation prior to working with residents. The facility identified 86 residents that required one person assistance with a gait belt, 27 residents that required two person assistance with a gait belt, and 37 residents that required two person assistance with a Hoyer lift. Of those residents, six were sampled and problems were identified with two. The census was 173. The administrator was notified on 9/1/22 at 12:30 P.M., of an immediate jeopardy (IJ) which began on 8/14/22. The IJ was removed on 9/2/22, as confirmed by surveyor onsite verification. Review of the Transfer and NO LIFT Staff Acknowledge form, undated, and to be reviewed and signed by new staff during orientation, showed: -This facility has a strict NO LIFT policy (meaning no one will physically lift a resident that requires a mechanical means of transfer): I acknowledge I have been trained on properly lifting and transferring a resident and the critical nature of compliance with using the designated mode of transfer for each resident. I have received a copy of our Transfer and Lift Policy and understand the policy and how to identify a resident's transfer status; -I understand that if I fail to follow the mode of transfer (using less assistance than recommended or not using a lift according to policy), I am subject to disciplinary action, up to and including termination. Review of the facility Transfer and Lift Policy (butterfly), dated 2/2020 and revised 5/2021, and to be reviewed and signed by new staff during orientation, showed: Purpose: -To provide communications to staff about resident transfer abilities and to assure we take all precautions necessary to maintain the safety of our residents including acknowledgement that this facility has adopted a NO LIFT policy for residents requiring a mechanical means of transfer. Policy: 1. Upon admission each resident will be assessed by the inter-disciplinary team on the capabilities of how the resident transfers, this will be re-assessed with changes in condition and at the quarterly care plan; 2. A butterfly magnet will be placed inside of the resident's room on the overhead light or door frame of the resident's room indicating how the resident transfers. The butterfly will be coded to inform the staff of transfer ability; -Teal butterfly: indicates no assistance required; -Orange butterfly: indicates a 1 person transfer with gait belt; -Purple butterfly: indicates a 2 person transfer with a gait belt; -Pink butterfly: indicates that a sit to stand lift (a mechanical device used to transfer residents capable of bearing weight); -Aqua butterfly indicates that a mechanical full body lift; 3. The resident's transfer ability will be indicated in the resident's orders and included on the resident profile and care plan, as well as the butterfly; 4. All staff involved in the transfer of residents will be trained on each lift including return competency demonstration; 5. Any change in resident condition will immediately be reported to the charge nurse if that change in condition affects the resident's current ability to assist in transfers; 6. When using a mechanical lift to transfer residents, two employees are required to assist in the transfer, without exception; 7. All staff involved in the transfer of residents will be responsible for knowing how to identify transfer status of each resident; 8. All assisted transfers and ambulation of a resident requires the use of a gait belt. Proper placement of the gait belt should be ensured before assisting resident; 9. Any infraction of this policy will be reported to the Director of Nursing/Nurse Manager and/or the Administrator; 10. Each employee will sign the Transfer and NO LIFT Staff Acknowledgement form upon hire and annually, which will be placed in their employee personnel file; Review of the Physical Therapy Orientation, showed the following skills that all staff will be trained on included: -Gait belt policy; -How to use a gait belt; -Body mechanics (the use of proper body movement in daily activities); -One person transfers; -Two person transfers; -Slide board transfers (a board used to assist a resident with surface to surface transfers); -Bed mobility; -Floor to stand transfers; -Repositioning in wheelchair; -Weight bearing status; -The form is to be signed and dated by the employee receiving the training as well as the therapist that provided the training. Review of the facility References Guide for New and Contracted Staff policy, to be reviewed and signed by new staff during orientation, dated 3/2022, included the following: Transfers: -All transfers requiring one or two persons must be done using a gait belt; -Gait belts are kept on the back of every resident's room; -All mechanical lifts, transfers must be done with 2 staff members; -Refer to transfer butterfly above the resident's bed or outside bedroom door to identify transfer mode; -Inappropriate transfers will result in immediate termination. Review of the facility CNA-Agency Staff Shift Checklist, to be reviewed and signed by agency staff on their first day of work, included the following: -On entrance ensure you have the facility badge buddy (a small laminated card that should worn on back of the staff member's name badge). The badge buddy will help you identify the different magnets used for resident care, for example: transfer status, Hoyer lift, etc., these magnets are placed on resident door frames and can be easily identified; -Ensure you have log-in for charting purposes; -Start of shift rounds with off-going CNA. At the start and end of shift perform walking rounds with the off-going or on-coming shift; -Receive resident assignment from nurse; -Check charting Kiosk for specific tasks, information and vital signs. Vitals and weights are very important and need to be documented; -Complete shift charting on kiosks; -End shift rounds with on-coming CNA; -This document needs to be reviewed and followed during shift, and turned into front administrative office at the end of your sift. 1. Review of Resident #3's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/9/22, showed: -admitted [DATE]; -Makes Self Understood: Understood; -Ability to Understand Others: Understands; -Short and long term memory problem; -No physical, verbal or other behaviors; -Rejection of Care: Behavior of this type occurred 1 to 3 days; -Total dependence of one person required for bed mobility, locomotion on the unit, dressing, personal hygiene and bathing; -Extensive assistance of two (+) persons required for transfers and locomotion on/off the unit; -Diagnoses of Alzheimer's disease, stroke, dementia, anxiety and depression; -Other Ulcers, Wounds and Skin Problems: Skin Tears; -Hospice. Review of the resident's care plan, located in the electronic medical record (EMR), showed: Problem Start Date 7/13/22: -Behavioral Symptoms: Resident is a threat to self and/or others related to combativeness during care; Approach: -Assess whether the behavior endangers the resident and/or others. Intervene as necessary; Problem Start Date 7/13/22: -Communication: Difficulty noted with communication related to diagnosis of dementia; Problem Start Date 7/13/22: -Skin: Resident has skin tears or cuts (other than surgery) related to combativeness. Fragile skin related to end of life skin changes. Resident bruises easily; Goal: -Resident's skin tear to right lower extremity and right lower extremity posterior (back side) will heal without complications; Approaches: -Record location, size, color, surrounding skin, presence/absence of drainage, pain and signs of healing every week; -Use derma sleeves to reduce trauma/damage to the skin surface; -Dress resident in long sleeve shirts and pants to protect extremities; Problem Start Date 7/13/22: -Cognitive Loss/Dementia: Impaired cognition related to diagnosis of dementia; Problem Start Date 7/13/22: -Activities of Daily Living ADLs)/Mobility: Resident has a deficit in ADL functioning and impaired mobility related to weakness; Approach: -Encourage ADL participation and allow resident sufficient time to perform ADLs without being rushed; -Transfer Status: Assist x two persons. Review of the resident's physician's order sheet (POS), located in the EMR, showed; -An order for dermasavers to the bilateral upper and bilateral lower extremities at all times. Remove for bathing/dressing; -Transfer Status: Assist x two persons. Review of the resident's progress notes, showed: -8/14/22 at 9:00 A.M., this nurse was told by CNA J, an agency CNA, that the resident received a skin tear during his/her transfer. The CNA said he/she did not know what happened, but the resident's legs were crossed, and when he/she went to uncross the resident's legs there was a [NAME] of blood. This nurse assessed laceration to left leg and it was about 12 cm long, in a V shape with exposed bone, subcutaneous tissue (the lower most or deepest layer of the skin) and a large amount of blood noted, coagulated (clotted or gel like) blood on the floor. This nurse called for help and instructed the Director of Nursing (DON) to call 911. Two other nurses present. Pressure applied to left leg with large towels and secured with tape on both ends of pad. Leg elevated. Right leg had a total of 3 no flap loss skin tears. Approximated skin (reconnected the skin) and applied adaptic (dressing) and kerlix (gauze dressing) leg also elevated. 