Every finding on record at Friendship Village

Based on observation, interview, and record review the facility failed to 1. Implement enhanced barrier precautions related to wound care for 1 (Resident #4) of 3 residents reviewed for wound care and 2. Ensure the use of personal protective equipment during high contact care activities for a resident in enhanced barrier precautions for 1 (Resident #58) of 2 resident reviewed for the activities of daily living resulting in the potential for the spread of infection, cross contamination, and disease transmission.Findings include:Resident #4 Review of an admission Record revealed Resident #4 was a male who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: Cellulitis (a bacterial infection in the skin) of the groin, pressure ulcer of the unspecified buttock Stage 2 (an injury/wound to the skin and/or underlying tissues that was a result of prolonged pressure to the skin area), and type 2 diabetes (a chronic condition that includes insulin resistance and high blood sugars). Review of a Minimum Data Set (MDS) assessment for Resident #4, with a reference date of 3/16/26 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #4 was cognitively intact. In an interview and observation on 3/31/26 at 1:57 AM, Resident #4 reported he had a couple of pressure wounds on his buttock. No signage was noted outside Resident #4's room to indicate he was in enhanced barrier precautions. Review of Order Summary for Resident #4 on 4/2/26 revealed .buttocks: apply remedy silicone cream as needed for R (right) buttock Pressure injury stage II.Buttock: apply remedy silicone cream two times a day for R buttock pressure injury stage II. with a start date of 4/2/26. left buttocks: apply remedy silicone cream as needed for pressure injury stage II.Left buttocks: apply remedy silicone cream two times a day for pressure injury stage II with a start date of 3/18/26. No physician order was noted for enhanced barrier precautions (EBP). Review of Care Plan for Resident #4 on 3/31/26 revealed Focus.has potential/actual impairment to skin integrity.R buttock pressure injury stage II.Interventions: apply moisture barrier as needed.initiated on 3/11/26.Risk for infection r/t (related to) wounds.interventions: evaluate wounds for signs / symptoms of infection.staff to follow standard precautions, including proper hand washing techniques, to minimize microorganism transmission. with an initiation date of 3/12/26. No care plan or intervention related to enhanced barrier precautions were noted. In an interview on 4/1/26 at 12:45 PM, Certified Nurse Assistant (CNA) Q reported Resident #4 was not in enhanced barrier precautions. When queried, CNA Q reported a resident who had a wound, or a catheter, or a drain wound need to be in enhanced barrier precautions, and the staff would have to wear a gown and gloves when providing care. CNA Q reported she was not aware if Resident #4 had a wound. At 12:50 PM, on 4/1/26 no signage was noted outside of Resident #4's room to indicate he had been placed into enhanced barrier precautions. In an interview on 4/1/26 at 3:38 PM, Admission/Outreach Coordinator (AOC) J reported she was responsible for entering orders for residents at admission after the orders were approved by the provider. AOC J reported she completed the resident's admission assessment and created their baseline care plan. AOC J reported an admitting resident's clinical needs were discussed at the team clinical meeting, and when queried, AOC J reported she received her directive from Infection Preventionist (IP) D if a resident needed to be in EBP when admitted . AOC J reported if a resident was admitted with a wound, they would typically require EBP and she would input the order and create the care plan if she was told to do so. In an interview on 4/1/26 at 4:27 PM, IP D reported admission Coordinator (AC) I received information regarding a resident's clinical status prior to admission. IP D reported the clinical team would discuss a resident's needs at the clinical meeting. IP D reported AC I, AOC J and Director of Nursing (DON) B, were responsible for initiating orders for EBP at admission, AC I was responsible for room readiness which included signage for precautions and a PPE cart, and she would do the audit of the orders and add any supplemental orders if needed. IP D reported EBP were used for an indwelling medical device and for chronic wounds. IP D reported Resident #4 was admitted with a pressure wound, and currently had two pressure wounds, and was not in enhanced barrier precautions. IP D confirmed there were no orders for EBP, nor a care plan related to EBP for Resident #4. At 8:12 AM on 4/2/26 no signage was noted outside or Resident #4's room to indicate he had been placed into enhanced barrier precautions. In an interview on 4/2/26 at 8:15 AM, MDS Coordinator (MDSC) C reported AC I was the one to get referral information from the hospital and she shared that information at the clinical meeting. MDSC C reported AOC J, AC I, and IP D would be the staff members who would input orders for a resident to be in enhanced barrier precautions. MDSC C reported EBP could be implement after a resident was admitted if there was found to be a need for it. AC I was not in available for interview on 4/2/26. At 10:51 AM on 4/2/26 no signage was noted outside Resident #4's room to indicate he had been placed into enhanced barrier precautions. Review of Resident #4's record on 4/2/26 revealed no noted physician order nor care plan in place for the implementation of enhanced barrier precautions. Resident #58 Review of an admission Record revealed Resident #4 was a female who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: diverticulitis (small pouches in the colon that become inflamed or infected), of the intensities part unspecified, with perforation (a hole in the wall of the intestine) and abscess (a swollen area of tissue containing pus) without bleeding, end stage renal disease (chronic condition where the kidneys no longer function), and dependent on renal dialysis (a process where the blood is filtered by a machine/artificial kidney). Review of a Minimum Data Set (MDS) assessment for Resident #58, with a reference date of 4/1/26 revealed a Brief Interview for Mental Status (BIMS) score of 13/15 which indicated Resident #58 was cognitively intact. On 3/31/26 at 11:14 AM, signage was noted on the door to Resident #58's room indicating she was on enhanced barrier precautions; meaning a gown and gloves needed to be worn by staff when providing high contact care. CNA L was observed providing peri care (cleaning of the genital area) to Resident #58 and was not wearing a gown while providing care. On 3/31/26 at 11:17 AM, CNA L and CNA P were observed using a gait belt and transferring Resident #58 from her bed to her wheelchair. Neither CNA L nor CNA P were wearing a gown or gloves during the observed transfer. In an observation and interview on 3/31/26 at 11:24 AM, CNA L reported Resident #58 had a fistula for dialysis, she did not have any wounds. Resident #58 was sitting in her wheelchair in her room at the foot of the bed and a JP drain (Jackson Pratt drain, closed suction surgical device that removes fluid from a wound) was noted to be pinned to her shirt on the left side of her body. CNA L was observed removing the linen from Resident #58's bed, he was not wearing a gown or gloves during the linen removal. Review of Order Summary for Resident #58 on 4/2/26 revealed .Coccyx/sacral pressure injury stage II: cleanse with soap and water. Pat dry. Apply purocol (collagen based wound dressing) to wound bed and cover with mepilex (a soft silicone wound dressing) every Tuesday and Thursday with a start date of 3/26/26 and a revision on 3/31/26.EBP-Enhanced barrier precautions due to JP drain with a start date of 3/26/26. Review of Care Plan for Resident #58 on 3/31/26 revealed Focus.Potential for the spread of multi-drug resistant organisms (MDROs) to other residents or staff during high contact related to: JP drain. Place enhanced barrier precautions signage outside of resident room to include all types of PPE to be utilized. Interventions: Place PPE personal protective equipment) near the resident's room for use. Provide education to resident and or resident representative on Enhanced barrier precautions per CDC (Centers for Disease Control and Prevention) guidelines. Provide education to staff on Enhanced Barrier Precautions. Enhanced Barrier Precautions PPE_ Apply gloves and gowns before performing the HIGH CONTACT (examples are dressing, bathing, hygiene, changing brief/assisting with toileting, transferring, providing bed mobility, changing linens, device care or use, wound care) resident care activity. Initiated on 3/26/26 with a revision on 3/30/26. In an interview on 3/31/26 at 2:21 PM, CNA P reported the signage posted on Resident #58's room door indicated she was in enhanced barrier precautions and that the staff should wear a gown and gloves when providing care to her. When queried, CNA P confirmed neither she nor CNA L were wearing gown and gloves when they transferred Resident #58 into her wheelchair, and they should have been wearing it. CNA P stated CNA L and I talked about how were weren't wearing it as soon as we all exited the room earlier. In an interview on 04/01/2026 at 11:35 AM, Infection Preventionist (IP) D reported that the facility's current practice for implementing Enhanced Barrier Precautions (EBP) included residents with indwelling medical devices and wounds that have been present for greater than 3 months. IP D reported that if a resident had a surgical wound they would not implement EBP unless it had been present greater than 3 months. IP D further explained that only chronic wounds required EBP and their understanding of chronic was if it had been present for greater than 3 months. IP D reported that the facility used CDC (Centers for Disease Control and Prevention) guidelines to develop their infection control policies. Review of the facility policy Enhanced Barrier Precautions dated 12/2024 revealed, .1. Enhanced barrier precautions (EBPs) refer to infection prevention and control interventions designed to reduce the transmission of multi-drug-resistant organisms (MDROs) during high contact resident care activities. 2. Enhanced barrier precautions apply when: a. A resident is infected or colonized with a CDC-targeted MDRO, but does not have a wound or indwelling medical device . b. A resident is NOT known to be infected or colonized with any MDRO, has a wound or indwelling medical devices, and does not have secretions or excretions that are unable to be covered or contained . 7. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). b. Personal protective equipment (PPE) is changed before caring for another resident. c. Face protection may be used if there is also a risk of splash or spray.8. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing; b. bathing/showering; c. providing hygiene or grooming; d. changing briefs or assisting with toileting; e. transferring; f. providing bed mobility; g. changing linens; h. prolonged, high-contact with items in the resident's room, with resident's equipment, or with resident's clothing or skin (e.g., in the shower room, therapy gym, or during restorative care); i. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); and j. wound care (any skin opening requiring a dressing) . References included CDC guidelines and APIC (Association for Professionals in Infection Control and Epidemiology) document Implementing the Use of Enhanced Barrier Precautions in Skilled Long-Term Care Nursing Facilities. Review of CDC guidance at www.cdc.gov/long-term-care-facilities, Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions in Nursing Homes revealed, .13. If a resident does not have a history of a MDRO but does have an indwelling medical device or wound, should they still be placed on Enhanced Barrier Precautions? Yes. Enhanced Barrier Precautions are recommended for residents with indwelling medical devices or wounds, who do not otherwise meet the criteria for Contact Precautions, even if they have no history of MDRO colonization or infection and regardless of whether others in the facility are known to have MDRO colonization. This is because devices and wounds are risk factors that place these residents at higher risk for carrying or acquiring a MDRO and many residents colonized with a MDRO are asymptomatic or not presently known to be colonized. 14. Why did CDC expand Enhanced Barrier Precautions to include all residents with wounds or indwelling medical devices, regardless of MDRO status? Indwelling medical devices and wounds are risk factors for colonization with a MDRO. Once colonized, these residents can serve as sources of transmission within the facility. The expansion of EBP for all residents with wounds or indwelling medical devices is intended to protect these high-risk individuals both from acquisition and from serving as a source of transmission if they have already become colonized .23. The guidance describes that all residents with wounds would meet the criteria for Enhanced Barrier Precautions. What is the definition of a wound in relation to this guidance? In the guidance, wound care is included as a high-contact resident care activity and is generally defined as the care of any skin opening requiring a dressing. However, the intent of Enhanced Barrier Precautions is to focus on residents with a higher risk of acquiring an MDRO over a prolonged period of time. This generally includes residents with chronic wounds, and not those with only shorter-lasting wounds, such as skin breaks or skin tears covered with a Band-aid or similar dressing. Examples of chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers, and chronic venous stasis ulcers. Ostomies, such as colostomies or ileostomies, are not defined as a wound for Enhanced Barrier Precautions Reviewed of Implementing the Use of Enhanced Barrier Precautions in Skilled Long-Term Care Nursing Facilities by APIC dated 2024 revealed, .What is considered a chronic wound? The longer a wound is present, the more concern we have for those wounds becoming colonized with an MDRO. Chronic wounds are often poorly healing wounds or areas of the skin in residents with underlying medical conditions, resulting in pressure areas, diabetic ulcers, and venous or arterial stasis wounds .

Based on interview and record review the facility failed to revise care plans timely for 2 (Residents #47 and #23) of 12 residents reviewed for person-centered care plans resulting in an inaccurate reflection of residents' care needs and the potential for incorrect care to be provided.Findings include:Resident #47:Review of Resident #47's Care Plan Report, indicated Resident #47 was admitted on [DATE] and included anticoagulant (blood thinner medication) therapy, diuretic medication ( water pill; increases passing of urine) use, and FDA (Food and Drug Administration) medication black box warning/DVT (deep vein thrombosis; blood clot forms in vein) care plans, all dated 3/6/26. The care plans stated, The resident (Resident #47) is taking a medication that is listed on the FDA's Black Box List (highlights risks of use) R/T (related to) DVT), The resident is on Anticoagulation therapy Enoxaparin (blood thinner medication), risk for bleeding, and The resident has potential for dehydration or fluid deficit. Diuretic use.During an interview on 04/02/2026 at 10:09 AM, Director of Nursing (DON) B reviewed Resident #47's current medications and confirmed Resident #47 was not receiving an anticoagulant, diuretic, or FDA black box warning medication. DON B confirmed Resident #47's anticoagulant medication (enoxaparin) was discontinued on 3/14/26, diuretic medication (furosemide) was discontinued on 3/30/26, and was no longer receiving any FDA black box warning medications. DON B confirmed the care plans had not been revised to reflect the changes.Resident #23:Review of Resident #23's Care Plan Report, indicated Resident #23 was admitted on [DATE] and included an anticoagulant therapy care plan, dated 2/25/26, that stated, The resident is on Anticoagulation therapy, is at risk for bleeding. A separate section of the care plan, dated, 2/25/26, stated, The resident (Resident #23) is on diuretic, at risk for dehydration.Review of Resident #23's physician orders, print date 4/2/26, revealed no anticoagulant or diuretic medications were ordered.Review of the facility's Resident Matrix (tool used to identify residents' care needs), dated 3/31/26, indicated Resident #23 was not receiving an anticoagulant or diuretic medication.During an interview on 04/02/2026 at 10:21 AM, DON B confirmed Resident #23's care plan indicated she received an anticoagulant medication, but Resident #23 was not prescribed any anticoagulant medication. DON B reported it was usually the unit manager who would update/revise resident care plans. DON B reported various methods staff could have used to make themselves aware of revisions that would need to be made to care plans such as review of 24-hour nurse reports, review of charts, and/or pulling order summaries. DON B confirmed updates to care plans could have been more timely. Review of the facility's Care Plans, Comprehensive Person-Centered policy, dated 3/2022, stated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

