Every finding on record at Eastridge

The facility had a census of 17 residents. Based on observation, interview, and record review, the facility failed to ensure an environment free from accident hazards when the facility left the active steam table, heating up to 180 degrees Fahrenheit (F), unattended and accessible to residents in the area. The facility reported three cognitively impaired, independently mobile residents who could potentially access the steam table without staff knowledge. This deficient practice placed three cognitively impaired, independently mobile residents in Immediate Jeopardy, and others at risk. The facility also failed to ensure residents did not have access to an unlocked blanket warmer. Findings included: - On 08/10/25 at 10:00 AM, the facility dining room was empty of residents and staff. The steam table in the dining room was unattended and accessible to residents. The steam table lids had a measured temperature of 135 degrees F. Upon request, Dietary Staff BB and Administrative Staff A obtained a facility thermometer, and the steam table lids registered at 180 degrees F. The facility reported three cognitively impaired, independently mobile residents could potentially access the steam table without staff knowledge. On 08/10/25 at 10:10 AM, Administrative Staff A stated for the immediate time, she placed a staff member in the dining room to assure no residents got close to the steam table. Administrative Staff A stated staff would turn the steam table off after meals, and once it was cool, staff would not man the area until the table was turned back on for evening meal service. On 08/10/25 at 11:05 AM, Dietary Staff BB stated she turned on the steam table around 06:00 AM and left it on all day, until after supper, and then turned it off for the night. Dietary Staff BB stated she did not check the temperatures of the steam table. On 08/10/25 at 02:30 PM, barriers and caution tape surrounded the steam table. The barriers stayed in place through 08/12/25 until a plexiglass barrier was installed. The Centers for Medicare and Medicaid (CMS) “State Operations Manual” (SOM) recorded temperatures at 124 degrees F can cause a third-degree burn ( serious burn which affects the outer layer of skin as well as the entire layer beneath and requires immediate medical attention) in three minutes of exposure; temperatures at 127 degrees F can cause third degree burn with one minute of exposure; temperatures at 133 degrees F can cause third-degree burn in 15 seconds of exposure, and water temperatures at 140 degrees F can cause a third-degree burn in five seconds of exposure. The facility’s “Department Safety” policy, reviewed 02/2024, stated all electrical machines with heat producing elements must be turned off when not in use. The department manager is responsible for maintaining safety standards and notifying the Safety Officer in case of any safety hazard. All department associates shall report defective equipment, unsafe conditions, acts, or safety hazards to the supervisor in writing or verbally. On 08/10/25 at 01:43 PM Administrative Staff A received the Immediate Jeopardy (IJ) template and notified the facility failure to have the steam table with steam table lids registered at 135 degrees F with one thermometer and 185 degrees F from another, accessible from all sides, and had lack of staff monitoring placed the residents in immediate jeopardy at F689 and constituted substandard quality of care at CFR 483.25. The facility submitted an acceptable immediate jeopardy removal plan on 08/10/25 at 02:21 PM, which included the following: 1. A staff member was placed in the dining room to ensure no residents got close to the steam table. 2. The steam tables have been shut off. Once it is cool, staff will not be in the area until the table is turned back on for the evening service meal. 3. A temporary barrier with cones, chairs, and caution tape to keep folks away from the area. 4. On 10/11/25, once local hardware/lumber yard stores are open, a board barrier will then be put up as a more secure yet temporary fix. 5. A long-term plan will be put in place, likely building up the partial wall that was already in place, to shield the steam table. The surveyor verified the above corrective actions were implemented while onsite on 08/10/25 at 02:30 PM, and the deficient practice remained at a “D” scope & severity. - On 08/11/2025 at 07:58 AM, observation revealed an unattended open room, without a door, which had an unlocked blanket warmer on a shelf, approximately 2 ½ feet (ft) from the floor, with a temperature reading on the front of the warmer of 157.8 degrees Fahrenheit (F). The top inside metal shelf of the blanket warmer was hot to the touch. The first thermometer, when pointed at the metal shelf, read 152.5°F. Administrative Nurse E verified the finding and stated it had never been a problem in the past. On 08/11/25 at 08:01 AM, Maintenance Staff (MS) U, when asked if he would temp the shelf with a second thermometer, stated the reading on the outside was 157°F and that was the right temperature inside the blanket warmer due to a company coming out and checking the temperature to make sure it maintained that temperature. On 08/11/2025 at 08:32 AM, Maintenance Staff U used a second thermometer to check the temperature of the metal shelf inside the blanket warmer, and it read 155°F. On 08/11/25 at 10:30 AM, Licensed Nurse (LN) H stated that she had not seen any resident enter the room where the blanket warmer was kept. On 08/11/25 at 01:36 AM, Certified Nurse (CNA) M stated she had never seen a resident go into the room where the blanket warmer was kept. On 08/11/25 at 10:40 AM, Administrative Nurse D stated that she did not feel the location of the unattended blanket warmer was a problem, as residents do not enter the room, but staff had moved it to a locked room. Upon request, the facility failed to provide an accident policy. How far off the floor was this shelf

The facility identified a census of 17 residents. The sample included eight residents. Based on record review and interview, the facility failed to provide a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week. This placed the residents at risk of decreased quality of care.Findings included:- The Payroll Based Journaling (PBJ) report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal Year (FY) 2025 Quarter One indicated the facility did not have RN hours on 11/30/24, 12/22/24, 12/25/24, and 12/28/24.Upon review of the facility's actual working nursing schedule from November 2024 and December 2024, it was revealed that the facility failed to have RN coverage on 12/28/24.On 08/11/25 at 03:05 PM, Administrative Staff A provided licensed nurse and RN punch times for all dates documented above except on 12/28/24, when the facility failed to have an RN staff member on duty that day. On 08/12/25 at 09:45 AM, Administrative Nurse D stated and confirmed that the facility did have RN coverage for all the days that were in question, except on 12/28/24, when the facility did not have RN coverage for that day. Administrative Nurse D stated that either she or Administrative Nurse E did their best to cover RN hours when another RN was not available.The facility's Staffing policy dated 05/19 documented it was the policy of this facility that there would be sufficient staff available to provide nursing and related care to the residents. A registered nurse will be present in the facility for at least eight hours each day, seven days a week. During hours when a registered nurse was not in the building, nursing administration would be available.

The facility identified a census of 17 residents. Based on record review and interview, the facility failed to submit accurate staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ) when the facility failed to submit accurate registered nurse (RN) and licensed nurse coverage 24 hours a day. Findings included:- The PBJ Staffing Data Report CASPER Report 1705D provided by the Centers for Medicaid and Medicare (CMS) for Fiscal Year (FY) 2025, quarter one and quarter two documented the following triggered areas: Quarter one: one-star staffing rating, no RN hours, and failed to have licensed nursing coverage 24 hours a day. The report documented no RN hours on 11/30/24, 12/22/24, 12/25/25, and 12/28/24.The report documented the facility failed to have a licensed nursing coverage 24 hours a day on 10/12/23, 10/13/24, 11/09/24, 11/23/24, 11/28,24, 11/30/24, 12/01/24, 12/14/24, 12/15/24,12/21/24, 12/22/24, 12/25/24, and 12/28/24Quarter two for FY 2025 triggered for failing to have licensed nursing coverage 24 hours a day on 02/09/25, 02/22/25, 02/23/25, 03/15/25, and 03/16/25.On 08/11/25 at 03:05 PM, Administrative Staff A provided licensed nurse and RN punch times for all dates documented above except on 12/28/24, when the facility failed to have an RN staff member on duty that day. On 08/12/25 at 09:45 AM, Administrative Nurse D stated that all nursing hours were sent to the corporate human resources person at the sister facility. Administrative Nurse D stated that at one point there had been an issue with the correct hours being submitted to CMS, but that she believed that issue had been resolved. Administrative Nurse D stated and confirmed that the facility did have 24-hour licensed nurse coverage for all the days that were in question, except on 12/28/24, when the facility did not have RN coverage for that day. Administrative Nurse D stated that either she or Administrative Nurse E did their best to cover RN hours when another RN was not available.The facility lacked a policy regarding PBJ Reporting.

The facility identified a census of 17 residents. The facility had one medication room and one medication cart. Based on observation, record review, and interview, the facility failed to ensure the medication cart was kept locked and secured when cognitively impaired and independently mobile residents were near the cart. This placed the residents at risk of accidental ingestion of medication and adverse reactions.Findings included:- On 08/10/25 at 09:44 AM, the medication cart near the nurse's station was left unlocked and unattended by staff. Resident (R) 14, a cognitively impaired, independently mobile resident, was near the medication cart.On 08/10/25 at 09:45 AM, Licensed Nurse (LN) G stated that the cart should always be locked when she was away from it. On 08/12/25 at 09:45 AM, Administrative Nurse D stated that the medication cart should never be left unlocked when staff were away from the cart. The facility's Medication Storage and Management policy dated 05/19 documented that medications and biologicals were to be stored safely, securely, and properly following the manufacturer's recommendations or those of the supplier. Medication rooms, carts, and medication supplies were to always be locked or attended by persons with authorized access.

