Every finding on record at East Bay Rehabilitation Center

Based on observations, interviews, and record review, the facility failed to ensure a clean, sanitary and maintained kitchen space to include: 1. Broken/missing trash receptacles at two of two hand washing stations; 2. A walk in freezer unit observed with heavy frosting crystallization on food items, shelving, and boxes of food items; 3. Overhead ceiling vents and ceiling tiles located above food prep and food service stations with dust and debris, 4. Various rusted areas near washed/sanitized cups and eating ware; and 5. Staff not wearing hair/beard covers appropriately while at food preparation and food service stations during three of four days observed, (2/12/2024, 2/13/2024, 2/14/2024). Findings included: 1. On 2/12/2024 at 9:07 a.m., the facility's kitchen was entered and toured with the Certified Dietary Manager (CDM). The hand washing sink was in a room next to the dish washing machine. The CDM stated he had only been back at the facility for two weeks, but has been employed at the facility about four years. A foot pedal operated trash receptacle was positioned at the right of the hand washing sink. The lid would not open when the foot pedal was depressed to dispose of paper towels used for hand hygiene. The only way to get the used paper towels in the receptacle was to lift the soiled lid. The lid to the receptacle was observed with various hardened food debris and dried colored liquid. The CDM stated he had been meaning to get a new trash receptacle. He confirmed due to the hand washing sink trash receptacle being in disrepair, staff would have to lift the lid with their bare hands to discard paper towels and other refuse. The CDM pointed out another hand washing sink in the kitchen, which was near a food preparation station. No trash receptacle was at or near the hand washing sink. There were no trash receptacles within eyesight of this hand washing station. The CDM again stated he was meaning to get a trash receptacle for this area. He stated when staff use this hand washing station, they would have to walk to another section of the kitchen and lift a lid to a trash receptacle and then discard their refuse. He stated the staff should not have to lift soiled trash receptacle lids with their clean/sanitized bare hands. (Photographic evidence was taken). 2. On 2/12/2024 at 9:30 a.m., and 2/14/2024 at 12:55 p.m. the kitchen's walk in refrigerator unit was entered. While inside and at the back of the unit, the back wall was observed with a cooling motor with a plastic covering/housing. The plastic housing for the main fan was observed with many areas with black biogrowth/debris. The inside of the refrigerator unit was observed full with packaged food items as well as boxes of unpackaged and uncovered vegetables and fruits. The boxes of vegetables and fruits were noted placed on shelves directly under the motor fan housing. The walk in freezer unit door was opened and there were about seven to ten plastic slats utilized as an air resistance curtain. All the plastic slats were observed with heavy built up icing. The CDM stated the unit has had recent repairs and everything was corrected during that repair. He could not remember exactly how long the repair was, but revealed the temperatures within the unit were at and below 32 degrees F. Upon entering the inside of this unit, there were shelves on either side as well as at the back of the unit. Observation revealed heavy icing and frosting at and near the motor housing; heavy icing on two of three shelves on the right side of the unit; heavy icing on three boxes of packaged food; heavy icing and frosting on an open box of food that contained plastic a large plastic wrapped roast, bags of opened vegetables, and other items within this box. Some of the items that had icing and frosting on them, could not be identified as the icing/frosting covered the entire food item. (Photographic evidence was taken). The CDM stated the iced and frosted food items should have been already thrown away, but he along with his staff must have missed those boxes of food items. He stated the unit appeared to be frosting/icing on one side of the unit and would need to put in a work order to get it fixed. He was not sure how long the inside of the freezer unit had been building up with ice and frost crystallization. 3. On 2/12/2024 at 9:30 a.m. and 2/14/2024 at 12:55 p.m. the main food service and food preparation area/station was observed with two ceiling vents directly above the food preparation table and the steam table where food is served from. The ceiling vents and surrounding ceiling tiles were observed with heavy dust/debris build up. The CDM stated the Maintenance Department is responsible for the cleaning and maintenance of the kitchen's ceiling and ceiling vents. He believed maintenance comes in about one a month or so. The CDM was not exactly sure how often maintenance has come in to clean the ceiling, but did confirm that he along with his staff should have seen all that dust/debris and should have put in a work order for maintenance to clean. 4. On 2/12/2024 at 9:30 a.m. and 2/14/2024 at 12:55 p.m. during kitchen tour, the back section of the room, where there was a food preparation table, and with staff preparing food items for resident consumption; revealed a long stainless steel shelf hanging on the wall directly above the table. Further observations revealed heavy rusting on the undercarriage of the shelf. The rusted areas were observed chipping and peeling away, which caused a risk for the debris to fall on exposed food items. Interview with the dietary staff in the room and the CDM revealed they were unaware of the rusted shelf. The area near the dish washing machine was observed with a large plastic and metal bug zapper device. The metal grating on this device was observed rusted and with paint chipping away. Directly below this device were crates of cleaned and sanitized cups and glasses. The rusted grating revealed chipped sections of paint and caused risk for the debris to fall on the already cleaned eating/drinking ware. On 2/14/2024 at 12:55 p.m. during the kitchen tour, the back room where a food preparation station was at, and also near the hand washing sink was observed with a long metal food preparation table. The metal table with an under shelf, was observed with a large gray round soiled trash can lid placed on the lower table shelf and leaning up against four various cleaned colored plastic cutting boards. Another section of under the metal table was observed with two full and used red and green sanitizer buckets with rags inside them. The buckets were observed placed directly next to a large clear plastic container of dry food product. The CDM stated the trash can lid and sanitizer bucket should not be in this area and certainly should not be leaning up against clean equipment. He stated the container of food should not have been in the same area as the sanitizer buckets and soiled trash lid. (Photographic evidence was taken). 5. On 02/14/24 at 1:31 p.m. during the kitchen tour Staff D, cook was observed with exposed facial hair from the chin up to his lower lip. On 02/14/24 at 1:34 p.m. an during an interview CDM, said staff should not have exposed hair while on duty. The CDM revealed he oversees the kitchen cleaning process and had listed duties each day, and a dedicated staff member has to complete and initial each task. He revealed there is a weekly cleaning scheduled for most areas and equipment in the kitchen. However, in between meal services, staff are expected to clean the floors, cooking equipment, eating ware, and as need areas. The CDM revealed during the cleaning process, he and his staff should have caught the above listed areas and either cleaned the areas or notified the maintenance department to repair equipment. A review of facility policy titled, Dietary Guidelines Manual, undated, Subject Person Hygiene revealed the following: Purpose: Staff involved in handling food follows proper hygiene practices to prevent contamination of food. -4) wear a hairnet at all times. -- caps are acceptable -- cover all hair including beards and mustaches. A review of the policy titled Dietary Guideline Manual related to Cleaning Freezers, dated 2015, revealed the following: Policy: The Freezers will be defrosted as needed (when frost is 1/4 inch thick, the freezer should be defrosted), or per the manufacturer's instruction. Procedures: Remove all food from the freezer. Sort out and throw away all that is not unusable. Store good food in another freezer, refrigerator or cooler until the freezer is cleaned. A specific policy with relation to kitchen and kitchen equipment sanitation was not provided.

Based on observations, interviews, and record review, the facility failed to implement interventions in the comprehensive care plan one resident (#90) of three resident sampled. Findings included: A review of the admission record showed Resident #90 was admitted to the facility on [DATE] with diagnoses including disorder of the skin and subcutaneous tissue, adult failure to thrive, cachexia (unintentional weight loss), and abnormal weight loss. A review of the active orders, as of February 2024, showed the following: -Bilateral heel elevation boots when in bed every shift. Remove for skin checks, hygiene and all cares as needed. Start date 4/5/23. A review of Resident #90's quarterly Minimum Data Set (MDS), dated [DATE], revealed the following: -Section C-Cognitive Patterns: Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment. -Section M M1200-Skin Conditions: requires pressure relieving devices while in bed and requires substantial/ maximal assistance (helper does more than half the effort) to roll from left to right in bed. A review of Resident #90's care plan, initiated 10/26/22 and revised on 1/23/24, showed Resident #90 had actual impairment to skin integrity of the right lateral foot. Interventions included bilateral heel elevation boots when in bed every shift; may remove for skin checks, hygiene and all cares as needed. A review of Resident #90's Treatment Administration Record (TAR), for February 2024, revealed a nursing treatment for bilateral heel elevation boots when in bed every shift. May remove for skin checks, hygiene and all cares as needed. Every shift for impaired skin integrity. Start date 4/5/2023. The nursing documentation revealed the treatment was administered by each shift from 2/1/2024 through 2/14/24. On 2/12/24 at 10:15 a.m. Resident #90 was observed lying in bed without heel elevation boots in place as ordered. On 2/13/24 at 9:40 a.m. Resident #90 was observed lying in bed without heel elevation boots in place as ordered. On 2/14/24 at 7:40 a.m. Resident #90 was observed lying in bed. The resident stated she slept well. Staff F, Certified Nurse Assistant (CNA) was present in the room and removed the covers to expose Resident 90's legs and feet. The resident was not wearing heel elevation boots as ordered. On 2/14/24 at 2:45 p.m. an interview was conducted with Staff L, Licensed Practical Nurse (LPN). Staff L stated, Resident #90 Should have heel elevation boots on, unless they are in the laundry. On 2/14/24 at 2:52 p.m. an interview was conducted with Staff I, RN, Assistant Director of Nursing (ADON). She said residents usually have two pairs of heel protector boots, and it Does not take long for the elevation boots to be returned from the laundry. She was unable to state what the turnaround time was for laundering the boots.