Based on observation, interview, and record review the facility failed to implement care plan interventions for 2 (Resident #30 and Resident #21) of 12 residents reviewed for care plan implementation, resulting in the potential for skin breakdown for Resident #30 who's heel protectors (a padded cushion for a heel to rest in to prevent pressure caused from a heel resting directly on a mattress) not being consistently applied while in bed and Geri sleeves (sleeves worn to protect fragile skin from tearing) not being consistently applied for Resident #21 and Resident #30, and Resident #21 not consistently receiving a straw in her drinks at meals. Findings include: Resident #30 Review of an Admission Record revealed Resident #30 had pertinent diagnoses which included: Alzheimer's disease, restlessness and agitation, and repeated falls. Review of Order Summary for Resident #30 revealed Geri-sleeves to bilateral upper extremities (both arms) ON in AM and OFF in PM two times a day for fragile skin ordered on 9/5/2024. Review of Care Plan for Resident #30 revealed problem: is at risk for impaired skin integrity related to impaired mobility .intervention/task-heel protectors on when resident is in bed and float heels off of bed initiated 7/03/24 .Geri-sleeves to bilateral upper extremities ON in AM and OFF in PM initiated 9/4/24. During an observation on 1/21/25 at 9:04 AM., Resident #30 was in bed, her feet were uncovered. Resident #30's left foot was bare, with a noted scab on the top of the second toe, and her right foot had a non-skid sock in place. Neither foot had a heel protector on, and both heels were resting directly on the mattress. Resident #30's heel protectors were observed in the tan recliner on the other side of the room. At this same time, Resident #30's tan geri sleeves were observed balled together on top of the end table beside the soft brown recliner chair in her room. In an interview on 1/21/25 at 12:11 PM., Certified Nurse Assistant (CNA) V reported Resident #30 should wear heel protectors when in bed and they were not on Resident #30's feet when she got her ready today. In an observation on 1/21/25 at 12:12 PM., Resident #30's Geri sleeves were observed balled together on top of the end table beside the soft brown recliner chair that Resident #30 was sitting in, in her room. Resident #30's geri sleeves were in the same position they had been in earlier this day. During an observation on 1/22/25 at 8:08 AM., Resident #30 was in bed, sleeping, and her heel protectors were observed in the soft brown recliner in her room and not on her feet. In an interview on 1/22/25 at 12:11 PM., CNA CC reported Resident #30 should wear heel protectors while in bed and geri-sleeves when she is up. In an observation on 1/22/25 at 12:14 PM., Resident #30 was in her soft brown recliner chair in her room and her geri sleeves were noted on the end table next to her. In an observation and interview on 1/23/25 at 9:27 AM., Resident #30 was sitting at a table in the dining room waiting for breakfast to be served. Resident #30 did not have her Geri sleeves on. This surveyor asked Resident #30 about her geri sleeves and Resident #30 stated I guess we forgot them today. In an interview on 1/23/25 at 9:45 AM., CNA Y reported that Resident #30 should wear heel protectors when in bed and geri sleeves when she gets up. CNA Y reported that Resident #30 was assisted this morning by a hospice aide and CNA Y confirmed that Resident #30 was not wearing her geri sleeves. CNA Y obtained a new pair and applied Resident #30's geri sleeves. In an interview on 1/23/25 at 10:43 AM., Health Center Manager (HCM) E reported her expectations were that the care plan interventions and physician orders were followed, and that Resident #30 should have heel protectors on when in bed and geri sleeves on when up. HCM E reported Resident #30 does refuse to wear heel protectors and geri sleeves at times. HCM E reported that refusal to wear should be documented. Review of Treatment Administration Record for Resident #30 for the dates of 1/21/25, 1/22/25, and 1/23/25 revealed on 1/21/25 'Licensed Practical Nurse (LPN) JJ documented Resident #30 geri sleeves were on. On 1/23/25 Registered Nurse (RN) GG documented Resident #30 geri sleeves were on. On both dates, Resident #30 was observed without her geri sleeves on. In an interview on 1/23/25 at 11:51 AM Director of Nursing (DON) B reported her expectation was that the care plan interventions were followed by staff. Review of facility policy Care Plans, Comprehensive Person-Centered with a revision date of March 2022 revealed . Each resident's comprehensive person-centered care plan is consistent with resident's rights to participate in the development and implementation of his or her plan of care . receive the services and/or items included in the plan of care . 47659 Resident #21 Review of Resident #21's Admission Record revealed Resident #21 was originally admitted to the facility on [DATE] with pertinent diagnoses which included depression and anxiety. Review of Minimum Data Set (MDS) assessment for Resident #21, with a reference date of 11/7/24 revealed a Brief Interview for Mental Status (BIMS) score of 1/15 which indicated Resident #21 was severely cognitively impaired. Review of Resident #21s Care Plan revealed, (Resident #21) is nutritionally at risk . Interventions: Per families request, please provide a straw with every meal. Start date: 9/18/23 . Review of Resident #21's Care Plan revealed, ( Resident #21) is at risk for alteration in skin integrity . Interventions: . Geri Sleeves (Skin protectors that can be worn on the arms and legs to protect against skin tears and friction) to bilateral upper extremities, ON in the AM and OFF in the PM. Date initiated: 6/13/23 . In an dining observation on 1/22/25 at 12:32 PM, Resident #21 was being assisted by Certified Nursing Assistant (CNA) X. CNA X held a cup of juice for Resident #21 and gave her sips in between bites of food. It was noted that Resident #21's cup did not have a straw. In an observation on 1/22/25 at 1:00 PM, Resident #21 was sitting in her wheelchair in the dining room. It was noted that Resident #21 was not wearing geri sleeves on either of her arms. In an observation on 1/23/25 at 10:01 AM, Resident #21 was sitting in her wheelchair in her room. It was noted that that Resident #21 was not wearing geri sleeves on either of her arms. In an interview on 1/23/25 at 10:10 AM, CNA BB reported that she did not think that Resident #21 had ordered for geri sleeves. CNA BB reported that Resident #21 was supposed to have a straw with her drinks at meals, because her daughter had noticed that she drinks more fluids when she has a straw. In an interview on 1/23/25 at 11:15 AM, Food Service Manager (FSM) LL reported that Resident #21's Care Plan noted that she required a straw with her drinks per her daughter's request, and that the expectation was that staff would provide a straw for all drinks at every meal for Resident #21. In an interview on 1/23/25 at 12:12 PM, Registered Nurse (RN) GG reported that she did not think that Resident #21 needed to wear geri sleeves if she had a long sleeve shirt on. In an interview on 1/23/25 at 12:18 PM, Health Care Manager (HC-M) E reported that Resident #21's care plan indicated that she required geri sleeves to be worn every day, and that she also required a straw with drinks at meals. HC-M E reported that Resident #21's care plan did not indicate that she could wear long sleeve shirts instead of geri sleeves. HC-M E reported that it was her expectation that staff would be applying the geri sleeves every day for Resident #21 and providing straws with all of Resident #21's drinks.

Based on interview and record review, the facility failed to revise the nutrition care plan of one resident (Resident #344) of 12 residents reviewed for comprehensive care plans resulting in confusion regarding the diet and fluid restriction. Findings include: Resident #344(R344) Review of the Admission Record and Minimum Data Set (MDS) dated [DATE] revealed R344 admitted to the facility on [DATE] with diagnoses including Stage 4 chronic kidney disease (kidney failure) and congestive heart failure (condition where the heart doesn't pump blood as it should). Brief Interview for Mental Status (BIMS) reflected a score of 13 out of 15 which indicated R344 was cognitively intact (13 to 15 cognitively intact). During an interview on 1/21/2025 at 10:23 AM, R344 reported that she had fluid retention in her legs which is an ongoing problem and she wishes it would go away. R344 also stated that she went to the hospital shortly after admission at the facility for fluid retention from congestive heart failure and renal disease. Review of R344's physician orders revealed 2 different nutrition orders. The first nutrition order revealed No concentrated sweets diet, Regular level 7 texture, regular/thin liquids (level 0) consistency. Under directions No added salt, 2000 ml (milliliter) fluid restriction qd (every day). The second order revealed No concentrated sweets diet, Regular level 7 texture, regular/thin liquids (level 0) consistency, fluid restriction 2000 ml/day. Dietary 1500 ml/day and nursing 500 ml/day. Under directions two times a day 2000 ml fluid restriction qd (every day). Review of the Dietary/Nutrition Evaluation-V 2.0 dated 1/10/2025 revealed Diet orders/Types specific to this resident: No added salt, NCS (no concentrated sweets) fluid restriction: yes, nursing fluid allowed per day (cc-cubic centimeter in volume; same as ml): 360, dietary fluid allowed per day (cc) :1140 6. Interventions fluid restriction 1500 ml qd no water at bedside. Review of R344's nutrition care plan revealed encourage fluids fluid Restriction: 2000ml per day, no water at bedside. Review of R344's individual service plan (ISP) that the certified nursing assistants (CNAs) have access to revealed Diet as ordered, honor food preferences as able. NCS diet, Regular texture, and regular/thin consistency liquids, Encourage fluid intake Fluid Restriction 2000 ml per day, no water pitcher at bedside, may have ice chips at bedside. Review of the Nutrition Note on 1/15/2025 completed by Food Service Manager (FSM) LL who was also the Certified Dietary Manager (CDM) revealed Per nursing/therapy: (R344) diet was upgraded to NAS/NCS (No added salt/No concentrated sweets) diet, regular texture and regular/thin consistency liquids Fluid restrictions was upgraded from 1500ml QD to 2000ml QD. Orders, care plan, Kardex have been updated. CDM will continue to monitor weights, labs, and FARS (food acceptance records). CDM will consult with IDT (interdisciplinary team) and RD (registered dietitian) as necessary. During an interview on 1/22/2025 at 1:04 PM, FSM LL stated that R344 should be on a NAS, NCS diet and 2000ml fluid restriction per day. FSM LL agreed that the care plan was confusing since it stated, encourage fluids and then has 2000 ml fluid restriction and stated she would talk to the Registered Dietitian. FSM LL agreed that on R344's ISP, NAS was missing on the diet since it wasn't on the care plan and didn't carry over. She also stated that she usually divides up fluid restriction between nursing and dietary and forgot to update it on the care plan which would show up on the ISP. FSM LL reported that nursing should get 360 ml of fluid a day and dietary should have 480 ml with each meal which leaves 200 ml for any other fluid during the day such as soups. During the interview, FSM LL updated the care plan and ISP to indicate she was on a NAS diet and fluid restriction divided between nursing and dietary and took out encourage fluids. During an interview on 1/23/2025 at 8:58 AM, Rehab Nurse Manager (RNM) F stated that she agreed that the care plan and ISP were confusing indicating to encourage fluids and then she was on a fluid restriction. RNM F reported that nursing was giving different amounts of fluid than what FSM LL had noted. RNM F stated she would talk to the FSM LL and the Registered Dietitian and make sure the care plan and ISP are updated to reflect the correct diet and fluid restriction. Review of the Care Plans, Comprehensive Person-Centered Policy with a revision date of March 2022 revealed Policy Interpretation and Implementation 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

Based on observation, interview, and record review, the facility failed to provide assistance with eating for 1 (Resident #5) of 12 residents reviewed for activities of daily living (ADL) care resulting in the potential for avoidable negative physical outcomes for resident's who are dependent on staff for assistance. Findings include: Resident #5 Review of Resident #5's Admission Record revealed Resident #5 was originally admitted to the facility on [DATE] with pertinent diagnoses which included dementia. Review of Resident #5's Care Plan revealed, (Resident #5) is at nutritional risk r/t (related to) receiving hospice care, gradual weight loss over past year, continued gradual weight loss in past 30 days, physical debility/decreased muscle mass . date revised on 10/26/24. Interventions: Offer set-up assist and verbal cues and encouragement q (every) meal. Date initiated: 6/14/23 Review of Resident #5's LCS Dietary/Nutrition Profile Note dated 10/25/24 revealed, .H. Oral Status. 2. Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident. E. Substantial/maximal assistance. 3. Adaptive Equipment: needing up to total assistance in the past 7 days . K. Nutritional Risk . 2. At risk for unintentional weight loss: yes. 3. If yes, please explain: Receiving Hospice care and showing gradual weight losses . Needing increased assistance at meals . In a interview on 1/21/25 at 9:52 AM, Family Member (FM) N reported that they had concerns with the facility's process for assisting residents in the dining room. FM N reported that they had frequently noticed residents in the dining room that needed more assistance with their meals than the facility provided. FM N reported concerns that the facility did not have enough staff in the dining room to monitor and assist residents when they ate. In an interview on 1/21/25 at 12:45 PM, CNA V reported that Resident #5 only needed verbal reminders from staff to eat. In an dining observation on 1/21/25 at 12:53 PM: Resident #5 was sitting at a table with her lunch plate in front of her untouched. It was noted that Resident #5 was closing her eyes. Certified Nursing Assistant (CNA) V approached Resident #5 and offered and assisted Resident #5 to take a spoonful of her meal. Resident #5 ate the spoonful of food that CNA V offered her. After Resident #5 ate the spoonful of food, CNA V left Resident #5's table to assist another resident out of the dining room. It was noted that after CNA V left Resident #5, she did not continue to eat and sat looking at her plate of food. Resident #5 was noted to attempt to take a drink of water from her cup, but her hands were too shaky for her to hold the cup, and she was unable to bring the cup to her mouth. At 12:57 PM, CNA V returned to Resident #5 and offered her a spoonful of her lunch which Resident #5 accepted. After CNA V offered and assisted Resident #5 with one spoonful of food, she left to assist another resident. It was noted that once CNA V left Resident #5, she did not continue to eat, and stared at her plate of food again. In an observation on 1/22/25 at 12:11 PM, CNA EE reported that she was unable to identify all the residents that required assistance with eating. CNA EE reported that most of the residents required assistance and that staff did the best they could to assist everyone that needed help. In an interview on 1/22/25 at 12:15 PM, CNA AA reported that Resident #5 did not require assistance with eating. In an observation on 1/22/25 at 12:17 PM, Resident #5 was sitting at the dining room table with a full plate of food in front of her that included mashed potatoes, vegetables, turkey, stuffing. Resident #5 also had a parfait dessert in a plastic cup. Resident #5 was sitting at the table staring at her plate with her food untouched. Resident #5 grabbed a fork and attempted to gather some of the turkey and mashed potatoes onto her fork, but was not able to. Resident #5 tried to maneuver her fork to get food onto it for a few minutes before she put the fork down and continued to stare at her plate. At 12:32 PM, CNA AA approached Resident #5 and verbally reminded Resident #5 to eat and then left Resident #5 seated at the table unassisted. Resident #5 continued to stare at her plate of food. At 12:51 PM, CNA W approached Resident #5 and verbally reminded Resident #5 to eat and asked if she was not hungry. Resident #5 told CNA W that she needed more time. CNA W left Resident # 5 and she continued to stare at her plate. At 12:59 PM, CNA AA approached Resident #5 and verbally reminded her to eat and offered to assist her. It was noted that with the assistance of CNA AA, Resident #5 began to take spoonfuls of her dessert parfait. After Resident #5 began to take spoonfuls of her parfait, CNA AA left Resident #5. Resident #5 continued to attempt to eat her parfait. It was noted that Resident #5 struggled to get the spoonfuls of food to her mouth, and spilled a lot of the food onto her lap and the floor. At 1:09 PM, CNA AA returned to Resident #5 and asked if she was ready to go back to her room. Resident # 5 agreed and left the dining room. It was noted that her plate of mashed potatoes, vegetables, turkey and stuffing remained untouched. In an interview on 1/23/25 at 10:10 AM, CNA BB reported that Resident #5 needed frequent verbal reminders to eat during meals because she would just sit there until she falls asleep. CNA BB did not think that staff needed to assist resident with eating. In an interview on 1/23/25 at 11:15 AM, Food Service Manager (FSM) LL reported that she did not think that Resident #5 required assistance with eating. FSM LL reported that staff needed to provide verbal reminders to Resident #5 because she would sometimes fall asleep at the table. When this writer queried about Resident #5's most recent LCS Dietary/Nutrition Profile Note dated 10/25/24 which indicated that Resident #5 had required up to total assistance, FSM LL was unable to report why Resident #5 had not been receiving more assistance at meals based on that note. FSM LL was unable to report what the expectation was for how often staff should be observing and reminding Resident #5 to eat. FSM LL confirmed that she had noticed that when Resident #5 was more lethargic, she did require more assistance. FSM LL reported that it was challenging for the facility to meet the needs of all of the residents in the dining room that required assistance with eating. FSM LL reported that she had voiced her concerns about this challenge to management, but that she was told that they had adequate staff in the facility to assist with dining. In an interview on 1/23/25 at 12:18 PM, Health Care Manager (HC-M) E reported that she did frequently observe dining, but she had not observed Resident #5 recently, and was unaware that Resident #5 required assistance with eating.

