Every finding on record at Glenfields Living With Care

Based on observation, interview, and document review, the facility failed to ensure residents were treated with dignity and respect for 6 of 6 residents (R76, R83, R46, R63, R67, and R6) when a nurse directed them to remain in the dining room until medications were administered. Findings included: During an observation on 8/19/26 at 8:20 a.m., R76 and R83 stood from the dining room table after finishing breakfast and began walking out of the dining room. Registered nurse (RN)-A told R76 and R83 they could not leave because she still needed to administer their medications. R76 and R83 turned around, returned to the table, sat down, and waited for RN-A to bring their medications. During a continued observation on 8/19/26 at 8:25 a.m., RN-A brought R83's medications to the dining room table, placed them on the table in front of R83, and walked away. R83 took the medications, stood from the table, and walked to his room. During a continued observation on 8/19/26 at 8:26 a.m., RN-A brought R76's medications to the dining room table and administered the medications by spoon. After the medication administration was completed, R76 stood from the table and walked to his room. During observation of dining room on 8/19/26 at 8:27 a.m. nursing assistant (NA)-A told R46 they could leave the dining room if they were done eating and wanted to leave, the registered nurse (RN)-A stated R46 could not leave the dining room until they had gotten their medications. RN-A administered R46's medications in the dining room then stated, ok, you can leave now. On 8/19/26 at 8:30 a.m. R63 attempted to stand, RN-A told R63 they could not leave yet, not until her medications were given. R63 was handed her medications, was then told she could leave the dining room. On 8/19/26 at 8:31 a.m. RN-A informed R67 they could not leave the dining room until they got their medications first when R67 stated they were done eating. At 8:41 a.m. RN-A handed R67 their medications, stated there, now you're done, now you can leave. During an observation on 8/19/26 at 8:36 a.m., nursing assistant (NA)-A approached R6 in the dining room to reposition R6 at the table after another resident's wheelchair bumped R6's feet underneath the table. RN-A asked NA-A what she was doing with R6. NA-A stated she was repositioning R6. RN-A stated R6 could not leave the dining room because she still needed to administer R6's medications. When interviewed on 8/19/26 at 1:04 p.m. NA-A stated residents were usually told they could go back to their rooms if they wanted to when they were done eating, most nurses did the medications in the rooms. Some days it depended on what nurse was working, NA-A stated some nurses were more particular, set in their ways and kept residents from leaving the dining room. When interviewed on 8/19/26 at 1:10 p.m. RN-A stated she asked the residents if they wanted their medications in the dining room, it was easier to give medications in the dining room where they already had something to drink. RN-A stated residents had arrived in the dining room for breakfast faster than what was normal which made her feel overwhelmed and later than normal with medications. When interviewed on 8/20/26 at 10:21 a.m. assistant director of nursing (ADON) stated where residents were administered their medications was up to the resident. ADON stated she had been made aware that the nurse had been rude, yelling, and was not letting residents leave the dining room. ADON stated that RN-A's approach was an unacceptable interaction between herself, the residents, and staff. It would not be tolerated. The facility's undated Resident Rights policy indicated the facility was to ensure each resident was afforded a dignified existence, was treated with respect and dignity, and received care in a manner and environment that promoted the maintenance or enhancement of the resident's quality of life.

Based on observation, interview, and record review, the facility failed to assess the use of a wheelchair seatbelt to determine whether the seatbelt restricted the resident's freedom of movement and constituted a physical restraint for 1 of 1 resident (R81) reviewed for physical restraints.Findings included:R81's admission Minimum Data Set (MDS), dated [DATE], identified R81 had severe cognitive impairment and required assistance with activities of daily living (ADLs). R81's diagnoses included non-traumatic brain dysfunction (impaired brain function not caused by an injury), vascular dementia with agitation (a decline in thinking and memory caused by reduced blood flow to the brain, accompanied by agitation), and non-Alzheimer's dementia (a decline in memory, thinking, and ability to function caused by a condition other than Alzheimer's disease).During observation on 8/19/26 at 8:32 a.m., R81 was seated in his wheelchair at the dining room table eating breakfast with a seatbelt fastened around his waist and wheelchair.During interview on 8/19/26 at 1:06 a.m., nursing assistant (NA)-A stated R81 needed to wear the seatbelt whenever he was in his wheelchair and had used the seatbelt since his admission in June 2026.During observation on 8/20/26 at 10:02 a.m., R81 was seated in his wheelchair with a seatbelt fastened around his waist and wheelchair.During interview on 8/20/26 at 10:14 a.m., licensed practical nurse (LPN)-A stated the care coordinator was responsible for completing resident assessments. LPN-A confirmed R81 used a wheelchair seatbelt and had the seatbelt in place at the time of the interview.During interview on 8/20/26 at 10:28 a.m., registered nurse care coordinator (RN)-B stated therapy had completed seatbelt assessments in the past and she was unsure why an assessment had not been completed for R81. RN-B stated R81 had used the seatbelt at his daughter's request since his admission in June 2026. RN-B confirmed an assessment addressing R81's use of the wheelchair seatbelt had not been completed.R81's electronic health record (EHR) identified no assessment addressing his use of the wheelchair seatbelt, including whether he could independently release the seatbelt or whether the seatbelt restricted his freedom of movement. The EHR contained no documentation that nursing or therapy had evaluated the seatbelt to determine whether it constituted a physical restraint.During interview on 8/20/26 at 11:49 a.m., the assistant director of nursing (ADON) stated an assessment should have been completed when a resident used a seatbelt. The ADON stated nursing might not necessarily complete the seatbelt assessment; however, therapy should have evaluated R81's use of the seatbelt. The ADON stated she had not been aware R81 used a seatbelt until 8/19/26. The ADON stated an assessment was important to determine whether the seatbelt constituted a restraint and whether it was safe for the resident to use.The facility's Restraint policy, undated, indicated the facility would foster a restraint-free environment and promote minimal use of restraints to enhance resident care and safety. The policy defined a restraint as anything used to limit an individual's ability to move their body or body parts and included a manual method, physical or mechanical device, including a belt, material, or equipment that immobilized or reduced a resident's ability to move their arms, legs, body, or head freely. The policy indicated nursing and/or therapy would determine whether a medical device or method was considered a restraint.

