Every finding on record at Gables of Boutwells Landing

Based on observation, interview, and document review, the facility failed to ensure milk was not in use past the use by date, refrigerated items were labeled and dated, and maintain cleanliness of ceiling vent, refrigerator, and freezers in the main kitchen. Furthermore, the facility failed to ensure beard nets were used in food preparation and service areas. This had the potential to affect all residents who received food from the facility kitchen. Findings include: An observation on 6/8/26 at 11:19 a.m., the main kitchen was observed. A walk-in storage freezer was observed to have boxes stored on the floor and several frozen tater tots scattered across one corner of the freezer floor. A refrigerator used for some of the independent living residents contained a tray of portion cups containing tartar sauce that were undated. The bottom shelf of this refrigerator was dirty and filled with crumbs and food debris. A walk-in freezer in the main kitchen area was found to have sticky floors and several frozen sausage links scattered on the floor. A walk-in refrigerator in the main kitchen had a tray of red sauce in portion cups. The cups were not labeled or dated for when they were filled. A Ziplock bag of what appeared to be sliced meat was on the shelf with a date of 5/6. The meat appeared to have a grayish white tint to it. Another Ziplock bag containing seasoned meat was in a container with no label or date on it. Cook-A was seen wiping off counters in the food prep area. He had a short, trimmed beard that was not covered. A ceiling vent above just to the right of the main stove had brown/black dust/dirt on it. When interviewed on 6/8/26 at 11:45 a.m., the Dietary Director (DD) verified the observations of the undated/unlabeled food items, food spilled on the floor of the freezers, dirty ceiling vent and lack of beard net. DD further stated the sliced meat didn't have a good color. DD expected all food items to be labeled and dated when stored, freezers, refrigerators and vents to be cleaned, and beard nets to be worn if applicable.An observation on 6/8/26 at 12:30 p.m., the 3rd floor kitchenette was observed. The small refrigerator in the serving area by the steam table contained 2 half gallons of [NAME] skim milk. A full unopened container had a best by date of 6/7/26. An opened container with approximately 1/2 cup left had a best by date of 6/6/26. Cook-B was working on the serving side of the kitchenette where the steam table was. [NAME] had a medium length beard and was not wearing a beard net. An interview on 6/8/26 at 12:35 p.m., nursing assistant (NA)-E verified the milk in the refrigerator and stated, those should be tossed. NA-E said it was unknown how many residents drank skim milk but had not served any to their group today. NA-E further stated the cooks checked for dates on items in the fridge in the mornings. An interview on 6/8/26 at 12:43 p.m., Cook-B was the afternoon cook, and stated the morning cooks should have reviewed the items in the fridge that morning. If items are past their dates, they should be thrown out. Cook- B was not sure if he needed a beard net and further stated he was not sure where to find them.A follow up interview on 6/9/26 at 9:05 a.m., DD stated the morning cooks were expected to review items in the service refrigerators in the mornings and discard any items out of date. DD further stated beard nets were expected to be worn in the unit serving kitchens as well as the main kitchen. An interview on 6/10/26 at 11:15 a.m., the administrator stated staff were expected to ensure all food items were dated and labeled when stored and refrigerators were reviewed and items thrown out if past their dates. Staff were expected to use beard nets when in the kitchen and serving areas. Furthermore, refrigerators, freezers and ceiling vents should be clean. A facility policy titled Labeling and Dating Policy revised 8/2019, directed staff to label and date foods that are opened or prepared with the name of the product (if not in the original container), when opened or prepared or when must be used by. Foods that are not marked will be discarded. A facility policy titled Safe Food Storage revised 5/219, directed staff to keep all food items stored on shelves at least 6 inches from the floors and label, date and properly cover all food items upon opening.

Based on observation, interview, document review, the facility failed to assess a resident's ability to self-administer medications for 1 of 1 resident (R126) reviewed for self-administration of medications. Findings include: R126's admission Minimum Data Set (MDS) dated [DATE], indicated R126 was cognitively intact. R126's diagnoses included compression fracture of the spine with routine healing, epilepsy (seizures), and gastroesophageal reflux disease (GERD) (heartburn).R126's physician orders dated 5/28/26, included Calcium Carbonate (Tums) 500 milligrams (mg), two tablets by mouth every four hours as needed for heartburn or upset stomach. R126's provider orders lacked indication R126 was able to self-administer medication.R126's comprehensive nursing data collection dated 5/28/26, indicated R126 had not brought medications with upon admission. The assessment further indicated R126 did not choose to self-administer medications.R126's care plan dated 6/1/26, indicated R126 chose not to self-administer medications. Interventions directed staff to administer medications as ordered.R126's medical record lacked indication R126 had been assessed to self- administer medications. During an observation and interview on 6/8/26 at 2:17 p.m., a container of Tums was observed on R126's bedside table. R126 stated the resident's family brought the medication to the facility. R126 stated he wanted Tums available because he had not received them when requested during a previous hospitalization.During an interview on 6/8/26 at 3:50 p.m., registered nurse (RN)-B confirmed that R126 had a container of Tums on his bedside table. RN-B further confirmed no self-administration of medication assessment had been completed. (RN)-B further stated if a resident was to self administer medications, an order and assessment were to be completed. During an interview on 6/10/26 at 8:07 a.m., the Director of Nursing (DON), stated when residents wished to self-administer medications, the facility's process required physician notification, completion of a nursing assessment, physician authorization, and care plan interventions to support safe self-administration. The DON stated this process was important to promote resident autonomy while ensuring medications were managed safely.The facility's policy titled, Self-Administration of Medication Policy dated 11/2016, directed staff to assess the resident's ability to safely self-administer medications prior to allowing medications to be kept at the bedside.

Based on observation, interview and document review, the facility failed to ensure call lights were within reach for residents who were dependent on staff assistance for 3 of 4 residents (R106, R24, and R9) reviewed for call light accessibility. Findings include: R106 R106's quarterly Minimum Data Set (MDS) dated [DATE], identified moderately impaired cognition, no behaviors or rejection of care. two falls since prior assessment, one with major injury, and that she required partial to moderate staff assistance for toileting hygiene, lower body dressing, sit to stand ability and chair/bed to chair transfers. R106 required partial/moderate staff assistance in her manual wheelchair to propel 50 feet and make two turns. Diagnoses included blindness and anxiety. R106's care plan intervention dated 5/20/26, identified due to limited physical ability assist of one staff was required for stand and pivot transfers. The care plan did not identify wheelchair mobility. R106 care plan intervention dated 1/15/26, identified to place call light within reach and answer promptly. Two call lights were in her room for safety. R106's nursing assistant (NA) Communication Sheet dated 6/8/26, identified she was at risk for falls and was one assist for pivot transfers. The bottom of the NA Communication Sheet identified to assure call light was within reach as indicated. During an observation on 6/8/26 at 12:11 p.m., R106 was seated in her wheelchair at the dining room table in her private room and no call light was within reach. One call light was observed on her bed which was about 7 feet away, and another call light was in the bathroom out of reach. Registered nurse (RN)-A brought R106's afternoon meal to her dining room table in R106's room and left without ensuring the call light was within reach. RN-A left the room and R106 began to eat her meal alone. During an observation and interview on 6/8/26 at 12:21 p.m., family member (FM)-A entered R106's room. FM-A stated upon entering the room, R106 had already moved her wheelchair away from the dining room table and was trying to self-propel toward the other side of her room. FM-A agreed that R106's call light should have been within reach at her dining room table because she had numerous falls and declining health. A hospice consult was in progress. FM-A assisted R106 into bed and put her call light within reach. During an observation on 6/9/26 at 8:04 a.m., R106 activated her own call light which was within reach in bed and pulled herself to a seated position at the edge of her bed. R24 R24's quarterly MDS dated [DATE], identified moderately impaired cognition, no behaviors or rejection of care, substantial/maximal staff assistance was required for toileting hygiene, lower body dressing, and chair/bed to chair to bed transfers. Partial/moderate assistance was required for sit to stand ability. R24 required partial/moderate staff assistance in her manual wheelchair to propel 50 feet and make two turns. Diagnoses included non-traumatic brain dysfunction and arthritis. R24's care plan intervention dated 11/24/25, identified to ensure/provide a safe environment and to ensure her call light was within reach and encourage her to use it for assistance. R24's care plan intervention dated 5/26/26, identified she could transfer and ambulate with one staff assist, gait belt and rolling walker (RW). She required two staff for bed mobility. The care plan did not address wheelchair mobility. R24's NA Communication Sheet dated 6/8/26, identified she was at risk for falls, transferred with one assist and wheeled walker and to ensure the call light was within reach in the chair and bed. During an observation on 6/8/26 at 3:27 p.m., R24 was seated in her wheelchair in her room between the bed and the room door. No call light was within reach. The call light was observed on the other side of the bed and underneath the blanket. At 3:30 p.m., RN-A was asked by surveyor to assist R24 with her call light. RN-A entered R24's room took the call light and placed it within R24's reach. RN-A stated a volunteer from activities may have brought R24 to her room and not put the light in place. Even though R24 might not always use her call light but it should be within reach. During an interview together on 6/10/26 at 8:40 a.m., activities (A)-A stated after a resident is brought back to their room after an activity, facility staff and volunteers were trained to place call lights within reach. (A)-B stated they would also send a notification over the walkie-talkies to nursing staff and let them know residents were on their way back to their rooms. During an interview on 6/9/26 at 12:48 p.m., NA-C stated call lights should be placed within arm's reach of residents so they can call for help easily. During an interview on 6/10/26 at 9:28 a.m., NA-D also stated even if a resident was independent with room mobility, staff should still ensure the call light was in an easily reachable area. During an interview on 6/10/26 at 9:40 a.m., trained medication assistant (TMA)-A stated call lights should be placed within arm's length of a resident. R9 R9's annual MDS dated [DATE], indicated severely impaired cognition and diagnoses of multiple sclerosis, dementia, muscle weakness and repeated falls. It further indicated R9 was dependent on staff with toileting, transfers, and had one fall with no injury prior to admission/readmission. R9's care plan dated 11/20/23, indicated R9 was at risk for falls related to physical weakness, history of falls, MS, hypertension, renal disease, neurogenic bladder with history of urinary tract infection (UTI), depression and dementia. R9 was known to self-transfer in and out of bed. It further indicated an intervention to place the call light within reach and answer it promptly if on. I'm known not to use my call light due to cognition and impulses. During observation on 6/10/26 at 8:25 a.m., R9 was in bed sleeping and his call light was coiled up neatly hanging on the wall by the foot of his bed. R9's call light was not within reach. During observation and interview on 6/10/26 at 8:33 a.m., nursing assistant (NA)-B stated R9 sometimes used his call light and that the residents call lights should be within their reach. NA-B also verified R9's call light was not within reach and was coiled up on the wall stating R9 must have thrown it up there. During observation and interview on 6/10/26 at 8:36 a.m., registered nurse (RN)-C stated they hadn't ever noticed R9 use his call light, but it should still be within reach. RN-C further stated the call lights should be within the resident's reach even if they had issues with their cognition and also verified R9's call light was coiled up on the wall and out of his reach. RN-C stated R9 was probably able to throw the call light, but he wouldn't have been able to put it up there so neatly. During interview on 6/10/26, at 8:40 a.m., RN-D stated call lights should be placed within reach even if the resident didn't always use it or had issues with their cognition. During interview on 6/10/26 at 8:42 a.m., RN-F stated all call lights should be within reach even if the resident had issues with their cognition or they didn't use the call light on a regular basis. During interview on 6/10/26 at 10:47 a.m., the director of nursing (DON), stated before nursing staff exited a resident's room, they should ensure their call light was within reach. If the resident moved independently after they placed the call light next to them, they can't help that, but they would put the call light within reach again when they were rounding. The DON further stated if a resident was unable to use the call light due to cognition, the call light should be removed as an intervention on their care plan. The facility policy regarding call lights dated November of 2022, indicated the following procedure for call light use: 1. All facility personnel must be aware of call lights at all times.2. Answer all call lights promptly whether or not you are assigned to the resident.3. See manufacturer's instructions for turning off the call light and managing the call light system.4. Answer all call lights in a prompt, calm, courteous manner; turn off the call light as soon as possible.5. Position the call light conveniently for the resident to use. Tell the resident where the call light is and show him/her how to use the call light when needed.a. Ensure the call light is accessible to the resident while in their bed or other sleeping accommodation in their room (e.g., recliner).b. Ensure the call light is accessible to the resident if they were lying on the floor near the toilet, bath or shower.6. Orient all new residents to the call light as appropriate.

Based on observation, interview, and record review, the facility failed to provide setup meal assistance for 1 of 2 residents (R28) reviewed for activities of daily living (ADLs). Findings include:R28's quarterly Minimum Data Set (MDS) dated [DATE], indicated R28 had severe cognitive impairment, required setup or clean up assistance with eating, and substantial/maximal assistance with mobility. R28's diagnoses included non-traumatic brain dysfunction (an alteration in brain function caused by internal factors such as illness, oxygen deprivation, or toxic exposure), dementia, and Alzheimer's disease. R28's care plan last reviewed 4/2/26, indicated R28 had ADL self-care performance deficit related to her diagnoses and that she was independent with eating after setup. During interview on 6/8/26 at 12:22 p.m., family member (FM)-A stated R28 required assistance with meals and needed to have her silverware placed out, otherwise she would eat with her fingers. During observation on 6/9/26 at 8:56 a.m., nursing assistant (NA)-A entered R28's room and assisted her to a sitting position on the edge of her bed. NA-A explained she was going to assist with a transfer to her chair. R28 refused to transfer. NA-A explained it was time for breakfast and left to retrieve R28's breakfast tray. During observation on 6/9/26 at 9:20 a.m., R28 was still sitting on the side of her bed with the bedside table approximately three feet away and at a 45 degree angle from R28. All items on the tray were covered and the silverware still rolled up in the napkin. During continuous observation between 9:20 a.m. and 9:39 a.m., NA-A walked past R28's room several times, looked in the room but did not enter, and did not offer to set up R28's meal. During observation on 6/9/26 at 9:39 a.m., housekeeper (H)-A walked by and stopped at R28's doorway. H-A entered and pushed the tray table over and positioned it in front of R28 who was still sitting on the edge of her bed. H-A uncovered her food and beverage, heated up the plate in the microwave, and unrolled the silverware. R28 immediately picked up the juice and began drinking and then proceeded to eat her breakfast independently. During interview on 6/9/26 at 9:41 a.m., H-A stated she had noticed R28's tray table and breakfast were not within her reach and had not been set up for her. H-A stated she heated up R28's meal and opened everything up for her. During observation on 6/9/26 at 10:04 a.m., R28 was done with breakfast and she had eaten approximately 75% of the eggs and 90% of what appeared to be French toast. R28 had not touched the bowl of fruit, but drank approximately 25% of both the milk and juice. During interview on 6/9/26 at 10:28 a.m., NA-A stated R28 could eat independently after everything was set up for her. NA-A stated if the lids were not removed from the food and beverages, she often would not know what to do and would not eat. During interview on 6/9/26 at 11:35 a.m., registered nurse (RN)-A stated would expect R28 to have her meal set up for her with lids removed and the tray table in front of her and within reach when the meal was delivered. RN-A stated this was the responsibility of nursing, and not housekeeping to ensure the resident was set up appropriately for a meal. RN-A stated R28 should be seated in a wheelchair or recliner for her meals when she was eating in her room, but she often refused. During interview on 6/10/26 at 11:14 a.m., director of nursing (DON) stated would expect a resident who required meal setup assistance would have their tray set up appropriately and within reach. Facility policy Meal Tray Delivery Policy - Care Center dated 7/2020, indicated, Assistance with tray set up and uncovering food items will be provided as needed.and Items will be placed so they are convenient for the individual and neatly arranged.