The facility identified a census of 17 residents. The sample included eight residents, with one sampled resident reviewed for hospice. Based on observation, record review, and interview, the facility failed to ensure the hospice provider provided the facility with Resident (R) 3's hospice plan of care. This placed R3 at risk of inadequate end-of-life care.Findings included:- R3's Electronic Medical Record (EMR) documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), hypertension (HTN- elevated blood pressure), and congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid).R3's Significant Change Minimum Data Set (MDS) dated 07/24/25 documented a Brief Interview for Mental (BIMS) score of 15, which indicated intact cognition. R3 required substantial assistance to be dependent on staff for her activities of daily living (ADL). R3 was on hospice services.R3's Functional Abilities Care Area Assessment (CAA) dated 07/26/25 documented the need for assistance with all ADLs. R3 did not ambulate and required a sit-to-stand lift (a specialized medical device designed to assist individuals with limited mobility in transitioning from a seated to a standing position) and occasional use of a Hoyer lift (total body mechanical lift) with transfers. R3 has worked with physical therapy and occupational therapy in the past after joint replacement (involves replacing a damaged or diseased joint with an artificial one) surgeries. R3 participates in a range of motion (ROM) exercise programs. R3 was admitted to hospice services on 07/16/25. R3 was at risk for further pain, and the need for more assistance with care, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), unmet care needs, and falls. R3's Care Plan, revised on 07/17/25, directed care staff that she had a terminal prognosis and was receiving hospice services. The Care plan directed staff that hospice would provide Durable Medical Equipment (DME) of briefs and wipes. Staff were directed hospice would provide medications of Losartan (a medication to treat HTN) 25milligrams (mg) daily, MiraLAX (laxative) 17 grams (gm) daily, potassium chloride (treatment for low potassium) 10 milliequivalent (mEq) daily, senna (laxative ) 8.6mg daily, Lasix (a medication used to reduce fluid retention) 20mg daily, fentanyl patch (an opioid patch used to manage moderate to severe pain) 50 mg every 48 hours, and milk of magnesia ( medication is used for a short time to treat occasional constipation) 30 milliliters (ml) every 24 hours as needed (PRN). The Care Plan directed staff to encourage a support system of family and friends. The Care Plan directed staff that the hospice nurse would visit up to two times a week and needed for additional cares, falls and death; the hospice nurse aide to visit two times a week for bathing; the hospice social worker would visit twice a month and PRN emergent psychosocial needs; the hospice physician as needed face to face and symptom management. The Care Plan directed staff that hospice would provide PRN Tylenol (pain reliever); hyoscyamine solution (medication used to relax muscles and reduce secretions), lorazepam liquid (medication used to treat anxiety); and roxanol (medication used to manage pain, restlessness, and air hunger). The Care Plan directed staff to work cooperatively with the hospice team to ensure the resident's spiritual, emotional, intellectual, physical, and social needs are met.On 08/11/25 at 01:55 PM, review of the hospice provider binder revealed that the hospice provider failed to provide R3's hospice plan of care. On 08/11/25 at 02:08 PM, Licensed Nurse (LN) H stated that R3's hospice binder should have the plan of care in it. LN H stated she had called the hospice provider, and they emailed her the hospice plan of care and provided a copy. LN H stated she would place a copy of the hospice plan of care in R3's binder.On 08/12/25 at 09:45 AM, Administrative Nurse D stated that the hospice provider had recently had a changeover in staff, and the plan of care might have been overlooked and not put in the binder. Administrative Nurse D stated she would ensure to get the hospice plan of care placed in R3's binder.The Hospice Services Agreement dated 05/17/23 documented that hospice shall be solely responsible for initially certifying and recertifying as necessary, the resident's terminal illness in accordance with applicable law. Hospice shall be solely responsible for conducting initial and comprehensive assessments upon a resident's election of hospice care. Hospice shall be responsible for determining, and modifying as necessary, the appropriate hospice plan of care. Such hospice plan of care shall encompass all issues related to the terminal illness and related conditions. Hospice shall communicate with the resident, family members, facility staff, and the attending physician to develop and update the content of the hospice plan of care. Hospice shall determine the appropriate course of hospice care for residents who was under hospice's care, including any determination to change the level of services provided to such residents.

The facility identified a census of 17 residents. The sample included eight residents. Based on observation, record review, and interview, the facility failed to ensure that daily posted nurse staffing data was posted daily.Findings included:- On 08/10/25 at 09:43 AM, upon the initial tour of the facility, it was noted that the daily posted nurse staffing hour sheet was dated Friday, 08/08/25.Upon request on 08/11/25, the facility was able to provide daily posted nurse staffing data from the prior 18 months, but was not able to provide a sheet for 08/09/25 and 08/10/25. On 08/12/25 at 09:47 AM, Administrative Nurse E stated that she typically provided the daily nursing hour staffing sheet to the night shift charge nurse. Administrative Nurse E stated she had been on vacation and just returned yesterday, and had realized that the sheets for the weekend had not been completed as they should have. The facility was unable to provide a policy regarding daily posted nurse staffing data.

The facility identified a census of 19 residents. The sample include nine residents. Based on observation, record review, and interviews, the facility failed to provide consistent activities for the residents during weekends. This deficient practice placed the affected residents at risk for decreased psychosocial wellbeing and boredom. Findings Included: - A review of the facility's Activities Calendar for September, October, and November of 2023 revealed two repeating activities for weekends. The September and October calendars noted catholic communion (10:45AM) and resident's choice (2:00PM) activities on Sundays. The September and October calendars noted recliner time (09:30AM) and movie time (02:00PM) on Saturdays. The November calendar indicated recliner time (09:30AM) and movie time (02:00PM) was noted as the only activities listed for the weekends. On 11/07/23 at 09:30AM the facility's coffee chat activity did not occur as listed on the calendar. A group of residents were moved to the television area to watch television. Administrative Staff B instructed the residents in the area she had to help another staff member and could not hold coffee chat. On 11/07/23 at 02:01 PM, Resident Council members reported most weekends do not have staff led activities or scheduled groups for the residents to attend. The council reported the facility provided puzzles and activities for the self-led resident activities on the weekends. The council reported weekends were boring and said they would like to see more staff led activities and involvement. The council stated recliner time was just staff moving some residents to the recliners in front of the television. They reported most of the time the weekdays stayed very eventful with activities but if the Activities Coordinator (AC) was off, some of the activities would not be completed. The Council reported the morning's scheduled coffee chat activity did not occur because the AC was at an appointment outside the facility. On 11/08/23 at 09:55 AM Certified Nurse's Aide (CNA) M stated weekends were usually resident choice or self-led activities. She stated she was not sure what recliner time was but may have been putting the residents in front of the television. On 11/08/23 at 11:00 AM Administrative Staff A reported the AC completed the monthly activity calendars and gave instructions to the staff on what to provide for the weekends. She stated staff were expected to ensure activities were being provided. She stated she would get with the interdisciplinary team to review the activity process. A review of the facility's Resident Rights policy revised 01/2020 indicated each resident will be provided opportunity to participate or refuse in opportunities that promote social, emotional, physical, and recreational activities to perform at their maximum level of functioning. The facility was not able to provide a policy related to activities as requested on 11/08/23. The facility failed to provide consistent activities for the residents during weekends. This deficient practice placed the affected residents at risk for decreased psychosocial wellbeing and boredom.

The facility had a census of 19 residents. The sample included nine residents with five residents reviewed for accidents and/or hazards. Based on observation, record review, and interview the facility failed to secure rooms containing hazardous materials out of reach of six cognitively impaired /independently mobile residents. This deficient practice placed the six residents at risk for preventable injuries and accidents Findings Included: - On 11/06/23 at 07:08AM a walkthrough of the facility was completed. An inspection of the facility's Activity Room revealed disinfectant wipes unsecured on a table. An inspection of a supply closet propped open next to the television sitting area revealed a bottle of isopropyl alcohol (rubbing alcohol) and a spray bottle labelled alcohol on a shelf. All products contained the warning Keep out of reach of children. An inspection of a refrigerator storage area next to the rehab gym revealed three full bottles of drinking alcohol unsecured in a small white refrigerator. On 11/07/23 at 03:33PM an inspection of the facility's unlocked laundry room revealed the chemical storage closet was unlocked with numerous hazardous cleaning agents. The laundry rooms electrical panel room was unlocked with the three panel's doors left open. The panel contained the label warning High Voltage, Keep Locked. On 11/08/23 at 09:30AM, Certified Nurse's Aide (CNA) M stated the laundry room's doors for the chemicals and electrical panels should always remain locked. She stated the disinfectant wipes should be stored in locked cabinets when not in use. She stated drinking alcohol usually is stored in the locked activity rooms cabinet and provided per the resident's orders or care plan. On 11/08/23 at 09:42AM, Licensed Nurse (LN) G stated hazardous chemicals and areas of the facility should be secured away from the residents. On 11/08/23 at 10:40AM Administrative Nurse D stated hazardous chemicals should be secured in locked area or cabinets. She stated the doors leading to the laundry closets should be always locked. She stated drinking alcohol should be locked up at the nurse's station or the activities cabinet. A review of the facility's Safety policy revised 01/2020 indicated the facility will ensure each resident's environment will remained free from hazardous materials and potential accidents by ensuring the materials are maintained in a secure and locked area away from the resident population. The facility failed to secure rooms containing hazardous materials out of reach of six cognitively impaired independently mobile residents. This deficient practice placed six residents at risk for preventable injuries and accidents.