911 present to take resident to hospital for trauma. Resident representative aware. Review of the resident's hospital records, admitted [DATE] and discharge date of [DATE], showed: -Resident presented to the emergency department today after noticing a large open laceration to his/her left medial calf/shin this morning. Due to the complexity of the wound, general surgery was consulted; -After a conversation with the family, we concluded that any attempt to avoid the operating room with anesthesia would be in the best interest of the resident. Thus we will wash out the wound and place a wound vacuum; -Resident is on Hospice with advanced dementia who presented to the emergency department today from a nursing facility after noticing a large laceration to the left calf this A.M. when transferring the resident out of bed into a wheelchair. No blood was found in the bed or on the sheets. Resident was seen picking at the wound and had blood beneath his/her fingernails. On exam, he/she is noted to have multiple skin tears on all extremities and very thin skin; -His/her left calf had a large, approximately 15 cm (length) by 6 cm (width) T shaped laceration down the muscle. His/her skin is paper thin; -Resident has multiple older skin tears to his/her right leg; -Resident is yelling in pain. We will give him/her morphine (pain medication used to treat moderate to severe pain). -Resident has large complex wound of his/her left lower extremity; -Plan for wound vacuum and wound care to follow; -Problem List: We don't know what exactly happened. Surgery washed out the wound. Wound vacuum in place. Severe dementia. 100% dependent.; -The emergency notes showed the resident received morphine and intravenous (IV) cefazolin (Ancef, an antibiotic) 1000 milligrams was started. -8/16/22, Day Three of Hospital Services, Wound Ostomy Services (Wound Vacuum Placement): From proximal (nearest) to distal (furthest) end of the wound 23 cm by 4 cm by 0.5 cm. Tissue is very friable (easily pulverized or crumbled). Periwound (the skin that surrounds to wound) bruised with area of purple and dark pink tissue. Resident complains of pain even with oral morphine given. Wound vacuum placed, change every Monday-Wednesday-Friday; -8/19/22: Wound vacuum removed today because resident was to be discharged back to nursing home today; -8/20/22, Day Three of Hospital Services, Wound Ostomy Services: Pain - resident does complain of pain. IV morphine and IV Ativan (used to treat anxiety) at dressing change. Review of the facility investigation, undated, (but received at the facility on 8/17/22), included the following: -Assistant Director of Nursing (ADON) statement: Resident is currently on Hospice. On the morning of 8/14/22 at 8:20 A.M., the resident's CNA (CNA J) reported to the nurse the resident sustained a skin tear while being transferred from the bed into a broda chair and he/she noticed blood and immediately reported it to the charge nurse (Nurse F). The CNA reports that he/she sat the resident up on the side of the bed, lifted the resident into a standing position by grasping the waistband of the resident's pants with both hands and pivoted the resident into the broda chair. The CNA reported that during the transfer, the resident's legs were crossed, and when he/she uncrossed them he/she noticed blood dripping down the resident's left leg. Large open wound noted to the left inner calf. Resident has very thin fragile skin related to end of life skin changes and has a history of many skin tears. Resident was transferred to the hospital after a pressure dressing was applied. Hospital reports they were unable to suture the wound due to thin skin. The resident is poor historian due to advanced dementia. Resident gets agitated easily and has a history of being combative with staff. Resident wears dermasavers to bilateral lower extremities and takes them off frequently. CNA stated there was no blood in the resident's bed when he/she was changing the resident; -Medical Records AA: Nurse F called the main office while he/she was speaking to the DON. Nurse F showed him/her the resident's wound that ran from the ankle (where it was fairly narrow and superficial) upward to just below the knee where it was about three inches across and approximately one-two inches deep with visible fatty layer, muscle and bone visible. The entire length of the wound to the left lower leg was approximately ten to 12 inches. The paramedics arrived around 8:45 A.M. and took the resident to the hospital. During an interview on 8/24/22 at 12:37 P.M., the DON said she was present the day the resident received the laceration. He/she does not recall the resident wearing dermasavers. During a telephone interview on 8/18/22 at 10:00 A.M., CNA J said he/she did sign an acknowledgement form from his/her agency prior to working at one of the sister facilities, but not for this facility. The facility does not have a system in place that lets you know what type of care a resident receives. The facility did not provide a CNA-Agency Staff Shift Checklist or a badge buddy on his/her first day of work. On 8/14/22, he/she reported to work. It took a long time for Nurse F to give her a handwritten daily assignment sheet. The assignment sheet the nurse gave him/her showed the resident required one person to transfer. She did not check the butterfly symbol on the resident's door because no one had showed him/her the symbols or what they meant until after the incident occurred. When she worked with the resident prior to 8/14/22, the resident was a two person transfer, but nurses and other staff told him/her the resident only required two person assistance for transfers if the resident was combative. The resident was in bed that morning and was not combative. He/she washed the resident and he/she put the resident's pants on prior to the transfer. He/she did not put dermasavers on the resident's legs because no one told him/her the resident should have them on. He/she did not see dermasavers in the room. She was never given a code to access the Matrix Care system to see what type of care a resident requires. After sitting the resident up on the side of the bed, he/she noticed the resident had crossed his/her legs. The wheelchair was close to the bed without the leg rests attached. She uncrossed the resident's legs then transferred the resident from the bed to the wheelchair. During the transfer the resident crossed his/her legs again. The resident's pant legs stayed down. The resident was calm during the transfer. He/she did not use a gait belt during the transfer. After setting the resident in the wheelchair, he/she uncrossed the resident's legs which is when he/she noticed the resident's leg was bleeding. He/she did not know what caused the bleeding and the resident did not act like she was in pain. She immediately went to notify Nurse F. Review of CNA J's skills check list, obtained by the administrator from the agency the CNA works for, showed he/she received training for transfers from the agency on 6/12/22. The list did not show what the transfer training included. During an interview on 8/17/22 at 9:05 A.M., Nurse F said he/she was the day shift charge nurse on 8/14/22. CNA J is an agency CNA that had previously worked at the facility. The CNA told him/her that he/she had worked that assignment before, and was familiar with the residents. That morning, the CNA reported to him/her the resident was bleeding and needed to be assessed. When he/she entered the room, the resident was sitting in his/her wheelchair with cotton pants on. He/she lifted the resident's left pant leg and found a V shaped 12 cm laceration on the inside of the left calf. He/she had never seen anything like that before. Blood was pouring out of the laceration. He/she could see fatty tissue and bone. The resident can be very combative during care, but was eerily calm and did not exhibit distress. The resident was not wearing dermasavers on his/her upper or lower extremities. He/she searched the room and did not see any dermasavers. He/she said the dermasavers were most likely in the laundry, and the resident does not have a second pair. The resident is supposed to wear dermasavers at all times except for bathing and hygiene. He/she is not sure what caused the laceration. He/she thinks it happened during the transfer. The leg rests had been removed from the wheelchair, and he/she thinks the metal brackets that the leg rests fit into caused the skin tears and laceration. The CNA told him/her the resident's legs were crossed during the transfer, and he/she transferred the resident by himself/herself He/she did not see a gait belt, but did not ask the CNA if one had been used to transfer the resident. The CNA told him/her he/she thought the resident was a two person transfer, but only if the resident was combative. Nurse F said the transfer butterfly on the door showed the resident was a two person with a gait belt transfer. As far as Nurse F is aware, if a resident is a two person transfer then that is how the resident should be transferred with no exceptions. During a telephone interview on 8/31/22 at 10:02 A.M., Nurse F said he/she gave CNA J an assignment sheet the morning of 8/14/22. The assignment sheet just has the resident names. He/she will block off the group of residents that is the CNA's group for the day. The assignment sheet does not have a resident's transfer status on it because the butterfly system is in place. At no time did the nurse tell the CNA the resident was a one person transfer. He/she did ask the CNAs that morning if anyone needed a verbal report on their residents and CNA J did not request a verbal report. During an interview on 8/17/22 at 9:45 A.M., the administrator said she thinks the incident occurred because CNA J improperly transferred the resident. The CNA is an agency CNA and has worked at the facility a few times. When a new agency staff member starts they are given a CNA-Agency Staff Shift Checklist to sign as well as a badge buddy. The facility staffer/openers (staff that ensure the facility is staffed appropriately), are supposed to give new agency staff the checklist to sign. She could not find a signed form for CNA J, and did not know why. She spoke to CNA J on the phone after the transfer incident occurred. The CNA told her he/she had received a badge buddy, but the administrator did not know if the CNA was wearing the badge buddy. The CNA told her he/she thought the resident was a one person transfer. The administrator did not know why the