Based on interview and document review, the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected residents' clinical status for 2 of 2 residents (R6 and R81) reviewed for MDS assessment accuracy.Findings included:R6R6's significant change MDS, dated [DATE], identified R6 had moderate cognitive impairment and required assistance with activities of daily living (ADLs). R6's pertinent diagnoses included progressive neurological conditions (conditions affecting the brain and nervous system that worsen over time), diabetes mellitus (a condition that causes elevated blood sugar levels and can impair wound healing), and renal failure (a condition in which the kidneys do not adequately filter waste from the blood). The MDS identified R6 had one Stage 1 pressure ulcer and one unstageable pressure ulcer.R6's Skin & Wound document, dated 7/17/26, identified R6 had a Stage 2 pressure ulcer to the left heel and a Stage 1 pressure ulcer to the right second toe.R6's MDS did not accurately reflect R6's documented pressure ulcer staging during the applicable look-back period.R81R81's admission MDS, dated [DATE], identified R81 had severe cognitive impairment and required assistance with ADLs. R81's pertinent diagnoses included non-traumatic brain dysfunction (impaired brain function not caused by an injury) and vascular dementia (cognitive impairment caused by reduced blood flow to the brain). The MDS did not identify R81's use of a restraint.Observations on 8/19/26 and 8/20/26 identified R81 utilized a seat belt while seated in the wheelchair.R81's MDS did not accurately reflect R81's use of a wheelchair seat belt as a restraint.During interview on 8/20/26 at 9:56 a.m., MDS coordinator (MDS)-A stated the floor nurses completed the assessments and MDS-A entered the assessment data into the MDS. MDS-A stated the look-back period for R6's significant change MDS was 7/14/26 through 7/20/26. MDS-A reviewed R6's MDS and stated it identified a Stage 1 pressure ulcer and a deep tissue injury. MDS-A further reviewed R81's MDS and confirmed the assessment did not identify the use of any restraints.During interview on 8/20/26 at 11:49 a.m., the assistant director of nursing (ADON) stated the look-back period for R6's significant change MDS was 7/14/26 through 7/20/26. The ADON confirmed R6 did not have an unstageable pressure ulcer during the look-back period and instead had a Stage 1 pressure ulcer to the right second toe and a Stage 2 pressure ulcer to the left heel.A facility policy related to MDS assessment accuracy was requested but was not received.

Based on record review and interview, the facility failed to obtain timely medical evaluation following an unwitnessed fall for 1 of 3 residents (R6) reviewed for accidents.Findings included:R6's significant change Minimum Data Set (MDS), dated [DATE], identified R6 had moderate cognitive impairment and required assistance with activities of daily living (ADLs). Pertinent diagnoses included Alzheimer's disease with late onset (a progressive disease that affected memory and thinking), arthritis (inflammation of the joints that could cause pain and impaired mobility), osteopenia (lower-than-normal bone density that could increase the risk for fractures), and a history of fracture.R6's incident report, dated 2/27/26 at 7:20 p.m., indicated R6 sustained an unwitnessed fall in her room. Staff had assisted R6 into bed following her bath and completed a skin assessment. Within approximately three minutes after staff left the room, R6 yelled for help and was found lying on her left side on the floor near the door.The incident report indicated staff used a Hoyer lift and two staff members to transfer R6 from the floor to her bed. R6 complained of left hip, low back, and left arm pain and sustained a large skin tear to her left inner arm. R6 reported pain at 7 out of 10. During the post-fall evaluation, R6 attempted to use the toilet. Although R6 was able to stand with her walker, she was unable to turn or walk to the bathroom due to low back pain. R6 was transferred to the toilet but was unable to transfer off the toilet and required assistance from two staff and a sit-to-stand mechanical lift to return to bed. The incident report indicated R6 was not sent to the hospital at that time.R6's progress note dated 2/27/26 at 7:45 p.m. indicated R6's granddaughter was notified of the fall and informed that R6 had sustained a large skin tear. Staff informed the granddaughter that R6 was otherwise okay and that she would be notified if R6's condition changed.R6's progress note dated 2/27/26 at 9:50 p.m. indicated R6 complained of low back pain following the unwitnessed fall and received two Tylenol 325 milligram (mg) tablets and a hot pack for pain.R6's progress note dated 2/27/26 at 11:14 p.m. indicated R6 complained of left hip, low back, and left arm pain. Although R6 was able to stand with her walker, she was unable to turn or walk to the bathroom due to pain. After R6 was transferred to the toilet, she was unable to transfer off the toilet and required assistance from two staff and a sit-to-stand mechanical lift to return to bed.R6's progress note dated 2/27/26 at 11:15 p.m. indicated the charge nurse was updated and the primary physician and fall team were notified by email. R6's granddaughter was also notified and requested that staff call her back if R6 needed to be sent to the ED.R6's progress notes indicated she continued to experience pain throughout the night. At 12:53 a.m. on 2/28/26, R6 reported a follow-up pain level of 3 out of 10 after receiving Tylenol. At 3:50 a.m., R6 received Tylenol for continued back and left hip pain. At 6:17 a.m., R6's follow-up pain level was documented as 4 out of 10.R6's progress note dated 2/28/26 at 6:40 a.m. indicated R6 had complained of left hip pain ranging from 3 to 5 out of 10 throughout the night. R6 had been offered transfer to the ED for an X-ray due to her pain but initially declined. R6 agreed to be evaluated the following morning. R6's granddaughter was updated and agreed with the transfer, and R6 was sent to the ED by emergency medical services.R6's progress note dated 2/28/26 at 1:12 p.m. indicated the ED notified the facility that R6 had been transferred to [NAME] with diagnoses that included an inferior ramus pelvic fracture.During an interview on 8/20/26 at 10:09 a.m., licensed practical nurse (LPN)-A stated that following a fall, staff remained with the resident while the nurse completed an assessment and obtained vital signs before transferring the resident from the floor. For an unwitnessed fall, staff completed neurological assessments and notified the resident's family and provider. LPN-A stated that when further evaluation was indicated, she would notify the charge nurse and obtain an ED referral, or the provider could order diagnostic imaging to be completed at the facility.During an interview on 8/20/26 at 10:28 a.m., registered nurse care coordinator (RN)-B reviewed R6's medical record and stated R6 was not at her baseline and complained of pain following the fall. RN-B stated she would have expected R6 to be sent to the ED for further evaluation and stated R6 should have been sent sooner.During an interview on 8/20/26 at 11:49 a.m., the assistant director of nursing (ADON) stated nurses were expected to complete a post-fall huddle, implement immediate interventions, and communicate the resident's condition to the provider. The ADON stated provider notification was expected by telephone or direct messaging. After reviewing R6's circumstances, the ADON stated that because R6 complained of pain following the fall, she would have expected staff to send R6 for further evaluation sooner.A facility policy related to falls and post-fall assessment was requested but was not received.