Based on observation, interview, and record review the facility failed to ensure accurate oxygen administration via nasal cannula (a tube with prongs into the nostrils of the nose to deliver additional oxygen to a body's blood) to 1 (Resident #4) of 1 reviewed for respiratory care, resulting in the resident not consistently receiving her oxygen at the level ordered. Findings include: Resident #4 Review of an Admission Record revealed Resident #4 had pertinent diagnoses which included: acute respiratory failure with hypoxia (caused when lungs cannot deliver enough oxygen or remove enough carbon dioxide from the body's blood). Review of Order Summary for Resident #4 revealed PRN (as needed), shortness of breath, wheezing O2 (oxygen) @ (at) 3L (liters) via nasal cannula, high flow cannula .as needed for hypoxia . started 8/27/2024 . Titrate Oxygen to keep O2 sat (blood oxygenation readings) @ 2-3 L via nasal cannula .< (greater than) 90% (percent). two times a day . started 7/23/2024. Review of Care Plan for Resident #4 revealed problem, oxygen therapy r/t (related to) Hypoxia . intervention/tasks . administer oxygen as ordered. On 1/21/25 at 10:43 AM., Resident #4 was observed sitting in her wheelchair, in her room, with a nasal cannula on her face and connected to the oxygen concentrator (machine that delivers oxygen) with the setting of 2L for oxygen delivery. On 1/22/25 at 8:40 AM., Resident #4 was observed lying in her bed in her room with a nasal cannula on her face and connected to the oxygen concentrator with the settings of 1.5L for oxygen delivery. On 1/22/25 at 12:07 PM., Resident #4 was observed sitting in her wheelchair in the dining room with a portable tank of oxygen present on the back of her wheelchair, with a nasal cannula connected to the tank and on the resident's face, with the setting on the tank of 1.5L for oxygen delivery. A tag was noted on the oxygen tank that revealed Resident #4's oxygen delivery settings were 1.5L. In an interview on 1/22/25 at 12:31 PM., Certified Nurse Assistant (CNA) X reported Resident #4's oxygen settings was 1L. CNA X reported that the oxygen settings were written on the tag present on the oxygen tank on the Resident's wheelchair. CNA X reported the tag was the only place she knew to get the oxygen settings for a resident. CNA R was present during this interview, and when CNA X reported Resident #4's oxygen settings were 1L CNA R asked CNA X Are you sure? and then CNA R stated I don't think so as her response to Resident #4's oxygen settings being 1L. CNA R reported she would have to confirm with the nurse what Resident #4's oxygen setting should be. In an interview on 1/23/25 at 8:24 AM., CNA T reported Resident #4's oxygen settings was 1L, and that was what was written on the tag on the oxygen tank on the back of Resident #4's wheelchair. CNA T reported the setting on the oxygen concentrator for Resident #4 was whatever it is when you turn it on. On 1/23/25 at 8:30 AM., Resident #4's oxygen tank on the back of her wheelchair, while she was eating breakfast in the dining room revealed a tag with 1.5L written on it and the tank dial turned to 1.5L of oxygen to be delivered through her nasal cannula. In an interview on 1/23/25 at 9:50 AM., Licensed Practical Nurse (LPN) FF reported Resident #4's oxygen orders were for 2L PRN via nasal cannula. LPN FF reported that Resident #4's oxygen liter flow could be adjusted per the assessment of her oxygen sats (reading that indicated how much oxygen was in the body) that was completed and documented by the nurse. In an interview on 1/23/25 at 9:57 AM., LPN FF reviewed the oxygen orders for Resident #4 and confirmed there were two active orders, and the orders included 2L or 2-3L. LPN FF reported that the nurses could titrate (adjust the flow of oxygen up or down) Resident #4's oxygen according to her O2 sats. LPN FF confirmed with this surveyor that Resident #4's oxygen concentrator in her room was set to 1.5L and Resident #4 was wearing the nasal cannula that was connected to the concentrator. LPN FF also confirmed that the tag attached to the oxygen tank on back of Resident #4's wheelchair did indicate that the tank setting was to be 1.5L. LPN FF reported she had no idea who changed the orders. Review of Treatment Administration Record (TAR) for Resident #4 for dates 1/22/25, and 1/23/25 revealed LPN FF documented that Resident #4's oxygen was titrated to maintain O2 sats <90%. No noted documentation of Resident #4's O2 sats was in the TAR. Review of O2 Sats Summary for Resident #4 revealed no O2 Sat documentation for 1/22/25 nor 1/23/25. In an interview on 1/23/25 at 10:55 PM., Health Center Manager (HCM) E reported Resident #4's oxygen order was PRN, and there was an order to titrate her oxygen as needed. HCM E reported she was aware there was an issue with the order, and it was now cleared up with the provider. New orders were being entered. In an interview on 1/23/25 at 12:03 PM., Director of Nursing (DON) B reported her expectation was that physician orders were followed. DON B reported she discussed Resident #4's oxygen orders with the provider and the order was changed immediately. Review of facility policy Medication Order with a revision date of November 2014, revealed oxygen orders-when recording orders for oxygen, specify the rate of flow, route and rationale.

Based on observation, interview, and record review, the facility failed to accurately document meal intake for 2 (Resident #5 and Resident #30) of 12 residents reviewed for complete and accurate medical records resulting in an inaccurate reflection of the resident's meal intakefor Resident #5 and an inaccurate reflection of care provided for Resident #30. Findings include: Review of Resident #5's Admission Record revealed Resident #5 was originally admitted to the facility on [DATE] with pertinent diagnoses which included dementia. Review of Resident #5's Care Plan revealed, (Resident #5) is at nutritional risk r/t (related to) receiving hospice care, gradual weight loss over past year, continued gradual weight loss in past 30 days, physical debility/decreased muscle mass . date revised on 10/26/24. Interventions: Monitor food consumption and offer sub (substitution) if 50% or more is uneaten, document intake of meals. Date initiated: 6/14/23 . In an observation on 1/22/25 at 12:17 PM, Resident #5 was sitting at the dining room table with a full plate of food in front of her that included mashed potatoes, vegetables, turkey, stuffing. Resident #5 also had a parfait dessert in a plastic cup. Resident #5 was sitting at the table staring at her plate with her food untouched. Resident #5 grabbed a fork and attempted to gather some of the turkey and mashed potatoes onto her fork, but was not able to. Resident #5 tried to maneuver her fork to get food onto it for a few minutes before she put the fork down and continued to stare at her plate. At 12:32 PM, CNA AA approached Resident #5 and verbally reminded Resident #5 to eat and then left Resident #5 seated at the table unassisted. Resident #5 continued to stare at her plate of food. At 12:51 PM, CNA W approached Resident #5 and verbally reminded Resident #5 to eat and asked if she was not hungry. Resident #5 told CNA W that she needed more time. CNA W left Resident # 5 and she continued to stare at her plate. At 12:59 PM, CNA AA approached Resident #5 and verbally reminded her to eat and offered to assist her. It was noted that with the assistance of CNA AA, Resident #5 began to take spoonfuls of her dessert parfait. After Resident #5 began to take spoonfuls of her parfait, CNA AA left Resident #5. Resident #5 continued to attempt to eat her parfait. It was noted that Resident #5 struggled to get the spoonfuls of food to her mouth, and spilled a lot of the food onto her lap and the floor. At 1:09 PM, CNA AA returned to Resident #5 and asked if she was ready to go back to her room. Resident # 5 agreed and left the dining room. It was noted that her plate of mashed potatoes, vegetables, turkey and stuffing remained untouched. Review of Resident #5's Amount Eaten tasks revealed that on 1/22/25 staff had documented that Resident #5 had eaten 51-75% of her lunch. It was noted that this documentation occurred at 12:43 PM, but Resident # 5 had not finished eating until 1:09 PM. In an interview on 1/23/25 at 11:15 AM, Food Service Manager (FSM) LL reported that a plate of food that was untouched and a half eaten dessert parfait would not be considered 51-75% intake of a meal. FSM LL reported that the facility did not have any guidance on how staff should determine what percentage of meal intake they should be documenting, and that they just used best judgement. FSM LL confirmed that it was her expectation that her staff were not documenting meal intake prior to the resident finishing the meal. FSM LL confirmed that the facility relied on accurate documentation of meal intake to monitor resident's nutritional needs. 47955 Resident #30 Review of an Admission Record revealed Resident #30 had pertinent diagnoses which included: Alzheimer's disease, restlessness and agitation, and repeated falls. Review of Order Summary for Resident #30 revealed Geri-sleeves to bilateral upper extremities (both arms) ON in AM and OFF in PM two times a day for fragile skin ordered on 9/5/2024. Review of Care Plan for Resident #30 revealed problem: is at risk for impaired skin integrity related to impaired mobility .intervention/task-heel protectors on when resident is in bed and float heels off of bed initiated 7/03/24 .Geri-sleeves to bilateral upper extremities ON in AM and OFF in PM initiated 9/4/24. During an observation on 1/21/25 at 9:04 AM., Resident #30 was in bed, her feet were uncovered. Resident #30's left foot was bare, with a noted scab on the top of the second toe, and her right foot had a non-skid sock in place. Neither foot had a heel protector on, and both heels were resting directly on the mattress. Resident #30's heel protectors were observed in the tan recliner on the other side of the room. At this same time, Resident #30's tan geri sleeves were observed balled together on top of the end table beside the soft brown recliner chair in her room. In an observation on 1/21/25 at 12:12 PM., Resident #30's Geri sleeves were observed balled together on top of the end table beside the soft brown recliner chair that Resident #30 was sitting in, in her room. Resident #30's geri sleeves were in the same position they had been in earlier this day. In an interview on 1/22/25 at 12:11 PM., CNA CC reported Resident #30 should have geri-sleeves on when she is up. In an observation on 1/22/25 at 12:14 PM., Resident #30 was in her soft brown recliner chair in her room and her geri sleeves were noted on the end table next to her. In an observation and interview on 1/23/25 at 9:27 AM., Resident #30 was sitting at a table in the dining room waiting for breakfast to be served. Resident #30 did not have her Geri sleeves on. This surveyor asked Resident #30 about her geri sleeves and Resident #30 stated I guess we forgot them today. In an interview on 1/23/25 at 9:45 AM., CNA Y reported that Resident #30 should wear geri sleeves when she gets up. CNA Y reported that Resident #30 was assisted this morning by a hospice aide and CNA Y confirmed that Resident #30 was not wearing her geri sleeves. CNA Y obtained a new pair and applied Resident #30's geri sleeves. Review of Treatment Administration Record for Resident #30 for the dates of 1/21/25, 1/22/25, and 1/23/25 revealed on 1/21/25 'Licensed Practical Nurse (LPN) JJ documented Resident #30 geri sleeves were on. On 1/23/25 Registered Nurse (RN) GG documented Resident #30 geri sleeves were on. On both dates, Resident #30 was observed without her geri sleeves on. Review of the facility's Charting and documentation policy last revised July 2017 revealed, Policy Statement: All services provided to the resident, progress toward the care plan goals, or any changes in the resident ' s medical, physical, functional or psychosocial condition, shall be documented in the resident ' s medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident ' s condition and response to care .Policy Interpretation and Implementation .3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate . According to Legal and Ethical Issues in Nursing, 4th Edition, ([NAME], G, 2006), A major responsibility of all health care providers is that they keep accurate and complete medical records. From a nursing perspective, the most important purpose of documentation is communication. The standards for record keeping attempt to ensure patient identification, medical support for the selected diagnoses, justification of the medical therapies used, accurate documentation of that which has transpired, and preservation of the record for a reasonable time period. Documentation must show continuity of care, interventions used, and patient responses. Nurses' notes are to be concise, clear, timely, and complete.