Based on observations, interviews, and record review, the facility failed to ensure one resident (#98), who was dependent on staff for eating assistance, received eating assistance in a manor to promote a safe and comfortable eating experience out of forty-seven sampled residents during one observed meal (12/12/2024) of one meal observed. Findings included: On 2/12/2024 at 11:55 a.m. an observation in the main dining room during the lunch meal was conducted. There were two sections of the dining room. A large section with ten tables where residents who dine and eat without eating assistance, and a smaller section with six tables where residents were assisted with their meals. Residents who dine in the small assistive dining room, require forms of assistance to include cueing, supervision or assistance with eating activities. Resident #158 was observed seated in a wheelchair at a table along with Resident #98, who was lying back in a reclined Geri chair. Resident #98 was observed with sheets covering her entire body, and a pillow on the right side of the head rest. Resident #98 was overheard calling out and moaning out loudly. Staff intervened and comforted her twice. Every time staff left Resident #98 began to moan aloud again. At 12:00 p.m. Residents #158 and #98 were still seated at the same table together. Resident #158 received his meal tray at 12:18 p.m. At 12:23 p.m. Resident #158 received a family member visit who sat down at the table with him. Staff B, Speech Therapy was observed to enter the room and seat herself at the table next to Resident #158 and across the table from Resident #98. Staff B evaluated and assisted Resident #158 with the meal. Resident #98 continued to sit reclined in her Geri chair and did not have her meal yet. At 12:27 p.m. all residents seated in the restorative/assistive dining room had all been served, set-up, and were being assisted with their meals. Resident #98 was still at the table and had not been served the meal. At 12:32 p.m. a Staff A, Certified Nursing Assistant (CNA), was observed bringing an uncovered plate of food into the assistive section of the dining room and placed it on the table next to Resident #98. Staff A left the area, leaving Resident #98 seated next to her food. The plate of food was uncovered exposing all the food items to the air element. Staff B, Speech Therapy continued to assist and evaluate Resident #158 while talking with his family member. At 12:42 p.m., Staff A, CNA walked into the room. At 12:44 p.m. Staff A sat down next to Resident #98 and tried to give her a spoonful of food while she was still in a reclined position with her head tilted on the right side on a pillow. Staff A got up and adjusted the head portion of the Geri chair to a 30 - 40 degree position. Staff A tried to give the resident a spoonful of food while her head was still tilted on the side on the pillow. Resident #98 opened her mouth but was not able to properly take food in and swallow. The resident had a puree textured diet, and was not able to accept bites appropriately due to head positioning. At 12:45 p.m. an interview was conducted with Staff A, CNA. Staff A, stated she assists Resident #98 with eating almost daily and she was fully dependent on staff for eating assistance. Staff A stated she brought in the meal for Resident #98 and had to leave to assist with the rest of the tray pass in the dining room. At 12:46 p.m. an interview with Staff B, Speech Therapy was conducted. Staff B stated Resident #98 was on her case load and she would be working with the resident, but positioning would be something for Occupational Therapy would address. She stated she was not aware if Occupational Therapy had Resident #98 on their case load. Staff B stated Resident #98 would not be comfortable eating in the position she was in. A review of Resident #98's medical record revealed she was admitted to the facility on [DATE], with a diagnoses to include sepsis, dehydration, protein calorie malnutrition, acute kidney failure, dysphagia, adult failure to thrive, and dementia. A review of the advance directives revealed Resident #98 had a Power of Attorney in place to make her medical decisions. A review of the admission Minimum Data Set (MDS), dated [DATE], revealed the following: -Section C-Cognition: Brief Interview Mental Status score 7 of 15, which indicated severe cognitive impairment. Section GG-Activities of Daily Living (ADL): utilizes a manual wheelchair, chair/bed-to-chair transfer = substantial assistance from staff. A review of the Physician's Order Sheet, dated 2/2024, revealed an order to include: Comfort Measures Only No weights, no labs, No tube feeding or artificial Hydration. Order date was 1/31/2024. A review of the CNA ADL flow sheet and kardex, for February 2024, revealed staff are to monitor and complete the following: 1. ADL - Eating 1. IF NPO/tube feed indicate here, 2. Requires (1 or 2) person is (independent, set up/supervision, limited, extensive, or total) 3. May indicate if participating in restorative dining here. 2. ADL - Locomotion on Unit 1. Requires (1 or 2) person & is (independent, set up/supervision, limited, extensive, or total) assist., 2. Uses (walker, cane, w/c, electric w/c, ambulatory, Geri/Broda chair, &/or specify specific device). 3. ADL - Locomotion off Unit1. Requires (1 or 2) person & is (independent, set up/supervision, limited, extensive, or total) assist.2. Uses (walker, cane, w/c, electric w/c, ambulatory, Geri/Broda chair, &/or specify specific device) A review of the Occupational Therapy Evaluation and Plan of Treatment, with a certification period of 1/31/2024 - 3/15/2024 and with a start of care date of 1/31/2024, revealed the following; Treatment approaches to include: Therapeutic exercises, Manual therapy exercises, Occupational Therapy (OT) evaluation moderate complexity, Self care management training for five days a week and with a duration period of 45 days. A review of the Occupational Therapy Treatment Encounter note, dated 2/9/2024, revealed a summary of daily skilled services to include: Wheelchair management and analysis of patient's body alignment and functional skills in a new or existing wheelchair and assessment of current seating system for appropriate modifications as patient is heavy left side lean even after neck light stretch and pillow for additional support. The skilled services also included; Patient was transferred max a to Geri chair which fully reclined and has the support of body as she needs for comfort and limited leaning head rest with half moon cut out. Patient requires light repositioning of neck i.e. gentle stretching and realignment, leans heavy to the right and fatigues easy, positioning with some mild yelling out. A review of the care plan, with next review date 4/30/2024, revealed the following: - The resident has an ADL self-care performance deficit r/t generalized weakness, impaired mobility, failure to thrive, with interventions in place, to include but not limited to: TRANSFER: extensive x 1. - The resident has impaired cognitive function or impaired thought processes r/t dementia, with interventions in place to include but not limited to: : Cue, reorient and supervise as needed. - The resident has a swallowing problem and is on a mechanically altered diet with thickened liquids, refer to physician's order for current diet orders, with interventions in place to include: Encourage resident to eat in an upright position, to eat slowly, and to chew each bite thoroughly, Keep head of bed elevated 45 degrees during meal and thirty minutes afterwards, Monitor/document/report PRN any signs and symptoms of dysphagia: Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing, Refusing to eat. On 2/14/2024 at 11:15 a.m. an interview was conducted with Staff C, Occupational Therapist (OT). Staff C stated she was familiar with Resident #98 and did have her on OT case load. Staff C stated Resident #98 had been declining and was on comfort measures only for a few weeks. Staff C revealed she had seen Resident #98 for positioning while in Geri chair and had to try different interventions to include more padding, in order for her to be correctly positioned. She further revealed Resident #98's head would routinely tilt to the side on her right side and off onto the side of the head of the Geri chair. She revealed an intervention to include an extra pillow on her right side helped some, but her head would still tilt off to the side. Staff C revealed she tried various interventions with her head positioning in order to decrease mouth drooling. She stated the resident would only keep her head in an upright position for so long and then her head would just tilt back to the side again. She stated there was routine staff intervention with the head repositioning and intervening when the resident would moan aloud. Staff C stated Resident #98 should not have been assisted with eating while her head was lowered and tilted to the side. She stated staff should have made sure she was positioned correctly while being assisted with her meal. A review of the policy titled Activities of Daily Living (ADL), Supporting, dated 01/2022, reveled the following: Policy: Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Procedure: 1. Residents will be provide with care, treatment and services to ensue that their activities of daily living (ADLs) do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs are unavoidable. 2. Appropriate care and services will be provide for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with, to include: Mobility (transfers and ambulation, including walking), Dining (meals and snacks).

Based on observations, interviews, and record review, the facility failed to provide quality care and services related to wound care for one resident (#88) out of 5 sampled residents. Findings included: Review of Resident #88's Admission Record revealed he was admitted to the facility on [DATE] from an acute care hospital. His diagnoses included weakness, altered mental status, need for assistance with personal care, cognitive communication deficit, muscle weakness, and a history of falling. An observation was conducted on 02/12/24 at 10:02 AM. Resident #88 was observed to have a bandage on his right shin which was not dated and was soiled with brownish yellowish drainage. Resident #88 said the bandage had been changed a few days ago. He said he can't remember how he got the wound. (Photographic evidence obtained) An interview was conducted on 02/12/24 at 12:28 PM with Resident #88's family member. The family said Resident #88 gets skin tears very easily. The family member said he was at the facility on Wednesday (2/7/24) and the resident did not have the bandage on his right shin at that time. The family member said the bandage was not dated and he was not sure when it happened or how. An observation was conducted on 02/12/24 at 01:51 PM. Resident #88 was observed to be sitting in his chair with the same unlabeled, soiled dressing on his right shin. An observation was conducted on 02/13/24 at 9:40 AM. Resident #88 was observed to be putting on his jacket with the same unlabeled, soiled dressing on his right shin. Review of Resident #88's medical record did not reveal a progress note about the right shin wound, there was no physician order to change or monitor the right shin wound, there was no change of condition related to the right shin wound, and there was no documented family or physician notification about the right shin wound. Review of Resident #88's Weekly skin observation tool, dated 2/6/24, revealed the following: Prior to skin check does the resident have any of the preexisting areas identified. 1. Check all areas that apply: 1. skin tears .4. bruises 3. Are there any new areas of skin irregularities notes for this skin check. No. An interview was conducted on 2/14/24 at 10:55 AM with the Director of Nursing (DON). He reviewed the photographic evidence of Resident #88's right shin dressing and confirmed it should be labeled, a change in condition should be documented, and notification to the family and physician should be documented. He said there should be physician orders to change the wound bandage. An interview was conducted on 2/14/23 at 12:58 PM with the DON. He said per the family, the resident hit his leg on the bed frame on Sunday (2/11/24) and the nurse put a bandage on it. The DON confirmed there was no physician order, the bandage should have been dated, and it should not have been soiled. Review of the facility's Skin Integrity policy, dated 09/2017, revealed the following: Purpose To Provide consistent assessment and evaluation, monitoring, documentation, and implementation of therapeutic interventions to heal and maintain skin integrity . .Assessment/Evaluation: .3. The resident will be placed on a weekly skin check by the Licensed Nurse, If new skin areas/areas are identified. A Change in Condition Evaluation will be completed. If indicated, with notifications of Physician and Resident/POA [Power of Attorney] or Resident Representative. Treatment orders will be implemented per Physician's orders.

Based on observations, interviews, and record review the facility failed to ensure 1) Medication pill splitters were maintained in a clean and sanitary manner in two of four medication carts, and 2) discontinued resident medications were disposed of within thirty days in two of two medication rooms. Findings included: On [DATE] beginning at 8:10 a.m. the Medication Storage facility task was conducted with Staff J, LPN Unit Manager, (LPM, UM). The following observations were noted: -In two of the facility's two medication storage rooms resident medications were stores in cardboard boxes labeled personal (Photographic Evidence Obtained). The boxes contained medication containers without a resident's name or the contents. -A clear amber pill bottle without a resident's name and the word Pepcid written on the lid, contained three different pill shapes and sizes (a capsule, a white round tablet, a white oblong tablet). (Photographic Evidence Obtained). - A three-section amber pill organizer was also in the box. (Photographic Evidence Obtained). -Staff J LPN, UM, said the pills are stored when residents are admitted and do not want the pills to be discarded. She stated she did not know which resident the pills belonged to or how long the pills had been stored in the medication room. -The medications belonged to residents who were discharged from the facility on [DATE] and [DATE]. -A heating pad, hearing aid containers, batteries, and hairbrush were stored in the medication box. (Photographic Evidence Obtained) -A bag with Intravenous (IV) antibiotic labeled Do Not Use after [DATE] was in the medication storage refrigerator. (Photographic Evidence Obtained). -Staff J LPN, UM said expired medication should be placed in the return to pharmacy bin. -A DNA test kit that contained a test tube labeled collect saliva by [DATE] was stored in a drawer with medical supplies including syringes. -Staff J LPN, UM, said she did not know why the test kit was stored in the drawer. (Photographic Evidence Obtained). -Two of the facility's medication carts were observed with pill cutters that contained rust and scattered white powder. (Photographic evidence obtained). Review of facility policy titled IC12: Medications brought to the Facility by a Resident or responsible party, undated, revealed the following: -Policy: Medications brought into the facility by a resident or responsible party are used only upon written order by the resident's attending physician, after the contents are verified, and if the packaging meets the facility's guidelines. Unauthorized medications are not accepted by the facility. -Procedures: C. Medications not ordered by the resident's physician are unacceptable for other reasons, are returned to the responsible party or designated agent. If unclaimed within 30 days, the medications are disposed of in accordance with facility medication destruction / disposal procedures. Review of the facility's Temperature log for vaccines revealed the following instruction, place an x in the box that corresponds with the temperature. The hatched represent unacceptable temperatures ranges. Review of facility policy, undated, titled Equipment and Supplies for Administering Medications. -Policy: the facility maintains equipment and supplies necessary for the preparation and administration of medications to the residence. -Procedures: -the following equipment and supplies are acquired and maintained by the facility for the proper storage preparation and administration of medications 6) devices for crushing and splitting pills -the charge nurse on duty ensures that equipment and supplies relating to medication administration or clean and orderly -the charge nurse is notified if supplies are inadequate, or equipment failed to work properly. The charge nurse reports equipment and supply deficiencies to the director of nurses,

Based observations, interviews, and record review, the facility failed to follow infection control guidelines related to hand hygiene during two of six medication administration observations. Findings Included: On 2/13 /2024 at 8:30 a.m. Staff M, Registered Nurse (RN) was observed during medication administration for Resident #37. Staff M did not perform hand hygiene before beginning the procedure. Staff M, RN prepared seven medications for the resident and administered them as ordered. An interview was conducted with Staff M and she stated she did not perform hand hygiene prior to her medication administration. Staff M stated she did not follow the hand hygiene policy. On 2/13/2024 at 8:50 a.m. Staff N, RN was observed during medication administration for Resident #358. Staff N, RN did not perform hand hygiene before beginning the procedure. Staff N, RN prepared twelve medications for the resident and administered them as ordered. An interview was conducted with Staff N and she stated she did not perform hand hygiene prior to her medication administration. Staff N stated she did not follow the hand hygiene policy. A review of the facility policy titled Medication Administration-General Guidelines revealed the following: Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by the persons legally authorized to do so personnel authorized to administer medications do so only after they have been properly oriented to the facilities medication distribution system, procurement, storage, handle in and administration. The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions. -Procedures 2) Hand washing and hand sanitation: the person administered medication at the ears to good hand hygiene, which includes washing hands thoroughly -before beginning a medication passed, -prior to handling medications