CNA did not look at the butterfly symbol on the door frame. She did call the agency and the CNA had electronically signed a facility document acknowledgement form for a sister facility on 6/12/22. That acknowledgement is supposed to cover facility policies, including transfer policies which are the same at all their facilities. Review of the agency form dated 6/12/22, showed: I acknowledge that I have received, read, and understand the following document: The facility's orientation. When you arrive on-site, you may ask to complete further documentation or signings. There was no other information on the form. During an interview on 8/16/22 at 10:40 A.M., CNA A said the resident is a two person transfer with a gait belt. The resident can help during a transfer. The resident's body stiffens up and he/she will cross his/her legs while being transferred. He/she thinks the resident stiffens up out of fear. You have to tell the resident to uncross his/her legs. The resident is frequently combative and will dig into your arms with his/her nails to the point where some of the staff have had nail marks. The resident's skin is thin, fragile, and tears easily. He/she is supposed to wear dermasavers to his/her upper/lower extremities at all times to protect from skin tears. The resident is currently at the hospital due to a gash on his/her leg. The facility uses butterfly symbols on resident room doorways so staff know what type of transfer assistance a resident needs. He/she was not sure how long ago the resident began crossing his/her legs, but he/she had not informed therapy. During an interview on 8/16/22 at 11:15 A.M., Nurse B said the resident is very confused and can get combative during care. He/she fights, pinches and scratches. His/her skin is sensitive, thin, and tears easily. He/she has an order to wear dermasavers at all times on the arms and legs. The dermasavers have been ordered for quite a while. He/she had not worked with the resident in a while. The facility posts a butterfly on the door frame to identify the transfer status of residents. During an interview on 8/17/22 at 7:40 A.M., Nurse K said the resident is combative and resists care frequently. His/her skin is frail and tears easily. He/she is to wear dermasavers at all times, but he/she will take them off himself/herself at times. The resident is a two person transfer with a gait belt. He/she worked the night shift prior to the day shift when the injury occurred. There was no blood on the resident's sheets and no reports of injuries on the night shift. During an interview on 8/17/22 at 9:30 A.M., CNA I, an agency CNA, said he/she had worked at the facility for about two years. He/she did receive the CNA-Agency Staff Shift Checklist to sign, and a badge buddy. Observation showed the CNA wore a badge buddy. The facility places a butterfly on the resident doors so staff will know what type of transfer assistance a resident needs. If you are not sure, you should ask the nurse. During an interview on 8/17/22 at 10:50 A.M., The Regional Therapy Director (RTD) said he had not seen the resident transfer before. No one had informed him the resident crossed his/her legs during transfers. No one had requested the resident be reassessed due to the resident crossing his/her legs. If a resident has a change in their transfer status, he should be notified. During an interview on 8/17/22 at 11:00 A.M., CNA G, an agency CNA, said he/she had been working at the facility since March, 2022. He/she received the CNA-Agency Staff Shift Checklist to sign and a badge buddy. Observation showed the CNA wore a badge buddy. He/she knows how to transfer a resident by the butterfly on the door frame. During an interview on 8/17/22 at 11:15 A.M., CNA H, an agency CNA, said he/she had been working at the facility for three or four weeks. He/she was given the CNA-Agency Staff Shift Checklist to sign and a badge buddy on his/her first day. Observation showed the CNA wore a badge buddy. The facility places a butterfly on the door frames so staff know how a resident transfers. During an interview on 8/24/22 at 10:42 A.M., CNA N, an agency CNA, said he/she started working at the facility about three or four weeks ago. He/she did not receive a badge buddy. Observation at that time, showed the CNA did not have a badge buddy. Review of the resident's progress notes, showed the resident was readmitted to the facility on [DATE]. 2. Review of Resident #8's quarterly MDS, dated [DATE], showed: -admitted [DATE]; -Makes Self Understood: Usually understood; -Ability to Understand Others: Usually understands; -Short and long term memory problem; -Brief Interview for Mental Status (a cognitive assessment) score of 05. A score of 00 - 07 indicates severe cognitive impairment; -No physical, verbal, or other behaviors; -Rejection of Care: Behavior not exhibited; -Extensive assistance of one person required for bed mobility, locomotion on/off the unit, dressing, personal hygiene and bathing; -Total dependence of two (+) persons required for transfers and toilet use; -Diagnoses of dementia, anxiety and depression; -Other Ulcers, Wounds and Skin Problems: Skin Tears. Review of the resident's POS, located in the EMR, showed: -4/12/22: Transfer with mechanical lift and assistance x two; -8/11/22: Hospice please supply broda chair and dermasavers for legs; -8/22/22: Bactrim DS (antibiotic), one tablet daily for seven days. Review of the resident's physical therapy (PT) assessments, showed: -4/9/22: Resident noted to be dependent assist x two for transfers. Poor ability to bear weight. Recommend Hoyer transfer; -5/18/22: Assessed transfers with staff. Hoyer lift x two assist. Review of the resident's care plan, located in the EMR, showed: Problem Start Date 4/24/22: -Skin tear to the left lower extremity. At risk for skin breakdown related to incontinence, and the need for assistance with repositioning; Approach: -Encourage to turn and reposition every 2 hours and as needed. Monitor skin weekly for redness or discoloration, blistering, and shearing; Problem Start Date 4/24/22: -Cognitive Loss/Dementia; Problem Start Date 4/24/22: -ADLs/Rehabilitation; Goal: -Staff will provide my ADL support thru my next review; Approach: -Do not rush resident. Allow extra time to complete ADLs; -Transfers - assistance of one person; -The care plan did not address the resident's dermasavers or the use of Hoyer lift. Review of the resident's progress notes, showed: -8/20/22 at 4:36 P.M., at around 1:20 P.M., the CMT came into the break room to let me know I was needed on the floor. Once I stepped on the floor, I was approached by the resident's family member stating there was blood all over the resident's floor and the resident was bleeding from his/her leg. When asked what happened, the family member was unaware. I moved resident from the nurse's station to his/her room to examine the leg. After examination, the DON was notified. Call placed to physician. Wound care provided by the DON; -8/20/22 at 5:08 P.M.: On call visit made this afternoon. Right lower leg, deep laceration assessed and dressing applied. Resident sustained it while being transferred to broda chair by CNAs (CNA Q and CNA R). 6.0 cm by 6.0 cm by 0.5 cm in size with white tendon like area exposed. It is an M shaped laceration. Resident tolerated well for dressing change. Spoke to family member who wants to keep resident at the facility instead of going to the hospital to be treated because it would be more stress for the resident. Called physician and explained family wanting to keep resident at facility. New order to extend Bactrim DS (antibiotic) seven more days after current order. Review of the facility's investigation, included the following statements: CNA Q's dated 8/22/22, showed; -We transferred the resident as a two man. CNA R had the lower legs and I had the arms. The chair was right next to the other chair. I asked CNA R how the resident got into the chair without the Hoyer and CNA R said he/she picked the resident up and placed the resident in there without the Hoyer lift. I just assisted because the certified medication technician (CMT) asked me to help switch chairs. After the transfer, I left the room and never noticed a gash or any blood; CNA R's dated 8/20/22, showed: -After lunch the resident's family member asked for the resident to be placed in his/her proper chair, so I grabbed another CNA and the two of us performed a two person transfer after we noticed no Hoyer pad underneath him/her. I don't know when or how the skin tear happened, nor did I notice any blood; CNA R's dated 8/21/22, showed: Shortly after lunch had ended, the resident's family member asked that the resident be placed in his/her proper chair. I asked another aide to assist in the transfer. The resident did not have a Hoyer pad under him/her, so we had to do a two person transfer. Afterwards I repositioned the resident in his/her chair and brought him/her back out to his/her previous spot. The other chair was still in the resident's room so I went back to remove it. It was then that I noticed blood on the floor, which prompted me to go back and check on the resident. I noticed the wound on the resident's right leg and immediately informed the nurse. I did not get the resident up that morning. It was a two person transfer with both people having a hand under the resident's arm, with the other holding the waistband of his/her pants. Neither of us had access to gait belts; CNA P's, undated, showed: -I orientated CNA R on a 3-11 shift. I showed CNA R basic things about the division. I told CNA R about the transfers and how to find out about transfer status, the diet, and how how to serve the food. During a telephone interview on 8/25/22 at 2:35 P.M., CNA Q said he/she had worked for the facility since 7/26/22. He/she was never provided transfer training with a return demonstration until today, when the facility called him/h