Based on observation, interview, and document review the facility failed to ensure 2 of 2 residents (R7, R9) with perimeter mattresses were assessed for safety. Findings include: R7R7's significant change Minimum Data Set (MDS) dated [DATE], indicated severely impaired cognition and diagnoses of dementia, reduced mobility and muscle weakness. It further indicated R7 required partial assistance with bed mobility (roll left and right), substantial assistance with lying to sitting on the edge of the bed, sitting to standing, and transfers.R7's care plan dated 2/13/24, indicated R7 had limited physical mobility related to dementia with mood disturbance and anxiety, [NAME] disease (genetic muscle disorder), spinal stenosis, and osteoarthritis. It further indicated an intervention of a perimeter mattress to assist R9 in finding the edges of her bed for bed mobility. R7's Mobility, Physical Device, and Fall Risk assessment dated [DATE], lacked documentation of an assessment for a perimeter/defined edge mattress. R9 R9's annual MDS 4/21/26 indicated severely impaired cognition and diagnoses of dementia, multiple sclerosis (MS), and repeated falls. It further indicated partial to moderate assistance with bed mobility and one fall with no injury prior to admission/readmission. R9's care plan dated 11/20/23, indicated R9 had limited physical mobility related to physical weakness, history of falls, incontinence, hypertension, renal disease, dementia, MS, depression and delusional disorder. It further indicated an intervention to use a bariatric sized bed with a perimeter mattress to define the edges of the bed. R9's Mobility Physical Device and Fall Risk assessment dated [DATE], lacked documentation of an assessment for a perimeter/defined edge mattress. During observation on 6/10/26 at 8:25 a.m., R9 was in bed asleep and had a perimeter mattress.During interview on 6/10/26 at 7:35 a.m., registered nurse (RN)-C stated they were unsure if a resident needed a physician's order or an assessment in order to have a perimeter mattress. During interview on 6/10/26 at 7:48 a.m., RN-D stated in order for a resident to use a perimeter mattress, they would need a doctor's order and an assessment. During interview on 6/10/26 at 8:47 a.m., RN-A stated they typically don't give out perimeter mattresses to residents, but one of the main reason's was so they can feel the edges of the bed, so they don't fall. They are never used to keep a resident in bed. Before a resident was permitted to use a perimeter mattress, the interdisciplinary team (IDT) would review the situation (Ex: fall), and engineering would check to make sure the resident was the appropriate size for the mattress. The nurse was also required to fill out a safety assessment. During an interview on 6/10/26 at 8:15 a.m. RN-F stated in order for a resident to be able to use a perimeter mattress, IDT would need to decide if it was appropriate (in order to ensure it wasn't used as a restraint), and maintenance would need to do an assessment for the entrapment zone which should also be done yearly. During a follow up interview at 8:42 a.m., RN-F stated the engineering department fills out the assessments. During interview on 6/10/26 at 9:54 a.m. the director of nursing (DON) stated in order for a resident to be able to use a a perimeter mattress, IDT would meet to discuss the situation and if they felt the resident needed it, they would put a TELS request (work order) in for the engineering department. The engineer ensures the perimeter mattress meets all the requirements. Then a clinical manager would be responsible for completing a Mobility Physical Device and Fall Risk Assessment to ensure it meets the resident's needs and is safe to use. These assessments are tracked on quarterly basis and through MDS assessments. The DON verified R7's last assessment was completed on 4/11/24 and R9's was on 4/23/24 and that both lacked documentation of an assessment for a perimeter/defined edge mattress. The facility policy titled Physical Device Assessment Policy dated November of 2022, indicated upon admission, with significant change, annually or the implementation of a new device, the resident will be assessed for physical devices. The assessment will be reviewed quarterly. The assessment includes but is not limited to an assessment of symptoms, ability to use the device, and potential risk and benefit.

Based on observation, interview, and document review, the facility failed to ensure proper infection control practices involving hand hygiene and glove use during incontinent care for 1 of 1 resident (R8) observed during cares. Findings include:R8's annual Minimum Data Set (MDS) dated [DATE], indicated R8 had moderately impaired cognition, had an indwelling urinary catheter, was frequently incontinent of bowel, required a feeding tube, and was dependent on staff for all personal care. R8's diagnoses included benign neoplasm of meninges (tumors in the protective membranes of the brain and spinal cord), chronic kidney disease, dysplasia (difficulty swallowing), aphasia (condition affecting speech), dependance on supplemental oxygen, and history of nontraumatic intracerebral hemorrhage (brain bleed not due to injury). R8's care plan dated 4/2/26, indicated R8 had a suprapubic catheter (tube directly through the skin into the bladder for draining), was incontinent of bowel, had a G/J (gastrojejunostomy) tube to receive nutrition, received supplemental support via nasal cannula, was at risk of infections, and required enhanced barrier precautions in addition to standard precautions during high-contact resident care activities. During observation and interview on 6/9/26 at 10:54 a.m., nursing assistant (NA)-B and NA-A entered R8's room to perform incontinent care. Both NAs performed hand hygiene, donned gloves and a gown prior to entering room. NA-B removed R8's brief and cleaned front peri area with premoistened wipes. R8 was then positioned on left side facing NA-A while NA-B wiped his bottom and removed the dirty brief. NA-A called for the nurse for a skin check and medication application to bottom. While waiting for the nurse, R8 was repositioned on his back and covered up. At 11:04 a.m., registered nurse (RN)-A entered with appropriate PPE (personal protective equipment). No glove change had been completed by either NA. R8 was repositioned on left side, NA-B used same gloved hands to reposition while touching R8's bare skin. R8 continued to have active soft bowel movement (BM). RN-A used wipes to clean the BM. NA-B took over incontinent care and cleaned the large amount of BM that continued to ooze out. NA-B removed all the soiled wipes, under pad, and draw sheet and placed soiled items in bags. NA-B did not change gloves and picked up the package of wipes to set aside, grabbed a new brief and opened a new package of chux (under pad) and grabbed several while RN-A applied ointment to R8's bottom. Again, R8 was repositioned with assistance from NA-B using same gloved hands touching R8's exposed legs and back bare skin. NA-B used same gloved hands to rip a slit in the new brief to fit around the suprapubic catheter insertion site just over the dressing. NA-B then situated R8. NA-B handled the catheter tubing, touched and pulled at sheet on all sides of the sheet, adjusted the oxygen tubing and the feeding tube tubing. At 11:20 a.m., NA-B removed his gloves and donned new ones, without performing hand hygiene and then retrieved a graduate cylinder. NA-B emptied R8's catheter bag. When asked, NA-B stated that was the first time during all of R8's cares that he had changed his gloves and confirmed he did not perform any hand hygiene in between glove change. NA-B further stated he had used the same gloves to reposition and touch other items after cleaning the BM from R8. NA-B stated he should have changed his glove and performed hand hygiene after incontinent care and prior to touching any other items. During interview on 6/9/26 at 11:25 a.m., registered nurse (RN)-A stated NA-B should have changed gloves after incontinent care and hand hygiene should have been performed and new gloves donned. During interview on 6/10/26 at 11:14 a.m. director of nursing (DON) stated expectation for staff to change gloves and perform hand hygiene when working from soiled to clean areas during incontinent care. Facility policy Infection Control Standard Precautions dated 2020, indicated, Appropriate hand hygiene is essential in preventing transmission of infectious agents. Hand Hygiene includes hand washing with soap and water and hand hygiene with alcohol-based hand rub (ABHR).Hand hygiene continues to be the primary means of preventing the transmission of infections. The policy further indicated, Hand Hygiene should be performed.Before donning [PPE] and After removing [PPE].

Based on observation, interview, and document review, the facility failed to ensure range of motion (ROM) was provided for 1 of 2 resident (R19) reviewed for mobility. Findings include: R19's quarterly Minimum Data Set (MDS) dated [DATE], indicated intact cognition, did not have hallucinations or delusions, and did not reject cares. Further, R19 had upper and lower extremity limitations in range of motion on both sides. R19's Optional State assessment dated [DATE], indicated R19 was totally dependent with bed mobility, transfers, and toileting. R19's Care Area Assessment (CAA) dated 8/7/24, indicated R19 could not ambulate, and had complications from immobility that included contractures. R19's Medical Diagnosis form indicated R19 had the following diagnoses: multiple sclerosis (a disease affecting the central nervous system), other specified polyneuropathies (nerve damage), muscle weakness, other reduced mobility. R19's physician's orders identified the following orders: 8/1/24, Occupational therapy and physical therapy to evaluate and treat. 2/13/25, Occupational therapy to evaluate and treat. 2/26/25, apply teal palm protector to the left hand in the morning and remove at night. The orders were reviewed and lacked information R19 was on a range of motion program. R19's medication administration record (MAR) and treatment administration record (TAR) dated March 2025, was reviewed and lacked information R19 received range of motion. R19's care plan dated 8/13/24, indicated R19 had an activity of daily living (ADL) self-care deficit related to multiple sclerosis, muscle spasticity, depression, dementia, neuropathic pain, decreased mobility,, and weakness. Interventions included assist of one for dressing, grooming and hygiene. R19's care plan dated 8/13/24, indicated R19 had limited physical mobility, was not able to ambulate, required two staff to reposition and turn in bed. Additionally, R19 wore a teal palm protector to the left hand and transferred with a full lift. R19 required passive range of motion (PROM) to bilateral lower and upper extremities daily and the care plan directed staff to see the handout for the ROM program. R19's NAR 1 Communication Sheet dated 3/21/25, indicated R19 required a teal palm protector to the left hand that was applied in the a.m., and taken off at bedtime. Further, was on a passive and active range of motion (PROM/AROM) program that directed staff to see POC. R19's nurse practitioner (NP) progress note dated 2/5/25 at 3:59 p.m., indicated R19 had lower extremity and left hand contractures, multiple sclerosis and was dependent in activities of daily living and major mobility. R19's nursing progress notes were reviewed on 4/1/25 at 6:45 a.m., from 2/26/25, to 4/1/25, and lacked information R19 refused range of motion. R19's progress notes in the electronic medical record from 8/1/24, through 3/30/25, were reviewed and lacked documentation R19 refused range of motion. A form, Supine Lower Extremity Caregiver Assisted Range of Motion, dated 8/8/24, with R19's name hand written on the top, indicated R19 required hip and knee flexion and extension 10 times daily to both legs, had straight leg raises 10 times daily to both legs either AROM, or caregiver holds the leg at the ankle and over the knee for PROM, hip abduction and adduction 10 times daily to both legs, and ankle flexion extension exercises to both legs 10 times daily. R19's Daily PROM form, Supine Upper Extremity Caregiver Assisted Range of Motion, undated, indicated PROM exercises for shoulder flexion and extension, shoulder abduction and adduction, and elbow flexion and extension without documented repetitions. R19's Occupational Therapy Toolkit form undated, indicated R19 required AAROM (active assisted range of motion) of 1 set of 10 for each exercise to the right side and PROM on the left side for the following exercises: bending and straightening the elbow, turning the palm up and down, bending the wrist up and down, moving the hand side to side, moving the hand in a circle, opening and closing the hand, bending the thumb over toward the base of the pinkie finger, and squeezing a soft ball or sponge. R19's Maintenance Program form dated 8/8/24, indicated R19 required PROM to bilateral lower extremities. The form directed staff to see the attached handout for the program. The attached form was the Supine Lower Extremity Caregiver Assisted Range of Motion form with R19's name at the top and was dated 8/8/24. R19's Maintenance Program form dated 8/29/24, indicated R19 required 10 repetitions daily of PROM to the upper extremity, but did not identify which upper extremity. Further, the form indicated, Carrot for L hand Ok to use rolled up wash cloth. R19's Maintenance Program form dated 9/12/24, indicated R19 required 10 repetitions daily of bilateral upper extremity PROM. R19's Maintenance Program form dated 11/18/24, indicated R19 required 10 repetitions daily of PROM to the left upper extremity and AAROM to the right upper extremity. R19's Maintenance Program form dated 3/18/25, indicated R19 required PROM to the right and left upper extremities including the left hand. R19's 90 day look back Task form reviewed on 4/1/25, PROM program: BUE {bilateral upper extremity} 10 reps daily. See handout for program from 1/2/25, through 3/31/25, indicated R19 received range of motion 17 times. R19 received range of motion on the following dates: 1/2/25, 1/5/25, 1/12/25, 1/16/25, 1/26/25, 1/30/25, 2/2/25, 2/13/25, 2/27/25, 3/7/25, 3/8/25, 3/9/25, 3/13/25, 3/16/25, 3/23/25, 3/27/25, and 3/30/25. Further, the form indicated R19 refused range of motion two times on 2/9/25, and 2/16/25, and was documented Not Applicable 66 times. R19's 90 day look back Task form reviewed on 4/1/25, PROM program: BLE {bilateral lower extremity} 10 reps daily. See handout for program from 1/2/25, through 3/31/25, indicated R19 received range of motion 17 times. R19 received range of motion on the following dates: 1/2/25, 1/5/25, 1/12/25, 1/16/25, 1/26/25, 1/30/25, 2/2/25, 2/13/25, 2/27/25, 3/7/25, 3/8/25, 3/9/25, 3/13/25, 3/16/25, 3/23/25, 3/27/25, and 3/30/25. Further, the form indicated R19 refused range of motion two times, on 2/9/25, and 2/16/25, and was documented Not Applicable 66 times. R19's OT (occupational therapy) Evaluation and Plan of treatment dated 2/20/25, through 3/21/25, indicated R19 had minimal movement to the upper extremity hand and elbow and R19 was at risk for further decline. Further, R19 was seen twice weekly. R19's OT Recert, Progress Report and Updated Therapy Plan form dated 3/20/25, through 4/18/25, indicated R19 would demonstrate compliance with the appropriate contracture management plan for the left hand to decrease the risk of further skin issues and further contractures. Further, R19 was seen twice weekly. R19's OT Treatment Encounter Notes were reviewed and R19 received OT on 2/20/25, 2/24/25, 2/27/25, 3/4/25, 3/6/25, 3/11/25, 3/13/25, 3/18/25, 3/20/25, 3/25/25, and 3/27/25. R19's OT note dated 3/20/25, indicated the OT checked on Tasks in the electronic medical record to ensure the maintenance program was followed and identified the PROM program was completed twice by the nursing assistants. R19's OT note dated 3/25/25, indicated R19 reported PROM was not completed daily. During interview and observation on 3/31/25 at 12:41 p.m., R19 stated she was not receiving range of motion every day. R19 had a hand protector on the left hand with nothing on the right hand. R19 stated she was supposed to have exercises with her arms. R19 had signage in her room that indicated PROM for shoulder flexion, R19 was to lie on her back with arms at the sides and raise arm up and over the head with the elbow straight slowly lower back to the bed. The form did not identify which arm to complete. Additionally, the form indicated R19 had shoulder abduction and adduction and directed to have R19 lie on her back with arms at the sides and lift the arm out to the side as far as possible keeping the elbow straight along with elbow flexion and extension. R19 had a form that indicated 1 set of 10 of each exercise and additionally, a form dated 8/8/24, indicated R19 required supine lower extremity caregiver assisted range of motion. During interview on 4/1/25 at 8:45 a.m., R19 stated she did not receive range of motion on 3/31/25, and stated nursing assistant (NA)-A worked evenings on 3/31/25, and had to take care of people and stated it didn't matter what time of day R19 received range of motion, and added they were supposed to do it. During interview on 4/1/25 at 1:22 p.m., NA-B stated she normally worked on the day shift and had been at the facility 6 to 7 months. NA-B stated she was familiar with all the residents on R19's floor and if she wasn't sure about something would look at the care plan sheet. NA-B stated if a resident refused cares, they asked three times and if a resident still refused, would document the refusal. NA-B stated R19 was on her group and usually did not get up out of bed unless she had an appointment. NA-B further stated R19 knew what she was talking about, was dependent on movement, and did not decline care. NA-B further stated her main priority was toileting, cleaning, and taking residents to activities and stated residents have range of motion on their sheets, but most of the time have OT or physical therapy (PT), but if on the sheet, tries to make sure it is completed and then documents how many repetitions of range of motion was completed. NA-B stated she didn't typically do R19's range of motion and stated R19 did not refuse care. NA-B stated she documented not applicable for range of motion today because R19 had an appointment. During interview on 4/1/25 at 2:02 p.m., NA-A stated he worked at the facility for three years and normally worked evenings on R19's floor. NA-A stated he looked at the care plan and stated the nursing assistants have assigned residents and further stated he was assigned to R19. NA-A stated he documents if a resident refuses cares and would talk to the nurse. NA-A stated R19 transferred with a lift and required full cares and stated R19 was an accurate historian. NA-A further stated for range of motion, everything clearly stated what he was supposed to do and there were diagrams in the room. NA-A further stated the aides had to document if range of motion was completed, if a resident refused, or if it was not applicable. NA-A stated he did not know what shift was responsible for R19's range of motion. NA-A stated he did not complete range of motion on 3/31/25, and further stated he did not recall if R19 refused, or if he did not get around to it, or non applicable. During interview with occupation therapist assistant (OTA)-A and physical therapist (PT)-B on 4/1/25 at 2:27 p.m., OTA-A stated there was a functional maintenance program sheet that described each exercise a resident required and get the sheets to the nursing assistants so they are aware of exercises needed. OTA-A stated R19 was on the OT program for lymphedema pumps and for range of motion to the upper extremities. OTA-A stated R19 had OT on 3/27/25, and declined today due to having an appointment and did not have OT on 3/31/25, because R19 was only seen twice a week. OTA-A stated R19 was on a functional maintenance program and expected nursing assistants complete the range of motion daily even while R19 received OT. PT-B stated R19 had a BIMS (brief interview for mental status) of 15, which was the best for cognition. During interview on 4/1/25 at 2:51 p.m., registered nurse (RN)-A stated she had worked at the facility over a year and stated they had stand up meetings and communication sheets to know the cares a resident required and verified the sheets were the NAR Communication Sheets. RN-A stated aides were supervised by providing the NAR worksheets. RN-A stated if a resident refused, the aide was supposed to let the nurse know and the nurse documents in a progress note. RN-A stated R19 did not refuse cares and was an accurate historian and required range of motion because she had pain in her hands, had muscle weakness, and reduced mobility with contractures to the left hand. RN-A stated therapy printed the exercises R19 needed and placed them in R19's room and the aides documented in their Ipad under Tasks. RN-A further stated she expected aides to report refusals or deviations in cares not being completed. RN-A viewed R19's Tasks form and stated staff documented not applicable and stated R19 should have been receiving range of motion daily and only had range of motion three times from 3/19/25, to 3/31/25, to the bilateral lower extremities. RN-A verified R19 lacked range of motion daily to upper extremities as well and stated it was important because of muscle atrophy and helped prevent future complications. During interview on 4/1/25 at 3:04 p.m., RN-B stated sometimes R19 refused depending on the aide and R19 worked with therapy who completed range of motion with R19 and stated there were days when range of motion did not get completed. RN-B stated staff should document refusals and they had to provide education because there should not be any not applicable documentation, but there was a spot for refusals. RN-B further stated if a resident refused, the aides were supposed to report to the nurse to make sure the endorsement was completed and stated it was important to complete range of motion due to lack of mobility. During interview on 4/2/25 at 9:55 a.m., with the director of nursing (DON) and assistant director of nursing (ADON), the DON stated anytime something was on the care plan, she expected the task be completed and if the task was not completed to notify the nurse regarding the circumstances why the task was not completed, or if a resident refused because if a resident continued to refuse, they may need to readjust the program to maintain a resident's quality of life. The DON stated they followed the interdisciplinary team (IDT) communication guidelines. A policy, Restorative Nursing and Functional Maintenance, dated December 2014, indicated the restorative program was to assist with various forms of activity, ambulation, PROM, feeding, ROM etc. in order for residents to maintain their maximum potential for as long as possible.