Based on observation, interview and record review, the facility failed to ensure gait belt (a strap with a buckle that helps residents who have trouble walking or standing. Gait belts are used to support patients and help them move safely) use while ambulating one resident (Resident #343) of two residents reviewed for falls resulting in a fall and potential for injury. Findings include: Resident #343(R343) Review of the Admission Record and Minimum Data Set (MDS) dated [DATE] revealed R343 admitted to the facility on [DATE] with diagnoses including tibia fracture (shinbone fracture), left patellar fracture (broken kneecap) and nondisplaced bilateral S4 fracture (sacral fracture, a triangular shaped bone at the base of the spine that hasn't moved out of place). Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which indicated R343 was cognitively intact (13 to 15 cognitively intact). During an interview on 1/21/2025 at 10:49 AM, R343 stated that she fell and had fractures prior to coming to the facility and then she fell 2 times after she was admitted to the facility. R343 stated that a gait belt wasn't used for one of the falls when she was walking with her walker to the bathroom with a Certified Nursing Assistant (CNA). She said the CNA tried catching her and she fell to the ground. Review of the fall report dated 1/12/2025 revealed Resident SBA (stand by assist) with walker to bathroom per therapy, resident walking with CENA, resident fell backwards, staff member lowered her to the ground. upon assessment resident sitting on the floor in front of bathroom door with walker and CNA, Resident ASSESSED NO INJURY v/s (vital signs) WNL (within normal limits). Current Status: (R343) requires up to the following staff assist: Substantial/maximum level of assist x1 for bed mobility, dressing, toilet use, personal hygiene and bathing, Substantial/maximum level of assist x1 for transfers and ambulation using gait belt/ Wheelchair. Use of a gait belt wasn't indicated on the fall report. Review of the post fall evaluation dated 1/12/2025 revealed walking unsteady gait, increased weakness and inability to sustain balance while walking, resident also stated she likes to hurry and has to remind herself to slow down. Review of R343's fall risk evaluation dated 1/12/2025 revealed Fall Risk: History of falls (past 3 months): 1-2 falls in past 3 months . Notes: FALL WITH FRACTURES Gait / balance: Balance problem while walking. Gait / balance: Decreased muscular coordination. Gait / balance: Change in gait pattern when walking through doorway. Gait / balance: Jerking or unstable when making turns. Gait / balance: Requires use of assistive devices (i.e. cane, wheelchair, walker, furniture). Gait / balance: Balance problem while standing . Fall Risk Score: 18.0 which indicates she was a high risk for falls. Review of R343's fall risk evaluation dated 1/9/2025 revealed Fall Risk: History of falls (past 3 months): 1-2 falls in past 3 months . Gait / balance: Requires use of assistive devices (i.e. cane, wheelchair, walker, furniture). Gait / balance: Balance problem while standing . Fall Risk Score: 12.0 which indicated she was a high risk for falls. During an interview on 1/23/2025 at 9:46 AM, CNA Z reported that she was the CNA with R343 when she fell on [DATE]. CNA Z stated that she was taking R343 out of the bathroom and R343 was using her walker and she was walking by her side with the wheelchair and she didn't use a gait belt. CNA Z said she received gait belt training but she doesn't think about using a gait belt with residents and is used to transferring residents without one. During an interview on 1/23/2025 at 11:09 AM, Director of Nursing B and Health Center Nurse Manager (HCNM) E stated that that they don't have a gait belt policy but gait belts should be used with all transfers. During an interview on 1/23/2025 at 11:17 AM, Rehab Director (RD) Q stated that a gait belt should be used with transfers when a resident needs assistance from a staff member. During an interview on 1/23/2025 at 11:27 AM, Occupational Therapist (OT) M stated that a gait belt should always be used when a resident is a 1-person assistance with staff. OT M stated that R343 needed assistance so a gait belt should always be used with her. OT M also said that R343 told her that staff wasn't using a gait belt when she fell on [DATE]. During an interview on 1/23/2025 at 12:15 PM, CNA T stated that a gait belt should always be used for transfers or when ambulating a resident when they need assistance. During an interview on 01/23/2025 at 12:29 PM CNA BB reported that a gait belt should always be used for transfers or when ambulating a resident when they need assistance. Review of CNA Z's Skills Fair Required Learning Stations on 1/7/2025 revealed 7. Lift and Gait Belt Training: demonstrate proper use of a sit to stand lift and hoyer lift. Demonstrate proper gait belt placement and transfer technique. The box was checked to show it was completed. Review of CNA Z's Transfer Training and Ergo (Ergonomics) quiz dated 11/19/2024 revealed that CNA Z answered the questions appropriately regarding use of a gait belt 3. True: use a gait belt with all transfers unless contraindicated. Review of CNA Z s new hire paperwork revealed transfers and gait belts skills were completed on 10/29/2024. During another interview on 1/23/2025 at 12:28 PM, DON B stated she wasn't aware that a gait belt wasn't used with R343's fall on 1/12/2025. 47955 On 1/22/25 at 12:45 PM., Certified Nurse Assistant (CNA) AA was observed walking with Resident #13 from the dining room down hall 1. CNA AA was holding on to left sleeve of Resident #13's fleece jacket, while Resident #13 used a front wheeled walker to ambulate. Resident #13 was not wearing a gait belt.

Based on observation, interview, and record review the facility failed to provide a dignified dining experience for 2 (Resident #14 and #21) of 2 residents reviewed for dignity resulting in the potential for feelings of diminished self-worth, sadness, and frustration. Findings include: Resident #14 Review of Resident #14's Admission Record revealed Resident #14 was originally admitted to the facility on [DATE] with pertinent diagnoses which included depression. Review of Minimum Data Set (MDS) assessment for Resident #14, with a reference date of 10/22/24 revealed a Brief Interview for Mental Status (BIMS) score of 5/15 which indicated Resident #14 was severely cognitively impaired. Review of Resident #14's Care Plan revealed, (Resident #14) is at nutritional risk due to receiving hospice care, needs assistance at meals-primarily dependent on staff . Resident #21 Review of Resident #21's Admission Record revealed Resident #21 was originally admitted to the facility on [DATE] with pertinent diagnoses which included depression and anxiety. Review of Minimum Data Set (MDS) assessment for Resident #21, with a reference date of 11/7/24 revealed a Brief Interview for Mental Status (BIMS) score of 1/15 which indicated Resident #21 was severely cognitively impaired. Review of Resident #21's Care Plan revealed, (Resident #21) is nutritionally at risk r/t (related to) . primarily totally dependent on staff at meals . In an dining observation on 1/22/25 at 8:52 AM, Resident #14 and #21 sat at a table together and were assisted with eating their meal by Certified Nursing Assistant (CNA) X. CNA X was talking loudly to Dietary Staff (DS) KK about her plans for when she got out of work. CNA X was overheard by this writer stating, I am so ready to go home, I don't want to be here all day, I don't really want to be here at all today. DS KK and CNA X continued to carry on a personal conversation with each other for several minutes. It was noted that CNA X and DS KK did not interact with Resident #14 or Resident #21 at all during the meal. In an dining observation on 1/22/25 at 12:32 PM, Resident #21 was being assisted with eating by CNA X. CNA X was sitting at the table next to Resident #21 and CNA W. It was noted that CNA X had turned her back to Resident #21 and would only turn towards Resident #21 when she was assisting her with bites of food. It was also noted that CNA X was having a personal conversation with CNA W, and would only stop to offer Resident #21 bites of food when CNA W would begin interacting with the resident that he was assisting to eat. In an interview on 1/21/25 at 9:52 AM, Family Member (FM) N reported that they felt like the staff could improve on how they assist residents with eating in the dining room. FM N reported that they felt like the staff rushed residents, and did not take the time to interact with the residents when they were assisting them to eat. In an interview on 1/23/25 at 11:15 AM, Food Service Manager (FSM) LL reported that she supervised the dining area and would observe meal times frequently. FSM LL reported that she had previously voiced concerns with management about the way that staff behaved and interacted with and in front of the residents as they were eating in the dining room. FSM LL reported that she had witnessed staff using their phones, wearing ear buds, and ignoring residents they were assisting frequently in the dining room. FSM LL reported that she had voiced her concerns to management and they had posted signs about not using phones in the dining room, but she felt that improvement was still needed on how staff interacted with the residents as they were eating. FSM LL confirmed that CNA X was a staff member that she had observed ignoring the residents as she assisted them to eat on multiple occasions. In an interview on 1/23/25 at 12:18 PM, Health Care Manager (HC-M) E' reported that she had been made aware of staff using phones in the dining room while assisting residents in the past, but she was not aware that there were still concerns with the way that staff were interacting with residents in the dining room during meals. Using the reasonable person concept, though Resident #14 and Resident #21 had decreased ability to verbally express their own thoughts due to medical diagnoses, any reasonable person would likely feel a decreased sense of self-worth and frustration in the situations observed. Review of the facility's Dignity Policy last revised February 2021 revealed, Policy Statement: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem .Policy Interpretation and Implementation: 1. Residents are treated with dignity and respect at all times .5. When assisting with care, residents are supported in exercising their rights. For example, residents are: .e. provided with a dignified dining experience .

Based on observation, interview, and record review, the facility failed to properly label, date, and discard opened food products. These conditions resulted in an increased risk of food borne illness that affected all residents who consume food from the kitchen. Findings include: On 2/27/24 beginning at 9:05 AM, an initial tour of the kitchen/food service was conducted with Director of Culinary Services (DCS) K. The following observations/interviews occurred during this initial tour: At 9:10 AM in the main kitchen dairy cooler, noted the following: an opened container of nonfat Greek yogurt that was not labeled with an opened date or discard date and an opened container of sour cream labeled with an opened date of 2/18/24 and a discard date of 2/24/24. At 9:20 AM in the cook's cooler, noted an opened container of hummus labeled with an opened date of 2/16/24 and a discard date of 2/22/24. At 9:37 AM in the skilled nursing kitchenette drink cooler, there was an opened container of soy milk labeled with an opened date of 2/5/24 and a discard date of 2/12/24 (8 days total). At 9:38 AM in the skilled nursing kitchenette nursing cooler (of which DCS K reported residents have access to), there was an opened container of applesauce that was not labeled with an opened date or discard date. At approximately 9:42 AM, DCS K reported that the opened food products identified should have been labeled with an opened date and a discard date and that food items past the discard date should have already been discarded. DCS K reported they needed to do some work on labeling, dating, and discarding of food products. According to the 2017 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. (B) Except as specified in (E) -(G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety . According to the 2017 FDA Food Code section 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A FOOD specified in 3-501.17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3-501.17(A), except time that the product is frozen; (2) Is in a container or PACKAGE that does not bear a date or day; or (3) Is inappropriately marked with a date or day that exceeds a temperature and time combination as specified in 3501.17(A) .

Based on interview and record review, the facility failed to submit complete and accurate direct care staffing data for the 4th quarter of 2023 (July, August, and September). Findings include: Review of PBJ (Payroll Based Journal) Staffing Data Report revealed no RN (registered nurse) hours and failed to have licensed nursing coverage 24 hours/day categories were triggered for every single day during the months of July, August, and September of 2023 (4th Quarter). During an interview on 2/27/24 at 3:40 PM., Nursing Home Administrator (NHA) A reported that he is responsible for submitting PBJ staffing data. NHA A reported that during the 4th quarter of 2023 only half of the staffing data was submitted to CMS (Centers for Medicare and Medicaid). Review of an electronic communication that included NHA A and Director of Nursing (DON) B as recipients dated 10/24/2023 at 1:41 PM., the body text revealed .the PBJ report did not have all our staffing information included in the 2nd quarter report .that is why we are 1-star in staffing .