Based on interview and record review, the facility failed to identify adequate meal time supervision and monitoring to prevent an avoidable choking accident, and a process for staff who are unfamiliar with the residents they are delivering meals to, to ensure each resident received the correct meal/diet consistency, for those in an assisted dining room. These failures resulted in the incorrect physical textural food plate being served to one resident, who was then left to feed him/herself. The resident choked on the meat, long enough for his/her face to turn blue from lack of oxygen, before one staff was made aware, by another resident, that the resident was choking. This affected one of three sampled residents (Resident #1). The census was 181. Review of Resident #1's physician's orders [REDACTED]. Meats are mechanically ground or finely cut to equal size, no bigger than one-quarter inch, and other foods can be easily broken apart without a knife. Foods that are in large chunks or pieces, or that are very hard and cannot be chewed easily, are to be avoided unless they are mechanically altered by whipping, blending, grinding, chopping, or mashing so they are easy to chew and swallow. This diet texture was designed for those who have trouble chewing and/or swallowing). Review of the resident's initial Registered Dietitian's progress note, dated [DATE], showed the resident was admitted to the facility on a mechanical soft diet. Review of the resident's plan of care, dated [DATE], showed the resident was at risk for poor nutrition due to advanced age, dementia, and adult failure to thrive. The following interventions were to be followed: -[DATE], serve a regular mechanical soft diet with Ensure plus (nutritional supplement) twice daily; -[DATE], encourage and record intake of food and fluids; -[DATE], new order for hospice services due to weight loss from poor dietary intake. The resident eats a mechanical soft diet, with moderate assistance, in the assisted dining room. Review of the resident's clinical bedside assessment of swallowing (for continuation of his/her mechanical soft diet), dated [DATE], and completed by Speech Therapist A, showed the following: -Clinical signs and symptoms of dysphagia (difficulty with swallowing); -Pocketing of food in the right cheek; -Oral residue (food left in mouth after swallowing); -Excessive mastication (chewing) time and piecemeal swallowing; -Decreased self-monitoring and safety awareness; -Recommendations for continuation of mechanical soft/ground textures, close supervision, and train caregivers in cueing hierarchy in order to enhance the resident's quality of life by improving ability to efficiently consume a least restrictive diet; -The resident is at risk for weight loss, aspiration (breathing foreign objects or substances into the airway, such as food, saliva or emesis) and further decline in function. During an interview on [DATE] at 10:49 A.M., Speech Therapist A said he/she did a swallowing evaluation on [DATE], because the resident wanted regular food, instead of ground up meat, and the staff said he/she was pocketing food. He/she evaluated the resident using mechanical soft food and found a moderate swallowing deficit. The resident was also pocketing food in his/her right cheek and not using his/her tongue that well; not easily clearing the food with his/her tongue. Speech Therapist A's recommendation was for the resident to remain on a mechanical soft diet with ground texture, because that was the optimal diet for safety and efficiency. Speech Therapist A said the mechanical soft was the most efficient and functional for the resident, because of his/her pocketing and extended mastication. A regular diet would increase pocketing of food and the resident's other oral deficits by increasing oral residue and increasing the risk of aspiration. Review of Resident #1's Registered Dietitian's monthly progress notes, dated [DATE], showed the resident had been on a mechanical soft diet. Review of the resident's nurse's note, dated [DATE] at 1:05 P.M., showed Nurse D was summoned to the division dining room by a certified nurse aide (CNA), due to the resident choking. The resident was blue in the face, gurgling, and unable to speak. Stat (respond immediately) was called, the [MEDICATION NAME] maneuver (a first-aid procedure for dislodging an obstruction from a person's windpipe in which a sudden strong pressure is applied on the abdomen, between the navel and the rib cage) was done, but was unsuccessful. The resident was rushed to the nearest available bedroom, positioned supine on the floor, Cardiopulmonary resuscitation (CPR) was initiated and 911 was called. The resident was suctioned, to remove food particles. The resident's head was turned on his/her right side after suctioning, and bouts of undigested food was removed. The resident remained unresponsive and CPR continued. The resident's oxygen saturations elevated to [AGE]% (normal range, 95 to 100%) with continuous CPR. The paramedics arrived at 1:13 P.M. and took over CPR. Review of the facility's lunch menu, for [DATE], showed beef top round, mixed green salad, baked potato, seasoned peas, dinner roll, and Boston cream pie. Review of CNA B's undated written statement for [DATE], showed he/she was feeding another resident, when a resident tapped his/her shoulder and said the resident was choking. He/she rushed over to the resident and then called the nurse. During an interview on [DATE] at 1:07 P.M., CNA B said he/she worked at the facility on an as needed basis and was assigned where needed. He/she had not been assigned to the resident before, but was assigned to care for the resident on [DATE]. He/she was the only one at lunch time on [DATE], who delivered the residents their drinks, plated their food in the servery (a separate room down the hall, approximately 30 feet from the assisted dining room, where food is placed in the warmer trays at meal time by dietary staff), carried the plates to the assisted dining room, and served the residents their food. The regular process for plating and serving the resident's food was supposed to be done by the dietary staff, but they were short of staff every other day. The other aide on the unit, CNA C, did not help because he/she was feeding another resident, in the resident's bedroom. The unit's charge nurse, Nurse D, was not around to help for breakfast or for lunch. CNA B said he/she started serving the residents their drinks and food at 12:00 P.M., and served the resident a regular diet plate, with whole slices of roast beef on it, and did not cut the meat into smaller pieces. He/she thought the resident was on a regular diet and did not know they had changed his/her diet. CNA B said the resident was on a regular diet a long while ago. CNA B said they were supposed to look in the book, which is kept in the servery, which has each of the resident's names and diet orders. He/she did not look in the book for any of the resident's diet orders that day, because he/she knew some of their diets, regarding who was pureed, mechanical, and regular. After he/she served all the residents their drinks and food, he/she sat down between two residents who needed help with eating, at a table in the middle of the dining room facing the television on the back wall, with his/her back to the resident. CNA B was helping feed the two residents for about 20 minutes and was eating potato chips at the same time, because he/she did not get a lunch break. The resident was sitting at a table behind him/her, with his/her body facing the outside hall and nurse's station, and he/she did not turn around to check on the resident's behind him/her. CNA B looked around the dining room, before sitting down, to see if everyone was eating. While he/she was still seated at the dining room table, another resident walked over, as he/she was leaving the dining room, tapped him/her on the shoulder, and said the resident was choking. He/she turned around, dropped everything, got up, and did the [MEDICATION NAME] maneuver, but nothing came out. The resident was blue when he/she turned around, was making a gurgling noise with his/her eyes open, and he/she looked scared. The resident was not gasping for air and was not able to breath. CNA C came around the corner, saw the resident, asked if the resident was choking, and he/she said, Yes, where is the nurse? CNA B said he/she did not yell out for the nurse, because he/she did not know where the nurse was. CNA C saw Nurse D down the hall and said, We need you. Nurse D came over, told him/her to move, stat was called over the intercom, and they took the resident to the nearest bedroom to start CPR. CNA B said they put something down the resident's throat and someone said they got the roast beef, which the resident had choked on, out of his/her throat. Review of CNA C's undated written statement, showed he/she came around the corner and saw CNA B patting a resident on the back, in the dining room. He/she asked what was going on and CNA B said the resident was choking. CNA B looked over, saw the nurse, and yelled they needed him/her. The nurse came and started assisting the resident. CNA C asked CNA B what was the resident choking from, he/she said he/she had given a regular plate to the resident and did not know that the resident's diet changed. During an interview at the facility on [DATE] at 1:15 P.M., CNA C said he/she did not know anything about the choking incident because he/she was not in the dining room at the time. The resident who choked was on a regular diet, but it had been changed to a mechanical. He/she could not say when that diet change had taken place. They all thought the incident would not have happened if the dietary staff was plating, delivering, and serving the residents' food in the assisted dining rooms, instead of the CNAs having to do it all, including clearing off the dirty plates and wiping down the tables. During a second interview on [DATE] at 4:30 