Based on observation, interview, and document review, the facility failed to ensure the provider documented a clear clinical rationale for actions taken or not taken; including risks and benefits to justify the continued use of medications identified to put the resident at risk for falls and adverse effects for 1 of 1 resident (R83) reviewed for requests for clinical rationale. Findings include: R83's admission Minimum Data Set (MDS) dated [DATE], identified a fall occurred in the past two to six months prior to admission. No behaviors or rejection of care occurred, and the mood interview indicated no depression. R83's corresponding Care Area Assessments (CAA), undated, identified falls was triggered related to history of falls, impaired mobility, cognition, hearing, pain, incontinence, anticipated decline, and medication side effects and care planning was in place to minimize risks and provide symptom relief or palliative measures. Additionally, psychotropic medication use was triggered related to high risk drugs taken (antipsychotic and antidepressant). Care planning was in place to minimize risks and provide symptom relief or palliative measures. R83's quarterly MDS dated [DATE], identified intact cognition, and no behaviors or rejection of care. The mood interview identified minimal depression. Diagnoses included metabolic encephalopathy (brain dysfunction), Alzheimer's disease, depression, and anxiety. No falls had occurred since the prior admission assessment. Impairments to upper or lower extremities were present, and a wheelchair was used for mobility. Hospice services were in place. High risk drugs used included antipsychotic, antianxiety, antidepressant, and opioid; and a gradual dosage reduction had not been attempted nor documented by a physician as clinically contraindicated. R83's anticonvulsant care plan dated 2/7/24, identified brain activity could be affected. Interventions to administer medications as ordered, monitor for side effects, inform the resident, family or caregivers about risks, benefits, side effects of medications, consult with pharmacy and physician to consider dosage reduction when clinically appropriate. R83's pain care plan dated 2/7/24, identified a risk for pain related to impaired mobility and cognition, history of falls, skin impairments and anticipated decline. Interventions included pain would be assessed, medications would be administered as ordered, non-pharmacological interventions as needed, and hospice consulted as needed. R83's antipsychotic care plan dated 2/8/24, identified diagnoses of delirium, agitation, anxiety and hospice care. Interventions to administer medications as ordered, monitor for side effects, inform the resident, family or caregivers about risks, benefits, side effects of medications, consult with pharmacy and physician to consider dosage reduction when clinically appropriate. R83's mood and behavioral care plan dated 5/21/24, identified diagnosis of depression and anxiety. Interventions included provide encouragement to participate in activities and demonstrate effective coping skills. Non-pharmacological interventions included: tell resident to take a breath, ask resident if she was in pain, talk to me about the North Shore, turn on TV (likes Greys Anatomy, music channel), encourage resident to be out of her room (tends to self-isolate). Target behaviors included: sadness or crying, anxiety related to where family members were, decreased appetite, self-isolation and paranoia. R83's pain ratings dated 2/7/24 through 6/27/24, identified consistent pain ratings of zero. R83's behavior tracking dated 5/11/24 through 7/10/24, identified no behaviors or mood concerns occurred. R83's Order Summary Report dated 7/10/24, identified the following active medications: 1. Start date 2/7/24, methocarbamol (central muscle relaxant) give 500 milligrams (mg) by mouth two times a day for muscle spasms. 2. Start date 2/7/24, tramadol (opioid agonist produces similar pain relief effects as morphine and other opioids) give 100 mg by mouth three times a day for pain. 3. Start date 2/7/24, C-morphine (opioid) give 5 mg sublingually every one hour as needed (PRN) for pain or dyspnea (difficulty breathing). 4. Start date 2/7/24 gabapentin (anticonvulsant) give 300 mg by mouth three times a day for nerve pain. 5. Start date 2/13/24, Seroquel (an antipsychotic) give 12.5 mg by mouth at bedtime for delirium, agitation, anxiety. 6. Start date 2/16/24, venlafaxine (Effexor, an antidepressant) give 37.5 mg by mouth one time a day for depression take in addition to the 150 mg tablet for a total daily dose of 187.5 mg. 7. Start date 2/16/24, Effexor give 150 mg by mouth one time a day for depression take in addition with 37.5 tablet for a total dose of 187.5 mg. 8. Start date 7/2/24, lorazepam (benzodiazepine) give 0.5 mg by mouth every 2 hours as needed for Anxiety for 14 days (renewed). R83's Medication Administration Records (MAR) dated 5/1/24 through 7/10/24, identified PRN morphine was never given. PRN lorazepam was given once, on 5/12/24 and marked as effective. All other medications listed above were taken routinely since their start date. R83's Consultant Pharmacist (CP) Communication to Physician dated 3/30/24, identified since a recent fall occurred, the resident was at risk for falls, and the above medications (1 through 7, specifically) might increase the risk of falls; an assessment for ongoing use was requested. Additionally, methocarbamol was strongly urged to avoid use in the elderly - strong correlation with falls. Also, the new guidelines from American Geriatric Society (AGS) Beers list (criteria for potentially inappropriate medications) strongly recommended avoiding three or more central nervous system (CNS)-active drugs as they can increase the risk of falls. CNS-active drugs included antidepressants, antipsychotics, benzodiazepines, and opioids. Lastly, a combination of some CNS medications could cause serotonin syndrome and the risk of QT prolongation (heart rhythm disorder which can be life threatening), as well as additional sedative, CNS and/or respiratory-depressant effects. The CP requested an assessment by the provider of the above medications to determine appropriateness of reducing the dose or frequency. Options provided were: - Discontinue (DC). - Reduce. - No changes because the medications are necessary, benefits outweigh the potential risks, and are required to maintain functional status. - Other. The box for other was checked and hospice was written next to it. The form was signed by nurse practitioner (NP)-A on 4/2/24. The form lacked documentation from the provider of clear clinical rationales including risks and benefits; to justify the continued use of medications identified to put the resident at risk for falls and adverse effects. R83's provider progress notes dated 3/20/24 and 6/17/24, lacked documentation of clear clinical rationales including risks and benefits; to justify the continued use of medications identified to put the resident at risk for falls and adverse effects. During an observation and interview on 7/8/24 at 5:13 p.m., R83 was in her wheelchair, self-propelling around her room, well-groomed and conversational. She stated she had no pain at the time, had good support and was happy with her hospice services. R83 stated her doctor and hospice managed her medications and she would go along with what they decided to do. During an interview on 7/10/24 at 9:55 a.m., nursing assistant (NA)-A stated she worked at the facility for over one year and R83 was alert with intermittent confusion, and she had not noticed any recent behaviors. During an interview on 7/10/24 at 9:57 a.m., NA-B stated she had worked routinely with R83 for about one month and mood was very stable, no delusions, agitation. R83 attended activities and could self-propel after being set up. During an interview on 7/10/24 at 10:07 a.m., registered nurse (RN)-C stated she had observed R83 transfer this morning with the NA and her transfer was steady. RN-C stated R83's mood and behavior and health were stable for the past couple of months. During an interview on 7/10/24 at 12:17 p.m., hospice RN-D stated they had not received a request to review R83's CNS-active medications for ongoing use, and that would typically be reviewed by the facility primary care providers. RN-D reviewed R83's hospice chart and stated it appeared she had been stable. Interviews with NP-A were attempted on 7/10/24 at 11:43 a.m., and 1:02 p.m. NP-A was out of the office and unable to provide information on the response to the CP communication form. During an interview on 7/10/24 at 12:45 p.m., the CP stated unless otherwise identified on the form, a response was expected by the next primary care provider visit, or about two months. The CP stated he would expect if the provider wanted no changes then to document the benefits outweighed the risk, and the medications were the least restrictive measures. The CP stated the 4/2/24, response of hospice on R83's communication form was not a clear rationale nor assessment of risks and benefits of ongoing use. During an interview on 7/10/24 at 1:49 p.m., the director of nursing (DON) stated if the CP requested an assessment on an identified medication irregularity for R83, it would be deferred to the facility primary care providers. The DON stated she thought hospice was an adequate rationale. The DON stated unless they saw a negative impact she would not expect further documentation from the provider. The facility's undated policy titled CP Reports identified recommendations would be acted upon and documented by the facility staff and/or the prescriber. If the prescriber had not responded the medical director would be contacted.

Based on observation, interview, and document review, the facility failed to ensure they were free of a medication error rate of five percent or greater. The facility had a medication error rate of 7.41% with 2 errors out of 27 opportunities for errors involving 2 of 7 residents (R25 and R34) who were observed during the medication pass. Findings Include: R25 R25's quarterly minimum data set (MDS) dated [DATE], identified R25 was cognitively intact and required staff assistance with most activities of daily living. The MDS indicated R25 had diabetes mellitus (DM) and received insulin daily in the 7-day lookback period. R25's care plan revised 5/14/24, identified a risk for alteration in blood glucose levels related to the diagnosis of diabetes and tasked staff with providing medications per orders. R25's provider order dated 6/28/24 indicated, HumaLOG Injection Solution 100 UNIT/ML (Insulin Lispro). Inject as per sliding scale: if 141-180 = 2 units give before meals, anything above 400 gives 14 units. May sub Admelog, or Novolog based on insurance.; 181 - 220 = 4 units, 221 - 260 = 6 units; 261 - 300 = 8 units; 301 - 340 = 10 units; 341 - 400 = 12 units; 401 - 999 = 14 units, subcutaneously before meals for T2 DM give before meals, anything above 400 give 14 units. R25's July 2024 Medication Administration Record (MAR), indicated R25 received Humalog three times a day. During observation on 7/9/24 at 11:58 a.m., registered nurse (RN)-A obtained R25's Humalog KwikPen. RN-A cleansed the tip of the pen with an alcohol wipe and applied a sterile needle. The pen was dialed to the ordered dose, 4 units. RN-A had not primed the needle prior to administering the medication to R25. R34 R34 admission MDS dated [DATE], identified R34 with moderate cognitive impairment and required staff assistance with most activities of daily living. The MDS indicated R34 had DM and received insulin daily in the 7-day lookback period. R34 care plan dated 6/3/24, indicated R34 at risk for alteration in blood glucose levels related to their diagnosis of diabetes and tasked staff with providing medications per orders. R34 provider order dated 7/8/24 indicated, HumaLOG Injection Solution 100 UNIT/ML (Insulin Lispro). Inject 5 unit subcutaneously with meals for Type 2 Diabetes. R34's Medication Administration Record printed 7/10/24, indicated R34 received Humalog three times a day. During an observation and interview on 7/9/24 at 12:19 p.m., RN-A obtained R34's Humalog KwikPen. RN-A cleansed the tip of the pen with an alcohol wipe prior to attaching a sterile needle. The pen was dialed to the ordered dose, 5 units. RN-A had not primed the needle prior to administrating the medication to R34. RN-A stated the needle did not need to be primed unless it was a new pen. During a follow up interview on 7/9/24 at 1:27 p.m., RN-A stated, I made a mistake, it should be primed. During an interview on 7/10/24 at 10:26 a.m., RN-B stated that insulin pens should be primed prior to administration because it could give a lesser dose of insulin. During an interview on 7/10/24 at 11:00 a.m., the director of nursing (DON) stated that insulin KwikPens should be primed prior to administration to ensure the correct dose was given to not cause an error. Manufacturers instructions regarding Humalog Kwikpen dated 8/23, indicated to first dial up to two units to prime the needle, turn pen with needle pointing up, tap pen gently to move air bubbles to the top, push the dose knob until it stops, and ensure insulin is visible at the tip of the needle.