Based on observation, interview, and record review, the facility failed to ensure medications were administered by a licensed nurse and not stored on an over bed table for self-administration for one (#4) out of three sampled residents. Findings Included: On 06/19/2023 at 10:00 a.m., the west unit was toured and revealed a souffle cup sitting on top of an over bed table. The cup was observed with multiple pills that ranged in different sizes and colors. Resident #4 was not in the bedroom at the time (photographic evidence obtained). At 10:11 a.m., Staff A, Assistant Director of Nursing (ADON) was in the hallway, and was asked who administered medications on the west unit. She stated, she's right there. The ADON went to the nursing station and returned shortly with Staff B, Registered Nurse. At 10:12 a.m., Staff B, along with the ADON observed the cup of medications on Resident #4's, over bed table. At that time, the ADON pushed the souffle cup next to the tissue box. Staff B stated, he can take his own medications. He went to take a shower first then to physical therapy. The ADON and RN were asked if the resident had a self-administration assessment. They left the bedroom and returned to the nursing station. The medications remained unsupervised on the over bed table. Staff B provided a copy of Resident #4 Self Administration of Medication Evaluation form with Effective Date: 01/10/2023. Review of the form Instructions: Complete this assessment prior to resident initiating self administration of medication and with any medication order changes, changes in function/condition that might affect the resident ability to safely self administer medications. A. List all medications that are being considered for resident self administration. List medication, route, dose and frequency. Number of medications considered for self administration Medication #1 order: albuterol inhaler, Medication #2 order: anoro elipata. At 10:28 a.m., the Director of Nursing (DON) was asked about their process on leaving medications at the bedside. He did not immediately respond. The DON observed the medications that remained on Resident #4's over bed table and removed the cup. The DON confirmed medications should not be left unattended. He was informed the ADON and Staff B had observed the cup of medications on the table and left the bedroom and the medications indicating it was common practice. The DON confirmed it was not a facility practice to leave medications unsupervised. Medical record of Resident #4 Admission Record form revealed he had resided at the facility over two years and was geriatric in age. The diagnosis information listed constipation, benign prostatic hyperplasia, anemia, type 2 diabetes, hypoglycemia, major depression disorder, hypertension, and Parkinson's disease. Review of Physician orders showed, May self-administer inhaler medications WITH SUPERVISION, dated 07/01/2022. On 06/19/2023 at approximately 1:00 p.m., the DON provided a copy of Resident #4's Progress note dated 06/19/2023 at 11:07 a.m., all 9 am medications were appropriately administered at 10:50 a.m. On 06/19/2023 at 3:57 p.m., an interview was conducted with Resident #4. He confirmed he had a shower this morning and went to physical therapy. Resident #4 stated, I don't know how many pills in the morning I'm supposed to have. He denied knowing the names of the pills and what they were for. Resident #4 stated a lot of them leave my medications on the table. I don't know who they are, but it happens a lot. Resident #4 stated I just take them when I return to my room. Review of facility policy Preparation and General Guidelines dated August 2014. II2 Medication Administration General Guidelines Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication system (procurement, storage, handing, and administration). Procedures A. preparation 4) FIVE RIGHTS- Right resident, right drug, right dose, right route, and right time, are applied for each medication being administered. B. Administration 4). When medications are administered by a mobile cart taken to the resident location medications are administered the time, they are prepared. 7) The person who prepares the does for administration is the person who administers the dose. 14) Residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with the procedures for self-administration of medications. 17) For residents not in their rooms or otherwise unavailable to receive medications on the pass, the MAR is flagged with [tags, colored plastic strips, drinking straw, or paper clips]. After completing the medication pass, the nurse returns to the missed resident to administer the medication. 18) The resident is always observed after administration to ensure that the dose was completely ingested.

Based on observations, record reviews, and interviews, the facility failed to store, distribute, and prepare food in accordance with professional standards for food service safety related to food stored underneath vents with an excessive amount of black build up in the mechanical room, a window blind with an excessive amount of dust and black build up directly behind food in the mechanical room, water stored on the floor in the mechanical room, a broken foot petal device on the trash can at the hand washing sink, inappropriate storage of utensils, and black buildup on the ice machine. Findings included: On 11/02/21 at 9:47 a.m., the Kitchen Manager reported that the hurricane supply was stored in the mechanical rooms, and he would have to get a key to open the door. At 9:49 a.m., the Kitchen Manager returned with the key and escorted the surveyor to the mechanical room next to the conference room near the 200 unit. The vent above cases of mashed potatoes, graham crackers, canned [MEDICATION(S)], and juices was observed with an excessive amount of black build up. The window blind behind cans of chicken and dumplings was observed with an excessive amount of dust and black buildup (photographic evidence obtained). A second mechanical room near the 100 unit was observed with the Kitchen Manager. Three cases of water and one big bottle of water was stored on the floor. On 11/02/21 at 10:00 a.m., an initial tour of the kitchen was conducted. The foot petal device used to lift the lid of the trash can at the handwashing sink near the three-compartment sink was not working. There was a second trash can at this handwashing sink without a foot petal to lift the lid of the trash can. There was a spoon observed hanging from the bin of flour that was uncovered. The Kitchen Manager stated that the spoon was used to get flour from the bin and immediately removed the spoon. The ceiling and ceiling vents throughout the kitchen were observed with an excessive amount of dust and black buildup. The white flap in the inside of the ice machine was observed with black build up (photographic evidence obtained). The Kitchen Manager stated it looked like mold and that he would get it cleaned. On 11/04/21 2:40 p.m., an interview was conducted with the Kitchen Manager, the Assistant Kitchen Manager, and the Regional Director of Employee Relations and Purchasing. During the interview, the Kitchen Manager reported that Maintenance was responsible for cleaning the vents, ceilings, and blinds. He stated that there was a work order in for the vents and ceiling, but the work order was probably not completed due to the change in Administration. He reported that the cases of water should be stored at least six inches off the floor. The Regional Director of Employee Relations and Purchasing stated that they use a system to submit work orders, but there was not an option in the system to submit a work order for vents. The Kitchen Manager reported that all kitchen staff was responsible for completing the Dietary Service Monitoring Sheet. The policy provided by the facility Food Storage Overview with a copyright date of 2015 revealed the following: Food is stored by methods designed to prevent contamination. 11. Food is stored a minimum of 6 inches above the floor and 18 inches from the ceiling on clean racks or other clean surfaces, and is protected from splash, overhead pipes, or other contamination. The policy provided by the facility Cleaning Ice Machines and Equipment with a copyright date of 2015 revealed the following: The ice machine and equipment (scoops) will be cleaned on a regular basis to maintain a clean, sanitary condition. The Daily Cleaning List reflected the following areas that would be checked: ice machine wiped down and ceiling clean. The Monthly Cleaning Schedule indicated that the interior of the ice machine would be cleaned. The Dietary Service Monitoring Sheet with a copyright date of 2015 indicated that the ceiling tiles would be free of stains and the ceiling vents would be free from dust.

Based on observation, interview, and record review, the facility failed to promote and honor resident rights for three (Residents #96, #106, and #20) of 15 sampled residents, related to ensuring that dignity was maintained related to urinary drainage bags. Findings included: 1) A review of Resident #96's admission record revealed that she was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #96's most recent Minimum Data Set (MDS) dated [DATE], documented in Section C (Cognitive Patterns) that Resident #96's cognition was intact with a Brief Interview for Mental Status (BIMS) score of 15. Review of Section G (Functional Status) reflected that Resident #96 required physical assistance with toileting, bed mobility, and supervision with eating. Section H (Bladder and Bowel) indicated that she had an indwelling catheter. On 11/02/21 at 11:18 a.m., Resident # 96 was observed sitting in a wheelchair in her bedroom. A urinary drainage bag was observed attached to the side of the wheelchair. The urinary drainage bag was not covered or placed in a privacy bag. On 11/03/21 at 7:59 a.m., Resident #96 was observed lying in bed. The urinary drainage bag was observed attached to the bed frame. The drainage bag was not covered with a privacy bag. On 11/03/21 at 8:09 a.m., in an interview with Staff J, Certified Nursing Assistance (CNA), she stated that Resident #96 's urinary drainage bag should have been placed in a privacy bag. She stated that she was not assigned to the resident but confirmed that the drainage bag should have been covered. On 11/03/21 at 8:12 a.m., in an interview with Staff H, Licensed Practical Nurse (LPN), he stated that urinary catheter drainage bags should be placed in privacy bag. He stated that he was not sure of the facility policy related to urinary drainage bag, but concurred that the resident's drainage bag should have a privacy bag. On 11/03/21 at 10:10 a.m., in an interview with the Regional Registered Nurse, she stated the resident's drainage bag should be covered to provide dignity. 2) A review of the admission record for Resident #106 revealed that she was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #106's MDS dated [DATE], in Section C (Cognitive Patterns), reflected a Brief Interview for Mental Status score (BIMS) of 15 indicating that her cognition was intact. Further review of Section G (Functional Status) revealed a score of 3, which indicated that Resident #106 required Two +persons physical assist with toileting, and bed mobility. On 11/2/2021 at approximately 8:40 a.m. during a tour of the facility east wing, Resident#106 was observed lying in bed. Her urinary drainage bag was observed attached to bed frame. The drainage bag was visible from the hallway with the door opened. A subsequent observation on 11/03/21 at 7:57 a.m., revealed Resident #106's drainage bag attached to the bed frame towards the door. The urinary drainage bag was not covered nor was a privacy bag in place. On 11/03/21 8:09 a.m., an interview was conducted with Staff J, Certified Nursing Assistance (CNA). She stated that Resident #106's drainage bag should have been placed in a privacy bag. She stated that she thought she had provided a privacy bag for the drainage bag yesterday. On 11/03/21 at 8:12 a.m., an interview was conducted with Staff H, Licensed Practical Nurse (LPN). Staff H stated that urinary catheter drainage bags should be placed in a privacy bag. He stated that he was not sure of the facility policy related residents with urinary drainage bags. On 11/03/21 at 10:10 a.m., an interview was conducted with the Regional Registered Nurse. She stated that urinary drainage bags should be covered to provide dignity. 3) A review of Resident #20's medical records revealed that she was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident #20 's MDS dated [DATE], documented in Section C (Cognitive Pattern) a Brief Interview for Mental Status (BIMS) score of 14, indicative of intact cognition. On 11/02/21 at 11:09 a.m., Resident #20 was observed sitting in her bedroom in a motorized wheelchair, with a urinary drainage bag attached to the front of the wheelchair. The drainage bag was visible to anyone entering the room. There was no privacy bag or covering to protect the drainage bag. On 11/02/21 at 3:15 p.m., Resident #20 was observed in her electric wheelchair in the hallway, with her urinary drainage bag attached to the front of the wheelchair. The urinary drainage bag was not covered, and was visible to staff, other residents, and visitors in the hallway. On 11/3/2021 at 9:00 a.m., during an interview with Staff I, Registered Nurse (RN), Unit Manger, she stated that Resident #20 had a privacy bag for her urinary drainage bag. She stated that Resident #20 removed her privacy bag as desired. Staff I concurred that the resident's urinary drainage bag should have been covered. On 11/03/21 at 10:10 a.m., during an interview with the Regional Registered Nurse, she stated that Resident #20 was noncompliant with the privacy bag for her urinary drainage bag. She confirmed that residents' urinary drainage bag should have been covered to provide dignity.