P.M., CNA C said CNA B made up, and served, all the residents' plates at lunchtime on [DATE], because there was no dietary staff to help. CNA C said they had not discussed who was to do what that shift and CNA B was on his/her second shift that day, having already worked the night shift and stayed over to work the day shift. Nurse D was not on the unit during this time. He/she saw the nurse sitting at the 400-hall desk, talking to another nurse. Nurse D was not in the dining room for breakfast or lunch. CNA C removed a disruptive resident from the dining room, right before CNA B completely finished serving the plates, because there were family members in the dining room. CNA C took the resident to their bedroom and fed him/her there. He/she returned to the dining room, about 10 minutes later, and as he/she came around the corner, CNA C was hitting the resident on the back. The resident was purple and looked like he/she was in a panic. The resident's eyes were open wider than usual and there was no coughing or gagging. CNA C asked what was wrong and CNA B said the resident was choking. CNA C looked down the hall, saw Nurse D walking back to the unit, waved to the nurse and said they needed him/her. CNA C said one of the therapists told him/her that the resident's diet changed from regular to mechanical, about 3 or 4 weeks ago. When asked if he/she was serving the resident a regular diet, prior to a month ago, he/she said yes. CNA C said he/she started clearing the plates off the tables, and wiping them down, after the nurses had finished with the resident. The resident's table had already been bussed by CNA B. During an interview on [DATE] at 9:27 A.M., Family Member A said the noon meal had always been a slow and varied process. Some days, all of the residents were in the dining room by noon, other days by 12:30 P.M., and other days the food was not served until 1:00 P.M. On [DATE], at lunch time, Resident #1 was sitting at a dining room table close to the sliding glass door, which led to an outside patio, and was facing the opening to the hall and nursing station. Family Member A did not know CNA B, who was all by him/herself, running back and forth from the servery to dish up and served all of the residents their food. During the workdays, Monday through Friday, there were usually two to three women behind the servery food counter, plating up the residents' food. More than half of the residents in the assisted dining room needed some kind of assistance and there were only a couple of residents who ate regular meat. CNA B sat at a dining room table, by the television, with his/her back to Resident #1 and to the family member's table. There were no other nursing staff in or nearby the assisted dining room. Family Member A said he/she did not see the resident start choking, because he/she was focused on trying to feed his/her family member and was concentrated on a resident at their table. Family Member A saw another aide walking past the dining room, then heard someone say, at 12:45 P.M., What's going on? and the resident's choking and turning blue. The aide in the hall yelled for help and when Family Member A turned around, he/she saw Resident # 1, with eyes wide open, and turning purple. Many nurses started coming so Family Member A quickly got his/her family member out of the dining room. Family Member A said he/she thought the owners of the facility were responsible for the residents' choking because the CNA in the dining room was not properly trained on what to do in an assisted dining room; who to help, how to help, where to sit so everyone in the dining room can be monitored, etc. Additionally, one CNA cannot plate all of the residents' food, serve all of the residents their food, and properly help everyone in the dining room. During an interview on [DATE] at 12:12 P.M., Family Member C said he/she was in the dining room at lunchtime on [DATE], sitting with his/her family member. There was only one CNA in the dining room, until the choking incident. The whole incident started when one of the residents in the dining room said, I think there's something wrong with (him/her). I think (he's/she's) choking. The CNA in the dining room got to the resident quickly and immediately started hitting his/her back, did the [MEDICATION NAME] maneuver and called for assistance. Another staff person went to the nursing desk and called stat overhead. The resident was slumped over and someone said he/she was turning blue. It was only a matter of a few seconds, from the time the [MEDICATION NAME] maneuver was started, until others were there. During an interview on [DATE] at 3:56 P.M., Nurse D said he/she had been in the main dining room, at the front of the building, giving one of the residents their medications around noon on [DATE]. Prior to leaving the unit, he/she did not know where CNA B or CNA C were at, but one CNA should have been helping feed the residents while the other CNA served the food. The plates had already been served and he/she thought CNA C was helping someone to the assisted dining room or to the main dining room. When asked why CNA B had served all the residents their lunch plates, instead of CNA C who knew all of the residents, Nurse D said he/she did not know the residents either, because he/she floated. Looking at the residents' diet board (the sheet of paper with the resident's names and diets) in the servery, would only work if you knew who the residents were. He/she would have had to look in everyone's medical chart, for their pictures, to identify each of the residents. Nurse D gave no directions to the aides and they did not ask for help or assistance. CNA B knew the residents' names, but did not know their diets. When walking back from the front dining room, and on the last hallway to the unit, he/she saw CNA C in the hall, in front of the assisted dining room, and CNA C called out Hey, He/she is choking. He/she ran to the dining room, CNA B was standing by the resident, the resident's face was blue, and he/she was making gurgling noises. Nurse D did the [MEDICATION NAME] maneuver 5 or 6 times in the dining room, but nothing came out of the resident's throat and he/she was still blue and not breathing. Stat had been called overhead, along with a call to 911, and many nurses and certified medication technicians (CMTs) were showing up. They took the resident to the nearest bedroom, laid the resident on the floor, and started cardiopulmonary resuscitation (CPR). One of the other nurses suctioned the resident and he/she saw chunks of meat coming out. Nurse D thought maybe they were chunks of pork steak because it was not like hamburger. A couple of the meat chunks were larger than a quarter. Nurse D did not know if the resident had been served the wrong diet. He/she later asked CNA B what kind of food he/she served the resident, because of the meat chunks in the resident's throat and because someone said the resident had been served the wrong diet. CNA B said he/she might have given the resident a plate of regular food. Nurse D told one of the CMTs who had shown up to help, to take notes with times, how many CPR cycles, blood pressures, and oxygen saturations. The CMT used a scrap piece of paper and he/she did not know what happened to it. He/she recalled they did 14 cycles of CPR, the resident's blood pressure was ,[DATE] (normal range, below ,[DATE] mm Hg and above ,[DATE] mm Hg), and his/her oxygen saturation was in the [AGE]s. Nurse D thought the way to prevent this type of mistake in the future would be to have a dietary aide plate and serve the food or to use single resident dietary slips, which would be used to plate the correct type of food texture, and would go with the plate to the resident, whose name was on the diet slip. Nurse D said no one asked him/her to write a statement about the choking and he/she did not ask the two CNAs to write a statement. The Administrator called him/her the next day and asked if he/she knew what kind of diet the resident had been served and he/she said No. The Administrator also asked if he/she had called the resident's family and told them the resident had choked. He/she called the resident's family member and told him/her the resident choked on some food in the dining room and they tried to dislodge it, but could not. During an interview on [DATE] at 11:40 A.M., Nurse H said he/she and Nurse I, who was supposed to be the weekend nurse manager on duty but had been pulled to the floor to pass medications, rushed to the resident's unit when they heard the stat call. They were the first two nurses to arrive from another unit and when they entered the bedroom where the resident was, Nurse I looked at the resident on the floor and saw food in his/her mouth. Nurse I scooped out the food with his/her fingers. It was pieces of meat, about the size of a dime. Nurse H said the residents had roast beef for lunch and one of his/her residents said the meat was tough, hard to chew, and had to be cut up. Someone started suctioning the resident, with a [MEDICATION NAME] tool (a firm/hard plastic suction tool with a large opening at the tip), and then Nurse H took over the suctioning. Nurse H pulled out pieces of meat in the resident's throat. One piece was very large, about two to three inches long, and he/she wondered if that was the piece the resident had choked on. Nurse H saw only meat chunks being pulled out of the resident's mouth and then throat, nothing else. The resident remained blue and unconscious the whole time. The nurses took turns doing CPR and it took about 10 minutes, or more, for emergency medical services (E[CONDITION]) to get there. During an interview on [DATE] at 12:30 P.M., Nurse I said when he/she arrived on the resident's unit, the resident was in a bedroom, on the floor, and was unconscious. There was another nurse, next to him/her, trying to get food out of the resident's mouth. Nurse I could not recall who did what