Based on observation, interview, and document review, the facility failed to ensure proper infection control practices were followed when staff failed to utilize enhanced barrier precautions (EBP) and proper hand hygiene for 1 of 1 resident (R20) observed during wound care. Findings include: R20's admission minimum data set (MDS) dated [DATE], identified R20 was cognitively intact, required partial to substantial staff assistance in most activities of daily living, and at risk for developing pressure ulcers. Diagnoses included debility (general weakness), chronic obstructive pulmonary disease (COPD), and oxygen therapy. R20's care plan (CP) dated 6/18/24, identified EBP was placed due to a wound. The CP directed staff to follow EBP, in addition to standard precautions, by wearing gown and gloves during high-contact care activities. R20's physician orders dated 6/18/24 indicated wound care to coccyx every shift and as needed for wound integrity. During an observation on 7/8/24 at 1:55 p.m., R20's door had an EBP sign posted and next to the door was an isolation cart inside it contained personal protective equipment (PPE). During an observation on 7/10/24 at 9:49 a.m., registered nurse (RN)-C entered R20's room, completed hand hygiene, donned gloves but not a gown. R20 was sitting on the toilet with the front of the wheelchair facing them. RN-C asked R20 to lean forward, the dressing was removed, gloves were doffed, new gloves donned, but no hand hygiene completed. The area was cleansed and patted dry twice followed by a skin prep solution spray. Gloves were doffed, and a clean set of gloves donned, but no hand hygiene between. A sealed alginate dressing opened, border foam dressing opened and dated, and two were applied to the wound, alginate followed by the foam dressing. Gloves were doffed, and a clean set of gloves donned, but no hand hygiene between. During an interview on 7/10/24 at 10:03 a.m., RN-C identified the EBP sign on R20's door and stated the precautions were in place due to R20's wound. RN-C stated, that's my fault for not following the precautions and that hand hygiene should have been completed when changing gloves. During an interview on 7/10/24 at 10:14 a.m., RN-B who stated staff should follow EBP by wearing the gown and gloves, and that hand hygiene was to be completed when changing gloves. During an interview on 7/10/24 at 10:31 a.m., the infection preventionist (IP) stated that EBP were placed for anyone with wounds, including pressure injuries. IP expected staff to gown and glove outside the room and hand hygiene to be performed when changing gloves. During an interview on 7/10/24 at 11:00 a.m., the director of nursing (DON) stated that staff should wear gown and gloves in accordance with EBP for high contact care and that it was expected for hand hygiene to be completed between glove changes. A facility policy titled EBP Policy and Procedure dated 4/24, identified the use of gowns and gloves were required for high contact cares for residents at increased risk of multidrug resistant organism (MDRO) acquisition. Therefore, EBP would be implemented for all residents with wounds, even if the resident was not known to be colonized or infected with a MDRO. A facility policy titled Infection Control Standard Precautions Hand Hygiene undated, identified that hand hygiene should be performed before donning and after doffing personal protective equipment.

Based on observation, interview and document review, the facility failed to implement assessed and directed fall prevention techniques for 2 of 3 residents (R1,R2) reviewed for falls. This resulted in actual harm for R1 who had an assisted fall to the floor when staff were not utilizing a gait belt during a transfer as assessed and R1 sustained a right ankle fracture. Findings include: R1's annual Minimal Data Set (MDS) dated [DATE], indicated R1 had diagnoses which included osteoporosis, Alzheimer's disease, and R1 had moderately impaired cognition. R1's care plan revised on 5/26/24, identified R1 had limited physical mobility related to muscle weakness and impaired gait/balance, chronic shoulder pain, dementia with memory loss and required a front wheeled walker and assistance by staff when transferring and ambulating. Further, R1's care plan identified R1 was at risk for falls. Review of facility's Summit 3 Communication Sheet dated 5/16/24, identified R1 was a fall risk and directed staff to assist R1 with transfers utilizing a front wheeled walker and a gait belt. Further, facility document revealed standard safety measures and directed staff to assure call light was within reach and gait belt was to be used when assisting with all transfers and ambulating. Review of facility report to the State Agency (SA) dated 5/20/24, indicated staff was assisting R1 to get ready for the day and ambulating R1 to the toilet. R1 was about to pass out while ambulating and assisted R1 to the floor. R1 complained of pain on her left side of the body and her right ankle, but was able to move all extremities. Review of facility's 5-day investigation to the SA revealed R1 was confirmed to have sustained a right bimalleolar fracture with mortise displacement. In addition, the staff did not follow the company's standard safety practice of utilizing a gait belt when transferring or ambulating a resident and facility wide education to ensure staff would follow plan of care and compliance with the company's standard safety practices was the action taken to prevent reoccurrence. R1's Final Report dated 5/19/24, completed by Dispatch Health Imagining, revelaed the findings of R1's x-rays was a fracture of the distal fibula and a chip fracture of the medial malleolus. R2's entry MDS dated [DATE], indicated R2 had diagnoses which included Alzheimer's disease, anxiety disorder and urgency of urination. R2's care plan as of 5/29/24, identified R2 as at risk for falls related to cognitive impairment, gait/balance problems, history of falls, poor communication/comprehension, and unaware of safety needs. R2's fall interventions included a toileting plan in place and directed staff to reference the communication sheet for details. Review of facility's Trolley 3 Communication Sheet dated 5/24/24, identified R2 was a fall risk and directed staff to keep bedroom door open for safety due to frequent self-transfers and toilet upon rising, before meals, at hour of sleep and every 3 hours during the night. R2's Resident Occurrence Report dated 5/26/24, indicated R2 had an unwitnessed fall in room at 3:50 a.m. and R2 did not sustain any injuries. R2 reported she was attempting to get out of bed to use the bathroom. R2 was last observed by nursing assistant (NA)-B at 3:30 a.m. and R2 was noted to be in her room laying in bed. R2 was last assisted to the bathroom at approximately 12:00 a.m. However, document lacked evidence of interdisciplinary team (IDT) addressing R2's toileting care plan was not followed at the time of the fall and what had been done to correct. Review of facility document titled Falls Tracking as of 5/29/24, revealed R2 had a fall on 5/26/24 and IDT intervention implemented based on root cause was identified as staff coaching. Review of facility document titled [NAME] Care Center dated 5/21/24, and name of education was identified as Communication Protocol and Gait Belts for Transfers and Ambulation directing staff to sign the document to verify staff were present and understood to follow policies and practices outlined within the presentation. Further, education provided included when providing cares to residents or responding to resident requests, all staff need to be aware of the individualized interventions for each resident and resident care specific information could be found on the Communication Sheet. Staff were directed to review the Communication Sheet each time they work with residents due to constant changes and adjustments made to the resident's cares. Also, education included Communication Sheet Guideline which included toileting schedule and transfer for staff to review. In addition, document revealed NA-B had not reviewed the document as evidenced by NA-B's signature was not on the document. On 5/29/24 at 2:49 p.m., R2 was observed in her room sitting in a standard wheelchair, slippers on and call light was within reach. R2 appeared comfortable and was drinking a cup of coffee. At 3:14 p.m., R2 was assisted to a table in the commons area with other female residents and an unidentified female staff remained in the area. On 5/30/24 at 8:51 a.m., registered nurse (RN)-A indicated R2 was at risk for falls and interventions included keeping R2's door open for staff to monitor her closely as well as toileting program every 2-3 hours and as needed. Further, RN-A stated fall interventions were located on the Communication Sheets which are available to staff and updated daily and with any changes. On 5/30/24 at 10:24 a.m., NA-C stated R2 requires staff assistance with transfers using a gait belt and she was at risk for falls due to self-transferring, adding R2's fall interventions included frequent glances into R2's room, keep door open, and toileting every 2-3 hours as well as upon rising, and before meals. Further, NA-C stated fall interventions were listed on each resident's care plan as well as the Communication Sheets. On 5/30/24 at 10:59 a.m., NA-A stated she was assisting R1 to get up in the morning on 5/19/24. NA-A stated R1 stood up from her bed and NA-A was supporting her but did not use a gait belt as required because NA-A stated she did not know she required one at that time. NA-A stated R1 expressed feeling lightheaded and NA-A offered her the wheelchair to which R1 declined. R1 then began falling forward and NA-A gently assisted her to the ground. Following the incident, NA-A stated management had called her and informed her she did not follow R1's care plan and NA-A should have used a gait belt. NA-A stated she resigned from the position and was no longer employed with the facility. On 5/30/24 at 1:31 p.m., RN-B stated following each fall she would review the form that was completed by the floor nurse at the time of the fall and bring it to the IDT meeting every weekday at 9:00 a.m. RN-B stated the IDT then goes through the fall and interventions and ideas are discussed as a team, and if the fall required follow up with the floor staff RN-B would do that within the same day or the next day depending on significance. RN-A stated interventions are determined based on the root cause analysis of the fall and what could staff do differently to prevent another fall, and the new intervention would then be communicated to the staff verbally on shift and updated the resident's care plan and staff Communication sheets that they are expected to review before every shift. RN-B stated R1 required assist of one staff with a gait belt and front wheeled walker for transfers and had been identified as a fall risk. RN-B indicated on 5/19/24, when R1 had a fall resulting in an ankle fracture, through the facility's investigation it was determined R1's care plan was not followed at the time of the fall due to NA-A not utilizing a gait belt while transferring R1 and the facility immediately implemented education to all staff on utilizing the Communication Sheet and all resident's require a gait belt to transfer. Further, RN-B stated R2 was a new admission and had only been at the facility approximately a week but was identified as a high fall risk with intervention that included wheelchair for mobility, toileting plan every three hours, upon rising, before meals and bed as well. RN-B stated on 5/26/24 R2 had an unwitnessed fall in her room and IDT determined the root cause of the fall to be R2's toileting program had not been followed on the overnight as R2 would have been due for toileting at time of the fall. R2 did not sustain any injuries from the fall and RN-B stated coaching to NA-B had not occurred yet but planned on completing today (5/30/24). RN-B confirmed NA-B had worked since the fall occurred and education could have been done prior to 5/30/24. On 5/30/24 at 1:55 p.m., director of nursing (DON) stated staff were expected to implement immediate interventions following a fall on the weekend and the IDT would review the next business day to provide an intervention. At 3:16 p.m., DON stated she was aware R2's care plan related to toileting was not followed at the time of R2's fall on 5/26/24 and confirmed NA-B had not been educated or re-trained but messages had been left for NA-B since the incident with no call back. DON stated NA-B worked at the facility on 5/27/24, 5/28/24 and 5/29/24 but no attempts were made to connect with NA-B while at work. At 4:10 p.m., DON stated the all-staff education for R1's fall should be completed by all staff within two weeks and for those who have not completed the education would be contacted by leadership. DON confirmed neither NA-B nor all facility staff had been re-educated at time of survey entrance for the R1's incident. On 5/30/24 at 2:36 p.m., family member (FM)-A stated she had received a call from the facility staff following R1's fall on 5/19/24, and staff informed FM-A they had called the physician to get orders to obtain an x-ray. FM-A stated she was agreeable to have R1 remain in the facility following the confirmation of R1's fracture, declining hospitalization , and FM-A stated she was concerned about R1's pain management, which the physician was involved and ordering medication. FM-A stated the facility scheduled an orthopedic appointment related to R1's fracture for the following week. On 5/30/24 at 3:46 p.m., an attempt to interview NA-B was made by phone but unsuccessful. Review of facility policy titled Fall Prevention and Management Program Policy modified 4/2021, indicated the clinical coordinator was responsible for implementation and oversight of individualized residents fall prevention care and supervising personnel in delivering safe and personalized care. Further, policy indicated members of the IDT are responsible for assessing, treating, and implementing strategies for the prevention of resident falls.

Based on observation, interview, and document review, the facility failed to provide a dignified dining experience for 6 of 6 residents (R6, R10, R36, R45, R50, R82) who required assistance with eating. This has the potential to impact all residents residing on memory care who require assistance with eating. Findings include: R6's significant change MDS dated [DATE], indicated R6 had severe cognitive impairment and diagnoses of Parkinson's disease and dementia. Furthermore, R6's MDS indicated R6 required extensive assist of one person for eating. R10's quarterly MDS dated [DATE], indicated R10 had mild cognitive impairment and had diagnoses of Parkinson's disease and dementia. Furthermore, R10's MDS indicated R10 required extensive assistance with one person for eating. R36's annual MDS dated [DATE], indicated R36 had severe cognitive impairment and diagnoses of Parkinson's disease and dementia. Furthermore R36's MDS indicated R36 required extensive assistance with one person for eating. R45's quarterly MDS indicated R45 had severe cognitive impairment and diagnoses of Alzheimer's disease and dementia. Furthermore, R45's MDS indicated R45 required supervision after set up for eating. R50's significant change Minimum Data Set (MDS) dated [DATE], indicated R50 had severe cognitive impairment and diagnoses of Alzheimer's disease and dementia. Furthermore, R50's MDS indicated R50 required extensive assist of one person for eating. R82's significant change MDS dated [DATE], indicated R82 had severe cognitive impairment and diagnoses of dementia and depression. Furthermore, R82 required supervision after set up for eating. An observation on 8/14/23 at 9:31 a.m., R6, R50, and R82 were the seated in the dining room. Nursing assistant (NA)-B greeted R50 and R82 who were seated at a table. NA-B stood between R50 and R82 and first took a spoonful of breakfast and fed to R50. Still standing, NA-B turned and took R82's spoon and took a spoonful of breakfast and fed R82. NA-B then moved to R6 who was seated at a table by herself. NA-B stood and fed R6 a spoonful of breakfast. NA-B went back over to R50 and 82's table. Still standing, NA-B spooned up some breakfast and handed the spoon to R50 to eat. NA-B stood over R82 and assisted R82 with a bite of breakfast before turning again to R50. NA-B still standing, assisted R50 with a bite of breakfast. NA-B returned to R6's table and stood over R6 and continued to assist with breakfast. When interviewed on 8/14/23 at 9:45 a.m., NA-B stated R6, R50, and R82 all required assistance and encouragement to eat. NA-B stated they needed to move around a lot to get to everyone that needs help. NA-B further stated usually were supposed to sit with residents, but other staff were assisting with cares on the unit, so NA-B had to be able to move and was unable to sit next to the residents. When interviewed on 8/15/23 at 1:25 p.m., registered nurse (RN)-E assisted with lunch. With residents still in the dining area, RN-E stated staff try to keep the feeders at a table together. RN-E verified the term feeders shouldn't be used to describe residents who need assistance with eating and shouldn't have been used. When observed on 8/16/23 at 1:25 p.m., R10 and R45 were seated next to each other in the dining room for lunch. NA-C walked over and stood in-between R10 and R45. NA-C took a spoonful of food and assisted R10 with eating. Next, NA-C turned to R45 and while still standing and without hand hygiene, picked up R45's spoon and assisted with eating. NA-C went back and forth between R10 and R45 and assisted them with eating and wiped their faces with napkins. When interviewed on 8/16/23 at 1:54 p.m., NA-C verified standing when assisting R10 and R45 with eating. NA-C stated sitting while assisting them was needed, but residents don't always get placed at the correct seating when coming to lunch right from activities. NA-C stated staff try to keep the feeders at the same table or in a location that allows staff to sit and assist them and when it doesn't happen, staff stand. NA-C acknowledged the word feeders shouldn't be used and it could make residents feel bad. NA-C explained but it wasn't to label the residents who need assistance, it was a way to differentiate those who need assistance from those who don't. When interviewed on 8/17/23 at 8:52 a.m., RN-B expected staff to assist no more than two residents with eating and to be seated next to them. RN-B stated standing over residents can be alarming or frightening. RN-B further stated using the word feeder to talk about residents who need assistance with eating should not be used with residents or in general when talking with each other. When interviewed on 8/17/23 at 11:30 a.m., the director of nursing (DON) expected staff to sit with residents when helping them eat and by standing may make the residents feel uncomfortable. DON further stated staff should not be using the term feeders when talking about residents as it can make residents feel bad about their assistant needs. A facility policy titled Dining Room Protocol Policy revised 2/2016, directed staff to provide a dignified and prompt meal service.