The facility identified a census of 19 residents. The sample included nine residents. Based on observation, record review, and interviews, the facility failed to ensure pressure reducing measures were placed on Resident (R) 11's bilateral lower extremities to prevent pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). This placed R11 at increased risk for pressure ulcer development. Findings included: - R11's Electronic Medical Record (EMR) documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), and weakness. The Significant Change Minimum Data Set (MDS) dated [DATE], documented R11 had a Brief Interview for Mental Status (BIMS) score of seven which indicated severe cognitive impairment. The MDS documented R11 was dependent on staff for toileting, dressing, bathing, rolling left and right, and chair/bed to chair transfers. The MDS further documented sit to lying, lying to sitting on the side of the bed, sit to stand and toilet transfers were not attempted due to R11's medical condition or safety concerns. The Functional / Rehabilitation Potential Care Area Assessment (CAA) dated 06/29/23, documented R11 was at risk for pressure ulcers due to need for assistance with bed mobility, weakness, functional decline and altered mental status. The CAA documented an intervention of foam heel lift boots (removes pressure from the heel to help prevent heel/pressure ulcers) for R11. The CAA further documented R11's Braden skin risk assessment (tool used to identify patients at-risk for pressure ulcers) score was 14 which indicated moderate risk of skin breakdown. R11's Care Plan listed an intervention initiated on 01/06/23 which directed staff to place heel lift boots on R11 every time he was in bed to prevent skin breakdown. R11's EMR lacked documentation of a refusal to wear the heel lift boots while in bed on 11/07/23. On 11/07/23 at 12:53 PM an observation revealed R11 rested in his room in bed. R11 did not have on any pressure reducing/heel lift boots and his heels rested directly on his mattress. On 11/08/23 at 09:42 Licensed Nurse (LN) G stated she was unsure of R11's current order; however, she stated if R11's care plan directed to have his heel lift boots on every time he was bed then he should have them on every time he was in bed. On 11/08/23 at 09:57 AM Certified Nurse Aide (CNA) M stated R11 was to have his heel lift boots on whenever he was in bed, even if during the day, and it would be documented if he had them on or if he refused. On 11/08/23 at 10:48 AM Administrative Nurse D stated staff were expected to place R11's heel lift boots on him every time he was in bed if it was on his care plan. Administrative Nurse D further stated R11's boots should be on even when he laid down during the day and staff were expected to document that they were placed on R11 or if he had refused to wear them. The facility provided Pressure Ulcer Prevention policy dated 06/18/01, documented it is a policy that all attempts and efforts will be made to prevent pressure sores from developing. The facility failed ensure pressure reducing measures were placed on R11's bilateral lower extremities to prevent pressure ulcers. This placed R11 at increased risk for pressure ulcer development.

The facility identified a census of 19 residents. The sample included nine residents with two residents sampled for position, range of motion (ROM), and mobility. Based on observation, record review and interview, the facility failed to ensure Resident (R) 5's right hand palm cushion was applied as directed to prevent an avoidable reduction of ROM and/or mobility. This deficient practice left R5 at risk for further decline and decreased ROM. Findings included: - R5's Electronic Medical Record (EMR) documented a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion), and fatigue. The Significant Change Minimum Data Set (MDS) dated [DATE] for R5 documented a Brief Interview for Mental Status (BIMS) score of three which indicated severe cognitive impairment. The MDS documented R5 was dependent on two staff for bed mobility, transfers, dressing and toileting. R5 was dependent on one staff for locomotion on and off the unit, eating and personal hygiene. The Cognitive Loss / Dementia Care Area Assessment (CAA) dated 06/08/23 documented R5 had a diagnosis of multiple sclerosis (MS - progressive disease of the nerve fibers of the brain and spinal cord) and had severe cognitive impairment. R5's Care Plan with an intervention initiated on 02/09/22, directed staff to place a splint to R5's right hand prior to all meals and to remove after each meal. The intervention further directed staff to place a palm cushion in R5's right hand at all times that splint was not on. R5's EMR lacked documentation that R5 refused to wear her brace or palm pillow on the following dates: 11/06/23, 11/07/23, 11/08/23. On 11/06/23 at 07:48 AM R5 sat in a common area/TV lounge in her Broda (specialty wheelchair with the ability to tilt and recline) chair. Her right arm laid across her abdomen and her right hand was closed into a fist. She did not have a brace or palm cushion to her right hand. On 11/07/23 at 11:55 PM R5 was propelled by staff in her Broda chair to her room after she finished lunch. No brace or palm cushion were in place to her right hand. On 11/07/23 at 12:24 PM R5 rested in her room in bed. Her palm pillow was on the ledge of her window. R5 did not have a brace or palm pillow in place while she rested in bed. On 11/08/23 at 08:03 AM R5 rested in her room in bed. Her palm pillow was on the ledge of her window. On 11/08/23 at 09:42 AM Licensed Nurse (LN) H stated the facility has gone through several different kinds of braces/palm pillows for R5 and that hospice supplied them for her. She stated R5 should have the brace and/or palm pillow in place. LN H further stated if it was in R5's care plan to have the brace on at meals and the palm pillow in place when the brace was not on, then R5 should have them on per the care planned intervention. She stated even while in bed, R5's palm cushion should have been on. On 11/08/23 at 09:57 AM Certified Nurse Aide (CNA) M stated R5's palm pillow should in her had all the time, unless she was at meals, and she would then have a brace on her right hand. She stated even when R5 was in bed her palm pillow should have been in place. She stated if R5 refused to wear either the brace or palm pillow it would have been documented as a refusal in her chart. On 11/08/23 at 10:48 AM Administrative Nurse D stated the expectation was that R5's palm pillow should have been in place while her brace was not on. She stated if R5 refused then it would have been documented in R5's EMR. The facility provided Restorative Nursing Program policy dated 06/04/06, documented Restorative nursing focuses on achieving and maintain optimal physical, mental, and psychological functioning of the resident. A resident will be given appropriate treatment and services to maintain or improve his/her abilities. Each resident will be given individual attention in regard to restorative care. The facility failed to ensure R5's right hand palm cushion was applied as directed to prevent an avoidable reduction of ROM and/or mobility. This deficient practice left R5 at risk for further decline and decreased ROM.

The facility identified a census of 19 residents. The sample included nine residents. Based on observation, record review, and interview the facility failed to ensure Resident (R) 13 was assessed for the ability to safely self-administer medications. This deficient practice placed R13 at risk for unsafe medication administration and adverse side effects. Findings included: - The electronic medical record for R13 documented diagnoses of hypertension (HTN- elevated blood pressure), benign prostatic hyperplasia (BPH-non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency, and urinary tract infections), and dyspnea (difficulty breathing). The Annual Minimum Data Set (MDS) dated [DATE] for R13 documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. R13 was independent with activities of daily living (ADLs) but required supervision with locomotion off unit and dressing. R13 utilized the use of a cane when ambulating. The Quarterly MDS dated [DATE] for R13 documented a BIMS score of 15 which indicated intact cognition. R13 was independent with ADLs and required limited physical help to transfer only during bathing of one staff. The ADL Care Area Assessment (CAA) dated 03/29/23 for R13 documented R13 needed assistance with bathing. Assistance usually was provided with transfers to chair/bench and supervision. R13 participated with an exercise program. R13 was at risk for falls and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The Health and Wellness Care Plan last revised on 05/09/23 for R13 lacked staff direction for R13's safe self-administration of medications/ointments. R13's clinical record lacked evidence of a self-administration of medications assessment for R13. On 11/06/23 at 09:15 AM observation revealed a container of Vicks VapoRub (a topical ointment with medicated vapors used to help relieve cough) on R13's nightstand beside his bed. R13 stated he has had the Vicks since he had been ill with COVID-19 (highly contagious respiratory virus) recently. R13 stated he did not believe that the nursing staff was aware he had it. R13 stated he put the Vicks on at night before he went to bed. On 11/07/23 at 02:25 PM Licensed Nurse (LN) G stated she was not aware that R13 had the container of Vicks in his room but did recall that R13 had smelled of the Vicks the other morning when she went into his room. LN G stated typically residents had to be assessed for safe self-administration of medications. LN G stated she would fax the physician and the assessment would be completed on R13 for self-administration of medications. On 11/08/23 at 10:48 AM Administrative Nurse D stated that any resident that self-administers or keeps medications and/or ointments in their room must be assessed for safe self-administration. Administrative Nurse D stated a physician order was also needed with the level of supervision needed and the self-administration would be added to the care plan. Administrative Nurse D stated staff was not made aware that R13 had the Vicks VapoRub in his room. The facility policy Self-Administration of Medication by Resident revised February 2020 documented: Each resident who desires to self-administer medications was permitted to do so if the facility's interdisciplinary team had determined that the practice would be safe for the resident and other residents of the facility. If a resident expressed the wish to self-administer his or her medications during the routing assessment, an assessment will be completed. Bedside medication storage was permitted only when it did not present a risk to confused residents who wander into rooms of or room with residents who self-administer. If medication is over the counter and the frequency was as needed. Medication will be managed by the resident in his/her room. The facility failed to ensure R13 was assessed for his ability to safely self-administer medications. This deficient practice placed R13 at risk for adverse side effects and unsafe medication administration.