because there were many people in the room and outside of the room. Nurse I could see food in the resident's mouth and another nurse pulled out some chewed up chunks that did not look like anything. Nurse I got further down in the resident's mouth, because the resident had no gag reflex, and dug out a mass of brown, white, chewed up chunks of food that was not like emesis (vomit). He/she hooked a finger full of the mass. Later, when one of the nurses was suctioning, he/she saw a string of long, brown, white, stuff that looked like un-chewed meat, which he/she pulled out of the resident's throat. The resident had a pulse, but they started CPR because the resident was blue and unconscious. They could not get any air in the resident's lungs with the Ambu bag (a manual resuscitator used to push air into the lungs when someone is not breathing) because they still had not cleared the resident's airway. Nurse I left the room when E[CONDITION] arrived. During an interview on [DATE] at 1:06 P.M., Nurse L said he/she was the nurse from the Rehabilitation Unit. When stat was called, on [DATE] a little after lunch time, he/she went to the resident's unit and saw them putting the resident on the floor and starting CPR. He/she and another nurse grabbed the suction machine off the crash cart, set it up, and plugged it in. The [MEDICATION NAME] maneuver had already been done in the dining room and someone had already called 911. There was many staff there and everyone had something to do. He/she was the one using the Ambu bag, from the start, and took turns with Nurse J. They did maybe 8 or 10 cycles of CPR, before E[CONDITION] showed up. Nurse L did not know if the air from the Ambu bag was going into the resident's lungs. The resident was not breathing by him/herself. He/she recalled E[CONDITION] asking them what kind of diet the resident was on. Nurse L said he/she had to go to the servery to get that information off the resident's diet sheet. The resident was on a mechanical soft diet. Nurse L said there was not a problem with their dietary meal delivery process because there was always one regular staff on each unit. The unfamiliar staff person will serve the plates, and the regular staff tells them who the residents are, or vice versa. Nurse L said unfamiliar staff would not pass any food if there were no one around to ask. Nurse L said no one asked him/her to write a statement or interviewed him/her regarding the choking incident. During an interview on [DATE] at 11:18 A.M., Nurse J said he/she was outside on break when the emergency stat call was announced. When he/she got to the resident, one nurse was doing compressions and another had the Ambu bag. There was a clear graduated cylinder by the resident, not the clear suction canister, and inside was a golf ball size of meat, in a ball. Nurse J said he/she remembered seeing the meat and knew it was the roast beef they just had for lunch, mixed with fat. The meat was all he/she could focus on, because it was a big ball. No one could deny that it was regular meat they got out of the resident, not mechanical. When E[CONDITION] arrived, they told them to continue doing CPR, because they were trying to intubate the resident. When the second group of E[CONDITION] people showed up, they asked the facility nursing staff to leave. When asked if he/she thought the nurse's should be in the assisted dining room at meal times to monitor and assist, Nurse J said no, because the CNAs know how to feed the residents. The nurses have to do the accuchecks (check diabetics blood glucose levels) and other nurses' work. There is no reason for a nurse to be in the assisted dining rooms to help or to monitor. There will always be a staff person working who knows whom the residents are to identify the residents for someone who does not know them. There will never be only two agency CNAs working a unit, and no regular staff. If there is no regular staff around, then the CNA should not be serving the residents. During an interview on [DATE] at 1:08 P.M., CMT K said he/she started taking notes, on [DATE] at about 1:05 P.M., of the CPR done on the resident who choked. He/she just scribbled about the compressions on a piece of scratch paper. He/she set it on the nursing station desk afterwards. Their process for serving the residents is to look at the diet sheet and match that with the resident. CMT K said there is always somebody around that knows the residents. The staff person must wait for clarification if nobody is around. During an interview on [DATE] at 1:53 P.M., the E[CONDITION] Deputy Chief said the resident's choking incident, on [DATE], caused [MEDICAL CONDITION] (the heart malfunctions, suddenly stops beating, unexpectedly, due to an electrical problem, which can be caused by a [MEDICAL CONDITION], respiratory arrest, choking, trauma, electrocution, or drowning). The resident's [MEDICAL CONDITION] etiology was respiratory. At 1:15 P.M., E[CONDITION] suctioned the resident with a [MEDICATION NAME] and removed contents from his/her throat, but the resident's response was unchanged. The resident's original three lead electrocardiogram (EKG, measures heart's electrical activity), at 1:17 P.M., showed pulseless electrical activity (PEA), which is a rhythm from a [MEDICAL CONDITION], not a [MEDICAL CONDITION] infarction ([MEDICAL CONDITION], a circulation problem due to a blockage of the blood flow to part of the heart, causing a section of the heart muscle to begin to die). The presenting rhythm associated with a [MEDICAL CONDITION] is ventricular fibrillation (the lower heart chambers quiver, or fibrillate, instead of contracting or beating normally). At 1:35 P.M., E[CONDITION] suctioned the resident's airway using a French Catheter, removed vomit contents (description of the vomit substance was not documented by E[CONDITION]), and the resident's response improved. At 1:46 P.M., the resident's ETCO2 (the amount of carbon [MEDICATION NAME] in exhaled air, which assesses ventilation) dropped to 8, which was very bad. When the ETCO2 drops below 10, a person cannot stay alive, because the body needs a healthy transfer of oxygen and carbon [MEDICATION NAME]. Emergency medical care may get the heart back, but not the brain. The resident was transferred to the hospital, and on the way there, they got return of spontaneous circulation, but the resident's blood pressure dropped, which meant the resident was losing his/her circulation on the way to the hospital. Review of the resident's hospital record, dated [DATE], showed the resident choked, then arrested and E[CONDITION] was called. During an interview on [DATE] at 2:00 P.M., Family Member D said over the past several months, things had been very different at the facility. There were new nurses and new CNAs all the time. When the new staff were working, they do not know the residents and do not know their diets, so he/she hears a regular staff person saying, No, (he/she) gets this kind of diet plate and and (he/she) gets that kind of diet plate. During an interview on [DATE] at 2:31 P.M., Certified Medication Technician (CMT) E said the residents in the assisted dining room have received the wrong plates of food at times. The staff were to use the list in the servery, which has the resident's names and diet orders on it, but the facility's frequent staff turn-over has caused a problem with that system. It is easy to say, or read, that person gets a pureed, mechanical, etc., but if the aide does not know the residents, then the wrong diet could be served to the wrong resident. The servery for the resident's dining room served three units, all from the same food cart. During an interview on [DATE] at 6:30 P.M., Nurse F said the resident had a good appetite and fed him/herself, with set up only. He/she said there have been problems with the agency aides and other aides who were unfamiliar with the residents, with serving the right diets to the right residents. When aides were working, who were not a regular aide on the unit, he/she used a black Sharpie, for a bold presence, and marked the corners of all the residents' paper placemats with their appropriate diet orders. He/she would put a P/N, if the resident needed a pureed diet with nectar thick liquids, an M of the resident needing a mechanical soft diet, an R if the resident was on a regular diet. He/she also educated the aide(s), before the meal started, on the Sharpie codes. He/she also told the aides to come to him/her, if they had any questions. During an interview on [DATE] at 4:43 P.M., the Administrator said they have a list, with the resident names and their diets, which the CNA looks at, then tells the dietary aide what to plate. Their dietary serving process was not the cause of the resident receiving the wrong food because CNA B knew the process. He/she was not a new employee, worked PRN (worked as needed), had floated through the whole facility, worked all shifts, and worked almost full time hours. During an interview on [DATE] at 4:43 P.M., the Administrator said the resident was on hospice and did not have a choking episode on [DATE], at lunchtime. The resident had a [MEDICAL CONDITION], at the same time, and the staff started with the [MEDICATION NAME], masticated food came out, like peas, and then they did CPR. The resident did eat his/her meals in the assisted dining room, but he/she still fed him/herself. The resident's unit was normally staffed with one nurse and two CNAs, for a usual census of 22. At the time of the incident, there was one aide in the dining room and the other aide was delivering hall trays. Usually the nurse is nearby, on the medication cart, or at the nursing station that is not very far and can be seen from the assisted dining room. There would have been less than 15 residents in the assisted dining room because some of the residents, from that unit, go to the main dining room for their meals. The Administrator said she thought the staff did all they were supposed to do. She did suspend one of the aides, CNA B, because the aide served the resident a regular diet and he/she was supposed to get a mechanical soft diet. She did talk to all of the staff, the resident did choke, they did the [MEDICATION NAME] maneuver, and the resident was breathing when he/she left with E[CONDITION]. Review of the facility's Meal Identification/Resident Diet Sheet from the facility's policy and procedure manual, 2014 edition, showed the following: -All residents will have a diet sheet on file, indicating significant food preferences and dietary needs; -Resident diet sheets will be utilized by Dining Services staff to identify and provide accurate meal service for residents while honoring their dining needs and desires; -The resident's diet sheet will be used during meal service to ensure proper diets are served and food preferences are honored. Review of the facility's undated Choking policy and procedure, regarding prevention of obstructed airway, showed the following: -Cut food into small pieces; -Chew food slowly and thoroughly, especially if resident is wearing dentures; -Avoid laughing and talking during chewing and swallowing; -Avoid excessive intake of alcohol before and during meals; -Feed the resident slowly; -Do not give liquids when mouth is full of food. MO 243