Based on observations, staff interviews, and medical record review, the facility failed to ensure care plans were followed related to checking for incontinence and repositioning for one (Resident #89) of fifty one sampled residents. Findings included: On 11/4/2021 from 7:20 a.m. -10:22 a.m., Resident #89 was observed seated in a fully reclined [Brand name] chair, positioned in the West unit television/activity lounge, which was directly across from the nurses' station. Resident #89 was positioned in the lounge and in front of the television. She was observed lying in a manner where she could watch the television. She was observed in the same position and without staff checking on her or interacting with her from at least 7:20 a.m. through to 10:22 a.m., which was over three (3) hours. During this period, staff did not speak with her, offer her hydration, nor repositioned her. Resident #89 was noted as dressed for the day and had a blanket over most of her body up to her neckline. She was observed with padding positioned off the head rest of the [Brand name] chair with her head positioned on the bar of the head rest. On 11/4/2021 at 10:22 a.m. Staff A, Certified Nursing Assistant (CNA) walked over to Resident #89 and asked her how she was doing. Staff A did not reposition the resident's head cushion so that her head was not lying on the bare metal frame. Staff A visited the resident for about twenty seconds and then left. On 11/4/2021 at 12:15 p.m., the West Unit Manger came into the lounge area, removed Resident #89 from the television/activity lounge, and transported the resident to her room. The door was closed after the Unit Manager took the resident into her room. The door was opened at 12:17 p.m. and the Unit Manager left the room. At 12:23 p.m., a staff member brought a meal tray to the roommate of Resident #89. However, Resident #89 was not provided her meal tray or eating assistance. Resident #89's roommate continued to eat from 12:23 p.m. until 12:44 p.m. On 11/4/2021 at 12:44 p.m., Staff B, CNA, was observed to a carry a lunch meal tray to Resident #89's room. Staff B confirmed she was bringing in Resident #89's meal tray. She said she would set up the meal tray and assist her with eating. Staff B could not provide an answer as to why the resident sat in her room for twenty-one minutes while her roommate was eating. She confirmed the resident did not have hydration served during that time. On 11/5/2021 at 7:07 a.m., Resident #89 was observed dressed for the day and reclined in her Geri chair in the West unit television lounge/activities area. She was noted positioned in front of the television and had a blanket over her upper body and entire head. On 11/5/2021 at 7:23 a.m., Staff C, CNA was observed to walk over to Resident #89, reposition her closer to the television, and remove the blanket from her head. The aide did not speak with her, but rather just moved her and then walked away. Staff C did not ask the resident if she was ok, if she needed anything, nor did she check her for incontinence. On 11/5/2021 from 7:23 a.m. through to 9:48 a.m., which was over two hours and twenty-five minutes, Resident #89 was observed in the lounge/activities area facing the television, with a blanket over her head, in the same position, and with no staff interaction. On 11/5/2021 9:48 a.m., Staff C was observed to walk over to the resident, pull the blanket off her head, pull up the surgical mask to cover both her mouth and nose, and walk away. On 11/5/2021 from 9:48 a.m. through to 9:54 a.m., Resident #89 again sat in the same position without any further staff interaction. At 9:54 a.m., Resident #89's husband came over to her, sat down in a chair, removed the blanket from her face, spoke to her for about four minutes, and then left. On 11/5/2021 from 9:58 a.m. through to 11:00 a.m., Resident #89 sat in the same position totally reclined in her Geri chair without any staff interaction, without being repositioned, and without being checked for incontinence. On 11/5/2021 at 11:00 a.m., Staff C was observed to walk to the resident. She took off the resident's right shoe, replaced it, and tied the laces. She then repositioned the blanket over the resident's entire body and repositioned the resident's head and feet. On 11/5/2021 at 7:10 a.m., an interview with Staff G, CNA revealed that the expectation was to check, change, and reposition a resident whether they were in bed, in a chair, or out of their room, at least every two hours per shift. He confirmed that he did not have Resident #89 on his work assignment. On 11/5/2021 at 10:00 a.m., an interview with Staff F, CNA revealed that during the shift, he was to check, change, and reposition a resident at least every two hours. He confirmed that even if the resident was out of the room and seated in a chair, the resident was to be checked for incontinence, or checked on to see if they needed anything. If positioned in a chair, they were to be repositioned at least every two hours. Staff F confirmed that he did not have Resident #89 on his work assignment. On 11/5/2021 at 11:01 a.m., an interview was conducted with CNA Staff C. She revealed that she checked her assigned residents for incontinence episodes twice a shift. She revealed that for Resident #89, she checked on her more than twice a shift. She revealed she would usually ask if she needed anything to drink or wanted anything. Staff C confirmed that she checked on the resident one time since breakfast this morning, 11/5/2021. She said the resident was sleeping so she did not wake her, nor did she check her for incontinence. Staff C further explained that the resident had therapy but not today. She confirmed that the resident was usually positioned in front of the television in the lounge after breakfast and just before lunch meal. Staff C said she had Resident #89 on her work assignment today and usually did every day. She did not have a reason as to why Resident #89 was not checked and repositioned for over two hours on both 11/4/2021 and 11/5/2021. On 11/5/2021 at 11:56 a.m., an interview with Staff E , West Unit Nurse revealed that residents were expected to be checked or changed every two hours at the very least. She revealed that Resident #89 sat out in the lounge so they (staff) could see and monitor her from the nurses' station at all times. She could not confirm that staff had repositioned the resident, checked the resident for incontinence, or asked her if she needed anything to drink this morning,11/5/2021. She further confirmed that the CNA should have checked and repositioned the resident while seated in the [Brand name] chair at least every two hours. Review of the medical record revealed that Resident #89 was admitted to the facility on [DATE]. Review of the advance directives revealed the resident had a Health Care Surrogate in place. Review of the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set for a significant change assessment dated [DATE] revealed: Cognition/Brief Interview Mental Status score - No score but indicated short term and long term memory problem and with Severely Impaired decision making skills; Activities of Daily Living - Toileting was total dependence on staff; Bowel and Bladder - Always incontinent of Bowel and Bladder and not on a retraining program. Review of the current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] [Brand name] chair with side supports when OOB (out of bed) with seat encouraged to keep in reclined position when not participating in any structured activities. [Brand name] chair to assist with optimal comfort and positioning, recline as needed to minimize the risk of falls Dx.(diagnoses) [CONDITION(S)] dated 3/26/2021. Review of the current care plans with next review date 12/28/2021 revealed the following areas: 1. Resident #89 prefers identification/arm band on her wheelchair. Resident #89 likes to put a blanket over her head and face when sitting in the common areas. She uses a [Brand name] chair and prefers to rest her head on the side of the chair instead of using a pillow or other supportive device, she will remove padding/pillow from the chair to rest her head on the chair. Interventions included but not limited to: Offer and assist with providing pillow/padding to chair for her to rest her head on as tolerated; Offer and assist with repositioning frequently to prevent pressure due to resting head on the chair instead of pillow while in chair. 2. Resident #89 is at risk for falls related to [CONDITION(S)], decreased safety awareness, weakness, gait disorder, and incontinence with interventions in place to include: [Brand name] chair to be utilized for safety and positioning; Is incontinent of Bowel and Bladder and is dependent on staff for incontinence care. 3. Resident #89 is at risk for constipation related to decreased mobility with interventions in place to include but not limited to: Encourage intake of fluids and food is not contraindicated, Encourage resident to sit on toilet to evacuate bowels if possible and assist as needed, Follow facility bowel protocol for bowel management 4. Resident #89 has bowel incontinence related to confusion, immobility, disease process with interventions to include but not limited to: Check resident frequently during each shift and assist with toileting as needed. 5. Resident #89 has risk of pressure injury related to immobility, incontinence, multiple co-morbidities with interventions to include but not limited to: Follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] 6. Resident #89 at risk for skin breakdown related to incontinence, decreased mobility, advancing disease process with interventions to include but not limited to: Check as required for incontinence, wash, rinse, and dry perineum. Change clothing PRN after incontinence episodes. Keep clean, dry, odor free as needed 7. Resident #89 is incontinent of bowel and bladder. Risk for [CONDITION(S)]/skin breakdown related to incontinence. Resident is not a candidate for retraining and with interventions to include but not limited to: Check as required for incontinence. The Director of Nursing was unable to provide a policy and procedure related to implementation of care plan interventions. However, the Director of Nursing did explain that direct care staff were trained and in-serviced on care plans and interventions. He further explained that the expectation was for staff to follow each intervention.

Based on observation, interview and record review, the facility failed to maintain an effective infection prevention program during a second active COVID-19 outbreak by: 1) one staff member (A) failing to disinfect reusable equipment and perform hand hygiene between six residents (#1, #2, #3, #4, #5, and #6) of six residents observed in one wing (West) of two wings, 2) two staff members (C & D) of five staff members observed failed to wear the required masks and stored mask in shirt pocket while in the facility. Findings included: 1. During an interview with the Infection Control Nurse on 1/5/21 at 11:15 a.m. she stated they had an active COVID-19 unit in October (2020) or November (2020) on the West hall then closed it. On 12/25/20 they reopened a new COVID-19 unit on the East hall after 5 residents resulted positive for COVID-19 following testing on 12/24/20 during routine testing. On 1/5/21 the COVID-19 unit housed 9 positive residents. An observation of Staff A, Certified Nursing Assistant (CNA) was observed on 1/5/21 at 10:03 a.m. going into Resident #3's room with three pieces of equipment (hand- held portable blood pressure monitor, pulse oximeter and thermometer) and held against Staff A's shirt. Staff A, CNA placed the pulse oximeter on the resident's finger, used the resident's personal blood pressure cuff and attached it to the portable blood pressure monitor, then placed the monitor on the resident's tray table with the thermometer. Staff A, CNA completed the process then placed the blood pressure monitor in her right pocket without disinfecting the monitor, attached the resident's blood pressure cuff to the bedrail on the left side of the bed and left the room without performing hand hygiene or disinfecting the equipment. Staff A, CNA walked directly to Resident #1's room and took their oxygen level and temperature and left the room without disinfecting the equipment or performing hand hygiene. Staff A, CNA then moved to Resident #2's room and took his oxygen and temperature and left the room without disinfecting the equipment or performing hand hygiene. Then Staff A, CNA went into Resident #4's room and placed the blood pressure cuff, thermometer and pulse ox on the resident's tray table. While the blood pressure monitor was on Resident #4, Staff A, CNA went to Resident #5 to obtain the pulse ox and temperature and failed to perform hand hygiene. Staff A, CNA then exited the room with the pulse oximeter hanging around her neck and the blood pressure monitor in her left hand with the thermometer. Staff A, CNA went into Resident #6's room and removed the pulse oximeter from her neck and without disinfecting the equipment or performing hand hygiene, placed it on the resident's right first finger with his hand resting on his tray table. The blood pressure cuff was attached to his right arm with the monitor resting on his tray table and the thermometer lying next to it. Staff A, CNA then left the room at 10:08 a.m. and gave the pulse oximeter to Staff B, Licensed Practical Nurse (LPN) where he donned gloves and bleach wipes to clean the pulse oximeter. An interview was conducted with Staff A, CNA at 10:09 a.m. and she stated that she gets the residents' information from the nurse and checks the vital signs according to what the nurse needs on each resident. Staff A, CNA confirmed she did go into the rooms of Residents #1,#2, #3, #4, #5, and #6 to check their vital signs to include blood pressure, pulse oximeter and temperature, and confirmed she did not disinfect the equipment between residents or perform hand hygiene because she was in a hurry as the nurse needed to give the residents' their medication. Staff A, CNA stated she would normally disinfect the equipment and perform hand hygiene but did not today. 2. During an observation of the laundry room on 1/5/21 at 1:05 p.m. two staff members (C & D) were observed sitting at the clean linen table not wearing any type of mask and sitting less than three feet apart. Staff C, laundry aide and Staff D, housekeeping jumped up, took their masks out of their right pockets, and left the room. Staff E, laundry stated they normally wear a mask when back there but may have just come back from lunch. During an interview with the Director of Nursing (DON) on 1/5/21 at 2:04 p.m. he confirmed the staff should be using the rolling cart (contains blood pressure, thermometer and pulse oximeter), which is stocked with disinfectant wipes to assure the cart is cleaned in between residents. The DON confirmed the CNA should not be using the pulse oximeter and blood pressure monitor from the nurse and should never use it without disinfecting it between residents and should always perform hand hygiene between residents. During an interview with the Infection Control Nurse on 1/5/21 at 1:32 p.m. she stated she was disappointed that staff were not wearing a mask while in the building. The Infection Control Nurse confirmed the staff should be performing hand hygiene and disinfecting reusable equipment between residents. Review of the facility policy for hand hygiene, dated 2013, 2 pages reflected: The facility will follow Center for Disease Control (and Prevention) (CDC) Guidelines for handwashing/hand hygiene. Handwashing/hand hygiene is the single most important procedure for preventing nosocomial infections. The facility requires personnel to wash hands thoroughly to remove dirt, organic material, and transient microorganisms. Handwashing is mandated between resident contact in an effort to prevent the spread of infection. Hands must be washed after the following, including, but not limited to: .Contact with resident, contact with contaminated items and surfaces, .initiating a clean procedure . Review of the facility policy for general precautions, dated 2013, 2 pages reflected: The facility will utilize the following general precautions to prevent/control the spread of infections. Documented for the Procedure for Care of Contaminated Articles and Equipment was, 10. Disinfect non-disposables with an Environmental Protection Agency (EPA) approved disinfectant or a freshly prepared bleach solution of one part bleach to ten parts water. Review of the facility policy for use and limited reuse of facemasks and N95 respirators, 3 pages, undated, reflected: To provide recommended practices for the extended use and limited reuse of facemasks and N95 respirators during the COVID-19 pandemic. Store used facemasks or respirators in a designated storage area or keep them in a clean, breathable container such as a paper bag between uses. Clean hands with soap and water or an alcohol-based hand sanitizer before and after touching or adjusting the facemask or respirator.