Based on observation, interview, and record review, the facility failed to ensure prescribed oxygen therapy was provided as ordered for 1 of 1 resident (R6) reviewed for respiratory care.Findings included:R6's significant change Minimum Data Set (MDS), dated [DATE], identified R6 had moderate cognitive impairment and required assistance with activities of daily living (ADLs). R6's pertinent diagnoses included progressive neurological conditions (conditions affecting the brain and nervous system that worsen over time), heart failure (a condition in which the heart did not pump blood effectively), and atrial fibrillation (an irregular and often rapid heart rhythm).R6's physician order, dated 8/10/26, directed staff to administer oxygen at 2 liters per minute (L/min) via nasal cannula (NC) for shortness of breath (SOB) or to maintain oxygen saturation greater than 90 percent.R6's care plan, printed 8/19/26, identified R6 received oxygen therapy related to congestive heart failure (CHF), shortness of breath, and comfort. The care plan identified a goal for R6 to remain comfortable and directed staff to administer oxygen at 2 L/min via nasal cannula for shortness of breath or to maintain oxygen saturation greater than 90 percent.During observation on 8/18/26 at 9:38 a.m., R6 sat in a Broda chair participating in exercises during activities. R6 was connected to a portable oxygen tank hanging from the back of the chair. The oxygen flow rate was set at 1 L/min, and the tank gauge indicated the tank was approximately one-quarter full.During observation on 8/19/26 at 7:08 a.m., R6 sat in the living room area in front of the television. R6 was connected to a portable oxygen tank hanging from the back of the wheelchair. The oxygen flow rate was set at 2 L/min, and the tank gauge was in the red zone, indicating the tank was empty.During observation on 8/19/26 at 8:13 a.m., R6 sat at the dining room table for breakfast. The portable oxygen tank gauge remained in the red zone. R6 exhibited long, deep breaths with visible chest rise and pursed-lip breathing. R6 ate little and sat looking around the dining room.During observation and interview on 8/19/26 at 9:02 a.m., nursing assistant (NA)-B brought R6 to the resident's room to connect R6 to the oxygen concentrator and waited for a nurse to assess R6's oxygen saturation. NA-B stated she did not know R6's prescribed oxygen flow rate and confirmed the portable oxygen tank was empty and had been empty for a while. NA-B stated the nurses were responsible for the oxygen tanks and were aware the tank was empty.During observation and interview on 8/19/26 at 9:04 a.m., registered nurse (RN)-A assessed R6's oxygen saturation. A pulse oximeter placed on R6's left middle finger indicated an oxygen saturation of 88 percent. RN-A subsequently placed the pulse oximeter on R6's left ear and obtained a reading of 93 percent. RN-A stated R6 received oxygen for comfort and was to receive oxygen at 1 to 2 L/min. RN-A confirmed the portable oxygen tank was empty and stated, yeah I know it is empty as I still have to get around to replacing the portables. RN-A stated R6's oxygen saturation had been 88 to 89 percent earlier that morning but R6 had been stable. RN-A confirmed the portable oxygen tank had been empty for at least two hours.During interview on 8/19/26 at 1:11 p.m., RN-A stated R6 received hospice services and used oxygen for comfort. RN-A stated she had reviewed R6's oxygen order earlier and it directed staff to administer oxygen to maintain an oxygen saturation greater than 90 percent. RN-A confirmed R6's oxygen saturation had been 88 percent and acknowledged R6 should have received oxygen based on the physician order. RN-A stated, It was completely my error. RN-A further stated she normally did not check oxygen saturations for residents receiving hospice services.During interview on 8/20/26 at 10:28 a.m., registered nurse care coordinator (RN)-B stated it was inappropriate for RN-A not to replace R6's portable oxygen tank after RN-A became aware the tank was empty. RN-B stated oxygen therapy had initially been started when R6 experienced fluid overload, which had since stabilized; however, RN-A should have replaced the empty tank or requested assistance if she did not have time to do so. RN-B stated R6 received hospice services and oxygen also assisted with R6's comfort.During interview on 8/20/26 at 11:49 a.m., the assistant director of nursing (ADON) stated nurses were responsible for replacing portable oxygen tanks when the tanks were identified as empty. The ADON stated she would have expected R6 to receive oxygen when R6's oxygen saturation was 88 percent. The ADON stated oxygen was important for R6's comfort, management of dyspnea (difficulty breathing), and overall functioning.A facility policy related to oxygen therapy and management of portable oxygen tanks was requested but was not received.