The facility identified a census of 18 residents, with 8 residents included in the sample. Four residents were sampled for accidents. Based on observation, record review, and interview, the facility failed to ensure that a Hoyer lift (a mechanical device used to assist in transferring a resident) full body sling strap (a fabric device used to help suspend and attach to the Hoyer lift when transferring a resident) was fully inserted and clasped into the hook on the lift arm of the Hoyer lift. As a result, Resident (R) 5 slipped from the sling and was lowered to the floor, which resulted in a fractured left ischial tuberosity (the curved bone that makes up the bottom of the pelvis). Findings included: - The Electronic Medical Record (EMR) for R5 documented diagnoses of [CONDITION(S)] (MS - a progressive disease of the nerve fibers of the brain and spinal cord), dementia with behavioral disturbances (a progressive mental disorder characterized by failing memory, confusion with behaviors of verbal and physical aggression), and mononeuropathy of the lower limb (damage to of nerves outside of the brain and spinal cord in the lower limb). The Annual Minimum Data Set (MDS) dated [DATE] documented R5 had a Brief Interview for Mental Status (BIMS) score of nine, which indicated moderately impaired cognition. She required extensive to total dependence of one to two staff for her activities of daily living (ADLs). She required total dependence of two staff for transfers. She had functional limited range of motion (ROM) impairment on both sides of her upper and lower extremities. She required the use of a wheelchair for mobility and had no history of falls since prior assessment. The Quarterly MDS dated [DATE] documented a BIMS score of 11, which indicated a moderately impaired cognition. She required extensive to total dependence of one to two staff for ADLs. She required total dependence on two staff for transfers. She had functional limitation ROM impairment of one side on her upper extremity and in both lower extremities. She required the use of a wheelchair for mobility and had no falls since the prior assessment. The ADLs Care Area Assessment (CAA) dated 10/06/21 documented R5 needed assistance with most ADLS and noted she had an unsteady transitional balance. Staff used a full body lift for transfers. R5 had very poor core strength and was unable to sit on a toilet. She had MS that had progressed to where she was unable to stand or walk. She was minimally able to use her upper body to help with cares, but required assistance. She participated with an exercise program that included ROM. R5 was at risk for further ADL decline, falls, contractures, and skin breakdown. The Falls CAA dated 10/06/21 documented R5 had an unsteady transitional balance. She had a Morse fall risk assessment on 09/21/21 with a score of 15, which indicated a low risk for falls. She had not walked for several years related to progression of MS. R5 transferred with a full body lift with the assistance of two and used a wheelchair for mobility. The Care Needs Care Plan for R5 documented a new intervention dated 02/28/22 to use a full body lift with assist of two for transfers. R5 always used a wheelchair for all mobility and required foot pedals. Staff were to assist R5 with wheelchair mobility. Transfers should be done using a Hoyer lift with the assistance of two. R5 was non-weight bearing to her left lower extremity. A Nurse Progress Note by Licensed Nurse (LN) H on 02/26/22 at 06:30 AM documented two Certified Nurse Aides (CNAs) were getting the resident up for her shower using the Hoyer lift. One of the upper straps of the lift sling slipped off during transfer. R5 slipped out of the sling and staff lowered her to the floor. R5 landed softly on her bottom and did not hit her head, per witness reports. LN H went to the room and assessed the resident. R5 reported slight pain to her left lower leg with no redness noted, though a reddened area was noted to her mid/upper back at that time. R5 was alert and oriented to person and place and could not rate her pain to the lower left leg. R5 denied any other pain at that time. Staff obtained vital signs which were within normal limits. R5 had equal grips, and her pupils were reactive. No other injuries were noted. Staff assisted R5 to the shower chair with the Hoyer lift with the assistance of two CNAs and the nurse. Staff sent a fax to the clinic to notify the provider. Staff notified R5's representative who had no questions/concerns. A Nursing Note dated 02/28/22 at 08:18 AM documented R5 continued to complain of pain to the left leg with movement. Staff requested and received an order for an x-ray of the left hip and left knee. A Radiology Report dated 02/28/22 at 09:13 AM documented the following impression: Suspect left inferior pubis ramus (a part of the pelvis) or posterior acetabular wall (the back part of your hip) fracture. Consider a computerized tomography scan (CT-a series of x-ray images taken from different angles around a body part) to confirm. A CT scan of the pelvis result dated 02/28/22 at 3:29 PM documented an impression of an acute left ischial tuberosity fracture. A Nursing Note dated 02/28/22 at 04:16 PM documented R5 returned to the facility with new orders for non-weight bearing status on the left lower extremity. The order directed staff may use the Hoyer lift if there was no undue stress/pressure on the pelvis and further ordered a consult with orthopedics (bone specialists) on 03/01/22. The Investigation Report documented on 02/26/22 at 06:30 AM, CNA M and CNA N transferred R5 from her bed to her shower chair. R5 had MS, was non-weight bearing, and always used a Hoyer lift for transfers. The CNA's lifted R5 from the bed in the sling and moved the lift away from the bed towards the wheelchair. CNA N pushed the lift and CNA M guided the sling. At that time, the left top strap of the sling slipped off, which caused the resident to fall/slide out of the sling. CNA M supported R5's upper body and prevented her head from hitting the floor while CNA N supported R5's lower extremities and lowered R5 as best they could. The legs of the lift had not been opened yet to straddle the wheelchair and R5 was lowered down onto the legs of the lift. R5 reported slight pain to her left lower leg upon assessment. The assessment revealed a reddened area to R5's mid/upper back. A Witness Statement from CNA M dated 02/26/22 documented R5 slipped out of the sling and was lowered to the floor by staff. CNA M wrote one of the hooks on the Hoyer lift came off. A Witness Statement from CNA N dated 02/26/22 documented the incident occurred in the middle of R5's room. CNA N stated staff transferred R5 and one of the slings straps came off (left top strap) of the hook. The resident slid out of the sling and staff held R5's head and lowered her to the floor. The facility provided a Post-Accident Interventions and Actions report which recorded the sling was not adequately rested in the sling cradle. On 03/21/22 at 09:22 AM R5 stated she was doing okay. She only had occasional pain when being transferred in the lift. On 03/22/22 at 07:15 AM R5 sat in her high-back wheelchair and had the Hoyer lift sling underneath her. Her wheelchair was at the dining table and staff assisted R5 to eat breakfast. On 03/23/22 CNA M and CNA N were unavailable for interview. On 03/23/22 at 11:04 AM CNA O stated there should always be two people assisting when doing transfers with the Hoyer lift. Both staff members should make sure that the sling straps are hooked onto the tabs/hooks. One of the staff members stays with the resident in the sling while the other staff member operated the lift. Staff members received training and were checked off on lift use when hired and annually. CNA O stated she knew there had been an incident with R5, but she was not working at that time. The facility obtained a new sling for R5. CNA O stated she was responsible for the cleaning and checking the lifts weekly to ensure they worked properly. On 03/23/22 at 10:46 AM LN G stated before the Hoyer lift could be used for a resident, the resident had to be assessed by therapy. Staff members were required to do skills training upon being hired and annually for use of the lifts. Any lift transfer required the assistance of two staff members. LN G would expect the CNA's to immediately report if a sling or lift was not operating properly. On 03/23/22 at 10:39 AM Administrative Nurse D stated new slings were ordered for R5 and she was using a different one than when the incident on 02/26/22 occurred. She stated she would expect when staff members transferred any resident in a lift that two people would assist the resident. Staff were checked off on lift use upon being hired as well as annually. On 03/23/22 at 10:40 AM Administrative Staff A stated that after an investigation it was hard to determine what the cause of the incident was other than that the staff members did not ensure that the sling strap was securely attached to the lift arm before the resident was moved. The facility policy Safe Patient Handling last reviewed February 2020 documented: Purpose- to provide caregivers with guidelines to assess and make decisions about the lifting and transferring methods required for residents weighing over 15.9 kilograms (35 pounds). Assistive devices-when using a mechanical lift, follow guidelines- staff will complete the lift training on hire, yearly, and as needed. This is to ensure that all staff is continuing to lift and use the lift properly. The facility failed to ensure the safe transfer of R5 with the use of a Hoyer lift and sling when staff members failed to ensure the sling strap was securely latched/attached to the lift arm hook/clasp. This deficient practice resulted in an avoidable accident when R5 slipped out of a mechanical lift sling, which resulted in a fracture to R5's left ischial tuberosity. On 03/02/22 the facility completed the following corrective actions: Staff were educated on being aware of the sling and resting it in the cradle and to double check all sling areas that was attached to the lift. Education that was done was as follows: Hoyer type lift competency checklist; All slings and lifts were inspected weekly; All staff to inspect the lift and slings at each use; All staff watched the instructional video for the lift. The facility ordered four new slings to test which ones gave the most security to the sling in the cradle. The facility reviewed the incident at the Quality Assurance Performance Improvement (QAPI) meeting. Education and any issues with the lift/staff/education/condition will be reviewed quarterly for three quarters and then annual thereafter. The deficient practice was cited at past non-compliance.