Based on observation, interview, and document review, the facility failed to ensure hand hygiene was completed during wound cares and wound cares were provided to minimize risk of cross contamination for 1 of 2 residents (R17) observed for pressure injuries. Furthermore, the facility failed to ensure hand hygiene was completed for 2 of 2 residents (R15, R29) observed for incontinent cares and 7 residents (R6, R10, R36, R45, R50, R54, R82) who required assistance with eating. The facility also failed to ensure disinfection of a glucometer was performed for 1 of 1 resident (R9) observed for medication administration. Findings include: Wound care R17's Medical Diagnosis form in the electronic medical record (EMR) indicated the following diagnoses: peripheral vascular disease, MRSA, cellulitis of right lower limb, polyneuropathy, and unstageable pressure ulcer of left heel. R17's physician's orders dated 6/18/23, indicated R17 was on contact precautions (measures intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment) with cares. R17's physician's orders dated 7/6/23, indicate the following order: left heel wound care cleanse with normal saline, apply xeroform gauze cover with telfa, wrap with gauze and ace wrap. Change daily. R17's physician's orders dated 7/29/23, indicated the following order: right ankle wound care: cleanse with normal saline, or wound cleanser, apply betadine. Cover with telfa and roll gauze. Apply sock for protection of toes. Change dressing every other day. R17's physician's orders dated 8/1/23, indicated the following order: wound care to buttocks: [NAME]: nystatin powder four million, hydrocortisone powder 1.2 grams, zinc oxide paste four ounces. Apply to buttocks twice a day with cares until cleared. R17's physician's orders dated 8/3/23, indicated the following order: skin prep to right heel every other day use heel cushion boot on right heel in bed. R17's right ankle wound culture obtained on 6/14/23, indicated the following bacteria: Escherichia coli, methicillin resistant staphylococcus aureus (MRSA-a type of infection resistant to many antibiotics making it difficult to treat), Enterococcus faecalis. R17's left buttock wound culture obtained on 7/25/23, indicated the following bacteria: Escherichia coli, Pseudomonas aeruginosa, Enterococcus faecalis, MRSA, Enterococcus faecalis. During interview and observation on 8/16/23 from 1:44 p.m. to 2:02 p.m., registered nurse (RN)-C took off R17's boot on the left foot and cut off the dressing with scissors and placed the soiled dressing on the floor. At 1:47 p.m., RN-C was kneeling on the floor without a barrier on the floor and took off the dressing on R17's right foot. RN-C donned another pair of gloves on top of the gloves RN-C already had on. RN-C cleaned the area on the inside of the left ankle with saline at 1:49 p.m., then cleaned the back of the left heel and applied new gauze dressings. Without changing gloves, RN-C took a roll of tape out of the basin where the clean dressing supplies were located, and secured the dressings with the tape. At 1:53 p.m., RN-C donned another pair of gloves on top of the two pair RN-C was already wearing without sanitizing hands and grabbed an additional gauze roll from the clean supply basin and set the scissors used to cut the soiled dressings back in the clean dressing supply basin without first sanitizing the scissors. At 1:57 p.m., RN-C placed the soiled dressings that were on the floor in the garbage bag. At 2:02 p.m., RN-C verified wearing three pairs of gloves and stated R17 had MRSA and thought donning new gloves over the old gloves was better while R17 was on contact precautions and added the dressings should have gone in the garbage can. During interview on 8/16/23 at 2:12 p.m., the infection preventionist (IP) stated gloves should be changed in between each wound dressing change, hand hygiene should be performed between each glove change, and the scissors should be cleaned after use. IP stated the MRSA was located on R17's coccyx and added the MRSA was also in R17's right ankle wound. IP further stated, she expected use of a chuck pad if the dressing changed was performed by staff kneeling on the floor and expected soiled dressings be placed in the trash versus on the floor. Further stated breaks in infection prevention practices could result in bacteria in wounds being transmitted to a different wound site. A policy, Infection Control Standard Precautions, dated 2020, indicated hand hygiene procedures were adhered to in order to prevent the transmission of pathogens. Hand hygiene was performed before and after contact with the resident, after contact with blood or body fluids, after contact with visibly contaminated surfaces, after contact with objects in the resident's room, before donning personal protective equipment and after removing personal protective equipment. A policy, Dressing Change-Sterile, dated 12/2014, indicated a plastic bag was placed near the foot of the bed to receive soiled dressing, donn the first pair of sterile gloves, remove soiled dressing and discard in the plastic bag. Remove gloves and discard in plastic bag and wash hands. Don a second pair of sterile gloves and cleanse wound with the prescribed solution and sterile gauze, apply the prescribed medication if ordered, apply sterile dressings, secure with tape, and remove sterile gloves and discard. A policy for non-sterile dressing changes was not provided. A Nurse Skill Competency: Wound Dressing Change form was provided (undated), indicated the following steps: wash hands and don gloves, loosen tape and remove dressing, pull gloves over dressing and discard, wash hands and don gloves, cleanse wound, remove gloves and wash hands, don gloves and dress the wound, then remove gloves and wash hands, and disinfect the scissors. Incontinent Cares R15's significant change Minimum Data Set (MDS) dated [DATE], indicated R15 had severe cognitive impairment and diagnoses of dementia and heart failure. Furthermore, R15's MDS indicated R15 was frequently incontinent. R29's signifigant change MDS dated indicated R29 had severe cognitive impairment and had diagnoses of dementia and depression . Furthermore, R29's MDS indicated R29 was frequently incontinent. An observation on 8/16/23 at 9:08 a.m., nursing assistant (NA)-D entered to assist R15. NA-D gathered supplies at the bedside, performed hand hygiene, and donned gloves. NA-D assisted R15 to pull down pants and opened R15's brief. R15's brief was wet and NA-D pushed the wet brief down in between R15's legs. NA-D had wanted to move to the other side of the bed so, without removing gloves or performing hand hygiene, NA-D pulled up R15's pants slighlty, and then moved the trash and supplies over to the other side of R15's bed. Once on the other side of the bed, NA-D adjusted R15's pants back down and obtained a wipe and cleansed the front of R15's perineal area. NA-D then assisted R15 to turn to her right side. With a new wipe, NA-D cleansed R15's backside, removed the wet brief from underneath R15, and placed it in the garbage. Without performing hand hygiene and glove exchange, NA-D placed barrier cream on the reddened area on R15's buttoks. R15's clean brief was then placed under R15 without performing hand hygiene and glove exchange, and NA-D called for assistance to help with positioning. Registered nurse (RN)-D entered to assist, and performed hand hygiene and donned gloves. NA-D and RN-D assisted R15 back on her back before turning to R15's right side so the clean brief could be adjusted. Without hand hygiene, NA-D then pulled R15's brief up and fastened it. Without hand hygiene, NA-D then assisted R15 with pulling up pants and to get adjusted in the bed. RN-D and NA-D gave R15 a boost up in bed. RN-D removed gloves and performed hand hygiene before exiting R15's room. NA-D removed gloves but did not perform hand hygiene before continuing to place R15's blanket on her, using the bed control to lower the bed down, putting supplies away and adjusting the bedside table. NA-D then placed R15's wheelchair breaks on and ensured R15's call light was in place before exiting the room and then performed hand hygiene. When interviewed on 8/16/23 at 9:22 a.m., NA-D acknowledged they had not exchanged gloves or performed hand hygiene in between handling R15's soiled brief and clean areas. NA-D further stated gloves were supposed to be changed, hand hygiene performed when gloves are removed, and when moving from dirty areas to clean areas. When observed on 8/16/23 at 2:06 p.m., NA-C entered R29's room to assist with toileting. NA-C performed hand hygiene and donned gloves. NA-C assisted R29 out of her chair with the ez-stand (lift machine that helps stand and transfer the resident). R29 was transferred to the bathroom. NA-C assisted to lower R29's pants and removed a wet brief. Without hand hygiene and glove exchange, NA-C then took the control for the EZ stand and lowered R29 to sit on the toilet. Without removing gloves or performing hand hygiene, NA-C then went to R29's cabinet and removed wipes and a clean brief. After R29 had sat for several minutes without voiding, R29 stated they were done. Without hand hygiene or glove exchange, NA-C took the EZ stand controller and lifted R29 off the toilet before obtaining wipes and performed perineal care. Without hand hygiene or glove exchange, NA-C placed barrier cream on R29's bottom, placed a clean brief, and pulled R29's pants up. NA-C then removed gloves but had not performed hand hygiene before transferring R29 back to the wheelchair. Once R29 was in the wheelchair, R29 had reached for the EZ stand controller and NA-C removed it from her hands and directed her hands back to the bar before lowering R29 back to the wheelchair. NA-C then removed sling off resident and hung it on the EZ stand. NA-C exited R29's room, then performed hand hygiene. When interviewed on 8/16/23 at 2:24 p.m., NA-C acknowledged gloves should have been removed, hand hygiene completed, and new gloves placed after removal of R29's brief and after cleaning R29's perineal area. NA-C further stated, they just wanted to get cares completed as R29 was going to music. When interviewed on 8/16/23 at 9:48 p.m., the infection preventionist stated staff were expected to perform hand hygiene during cares when touching soiled items to clean items. IP further expected staff to sanitize hands after each glove removal. When interviewed on 8/17/23 at 11:30 a.m., the director of nursing expected staff to perform hand hygiene to be completed when moving from a dirty area to a clean area and anytime gloves were removed. DON further stated, this was important to minimize risk of bacteria spread and infections. Dining R6's significant change MDS dated [DATE], indicated R6 had severe cognitive impairment and diagnoses of Parkinson's disease and dementia. Furthermore, R6's MDS indicated R6 required extensive assist of one person for eating. R10's quarterly MDS dated [DATE], indicated R10 had mild cognitive impairment and had diagnoses of Parkinson's disease and dementia. Furthermore, R10's MDS indicated R10 required extensive assistance with one person for eating. R36's annual MDS dated [DATE], indicated R36 had severe cognitive impairment and diagnoses of Parkinson's disease and dementia. Furthermore, R36's MDS indicated R36 required extensive assistance with one person for eating. R45's quarterly MDS indicated R45 had severe cognitive impairment and diagnoses of Alzheimer's disease and dementia. Furthermore, R45's MDS indicated R45 required supervision after set up for eating. R50's significant change Minimum Data Set (MDS) dated [DATE], indicated R50 had severe cognitive impairment and diagnoses of Alzheimer's disease and dementia. Furthermore, R50's MDS indicated R50 required extensive assist of one person for eating. R54's annual MDS dated [DATE], indicated R54 had mild cognitive impairment and had diagnoses of Alzheimer's disease and dementia. Furthermore, R54's MDS indicated R54 was independent with eating after set up. R82's significant change MDS dated [DATE], indicated R82 had severe cognitive impairment and diagnoses of dementia and depression. Furthermore, R82 required supervision after set up for eating. An observation on 8/14/23 at 9:31 a.m., R6, R50, R54, and R82 were the only residents seated in the dining room. Nursing assistant (NA)-B greeted R50 and R82 who were seated at a table. NA-B stood between R50 and R82 and first took a spoonful of breakfast and fed to R50, placed spoon back on R50's plate. Without performing hand hygiene, NA-B turned and with the same hand took R82's spoon and took a spoonful of breakfast and fed R82. NA-B then moved to R6 who was seated at a table by herself. Without hand hygiene and using the same hand, NA-B stood and fed R6 a spoonful of breakfast. NA-B then obtained a dirty clothing protector laying on R6's table, folded it and placed it on a dirty plate. NA-B noticed R50 was picking up her plate and placing in her lap. Without hand hygiene, NA-B went over to R50 to assist her with placing the plate back on the table. NA-B spooned up some breakfast and handed the spoon to R50 to eat. R50 took the spoon and started to eat. NA-B then performed hand hygiene before walking back to R82. NA-B stood and assisted R82 with a bite of breakfast before turning to R50. Without hand hygiene and use of the same hand, NA-B still standing, assisted R50 with a bite of breakfast. NA-B returned to R6's table and without hand hygiene stood over R6 and assisted with breakfast. NA-B then walked over to the other side of the table and picked up used silverware from the floor and placed next to dirty dishes on the table. Without hand hygiene, NA-B walked over and opened a jelly packet for R54. When interviewed on 8/14/23 at 9:45 a.m., NA-B verified hand hygiene was not performed in between assisting resident with eating. NA-B stated she usually had hand sanitizing wipes in her pockets to use in between residents but didn't have them today. NA-B further acknowledged hand hygiene should have been completed in between assisting residents, after handling dirty napkins and dirty clothing protectors, and after picking up items from the floor. An observation on 8/15/23 at 1:18 p.m., residents were being escorted out of the dining room as lunch was ending. A few residents remained and R45 was in her wheelchair sitting at a table. R45 appeared to be done with her meal and was self-propelling around the dinning room in her chair. R45 had went to a table where residents had finished eating however dirty dishes, napkins and clothing protectors remained. R45 moved some dirty napkins around and folded a dirty clothing protector. Registered Nurse (RN)-A was in the dining room but was unaware of R45's actions. R45 then wheeled over to another table and again was moving dirty napkins and dirty plates around. One of the plates contained a half-eaten piece of pie with whipped cream. R45 took her finger and stuck it in the pie and licked her finger clean. R45 then wheeled away from the table and closer to RN-B who then helped R45 remove the clothing protector and sanitize her hands. When interviewed on 8/15/23 at 1:25 p.m., RN-B stated staff had to be in the dining room to supervise or assist residents. RN-B stated some residents will eat whatever is on the table even if it was a different consistency than was ordered for them. RN-B verified R45 often wandered around the dining room, had taken food off other residents' plates, and had not noticed R45 do that today as she was at another table. RN-B verified eating off dirty plates could place residents at risk of infection or sickness. When observed on 8/16/23 at 1:25 p.m., R10 and R45 were seated next to each other in the dining room for lunch. NA-C stood in-between R10 and R45 and took a spoonful of food and assisted R10 with eating. Next, NA-C turned to R45 and without hand hygiene picked up R45's spoon and assisted with eating. NA-C went back and forth between R10 and R45 assisting with their napkins to wipe face and with eating. Hand hygiene was not performed during the observation. When interviewed on 8/16/23 at 1:54 p.m., NA-C stated there was not a need to perform hand hygiene in between residents when assisting with eating. NA-C further stated hand hygiene was required if hands had gotten some food on them. When interviewed on 8/17/23 at 8:52 a.m., RN-B stated staff tried to position residents so one staff member would be helping no more than 2 residents. The staff who was assisting with eating should be seated in between the residents they were assisting. RN-B stated hand hygiene needed to be completed in between residents when assisting more than one resident with eating. RN-B further stated hand sanitizing wipes should be available at the table to ensure hand hygiene was completed in between residents. When interviewed on 8/17/23 at 11:30 a.m., the director of nursing (DON) expected staff to complete hand hygiene when assisting multiple residents with eating. Furthermore, the DON stated this was important to minimize any contamination or infection. A facility policy titled Infection Control Standard Precautions-Hand Hygiene revised 2020, directed staff to perform hand hygiene after contact with blood or body fluids and after removing personal protective equipment. The policy further directed staff to follow hand hygiene policy and procedures to prevent the spread of pathogens. 46885 R9's quarterly Minimum Data Set, dated dated dated [DATE], indicated R9 had diabetes mellitus and took insulin. R9's physician orders indicated R9's blood sugars were checked in the a.m., and before supper. During observation on 8/17/23, at 8:06 a.m., trained medication aide (TMA)-A took a glucometer out of the medication cart, brought R9 to her room and checked R9's blood sugar and put the glucometer in a basket and brought it back to the medication cart and set the glucometer on top of the medication cart. At 8:09 a.m., TMA-A brought R9 back to the dining room and sanitized her hands. At 8:10 a.m., TMA-A opened the medication cart and put the glucometer back in the cart without sanitizing the glucometer. During interview on 8/17/23, at 8:18 a.m., TMA-A verified she had not wiped down the glucometer and stated she would grab a Super Sani Cloth. TMA-A had to find a Super Sani Cloth because they were not located on the medication cart and added they had hand sanitizer, but not Super Sani Cloths on the medication cart and further stated they should be wiped down after each use. During interview on 8/17/23, at 8:22 a.m., IP stated glucometers should be cleaned between use and before putting back in the medication cart. During interview on 8/17/23, at 10:51 a.m., TMA-A stated the glucometer used was an Assure Platinum Arkray meter and stated the glucometer was not R9's personal glucometer. During interview on 8/17/23, 11:32 a.m., the director of nursing (DON) stated ideally dressing changes were not performed on the floor and stated there should be a barrier for infection reasons and stated dressings should be placed in the trash not on the floor and every time you doff gloves, hands were sanitized and new gloves were donned and scissors should have been cleaned with bleach and allowed to dry on a clean surface and expected glucometers be cleaned with bleach scrubs on the medication carts and disinfected between resident use. A policy, Infection Control Standard Precautions, dated 2020, indicated hand hygiene procedures were adhered to in order to prevent the transmission of pathogens. Hand hygiene was performed before and after contact with the resident, after contact with blood or body fluids, after contact with visibly contaminated surfaces, after contact with objects in the resident's room, before donning personal protective equipment and after removing personal protective equipment. A policy, Blood Glucose Monitor Disinfection dated 2/2010, indicated for use of the glucometer for a single resident the glucometer was cleaned with an alcohol wipe if there was any visible soiling of the glucometer and if the glucometer was to be used with another resident, for example after the resident discharges then follow the steps for glucometer use between multiple residents: apply a clean pair of gloves, if any visible soiling of the glucometer, first clean the glucometer with an alcohol wipe and disinfect the glucometer using a bleach based disinfectant wipe. Disinfectant sani-Cloth Bleach wipe meets the requirement and the glucose monitor must be disinfected for four minutes using the wipes and then thoroughly dried prior to use between clients. Manufacturer cleaning and disinfecting guide for Assure Platinum blood glucose monitoring system dated September 2019, indicated only the following wipes were validated for use in cleaning and disinfecting the meter: Clorox Germicidal Wipes with an EPA number 67619-12, Dispatch Hospital Cleaner Disinfectant Towels with Bleach with an EPA number 56392-8, Super Sani-Cloth Germicidal Disposable Wipe with an EPA number 9480-4, and CaviWipes with an EPA number 46781-8.