Based on observation, interview, and record review, the facility failed to follow professional standards of practice for (1) documentation of medication administration in 3 of 7 residents (Resident #1, #37, & #145) reviewed for medication administration, and (2) medication handling/storage in 1 of 8 residents (Resident #3) reviewed for medication storage, resulting in medications being left unsupervised at the bedside, and the potential for medication errors. Findings include: According to [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing.High-quality documentation is necessary to enhance efficient, individualized patient care. Quality documentation has five important characteristics: it is factual, accurate, complete, current, and organized . Accessed from: Kindle Locations 24106-24108). Elsevier Health Sciences. Kindle Edition. Resident #1 Review of an Admission Record revealed Resident #1 was a female, with pertinent diagnoses which included heart failure, kidney disease, vitamin D deficiency, vitamin B12 deficiency anemia, atrial fibrillation (an abnormal heart rhythm that results in poor blood flow), joint pain, edema (swelling), high blood pressure, esophageal reflux (heartburn), arthritis, and constipation. Review of an Order Summary Report for Resident #1 revealed active physician orders for .Acetaminophen Oral Tablet 500 MG (Acetaminophen) Give 2 tablet orally three times a day . with a start date of 6/13/23, .CeleBREX Oral Capsule 50 MG (Celecoxib) Give 1 capsule by mouth two times a day . with a start date of 2/26/24, .Eliquis Oral Tablet 5 MG (Apixaban) Give 1 tablet orally two times a day . with a start date of 6/13/23, .Furosemide Oral Tablet 40 MG (Furosemide) Give 1 tablet orally one time a day . with a start date of 6/13/23, .MagOx 400 Oral Tablet (Magnesium Oxide (Mg Supplement)) Give 1 tablet orally one time a day every 2 day(s) . with a start date of 6/13/23, .Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 50 MG (Metoprolol Succinate) Give 1 tablet orally one time a day . with a start date of 6/13/23, .Oyster Shell Calcium + D Oral Tablet 500-5 MG-MCG (Calcium Carbonate-Cholecalciferol) Give 1 tablet orally one time a day . with a start date of 6/13/23, .Potassium Chloride ER Oral Capsule Extended Release 10 MEQ (Potassium Chloride) Give 1 capsule orally one time a day . with a start date of 6/13/23, .Omeprazole Oral Capsule Delayed Release 20 MG (Omeprazole) Give 1 capsule orally one time a day . with a start date of 6/13/23, .Senna Plus Oral Tablet 8.6-50 MG (Sennosides-Docusate Sodium) Give 1 tablet orally one time a day . with a start date of 6/13/23, .Vitamin D3 Oral Capsule 25 MCG (1000 UT) (Cholecalciferol) Give 1 capsule orally one time a day . with a start date of 6/13/23, and .Cyanocobalamin Oral Tablet 500 MCG (Cyanocobalamin) Give 2 tablet orally one time a day . with a start date of 6/13/23. In an observation on 2/28/24 at 8:21 AM, Licensed Practical Nurse (LPN) BB prepared scheduled medications for Resident #1. Observed LPN BB prepare two tablets of Acetaminophen Oral Tablet 500 MG, one CeleBREX Oral Capsule 50 MG, one Eliquis Oral Tablet 5 MG, one Furosemide Oral Tablet 40 MG, one Magnesium Oxide 400 MG oral tablet, one Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 50 MG, one Oyster Shell Calcium + D Oral Tablet 500-5 MG-MCG, one Potassium Chloride ER Oral Capsule Extended Release 10 MEQ, one Omeprazole Oral Capsule Delayed Release 20 MG, one Senna Plus Oral Tablet 8.6-50 MG, one Vitamin B-12 1000 MCG oral tablet, and one Vitamin D3 1000 IU oral capsule for Resident #1. LPN BB placed all ordered medications in a medication cup for administration. LPN BB then documented the medications as given (signed the Medication Administration Record (MAR)) prior to administration to Resident #1. In an interview on 2/28/24 at 8:21 AM, LPN BB reported she generally documents medications as administered before they are taken. LPN BB stated .it's a habit . and reported if the medications are refused or not taken for any reason, she would go back and modify the documentation. In an interview on 2/28/24 at 8:54 AM, Registered Nurse (RN) H reported medications should not be documented as given/signed until after administration. In an interview on 2/28/24 at 12:00 PM, RN DD reported administration of medication is documented after the medication is given. Resident #37 Review of an Admission Record revealed Resident #37 was a female, with pertinent diagnoses which included diabetes and joint replacement surgery. Review of an Order Summary Report for Resident #37 revealed an active physician order for .Gabapentin Oral Capsule 400 MG (Gabapentin) Give 2 capsule by mouth three times a day . with a start date of 2/13/24. In an observation on 2/28/24 at 12:36 PM, RN DD prepared a scheduled medication for Resident #37. Observed RN DD prepare two capsules of Gabapentin 400 MG for Resident #37. RN DD placed the ordered medication in a medication cup for administration. RN DD then documented the medication as given (signed the MAR) prior to administration to Resident #37. Resident #145 Review of an Admission Record revealed Resident #145 was a female, with pertinent diagnoses which included nerve pain, diabetes, spinal stenosis (a condition that can put pressure on the spinal cord and nerves that travel through the spine), and spinal fusion. Review of an Order Summary Report for Resident #145 revealed an active physician order for .Gabapentin Oral Capsule 100 MG (Gabapentin) Give 2 capsule by mouth three times a day for pain . with a start date of 2/16/24. In an observation and interview on 2/28/24 at 12:45 PM, RN DD prepared a scheduled medication for Resident #145. Observed RN DD prepare two capsules of Gabapentin 100 MG for Resident #145. RN DD placed the ordered medication in a medication cup for administration. RN DD then documented the medication as given (signed the MAR) prior to administration to Resident #145. RN DD reported controlled medications are documented as administered prior to being given, so that the times in the MAR match the times on the controlled medication count sheets. In an interview on 2/29/24 at 10:00 AM, Director of Nursing (DON) B reported the expectation for the nursing staff would be to document medications as given after administration. Review of the policy/procedure Documentation of Medication Administration, dated 11/2022, revealed .A medication administration record is used to document all medications administered .A nurse or certified medication aide (where applicable) documents all medications administered to each resident on the resident's medication administration record (MAR) .Administration of medication is documented immediately after it is given . 47955 Resident #3 Review of an Admission Record revealed Resident #3 had pertinent diagnoses which included: dementia, gastrostomy (feeding tube), and dysphagia (difficulty swallowing). Review of a Minimum Data Set (MDS) assessment for Resident #3, with a reference date of 1/05/24 revealed a Brief Interview for Mental Status (BIMS) score of 5/15 which indicated Resident #3 was severely cognitively impaired. During an observation on 2/28/24 at 12:39 PM., Licensed Practical Nurse (LPN) BB placed a medication cup of crushed medications in water on a chair in Resident #3's room. LPN BB began to administer a water flush to Resident #3's feeding tube, experienced difficulties, and stated I'm going to get a stick. I'll be right back. During an observation on 2/28/24 at 12:49 PM., LPN BB exited Resident #3's room. A cup of medications dissolved in water were noted on a chair in Resident #3's room. During an observation on 2/28/24 at 12:51 PM., LPN BB entered Resident #3's room. During an observation on 2/28/24 from 12:49 PM to 12:51 PM a cup of medications dissolved in water were noted to be sitting on a chair in Resident #3's room, unattended, with no staff noted in the room. During an observation on 2/28/24 at 12:57 PM., LPN BB stated we need coke to unclog this tube . I'll be back shortly .Are you going to ding me if I leave these medications in here? During an interview on 2/28/24 at 1:14 PM., LPN BB reported there were 4 medications dissolved in water in the cup for Resident #3. LPN BB reported medications should not be left unattended. LPN BB confirmed she left the cup of medications dissolved in water unattended. During an interview on 2/28/24 at 1:53 PM., Director of Nursing (DON) B reported that the expectation was that mediations were not left unattended.

This citation has two Deficiency Practice Statements, 1 & 2. Deficiency Practice Statement 1: Based on observation, interview, and record review, the facility failed to: (1) perform hand hygiene when moving between resident rooms after performing resident care; (2) sanitize resident shared equipment between resident use; (3) wear appropriate PPE (personal protective equipment) while sorting soiled laundry, including laundry from transmission-based precaution isolation rooms; and (4) implement precautions and utilize appropriate PPE per physician order in 1 of 3 residents (Resident #3) reviewed for transmission-based precautions. These deficient practices resulted in the potential for cross-contamination, disease exposure, and the development and spread of infection to a vulnerable population. Findings include: During an observation/interview on 2/27/24 beginning at 11:38 AM, noted Certified Nurse Aide (CENA) T entered room [ROOM NUMBER] with a vitals machine, and checked the temperature, pulse oximetry (saturation of oxygen in the blood), and blood pressure of the resident in the room. CENA T then exited room [ROOM NUMBER] with the vitals machine, entered room [ROOM NUMBER] and began checking the blood pressure of the resident in room [ROOM NUMBER]. CENA T did not sanitize the vitals machine between the two residents. CENA T did not perform hand hygiene after exiting room [ROOM NUMBER] or before entering room [ROOM NUMBER]. While measuring the blood pressure of the resident in room [ROOM NUMBER], CENA T looked up and noticed this surveyor observing and stated oh no. CENA T then removed the blood pressure cuff from the resident in room [ROOM NUMBER], walked into the bathroom and washed her hands for 10 seconds. CENA T then exited room [ROOM NUMBER] with the vitals machine, obtained a sanitizing wipe from the dispenser on the wall in the hallway, and began sanitizing the vitals machine. This surveyor queried CENA T as to why she looked up and said oh no and CENA T reported it was because she forgot to sanitize the vitals machine after using it on the resident in room [ROOM NUMBER]. When queried about hand hygiene between residents and the length of time she washed her hands, CENA T reported when she realized she had not hand sanitized between resident care, she went into the bathroom in room [ROOM NUMBER] and washed her hands. CENA T reported she did not know for sure how long she washed her hands but agreed that it was probably less than 20 seconds. During an observation/interview on 2/29/24 at 11:19 AM, noted CENA QQ retrieved a vitals machine located next to the nurses' station on the 400 hall. CENA QQ took the vitals machine to room [ROOM NUMBER]. This surveyor obtained permission from the resident to observe her vitals being taken. CENA QQ measured the blood pressure of the resident with the blood pressure monitor and reported did not think the machine was working. CENA QQ then measured the pulse oximetry of the resident and reported did not think that was working either and explained to the resident that she was going to get some different equipment. This surveyor followed CENA QQ as she exited room [ROOM NUMBER] with the vitals machine and returned it to the 400 hallway next to the nurses' station. CENA QQ did not sanitize the vitals machine before or after use. CENA QQ then retrieved a pink bag from the nurses' station overhead file cabinet and returned to room [ROOM NUMBER]. CENA QQ explained to this surveyor that the pink bag belonged to one of the nursing staff and contained the same equipment as the vitals machine (a thermometer, a pulse oximeter, and a blood pressure monitor.) Using the equipment from the pink bag, CENA QQ then measured the temperature, pulse ox, and blood pressure of the resident in room [ROOM NUMBER]. After use, CENA QQ put the equipment back in the pink bag without sanitizing it. This surveyor followed CENA QQ as she then returned the pink bag to the nurses' station overhead file cabinet. In an interview on 2/28/24 at 2:00 PM, Infection Preventionist (IP) H reported that handwashing should be performed for at least 20 seconds and that proper handwashing was important to prevent the chain of infection. IP H went on to say that proper hand hygiene was the number one way to prevent the spread of infection. IP H reported vitals machines/equipment should be wiped down in between resident use to prevent the spread of infection. In an interview on 2/29/24 at 11:35 AM, Licensed Practical Nurse (LPN) Z reported vitals machines/equipment should be sanitized between resident use. LPN Z reported you should wash your hands for 20 seconds or more. In an interview on 2/29/24 at 11:42 AM, CENA SS reported vitals equipment should be cleaned after each resident use and handwashing should be done for at least 20 seconds. 47955 Resident #3 Review of an Admission Record revealed Resident #3 had pertinent diagnoses which included: dementia, gastrostomy (feeding tube), and dysphagia (difficulty swallowing). Review of a Minimum Data Set (MDS) assessment for Resident #3, with a reference date of 1/05/24 revealed a Brief Interview for Mental Status (BIMS) score of 5/15 which indicated Resident #3 was severely cognitively impaired. Review of Physician Orders for Resident #3 revealed, . Enhanced barrier precautions, ordered on 11/17/2023 . Review of Care plan for Resident #3 revealed, . Problem-Risk for infection r/t (related to) G-tube (feeding tube inserted into the stomach for nourishment) site .goal- Resident will show no signs or symptoms of infection . Interventions-precautions per physician order . initiated on 6/27/2023. During an observation on 2/27/24 at 10:00 AM., it was noted outside of Resident #3's room was signage indicating enhanced barrier precautions be used when entering the room. The signage revealed that anyone entering the room should perform hand hygiene, apply a gown and gloves before entering the room. Noted outside of Resident #3's room was a grey in color upright storage container with drawers that contained a box masks, boxes of gloves, and folded gowns. Hand sanitizer bottles were noted in a wire basket on the wall outside of Resident #3's room. During an interview on 2/27/24 at 10:12 AM., Registered Nurse (RN) EE reported that staff were to use enhanced barrier precautions when caring for Resident #3. RN EE reported that enhanced barrier precautions meant staff should wear a gown and gloves when providing care to Resident #3. During an interview on 2/27/24 at 10:32 AM., Certified Nurse Assistant (CENA) X reported that the signage and the storage bin containing personal protective equipment (PPE) outside of Resident #3's room indicated that staff should wear a gown and gloves when providing care to Resident #3. During an interview on 2/27/24 at 10:45 AM., CENA Q reported that the signage and the storage bin containing PPE outside of Resident #3's room indicated that staff should wear a gown and gloves when providing care to Resident #3. During an observation and interview on 2/28/24 at 11:35 AM., Licensed Practical Nurse (LPN) BB entered Resident #3's room. LPN BB did not perform hand hygiene, put on a gown or gloves before entering Resident #3's room. When asked, LPN BB reported she should have applied PPE before entering Resident #3's room. During an observation on 2/28/24 at 11:40 AM., CENA Y opened the door of Resident #3's room and spoke to the other staff in the room. Through the open-door, CENA Q was observed without a gown on in Resident #3's room. CENA Y entered Resident #3's room without applying any PPE. During an observation and interview on 2/28/24 at 11:43 AM., CENA Y exited Resident #3's room. When asked, CENA Y reported that Resident #3 was on enhanced barrier precautions and the signage posted outside of Resident #3's room indicated to staff they should apply PPE before providing care. CENA Y reported she did not apply PPE and that she was in the room assisting with personal care for Resident #3. During an interview on 2/28/24 at 11:57 AM., CENA Q reported that the signage posted outside of Resident #3's room indicated to staff they should wear a gown when providing care to Resident #3. CENA Q reported she was not wearing a gown when she provided care to Resident #3. During an interview on 2/28/24 at 3:15 PM., Director of Nursing (DON) B reported that the expectation was that if a resident was in precautions, staff would wear the appropriate PPE every time they provided care. Review of Facility Policy Isolation- Categories of Transmission-Based Precautions with a revision date of September 2022 revealed, .appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for and the type of precaution. The signage informs the staff of the type of CDC (Centers for Disease Control) precaution (s), instructions for use of PPE . During an interview on 2/28/24 at 10:24 AM., Laundry Aide (LA) OO reported that a gown should be worn to sort soiled laundry. When asked, LA OO reported that she does not always wear a gown when sorting soiled linen. During an interview on 2/28/24 at 10:45 AM., Housekeeper (HK) PP reported that a gown was supposed to be worn when sorting soiled linen. During an observation and interview on 2/29/24 at 9:26 AM., LA OO was not wearing a gown in the dirty laundry room while sorting soiled linen. LA OO reported that she only wears a gown to sort contaminated linen. During an interview on 2/29/24 at 9:38 AM., Environmental Service Manager (ESM) NN reported that the expectation is that staff will wear gloves and a gown or apron when sorting soiled linen in the dirty laundry room. Review of Facility Policy Laundry and Bedding, Soiled with a revision date of September 2022, revealed, .handling .all used laundry is handled as potentially contaminated using standard precautions (e.g., gloves, and gowns when sorting) . 38905 DPS 2 Based on interview and record review, the facility failed to have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in water borne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among any or all of the residents in the facility. Findings include: During an interview with Director of Plant Operations (DPO) TT, at 2:20 PM on 2/28/24, it was found that the facility does not currently test their water supply for any type of control measure, but has started the process of working with a vendor to help update the plan and get it going. When asked if there was a regular flushing schedule for minimum use or unused fixtures, DPO TT stated that currently there is no regular schedule for flushing in the health center or rehab, but rooms don't stay vacant for very long. When asked if he knew if there were minimum use fixtures that should be regularly flushed, DPO TT was unsure. A review of the Water Management Plan, with DPO TT, found no assigned water management team or sign off, of an annual review of the plan. No completed CDC Tool kit was found in the documentation. A review of the facilities Water Management Policy, dated 2017, found that . control measures will be established to address potential hazards .including physical controls, temperature management, disinfectant level control, visual inspections, or environmental testing for pathogens .Testing protocols and acceptable ranges (control limits) will be established for each control measure. Further review found that, The facility will conduct an annual review of the water management program .