Based on observation, interview, and document review, the facility failed to ensure proper hand hygiene was completed for 2 of 2 residents (R8, R63) observed for wound care and failed to properly implemented enhanced barrier precautions (EBP) for 4 of 4 residents (R8, R63, R66, R73)) reviewed for contact precautions. Findings include: R8's admission Minimum Data Set (MDS) dated [DATE], included R8 was cognitively intact, was able to make self be understood and was able to understand others. R8 had a diagnosis of stage 4 pressure ulcer on her sacral region (a wound caused by pressure extending to underlying tissue like muscle, bone or tendon), multiple sclerosis (MS)(a disease that can cause weakness, pain, fatigue and impaired coordination), and malnutrition (a lack of proper nutrition). During observation on 6/4/25 at 10:38 a.m., registered nurse (RN)-A completed wound care on R8. RN-A washed hands with soap and water and applied gown and gloves prior to starting wound care. RN-A removed soiled dressing and cleansed wound as ordered. RN-A changed gloves but did not complete hand hygiene. RN-A cleansed second wound as ordered. RN-A removed gloves, washed hands with soap and water and applied new gloves. RN-A packed first wound as ordered. RN-A changed gloves but did not complete hand hygiene. RN-A packed second wound as ordered. RN-A changed gloves but did not complete hand hygiene. RN-A placed a clean dressing as ordered to both wounds. RN-A changed gloves but did not complete hand hygiene. RN-A started wound care on wound to R8's thigh by removing soiled dressing. RN-A changed gloves but did not complete hand hygiene. RN-A cleansed wound as ordered. RN-A changed gloves but did not complete hand hygiene. RN-A completed wound care to thigh by applying new clean dressing. RN-A completed hand hygiene with soap and water and applied clean gloves prior to completing wound care on ankle wound. RN-A removed soiled dressing and changed gloves without completing hand hygiene. RN-A cleansed wound and completed wound care as ordered. RN-A removed gloves and washed hands with soap and water. During interview on 6/4/25 at 11:23 a.m., RN-A stated hand hygiene should be completed prior to starting wound care, any time you remove a soiled dressing and when wound care is completed. RN-A stated she had been taught to complete hand hygiene every time gloves were changed, but did not feel it was necessary to complete hand hygiene as frequently during wound care and does not complete it every time she changes her gloves. RN-A stated changing gloves was not a substitute for hand hygiene. R63's admission MDS dated [DATE], included R63 had an admission date of 4/14/25. R63 was cognitively intact and had diagnoses of diabetes with skin complications, peripheral vascular disease (a condition that narrows blood vessels and reduces blood flow to limbs), multidrug-resistant organism (MDRO), and a surgical wound without normal wound healing. During observation on 6/4/25 at 10:00 a.m., RN-B completed wound care for R63. RN-B completed hand hygiene, applied gown and gloves prior to starting wound care. RN-B removed soiled dressing and changed gloves. RN-B did not complete hand hygiene. RN-B cleansed wound as ordered. RN-B did not complete hand hygiene or change gloves. RN-B completed wound care and completed hand hygiene upon completion. During interview on 6/4/25 at 12:15 p.m., RN-B stated she completes hand hygiene prior to starting wound care and after completion of wound care. RN-B stated she would not wash her hands at any other time, except if she was moving from one wound to another. During interview on 6/4/25 at 11:29 a.m., charge nurse RN-C stated the expectation was for staff to wash hands with soap and water prior to starting wound care and upon completion. Hand sanitizer could be utilized with glove changes and when going from dirty to clean tasks. During interview on 6/4/25 at 11:38 a.m., director of nursing (DON) stated hand hygiene was expected prior to starting wound care and when hands are visibly soiled. The DON stated she expected hand hygiene to be completed any time gloves were changed even if hands were not visibly soiled. Facility policy for hand hygiene requested and not provided. Facility document for infection prevention included to perform hand hygiene immediately after removal of gloves. EBP: R8's admission Minimum Data Set (MDS) dated [DATE], included R8 was cognitively intact, was able to make self be understood and was able to understand others. R8 had a diagnosis of stage 4 pressure ulcer on her sacral region (a wound caused by pressure extending to underlying tissue like muscle, bone or tendon), multiple sclerosis (MS)(a disease that can cause weakness, pain, fatigue and impaired coordination), and malnutrition (a lack of proper nutrition). During interview and observation on 6/2/25 at 1:14 p.m., R8 stated she had multiple wounds that staff completed daily wound care on. R8's room did not have any signage indicating R8 should be on precautions or storage for personal protective equipment (PPE) visible. Facility document titled Negotiated Risk Agreement and Release signed 4/10/25, included R8 had a Foley catheter, ostomy, and open wounds and EBP was recommended with high-contact resident care per Center for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS) guidance. The document described the potential negative outcomes to the resident and alternative plan to reduce the risk the facility would take. During interview on 6/3/25 at 10:55 a.m., R8 stated she did remember the facility discussing the form with her, but felt it was presented as information and not as an option she could choose. R8 confirmed the staff do not wear a gown when working with her catheter, only gloves. R63's admission MDS dated [DATE], included R63 had an admission date of 4/14/25. R63 was cognitively intact and had diagnoses of diabetes with skin complications, peripheral vascular disease (a condition that narrows blood vessels and reduces blood flow to limbs), multidrug-resistant organism (MDRO), and a surgical wound without normal wound healing. During interview and observation on 6/2/25 at 6:37 p.m., R63 stated she had a diabetic ulcer on her foot and had wound care completed by staff. R63's room did not have any signage indicating R63 should be on precautions or storage for PPE. Facility document titled Negotiated Risk Agreement and Release signed 4/14/25, included R63 had a diabetic foot wound and EBP was recommended with high-contact resident care per CDC and CMS guidance. The document described the potential negative outcomes to the resident and alternative plan to reduce the risk the facility would take. During interview on 6/3/25 at 10:28 a.m., R63 stated she did not remember reviewing the form and did not remember signing it. R63 confirmed she was admitted on [DATE] and recalled signing a lot of paperwork that day. R66's admission Minimum Data Set (MDS) dated [DATE], included R66 had severe cognitive impairment. R66 had diagnoses of hypertension (high blood pressure), diabetes, Alzheimer's disease (a condition that affects memory, thinking, and behavior), and benign prostatic hyperplasia (enlargement of the prostate gland which can cause difficulty with urination). During interview and observation on 6/2/25 at 4:21 p.m., FM-B confirmed R66 had a urinary catheter. R66's room did not have any signage indicating R66 should be on precautions or storage for PPE. Facility document titled Negotiated Risk Agreement and Release signed 2/12/25, included R66 had an indwelling Foley catheter and EBP was recommended with high-contact resident care per CDC and CMS guidance. The document described the potential negative outcomes to the resident and alternative plan to reduce the risk the facility would take. During interview on 6/3/25 at 11:48 a.m., FM-B stated she did not remember reviewing the consent. FM-B stated she did not remember the facility discussing care of his catheter or risks. R73's quarterly MDS dated [DATE], included R73 was rarely or never able to make self be understood and sometimes able to understand. R73 had diagnoses of dysphagia (difficulty swallowing) and had a gastronomy tube (g-tube)(a device that delivers nutrition directly to the stomach or small intestine). During interview and observation on 6/2/25 at 2:01 p.m., family member (FM)-A confirmed R73 had a feeding tube. R73's room did not have any signage indicating R73 should be on precautions or storage for PPE. Facility document titled Negotiated Risk Agreement and Release signed 10/1/24, included R73 had a g-tube and EBP was recommended with high-contact resident care per CDC and CMS guidance. The document described the potential negative outcomes to the resident and alternative plan to reduce the risk the facility would take. During interview on 6/3/25 at 11:32 a.m., FM-A stated she did not recall being educated on precautions for R73's g-tube nor signing a consent form to waive EBP. Undated facility provided document titled Enhanced Barrier Precautions (EBP) Lists included 20 residents. All 20 residents had yes under the column indicating they signed a negotiated risk agreement. During interview on 6/4/25 at 1:01 p.m., DON confirmed the facility had identified 20 residents who qualified for EBP and all 20 had signed a negotiated risk agreement to opt-out of EBP. The DON stated it was the goal of the facility to provide a homelike environment and all of the residents who signed the form understood the risks. Conditions were reviewed at admission and periodically to ensure the facility was providing the necessary precautions. The DON confirmed the EBP negotiated risk form was not reviewed with residents who did not qualify for EBP. During interview on 6/5/25 at 10:06 a.m., DON stated she was unsure how the EBP negotiated risk form was presented to residents, but everything on the form should be explained to the resident and their family. The DON stated there was a lot of information presented during admission and it would be hard to remember every piece of information presented. Undated facility policy for enhanced barrier precautions, included an EBP risk assessment would be completed on all new admission and as needed to determine if EBP was recommended. If a resident decline or refuses EBP, a negotiated risk agreement would be signed by the resident or representative.