Based on observation, interview and medical record review the facility failed to honor the bathing preference of a shower for one resident (#75) of forty nine sampled residents. Findings included: On 2/17/2020 at 9:35 a.m. a family member was observed at the 100-unit nursing station asking the nurse, Is my father going to get his shower this morning. She then asked the nurse for towels as she was heard saying my father has food in his beard. At 10:37 a.m. an interview was conducted with Resident #75's daughter and she said that she had concerns with her father getting his weekly showers since he had been admitted . Resident #75's daughter stated, My father is supposed to get two showers a week and that has not been happening. The daughter was asked if she had told anyone about her concerns, she stated, I told his nurse today. I went to the desk this morning and had to ask for towels. My father had food in his beard this morning when I got here. I know he didn't get his shower this morning. Resident# 75's daughter said that she comes to the facility every day to make sure he gets out of bed and that he gets his showers. She said that it takes two people to give him a shower. It takes a long time because he is a mechanical lift. His shower is normally in the morning. I don't know why he hadn't had his shower today. She went on to say his last shower was last week on Monday. He was scheduled for one on Thursday, and I know that he didn't get it. I can tell he didn't get it just by his hair and beard. She was asked if her father has ever refused. She said that he is confused and will resist at times. But I told them I am just eight minutes down the road, and to call me and I will come in and help with my father whenever they need help. Resident #75 was observed in a chair during the interview and would not verbalize. A review of the Admission Record for Resident #75 revealed an original admission date of [DATE] and a re-admission date of [DATE]. The [DIAGNOSES REDACTED]. A review of the Minimum Data Set ((MDS) dated [DATE] revealed in Section F-Preferences for Customary Routine and Activities that choosing between a tub bath, shower, bed bath, or sponge bath was very important to Resident #75. The Shower Schedule sheet indicated Resident #75's showers were scheduled on Mondays and Thursdays on the day shift (7:00 a.m. - 3:00 p.m.). The documentation in the Task Section for 2/3/20 - 2/17/20 showed that only one shower was provided. The bathing was documented as follows: 2/3/2020 - a bed bath was given 2/6/2020 - marked as not applicable 2/7/2020 - a bed bath was given 2/10/2020 - a shower was given 2/13/2020 - a bed bath was given 2/17/2020 - a bed bath was given On 2/18/20 at 4:38 p.m. an interview was conducted with the Director of Nursing (DON) and Nursing Home Administrator related to the concern of Resident #75's daughter with her father not getting his scheduled showers. The Nursing Home Administrator said we look at assignments. It's something that we look at and if it has more to do with the patient. She said that he was not always cooperative with staff. Resident #75's current care plan revised on 2/3/2020 was reviewed and did not reveal a plan of care was in place related to the resident refusing showers and or being resistant with staff during care. A review of the nursing progress notes revealed a note dated 2/3/2020 at 7:18 (a.m.), Upon admission alert with confusion . Requires total assist with adl's (activities of daily living) with mechanical transfers . history of noncompliance and refusal of care with behaviors .he was admitted with a [DIAGNOSES REDACTED]. [MEDICATION NAME] IV thru 2/11/2010 [MEDICAL CONDITION] and uti . [MEDICATION NAME] ointment to nares for [MEDICAL CONDITION] ([MEDICAL CONDITION]-Resistant Staphylococcus Aureus). On 2/20/20 9:58 a.m. an interview was conducted with Staff A, Licensed Practical Nurse (LPN) that confirmed she use to be the unit manager on the unit and still works on the unit. She confirmed Resident #75's daughter has always told the staff to call her if they needed help. She said, I have seen her a lot of times here helping get him in the shower. She said that she was aware the daughter had come in the evening shift to help them out. She said that he is adamant at times. If he doesn't want to do something. On 2/20/20 at 10:09 a.m. an interview was conducted with Staff C, Certified Nursing Assistant (CNA). She said he (Resident #75) had one today. She said on Monday (2/17/2020) we gave him a bed bath. Staff C, CNA stated, After he came back from the hospital and had that infection, I wasn't sure if I could take him in to the shower room, because the infection in his urine and they say he pees a lot. I didn't want to spread whatever he had in the shower. So, we gave him bed baths. She stated that his daughter wants us to get him up every day. Even when he doesn't want to. He is very time consuming when we give him a shower. We have to do multiple (mechanical) lifts. She denied that he was physically aggressive. On 2/20/20 at 11:39 a.m. an interview was conducted with Staff B, CN[NAME] She confirmed that she had cared for Resident #75 every day, before he went to the hospital. After he came back from the hospital he was on a different assignment. She stated, I still help him with his showers, it takes two people. Staff B, CNA was asked about the documentation in the Task section on the Shower Sheet. She said that she knew after he came back from the hospital, he [MEDICAL CONDITION] ([MEDICAL CONDITION]-Resistant Staphylococcus Aureus), so we had to gown up and gave him a bed bath. She went on to say that the resident's (#75) daughter told her it was okay for a bed bath instead of a shower. Staff B, CNA stated, The daughter helps us bathe him and she wanted him to have a shower. Staff B, CNA was asked how often the daughter visits and she said that she comes here every day. Staff B, CNA stated, It takes a lot for us to get him ready. He grabs the railing of the bed and he won't let it go. She said sometimes it takes a half an hour before he will let go of the railing. She was asked if he is aggressive during this time. Staff B said that he will get mad by showing you his fists. That's about all he does. On 2/20/2020 at 2:30 p.m. during an interview with the facility's Infection Control Preventionist and DON it was relayed that the CNAs confirmed they had been providing bed baths to Resident #75 instead of showers due to not wanting to spread his infection (MRSA) in the shower. The DON said we have things for that (indicating the shower can be cleaned). He stated, The resident could have had a shower.

Based upon observation, interviews, and record review the facility failed to appropriately secure medications in two medication carts (#2 East Hall, #1 West Hall) of four medication carts sampled. Findings included: A review of the facility policy titled, Medication Storage in the Facility, Page 48, with a revision date of (MONTH) 2014, reads under Procedures: [NAME] The provider pharmacy dispenses medications in containers that meet regulatory requirements, including standards set forth by the United States (USP). Medications are kept in these containers. C. All Medications dispensed by the Pharmacy are stored in the container with the pharmacy label. On 02/20/2020 at 11:25 a.m., an observation of the East Hall Medication Cart #2 was conducted. The second drawer from the top of the medication cart contained a one-half (½) loose orange tablet, and in the back of the drawer it was observed that one-half (½) of a pink tablet was also loose amongst the punch cards in the drawer. Staff D, Registered Nurse (RN) confirmed the presence of the unsecured tablets. (Photographic Evidence Obtained) On 02/20/2020 at 11:40 a.m., an observation of the West Hall Medication Cart #1 was conducted. The fourth drawer from the top of the medication cart was pulled out and it was observed to contain, behind the drawer, a loose one-quarter (¼) white tablet. Staff E, Licensed Practical Nurse (LPN) reached behind the drawer and confirmed the presence of the unsecured tablet. On 02/20/2020 at 12:00 p.m., an interview with the Director of Nursing (DON) was conducted. He was informed of the observations made, and indicated he was made aware of the loose and unsecured tablets by both Staff D,RN and Staff E, LPN prior to the interview. He stated, My expectation is that there are no loose or unsecured pills in the medication carts.

Based on observation, interview, record review and review of the Centers for Disease Control and Prevention guidelines, the facility failed to ensure that direct caregivers (Staff G, Staff I and a Therapy Tech) followed standard infection control precautions related to artificial nails and nail length. Findings included: On [DATE] at 12:15 p.m. lunch trays were being distributed to residents in the 100-hallway. Staff G, Certified Nursing Assistant (CNA) was observed delivering meal trays to multiple resident rooms. She was observed to have fingernails approximately one inch in length from the nail bed. She was observed to use a hand sanitizer as she rubbed the front and back of her hands with no care to the front or under sides of her fingernails. On [DATE] at 2:00 p.m. Staff G, CNA was observed leaving a resident room in the 100-hallway. She was carrying a clear colored plastic bag that contained an incontinent product. She went to the soiled utility room as she disposed of the bag. She was observed to have fingernails approximately one inch in length from the nail bed. She was observed to use a hand sanitizer as she rubbed the front and back of her hands with no care to the front or under sides of her fingernails. On [DATE] at 11:00 a.m. a therapy tech was observed in the 100-hallway exiting a room while pushing a resident in a wheelchair. She went to the therapy room with the resident. She shortly left the therapy room. She was observed walking up to a resident and touched her left shoulder with her left hand. The therapy tech was observed with long artificial nails approximately one inch in length. She was observed to use a hand sanitizer as she rubbed the front and back of her hands with no care to the front or under sides of her fingernails. On [DATE] at 12:21 p.m. Staff G, CNA was observed in the main dining room as she delivered soup to a resident. She was observed to have fingernails approximately one inch in length from the nail bed. She was observed to use a hand sanitizer as she rubbed the front and back of her hands with no care to the front or under sides of her fingernails. Staff G was observed to walk over to a large serving tray and picked up a plate of food with her right hand. As she walked over to a table, she transferred the plate of food to her left hand, in doing this her left thumb nail was touching the roast beef on the plate. She then placed the plate of food in front of the resident to eat. On [DATE] at 1:50 p.m. Staff I, CNA was observed on the 100-hallway walking toward the nursing station. She was noted to be carrying a clear plastic bag. She entered the soiled utility room. Her fingernails appeared to be over an inch in. She was observed to use a hand sanitizer as she rubbed the front and back of her hands with no care to the front or under sides of her fingernails. On [DATE] at 2:30 p.m. an interview was conducted with the Director of Nursing (DON) as he was asked about the facility policy on staff members and their fingernails. He was asked to observe Staff G's fingernails. Staff G was in the 100-hallway and she was asked how long her fingernails were and she confirmed that they were about an inch in length and were artificial. She confirmed that they were long and added, it's time to get them cut and down again. Staff H,CNA was also observed on 100-hallway using a computer screen. The DON was asked what Staff H's job position was. He said that she is a nursing assistant. He confirmed that she provided direct care to the residents at the facility. Her nails were observed to be over an inch in length that contained multiple different colored glistening jewels. On [DATE] at 12:55 p.m. an interview related to hand hygiene and the length of direct care staff fingernails was conducted with the Infection Control Preventionist Nurse. She stated that artificial nails are not recommended. She provided a copy of her random audits that she performs in the facility. A review of the undated audit titled, Handwashing and Hand Hygiene Surveillance Audit, showed an area of maximum points awarded. Listed under hand hygiene 1. No artificial nails or nail enhancements. Max points awarded 50. 2 Natural nails are short and well- groomed points awarded 25. The facility's Dress Code Guideline, documented, The facility expects you to maintain a neat, well-groomed appearance at all times. This means good personal grooming habits and the proper attire for your position with the facility. The following guidelines have been established to assist you in understanding the Facility's basic standards. Please note this guideline is in effect as of (MONTH) 1,2017 . *Fingernails should be kept short to below the fingertip with smooth edges in order to maintain infection control and prevent injury. *Associates working in dietary cannot wear acrylic, gel or other nail extensions. The facility's undated Certified Nursing Assistant job description showed: Position Overview . Competencies of Position: Safety Awareness .consistently follows infection control and universal precautions and other guidelines . Centers for Disease Control and Prevention guidelines for Skin and Nail Care (https://www.cdc.gov/handhygiene/providers/index.html) showed: Fingernail care and jewelry - *Germs can live under artificial fingernails both before and after using an alcohol-based hand sanitizer and handwashing * It is recommended that healthcare providers do not wear artificial fingernails or extensions when having direct contact with patients at high risk (e.g., those in intensive-care units or operating rooms) *Keep natural nail tips less than ¼ inch long . Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines-H.pdf, updated (MONTH) 2019, pages 50 - 51, revealed: The effectiveness of hand hygiene can be reduced by the type and length of fingernails 559, 718, 719. Individuals wearing artificial nails have been shown to harbor more pathogenic organisms, especially gram negative bacilli and yeasts, on the nails and in the subungual area than those with native nails720, 721. In 2002, CDC/HICPAC recommended (Category IA) that artificial fingernails and extenders not be worn by healthcare personnel who have contact with high-risk patients due to the association with outbreaks of gram-negative bacillus and [MEDICAL CONDITION] as confirmed by molecular typing of isolates30, 31, 559, ,[DATE].The need to restrict the wearing of artificial fingernails by all healthcare personnel who provide direct patient care or by healthcare personnel who have contact with other high risk groups (e.g., oncology, [DIAGNOSES REDACTED] patients), has not been studied , but has been recommended by some experts20.

Based on resident and staff interviews, and facility record review, the facility failed to ensure areas of concern raised during the Resident Council meetings, were documented in the monthly minutes. In addition, the facility failed to demonstrate verification of reasons, rationale or resolutions of the areas of concern in preceding monthly Resident Council Meeting minutes for eight (12/2017, 1/2018, 2/2018, 3/2018, 5/2018, 7/2018, 9/2018, and 11/2018) of twelve months of meetings. Findings included: On 11/7/18, upon review of the Resident Council Meeting minutes, as given permission from the Resident Council President, it was determined the facility used a Resident Council Meeting form to include Old business, and New business. Review of the minutes revealed: 1. Resident Council Minutes dated 12/12/2017 revealed as old business, The concerns were resolved by department head. However, the minutes did not indicate what concerns were resolved. Further review of the previous month's minutes, dated 11/2017, did not indicate what type of concerns the Resident Council had. 2. Resident Council Minutes dated 1/11/2018 revealed as old business, The concerns were resolved by department head. However, the minutes did not indicate what concerns were resolved. Further review of the previous month's minutes, dated 12/12/2017, did not indicate what type of concerns the Resident Council had. 3. Resident Council Minutes dated 2/6/2018 indicated in new business, Residents also have expressed concerns in the following departments: Nursing and Housekeeping. The minutes did not list what concerns were expressed. 4. Resident Council Minutes dated 3/6/2018 revealed in old business, The concerns were resolved by department head.However, the minutes did not indicate what type of concerns the Resident Council had. On 11/7/18 at 11:00 a.m., a meeting was held with five residents who routinely attend monthly Resident Council meetings. During this meeting, the group indicated that they can express their concerns to the Activities Director who writes the meeting minutes, but they did not know what happened or who the concerns go to from there. The group was asked about meetings that were held on 12/2017, 1/2018, 2/2018, and 3/2018 with regards to documentation only indicating, The concerns were resolved by department head. None of the group could remember what the concerns were from those months. The Resident Council President did confirm that she reviewed the minutes, but did not take the minutes. She too indicated that she could not remember what the concerns were for those months. She confirmed that it would be easier if the Activities Director would document the concerns that the group had, so they remember the next month. On 11/7/18 at 10:00 a.m., an interview with the Activities Director indicated that she would document minutes for the Resident Council as permitted by the group. She confirmed that she had not listed specific concerns in the minutes and just indicated what department was spoken about with group concerns. She indicated that the concerns would go to the grievance log, and then each department head and Social Services would handle each grievance. She further indicated that she would review the grievance log and see if each grievance was corrected or not. It was also indicated by the Activities Director that each grievance would be listed by an individual only, and not the group. So, if the group collaboratively had a concern, only one resident would be listed in order to address the issue. The Activities Director could not recall or give an explanation of what specific concerns the Resident Council had for the months of 12/2017, 1/2018, 2/2018, and 3/2018. On 11/8/18 at 10:16 a.m. an interview with the Director of Nursing (DON) revealed that he believed that if the Resident Council had a concern, it was only documented and brought to grievance log and sent to department heads to correct and the Activities Director would review the grievance log before the next meeting to see if the issue had been corrected or not. He confirmed that the Resident Council Meeting minutes did not reflect specific concerns made and specific concerns that were resolved. In addition, the DON was asked if he could find out what concerns the Resident Council had during the months of 12/2017, 1/2018, 2/2018, and 3/2018. He was given the meeting minutes to take with him. At 12:00 p.m. the DON brought back the meeting minutes with added documentation reflecting what type of concerns were expressed. He documented that information as a updated, dated 11/7/2018 and signed. The DON confirmed that the concerns were written on the Resident Council Meeting minutes as a late entry on 11/7/2018. The Resident/Family Concern Logs for the past twelve months to reflect 11/2017 through to 11/2018, were reviewed. Review of the logs, did not reflect any of the concerns listed by the DON, to include: 12/12/2017 minutes concerns related to nursing call light response time, and dietary with salty soups, 1/11/2018 minutes related to nursing concern regarding staffing, and dietary regarding likes and dislikes, and 3/6/2018 minutes related to dietary with clothing protectors, housekeeping regarding bathroom cleanliness, and Aides were not consistently introducing themselves. The only time the above issues were documented and verified was after the DON listed them on the monthly Resident Council Meeting minutes on 11/7/18.