Based on observation, interview, and record review, the facility failed to ensure safe transport of a resident in a wheelchair footrests were in place, or properly used, in 1 (Resident #6) of 13 sampled residents, resulting in the potential for an accident or an injury to occur during transport. Findings include: Resident #6 Review of an Admission Record revealed Resident #6 had pertinent diagnoses which included: dementia, weakness, and repeated falls. Review of a Minimum Data Set (MDS) assessment for Resident #6, with a reference date of 2/14/24 revealed a Brief Interview for Mental Status (BIMS) score of 8/15 which indicated Resident #6 was moderately cognitively impaired. During an observation on 2/28/24 at 12:19 PM., Certified Nurse Assistant (CENA) U was observed pushing Resident #6 in a wheelchair near the nurse's station and down the hallway to Resident #6's room. Resident #6's wheelchair did not have any footrests in place. Resident #6 was observed holding her feet off the floor while in motion. During an observation on 2/28/24 at 12:21 PM., CENA U was observed pushing Resident #6 in a wheelchair down the hallway from Resident #6's room to a snack cart in the dining room. Resident #6's wheelchair did not have any footrests on her wheelchair. Resident #6 was observed holding her feet off the floor while in motion. CENA U did not provide any instructions to Resident #6 before pushing on her wheelchair. During an observation on 2/28/24 at 12:22 PM., CENA U was observed pushing Resident #6 in a wheelchair from the snack cart in the dining room to a table in the dining room. Resident #6's wheelchair did not have any footrests in place. Resident #6 was observed holding her feet off the floor while in motion. CENA U did not provide any instructions to Resident #6 before CENA U pushed on Resident #6's wheelchair. During an interview on 2/28/24 at 12:28 PM., CENA U reported that Resident #6 does not use footrests on her wheelchair. CENA U reported that for safety residents should not be pushed in their wheelchair without footrests in place. CENA U confirmed when asked that she did push Resident #6 to her room, from her room, and to her table without footrests on her wheelchair. During an interview on 2/28/24 at 12:32 PM., CENA R reported that no resident should be pushed in a wheelchair without their footrests in place. During an interview on 2/28/24 at 12:38 PM., Licensed Practical Nurse (LPN) BB reported that no resident should be pushed in a wheelchair without their footrests in place. During an interview on 2/28/24 at 3:15 PM., Nurse Manager (NM) E reported that no resident should be transported in their wheelchair without their footrests in place. During an interview on 2/28/24 at 3:20 PM., Director on Nursing (DON) B reported that her expectation is that no resident should be transported in their wheelchair without their footrests in place. 41982 During an observation on 2/29/24 at 12:08 PM, noted Resident #6 was wheeling down the hall in her wheelchair. Foot pedals were on her wheelchair, but footrests were folded up. Licensed Practical Nurse (LPN) Z, who was seated at the nurses' station, noticed Resident #6 wheeling down the hall and called to her that she was going down the wrong hall. LPN Z then walked over to Resident #6 and told her she would take her to the hall where she resides. LPN Z then pushed Resident #6 in her wheelchair back down the wrong hall and over to the hall where the resident resides. LPN Z did not unfold the footrests and put them down so the resident could rest her feet on them. Resident #6 was able to hold her feet up part of the time she was being pushed in her wheelchair by LPN Z and then rested her feet on the floor for an approximate distance of 15-20 feet while being pushed.

Based on interview and record review, the facility failed to develop and implement a person-centered comprehensive care plan for a high-risk medication for 1 (Resident #32) of 13 sampled residents reviewed for care plans, resulting in an incomplete reflection of the residents' care needs. Findings include: Resident #32 Review of an Admission Record revealed Resident #32 was a female, with pertinent diagnoses which included: respiratory failure and heart failure. Review of an active Physician's Order for Resident #32 revealed, Torsemide Oral Tablet 10 MG (milligrams) Give 10 mg by mouth one time a day . with a start date of 10/3/23. Review of a current Care Plan for Resident #32 revealed no care planned focus, goals, or interventions related to Resident #32's diuretic (Torsemide) use. In an interview on 2/29/24 at 9:34 AM, Nurse Manager (NM) E reported she was responsible for developing the resident care plans for diuretic use, among other things. NM E was requested to show this surveyor a care plan for Resident #32's diuretic use. NM E reviewed Resident #32's current care plan and reported there was no care plan in place for her diuretic use but there should have been. NM E reported it was important to care plan diuretic use due to increased urination and risk for dehydration.

Based on observation, interview, and record review, the facility failed to ensure proper care and services related to tube feeding management in 1 (Resident #3) of 1 resident reviewed for tube feeding management, resulting in the potential for decreased feeding tube patency, feeding tube damage, and/or resident infection or injury. Findings include: Resident #3 Review of an Admission Record revealed Resident #3 had pertinent diagnoses which included: dementia, gastrostomy (feeding tube), and dysphagia (difficulty swallowing). Review of a Minimum Data Set (MDS) assessment for Resident #3, with a reference date of 1/05/24 revealed a Brief Interview for Mental Status (BIMS) score of 5/15 which indicated Resident #3 was severely cognitively impaired. Review of Physician Orders for Resident #3 revealed . tube feeding diet . osmolyte 1.5 Cal oral liquid (nutritional supplement) give 30ml via G-tube (tube into the stomach for nutritional supplement) two times a day, to run continuously at 30 ml/hour . During an observation on 2/28/24 at 12:39 PM., Licensed Practical Nurse (LPN) BB was unable to administer a water flush to Resident #3's feeding tube. LPN BB stated I'm going to get a stick, we have de-cloggers to use for this. During an observation on 2/28/24 at 12:51 PM., LPN BB inserted into a syringe attached to Resident #3's feeding tube a device that was white in color, had a grey molded handle that was attached to a very thin piece of plastic and was all one piece. LPN BB reported that this device was called a de-clogger. This de-clogger was long enough to pass through the opening of the syringe and into the feeding tube that was inserted into Resident #3's stomach. LPN BB was then observed vigorously inserting and retracting the de-clogger in Resident #3's feeding tube. LPN BB was unable to administer a water flush to Resident #3's feeding tube. LPN BB was then observed vigorously inserting and retracting the de-clogger in Resident #3's feeding tube. LPN BB was then unable to administer water flush to Resident #3's feeding tube. During an observation on 2/28/24 at 12:57 PM., LPN BB was unable to administer a water flush to Resident #3's feeding tube. LPN BB then inserted the de-clogger into the syringe attached to Resident #3's feeding tube and was observed vigorously inserting and retracting the de-clogger in Resident #3's feeding tube. LPN BB was unable to administer a water flush to Resident #3's feeding tube. LPN BB stated I need coke and exited Resident #3's room. During an observation on 2/28/24 at 1:05 PM., LPN BB entered Resident #3's room with a can of carbonated cola beverage. LPN BB then opened the cola, poured some into the syringe attached to Resident #3's feeding tube. LPN BB then inserted the de-clogger into the syringe attached to Resident #3's feeding tube and was observed vigorously inserting and retracting the de-clogger in Resident #3's feeding tube. LPN BB was unable to administer the cola to Resident #3's feeding tube. During an observation on 2/28/24 from 1:08 PM until 1:13 PM. LPN BB vigorously inserted and retracted the de-clogger through a syringe and into Resident #3's feeding tube. During an observation on 2/28/24 at 1:13 PM., LPN BB stated I got 10 cc of coke to flow, now we wait. During an interview on 2/28/24 at 1:20 PM., when asked LPN BB reported that the de-clogging sticks and coke is what we have always used for Resident #3's clogged feeding tube. When asked, LPN BB was not sure if there was a physician order or if they needed a physician order to use those interventions. During an interview on 2/28/24 at 1:53 PM., Director of Nursing (DON) B reported that the facilities policy and procedure to unclog a feeding tube should be followed. DON B reported that her expectation for a clogged feeding tube was to stop the procedure, notify the physician, and obtain an order to use the de-clogger stick or any other order that the physician provided. Review of Care plan for Resident #3 revealed no listed intervention for the use of a de-clogger in the feeding tube nor the use of a carbonated cola beverage in the feeding tube to remove a clog. Review of Physician Orders for Resident #3 revealed no order for the use of a de-clogger in the feeding tube nor the use of a carbonated beverage in the feeding tube to remove a clog. During an interview on 2/28/24 at 2:06 PM., Infection Preventionist/Registered Nurse (IP/RN) H reported that a physician order was needed to use a de-clogger in a feeding tube. During an interview on 2/28/24 at 3:15 PM., Registered Nurse/Nurse Manager (RN/NM) E reported that Resident #3 did not have care plan interventions to use a de-clogger or a carbonated cola beverage to unclog her feeding tube. During an interview on 2/28/24 at 3:20 PM., DON B reported that her expectations were that care plan interventions or physician orders should be in place to use a de-clogger or carbonated cola beverage to unclog a feeding tube. Review of facility policy Maintaining Patency of a Feeding Tube (Flushing) with a revision date of November 2018 revealed .for opening a clogged feeding tube . use warm water for initial declogging efforts. Do not use cranberry juice or carbonated beverages .

This citation pertains to intake MI00135557. Based on interview and record review, the facility failed to follow the care plan in one of three residents reviewed for falls (Resident #1), resulting in a large laceration and hematoma to her head, transfer to the emergency department, and pain. Findings include: Resident #1 (R1) R1's care plan notes dated 11/17/22 revealed she was admitted to the facility on [DATE], her cognition was severely impaired and had the diagnoses of dementia, severe depression, anxiety, and history of a stroke. R1's same care plan notes revealed she was at low risk for falls and had no falls that quarter. R1's fall risk care plan dated 2/12/19 revealed her bed was to be in the lowest position and locked when in bed. R1's annual Minimum Data Set (MDS) assessment dated [DATE] indicated she was completely dependent on staff for bed mobility and transfers. R1's Clinical notes dated 1/27/23 at 7:02 PM revealed she fell from her bed on 1/27/23 at 4:45 PM. R1 was found on the floor next to her bed, laying on her left side, face down, with blood surrounding her head. The nurse's note indicated she was unsure where R1's blood was coming from at that moment. 911 was called and pressure was applied to stop the bleeding. The same note revealed R1 was complaining of severe pain in her head, knees, hips, hands, mouth, neck, and elbows. R1 had a large hematoma and abrasion. The root cause of the fall was that R1 rolled out of bed; the immediate intervention was to keep her bed in lowest position. Nursing Notes dated 1/27/23 at 11:07 PM revealed R1 had returned from the emergency room with a large hematoma on her left forehead that was 2 to 2.5 inches in circumference. R1 was also noted with a bruise and bleeding from her lip. The same note indicated the nurse applied multiple wound closer strips to her head to stop the bleeding and dressed the area with gauze pads. Nursing Notes dated 1/28/23 at 3:39 PM revealed R1 had a hematoma on her right hand with a small skin tear on her knuckle. A skin tear to her right elbow was noted from the fall. R1 had bruises on her lips and left eye and left side of her head. Her lips were very swollen and painful to the touch. R1's left eye could not open, so pupil reaction was not assessed on her left eye. The hematoma on the left side of her head was oozing a small amount of blood. Wound closer strips were in place, the nurse removed the old abdominal dressing pad and gauze wrap and applied new dressings. R1 was still complaining of pain in her legs, knees, arms, and head. Nursing Note dated 1/29/23 at 10:11 AM revealed R1 was in bed, bruising was noted to the left side of her face and lips. R1 stated she was in pain. Nursing note dated 1/30/23 at 2:21 AM revealed R1 was lying in bed crying out and moaning and reported she was in pain. Repositioning and scheduled acetaminophen was ineffective. Morphine was administered at 11:00 PM, R1 continued to yell out and moan; another dose was administered a 1:00 AM. Nursing Note dated 1/30/23 at 6:35 PM revealed R1 was heard crying out at approximately 8:20 AM, of Morphine pain medication was also administered at 11:30 AM, 3:00 PM, and 5:30 PM, due to R1 crying out in pain and at times was effective. Dietary note dated 2/01/23 at 10:54 AM revealed R1 had a fall on 1/27/23 resulting in facial injury and since her fall her oral intake of diet had decreased and was eating 25 percent of meals. Supplements were being offered with every meal. Certified Nurse Assistant (CNA) D was contacted via telephone on 6/01/23 at 1:35 PM and confirmed she was the CNA that was assigned to R1 at the time of her fall on 1/27/23. CNA D stated she was not able to be interviewed at that time as she was driving and would not be able until the following Monday. CNA D stated she had been called in for the investigation of R1's fall and she had written the details of the event in a statement. Registered Nurse Manager (RN) C was interviewed on 6/01/23 at 2:55 PM and stated R1's bed was not left in low position at the time of her fall on 1/27/23. Director of Nursing (DON) B was interviewed on 6/01/23 at 3:00 PM and stated she was not able to locate CNA D's statement following R1's fall on 1/27/23. DON B stated CNA D left R1's bed in high position after providing care prior to R1's fall. DON B stated CNA D had been educated to follow R1's care plan.

Based on observation, interview, and record review the facility failed to: 1. Protect open and exposed food; 2. Date and discard potentially hazardous foods; 3. Upkeep general repair; 4. Clean food and non-food contact surfaces to sight and touch; and 5. Use proper concentration of sanitizer and have test strips available. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that affected 41 residents who consume food from the kitchen. Findings Include: 1. During an initial tour of the kitchen, starting at 9:10 AM on 3/13/23, it was observed that a sheet pan, filled with individual cups of Panna [NAME], were found open and exposed near the bottom of an expediting rack. When asked if these items were stored properly, Dining Director (DD) QQ stated that they should be covered. According to the 2017 FDA Food Code section 3-302.11 Packaged and Unpackaged Food -Separation, Packaging, and Segregation. (A) FOOD shall be protected from cross contamination by .storing the FOOD in packages, covered containers, or wrappings; . 2. During an initial tour of the facility, at 9:12 AM on 3/13/23, it was observed that an open bag of spinach, opened on 3/12, was found with a manufacture best by date of 3/5/23. During an initial tour of the facility, at 9:21 AM on 3/13/23, observation of the dairy walk-in cooler found three unopened gallons of apple cider with best by dates of 1/11/23. It was also observed that an opened gallon container of whole milk was found with a best by date of 3/12/23, a large container of ranch dressing was dated 3-1 to 4-1. When asked if they make the ranch dressing in house DD QQ stated yes. During an initial tour of the facility, at 9:26 AM on 3/13/23, observation of the cooks cooler found a bag labeled cut up lettuce with no date, and an opened bag of spinach dated 3/9 to 3/13 with a best by date of 3/5. Further review of the cooler found a container of Greek salad dressing dated for 4/6/23. When asked if this was an in house prepared product, Executive Chef (EC) RR stated it was. During an initial tour of the facility, at 11:19 AM on 3/13/23, observation of the front of house service area found an opened gallon of whole milk dated 3-6 to 3-10. During the initial tour of the health center serving kitchen, at 11:44 AM on 3/13/23, it was found that an open gallon of whole milk was found dated 3/13 to 3/18 with a best by date of 3/13. According to the 2017 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. (B) Except as specified in (E) -(G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety . According to the 2017 FDA Food Code section 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A FOOD specified in 3-501.17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3-501.17(A), except time that the product is frozen; (2) Is in a container or PACKAGE that does not bear a date or day; or (3) Is inappropriately marked with a date or day that exceeds a temperature and time combination as specified in 3501.17(A) . 3. During an initial tour of the facility, at 9:16 AM on 3/13/23, the surveyor had noticed new lights in the kitchen and asked about improvements that had been done. DD QQ stated that about a year ago they were able to get all new lights and ceiling tiles for the kitchen, along with some new equipment. Upon observation of the ceiling, it was noted a few areas where ceiling tiles were already showing distress with moisture accumulation. When asked about issues with the ceiling tiles accumulating moisture, DD QQ stated that about a month after installation they started to develop these issues in a couple areas of the ceiling and have not been able to find a good long-term solution. At this time it was noted that ceiling tiles near the end of the cook line, near the ice machine, and over the preparation area near the mixers, show tiles that have been observed to be continually saturated and dried over time. According to the 2017 FDA Food Code section 6-501.11 Repairing. PHYSICAL FACILITIES shall be maintained in good repair. 4. During an initial tour of the facility, at 9:43 AM on 3/13/23, observation of the four door traulson refrigeration unit found increased amounts of debris on the gaskets and seals of the unit. During an initial tour of the facility, at 9:52 AM on 3/13/23, observation of the ice scoop holder found with an accumulation of black debris in the bottom of the holder. When shown to DD QQ, it was taken to the dish area to be washed. During an initial tour of the facility, at 10:00 AM on 3/13/23, observation of the mechanical scoop drawer found excess crumb debris. When asked when staff would clean these areas, EC RR stated they should be doing a nightly check. During an initial tour of the facility, at 10:29 AM on 3/13/23, observation of the 3 door [NAME] unit, in the receiving room, was found with an increase of crumb debris and accumulation inside of the unit. During an initial tour of the facility, at 11:18 AM on 3/13/23, observation of the main drink station found heavy accumulation of sticky debris under the spouts of the juice machine. During an initial tour of the health center serving kitchen, at 11:43 AM on 3/13/23, it was found that an increased amount of accumulation was found on the underside of the juice dispensers. According to the 2017 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. 5. During an initial tour of the health center serving area, at 11:35 AM on 3/13/23, it was observed that Cook TT was pouring bleach into a sanitizer bucket to make sanitizer. When asked if they had bleach test strips, Cook TT was unsure. During an interview with Dietary Manager (DM) SS, at 11:40 AM on 3/13/23, it was found that staff do not have bleach test strips to ensure proper concentration of sanitizer. When asked how strong the bleach sanitizer should be, DM SS stated 50 parts per million (ppm). The surveyor tested the bleach solution with his test strips and found it to be 150 -200 ppm. According to the 2017 FDA Food Code section 4-302.14 Sanitizing Solutions, Testing Devices. A test kit or other device that accurately measures the concentration in MG/L of SANITIZING solutions shall be provided.