Based on interview and document review, the facility failed to ensure the care plan included management and monitoring of anticoagulant (blood thinner) therapy for 2 of 3 residents (R30, R66) reviewed for anticoagulants. Findings include: R30's annual minimum data set (MDS) dated [DATE], indicated cognitively intact. R30 had diagnoses of atrial fibrillation (an irregular heart rate that commonly causes poor blood flow), hypertension (high blood pressure), and history of cerebral infarction (stroke). R30's electronic medical record (EMR) included an order for Eliquis (a blood thinner) 5 milligrams (mg) twice a day, with a start date of 7/4/23. However, failed to include an order to monitor for potential side effects or signs ob bleeding due to Eliquis use. R30's care plan last revised 5/20/25, failed to include anticoagulants or to monitor for side effects of the medication. R66's admission MDS dated [DATE], indicated severe cognitive impairment. R66 had diagnoses of hypertension (high blood pressure), diabetes, Alzheimer's disease (a condition that affects memory, thinking, and behavior), and history of cerebral infarction (stroke). R66's order summary report dated 6/5/25, included an order for warfarin sodium 10 milligrams (mg) ever Wednesday and Saturday and warfarin sodium 7.5 mg every Monday, Tuesday, Thursday, Friday and Sunday. Order Summary Report failed to include an order to monitor for potential side effects or signs of bleeding due to warfarin use. R66's undated care plan failed to include he took anticoagulants or to monitor for side effects of the medication. During interview on 6/4/25 at 9:29 a.m., registered nurse (RN) case manager (CM)-C stated nursing would review a resident's medication list to know if anyone was on an anticoagulant. CM-C stated nursing assistants (NA) do not have access to the medication list but should report any signs of bleeding to a nurse because that would be abnormal. During interview on 6/5/25 at 8:53 a.m., consultant pharmacist (CP) stated he reviewed charts during monthly pharmacy reviews to look for any necessary labs and interactions. The CP stated he expected monitoring for bruising and bleeding. The CP also stated it would be important to be aware when someone was on a blood thinner because they would be more prone to bleeding with routine dental care. During interview on 6/5/25 at 9:42 a.m., the director of nursing (DON) stated nursing assistants should monitor for bruising and update nursing when needed. Nursing should watch for bruising and other side effects of anticoagulants. The DON stated the care plan should include when a resident was on an anticoagulant. Undated facility policy for anticoagulants use failed to address monitoring for anticoagulants.

Based on interview and document review, the facility failed to update the primary care physician (PCP) with significant weight gain for 1 of 1 residents (R66) reviewed for nutrition. Findings Include: R66's admission Minimum Data Set (MDS) dated [DATE], included R66 had severe cognitive impairment. R66 had diagnoses of hypertension (high blood pressure), diabetes, Alzheimer's disease (a condition that affects memory, thinking, and behavior), and obstructive sleep apnea (a collapse or closure of the airway during sleep). R66's weight was recorded at 252 pounds (lbs). According to R66's electronic medical record (EMR) on 02/12/2025, R66 weighed 252.0 lbs. On 05/28/2025, R66 weighed 292.0 pounds which was a 15.87 % gain. R66's weight change note dated 2/26/25, included a weight warning that was not likely nutrition related and that the nurse manager was notified to follow up. R66's health status note dated 3/8/25, included R66 had audible wheezing and a 13 lb weight increase since 2/2/25. No update to PCP was noted. R66's weight change note dated 5/8/25, included a weight warning of 288 lbs and that note was likely not nutritionally related. RN was updated for fluid status evaluation. R66's weight change note dated 5/21/25, included a weight warning and that note was likely not nutritionally related. RN was updated for fluid status evaluation. R66's care conference note dated 5/23/25, included weight fluctuations likely fluid related and that RN was notified of weight change. R66's health status note dated 5/24/25, included a respiratory and edema assessment. No update to PCP was noted. During interview on 6/4/25 at 9:33 a.m., registered nurse (RN) case manager (CM)-C stated the registered dietitian (RD) monitored weights and updated nursing with an email when there was a weight gain concern. CM-C stated nursing did a cardiac assessment and updated the provider after the RD noted a weight increase concern. CM-C confirmed a cardiac assessment was noted on 5/24/25. CM-C confirmed R66 had a 40 lb weight increase since admission and the provider should have been updated with the increase, but was not. During interview on 6/4/25 at 8:06 a.m., RD stated she monitored weights weekly and checked in with nursing and the homemakers to see if they have noticed any changes. The RD stated she depended on them for updates on changes because they were there daily. RD stated she noticed an increase in R66's weight and, after reviewing intakes and rate of increase, she felt it was possibly related to fluid retention. RD stated her process was to send an email to update nursing, along with putting a progress note into the resident's chart. The RD confirmed she sent two email updates, one on 5/8 and one on 5/23 to update nursing on the weight concern. Email from RD to CM-C dated 5/8/25 included R66 had ongoing significant weight gain, with a gain of 13 lbs in 7 days that was not likely related to nutrition. Email from RD to CM-C dated 5/21/25, included R66 had a 24 lb weight gain in the last 30 days and was not likely due to nutrition. Email included a request to monitor fluid status change. During interview on 6/5/25 at 9:48 a.m., the director of nursing (DON) confirmed weights were obtained weekly on bath day unless otherwise ordered by a provider. Weights were monitored by the RD and updated nursing with any increase thought to be medially related. The DON stated she expected nursing to follow up with a cardiac assessment and review of potential reasons for increase. The DON confirmed a 40 lb weight gain since admission would have been a significant increase and she expected nursing to update the PCP for follow up. The DON stated it was important to update the PCP with weight increase because there may be a medical reason that was not being addressed. Facility policy for weight monitoring dated 2/11/22, included nursing assistants (NA) are to obtain weights on bath days. The NA should review previous weight and if the weight had changed by 3 lbs in a week or 5 lbs in a month, the weight should be rechecked immediately.