The facility identified a census of 21. The sample included 13 residents. Based on observations, record review, and interviews, the facility failed to maintain adequate infection control practices and hand hygiene during meal service, failed to disinfect Hoyer lift (total body mechanical lift used to transfer residents) and sit-to-stand lift (lift designed to assist resident from sitting to standing position for transfers) between resident use, failed to transport soiled linens in a sanitary manner to soiled utility room, and failed to perform hand hygiene between donning (put on) and doffing (take off) gloves during foley catheter (tube inserted into the bladder to drain urine into a collection bag) care for Resident (R) 14. Findings included: - An observation on 03/02/21 at 11:41 AM revealed Dietary Staff BB wore gloves and delivered lunch plate to a female resident. He touched resident's shoulder with gloved hand and table with the other gloved hand. He then proceed to another table and touched a male resident's shoulder and table with gloved hands then went to front of the steam tables where he touched the top of steam table to obtain male resident's plate and delivered it to him where he touched his shoulder again with same gloved hand. No hand hygiene or donning/doffing of gloves observed between resident contact or after contact with potentially contaminated surfaces observed. An observation on 03/02/21 at 11:44 AM revealed Dietary Staff BB wore same gloves as above observation and walked into kitchen to grab tray of dessert from fridge. He wore same gloves and delivered two desserts to two female residents. He proceeded to another table and touched a female resident's walker and table with gloved hands then walked into kitchen again then back out to steam table where he leaned with gloved hands on top of steam table while he waited for plate. He delivered plate to another female resident and touched her wheelchair and table with gloved hands. No hand hygiene or donning/doffing of gloves observed between resident contact or after contact with potentially contaminated surfaces observed. An observation on 03/02/21 at 11:47 AM revealed Dietary Staff BB wore same gloves as above observations and proceeded to another female resident where he touched her wheelchair and table, he then leaned against top of steam table with gloved hands while he waited for plate then delivered plate to resident. He proceeded to kitchen while he wore same gloves and grabbed two desserts which he delivered to one male and one female resident. No hand hygiene or donning/doffing of gloves observed between resident contact or after contact with potentially contaminated surfaces observed. An observation on 03/02/21 at 11:49 AM revealed Dietary Staff BB wore same gloves as above observations and leaned against top of steam table with gloved hands while waited for a plate which he delivered to a female resident, he then walked into kitchen to obtain a dessert which he delivered to same female resident. No hand hygiene or donning/doffing of gloves between resident contact or after contact with potentially contaminated surfaces observed. An observation on 03/02/21 at 11:51 AM revealed Dietary BB wore same gloves as above observations and touched the wheelchair of a female resident, he then leaned on top of the steam table with gloved hands. He then reached around behind the steam table to grab a pureed lunch plate which he then delivered to another female resident. No hand hygiene or donning/doffing of gloves between resident contact or after contact with potentially contaminated surfaces observed. An observation on 03/02/21 at 11:52 AM revealed Dietary Staff BB wore same gloves as above observations and leaned on a female resident's table with gloved hands. He then pushed open kitchen doors with gloved hands and proceeded into kitchen where he grabbed a container out of the fridge. He grabbed a serving utensil and transferred fruit cocktail from container into a bowl. He returned container to fridge and grabbed bowl of fruit cocktail with gloved hands. He left kitchen and wore same gloves as previously observed. No hand hygiene or donning/doffing of gloves between resident contact or after contact with potentially contaminated surfaces observed. An observation on 03/04/21 at 08:32 AM revealed two unidentified nursing staff brought a Hoyer lift to the common area to assist a resident from wheelchair to a recliner. After using the lift, nursing staff returned the lift to the storage room without sanitizing the lift. An observation on 03/04/21 at 08:38 AM revealed Certified Nurse Aide (CNA) M donned gloves in R14's room. She changed R14's socks then doffed gloves. No hand hygiene performed. She donned new gloves and replaced R14's dependent drainage foley catheter night bag with dependent drainage foley catheter leg bag. Nursing staff then doffed gloves, donned new gloves, and assisted R14 with dressing. Staff transferred R14 with sit-to-stand lift then moved lift to another resident's room without disinfecting lift. An observation on 03/04/21 at 09:51 AM revealed CNA M carried soiled linen unbagged to soiled linen room. She then proceeded to clean linen room and carried clean linens down the hall, no hand hygiene was observed. In an interview on 03/02/21 at 11:56 AM, Dietary Staff BB stated he changed his gloves when he needed to. He stated he washed his hands before he started serving and after serving was completed. He stated he did not touch anything when serving that would need him to change his gloves or perform hand hygiene. In an interview on 03/04/21 at 08:24 AM, Dietary Staff CC stated she expected staff to perform hand hygiene anytime they touched a plate, a door handle, or a resident. In an interview on 03/04/21 at 09:55 AM, Certified Medication Aide (CMA) R stated lifts were disinfected between each resident and staff washed hands between donning and doffing gloves. In an interview on 03/04/21 at 10:08 AM, CNA N stated the lifts were sanitized before and after each use. In an interview on 03/04/21 at 10:12 AM, CNA M stated soiled linen was placed in a bag then taken to soiled utility room and hand hygiene was performed after completed. In an interview on 03/04/21 at 10:53 AM, Licensed Nurse (LN) H stated soiled linen was placed in a bag then placed in soiled utility room, but it was always bagged. In an interview on 03/04/21 at 11:11 AM, Administrative Nurse D stated she expected staff to wash hands when visibly soiled and perform hand hygiene before and after contact with residents and before and after donning/doffing gloves. She expected staff to sanitize mechanical lifts before and after each use. She expected staff to transport soiled linens in a bag to soiled utility room. In an interview on 03/04/21 at 11:32 AM, Administrative Staff A stated she expected meal serving staff to perform hand hygiene if they touched anything besides just the clean the plate between residents. The facility's Infection Control policy last revised 11/21/16 directed soiled linen was placed in an impervious bag of sufficient strength to contain wet/soiled linen and reusable equipment was cleaned between each resident use according to manufacturer's instructions. The facility's Hand Hygiene policy last revised May 2017 directed staff decontaminated hands before direct contact with residents, after removing gloves, and after contact with inanimate objects in the immediate vicinity of the resident. The facility's Infection Control during Food Preparation policy last revised 03/07/18 directed proper hand washing procedures were followed. The facility failed to ensure adequate infection control practices and hand hygiene during meal service, disinfection of mechanical lifts between resident usage, sanitary transportation of soiled linens to soiled utility room, and hand hygiene between donning/doffing gloves during foley catheter care. These deficient practices had the risk to spread infection and illness to all residents.

The facility identified a census of 21 residents. The sample included 13 residents. Based on observation, record review, and interviews, the facility failed to clearly identify the expressed choices to initiate or withhold resuscitative measures (restoration to life or consciousness of one apparently dead, or whose respirations had ceased) by maintaining a Do Not Resuscitate (DNR) (an order to withhold resuscitative measures) advance directive for Resident (R) 18. Findings included: - R18's electronic medical record (EMR) from the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 12 which indicated moderately impaired cognition. The MDS documented R18 required extensive assistance of one staff member for Activities of Daily Living (ADL). The Quarterly MDS dated [DATE] documented a BIMS score of 10 which indicated moderately impaired cognition. The MDS documented R18 required extensive assistance of one staff member for ADL's. The ADL Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 03/26/29 documented R18 needed assistance with most ADL's. R18's Care Plan with a revision date of 09/20/20 documented her code status was DNR. R18's EMR revealed a signed DNR under MISC tab. R18's EMR lacked a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 03/03/21 at 10:22 AM R18 sat on a chair, in the common area, with her walker in front of her as she listened to music. R18's name plate on her room lacked a circle with a line thru it. On 03/03/21 at 04:16 PM Licensed Nurse (LN) G stated a resident's code status was known by a circle with a line thru it on their name plate which indicated a DNR and nothing on the name plate indicated the resident was a full code. LN G stated that code status was listed under the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LN G was unable to locate R18's code status from the EMR under the Orders tab or from the PCC under face sheet. On 03/04/21 at 09:55 AM Certified Medication Aide (CMA) R stated a resident's code status was found on the medication administrative record (MAR) and in the EMR under the name on the face sheet. On 03/04/21 at 11:11 AM Administrative Nurse D stated a resident's code status was located on the care plan, on the name plate outside the room if a resident had chosen to be a DNR it would have a circle with a line thru the circle, and in PCC. The Advanced Care Planning Rights facility policy with revision date of 11/17 documented that it was a process used to identify and update the resident's preference regarding care and treatment. The facility failed to maintain a way for documentation and communication of R18's choice of DNR, which put her at risk of facility staff not being aware of her chosen advance directives and rights.