Based on observation, interview, and record review, the facility failed to provide the care and services necessary to maintain good nutrition for two residents (#4 and #60) of thirty-eight residents sampled. Findings included: An observation was conducted of the lunch meal in the facility's 200-Hall West Wing on 11/6/18 at 12:23 p.m. A Certified Nursing Assistant (CNA) was observed carrying a lunch tray with a covered platter into Resident #60's room at 12:23 p.m. Resident #60 was lying in her bed, with the head of her bed raised. The CNA placed the tray on an over-bed table in front of the resident, and took the cover off the platter. The CNA then exited the room. At 12:29 p.m., the same CNA entered the resident's room and encouraged Resident to take a few bites. The CNA then exited the room. At 12:43 p.m., Resident #60 was observed in the room by herself. The resident had finished less than 25% of the food on the plate. A dessert on the tray was untouched, and drinks on the tray were untouched. It was observed that the resident had eaten a few bites of one of three items on the plate. At 12:47 p.m., the same CNA entered Resident #60's room and removed the lunch tray from the room. An interview was conducted with Staff G, CNA on 11/6/18 at 2:12 p.m. Staff G reported that each resident's percentage of each meal eaten was documented on a daily flow sheet, which also included the number of times a resident had certain behaviors, including resist care. If the resident refuses a meal, the flow sheet was marked R for Refused. Review of the CNA daily flow sheet for Resident #60 dated 11/6/18 revealed under meal percentage for lunch that the resident was marked as R for Refused. Review of Resident #60's care plan, revised 11/5/18, revealed the resident was identified as having a nutritional problem related to poor PO (oral) intake of meals and history of weight loss, with the revision noting continues significant weight loss, inadequate oral intake and now has a wound. The interventions included but not limited to, Provide, serve diet as ordered. Monitor intake and record q (every) meal. An observation was conducted of the lunch meal in the facility's 200-Hall West Wing on 11/7/18 at 12:35 p.m. A CNA was observed carrying a lunch tray with a covered platter into Resident's # 4's room at 12:35 p.m. The CNA placed the lunch tray on the resident's over-bed table and exited the room. No other staff was observed entering or exiting the resident's room for thirty four minutes. At 1:09 p.m., a second CNA was observed entering the room. Four minutes later, at 1:13 p.m., the CNA was observed exiting the room carrying the resident's lunch tray. Review of the CNA daily flow sheet for Resident #4 dated 11/7/18 revealed under meal percentage for lunch that the resident was marked as R for Refused. Review of Resident #4's care plan, revised 10/18/18, revealed the resident was identified as At risk for alteration in nutrition/hydration, with the revision noting significant weight loss. Interventions for the care plan included but not limited to, Allow ample time to eat meal. An observation was conducted of the lunch meal for Resident #60 in the facility's 200-Hall West Wing on 11/7/18 at 12:35 p.m A CNA was observed carrying a lunch tray with a covered platter into Resident #60's room at 12:43 p.m. The CNA placed the lunch tray on the resident's over-bed table and exited the room. No other staff was observed entering or exiting the resident's room for twenty-three minutes. At 1:06 p.m., the same CNA was observed entering the room. Three minutes later, at 1:09 p.m., the CNA was observed exiting the room carrying the resident's lunch tray. Review of the CNA daily flow sheet for Resident #60 dated 11/7/18 revealed under meal percentage for lunch that the resident was marked as R for Refused. An observation was conducted of the lunch meal for Resident #60 in the facility's main dining room on 11/8/18 at 12:47 p.m. Resident #60 was observed sitting at a table with three other residents. One staff member was assisting two of the residents with their meals. Resident #60 was wearing a clothing protector, and on the table in front of the resident was a glass of apple juice and a plate of food with a few bites missing from one of three items on the plate. There was an empty chair positioned next to the resident. A CNA asked the resident You going to eat more? and received no response. Six minutes later at 12:53 p.m., Resident #60 was again asked if she was going to eat anymore and gave no physical or verbal response. At 12:55 p.m., a CNA sat down in the chair next to Resident #60 and asked her, Do you want a straw? The resident gave no response and the CNA left the table and the room, then returned with a straw. The CNA then asked a second CNA standing near the table, You going to get her? I want to give her a drink. Resident #60 did not respond to the offer of a drink. The second CNA then removed the clothing protector and wheeled Resident #60 out of the dining room at 12:57 p.m. Three minutes later at 1:00 p.m., a CNA was observed wheeling a dessert tray into the dining area. The 2 remaining residents at Res. #60's table were offered dessert, and the CNA assisting the 2 residents removed 2 desserts from the cart. The first CNA then wheeled the dessert tray out of the room. three minutes later, at 1:03 p.m. Resident #60 was observed in the lobby area along with five other residents. Resident #60 was seated in a wheelchair at a table in front of the television. Review of the CNA daily flow sheet for Resident #60 dated 11/8/18 revealed under meal percentage for lunch that the resident was marked as R for Refused. Review of Nutrition/ Dietary notes for Resident #60, dated 11/5/18, revealed Resident #60 had significant weight loss at 11.8% x 3 months and 18.2% x 6 months. Resident's weight status continues to be affected by inadequate oral intake of meals. An interview with Staff H, Registered Nurse (RN) Unit Manager on 11/9/18 at 9:50 a.m., Staff H stated Resident #4 and #60 needed assistance with feeding, and were on the feeding assistance list. The feeding assistance list was a list of residents that required CNAs or other staff to assist and/or feed the residents during all meals. Staff H confirmed both residents had significant weight loss, and stated that both residents were also on appetite stimulants to increase their food intake. Staff H confirmed that three-four minutes time was not enough time to ensure Resident #4 and Resident #60 were given an opportunity to eat.

Based on observations, staff interview and policy review, the facility failed to ensure staff either washed or sanitized their hands between and after resident contact, during meal service for two of four lunch meal observations in the main dining room on 11/6/18 and 11/7/18. Findings included: On 11/6/18 11:55 a.m., the main dining room was observed for lunch meal service. The room consisted of two sections, the larger portion was for residents who dined without assistance, and the smaller section was for residents who required assistance. The large section had a small steam table where staff prepared plates of food. The steam table was located at the door to the kitchen. Also, the area contained a soup service station, just to the right side of the steam table. During this time there were approximately thirty residents seated at tables and were already provided with hydration, soup and clothing protectors. There were six aides in the room assisting with requests and meal orders. The smaller room had seven residents, who required assistance and two aides. Staff E, Staffing Coordinator and Staff, F, Certified Nursing Assistant (CNA) were observed to prepare and serve soup from this station. Staff E did not wash or sanitize hands between and after each soup service, which occurred five times prior to sanitizing. Staff E was observed touching resident arms, shoulders, a wheelchair, and the condiment cabinet. From 12:05 p.m. to 12:10 p.m., Staff E again, was observed to prepare, serve and set up bowls of soup for three residents and did not sanitize hands between or after each service. On 11/7/2018 at 12:03 p.m. Staff F, CNA was observed in the main dining room and at the soup service station ladling soup into five bowls. She then served each bowl to residents seated at different tables. She did not wash or sanitize her hands between or after resident contact. She was observed to touch resident equipment to include wheelchair backs/handles, armrests, resident eating utensils and then going to get a bowl of soup and take it to another resident at another table. She did this five times in a row without washing or sanitizing hands first. Staff E, Staffing Coordinator was observed to use the soup service station and proceeded to pour soup in a bowl, walked it to a resident table, touched used eating utensils, touched resident arms, armrests, and then went back to soup station and proceeded to get more bowls of soup without first sanitizing or washing hands. She did this four times before finally sanitizing her hands. Staff E was also observed pouring hydration and touching resident glasses without first sanitizing her hands. She also touched and picked up other resident glasses that were already used and needed refills. She did not wash or sanitize hands after contact with used glasses and before touching other resident glasses. On 11/9/2018 at 11:00 a.m. an interview with the Nursing Home Administrator and the Director of Nursing confirmed that staff should be washing or sanitizing their hands between and after resident contact and after preparing and serving soup to residents repetitively. On 11/9/2018 at 1:00 p.m. the Nursing Home Administrator provided the facility policy titled, Section: Infection Control Manual, Subject: Infection Prevention - Hand Hygiene, CCHC0113, dated 2013. The Overview section reflected, The facility will follow the Center for Disease Control (CDC) Guidelines for handwashing/hand hygiene. Handwashing/Hand hygiene is the single most important procedure for preventing nosocomial infections. The Overview continued with, The facility requires personnel to wash hands thoroughly to remove dirt, organic material, and transient microorganisms. Handwashing is mandated between resident contact in an effort to prevent the spread of infection. Hands must be washed after the following, including, but not limited to: .Contact with resident, Contact with contaminated items or surfaces, and Contact with mucous membranes.