Based on interview and record review, the facility failed to consistently offer range of motion (ROM) and exercises for 1 of 1 residents (R8) reviewed for restorative nursing program. Findings include: R8's admission Minimum Data Set (MDS) dated [DATE], included R8 was cognitively intact, able to make self be understood, and able to understand others. R8 had a diagnoses of stage 4 pressure ulcer on her sacral region (a wound caused by pressure extending to underlaying tissue like muscle, bone or tendon), multiple sclerosis (MS)(a disease that can cause weakness, pain, fatigue and impaired coordination), and malnutrition (a lack of proper nutrition). During interview on 6/2/25 at 1:11 p.m., R8 stated she was supposed to get ROM exercises, but staff do not always offer them to her. R8 wanted to complete ROM exercises because she knew it was important to prevent weakness from MS. R8's task documentation for restorative program - exercise orders for dates 5/15/25 to 6/4/25, included 12 yes responses, 3 no responses, and 26 not applicable responses. R8's task documentation for Restorative Program - other for dates 5/6/25 to 6/4/25, included 19 yes responses, 2 no responses, and 38 not applicable responses. R8's task documentation for Restorative Program - ROM for dates 5/6/25 to 6/3/25, included 9 yes responses, 4 no responses, and 45 not applicable responses. Progress notes dated 6/2/25, 5/28/25, 5/19/25, 5/11/25, 5/5/25, 4/27/25, 4/23/25, and 4/17/25, included a summary of restorative activity for the week. Progress notes included a therapy referral would not be submitted due to there being ample opportunities for staff to offer the program. During interview on 6/4/25 at 10:20 a.m., nursing assistant (NA)-A stated ROM exercise were listed on a restorative list and documented in the electronic charting system. NA-A stated a refusal slip needed to be filled out when a resident refused. NA-A stated she documented not applicable when the task was not offered or completed on that shift because of not having time. During interview on 6/4/25 at 10:28 a.m., NA-B stated restorative and ROM tasks were documented in the electronic charting system and on restorative papers. NA-B stated she marked not applicable when she did not offer the task to the resident. During interview on 6/5/25 at 8:17 a.m., director of therapy (DOT) stated therapy was involved in creating restorative nursing programs. DOT stated she expected an update if the restorative program was not completed as ordered for any reason, including when it was not offered. DOT stated she spoke with R8 recently and R8 stated she wished to continue with the restorative programs as ordered. DOT stated completing the restorative program and ROM exercises was important to prevent decrease in mobility and prevent falls. During interview on 6/5/25 at 9:57 a.m., director of nursing (DON) stated the registered nurse care coordinators monitored the restorative task completion weekly and documented with a progress note. The DON expected follow up with the NA team to find out why the task was not completed. DON stated when not applicable was charted, it meant the task was not completed on that shift. The DON stated the restorative progress notes indicated the program was not offered. The DON stated the resident was at risk for deconditioning and decline in ability if the program was not being offered and completed. Undated facility policy for repositioning included a restorative program would be designed according to the resident's goals, ability and desires.

Based on document review and interviews, the facility failed to develop a comprehensive care plan to maintain safety for 1 of 4 (R1) residents reviewed for choking risks and refusal of care. Findings include: R1's face sheet dated [DATE], indicated diagnoses of hemiplegia (one-sided paralysis or weakness) and hemiparesis (one-sided muscle weakness) following stroke affecting left non-dominant side, vascular dementia (lack of blood to carry blood to a part of the brain, results in problems with reasoning, judgement, planning, and memory) with other behavioral disturbance, chronic kidney disease, heart failure, type II diabetes, need for assistance with personal care, reduced mobility, depression, dysphagia pharyngoesophageal phase (when the brain makes the decision to swallow and several reflexes begin) and dysphagia oropharyngeal phase (the first phase of swallowing when food or liquid is contained in the mouth by the tongue and palate). R1's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated R1 had moderately impaired cognition. R1 rejected care and had physical behaviors towards others one to three days per week. He required set up help for eating, one person assist for toileting and bed mobility and two person assist for transfers. R1's care plan dated [DATE], indicated in the nutrition section that R1 must be upright for all meals and for 30 minutes after meals. His diet was regular with nectar thick liquids. The activities of daily living section indicated R1 must be fully upright in wheelchair for all meals. The care plan failed to identify staff interventions when R1 refused to sit upright in his wheelchair for meals or eat in a supervised location such as the dining room. R1's Kardex dated [DATE], included directions to sit fully upright in wheelchair for all meals. Regular diabetic diet with nectar thickened liquids. Upright position for all meals and for 30 minutes after meals. There was no direction related to choking or aspiration risk. R1's diet order started [DATE], indicated regular diet, regular texture, nectar consistency. Must be in fully upright position in wheelchair for all meals. R1's Speech Therapy Progress Report and Updated Therapy Plan for [DATE]-[DATE] indicated patient continues to be noncompliant with sitting in upright position after meals. Patient will self transfer to bed and lower bed flat. Video swallow study was completed, results showed oropharyngeal dysphagia. A new goal, patient will demonstrate a reduction in the need for supervision at mealtime due to swallow safety to ,d+[DATE]% of the time. On [DATE] R1 required supervision ,d+[DATE]% of the time. A Clarification Order, dated [DATE] indicated speech therapy was discontinued for R1. No reason was indicated. R1's header, dated [DATE], in the electronic health record included his diet order but did not include anything related to aspiration or choking risk. R1's long term care discharge summary dated [DATE], indicated principal diagnosis at discharge: natural causes related to cardiac event. A progress note dated [DATE], indicated R1 was asked if he wanted to come out of his room for lunch, he replied leave me alone. A nursing assistant (NA) sat with him while he ate in his room. A progress note dated [DATE], indicated R1 refused to leave his room for dinner. His tray was brought to his room and a nurse conversed with him during his meal. A progress note dated [DATE], indicated R1 requested to eat lunch in his room and ate while lying in bed at a 30-degree incline. A nurse