The facility identified a census of 21 residents. The sample include 13 residents. Three residents were sampled for beneficiary notification. Based on record review and interviews, the facility failed to follow-up with receipt and acknowledgment of notices for Medicare non-coverage that were sent to resident family/Durable Power of Attorney (DPOA- document that designated a person who made health care decisions for resident if they were no longer able to make their own decisions) for Resident (R) 4 and R171. Findings included: - Review of the Medicare Liability Notice, CMS 3- Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) indicated skilled services ended on 12/29/2020 for R4. Facility indicated on top of NOMNC form that NOMNC and SNF ABN were sent on 12/22/20 to R4's family/DPOA. Neither NOMNC or SNF ABN were returned signed to the facility and were not followed up with by facility for receipt or acknowledgement of notice. Review of the Medicare Liability Notice, CMS 3- Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) indicated skilled services ended on 11/04/2020 for R171. Facility indicated on top of NOMNC form that NOMNC and SNF ABN were sent on 10/29/20 to R171's family/DPOA. Neither NOMNC or SNF ABN were returned signed to the facility and were not followed up with by facility for receipt or acknowledgement of notice. In an interview on 03/02/21 at 01:10 PM, Administrative Staff A stated R4 and R171's NOMNC and SNF ABN notices were sent to the residents' families but were not returned signed and no follow-up was completed for acknowledgement of notices. In an interview on 03/04/21 at 09:52 AM, Administrative Staff B stated when the non-coverage notices were sent out and not returned signed, she called the resident's family to follow-up and encouraged them to sign the notices and return them to facility. In an interview on 03/04/21 at 11:29 AM, Administrative Staff A stated she expected that the non-coverage notices were sent out and returned as requested. If the notices were not returned, she expected a phone call to follow up. The facility's Medicare Coverage and Therapy policy last revised 09/21/11 directed administrative assistant sent paperwork to the family/DPOA to sign for admission and discharge to Medicare Part A. The policy directed the family/resident was given 72-hour notice prior to being discharged from Medicare Part A. The facility failed to follow-up with receipt and acknowledgment of notice for Medicare non-coverage and beneficiary notification that was sent to resident family/DPOA for R4 and R171 which had the potential for miscommunication between resident/resident family and facility and potential for missed skilled services and unanticipated charges.

The facility identified a census of 21 residents. The sample included 13 residents. Five residents were sampled for unnecessary medication review. Based on observation, record review, and interviews, the facility failed to follow the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings included: - The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented that R10 required extensive assistance with one staff member for Activities of Daily Living (ADL's). The Quarterly MDS dated [DATE] documented a BIMS score of 15 which indicated intact cognition. The MDS documented that R10 required limited assistance with one staff member for ADL's. The MDS documented that R10 had received diuretic (medication to promote the formation and excretion of urine) medication for seven days during the look back period. The ADL Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 06/21/20 documented that R10 needed assistance with most ADL's. The Care Plan dated 06/08/20 directed staff to administer medications ordered and to monitor for side effects for R10. The Orders tab of R10's EMR documented an order with a start date of 06/16/20 for [MEDICATION(S)] (antihypertensive medication) 25 milligram (mg) one tablet twice a day related to hypertension, the order directed nursing staff to notify physician if systolic blood pressure (SBP- the pressure of the blood against artery walls as the heart beats) is less than 100 millimeters of mercury (mmHg) or greater than 170 mmHg. The Orders tab documented an order with a start date of 12/08/20 for [MEDICATION(S)] (antihypertensive medication) 0.1 mg daily every 24 hours as needed (PRN) for SBP greater than 180 mmHg. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . There were two occurrences in December 2020 when SBP was greater than 180 mmHg and PRN [MEDICATION(S)] was not given as ordered and seven occurrences in December 2020 when SBP was greater than 170 mmHg and EMR lacked documentation of physician notification. There were five occurrences in January 2021 when SBP was greater than 180 mmHg and PRN [MEDICATION(S)] was not given as ordered and seven occurrences in January 2021 when SBP was greater than 170 mmHg and EMR lacked documentation of physician notification. There were five occurrences in February 2021 where SBP was greater than 180 mmHg and PRN [MEDICATION(S)] was not given as ordered and nine occurrences in February 2021 where SBP was greater than 170 mmHg and EMR lacked documentation of physician notification. In an observation on 03/04/21 at 07:41 AM R10 ambulated with facility staff in the hallway to the dining room for breakfast. In an interview on 03/03/21 at 04:16 PM Licensed Nurse (LN) G stated that the Certified Medication Aides (CMA) obtained the vital signs before they administered the medication. She stated the CMA was to notify the nurse if a blood pressure was out of the parameters ordered by the physician. LN G stated that physician notification would have been documented in the EMR under Progress Notes. In an interview on 03/04/21 at 09:55 AM CMA R stated that she notified the nurse when SBP was out of parameters for R10. CMA R stated that she had not given any PRN [MEDICATION(S)] without instructions from the nurse. In an interview on 03/04/21 at 11:11 AM Administrative Nurse D stated that the CMA obtained the vital signs and notified the nurse of any blood pressure readings outside of physician ordered parameters. The Prescribed Medication Orders facility policy with revision date of 05/19 documented that a PRN order must specify the condition which they are to be administered. The facility failed to ensure that the physician was notified when SBP was outside parameters as ordered by physician and failed to administer PRN antihypertensive medication as ordered. This deficient practice had the potential for unnecessary medication use and unwarranted side effects.

Based on observation, interviews, record review and policy review the facility failed to assure staff followed infection control policies related to transmission-based precautions, to prevent the spread of infections for one of five residents, (R)1, observed for infection control practices. A Certified Nurse Aide (CNA)1 cared for a COVID-19 ([MEDICAL CONDITION]) suspect resident in isolation, (R1), without wearing the appropriate personal protective equipment (PPE). This deficient practice had the potential to spread infections to other residents in the facility. The facility census was 29. Findings Include: Review of a Progress Note, dated 06/25/20 at 8:10 PM, found in the electronic medical record (EMR) under the Progress Note tab, showed that R1 did not feel well and reported she had chills, a cough, and a low-grade temperature of 99.7 degrees Fahrenheit (F). The nurse documented the resident had wheezing in the bilateral upper lobes and crackles (abnormal lung sounds) in the bilateral lower lobes. Review of another Progress Note, dated 06/26/20 at 11:19 AM, found in the EMR under the Progress Note tab, showed a COVID-19 test was performed and the resident would remain in isolation pending results of the test. During an observation on 06/29/20 at 9:43 AM, the door of R1's room had an isolation sign prominently displayed. The sign posted ISOLATION: PPE REQUIRED: MASK (NOT THE SAME ONE YOU ARE USING IN THE FACILITY), GOWN, SAFETY GLASSES, GLOVES. CNA1 was in R1's room at the bedside table adjacent to the resident's bed. CNA1 was not wearing a gown or goggles, as directed by the sign posted on the resident's door. The aide was wearing a blue surgical mask and gloves. When CNA1 exited the resident's room, she discarded the gloves and used alcohol-based hand rub. During an interview on 06/29/20 at 9:48 AM, CNA1 stated that she went into R1's room to give her some string and initially had a gown on, which she hung up in the resident's room; however, R1 called her back into the room. She said she went over to the bedside to give her the item that she wanted and slid it across the bedside table, without making any contact, and left the room. CNA1 said she was aware the resident was on isolation precautions, which required the use of a mask, gown, goggles and gloves in the resident's room. During an interview on 06/29/20 at 3:20 PM, Director of Nursing (DON), responsible for the Infection Prevention and Control (IPC) program, stated that R1 was on isolation for new respiratory symptoms. The DON revealed a COVID test was obtained, and the results were pending. She said staff were expected to wear full PPE when they provided care to R1. The DON stated that it was not okay for CNA1 to return to the resident's bedside and provide care without donning (putting on) a mask, goggles or gloves. She stated all staff were trained months ago, when the pandemic was issued on COVID infection control and were required to pass competencies on donning and doffing (taking off) PPE. Review of the facility's policy titled, Novel Coronovirus (Covid 19), dated 03/31/20, noted for isolation precautions .staff will follow full PPE precautions for airborne agents when in the room at all times including gown, gloves, eye protection, face covering, surgical mask.

The facility identified a census of 29 with one kitchen and one main dining room. Based on observation, record review and interview, the facility failed to ensure proper sanitation and food handling practices. Findings included: - An observation on 06/19/19 at 10:32 revealed dietary staff DD, who had full facial hair, handling food in the kitchen without a proper beard guard. An observation on 06/19/19 at 10:51 AM of dietary staff DD tested the Quat sanitizer solution (a surfactant cleaning chemical that is typically used in hospitals and food processing plants) in the bucket at the food prep counter and in the bucket at dishwashing station. Both solutions tested below 100ppm (parts per million). An observation on 06/19/19 at 4:27 PM revealed dietary staff DD in the dining room setting up the food for supper without a beard guard. An interview on 06/19/19 at 10:51 AM with dietary staff CC stated they do not routinely test or keep logs of the concentration of the sanitizing solution. Dietary staff CC stated the sanitizing solution in the buckets was used to wipe down kitchen counters and dining room tables, and the solution was changed every 4-6 hours. An interview on 06/20/19 at 1:19 PM with dietary staff DD stated beard guards were not available for use within the facility and was not informed that a beard restraint was required. An interview on 06/20/19 at 1:23 PM with dietary staff BB stated he/she was unaware of the requirement for beard guards for dietary staff. Dietary staff BB stated the sanitizing solution in the buckets was used directly from the sanitizer pump, undiluted, and the solution in buckets were changed after each meal or every 4-5 hours. Dietary staff BB stated that nobody tested the sanitizer in the buckets and there were no logs of monitoring the sanitizing solution. An interview on 06/20/19 at 02:08 PM with administrative nursing staff D and administrative staff A stated that dietary staff who have a beard or facial hair should wear a beard guard. Administrative staff A stated the facility did not monitor concentrations of the sanitizing solution and they did not have a policy for monitoring the sanitizing solution. The facility's infection control policy for cleaning and maintenance, last revised on 09/27/16, documented the Quat sanitizing solution should be 200-400ppm while in use. The policy stated the sanitizing solution was used to sanitize food carts, dining room tables and chairs, microwaves, the ice machine, stainless steel, food utility carts, all counters and all sinks. The facility did not provide a policy regarding the use of hair nets or beard restraints. The facility failed to ensure proper sanitation and food handling practices.