Based on observation, interview, record review and facility policy review, the facility failed to maintain the identified contact precautions as evidenced by staff unable to identify which resident had the precautions in place and utilization of equipment to prevent possible cross contamination for two (#58 and #96) of thirty-eight sampled residents. Findings included: On 11/6/18 at 11:54 a.m., Resident #58 was observed lying in his bed. His roommate was noted with a staff member standing at the left side of the bed. The staff member while standing was noted leaning toward the resident. Her shirt was resting on the side rail. On the outside of the Resident's room an isolation kit was hung on the door. The kit contained Personal Protective Equipment (PPE). Along with a sign that was attached to it. The sign reflected, Contact Isolation. Has been identified for Resident in- window (window- was hand written) bed. During this observation Staff A, Certified Nursing Assistant (CNA) walked out from behind a curtain partition in the room. She exited the room and walked directly into a resident room that was next door. Staff A exited and entered the resident room next door and was observed pulling behind her a portable vital sign machine. At 11:56 a.m. an interview was conducted with Staff C, Speech Therapist (ST) as she exited Resident # 58's room. She was asked which of the residents in the room was on isolation. Staff C stated, It's for the door bed. It's for [MEDICAL CONDITIONS] I think. Staff C was noted while in the room not utilizing the contact isolation precaution that was posted on the room door. She was without a gown and was not wearing gloves. Additionally, she did not performed hand hygiene when exiting the room. At 11:58 a.m. an interview was conducted with Staff A, CNA as she was leaving the resident room next door. She confirmed at that time she performed vital signs to both of residents that were in the room. The two residents that resided next door were not on contact isolation. She was asked who was on contact isolation in Resident #58's room. She stated that it was Resident #58's roommate, By the window. Staff A was asked what type of infection the resident had. She stated, Usually it's just [MEDICAL CONDITION]. Staff A was asked if she was using the same blue blood pressure cuff that was attached to the vital sign machine. She stated, Yes. She was asked if the cuff was cleaned in-between use. She stated, For some reason there is no (bleach) on it to use. It's probably locked up at the nursing station. Staff A was asked if she had taken Resident #58's vital signs and blood pressure and she confirmed that she had. She said that she also had taken his roommate's vital signs. At 12:00 p.m., an interview was conducted with the Staff B, Registered Nurse (RN)/Unit Manager of the East Unit (UME). She confirmed that the isolation sign posted on Resident #58's door was not correct. She said that it had changed on Sunday. She said that the resident at the window came off on Sunday, but the resident at the door still remained on it. She also confirmed that contact isolation precautions needed to be followed. At 12:21 p.m. a second resident room on the same unit was observed with a PPE kit hung on the outside of the door. Two separate signs were attached to the kit. One of the signs reflected, Contact Isolation Has been identified for Resident in (area was blank) bed. This Resident must not leave room. The second sign stated Contact Isolation Has been identified for Resident in (area was blank) bed. Neither of the two signs indicated which resident was on contact isolation. Additionally, no residents were visualized in the room. At 12:27 p.m. Resident #96 that resided in the second Contact Isolation room along with her roommate were observed sitting up in their wheelchairs. Both residents were in the main dining room sitting amongst their peers as they were being served their lunch meal. At 12:29 p.m. an uncovered food cart was parked outside of Resident #58's door. The cart contained two lunch trays. Lying on top of one of the lunch trays was a pair of reading glasses. (Photographic evidence) At 12:33 p.m. Staff I (CNA) exited Resident #58's room. He walked up to the cart that was positioned outside of Resident #58's room, and as he did this he picked up the eye glasses and placed them on top of his head. On 11/6/18 at 12:49 p.m. an interview was conducted with the Director of Nursing (DON) and he confirmed that he was aware of concerns related to isolation signs. He stated that the Staff B, UME had informed him of that. He was informed at that time staff members were not able to identify which of the two residents that resided in Resident #58's room was on contact precautions. The DON confirmed that the isolation sign had indicated that the resident that resided at the window was on precautions. He said that that Staff B, UME had changed the sign when it was brought to her attention. He was also informed that Resident #96's room door had two different isolation signs posted. One specifically stated that, The resident must not leave the room, and it was still undetermined which of the two residents were on isolation. Since both residents were observed eating in the dining room. The DON stated that, As long as they have control of their bowels. They can leave the room. He stated, We try not to isolate people. The DON was asked about the facility's portable vital sign machine being wheeled into a room that had been identified with contact isolation, and then the same machine was brought into another resident's room without being cleaned in-between use. He said that we have a process in place for that. That should not happen. He stated that all of the residents have their own blood pressure cuffs. He asked what color were the cuffs, white? He was informed that only one cuff was attached to the machine, and that Staff A, CNA confirmed that was the only one being used. He was informed that the color of the cuff was blue. On 11/6/18 at 2:20 p.m. an interview was conducted with Staff I, CNA and he said that he did not take his glasses into the isolation room. He confirmed that he left them on the lunch tray. He stated, I should not have left them on the cart. Especially on a resident's lunch tray. He stated, I'm sorry and I knew better then to do that. A review of the medical record for Resident #58 revealed on his Admission Record sheet that he was readmitted to the facility less than a month. The history dated 9/7/18 was for surgical aftercare following surgery on digestive system. Physician orders [REDACTED]. Last dose that was given was on 10/14/18. Physician orders [REDACTED]. Last dose that was given was on 10/11/18. On 10/23/18 Resident #58 restarted [MEDICATION NAME] 500 mg give one tablet by mouth every 6 hours for [MEDICAL CONDITION] for 14 days. Additionally on 10/23/2018 he restarted [MEDICATION NAME] for 10 days for [MEDICAL CONDITION]. Further review of physician orders [REDACTED]. A nursing note dated 10/31/18 at 2:14 p.m. (1419) revealed that Resident #58 was on antibiotic (atb) for [MEDICAL CONDITION] and now shingles. Nursing notes on 11/6/18 reflected that Shingles rashes decreasing in size and volume. Family into see resident, took him outside on patio. On 11/7/18 at 10:00 a.m., Resident #58 was observed sitting up in his wheelchair in his room. He was receptive to an interview. He was alert and oriented. He stated, that they took me (him) off of isolation today. I told them my stool was formed. But I flushed it. They want another one I hope they put something in the bathroom for me to use. The bathroom was noted with a hat (container) on the commode. He was informed of this and stated good then I won't flush it next time. He said that he is trying to get better to go home. As he spoke of getting an intestinal infection and the shingles. He denied pain and appeared comfortable. A record review for Resident # 96 revealed on her Admission Record sheet that she was readmitted to the facility less than two months. Physician orders [REDACTED]. Physician orders [REDACTED].>On 11/7/18 at 11:00 a.m., Resident #96 smiled when approached while she was in her room. She appeared comfortable and in no distress. She was unable to answer simple questions. As she presented with cognitive deficit. On 11/09/2018 at 12:15 p.m. an interview was conducted with the Director of Nursing and Infection Control Nurse. He stated, What had happened with Resident # 58 and was just miscommunication. According to the CDiff Foundation at https://cdifffoundation.org/what-is-[MEDICAL CONDITION]-,[MEDICAL CONDITION].-difficile: [MEDICAL CONDITION] is gram-positive, anaerobic, and a spore, rod/spindle-shape, a common bacterium of the human intestine in 2 - 5%.[DIAGNOSES REDACTED]. becomes a serious gastrointestinal infection when individuals have been exposed to antibiotic therapy, and/or have experienced a long-term hospitalization , and/or have had an extended stay in a long-term care facility. [DIAGNOSES REDACTED] is contagious. Microorganisms can be spread from person-to-person by touch or by direct contact with contaminated objects and surfaces (for example, clothing, cell phones, door handles). Some individuals are carriers of this bacterium but have no symptoms of infection. According to the Center for Disease Control (CDC) at Identifying Potentially Infectious Patients CDC 2007 Guideline for Isolation Precautions https://www.cdc.gov/hicpac/pdf/isolation/Isolation2007: Contact Precautions: Apply to patients with any of the following conditions and/or disease: o Presence of stool incontinence (may include patients with norovirus, rotavirus, or [MEDICAL CONDITION]), draining wounds, uncontrolled secretions, pressure ulcers, or presence of ostomy tubes and/or bags draining body fluids o Presence of generalized rash or exanthems (eruptive disease) o Prioritize placement of patients in an exam room if they have stool incontinence, draining wounds and/or [MEDICAL CONDITION] that cannot be covered, or uncontrolled secretions o Perform hand hygiene before touching patient and prior to wearing gloves o PPE use: o Wear gloves when touching the patient and the patient's immediate environment or belongings o Wear a gown if substantial contact with the patient or their environment is anticipated o Perform hand hygiene after removal of PPE; note: use soap and water when hands are visibly soiled (e.g., blood, body fluids), or after caring for patients with known or suspected infectious diarrhea (e.g., [MEDICAL CONDITION], norovirus) o Clean/disinfect the exam room accordingly (refer to Section IV.F.4.) o Instruct patients with known or suspected infectious diarrhea to use a separate bathroom, if available; clean/disinfect the bathroom before it can be used again (refer to Section IV.F.5. for bathroom cleaning/disinfection)

Based on record review and interview the facility failed to ensure care was given according to professional standards by not implementing wound care at the time of admission for one (#3) out of eight sampled residents. Findings included: Resident #3 was admitted to the facility on [DATE]. A review of Resident #3's medical record included cumulative [DIAGNOSES REDACTED]. The 14-day Minimum Data Set ((MDS) dated [DATE], identified Brief Interview of Mental Status of 14, cognitively intact and no skin issues. The written discharge instructions from the hospital, acute care facility, reviewed from Resident #3's facility chart, stated, Keep Dressing Dry: Soak right hand in peroxide and water for five minute intervals 3x daily until wound is dry. Leave wound open to air. The AHCA form 5000-3008, for Resident #3 indicated the resident transferred to the facility from an acute healthcare facility. The 3008 identified right hand wound with instructions: soak peroxide & H2O (water) 3x (3 times), 5 minute intervals until wound dry, leave open to air. The Admission Summary, dated 4/27/18 at 6:58 p.m., did not reveal a wound to Resident #3's right hand. The IDT (Interdisciplinary Team) note, dated 4/29/18 at 10:02 p.m., identified Resident #3 had three sutures to right hand and had tx (treatment) ordered. A physician order, dated 4/29/18 at 2:19 p.m., stated, Soak right hand in peroxide & water for 5 minute intervals, 3 times daily, until wound is dry, then leave open to air. (MONTH) cover with dry drsg (dressing) while there is drainage. The (MONTH) Treatment Administration Record (TAR) for Resident #3 revealed monitoring of vital signs (blood pressure, temperature, pulse, respirations, and oxygen saturation) started on 4/27/18. The TAR indicated treatment for [REDACTED]. The facilities Admission Completion Check Off List, copyright (YEAR), indicated upon admission staff were to complete a skin evaluation, verify Admit/Readmit orders with practitioner, and verify orders documented on the POS (physician order [REDACTED]. The check off list indicated staff were to obtain treatment orders for all skin areas/wounds noted upon admission. During an interview on 7/16/18 at 2:29 p.m., the Director of Nursing (DON) confirmed Resident #3's admission date of [DATE] and that the facility had peroxide in stock. The DON reviewed the 3008 and discharge instructions from the acute facility, he stated, the wound care order should have been taken from the discharge instructions at time of admission. The DON reviewed the resident's TAR and confirmed the other physician orders [REDACTED]. The DON stated he was unaware the resident had missed wound care. At 3:24 p.m., the DON stated the weekend supervisor reviewed admissions on weekends and Resident #3 was at [MEDICAL TREATMENT] on Saturday so the supervisor was unable to review the skin until Sunday. He stated the regional DON and he looked to see if there was a different order time for wound care and was unable to locate one. At 4:12 p.m., the DON stated the facility does not have a policy for admitting residents, staff use the Admission Completion Check Off List.

Based on observations, interviews and policy review the facility did not ensure that the resident dignity was maintained during dining for one of the residents (#38), did not ensure that dignity was maintained in the main dining room during lunch service, and related to staff not knocking on doors and announcing themselves before entering resident rooms during dining services for 6 Resident rooms of 31 rooms (#102, #110, #114, #119, #124, and #125) on the east nursing unit, for one of two nursing units. Findings included: 1. During an observation on 08/08/2017 at 12:45 P.M. Staff # H was observed standing at bedside assisting Resident #38 with her meal until resident finished and the tray was removed from the room. In an interview, on 08/08/2017, at 1:13 P.M. with West Unit Manager and Staff member # H confirmed that she stood while assisting Resident # 38 with her meal. The policy Resident Dignity & Personal Privacy, undated, was reviewed and the following was found: Policy The facility provides care for residents in a manner that respects and enhances each resident's dignity, individuality, and right to personal privacy. Procedure 1. Care for residents in a manner that maintains dignity and individuality: Call individuals by their preferred name. Knock on doors before entering; announce your presence 2. During the initial lunch observation in the main dining room, on 8/8/17, at 12:10 p.m. asked, Staff ( L) about the residents seated in the alcove off the dining room That is our feed room, you know- people who need to be fed. The comment was overheard by residents, staff and visitors in the dining room. 3. During the lunch meal, on 8/08/2017, at 12:14 p.m. an observation was conducted on the East nursing unit. Staff D, CNA removed a lunch tray from meal cart. She took the tray down the hall and entered resident room [ROOM NUMBER] without knocking or announcing herself. At 12:18 p.m. Staff C, CNA removed a tray from the meal cart and entered resident room [ROOM NUMBER] without knocking or announcing herself. Another staff member, Staff F, CNA was also observed entering resident room # 109 with a lunch tray. Staff F also did not knock or ask permission to enter the room. After exiting the room, Staff F returned to the meal cart and removed another lunch tray. He proceeded down the hall and entered resident room [ROOM NUMBER] without knocking or asking permission to enter the room. At 12:20 p.m. Staff C was again observed delivering a lunch tray. She took it to resident room [ROOM NUMBER] and entered the room without knocking or announcing herself. She exited the room and went down the hall where she retrieved coffee from the beverage cart. She returned to resident room [ROOM NUMBER] and reentered the room, without knocking or announcing herself. At 12:28 p.m. Staff D entered resident room [ROOM NUMBER] with a lunch tray. She did not knock or request permission to enter the room. At 12:29 p.m. Staff D removed a lunch tray from the meal cart and entered resident room [ROOM NUMBER]. She did not knock or announce herself. Staff C was also observed bringing tea to resident room [ROOM NUMBER]. She did not knock or request permission to enter the room. On 8/09/2017 at 12:21 p.m. an additional dining service observation was conducted on the East nursing unit. Staff E, CNA removed a lunch tray from the meal cart and proceeded down the hall to resident room [ROOM NUMBER]. She entered the room without knocking or announcing herself. At 12:41 p.m. in an interview with Staff E she confirmed she did not knock or announce herself before entering the resident's room. An interview was conducted with the DON on 08/10/2017 at 10:16 a.m. He said he prefers staff to knock before entering the residents' rooms during meals.