Based observation, interview, and document review, the facility failed to provide repositioning in a timely manner to prevent reoccurrence of pressure injury for 1 of 2 residents (R29) reviewed who were at risk for pressure ulcer. Findings include: R29's significant change Minimum Data Set (MDS) dated [DATE], indicated R29 had severe cognitive impairment and diagnoses of dementia and depression. R29's MDS further indicated R29 was at risk for pressure ulcer/injury. R29's pressure ulcer/injury care area assessment (CAA) dated 5/31/23, indicated R29 was at risk for pressure ulcer/injury related to dementia and impaired mobility. R29 required use of a stand lift for transfers and staff assistance with activities of daily living (ADL)s. R29's care plan revised 6/6/23, indicated R29 had limited physical mobility related to physical weakness, dementia, and impaired cognition. R29 required a broada wheelchair, assist of one staff for bed mobility and a stand liftwith one staff assistance for transfers. Furthermore, R29's care plan indicated R29 had a risk for pressure injury/impaired skin integrity related to incontinence and impaired mobility. R29 required repositioning every three hours. A review of R29's nursing progress notes revealed: -on 7/6/23 at 10:06 pm., R29 had new open areas on the sacrum that measured 3centimiters (cm) by 1 cm and 2 cm by 1 cm. -on 7/10/23 at 10:09 a.m., interdisciplinary team (IDT) follow up for R29's skin alteration. Interventions were to transfer resident to bed for naps rather than sleeping in wheelchair, repositioning every three hours, and weekly measurements with ongoing evaluation. -on 7/20/23 at 9:31 a.m., R29's wound had resolved/healed. R29's body audit assessment dated [DATE], indicated R29 had redness on her coccyx and no open areas were identified. A continuous observation on 8/16/23 at 10:30 a.m., R29 was in a group activity and was sitting upright in her broada wheelchair. At 10:38 a.m., R29 was still in group activity with several other residents. Activity staff was engaging residents in discussion about neighbors growing up as well as neighbors at facility. At 11:08 a.m., R29 was still sitting upright in her broada chair and group activity changed to volleyball with a large balloon and pool noodles. At 11:17 a.m., R29 was engaged in group and hit the balloon. At 11:45 a.m. activity staff announced it was time to transition to the dining area to lunch and turned-on music while staff started bringing residents to the dining room. At 11:59 a.m., R29 was pushed down to the dining room and placed at a table. R29 was still seated upright in her broada wheelchair. At 12:45 p.m., R29 was still seated in the dining area with residents and staff. At 1:12 p.m., the infection preventionist (IP) helped R29 clean up and brought R29 down to a table located in a common area near R29's room. R29 remained seated upright in her broada wheelchair. At 1:25 p.m., dominos was going to be played at the table with activity staff and other residents. R29 was now sleeping sitting upright in her broada wheelchair. At 1:34 p.m., registered nurse (RN)-B brought R29 into her room. RN-B placed R29 in front of her television and tilted the broada chair into a slightly reclining position. RN-B did not adjust or ensure R29's buttocks had been adjusted when reclining R29's chair. RN-B then took pillows to place under R29's arms and provided R29 a blanket. At 1:37 p.m., nursing assistant (NA)-C entered room to help. RN-B asked NA-C to find the music channel and then exited R29's room without any repositioning to ensure R29's buttocks had been adjusted to relieve pressure . NA-C found the music channel, provided R29 with the call light and exited R29's room at 1:44 p.m., without any further repositioning. At 1:57 p.m., a visitor entered R29's room. At 1:57 p.m., NA-C was approached to inquire about R29's need for repositioning. At 2:06 p.m., NA-C entered R29's room to provide cares and reposition R29 off her buttocks. The observation showed R29 had not been offered effective repositioning or toileting for 3 hours and 36 minutes. When interviewed on 8/16/23 at 1:40 p.m., RN-B stated R29 was returned to her room for dignity reasons as she was sleeping at the table when a game was going to be started. RN-B stated R29 was dependent and would not be able to request to be repositioned. RN-B further stated in a perfect world, R29 would have been transferred back to bed to have a full reposition to relieve any pressure off her buttocks. When interviewed on 8/16/23 at 1:57 p.m., NA-C stated R29 required repositioning every 3 hours. NA-C acknowledged they had not repositioned R29 after lunch and further stated the written log identified the last time R29 had been repositioned was with morning cares around 9:00 a.m. NA-C stated staff try to reposition right before or after lunch, but it doesn't always happen. NA-C stated he will go and reposition R29 now. A follow up interview on 8/17/23 at 8:36 a.m., RN-B stated R29 was at risk for pressure injury and had recently healed some skin openings on her sacrum. R29 could help some and had more mobility in her upper body but was totally dependent to mover her lower body. RN-B further stated repositioning residents in a broada wheelchair required more than just reclining, but a weight shift as well. RN-B acknowledged repositioning R29's arms did not provide any weight shift on R29's bottom and that is where R29 was most at risk of skin breakdown. RN-B further stated R29 required repositioning every three hours. When interviewed on 8/17/23 at 11:30 a.m., the Director of Nursing (DON) expected staff to follow the care plan to reposition residents. Furthermore, DON stated this was important to minimize any skin breakdown or pressure injury. A facility policy for pressure injury prevention was requested however, not provided.

Based on observation, interview, and document review, the facility failed to ensure timely incontinence cares were provided for 1 of 2 residents (R29) reviewed for bladder incontinence. Findings include: R29's significant change Minimum Data Set (MDS) dated [DATE], indicated R29 had severe cognitive impairment and diagnoses of dementia and depression. R29's MDS further indicated R29 was frequently incontinent of bowel and bladder. R29's urinary incontinence care area assessment (CAA) dated 5/31/23, indicated R29 was frequently incontinent and required extensive assist of one staff and a stand lift for transfers. R29's care plan revised 6/6/23, indicated R29 had limited physical mobility related to physical weakness, dementia, and impaired cognition. R29 required a broada wheelchair, assist of one staff for bed mobility and a stand lift with one staff assist for transfers. Furthermore, R29's care plan indicated R29 was frequently incontinent due to impaired cognition. R29 required repositioning and toileting every three hours. A continuous observation on 8/16/23 at 10:30 a.m., R29 was in a group activity and was sitting upright in her broada wheelchair. At 10:38 a.m., R29 was still in group activity with several other residents. Activity staff was engaging residents in discussion about neighbors growing up as well as neighbors at facility. At 11:08 a.m., R29 was still sitting upright in her broada chair and group activity changed to volleyball with a large balloon and pool noodles. At 11:17 a.m., R29 was engaged in group and hit the balloon. At 11:45 a.m. activity staff announced it was time to transition to the dining area to lunch and turned-on music while staff started bringing residents to the dining room. At 11:59 a.m., R29 was pushed down to the dining room and placed at a table. R29 was still seated upright in her broada wheelchair. At 12:45 p.m., R29 was still seated in the dining area with residents and staff. At 1:12 p.m., the infection preventionist (IP) helped R29 clean up and brought R29 down to a table located in a common area near R29's room. R29 remained seated upright in her broada wheelchair. At 1:25 p.m., dominos was going to be played at the table with activity staff and other residents. R29 was now sleeping sitting upright in her broada wheelchair. At 1:34 p.m., registered nurse (RN)-B brought R29 into her room. RN-B placed R29 in front of her television and tilted the broada chair into a slightly reclining position. At 1:37 p.m., nursing assistant (NA)-C entered room to help. RN-B asked NA-C to find the music channel and then exited R29's room without offering toileting or checking for incontinence. NA-C found the music channel, provided R29 with the call light and exited R29's room at 1:44 p.m., without offering toileting or checking for incontinence. At 1:57 p.m., a visitor entered R29's room. At 1:57 p.m., NA-C was approached to inquire about R29's need for toileting or incontinent care. At 2:06 p.m., NA-C entered R29's room to toilet and provide cares and the continuous observation ended. The observation showed R29 had not been offered incontinence care or toileting for 3 hours and 36 minutes. When interviewed on 8/16/23 at 1:40 p.m., RN-B stated R29 was returned to her room for dignity reasons as she was sleeping at the table when a game was going to be started. RN-B stated R29 was dependent and would not be able to request to be cleaned up and staff needed to check for incontinence. RN-B verified she had not checked to see if R29 required a new brief and stated in a perfect world, R29 would have transferred back to bed for staff to check and determine if incontinent care was needed. When interviewed on 8/16/23 at 1:57 p.m., NA-C stated R29 required repositioning and toileting every 3 hours. NA-C acknowledged they had not checked R29 for incontinence after lunch and further stated the written log identified the last time R29 had been toileted was with morning cares around 9:00 a.m. NA-C stated staff try to reposition and toilet right before or after lunch, but it doesn't always happen. NA-C stated he will go and toilet R29 now. A follow up interview on 8/17/23 at 8:36 a.m., RN-B stated R29 required repositioning and toileting every three hours with a stand lift. RN-B verified this information on R29's care plan and NA task sheet. RN-B further stated staff should be checking R29 for incontinence or toileting every 3 hours as indicated. When interviewed on 8/17/23 at 11:30 a.m., the director of nursing (DON) expected staff to follow the care plan toileting schedules for residents. Furthermore, DON stated this was important to minimize risk of skin breakdown or risks of urinary tract infection. A facility policy titled Incontinence Care dated 12/2014, directed staff to provide incontinence care to prevent skin breakdown and prevent infections.