The facility identified a census of 29 residents, 1 medication cart, 1 treatment cart, 1 medication storage drawer in the secured unit and 1 medication storage room in the main unit. Based on observations, and interviews the facility failed to properly label and store Findings included: - On 6/17/19 at 8:00 AM the medication cart contained 1 [MEDICATION NAME] inhaler (medication used to treat asthma (disorder of narrowed airways that caused wheezing and shortness of breath) and [MEDICAL CONDITION] ([MEDICAL CONDITION]- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing) and 1 Stiolto Respimat inhaler (medication to treat [MEDICAL CONDITION]) opened and undated. On 6/17/19 at 8:07 AM the main unit medication storage room contained 1 bottle of Alaway eye drops (medication to treat itchy eyes) with an expiration date of (MONTH) 2019, 2 bottles of B-12 (dietary supplement) and a box of [MEDICATION NAME] (dietary supplement) with expiration date of (MONTH) 2019. On 6/18/19 at 3:52 PM the medication storage drawer in the secured unit contained 1 bottle of [MEDICATION NAME] (medication to treat diarrhea) with an expiration dated on (MONTH) (YEAR) and a bottle of [MEDICATION NAME] (medication to treat indigestion) with an expiration date of (MONTH) (YEAR). According to www.azpicenteral.com/[MEDICATION NAME] the inhalers are to be discarded within 3 months after removing from the foil pouch. According to https://docs.boehringer-[MEDICATION NAME].com the Stiolto Respimat inhalers are to be discarded 3 months after insertion of the cartridge or when inhaler are locked or when they expire which-ever comes first. On 6/17/19 at 8:05 AM licensed staff G stated he/she dated inhalers after opening them and verified the [MEDICATION NAME] and Stiolto Respimat inhalers were opened and undated. On 6/17/19 at 8:21 AM licensed staff H verified the expired meds in the main unit medication storage room. He/she stated the nurses administering medications check for the expiration dates. On 6/20/19 at 2:07 PM administrative staff D stated the nurses check the medications for expiration dates on the weekend shifts. He/she expected the nurses to date respiratory inhalers after opening them. The facility's Medication Storage and Management policy dated (MONTH) (YEAR) documented medications and biological are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The facility failed to properly label medication and dispose of expired medications according the manufacturer's recommendations, which could potentially cause adverse consequences or ineffective treatment to the residents.

The facility identified a census of 29 residents. The sample included 21 residents. Based on observations, interviews, and record reviews; the facility failed to complete accurate Minimum Data Set (MDS) assessments for 1 resident sampled for hospice services, and 1 (#27) of 4 residents sampled for accidents. Findings included: - The Electronic Medical Record (EMR) for resident #4 documented [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] documented 12/19/18 documented a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment. The MDS indicated the resident was on hospice yet did not indicate the resident had 6 months or less to live. The annual MDS dated [DATE] documented a BIMS score of 9, which indicated moderately impaired cognition. The MDS indicated the resident was on hospice services yet did not indicate the resident had 6 months or less to live. The cognition Care Area Assessment (CAA) dated 3/30/19 documented the resident answered questions and required facility staff assistance for his/her cares. The resident admitted to hospice services for late stage dementia. The hospice care plan dated 3/23/19 documented the facility staff worked cooperatively with the hospice team to ensure the resident's spiritual, emotional, intellectual, physical, and social needs were met. The resident's hospice communication book contained a recertification statement, signed by the physician, which indicated the resident had 6 months or less to live dated 3/18/19 through 5/16/19. On 6/17/19 at 4:20 PM the resident sat in his/her wheelchair, near the nurse's station. His/her body positioning appeared comfortable, with no non-verbal signs of pain noted. On 6/20/19 at 2:07 PM administrative staff D stated information for the MDS assessments are gleaned from the resident's medical records. He/she assists the MDS coordinator with assessments at times but did not realize the omission of this assessment. The facility's Comprehensive Assessment Policy Including the MDS and CAAs dated 2/2019 documented the facility conducted initial and periodic comprehensive, accurate, standardized, reproducible assessment of each resident's function capacity. The team members used a variety of methods in addition to the Resident Assessment Instrument (RAI) to collect information about the resident as a unique individual. The facility failed to develop an accurate MDS assessment which indicated 6 months or less to live for this resident (#4) on hospice services. - The Electronic Medical Record (EMR) for resident #27 documented [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 2, which indicated severely impaired cognition. The resident required limited to extensive staff assistance with his/her Activities of Daily Living (ADLs). The resident did not sustain any falls since the prior assessment. The quarterly MDS dated [DATE] documented a BIMS score of 0, which indicated severely impaired cognition. The resident required supervision to extensive staff assistance with his/her ADLs. The resident sustained [REDACTED]. The fall Care Area assessment dated [DATE] documented the resident had and unsteady transitional balance and was at high risk for falls. The resident's fall care plan dated 3/4/18 documented the resident was unaware of his/her safety needs and had gait and balance problems. A nursing progress note dated 8/4/18 documented the resident fell in the shower room sustaining scrapes to his/her buttocks and left side of his/her back. On 6/18/19 at 7:25 AM the resident sat in his/her wheelchair eating breakfast without difficulty. On 6/20/19 at 2:07 PM administrative staff D stated information for the MDS assessments are gleaned from the resident's medical records. He/she assists the MDS coordinator with assessments at times but did not realize the omission in this assessment. The facility's Comprehensive Assessment Policy Including the MDS and CAAs dated 2/2019 documented the facility conducted initial and periodic comprehensive, accurate, standardized, reproducible assessment of each resident's function capacity. The team members used a variety of methods in addition to the Resident Assessment Instrument (RAI) to collect information about the resident as a unique individual. The facility failed to develop an accurate MDS assessment for this resident (#27) sustaining 1 fall prior to the annual assessment.