Based on interview, record review and interview the facility failed to ensure that the plan of care accurately reflected the transfer status for one (Resident #1) of three residents reviewed. Resident #1 fell to her knees when a nurse attempted to transfer her alone. The resident was discharged to the hospital with a fractured femur. Findings Included: Resident #1 was admitted to the facility on [DATE] status [REDACTED]. Per the Fall Risk Evaluation dated 11/18/2016 the resident scored an 18. Per the instructions on the Fall Risk Evaluation if the score is 8 or greater the resident is considered to be at high risk for potential falls. Preventative intervention should be initiated immediately and documented on the care plan. Per the Nursing Admission Evaluation dated 11/18/2016, under the Personal Data section: Assist with Transfer on Admit was documented as Extensive Assist of 2. Under the Activities of Daily Living section: Transfer was documented as Extensive Assist of 2. A review of the Resident Information Sheet revealed that under the Transfer section an X was placed beside Extensive Assist 2 person. On 1/27/2017 at 2:55 p.m., an interview was conducted with the Minimum Data Set (MDS) Coordinator (Staff E) in the presence of a second MDS coordinator (Staff F). Per the MDS Coordinator (Staff E) the Resident information Sheet is started on admission by the nurse and is placed in front of the CNA flowsheets so the CNAs know the care needs of each resident. The hospital transfer form AHCA Form 5000-3008 was signed and dated by the Physician on 11/18/2016. Under Section S Physical Function- Transfer with 2 assistants was designated with an X. Walker was hand written beside the 2 Assistants. A review of the progress notes dated 11/18 - 12/14/2017 revealed the following information: The resident was admitted on [DATE]. The first progress note dated 11/18/2016 at 3:26 p.m. said the resident wad cooperative, staples to her bilateral knees were intact, the physician was notified of her arrival, Foley catheter was removed and she was medicated for pain at the hospital. Ext. assist x 2 to transfer from wheelchair to bed, pt. reminded to use call light for assist. 11/22/2/016 at 2:30 p.m. Ext assist x 2 with ADLS and bed mobility. Ext. assist x 2-3 to transfer. 11/25/2016 at 1:26 p.m. Ext. assist x to transfer 11/30/2016 at 1:51 p.m. Ext. assist x 2 to transfer 12/2/2016 at 1:26 a.m. Max. assist of 2 for ADLS and transfers 12/6/2016 at 2:08 p.m. Ext. assist x 2 with ADLs and transfers. 12/8/2016 at 3:01 p.m. Alert to self with occasional confusion out of bed with ext. assist x 2 12/12/2016 at 12:32 p.m. Assist x 2-3 to transfer During the interview and review of the care plan for Resident #1 with the MDS Coordinators, Staff E said she reviews the Activities of Daily Living (ADL) flowsheets, progress notes, resident information sheets, therapy notes; and, she interviews the CNAs, nurses, and therapists to determine had to code the MDS and complete the care plan. Care Plan for the resident was as follows: Problem Onset: (Resident) at risk for decline with mobility and Activities of Daily Living (ADL) related to requires limited to extensive assist, muscle weakness, impaired mobility, and [DIAGNOSES REDACTED]. Interventions did not include the number of persons the resident needed for a safe transfer. When the MDS coordinator was asked to explain the difference between limited assist and extensive assist, she said the limited assist was related to eating meaning no hands on staff assistance needed. The extensive assist was related to bed mobility, transfers, ambulation with hands on assistance. She said extensive assistance meant one or two staff members were needed for the task. When she looked at Resident #1's care plan she said she should have put extensive assistance of 2 persons for transfers in the intervention column. A review of the Admission MDS with an Assessment Reference Date (ARD) of 11/25/2017 revealed Under Section G - Functional Status, subsection B. Transfer 1. Self Performance: Coded as 3 meaning the resident needed Extensive assistance-resident involved in activity, staff provide weight-bearing support. 2. Support: Coded as 3 meaning the resident needed Two + persons physical assist Per the CNA Flowsheets dated 11/18-12/13/2016 the amount of assistance needed transfers for all three shifts were coded as either the resident was not transferred, the resident was transferred with extensive assistance, or the resident needed total assistance for the transfer. During the same time period 11/18-12/13/2016 the number of staff members required to assist the resident was coded for the 11:00 p.m. - 7:00 a.m. shift as the resident was not transferred on 21 of 25 shifts; and, the resident was transferred with one person 4 of 25 times. On the 7:00 a.m. - 3:00 p.m. shift the resident required a 2 person assist on 17 of 23 shifts. The resident required a 1 person assist for transfers on 2 of 23 shifts and she was not transferred on 4 of 23 shifts. On the 3:00 p.m. - 11:00 p.m. shift the resident required 2 persons to assist her to transfer on 19 of 26 shifts. The resident was not transferred on 7 of 26 shifts. On 1/27/2017at 1:03 p.m., an interview and review of the Physical Therapy discharge notes was conducted with the Rehabilitation Director. Per the discharge summary note dated 12/19/2016, the resident's end of therapy was dated 2/13/2016 due to hospitalization . End of Goal status as of 12/13/2016: Goal not met-on 12/13/2017. The patient is able to safely complete all functional transfers requiring maximum assistance x 2 (76%-99% assist with 2 people.) On 1/27/2017 at 12:30 p.m., an interview and review of the event report was conducted with the Nursing Home Administrator (NHA) regarding the event. She read the following from the event report as written by the nurse involved in the incident: Description: Assisted the resident to transfer from the bed to wheelchair right knee started to buckle patient said, 'I'm falling', assisted patient down to the floor. On 1/27/2017 at 12:40 p.m., a telephone interview was conducted with the Director of Nurses (DON). Per the DON, the nurse said she verbally asked the resident if she could transfer herself with the assistance of the nurse and the resident said yes. He said the resident stood up without difficulty; however, her knee started to buckle and the resident said, I'm falling. At that time, the nurse lower the resident to the floor. Per the progress notes dated 12/14/2016 at 3:04 a.m. the nurse attempted to transfer the resident from the bed to the wheelchair. The note read as follows: When assisted pt off the bed to the w/c, patient's right knee started to give out, pt. was unable to stand and started to fall to her knees, assisted pt. to her knees. Pt. started c/o right knee pain. Medicated for pain, right knee x-ray ordered. On 1/27/2017 at 12:15 p.m., an interview was conducted with the unit manager regarding the fall with a resulting femur fracture. The unit manager said the nurse attempted to transfer the resident from the bed to wheelchair but during the transfer the resident's knee gave out and the nurse lowered the resident to the floor. The resident complained of pain to her right leg. The physician was notified and ordered X-rays, which showed a right femur fracture. The unit manager said the nurse transferred the resident by herself because before she transferred the resident she asked the resident if she was able to transfer with one person. Per the unit manager, the resident said, Yes. Per the right femur X-Ray report dated 12/14/2016 at 4:05 a.m., Impression: Oblique mid one third femoral diaphysis acute fracture. The resident was transferred to the hospital on [DATE]. She did not return to the facility.

Based on interview, record review and interview the facility failed to use an adequate amount of staff to safely transfer one (Resident #1) of three (Resident #2 and #3) residents from the bed to the wheelchair resulting in a right femur fracture. Finding included: Resident #1 was admitted to the facility on [DATE] status [REDACTED]. Per the Fall Risk Evaluation dated 11/18/2016 the resident scored an 18. Per the instructions on the Fall Risk Evaluation if the score is 8 or greater the resident is considered to be at high risk for potential falls. Preventative intervention should be initiated immediately and documented on the care plan. Per the Nursing Admission Evaluation dated 11/18/2016, under the Personal Data section: Assist with Transfer on Admit was documented as Extensive Assist of 2. Under the Activities of Daily Living section: Transfer was documented as Extensive Assist of 2. A review of the Resident Information Sheet revealed that under the Transfer section an X was placed beside Extensive Assist 2 persons. On 1/27/2017 at 2:55 p.m., an interview was conducted with the Minimum Data Set (MDS) Coordinator (Staff E) in the presence of a second MDS coordinator (Staff F). Per the MDS Coordinator (Staff E) the Resident information Sheet is started on admission by the nurse and is placed in front of the CNA flowsheets so the CNAs know the care needs of each resident. The hospital transfer form AHCA Form 5000-3008 was signed and dated by the Physician on 11/18/2016. Under Section S Physical Function- Transfer with 2 assistants was designated with an X. Walker was hand written beside the 2 Assistants. A review of the progress notes dated 11/18 - 12/14/2017 revealed the following information: The resident was admitted on [DATE]. The first progress note dated 11/18/2016 at 3:26 p.m. said the resident wad cooperative, staples to her bilateral knees were intact, the physician was notified of her arrival, Foley catheter was removed and she was medicated for pain at the hospital. Ext. assist x 2 to transfer from wheelchair to bed, pt. reminded to use call light for assist. 11/22/2/016 at 2:30 p.m. Ext assist x 2 with ADLS and bed mobility. Ext. assist x 2-3 to transfer. 11/25/2016 at 1:26 p.m. Ext. assist x to transfer 11/30/2016 at 1:51 p.m. Ext. assist x 2 to transfer 12/2/2016 at 1:26 a.m. Max. assist of 2 for ADLS and transfers 12/6/2016 at 2:08 p.m. Ext. assist x 2 with ADLs and transfers. 12/8/2016 at 3:01 p.m. Alert to self with occasional confusion out of bed with ext. assist x 2 12/12/2016 at 12:32 p.m. Assist x 2-3 to transfer During the interview and review of the care plan for Resident #1 with the MDS Coordinators, Staff E said she reviews the Activities of Daily Living (ADL) flowsheets, progress notes, resident information sheets, therapy notes; and, she interviews the CNAs, nurses, and therapists to determine had to code the MDS and complete the care plan. Care Plan for the resident was as follows: Problem Onset: (Resident) at risk for decline with mobility and Activities of Daily Living (ADL) related to requires limited to extensive assist, muscle weakness, impaired mobility, and [DIAGNOSES REDACTED]. Interventions did not include the number of persons the resident needed for a safe transfer. When the MDS coordinator was asked to explain the difference between limited assist and extensive assist, she said the limited assist was related to eating meaning no hands on staff assistance needed. The extensive assist was related to bed mobility, transfers, ambulation with hands on assistance. She said extensive assistance meant one or two staff members were needed for the task. When she looked at Resident #1's care plan she said she should have put extensive assistance of 2 persons for transfers in the intervention column. A review of the Admission MDS with an Assessment Reference Date (ARD) of 11/25/2017 revealed Under Section G - Functional Status, subsection B. Transfer 1. Self Performance: Coded as 3 meaning the resident needed Extensive assistance-resident involved in activity, staff provide weight-bearing support. 2. Support: Coded as 3 meaning the resident needed Two + persons physical assist At 2:30 p.m., an interview was conducted with the resident's regular CNA (Staff C) on the 7:00 a.m. - 3:00 p.m. shift. She said depending on the day (resident was not always motivated) and the resident's pain level, the resident needed two staff members to assist her with transfers. The CNA said the resident could stand up with her rolling walker and pivot to sit in a chair but the CNA said she did not remember transferring the resident without a second person to assistance. At 2:40 p.m., an interview was conducted with a CNA (Staff D) that assisted with transfers for Resident #1. She said she assisted the resident's CNA (Staff C) on several occasions to help her transfer the resident from the bed to the chair. She said, she did not recall seeing a nursing staff member transfer the resident with one person. On 1/27/2017 at 1:03 p.m. an interview and review of the Physical Therapy discharge notes was conducted with the Rehabilitation Director. Per the discharge summary note dated 12/19/2016, the resident's end of therapy was dated 2/13/2016 due to hospitalization . End of Goal status as of 12/13/2016: Goal not met-on 12/13/2017. The patient is able to safely complete all functional transfers requiring maximum assistance x 2 (76%-99% assist with 2 people.) Per the progress notes dated 12/14/2016 at 3:04 a.m., the nurse attempted to transfer the resident from the bed to the wheelchair. The note read as follows: When assisted pt off the bed to the w/c, patient' right knee started to give out, pt. was unable to stand and started to fall to her knees, assisted pt. to her knees. Pt. started c/o right knee pain. Medicated for pain, right knee x-ray ordered. On 1/27/2017 at 12:15 p.m. an interview was conducted with the unit manager regarding the fall with a resulting femur fracture. The unit manager said the nurse attempted to transfer the resident from the bed to wheelchair but during the transfer the resident's knee gave out and the nurse lowered the resident to the floor. The resident complained of pain to her right leg. The physician was notified and ordered X-rays, which showed a right femur fracture. The unit manager said the nurse transferred the resident by herself because before she transferred the resident she asked the resident if she was able to transfer with one person. Per the unit manager, the resident said, Yes. At approximately 12:30 p.m., a call was placed to the nurse involved in the event, however by the end of the investigation the nurse had not returned the call. On 1/27/2017 at 12:30 p.m., an interview and review of the event report was conducted with the Nursing Home Administrator (NHA) regarding the event. She read the following from the event report as written by the nurse involved in the incident: Description: Assisted the resident to transfer from the bed to wheelchair right knee started to buckle patient said, 'I'm falling', assisted patient down to the floor. On 1/27/2017 at 12:40 p.m., a telephone interview was conducted with the Director of Nurses (DON). Per the DON, the nurse said she verbally asked the resident if she could transfer herself with the assistance of the nurse and the resident said yes. He said the resident stood up without difficulty; however, her knee started to buckle and the resident said, I'm falling. At that time, the nurse lower the resident to the floor. Per the right femur X-Ray report dated 12/14/2016 at 4:05 a.m.: Impression: Oblique mid one third femoral diaphysis acute fracture. The resident was transferred to the hospital on [DATE]. She did not return to the facility.