Based on observation, interview and document review, facility staff failed to follow the interventions for 1 of 4 residents (R64) reviewed for falls. Findings Include: R64's diagnoses obtained from the admission record printed 4/20/22, included [CONDITION(S)], dementia, hallucinations, delusions, repeated falls, unsteady on feet and difficulty walking. R64's quarterly Minimum Data Set (MDS) dated [DATE], indicated R64 had severe cognitive impairment and required extensive assist of two staff during transfers. R64's significant change MDS's dated 12/28/21, Care Area Assessment indicated R64 remained at risk for falls due to frequent falls, self transfer attempts, unsteady gait, cognitive and vision impairments, delusions, and hallucinations. R64's care plan with an initiated date of 6/5/20, indicated R64 was at risk for falls due to impaired balance, multiple falls, self transfers without using a walker, weakness/impaired balance, and hallucinations/delusions. The care plan further indicated R64 was not to be left alone in his room when sitting in his wheelchair. R64's communication sheet dated 4/20/22, directed staff do not leave alone in room if in w/c [wheelchair]. During an observation on 4/20/22, at 9:43 a.m. occupational therapist student assisted R64 back to his room, where he was left alone while seated in his wheelchair. While R64 was in his room alone, he was able to position his walker in front of him and began to attempt to stand up from the wheelchair while using the walker. -At 9:47 a.m. surveyor intervened and alerted nursing assistant (NA)-B of R64 in a standing position from his wheelchair while using his walker. NA-B stated oh my gosh and immediately went into R64's room and provided assistance. -At 9:50 a.m. NA-B assisted R64 into the common area of the unit while asking NA-C how did R64 got into his room. NA-C indicated not knowing how R64 was left alone in his room. During an interview on 4/20/22, at 9:51 a.m. NA-B indicated R64 self transfers frequently, that staff needed to keep an eye on him, and that R64 was not to be in his room alone because of the risk of falling. During an interview on 4/20/22, at 9:56 a.m. registered nurse (RN)-C indicated R64 was at risk for falling and that R64 was not to be left alone in his room while up in his wheelchair. RN-C further indicated R64 will try to self transfer and stand up from his wheelchair without asking for help if he's in his room alone. RN-C then indicated R64 was to be in the common area where all staff can keep an eye on him. During an interview on 4/20/22, at 10:30 a.m. with occupational therapist student and life enrichment director, the occupational therapist student indicated she was not aware that R64 was not to be in his room alone while up in his wheelchair. The life enrichment director further indicated R64 frequently tries to stand up on his own without asking for help. During an interview on 4/20/22, at 11:32 a.m. RN-B indicated R64 had an intervention put in place that R64 was not to be in his room alone while up in his wheelchair. RN-B further verified R64's communication sheet had indicated R64 was not to be left alone in his room while in his wheelchair and that staff should be following what is on the communication sheet. During an interview on 4/20/22, at 11:53 a.m. clinical administrator indicated R64 was to be encouraged to stay in the common areas to prevent falling in his room. Clinical administrator further indicated nurses were to educate any staff member not familiar with R64 about fall interventions put in place. A Fall Prevention and Management Program policy dated April 2021, directed care plans will indicate the resident specific interventions to prevent falls. A Northwood Technical College Occupational Therapy Assistant Program sheet undated, directed occupational therapy assistant to follow facility procedures and policies for safety.

Based on observation, interview and document review, the facility failed to ensure 2 of 2 residents' (R6 and R9) respiratory equipment was properly replaced and cleaned who were reviewed for respiratory care. Findings include: R6's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R6's annual Minimum Data set (MDS) assessment dated [DATE], indicated impaired cognition. R6's care plan with a last review date on 4/12/22, indicated use of oxygen per nasal cannula and to follow facility protocol for care and maintenance of equipment On 4/19/22, at 2:14 p.m. R6's oxygen was observed connected to a humidifier bottle on a large oxygen tank in R6's room. The oxygen tank was set at 2 liters (L). The date on the humidifier bottle was 3/27/22. On 4/20/22, at 9:48 a.m. R6 was observed up in a wheelchair, and received oxygen per nasal cannula. The humidifier bottle was dated 3/27/22. On 4/20/22, at 10:38 a.m. registered nurse (RN)-D stated oxygen equipment, including tubing, humidifier bottle and nasal cannula were to be changed once a week, and verified R6's humidifier bottle was dated 3/27/22, which meant it was last changed 3/27/22, three weeks ago. R6's treatment sheet dated April 2022 indicated every evening shift every Tues [Tuesday] for oxygen maintenance change tubing, mask &/or humidifier and date clean concentrator filter every Tuesday. RN-D verified the treatment was signed by a staff on 4/5/22, 4/12/22 and 4/19/22. Review of the Presbyterian Homes and service Oxygen Equipment care and maintenance policy dated reviewed 2/2016 indicated 1. Tubing a. change and date tubing weekly 2. Cannula's/Masks a. change weekly 3. Humidifiers a. Humidifier bottles will be changed and dated weekly R9's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R9's annual MDS assessment dated [DATE], indicated intact cognition. R9's care plan with an initiated date of 1/22/21, indicated use of the [CONDITION(S)] (Continuous Positive Airway Pressure), needed assistance to apply the [CONDITION(S)] and to follow facility protocol for care and maintenance. On 4/18/22, at 3:04 p.m. R9's [CONDITION(S)] was observed with several white spots on the plastic mask, and around the rubber seal portion. There was also a several brown spots observed on the lower portion of the mask, inside the rubber seal. The [CONDITION(S)] mask also appeared to have a foggy haze inside the mask. On 4/19/22, at 2:21 p.m. R9's [CONDITION(S)] mask was observed again with several white spots all over the mask. There also was the brown spots on the lower portion of the mask just inside of the rubber seal. The mask appeared to have a foggy haze film on the inside of the mask. During an interview on 4/19/22, at 2:21 p.m. R9 indicated he did not recall seeing staff clean his [CONDITION(S)] mask. During an interview on 4/19/22, at 2:35 p.m. nursing assistant (NA)-A indicated the nurse was to clean the [CONDITION(S)] mask. During an interview on 4/19/22, at 2:41 p.m. registered nurse (RN)-A indicated [CONDITION(S)] masks can be cleaned by either the nursing assistants or nurses. RN-A further indicated there is a section to sign off a yes or no that it was completed on the treatment administration record (TAR). RN-A then indicated usually the day shift nurses or nursing assistants would clean the [CONDITION(S)] mask. During an interview on 4/19/22, at 2:51 p.m. RN-B verified R9's [CONDITION(S)] mask did not appear to be cleaned. RN-B further verified in the electronic medical record (EMR) there was no orders for nurses to indicate if R9's [CONDITION(S)] mask was cleansed or not. RN-B indicated R9's [CONDITION(S)] mask should be kept clean after use. During an interview on 4/19/22, at 3:03 p.m. clinical administrator/director of nursing (DON) indicated there should be two orders in the EMR for cleaning of a [CONDITION(S)] mask, one for a weekly clean and one for a daily clean. The clinical administrator further indicated the weekly clean would be with soap and water and the daily clean would be to wipe the [CONDITION(S)] mask out with a damp cloth. The clinical administrator showed the surveyor in the EMR a different resident that had orders for [CONDITION(S)] mask cares, and then verified R9 did not have the same orders. A Presbyterian Homes and Services policy titled [CONDITION(S)] and [CONDITION(S)] Cleaning with a modified date of February 2018, indicated daily maintenance of wiping the portion of the mask that comes in contact with the resident skin with a damp cloth. The policy further indicated weekly maintenance of using soapy water to clean the headgear, chin strap, mask, nasal pillows and tubing.

Based on interview, and document review, the facility failed to ensure interventions identified at care conference were implemented for 1 of 3 residents (R2) interventions for therapeutic diets was followed to prevent potential allergic reactions. Findings include: A State Agency (SA) report on 12/30/19, identified R2's developed an allergy to eggs, causing him to break out in hives. The report identified the facility was aware of the allergy, but had continued to feed R2 meals containing eggs. R2 ate foods containing eggs five times in the past week. An interview on 1/23/19, at 9:45 a.m. complainant (C)-A stated she attended a care conference about a week ago. R2 had an allergy to melons, and had recently developed an allergy to eggs. When R2 consumed these food items, he broke out in hives. R2 required numerous alterations to his diet to ensure staff served no eggs or melons to him. R2's family members were active in his care, and closely monitored his meals. On several occasions, they had had identified staff continued to serve R2 melons and eggs despite knowing he had allergic reactions to them. Family members had taken photos when they visited and observed staff served melons, eggs and egg products to R2 on several occasions. C-A was frustrated because the facility continued to have issues ensuring R2 had not consumed foods he was allergic to despite reassurance staff had been educated about his allergies [REDACTED]. The administrator attended the care conference and told family the facility had cameras in the dining room, and he would review them to see if this was a concern. C-A reported the incident as there continued to be concerns after repeated voicing of those concerns to the facility. An interview on 1/23/20, at 9:41 a.m. FM-A stated about a month and half ago, R2 was identified to have and allergic reaction to eggs. Since that time, the facility struggled to prevent R2 from receiving eggs and foods containing eggs. FM-A felt the facility had staffing and training issues. R2 had dementia and was unable to remember he had allergies [REDACTED]. R2 was admitted to the facility with an allergy to watermelon. R2 developed a rash last summer. It was found he was being served melons that were mixed with watermelon, causing a pinpoint rash covering his body. The facility had struggled to ensure he no longer received melons for several months. R2 continued to have similar rash flares any time staff served him melons. In (MONTH) 2019, R2 was found to be allergic to eggs. He was no longer able to consume eggs, or foods containing egg products. Despite knowing this, staff continued to inadvertently serve R2 foods he was allergic. R2 has had issues with rashes associated with allergic reactions for about 9 months. The facility tried to ensure R2 received no food with egg products, but had told her it would be impossible to do all the time. FM-A stated within 24 hours of consuming melons or eggs, R2 would break out in hives. FM-A had observed a lot of staff turnover, and the frequently used pool staff. R2 often requested foods and snacks that contained egg products. FM-A had voiced their concerns repeatedly to the facility's management, and felt R2's allergy was a serious issue that the facility should have been able to resolve in a more timely manner. FM-A stated staff continued to serve R2 desserts containing eggs. The facility stated they were unable to identify what exactly R2 was served from the cart, and reassured her they would keep the desert tray in the kitchen. Even though the facility had gone to great lengths to prevent R2 from receiving foods R2 was allergic to, things were still falling through the cracks. The facility had a lot of turnover, which made it difficult to ensure all staff were made aware of R2's allergies [REDACTED].>An interview on 1/23/20, at 10:15:18 a.m. FM-B stated the biggest issue regarding R2's care was family had to continue to keep telling management about R2's food allergies [REDACTED]. Family's intent was to place R2 somewhere safe where he would receive very good care. During the last meeting with the facility management, FM-B identified R2 was able to access the dessert tray during the dinner hour. Staff have caught R2 eating desserts from the dessert tray. The administrator stated he would check the camera in the dining room to ensure staff were following protocol. The past time FM-B audited R2's care was 1/13/20. Staff had not documented what R2 ate. R2 also received food choices not on the menu. R2 received beef stroganoff with egg noodles. On 12/27/19, R2 had asked for R2's meal record, and found R2 received battered fish, made with eggs. R2's last rash flare up occurred in December, 2019. R2's current face sheet identified R2's allergies [REDACTED]. Special instructions on face sheet and resident profile indicated R2 had an allergy to melon and eggs. R2's [DIAGNOSES REDACTED]. R2's care 1/9/20, care conference notes stated FM-B was present at the care conference. FM-B was concerned the dessert cart was left out in the main dining room at times accessible to R2. The facility was to have placed a sign was on the dessert cart, reminding staff to keep the cart in the serving area, away from R2. R2's 1/23/20, care plan identified R2 had impaired cognitive function. Staff interventions included to cue, reorient, and supervise as needed. R2 had impaired skin integrity and used steroids to treat an allergic rash. R2 had a potential nutritional problem related to Alzheimer's, dementia, memory loss, altered skin integrity and food intolerance's to melons and eggs. R2's care plan made no mention of interventions to keep food carts out of R2's reach, and made no mention signs were posted on the cart. An interview on 1/23/20, at 11:25 a.m. nursing assistant (NA)-A stated he worked here for about six months. NA-A had not had any recent or specific training regarding R2's food allergies [REDACTED]. An interview on 1/23/20, at 11:27 a.m. registered nurse (RN)-A stated she had worked at the facility since November, 2019. She was assigned to work on both the 1st and 3rd floors. She was unable to recall any recent or specific training regarding R2's allergies [REDACTED]. She was familiar with R2's care, but was unaware of any interventions in place to prevent R2 from access to or consuming foods containing eggs or melons. An interview on 1/23/20, at 2:26 p.m. the culinary director (CD) stated R2 was allergic to melons and eggs. When R2 was found to have an allergy to eggs, R2 was observed by staff taking foods off the food cart. Staff were to keep the dessert cart in the kitchen away from where R2 could access cart. Meal tickets identify food allergies [REDACTED]. All dietary staff were trained regarding R2's dietary needs, however, no documentation was available to verify the training. The CD had not audited the kitchen to ensure the desert cart was kept out of R2's reach. CD agreed no monitoring of the interventions were completed to ensure staff followed R2's plan of care to keep desserts out of his reach. An interview on 1/23/20 at 2:52 p.m. registered dietitian (RD) stated diets and allergies [REDACTED]. The RD reviewed resident diets on a monthly basis, and dietary assessments were done quarterly. She completed meal rounds twice a week and reviewed residents at meals to identify concerns with eating, diet issues, and compared meal tickets with diets. The RD did no audits between meals or other times. R2's most likely place to receive food-containing eggs was from the dessert cart. Nursing and NAs aids had copies of what foods staff were supposed to serve. She was not at the last care conference, and was not aware R2's family still had issues with receiving foods resident was allergic to. The RD was not aware of any specific training staff received regarding R2's specific food allergies [REDACTED]. An interview on 1/23/19, at 4:10 p.m. the DON expected staff to follow R2's dietary orders and provide supervision to ensure R2 does not received foods containing eggs. Staff were trained and audits completed regarding R2's allergic reaction to melons in August, 2019 regarding R2's allergies [REDACTED]. She had no documentation for education provided regarding R2's egg allergies [REDACTED]. An interview on 1/23/19 at 4:20 p.m. the administrator stated there were no audits available following the R2's care conference to ensure the desert cart kept in the kitchen. The administrator stated the kitchen staff were aware of what to do, and R2 was never left alone in the dining room while the desert tray was in use. The administrator was unable to provide additional information to verify all staff who provided care to R2 were educated on the interventions to keep carts with egg products out of R2's reach, and the interventions monitored to ensure R2's interventions prevented R2 from being able to access foods containing egg products.