Based on observation, interview and record review, the facility failed to ensure staff assisted a resident, who required assistance with ambulation. The resident fell , sustained a fractured nose and required hospitalization (Resident #46). The sample size was 34. The census was 189 with 172 in certified beds. Review of Resident #46's medical record, showed: -admission date of [DATE]; -[DIAGNOSES REDACTED]. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 8/13/18, showed: -Brief interview for mental status (BIMS, a screen for cognitive impairment) score of 5 out of 15. A BIMS score of 0-7, showed severe impairment; -[DIAGNOSES REDACTED].>-Required limited assistance from one staff for bed mobility, transfers and ambulation; -History of falls, occurred 2-6 months prior to admission, entry and/or re-entry to the facility. Review of the resident's quarterly MDS, dated [DATE], showed: -BIMS score of 3 out of 15; -[DIAGNOSES REDACTED].>-Required limited assistance from one staff for bed mobility, transfers and ambulation; -Two or more falls without injury since admission, entry/re-entry and/or since last assessment. Review of the resident's physician's orders [REDACTED]. -An order dated 7/23/17, Transfer Needs: assist of one staff; -A (nursing order) dated 11/13/18, participate in walking club program consisting of assist of one with walker on day and evening shift. Review of the resident's care plan, dated 9/12/16 and in use during the survey, showed: -Problem: Risk of falls related to dementia and lack of safety awareness; -Goal: Will remain free from injury from falls through next review; -Approaches: (updated approaches) Returned to the facility on [DATE], new [DIAGNOSES REDACTED]. Remains a high fall risk. Review of the resident's care plan, dated 12/4/17 and in use during the survey, showed: -Problem: Requires limited assistance with all activities of daily living (ADLs), except eating with supervision and extensive assistance with toileting and bathing. Uses walker for locomotion; -Goal: Will maintain and improve current level of ADL functioning through next review; -Approaches: To participate in walking club program consisting of assistance of one staff with walker. Safest mode of transfer is assist of one staff. Review of the resident's care assessment card, dated 9/7/17 and in use during the survey, showed: -Ambulation with walker and assist of one staff; -Walk to Dine. Review of the nursing staff report sheets, showed on 1/28/19 through 1/30/19, the resident's weight bearing status was as tolerated with assist of one staff. Review of a progress note dated 1/30/19 at 4:30 P.M., showed the resident was walking into the dining room, lost his/her balance and fell face first onto the floor with a moderate amount of blood coming from the nose. Ambulance was immediately contacted, certified nurse aide (CNA) stayed with the resident. Vital signs were within normal limits, blood pressure 134/72 (normal 120/80), pulse rate 78 (normal 60 - 100), respirations 18 (12 - 20) and oxygen saturation (percent of oxygen in the blood) level 95% (normal above 92). Conscious and alert during the fall, able to answer yes or no questions. Not moved until ambulance arrived at 4:40 P.M. Resident's physician and family notified. Review of the hospital history and physical report dated 1/30/19, showed the resident had fallen at the facility when walking with his/her walker. Resident slipped and fell face first. Staff at the facility was not present at the time of the fall. resident sustained [REDACTED]. The computer tomography scan (CT, detailed images of internal organs are obtained by this type of sophisticated X-ray) showed a comminuted fracture (a break or splinter of a bone into more than two fragments) of the nasal bone. Review of the facility's post fall assessment dated [DATE], showed: -Incident: Fall occurred at approximately 4:30 P.M.; -Location: Fall occurred in the 600 hall dining room; -Description: Resident was walking into the dining room, unwitnessed fall, lost his/her balance and fell face first. Ambulance immediately contacted. CNA stayed with the resident, vial signs obtained, within normal limits, resident remained conscious and alert, resident was not moved, emergency personnel arrived and transported to the hospital. Resident's physician and family contacted. Resident with unsteady gait and ambulated at the time of the fall. Initial neurological (neuro-checks, an assessment completed by nursing staff to monitor for neurological (nervous system) changes) were completed at the time of fall; -Additional observations: Aides were in dining room with resident for dinner. Review of the progress note dated 2/1/19 at 6:41 P.M., showed the resident was discharged from the hospital and returned to the facility at 3:45 P.M. [DIAGNOSES REDACTED]. CT scan showed negative for stroke. Left arm discoloration measured 2.5 cubic centimeters (cc) by 2.0 cm, right hand with discoloration measured 4.5 cm by 2.5 cm, right eye bruising measured 4.5 cm by 4.0 cm, right side facial bruising, left eye bruising measured 5.0 cm by 4.5 cm, upper lip bruising, bruising to bridge of nose measured 3.5 cm by 1.5 cm, left side facial bruising, right inner arm, left temple bruising measured 1.5 cm by 1.0 cm and bilateral side of mouth bruising. Observations of the resident during the survey, showed: -On 2/3/19 at 7:30 A.M., multiple dark, purple colored bruising to left and right side of face, under both eyes and across the bridge of his/her nose; -On 2/5/19 at 6:10 A.M., multiple dark, fading purple, green and yellow colored bruising to his/her face, under both eyes and across the bridge of his/her nose. During interviews on 2/5/19 at 2:20 P.M. and 2/6/19 at 10:00 A.M., CNA A said he/she worked the evening shift on the 600 Hall on 1/30/19. He/she was in the serving area of the kitchen in the 600 dining room, getting ready to serve the food, when he/she heard CNA D scream. He/she ran out of the serving area into the dining room and witnessed the resident face down on the floor with large amount of blood. Nurse B, who was the evening shift charge, nurse was not present on the 600 hall because he/she was also the charge nurse for the 500 Hall. Nursing staff ran from the 500 Hall to the 600 Hall. Nurse B immediately assessed the resident, called emergency 911 and the resident was transported to the hospital. Prior to the resident's fall, the resident was with other residents in the 600 Hall television room playing balloon volley ball. He/she did not witness the fall. The resident's ambulation status is assist of one staff due to the resident's unsteady gait and for safety precautions. The resident should be a one person assist with a gait belt for ambulation due to the resident's unsteady gait and impaired safety awareness. The resident's care card is in his/her closet for all staff and shows assist of one person for ambulation and transfers. CNA A said CNA D should have been with the resident, but was not with the resident at the time of the fall. During interviews on 2/5/19 at 3:00 P.M. and 2/6/19 at 4:10 P.M., Nurse B said he/she worked as the evening shift charge nurse for both 500 and 600 halls on 1/30/19. CNAs A and D were the two CNAs assigned to provide care for the residents on the 600 hall. At approximately 4:20 P.M., he/she returned from the 500 hall to the 600 hall. He/she sat at the nurse's desk and started charting, when he/she witnessed the resident coming out of the bathroom across from the nurse's desk unattended. The resident ambulated with his/her walker, gait steady and without assistance into the dining room. When he/she looked down to finish charting, he/she heard a loud noise and staff scream. He/she immediately ran into the dining room, witnessed the resident face down on the floor with his/her walker next to him/her and a large amount of blood on the floor. He/she immediately assessed the resident, called emergency 911 and the resident was transported to the hospital. Nursing staff did not move the resident at all because of the large amount of blood and waited until emergency staff arrived to move the resident. He/she had worked at the facility for approximately one month and never witnessed any staff assist the resident with ambulation. Prior to the fall, since he/she started working as the charge nurse on 600 hall, the resident had always ambulated with the use of his/her walker without staff assistance. No staff communicated to him/her the resident required assistance from staff with ambulation. Nurse B verified when he/she returned to the 600 hall at approximately 4:20 P.M. on 