The facility had a census of 28 residents. The sample included 14 residents. Based upon observation, record review, and interviews the facility failed to promote the healing of a pressure ulcer for 1 (#34) of 2 residents sampled for pressure ulcers. Findings included: - A hospital's discharge summary for resident #34 dated 9/5/13 included the resident developed a blister (small pocket of fluid within the upper layers of the skin) on the back of his/her right heel. The resident did not develop any subsequent complications associated with it and the resident was discharged to the facility. The resident's admission nursing assessment dated [DATE] documented the resident had a red scab on his/her right heel. The assessment did not include documentation regarding the status of the resident's left heel. The admission Minimum Data Set (MDS) 3.0 dated 9/13/13 identified the resident scored 15 (cognition intact) on the Brief Interview for Mental Status, did not have behaviors, was independent with bed mobility, transfers, walking in the room/corridor, locomotion on/off unit, dressing, eating, toilet use, and personal hygiene. The MDS recorded the resident did not use mobility devices, was always continent of bowel and bladder, weighed 129 pounds and did not experience a weight loss. The MDS coded the resident did not have a Stage 1 or greater pressure ulcer, was at risk for the development of pressure ulcers, did not have a pressure relieving device on his/her bed or chair, and was not on a turning/repositioning program. The resident's Activities of Daily Living Care Area Assessment (CAA) dated 9/17/13 included the resident had a [DIAGNOSES REDACTED]. The resident's Pressure Ulcer CAA dated 9/17/13 identified the resident was at risk for the development of pressure ulcers. He/she scored 20 on the Braden Scale (scale used to predict the development of pressure ulcers) which indicated the resident was at low risk. The CAA included the resident had a [DIAGNOSES REDACTED]. The CAA documented the resident did not have pressure ulcers or other skin issues, the facility would develop a care plan for staff to encourage the resident to move about and change positions frequently and staff would encourage good nutritional intake including a supplement. The resident's care plan dated 9/26/13 addressed the resident walked independently without assistive device, was independent with transfers and bed mobility, was continent of bowel and bladder, ate a mechanical soft diet and received Ensure (a nutritional supplement that provided extra protein, vitamins and minerals) three times a day. Review of the resident's care plan on 12/9/13 at 10:20 A.M. revealed the resident's care plan did not address the resident was at risk for the development of pressure ulcers nor did it address the resident had a Stage 3 pressure ulcer on his/her left heel. The care plan did not include interventions for pressure ulcer prevention/healing. The resident's care plan did not support the facility educated and/or explained the risk and benefits of relieving pressure on his/her heels. The care plan also did not support the facility discussed alternate shoe wear for the resident to wear during the day. The resident's alteration in skin integrity sheets included staff provided the pressure ulcer treatment as physician ordered, monitored the wound for signs/symptoms of infections, and staff notified the resident's physician if the wound did not show signs of healing. The skin integrity sheets did not include interventions for the prevention/healing of the pressure ulcer. The resident's alteration in skin integrity sheets dated 10/3/13 documented the resident's left heel had a hematoma (localized collection of blood outside the blood vessels) that measured approximately the size of a nickel to a quarter. The resident's clinical record lacked skin integrity sheets from 9/5/13 to 10/3/13. A physician's progress note dated 10/3/13 documented the resident's heels bilaterally had dark purplish Stage 2 pressure ulcers. The pressure ulcer on the resident's left heel measured 4.5 centimeters (cm). The pressure ulcer was not open. A physician's progress note dated 10/7/13 documented the resident had skin breakdown on his/her heels. The resident reported he/she rubbed his/her heels on the bedding and thought these changes worsened by shearing (an applied force or pressure exerted against the surface and layers of the skin as tissues slide in opposite but parallel planes) of the sheets. During the day when the resident was up, he/she insisted on having his/her shoes in place and the resident was ambulatory. The resident's left heel had a leaking [MEDICATION NAME] (outermost part of the skin) blister that measured 3.0 cm by 3.2 cm and macerated (softening of tissue) tissue noted beneath the dressing. The left heel was left with a blister. Staff would continue to encourage offloading (relieve pressure), the pressure ulcer was non-stageable but given it's location it was considered of pressure etiology. A physician's progress note dated 10/24/13 documented the resident's left heel experienced a presumed secondary infection and increased necrosis (dead tissue) with associate exduate (drainage) and malodor. A physician's progress note dated 10/28/13 documented the pressure ulcer on the resident's left heel measured 1.3 cm by 1.0 cm by 0.3 cm with brown slough (non-viable tissue) around the periphery. A physician's progress note dated 11/4/13 documented the resident was ambulatory, desired to wear his/her shoes during the day and was not compliant with the pressure reduction boots. The resident allowed staff to offload his/her feet with pillows when in bed. The resident's left heel had a Stage 3 pressure ulcer that measured 1.3 cm by 1.0 cm by 0.1 cm. A physician's progress note dated 11/18/13 documented the Stage 3 pressure ulcer on the resident's left heel measured 1.4 cm by 0.9 cm by 0.3 cm and the periphery of the pressure ulcer had approximately 30-40 percent (%) slough. A physician's progress note dated 12/2/13 documented the resident was ambulatory, desired to wear his/her shoes during the day and allowed staff to offload his/her heels with pillows when he/she was in bed. The Stage 3 pressure ulcer to the resident left heel measured 0.9 cm by 2.4 cm by 0.2 cm, the medial (inner aspect) margin was soft with tan slough measuring 0.9 cm by 0.9 cm. A laboratory report dated 10/3/13 recorded the resident's serum [MEDICATION NAME] (indicator of protein storage) as 3.4 grams/deciliter (g/dL), normal reference range 3.5-5.0 g/dL. The laboratory report recorded the resident's protein level at 6.4 g/dL, normal reference range 6.5-8.1 g/dL. A Registered Dietician's note dated 11/18/13 and timed 10:45 A.M. documented the resident had a pressure ulcer on his/her left heel, the dietician reviewed protein foods with him/her and encouraged the resident to eat them. The note included the resident currently received Ensure Plus three times a day with meals and consumed 100% of the supplement. . On 12/4/13 the resident laid on top of the bed on his/her back at 12:05 P.M., 12:20 P.M., 12:32 P.M., 12:45 P.M., 1:00 P.M., 1:10 P.M., and 1:15 P.M. Observation revealed the resident had shoes on and the resident's feet were not offloaded. On 12/4/13 at 1:20 P.M., 1:40 P.M., 1:55 P.M., 2:00 P.M., 2:15 P.M., 2:20 P.M., 2:30 P.M., 2:45 P.M., 3:00 P.M., 3:11 P.M., 3:15 P.M., and 3:30 P.M. the resident laid in bed on his/her back under the covers. Observation revealed the resident's heels were not offloaded and the resident's heel protector boots were on the other bed in the resident's room. The resident was the only resident who resided in the room. On 12/9/13 at 9:00 A.M., 9:15 A.M., 9:30 A.M., 9:39 A.M., 9:52 A.M., 10:03 A.M., 10:15 A.M., 10:25 A.M. and 10:38 A.M., the resident laid on top of the bed with his/her shoes on and the resident's feet were not offloaded. On 12/9/13 at 10:38 A.M. observation revealed the resident had a pressure relieving device on his/her bed. During interview with the resident at that time, the resident stated he/she had a pressure ulcer on his/her left heel. The resident stated at night when he/she was in bed, staff placed pillows under his/her feet and his/her heels did not touch the linens. The resident stated during the day staff did not offer to elevate his/her feet with pillows when he/she was in bed. The resident stated he/she wore shoes during the day because when he/she got up to go the the bathroom the floor was cold and the facility had not spoke with him/her regarding alternate footwear during the day. The resident stated he/she would allow staff to offload his/her feet during the day if offered. The resident stated he/she received Ensure at meals. On 12/9/13 at 10:51 A.M. the resident rose from the recliner in his/her room. Observation revealed the recliner did not have a pressure relieving device. On 12/9/13 at 11:00 A.M. the resident sat in the recliner in his/her room without a pressure relieving device. On 12/9/13 at 11:15 A.M. the resident ambulated independently to the dining room with shoes on. On 12/9/13 at 12:06 P.M., 12:15 P.M., 12:29 P.M., 12:35 P.M., 12:50 P.M., 1:03 P.M., 1:15 P.M., 1:30 P.M., 1:35 P.M. and 1:55 P.M. the resident laid on his/her back on top of the bed covers. Observation revealed the resident had shoes on and the resident's feet were not offloaded. On 12/9/13 at 4:18 P.M. licensed nurse I performed the treatment to the pressure ulcer on the resident's left heel. Observation revealed the Stage 3 pressure ulcer on the resident's left heel measured approximately 2 cm by 0.4 cm by 0.25 cm and the outer right edge had a small amount of slough. Licensed nurse I stated staff offloaded the resident's heels at night. On 12/10/13 at 8:00 A.M., 9:00 A.M., and 9:15 A.M. the resident laid in bed on his/her back. Observation revealed the resident had on shoes and the resident's feet were not offloaded. On 12/9/13 at approximately 1:40 P.M. health care provider Y stated the resident was admitted to the facility with bilateral heel pressure ulcers. Health care provider Y stated he/she debrided the pressure ulcers since the resident's admission to the facility. The pressure ulcer on the resident's right heel healed and the resident had a Stage 3 pressure ulcer on his/her left heel. Health care provider Y stated facility staff should offload the resident's feet even when the resident wore shoes in bed during the day. Health care provider Y stated the resident's [MEDICATION NAME] level was low and the resident received Ensure three times a day which should promote wound healing. On 12/9/13 at 2:20 P.M. direct care staff P stated the resident was mostly independent. Direct care staff P stated staff offloaded the resident's heels at night when the resident was in bed. Direct care staff P stated the facility communicated the resident's needs and care via the resident's care plan. On 12/10/13 at approximately 12:50 P.M. licensed nurse G stated upon admission, the resident's heels had a layer of dark area that resembled a bruise and the health care provider debrided the area after the resident's admission. The resident had a pressure ulcer on his/her left heel. Licensed nurse G stated the resident laid flat on his/her back when in bed, staff spoke to the resident about repositioning on his/her side and the resident was doing better with repositioning on his/her side. Licensed nurse G stated at night the resident wore heel protectors but during the day the resident wore shoes and socks when in bed. Licensed nurse G stated the facility communicated the resident's care via the resident's care plan. On 12/10/13 at 12:57 P.M. administrative nursing staff D stated upon admission the resident's left heel was red. Administrative nursing staff D stated the resident laid in bed flat on his/her back and the resident's feet were in direct contact with the bed spread. Staff encouraged the resident to wear heel protectors and staff offloaded the resident's feet with pillows but the resident eventually always went back on his/her back without his/her feet offloaded. Administrative nursing staff D stated staff should offload the resident's feet even when the resident wore the shoes in bed during the day. Administrative nursing staff D stated the resident's care plan should address the resident's pressure ulcer. On 12/10/13 at 1:09 P.M. administrative nursing staff D confirmed the resident's care plan did not address the resident pressure ulcer or interventions to promote healing and/or to prevent new pressure ulcers from developing. The facility's Skin protocol revised 12/11 included the facility developed a care plan for alteration in skin integrity, staff measured skin issues weekly and as needed and documented the measurements on the PUSH tool. Staff ensured residents utilized pillows and other devices to relieve pressure on bony prominence's. The facility failed to promote healing of the left heel pressure ulcer by offloading and educating the resident regarding the interventions to promote healing of the pressure ulcer. The facility acquired pressure ulcer progressed to a Stage 3.