Based on interviews and record review, the facility failed to ensure that 5 of 32 Certified Nursing Assistants (CENA's) had the required annual competency training, resulting in the potential for the delivery of nursing and related services that did not support the attainment or maintenance of the Resident's highest practicable physical, mental, and psychosocial well-being. Findings include: In an interview on 3/15/23 at 9:35am, Infection Assistant EE revealed nursing staff education was tracked via a spreadsheet. A copy of the spreadsheet was requested for later review. A record review of a spreadsheet titled CERT, provided by Infection Assistant EE revealed 5 of 32 Certified Nursing Assistants (CENA's) had not completed required annual training in the last 12 months. In a follow up interview on 3/15/23 at 1:05pm, Infection Assistant EE confirmed that all 5 of the Certified Nursing Assistants (CENA's) who had not completed the required annual training, continued to work at the facility. Infection Assistant EE reported that although the education was required to ensure appropriate care was provided, the facility struggled with staffing issues and could not remove the staff from the schedule or provide them with the training within the last 12 months.

Based on interview and record review, the facility failed to ensure Minimum Data Set (MDS) discharge assessments were transmitted the Centers for Medicare and Medicaid Services (CMS) for 4 (R#'s 2, 33, 40 and 41) of 7 Residents reviewed for automated data processing requirements, resulting in the potential for inaccurate tracking of resident's assessments and discharges. Findings include: Resident #2 A review of the admission and discharge records revealed Resident #2 was discharged from the facility on 9/28/22. However, a review of Minimum Data Set (MDS) data revealed a discharge assessment had not been submitted. Resident # 33 A review of the admission and discharge records revealed Resident #33 was discharged from the facility on 10/18/22. However, a review of Minimum Data Set (MDS) data revealed a discharge assessment had not been submitted. Resident #41 A review of the admission and discharge records revealed Resident #41 was discharged from the facility on 10/18/22. However, a review of Minimum Data Set (MDS) data revealed a discharge assessment had not been submitted. In an interview with Director of Nursing (DON) B' confirmed that Minimum Data Set (MDS) assessments are required at various intervals of a Residents' stay. DON B could not identify the specific situations/timeframes in which MDS assessments must be completed and submitted. In an interview on 3/15/23 at 4:26pm with Interim Minimum Data Set Coordinator (MDS Coordinator) K, it was revealed that a discharge assessment should be submitted to the Center for Medicare and Medicaid Services (CMS) for each Resident. The deadline for submission is within 31 days of the discharge. MDS Coordinator K could not provide a reason regarding the missing discharge assessments. 41424 Resident #40: In an interview on 3/14/23 at 11:43 AM, MDS Coordinator UU reported the facility currently has an interim MDS Coordinator who comes from an agency. MDS Coordinator UU reported the prior MDS Coordinator left in December 2022 and the interim MDS Coordinator K was working to get the MDS assessments caught up. Review of Resident #30's medical record revealed, Resident #30 was discharged from the facility on 10/21/22. Review of MDS Assessments for Resident #30 revealed no MDS Discharge assessment was completed. Review of Nursing Note dated 10/21/22 at 2:29 PM, revealed, .Reviewed discharge instructions and medication list with (Resident #40) and daughter (first name of daughter), they verbalized understanding. copy given to (Resident #40). dressing supplies sent with them and new medications. no further needs identified . Review of electronic correspondence with RAI/MDS &OASIS Education Coordinator(OEC) VV on 3/15/23 at 5:16 PM, revealed, .This resident also had 2 assessments. Entry record with the target date 10/07/2022 and OBRA admission assessment with the target date of 10/13/2022. There is no other assessment in the system for this resident. If the resident is still in the facility he should have the quarterly assessment or if discharged , he must have an discharge assessment. Which neither was completed .

This citation pertains to MI 257. Based on observation, interview and record review the facility failed to maintain resident safety during a transfer for 1 of 3 residents (Resident #101) resulting in a fall and fracture of a resident's spine. Findings include: Review of the Policy Lifting machine, Using a mechanical dated 7/2017 revealed, the purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device and At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift. Review of the Facility Reported Incident (FRI) report dated 8/20/21 at 9:30 AM revealed Certified Nurse Aide (CNA) G was transferring resident (Resident #101) from the bed to a chair using a Hoyer (brand name mechanical lift) lift. The resident (Resident #101) fell out of the Hoyer and landed on the floor. Open gash noted on the back of resident's head. The FRI report revealed Resident #101 Was Harmed: Yes and had Serious bodily injury. The FRI report further revealed Resident #101 .was sent to the hospital ER (emergency room ). 6 staples placed in her head to close her (Resident #101) laceration of her scalp. Resident (Resident #101) also has a fracture of the 1st [MEDICATION(S)] (vertebral/spine area) vertebra per hospital records. Review of the Face Sheet revealed Resident #101 was a female admitted to the facility in 2019 and diagnosed with muscle weakness and unsteadiness on feet. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #101 had a brief interview for mental status (BIMS) score of 3 out of 15 which indicated she had severe cognitive impairment and was a total dependence on 2 staff members for transfer. Review of the Care Plan Transfers dated 11/30/21 revealed, transfers will be completed with Hoyer lift and 2 person assist. During an observation on 8/25/21 at 8:43 AM, Resident #101 was noted to be in bed on oxygen with her eyes closed . During an interview on 8/25/21 at 11:17 AM, CNA G stated when she transferred Resident #101, on 8/20/21, she lifted Resident #101 off the bed with the Hoyer lift and suddenly Resident #101 .went over backwards and fell out of the Hoyer lift onto the floor. CNA G stated, there was blood from the back of Resident #101's head. CNA G stated Resident #101 was taken to the hospital by ambulance. CNA G stated she was the only staff member in the room during the Hoyer lift of Resident #101 and there should have been 2 staff members for safety. Review of the Hospital Emergency Department Note dated 8/20/21 at 11:00 PM revealed Resident #101 had a chief complaint of Fall and fell out of Hoyer lift, lac (laceration/cut) to posterior (back) of skull. The Hospital Emergency Department Note further revealed Resident #101 had a skin repair of 6 staples and 1 suture (stitch for holding together the edges of a wound or surgical incision) to close Resident #101's laceration. Review of the Hospital Radiology Report dated 8/20/21 at 11:35 PM revealed the indication for the CT (computed tomography) scan was Fall and head trauma and the results were Acute (sudden) fracture (broken bone) through the anterior inferior corner of the T1 (first [MEDICATION(S)]) vertebral body . Review of the Corrective Action Notice dated 8/20/21 revealed CNA G had a Final Warning for failure to follow resident's (Resident #101) care plan while operating a mechanical lift/Hoyer (name brand name mechanical lift) CNA G .transferred resident by herself causing harm to a resident and Due to the severity of the safety violation this is a final warning. During an interview on 8/25/21 at 1:26 PM, Director of Nursing (DON) B stated CNA G .transferred her (Resident #101) by herself and Resident #101 fell to the floor. DON B stated the facility sent her (Resident #101) to the hospital and Resident #101 had a laceration (cut) to scalp which had 6 staples to close the wound and a [MEDICATION(S)] (spine) fracture. DON B stated Resident #101 had always been a 2 person assist.

Based on observation, interview, and record review the facility failed to implement measures to prevent the development of pressure ulcer in 2 of 2 sampled residents (Resident #7 and Resident #10) reviewed for skin care, from a total sample of 13 residents, resulting in the delayed healing and the worsening of pressure ulcers. Findings include; Resident #7 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], revealed Resident #7 was an [AGE] year old female admitted to the facility on [DATE], whose [DIAGNOSES REDACTED]. The MDS revealed Resident #7's ability to make daily decisions was cognitively intact and she was extensively dependent on one to two facility staff members for bed mobility, dressing, transfers, bathing, hygiene, and toilet use. The MDS revealed Resident #7 had a Stage II pressure wound to her coccyx area (bottom) upon admission. Review of the Initial Care Plan dated 4/25/14, revealed Resident #7 had a "Pressure Ulcer/Skin at Risk and Goal: Prevent/Heal pressure sores, Prevention: Pressure reducing mattress and chair cushion, Float heels." Review of the Initial Nursing assessment dated [DATE], revealed the skin assessment did not indicate that Resident #7 had any concerns with her feet. Review of the physician progress notes [REDACTED].#7 was seen due to right heel will 2" fluid filled blister and the left heel was soft and mushy. Review of the Nursing Notes dated 5/7/14 at 1400 (2:00 p.m.), revealed "Resident was noted on 4/28/14 with a 2" blister fluid filled to right heel. Today blister measures 4 cm wide by 3 cm long..." Review of the Nursing Noes date 5/28/14 at 10:00 a.m. revealed, Resident #7's "right outer heel blister popped-area where clear fluid blister was present now has a brown /deep red eschar like scab present." 12:30 p.m. Nurse Practitioner notified of right outer heel. Observations by this Surveyor during the on-site visit 5/2/14 through 5/4/14, revealed Resident #7 resting in bed after meals with her heels not elevated. Resident #10 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], revealed Resident #10 was an [AGE] year old male admitted to the facility on [DATE], whose [DIAGNOSES REDACTED]. The MDS revealed Resident #10's ability to make daily decisions moderately impaired and he was extensively dependent on one to two facility staff members for bed mobility, dressing, transfers, bathing, hygiene, and toilet use. Review of Skin Care Plan dated 2/18/14, revealed Resident #10 was at risk for alteration in skin integrity related to bed mobility and the facility approaches included turn and repositioning him every 2 hours and as needed, with heels off bed onto pillow. The Skin Care Plan was updated on 4/24/14 to include a Stage 2 pressure ulcer to the buttock cheek of Resident #10. The new approach for care was to use DuoDerm dressing change every three days until healed. The Skin Care Plan was updated 5/7/14 to include an unstageable pressure ulcer to left heel of Resident #10, which measured 4cm x 5cm the new approach for care were to float heels while in bed (which was in place on 2/18/14), and mediboot to left heel. Review of the Nurse's Wound Notes dated 6/4/14 at 12:30 p.m., revealed Resident #10's "Left outer heel - pressure area edges very macerated. approximately 1cm - pressure area measures 5cm W by 4cm with area of slough in center measuring 2.1cm L by 3cm wide...slough is tan in color with an area of black eschar noted in area of slough..." Hospice Physician notified new orders received. In an observation on 6/4/14 at 11:45 a.m., this Surveyor noted Resident #10 left heel during a dressing change, the old dressing was removed, noted to have a foul odor, there was eschar on the dressing approximately the size of a quarter with tannish yellow stains to the remainder of the 2 x 2 old heel dressing. Resident #10's feet were [MEDICAL CONDITION], the skin was dry with a black red tone in the calf area radiating to a reddish purple tone in the toes. The wound appeared to be approximately the size of a half dollar with the center area measuring the size of a quarter with yellowing white area angle into a crater in Resident #10's foot that was an unknown depth 2:1 angle going to a black area In an interview on 6/5/14 at 1:20 p.m., Licensed Practical Nurse (LPN) "M" reported that Resident #10 was up and down all day and usually co-operative with care. LPN "M" reported that Resident #10's feet were very swollen and he would sit up in his wheelchair with feet in the foot rest with socks on, but staff encouraged him to switch positions every two hours. LPN "M" reported that at times there was an activity Resident #10 wanted to attend so then it was difficult to lay him down. In an observation on 6/4/14 at 2:03 p.m., Certified Nursing Assistant (CNA) "L" was assisting Resident #10 with a transfer to his chair from the sit to stand mechanical lift and pulled the base of the sit to stand out dropping Resident #10's heel's to the floor and left the room. Resident #10 was observed without the heel protection boot when his foot dropped to the floor. #