1/30/19, he/she sat down at the nurse's desk to chart. He/she witnessed the resident without assistance from staff, enter the bathroom with his/her walker, resident came out of the bathroom and ambulated with his/her walker into the dining room without any staff assistance. The resident's walker was on the floor next to him/her. He/she could not recall if the resident had a gait belt around his/her waist because the incident happened so fast. Nurse B said the facility does have report sheets that all licensed nursing staff used which showed the resident required assistance with weight bearing as tolerated and verified the resident's care card, showed the resident's transfer and ambulation status was with a one person assist. If he/she would have known the resident still required assistance of one staff person for ambulation, he/she would have assisted the resident to the dining room when he/she saw the resident came out of the bathroom. During an interview on 2/6/19 at 10:00 A.M., Nurse E said the resident should be a one person assist with ambulation due to the resident's weakness and unsteady balance. He/she works on the 600 hall at least one to two times a month and every time he/she worked, the resident is always ambulated with one person assist. During an interview on 2/6/19 at 10:15 A.M., Therapy Coordinator C said the therapy department provided the resident with a physical therapy screen on 11/26/18, due to falls, but did not place the resident on skilled therapy services at that time, as the resident continued to require assist of one staff for all functional mobility. The resident required assistance of one staff person for ambulation due to his/her unsteady gait and balance and impaired safety awareness. The resident should not be allowed to ambulate without assistance. In his/her professional opinion, the resident should always be ambulated with staff assistance and should not be allowed to ambulate independently. He/she reviewed the resident's care card, dated 9/7/17, which showed ambulation with one person assist and said it was appropriate for the resident. During an interview on 2/7/19 at 7:00 A.M., CNA D said he/she usually worked the night shift on the 600 hall, but worked the evening shift on 1/30/19, on the 600 hall. The resident's ambulation status is with an assist of one person. The resident was with other residents in the television room playing balloon toss. At approximately 4:00 P.M., he/she ambulated the resident with his/her walker and gait belt around the resident's waist to the bathroom across from the nurse's desk. After the resident was toileted, he/she assisted the resident with ambulation back into the television room and sat the resident in the recliner. He/she locked the bathroom door after the resident was toileted. At approximately 4:30 P.M., he/she placed a gait belt around the resident's waist, assisted the resident to stand and walk with his/her walker into the dining room. When he/she entered the dining room, he/she still held onto the resident's gait belt, but a few seconds later, another resident at the dining room table, spilled his/her milk and he/she let go of the resident's gait belt. He/she turned back around, saw the resident on his/her tip toes and the resident fell face first onto the floor. He/she could not recall if any staff witnessed him/her assisted with the resident's ambulation and/or any staff were present in the dining room when the resident fell . Only other residents were present in the dining room when the resident fell . CNA A was in the serving area of the kitchen in the dining room and did not witness him/her walk the resident into the dining room and/or the resident's fall. He/she did not see Nurse B at the nurse's desk when he/she walked the resident from the television room into the dining room. CNA D said he/she should have sat the resident in the chair and not let go of the resident due to the resident's unsteady balance. He/she verified the resident's care card, showed the resident required a one person assist for ambulation and transfers. When the resident fell , CNA A ran out of the serving area of the kitchen into the dining room. He/she could not recall if Nurse B was on the 600 hall or not at the time when the resident fell . When the resident fell , staff immediately entered the dining room. The resident could not have toileted himself/herself and could not have walked into the bathroom because he/she required assistance with toileting. Nursing staff are aware of the resident care cards, located in each resident's closet, which direct staff on how to provide care for each resident. The night shift charge nurse gives report to each CNA about the care of the residents including transfer and/or ambulation status. During an interview on 2/7/19 at 10:25 A.M., Dietary Aide F said he/she brought food into the serving area of the kitchen in the 600 hall dining room at approximately 4:30 or 4:35 P.M., on 1/30/19. CNA A was present in the serving area of the kitchen and asked him/her what was on the menu for dinner. The dietary aide said he/she heard a loud noise and heard a resident in the dining room say, Resident fell . CNA A ran immediately out of the serving area of the kitchen into the dining room. He/she stuck his/her head out of the corner of the kitchen door, saw the resident face down on the floor, not moving and a lot of blood on the floor. No staff were present in the dining room, only CNA A went to the resident at the time of the fall. The dietary aide said he/she is very familiar with CNA D and CNA D was not present in the dining room with the resident when he/she fell . During an interview on 2/8/19 at 8:25 A.M., CNA I said he/she worked the evening shift on the 500 hall on 1/30/19. At approximately 4:30 P.M., he/she walked into the 600 hall unit and saw the resident with his/her walker, walking unassisted in the hallway behind CNA D, into the dining room. No staff were assisting the resident with ambulation when he/she saw the resident in the hallway. He/she could not recall if the resident had a gait belt around his/her waist. He/she walked past the dining room, heard a loud noise, a scream and walked back down the hallway to the dining room. He/she saw the resident face down on the floor and yelled at Nurse B, who was at the nurse's desk, about the resident's fall. During an interview on 2/7/19 at 11:00 A.M., Music Therapist G said he/she did not witness CNA D ambulate the resident from the television room into the dining room and did not witness the resident's fall. The resident was in the television room with other residents playing a balloon toss activity at approximately 4:00 P.M., on 1/30/19. At approximately 4:30 P.M., he/she took the dog from the 600 hall outside and did not return to the 600 hall until after the resident had fallen and emergency staff were transporting the resident to the hospital. The resident required assistance from staff for ambulation due to his/her unsteady gait and balance. The nursing staff have always assisted the resident with ambulation and transfers. The resident was not allowed to ambulate independently due to his/her unsteady gait, balance, impaired safety awareness and history of falls. During an interview on 2/7/19 at 11:05 A.M., Nurse H said the resident required assistance from staff for ambulation and transfers due to his/her unsteady gait, balance and impaired safety awareness. The resident's ambulation status of assist of one staff had been this way for the past 6 months. He/she said the resident's care card dated 9/7/17, showed ambulation and transfers with one person assistance. The licensed nursing staff have a 24 hour report sheet which showed the resident's weight bearing status as assist of one person. All nursing staff are aware of each resident's care card and Nurse B is aware of where to find the residents' care cards which showed information regarding how to provide care for each resident, including transfer and/or ambulation status. He/she has worked as the day shift charge nurse on the 600 hall for approximately 3 to 4 years. The resident is not capable of toileting himself/herself and required assistance from staff due to his/her unsteady gait, balance and impaired safety awareness. During an interview on 2/7/19 at 1:00 P.M., the administrator said she obtained written employee statements and interviewed staff. The stories of Nurse B, CNA A and CNA D remained the same, she but re-interviewed them because their accounts of the incident were inconsistent. She expected Nurse B and other staff to have assisted the resident with ambulation due to his/her unsteady gait, balance and impaired safety awareness. When nursing staff are hired, during their orientation they are made aware of the resident care cards, where to find the care cards and about the 24 hour report sheets. Nurse B was made aware of how to find out about each resident's care needs, including where to find the resident care cards which are maintained in each resident's closet. She would have expected Nurse B to have assisted the resident with ambulation when he/she witnessed the resident coming out of the bathroom prior to the fall. On 2/6/19 the facility in-serviced nursing staff, including Nurse B regarding report sheets, resident care cards, plan of care, magnets (resident information of transfers/ambulation status) on resident's doors and communication of the residents' ADLs and ambulation status information. During an interview on 2/14/19 at 8:20 A.M., the resident's attending physician said he/she expected staff to have known the resident's ambulation status, which was that he/she required the assist of one staff person when ambulating and assisted the resident with his/her ambulation. If the resident's care card, care plan and MDS, showed the resident required limited assistance of one staff person with ambulation, he/she expected staff to have assisted the resident with ambulation.