Based on observation, interview and document review, the facility failed to ensure choices were honored for 1 of 3 residents (R82) reviewed for waking time preferences. Findings include: R82's quarterly Minimum Data Set ((MDS) dated [DATE], included intact cognition, did not reject cares, required extensive assistance with transfers, dressing, toileting and personal hygiene. R82's [DIAGNOSES REDACTED]. R82's admission MDS dated [DATE], included it was very important to him to do things with groups of people. R82's mobility Care Area Assessment (CAA) dated 3/21/19, indicated R82 had limited mobility and required assistance with transfers, mobility and self cares. R82's care plan dated 9/10/19, included, This is my home now. Staff were instructed to, Allow me to make choices in my daily care. The care plan dated 6/21/19, also included, an activities of daily living self care performance deficit and directed staff to assist with dressing, grooming, bathing, hygiene and transfers. R82's Care Conference Summary dated 9/18/19, included, Resident likes to get up around 7 am. This preference was not added to R82's care plan. R82 filed a grievance, a facility Quality Concern Form dated 1/3/20, included, Understaffing is causing me unacceptable delays in rising in the morning. Three times in the last month or so I have missed things like mass on Sunday. On (MONTH) 3, 2020 I had my call button on at 7:00 a.m. and no one came until 8:30 a.m. I wasn't ready for breakfast until well after 10:00 a.m. A follow up by the administrator included, (R82) has expressed his dissatisfaction to staff in the past and I have met with him x 3 to discuss staffing for (illegible) of lack of applicants as well as QAPI (quality assurance and performance improvement) efforts with staffing. Education to be rolled out to N[NAME] (night) sups (supervisors) to orientate pool nurses on process for assigning NAR's (nursing assistant registered) when there are call-ins. An interview with the nurse responsible for assigning nursing staff on this day included, If we are 'short staffed,' 'staffing challenged,' missing a staff, or whatever it may be, we do not ever want to tell a resident we are short staffed. This could upset the resident, scare the resident, etc. in this case you could have responded to (R82), 'We apologize, there was some miscommunication this morning. If you would like to speak to management I will get someone for you. A hand written follow up form included a conversation with R82, a nurse explained to R82 that administration and management were working on the issue of staffing. The form failed to include any resolution that was acceptable to R82. R82's call light record for 1/3/19, at 7:34 a.m. showed a 1 hour and 49 minute wait before the call light was answered. When interviewed on 1/6/20, at 1:59 p.m. R82 stated he would prefer to get up for the day between 6:45 a.m. and 7:15 a.m. A sign on R82's door was noted to direct staff to awaken R82 between 6:45 a.m. and 7:15 a.m. R82 stated staff are not normally able to accommodate his choice in time to get up and ready for the day. Breakfast starts at 8:00 a.m. and he is often he is unable to get to breakfast until 10:00 a.m. or 11:00 a.m. This does not allow him the opportunity to socialize with other residents at breakfast as others have already eaten and left the dining room. This is something that is important to him and he has expressed this frustration to staff many times. There has been no resolution and the problem continues. During observation on 1/8/19, at 7:02 a.m. R82's call light was on. At 7:18 a.m. a nurse stopped in the room and radioed staff R82 wanted to get up for the day. The nurse left the room. At 7:24 a.m. R82 again turned on call light as no one had returned to assist him. Nursing assistant (NA)-F entered the room at 7:42 a.m. This was 40 minutes after R82 originally requested assistance for morning cares. NA-F assisted R82 with morning cares and brought R82 to the dining room at 9:52 a.m. All of R82's tablemates had already eaten and left the dining room. At 10:17 a.m. R82 stated he really preferred to eat breakfast with others, he had reported this problem to management several times with no resolution for him. R82 continued to eat his breakfast by himself. When interviewed on 1/8/20, at 10:24 a.m. NA-F stated R82 likes to get up at 7:00 a.m. It was kind of a crazy day, sometimes I get stuck in a room. NA-F explained she has 8 other residents to care for and there is not enough time to get everyone up when they want to get up. NA-F stated that often on the weekends R82 has to wait until 10:00 a.m. or 11:00 a.m. to get up as they have even less staff. When interviewed on 1/8/20, at 10:32 a.m. registered nurse (RN)-F stated it is hard to accommodate resident wishes in the morning as there are so many residents to assist. R82 likes to get up between 7:00 a.m. and 8:00 a.m. but often has to wait. R82 was observed on 1/9/20, at 8:02 a.m. NA-F was assisting him with morning cares. At 9:17 a.m. R82 was assisted to the dining room where his tablemates had been served and were finishing up breakfast. R82's tablemates finished eating and left him to eat alone at 9:23 a.m. When interviewed on 1/9/20, at 11:56 a.m. the director of nursing (DON) stated staff should respond to call lights, around the 5 minute mark. R82 should be assisted in the time frame he has designated. The facilities Grievance Process, undated, included, All grievances will be addressed timely and action items communicated to the individual filing the grievance unless indicated as anonymous. The administrator, will take any remaining follow up steps to resolve the issue . The facilities Resident Rights Policy, dated (MONTH) 2019, included, Facility staff will collaborate with the resident during the initial care conference and ongoing during quarterly care conferences to address aspects of their daily routine that they would prefer a change in.

Based on observation, interview and document review, the facility failed to provide services to maintain as much bowel continence as possible for 1 of 1 residents (R40) reviewed for bowel incontinence. Findings include: R40's quarterly Minimum Data Set ((MDS) dated [DATE], included severe cognitive impairment with a [DIAGNOSES REDACTED]. R40 was not on a toileting plan to manage bowel incontinence. R40's admission MDS dated [DATE], indicated R40 was always continent of bowel. R40's care plan dated 8/3/19, included, I am continent of bowel. A goal was listed as, I will continue to be continent of bowel through review date. Date initiated 8/3/19. Staff were instructed to, Assess/evaluate my bowel and bladder function upon admission, and quarterly and per policy as needed. Observe for and report to my physician as needed possible medical causes of incontinence's: bladder infection, constipation .medication side effects. Toileting schedule: I require assist of one every 3 hours. Monitor and record my bowel movements. Treat absence of bowel function per facility protocol. Facility Standing House Orders included the following facility protocol for bowel constipation. 1. Encourage 2,000 milliliters fluid intake unless contraindicated 2. Consult nutrition services for dietary recommendations 3. Senna 2 tablets by mouth twice daily if no bowel movement in 3 days 4. If no results-perform rectal check to determine if impaction is present 5. If not results within 24 hours give [MEDICATION NAME] (laxative) suppository rectally each day as needed 6. Fleets enema (laxative) every 3 days as needed if no results from suppository. R40's quarterly Bowel, Bladder, and Skin Risk assessment dated [DATE], indicated R40 did not need a, Current elimination pattern for bowel and bladder, as, Not applicable: resident is continent of bowel and bladder. There was no assessment of why R40 was now occasionally incontinent of bowel when R40 had been continent on the previous assessment. R40's care plan was not updated to include the change in continence status. R40's progress note, Care Conference Summary, dated 11/17/19, at 7:50 p.m included, Daughter ((F)-A and power of attorney (POA)) would like prune juice used with resident instead of using medication. Resident has a history of toileting herself and is not a reliable source for stating when she has had a BM (bowel movement). R40's care plan was not updated with this information from R40's PO[NAME] R40's care plan note from 12/5/19 at 10:52 a.m. documented, No bowel movement for 2 days. Resident denied pain. Bowel sounds are active. Abdomen is soft and not distended. SHO ( Standing House Orders) Senna (laxative and bowel stimulant) initiated. This was despite the direction from F-A to use prune juice instead of medication on 11/17/19. On 12/20/19 F-A emailed the director of nursing (DON), (R40) had another bowel accident (ruined pajama bottoms in her garbage can), so I wonder if (R40) is still getting Senna .I still don't know how (R40's) normal bowel movements are being tracked, since (R40) is independent for bathroom activities. And (R40) will not remember when asked if (R40) had a BM. As (R40's) health care POA I request that no laxatives are given to (R40) .I just want that (R40) not to have these urgent bowel movements as (R40) cannot get to the bathroom in time to manage and it causes (R40) distress. R40's Medication Administration Record [REDACTED]. On 1/2/20 (F)-A again emailed DON after not receiving a reply from the facility regarding the previous e-mail, including the following in the e-mail, I am writing to follow up on (R40's) care plan regarding (R40's) bowel protocol. I have not heard back from the interim clinical coordinator .and there has been another bowel accident. I am looking for some reassurance that my concerns on (R40's) behalf are being looked into .Can you check to see if (R40) has been given Senna again recently? One of the nursing staff I had talked with previously explained that this is protocol, that if no bowel movement is noted/charted, laxative is given every 3rd day .Noting that this is now another distressing event for (R40), as (R40's) health care POA, I would like to make sure that (R40's) care plan is updated to either specifically exclude Senna or anything that strong, and that (R40) have prune juice instead .I am hoping that we can avoid these distressing events for (R40) by updating her care plan. R40's current care plan again had not been updated with this information. R40 was observed on 1/7/20 at 3:22 p.m. and 1/8/20 at 10:12 a.m. in the bathroom independently. When interviewed on 1/7/20, at 5:09 p.m. F-A stated, They have a bowel protocol and if there is no bowel movement in 3 days they give you Senna. R40 can toilet herself but due to dementia is not able to recall and report it. This results in, [MEDICAL CONDITION] which causes R40 to become, very distressed, distraught and humiliated. Even though F-A has brought this to the facilities attention multiple times, R40 continued to receive Senna. F-A had not received any response from the emails to the director of nursing (DON). When interviewed on 1/9/20, at 10:34 a.m. nursing assistant (NA)-C stated the Aide Sheet directs them to assist R40 to the bathroom every 3 hours. R40 is forgetful and is not able to recall if she has had a bowel movement or not. R40 has had incontinent stools after receiving a laxative, which has caused her to be upset. R40's Aide Care Plan dated 1/7/20, listed for the aide to offer assist with toileting every 3 hours. When interviewed on 1/9/20, at 10:44 a.m. registered nurse (RN)-B stated R40 is unable to say if she has had a bowel movement, R40 toilets herself often so staff are not aware if she has had a bowel movement or not. RN-B was aware of F-A's request to provide prune juice instead of the Senna laxative as when R40 takes Senna she is unable to make it to the bathroom, has [MEDICAL CONDITION] and becomes very distressed. RN-B did not know why R40 continues to receive the Senna, or why R40's care plan had not been updated to reflect this information. When interviewed on 1/9/20, at 11:46 a.m. DON stated that the expectation from the care conference on 11/17/20, would be that the nurse contact the provider regarding the R40's responsible party's request not to use Senna and to get the provider's permission to go against the standing order for Senna. DON stated the order would appear as, before Senna, give prune juice. DON recalled receiving emails in the past from F-A regarding not giving Senna. However, was unable to say why they had not been followed up on. A facility bowel policy revised (MONTH) (YEAR), included in the procedure section, If resident has not had a bowel movement for 3 days nursing will administer Senna to residents per standing orders (or specific order for that resident) A Facility policy entitled Grievance Process, undated, included, When an employee receives a complaint from a resident/family member or employee, give the complainant your full attention. The procedure directs staff to fill out a Quality Concern Form, write a brief description of the concern and immediately address the issue. All grievances will be addressed timely and action items communicated to the individual filing the grievance .

Based on observation, interview and document review, the facility failed to implement interventions to prevent the development of a pressure ulcer for 1 of 4 residents (R69) reviewed for pressure ulcers. This resulted in harm for R69 who developed a stage III pressure ulcer however, because the provider had already implemented corrective action, the deficiency is being issued at non compliance. Findings include: On 12/4/18, at 9:24 a.m. R69 was observed in his room, seated upright in a chair by the wall. R69 was observed to be wearing a soft black post-surgery style shoe on the right foot. At that time, R69 stated he had a wound on his right heel, and explained the nursing staff changed wound dressings twice daily. R69 said staff ordered the special shoe for him after the wound developed, and said the wound was healing. R69 was observed to have a special air mattress on the bed, and he stated he thought the facility had ordered the air mattress after they'd noticed his heel wound. Review of the Admission Record face sheet revealed R69 had been admitted from the hospital to the facility for orthopedic aftercare on 10/26/18, following a right total hip revision. The hospital discharge summary dated 10/26/18, revealed the following instructions: Monitor heel integrity. This precaution was transcribed as an order into the facility's electronic medical record (EMR) upon admit 10/26/18. The Comprehensive Nursing Data Collection assessment at the time of admit 10/26/18, noted R69's skin was intact. The interventions checked on the assessment included a pressure-reducing mattress. The initial skin care plan described R69 as being at risk for impaired skin integrity, and did not have a turning and repositioning schedule, but noted that R69 was able to request assistance with repositioning. The facility's initial Bowel, Bladder and Skin Risk assessment effective 10/27/18, included: Repositioning is required to maintain skin integrity. Interventions were identified as the resident calling for help when needing repositioning, and described R69 as needing assistance of one staff to reposition. During interview on 12/5/18, at 2:18 p.m. registered nurse (RN)-A confirmed that the facility did not automatically set all residents up on a turning and repositioning schedule. RN- A stated if a resident was alert and oriented enough to call for help when they were uncomfortable, or wanted to be repositioned there was not an automatic schedule. The care area assessment from the comprehensive minimum data set (MDS) assessment dated [DATE], revealed R69 was at risk for impaired skin integrity/pressure ulcers [due to] his need for physical assistance with bed mobility [related to] his [right] hip dislocation with acetabular [hip socket] repair. At the time of the initial physical therapy assessment on 10/27/18, the physical therapist also assessed R69 to need moderate assistance with bed mobility. During interview on 12/6/18, at 8:14 a.m. the director of therapy (DOT) confirmed that at admit, R69 needed moderate, hands on assist, with the staff lifting 26-75%. The DOT clarified that meant R69 was doing some of the work, but would not have been able to perform bed mobility independently. The DOT explained that bed mobility included movements such as rolling side to side. Documentation of a Body Audit dated 11/4/18, indicated staff had noted an alteration in R69's skin integrity. Both the right and left heels were documented to be soft and spongy, with blanchable redness. Review of R69's orders did not provide evidence of a heel treatment to protect the skin at that time. Additionally, review of the care plan did not provide evidence that new interventions had been put in place at the time the alteration in skin integrity was identified. Review of the next Body Audit dated 11/10/18, revealed the softy and spongy, reddened heel had developed into an open blister on R69's right heel. On 11/10/18, staff added orders for R69 to receive daily monitoring and dressing changes of the heel blister. On 11/12/18, the care plan was updated to include information about a pressure ulcer on the right heel, and interventions including a special pressure-relieving air mattress, elevating heels off the bed surface, and repositioning every three hours. A Body Audit dated 11/18/18, revealed the right heel wound had been categorized as a stage III pressure ulcer (defined by the National Pressure Ulcer Advisory Panel as full-thickness loss of skin). On 12/6/18, at 10:41 a.m. RN-A was asked about the development of R69's pressure ulcer. RN-A said anytime a resident developed a pressure ulcer that was not present upon admission, staff had a process to look back in the record. RN-A said the nurse who completed the body audit on 11/4/18, and found the soft heels, should have told someone about it because it was possible the stage III pressure ulcer could have been prevented. RN-A said if the nurse notified her or the nurse practitioner about the soft heels on the day they were found, staff would have started an intervention like skin prep (liquid, film forming dressing that protects intact skin), or floating R69's heels off the bed surface in order to try and prevent the development of an open area. RN-A described providing education to the nurse who failed to report the initial change in skin integrity. Although the provider has provided coaching and education for staff, R69 developed a stage 3 pressure ulcer when staff had not conducted adequate assessment and communication in order to determine and implement appropriate interventions in a timely manner. The facility provided documentation of their Supervisors/Managers Coaching Note dated 11/13/18. The note consisted of a formally documented conversation between the nurses involved in the care of R69 and reflected guidance regarding their lack of communication regarding R69's pressure ulcer. The documentation verified the nurses had been coached, and educated regarding the facility's expectations to ensure notification of a supervisor regarding skin integrity changes in order to determine and implement necessary interventions. The facility's Skin Integrity Management Policy last modified 9/18, indicated: to properly identify, assess and monitor residents whose clinical conditions increase the risk for impaired skin integrity, and pressure ulcers/injuries; to implement preventative measures; and to provide appropriate treatment modalities for pressure ulcers/injuries Weekly documentation included a weekly body audit, and review and revising the care plan based on response, outcome, and needs of the resident.