sat with him during the meal. R1 finished his meal in three minutes and did not have a choking episode. A progress note dated [DATE] at 12:15 p.m., indicated NA-A brought R1's lunch tray to his room. R1 refused to get up in his wheelchair to eat but agreed to sit at the edge of the bed with head of bed raised up to support his left side, his lunch tray was placed in front of him. NA-A left R1's room to assist another resident. R1's call light and bed control were attached to the bed rail. A progress note dated [DATE] at 12:54 p.m., indicated R1 was found in his bed with his tongue and food sticking out of his mouth, unresponsive and with the head of the bed elevated at 15 degrees. Staff initiated CPR. A progress note dated [DATE] at 1:33 p.m., indicated R1 was found unresponsive on his back in his room. Staff initiated CPR, call 911 and the resident was pronounced deceased at 1:33 p.m. by a physician. On [DATE] at 8:55 a.m., R1's Speech language therapist (SLT) was interviewed. The SLT stated they started working him during fall 2023 because nurses were noting he was coughing on his secretions. The evaluation was made that he needs to sit fully upright in a wheelchair during meals and 30 minutes following the meal. The SLT stated he ate very quickly and was noncompliant with most cares and recommendations. During [DATE] he started vomiting after eating too quickly. R1 couldn't do an esophageal study because he couldn't stand up. A swallow study was done instead, and it was determined he needed a regular diet, cut up meats and nectar thick liquids. He was then non-compliant with sitting in his wheelchair and would self-transfer back to bed and put the head of his bed down. The SLT recommended he should be eating in the dining room for supervision. A negotiated risk form about eating in his room and in bed was sent to R1's guardian several times but was not signed. R1 was then discharged from therapy in [DATE] because he was non-compliant with recommendations. On [DATE] at 10:09 a.m., NA-A who brought the tray to R1 before he passed, was interviewed. NA-A stated R1 was supposed to be in the dining room. NA-A was new to R1's unit and was not aware R1 was at risk for choking, she would have to ask the nurses for that information. R1 did not intentionally use the call light while NA-A was working with him, only accidental bumps and would say he didn't need anything when NA-A responded to the light. NA-A stated during lunchtime on [DATE], she was told to bring the meal tray to him but supervision needs were not communicated to her. NA-A stated she would have had time to sit with him if she had known or was directed to. NA-A stated there was a debrief following R1's passing but she was not provided any education. On [DATE] at 10:32 a.m., registered nurse (RN)-A, the nurse manager for R1's unit, was interviewed. RN-A stated nursing assistants would be aware of choking risk through daily huddles or reading the Kardex. When asked how staff can increase safety for residents who are known choking risks who want to eat in their rooms, RN-A stated staff encourage them to get up as much as they can and get them in the best position. RN-A stated R1 would occasionally use the call light but he would usually not use it and wait for staff to notice that he needed help. When asked if R1 was supposed to be supervised while eating, RN-A stated it would be preferable if he ate in the dining room. Staff would stay with him because he ate so fast, they could take the meal tray out right away. RN-A stated risk of aspiration should be in the dietary section of the care plan but R1 never had aspiration pneumonia, he only coughed with liquids. RN-A stated there has not been any formal education completed by staff following R1's death besides a team huddle. On [DATE] at 11:25 a.m., RN-B, who sat with R1 for several meals in his room, was interviewed. RN-B stated nursing assistants are made aware of residents who are choking risks through morning huddles and that information should be in the header in the resident's file in the electronic health record (EHR). RN-B stated R1 was an official choking hazard because he was post-stroke and had dysphagia. He was supposed to be eating supervised. RN-B stated she would always try to sit with him during meals. He used to use his call light frequently but in the past 6 months his depression took over and he wouldn't use his call light. Staff checked on him every few hours. RN-B stated R1 would eat quickly and would cough a lot. He had to be watched with beverages because he would chug his drinks. RN-B stated risk of aspiration should be in the care plan. RN-B stated she did not receive any education following R1's death. On [DATE] at 11:39 a.m., NA-B was interviewed. NA-B stated nursing assistants know someone is a choking hazard by asking nurses or it should be indicated in the Kardex. NA-B stated R1 required supervision while he was eating in his room but not physical assistance. NA-B stated she had not received any education following R1's passing. On [DATE] at 12:29 p.m., nurse practitioner (NP)-A was interviewed. NP-A stated there was not enough evidence to determine that R1 passed from choking. R1 was always going to be an aspiration risk because he was a fast eater. Swallowing concerns should have been in his care plan unless speech therapy cleared him. On [DATE] at 12:42 p.m., R1's guardian was interviewed. She stated she was aware of R1's swallowing issues and was told by RN-A that R1 should be supervised while eating. The guardian stated she had signed a negotiated risk form for concerns about self transfers but was unaware of the facility trying to send her a negotiated risk for for swallowing concerns. On [DATE] at 1:16 p.m., R1's primary physician was interviewed. The physician stated R1 had significant reflux, he had problems with chewing and would regurgitate foods at the table. He inhaled his foods. The physician stated she would expect to see documentation about choking risks in R1's care plan. She stated that it should have been documented somewhere that if he doesn't leave his room for meals, he required supervision or staff should do checks on him. On [DATE] at 1:59 p.m., the assistant director of nursing (DON), was interviewed. The DON stated what goes in the care plan depends on the written orders from the speech therapist, staff only receive the written order and not her thoughts and feelings. When asked if care plans should include interventions addressing repeated refusal of care, the DON stated they operate under a resident's right to chose and there are negotiated risks that go into place if needed. When asked if supervision or checks should have been included, the DON stated the care plan is not updated day to day. When asked if there should be documentation of choking risk in the Kardex for nursing assistants to be aware of, the DON stated an individual can have dysphagia without significant risk of choking. Policies related to aspiration risk, choking risks or supervision during mealtimes was requested but not received.