Based on interview and record review, the facility failed to provide the necessary care and services to maintain the highest practical well being (appropriately assess, monitor and treat an acute change in condition related to an infection) in 1 (#103) of 3 sampled residents reviewed for change in condition related to an infection, of a total sample of 3 residents, resulting in the Resident #103 not receiving antibiotic as ordered and developing increased respiratory distress and death. Findings include: According to the Fundamentals of Nursing, 6th edition (Potter-Perry, Mosby, 2005, page 419), "The physician is responsible for directing medical treatment. Nurses are obligated to follow physicians' orders unless they believe the orders are in error or would harm clients." The reference goes on to indicate that all orders must be assessed and further clarification from the physician retrieved if necessary. "If there is a "missed dose" for any reason the nurse is "require(d) to circle (her initials on) the prescribed administration time on the medication administration record" and explain the reason for the missed dose on the back side of the MAR. (Potter, P. A. & Perry, A. G. (2005) Fundamentals of Nursing (6th ed.). St. Louis: Mosby.). "Documentation within a client medical record is a vital aspect of nursing practice. Nursing documentation must be accurate, comprehensive, and flexible enough to retrieve critical data, maintain continuity of care, track (resident) outcomes, and reflect current standards of nursing practice ...Effective documentation ensures continuity of care, saves time, and minimizes the risk of errors ...The record is a means by which health care team members communicate (resident) needs and progress ...The record should be the most current and accurate source of information about a client ' s health care status ...High-quality documentation...(is) necessary to enhance efficient, individualized (resident) care. Quality documentation...(has) five important characteristics: they are factual, accurate, complete, current, and organized " (Potter, P. A. & Perry, A. G. (2005) Fundamentals of Nursing (6th ed.). St. Louis: Mosby.). According the the facility Face Sheet dated 5/20/13, Resident #103 was a [AGE] year old male admitted to the facility 5/15/13. According to the Physician's Admitting Orders dated 5/15/13, Resident #103 had [DIAGNOSES REDACTED]. On 1/15/14 at 10:00 a.m. an interview with the Director of Nursing (DON) #1 was conducted. DON #1 stated that Resident #103 had been admitted to the facility on [DATE] after being at a hospice facility. DON #1 stated that Resident #103 had "graduated" from the need of hospice services and needed long term care. Review of the document title Nurses Notes dated 5/15/13 at 10:37 a.m., reflected that Resident #103 arrived at the facility, "alert times 3 pleasant, cooperative...ls (lung sounds)clear, denies cough at this time...". Review of the Initial Nursing Assessment completed 5/15/13, the day of Resident #103's admission to the facility, under "#3. Cognitive status Resident #103 was alert with short and long term memory loss, and was able to recall the season, recognize family and staff. Under the section #5. communication it stated resident #103 communicated with speech, was able to understand and could be understood." According to the Progress note completed and dated 5/16/13, by Nurse Practitioner (N.P.) #6 under section "Physical Exam: Neuro: Alert...Resp: lungs clear/diminished..." Review of the document titled Nurses Notes reflected that on 5/16/13 during the supper meal Resident #103 demonstrated difficulty eating his ordered diet. The notes did not reflect that Resident #103's Dr. was notified of the episode. On 5/18/13 at 10:00 a.m. the Nurses Notes reflected that Resident #103 "has very wet gurgle cough, wheezes throughout...O2 (oxygen) 2L (liters) per NC (thru the nose).Chest x-ray ordered stat (immediately)..." On 5/18/13 at 1420 (2:20 p.m.) the Nurses Notes reflected "...N.O. (new order) for [MEDICATION NAME] (an antibiotic) 400 mg (milligrams) once daily for 10 days...x-ray showed persistent right sided effusion with infiltrates (fluid) and atelectasis (collapsed lung tissue)...". Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. In the box under the date of 5/17/13 Licensed Practical Nurse (LPN) #2 had placed her initials with a circle around her initials of the back of the MAR but reflected no documentation as to why Resident #103 did not receive the dose as ordered. Under the date of 5/18/13 no initials were indicated in the box below date. Review of the Nurses notes dated 5/17/13 revealed they did not reflect any documentation for the start of the antibiotic, that the medication was refused or that Resident #103's doctor had been notified of Resident #103's refusal of antibiotic. Review of the Nurses notes dated 5/18/13 revealed they did not reflect any documentation that the medication was refused or that Resident #103's doctor had been notified of Resident 103's refusal of antibiotic. On 5/18/13 at 2000 (8:00 p.m.), the Nurses Notes reflected for Resident #103, "Resident alert, awake VS (Vital signs) 106/58 (blood pressure), 99.0 (temperature), 62 (heart rate) and 18 (respirations)...lung sounds wet some crackles in bases noted...". On 5/18/13 at 2345 (11:45 p.m.), the Nurses Notes reflected "...audibile gurgling heard. Lungs with crackles thru-out. Pox (oxygen level in blood) 87% (normal above 92%) on 4 L (of oxygen)...N.P. (nurse practitioner #4) notified N.O. for [MEDICATION NAME] (Medication used to dry up oral secretions)...". On 5/19/13 at 0330 (3:30 a.m.), the Nurses Notes reflected "Resting with eyes half open. not responding when spoken to. flutters eyes when touched. Gurgling continues. fingernails blue but warm pox 56% on fingers. pox 82-88% on little toe. O2 at 4.5 L...". On 5/19/13 at 0630 (6:30 a.m.), the Nurses Notes reflected, "...PO (medications by mouth) held...O2 at 4.5 l pox 82-88%...". On 5/19/13 at 0915 (9:15 a.m.), the Nurses Notes reflected "Resident with labored breathing with accessory muscles and jerky...". On 5/19/13 at 10:45 a.m., the Nurses Notes reflected "TPR (temperature, Respirations, and Pulse) 98.8, 119, 10 and 89/53 (blood pressure). unable to get pox on 4.5 L...remains unresponsive...". Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the Nurses notes dated 5/19/13 did not reflect any documentation that the medication was refused or that Resident #103's doctor had been notified of Resident #103's refusal of antibiotic. On 5/19/13 1527 (3:27 p.m.), the Nurses Notes reflected "Attempted to call (N.P.# 4's name) a condition report, message left. Respirations range 6-10 (per minute, normal is 16 per minute)...nonresponsive". On 5/19/13 at 2130 (9:30 p.m.), the Nurses Notes reflected "N.P. notified of condition change, unable to take medications. Breathing more labored O2 81-84% on 4.5 L...N.O. to DC (discontinue) po medications with the exception of [MEDICATION NAME] (a pain medication)...90/68 (blood pressure), 99.2 (temperature), 60 (pulse), 12 (respirations)... DPOA (legal representative) notified" On 5/19/13 at 2150 (9:50 p.m.), the Nurses Notes reflected "ABT (antibiotic) for infiltrate has also been discontinued.". On 5/20/13 at 0230 (2:30 a.m.), the Nurses Notes reflected "T (temperature) 98.7 ax (under the arm)-60 ( pulse)- 20 (respirations) 90/60 (blood pressure)...wet sound to lungs...diminished breath sounds...". According to the physician History and Physical dated 5/20/13, under "History Of Present Illness:...Family...wanted him to be treated symptomatically". Under "Physical Examination: ...mild distress secondary to shortness of breath...gurgling...rales at the base of his lungs". On 5/20/13 at 1815 (6:15 p.m.), the Nurses Notes reflected "Condition remains the about the same. Unable to verbalize needs...DPOA called and suggested IM (an injection) versus po (oral) for infiltrates. Call out to N.P." On 5/20/13 at 1930 (7:30 p.m.), the Nurses Notes reflected "N.P. (#5) called and stated to discuss with (N.P. #6's name)." According to the Progress note completed and dated 5/21/13, by Nurse Practitioner, N.P. #6 under section "Interval History: Fever, niece question if antibiotics can be resumed (question aspiration over weekend- Chest x-ray persistent right sided effusion with infiltrate/atelectasis, no significant change from 5/10) [MEDICATION NAME] ordered but looks like not given secondary to unable to swallow and po med's d/c". Under section "Physical Exam: Temp: 100.4 P: 92 Respirations: 24 Neuro: lethargic...Speech: garbled Resp: lungs rhonchi/wheezes..." On 5/21/13, no time indicated, the Nurses notes reflected "...100.4 (temperature), 92 (pulse), 24 (respirations)...awake no speech...weak". On 5/21/13 at 2100 (9:00 p.m.), the Nurses Notes reflected "...following p.m. meal resident became unresponsive could not waken, no pulse, or b/p noted resident was pronounced dead at 1935 (7:35 p.m.)...". On 1/16/13 at 11:45 a.m. a telephone interview was conducted with N.P. #6. During that interview N.P. #6 stated that she had assessed and reviewed Resident #103's Medical Record on the day after admission to the facility 5/16/13. At the time of the assessment on 5/16/13 Resident #103 did not present with sign and symptoms of infection. N.P. #6 stated that she had not been contacted with Resident #103 having trouble with supper meal on 5/16/13 and was not on call for the weekend 5/17 to 5/19/13. N.P. #6 stated that Resident #103's Physician #7 had seen him on 5/20/13. N.P. #6 stated that she assessed Resident #103 on 5/21/13 and began [MEDICATION NAME] for Resident #103. An interview with LPN #2 on 1/16/14 at 10:15 a.m. was conducted. LPN #2 revealed that Resident #103 had demonstrated a change in condition on Saturday the 18th of May and that she had contacted the Dr. for an order of a stat (immediate) x-ray of Resident #103's lungs. Upon results of the x-ray LPN #2 then received an order for [REDACTED]. LPN #2 stated that the facility policy is that if a medication was not given for any reason that the nurse would circle his/her initials and document on the back of the MAR indicated [REDACTED]. An interview with LPN #3 on 1/16/14 at 2:30 p.m. was conducted. LPN #3 revealed that on 5/19/13 Resident #103 had been unable to take any of his medications that day and that LPN #3 had not given Resident #103 his antibiotic as ordered. LPN #3 verified that she should have indicated, but did not, on the back of the MAR indicated [REDACTED]. LPN #3 stated that she did leave a message on the answering machine for the Nurse Practitioner #4, but was unable to recall if Resident #103 antibiotic refusal was discussed. On 1/17/14 at 11:15 a.m. a telephone interview was conducted with Resident #103's Physician #7. Physician #7 stated that he had been in on 5/20/13 and physically assessed Resident #103. At that time he felt that Resident #103's based on clinical signs and symptoms antibiotic was not indicated at that time, but antibiotic would be appropriate if family wanted him treated symptomatically.

Based on interview and record review, the facility failed to administer an antibiotic for 1(#103) of 2 sampled residents reviewed for medication administration and treatment of [REDACTED].#103 developing increased respiratory distress and death. Findings include: According to the Fundamentals of Nursing, 6th edition (Potter-Perry, Mosby, 2005, page 419), "The physician is responsible for directing medical treatment. Nurses are obligated to follow physicians' orders unless they believe the orders are in error or would harm clients." The reference goes on to indicate that all orders must be assessed and further clarification from the physician retrieved if necessary. "If there is a "missed dose" for any reason the nurse is "require(d) to circle (her initials on) the prescribed administration time on the medication administration record" and explain the reason for the missed dose on the back side of the MAR. (Potter, P. A. & Perry, A. G. (2005) Fundamentals of Nursing (6th ed.). St. Louis: Mosby.). "Documentation within a client medical record is a vital aspect of nursing practice. Nursing documentation must be accurate, comprehensive, and flexible enough to retrieve critical data, maintain continuity of care, track (resident) outcomes, and reflect current standards of nursing practice ...Effective documentation ensures continuity of care, saves time, and minimizes the risk of errors ...The record is a means by which health care team members communicate (resident) needs and progress ...The record should be the most current and accurate source of information about a client ' s health care status ...High-quality documentation...(is) necessary to enhance efficient, individualized (resident) care. Quality documentation...(has) five important characteristics: they are factual, accurate, complete, current, and organized " (Potter, P. A. & Perry, A. G. (2005) Fundamentals of Nursing (6th ed.). St. Louis: Mosby.). According the the facility Face Sheet dated 5/20/13, Resident #103 was a [AGE] year old male admitted to the facility 5/15/13. According to the Physician's Admitting Orders dated 5/15/13, Resident #103 had [DIAGNOSES REDACTED]. Review the Physician's Telephone Orders dated 5/18/13, revealed Resident #103 was to receive the antibiotic [MEDICATION NAME] 400 mg (milligrams) one by mouth daily for 10 days for a [DIAGNOSES REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. In the box under the date of 5/17/13, Licensed Practical Nurse (LPN) #2 had placed her initials with a circle around her initials (indicating the medication was not given). On the back of the MAR indicated [REDACTED]. Under the date of 5/18/13 no initials were written in the box on the MAR (indicating the medication was not given). Review of the Nurses notes dated 5/17/13 revealed they did not reflect any documentation for the start of the antibiotic, that the medication was refused or that Resident #103's doctor had been notified of Resident #103's refusal of antibiotic. Review of the Nurses notes dated 5/18/13 revealed they did not reflect any documentation for the start of the antibiotic, that the medication was refused or that Resident #103's doctor had been notified of Resident 103's refusal of antibiotic. An interview with LPN #2 on 1/16/14 at 10:15 a.m. was conducted. LPN #2 reported that Resident #103 had demonstrated a change in condition on Saturday the 18th of May and that she had contacted the doctor for an order of a stat (immediate) x-ray of Resident #103's lungs. Upon results of the x-ray LPN #2 then received an order for [REDACTED]. LPN #2 stated that the facility policy is that if a medication was not given for any reason that the nurse would circle his/her initials and document on the back of the MAR indicated [REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the Nurses notes dated 5/19/13 did not reflect any documentation that the medication was refused or that Resident #103's doctor had been notified of Resident #103's refusal of antibiotic. An interview with LPN #3 on 1/16/14 at 2:30 p.m. was conducted. LPN #3 reported that on 5/19/13, Resident #103 had been unable to take any of his medications that day and that LPN #3 had not given Resident #103 his antibiotic as ordered. LPN #3 verified that she should have indicated, but did not, on the back of the MAR indicated [REDACTED]. LPN #3 stated that she did leave a message on the answering machine for the Nurse Practitioner #4, but was unable to recall if Resident #103 antibiotic refusal was discussed. According to the Progress note completed and dated 5/21/13, by Nurse Practitioner (N.P.) #6 under section "Interval History: Fever, niece question if antibiotics can be resumed (question aspiration over weekend- Chest x-ray persistent right sided effusion with infiltrate/atelectasis, no significant change from 5/10) [MEDICATION NAME] ordered but looks like not given secondary to unable to swallow and po med's d/c". Under section "Physical Exam: Temp: 100.4 P: 92 Respirations: 24 Neuro: lethargic...Speech: garbled Resp: lungs rhonchi/wheezes..." On 5/21/13, no time indicated, the Nurses notes reflected "...100.4 (temperature), 92 (pulse), 24 (respirations)...awake no speech...weak". On 5/21/13 at 2100 (9:00 p.m.), the Nurses Notes reflected "...following p.m. meal resident became unresponsive could not waken, no pulse, or b/p noted resident was pronounced dead at 1935 (7:35 p.m.)...".