Based on observation and interview, the facility failed to ensure staff were following standard precaution guidelines to prevent the spread of infection by wearing personal protective equipment (PPE), while processing contaminated linens. This had the potential to affect all 80 resident who resided within the facility. Finding include: On 8/29/23 at 1:04 p.m., nursing assistant (NA)-D provided a tour of the soiled utility room and described the process for rinsing out heavily soiled linen in the hopper. It was observed that the hopper did not have a protective splash screen on the hopper, it was on the floor next to the hopper. NA-D stated she would use gloves to rinse and soak the heavily soiled linens in the hopper. NA-D stated she did not typically wear a protective gown or eye wear, only gloves when using the hopper. On 8/29/23 at 1:15 p.m., NA-C provided a tour of the second soiled utility room and described the process for rinsing out heavily soiled linens. NA-C stated she was not aware any protective gown or eye wear to be worn when using the hopper only gloves. An observation of the second hopper room revealed the hopper protective splash screen was not on the hopper but off to the side. On 8/29/23 at 2:58 p.m., NA-B stated she used gloves while rinsing heavily soiled linens in the hopper. NA-B stated she was never instructed to wear a protective gown or eye wear while using the hopper to rinse out heavily soiled linens. The hopper was observed and did not have a protective splash screen on the hopper, it was on the floor next to the hopper. NA-B stated she would have to put a maintenance request in to get the protective splash screen put on the hopper. On 8/30/23 at 10:53 a.m., NA-A stated it could splash quite a bit when using the hopper. NA-A stated she did not wear eye protection or a protective gown when using the hopper. NA-A stated the splash shield never stayed on, so it was on the floor next to the hopper. NA-A stated she was not aware she needed PPE when there was splashing of soiled water. An interview on 8/30/23 at 9:30 a.m., director of nursing (DON) stated staff used the hoppers to rinse off heavily soiled items and if there was splashing, they needed to wear PPE. DON stated staff should wear a PPE gown, eye protection, and gloves when using the hopper. DON stated if staff were not wearing PPE, then there was no protection for the staff or residents. The facility policy Laundry Infection Prevention and Control undated, indicated staff will wear gloves and other appropriate personal protective equipment (PPE) when handling soiled linen.

Based on observation and interview, the facility failed to ensure nails were trimmed and clean for 1 of 1 residents (R6) reviewed for dependant cares. Findings include: Quarterly Minimum Data Set (MDS) identified R6 required extensive to total staff assistance with personal hygiene and grooming. She was moderately cognitively impaired. R6's care plan printed 8/30/23, indicated maximum assist from another person to complete personal hygiene. R6's's face sheet printed 8/30/23, included diagnoses of Alzheimer's and diabetes mellitus (DM). On 8/28/23 at 1:06 p.m., R6 was observed to have 1/2 inch long painted fingernails, with a dark brown, unknown substance caked under each nail on both hands. On 8/29/22, at 10:39 a.m., R6 was observed with 1/2 inch long fingernails, and a dark brown, unknown substance caked under each nail on both hands. On 8/29/23 at 11:44 a.m., certified nursing assistant (CNA)-C confirmed R6's fingernails were long, dirty, and needed to be clipped. She stated they usually do nails on bath day or sometimes with 1:1 activity unless the resident refused. CNA-C stated R6 liked to have her nails painted and did not usually refuse. On 8/29/23 at 10:58 a.m., registered nurse (RN)-A confirmed R6's fingernails, on both hands, were approximately 1/2 inch long with a dark brown, unknown substance under each nail. RN-A took a wet paper towel and gently rubbed and pulled out chunks of an unknown brown substance from under R6's nail's. RN-A expected staff to cut and clean fingernails for residents on their bath day and as needed. RN-A stated the resident needed staff to anticipate her needs. Cut and clean nails prevented infection control issues and promoted dignity. Facility policy: Quality of care instructed, residents shall be clean, neat and well groomed daily. Fingernails and toenails shall be trimmed on bath day unless contraindicated by M.D.

Based on observation, interview, and document review, the facility failed to follow order for treatment and reduction of a pressure ulcer for 1 of 2 residents (R40) reviewed for pressure ulcers. Findings include: R40's Minimal Data Set (MDS) dated [DATE], indicated intact cognition (able to fully understand). Diagnoses of medically complex conditions (more than one complicated medical diagnosis), anemia (not enough red blood cells), heart failure, and hypertension (high blood pressure). Further, R40 was at risk for pressure ulcers (bed sores) and had an unstageable pressure ulcer present on admission. R40 received pressure ulcer care. R40's orders dated 8/23/23, indicated apply L'Nard splints (heel protecting shoes) to both feet, to keep heels elevated, and wear at all times. R40's care plan revised on 7/5/23, indicated potential for pressure ulcers to upper and lower extremities. Care plan identified intervention of administer medications and treatments as ordered. On 8/27/23 at 2:30 p.m., R40 was seated in a wheelchair in his room. His feet were down and wore read grippy socks. R40 said he had sores on his feet. On 8/28/23 at 8:57 a.m., R40 was seated in a wheelchair at dining room table, with feet down and red grippy socks on feet. On 8/28/23 at 2:09 p.m., certified nursing assistant (CNA-E) and licensed practical nurse (LPN-A) completed wound cares, and transfered to bathroom. R40 was placed in wheelchair with red socks on. L'Nard splints were on desk space in room. R40 was not offered L'Nard splints and did not wear at any point during cares or transfers. On 8/28/23 at 2:09 p.m., CNA-E stated she needed to check if R40 wore L'Nard splints. On 8/28/23 at 2:16 p.m., LPN-A said she thought the L'Nard splints were to be worn only in bed and would review orders. On 8/28/23 at 2:44 p.m., R40 sitting up in wheelchair with L'Nard splints on both feet. On 8/28/23 at 3:23 p.m., LPN-A stated there had been some confusion with the L'Nard splint orders. She received clarification the splints should be worn at all times, except during transfers. LPN-A stated R40 generally did not wear the splints. On 8/28/23 at 4:28 p.m., Registered Nurse (RN-B) confirmed R40 should wear the splints at all times. RN-B stated the ulcers may not heal correctly if not worn, and she expected staff to follow the orders and the care plan. On 8/30/23 at 10:26 a.m., Director of Nursing said she expected staff to follow orders. She felt R40 refused to wear the splints but acknowledged there was no documentation of R40's refusal. Facility document, titled, GlenFields Living with Care Skin Risk and Reposition in Household Model of Care, under supportive devices, indicated, L'Nard splints, heel cuffs, and heelz up cushions are available and utilized as determined by resident need. Instructions for use will be indicated in the care plan.

Based on observation, interview and document review, the facility failed to maintain clean and sanitary conditions in the main kitchen. This practice had the potential to affect all residents, staff and visitors who ate at the facility. Findings include: On 7/19/21, at 12:53 p.m. the initial tour of the kitchen was completed with the dietary director (DD). The following areas of concern were identified. -walk in cooler floor was observed to have food debris and plastic items on the floor. A light fixture hanging from the ceiling in front of fans had approximately one quarter inch layer of black fluffy debris between the inner glass cover and the outer cage. The debris at the bottom of the light fixture was waving in the breeze from the fans. The inner glass cover of the light fixture had an area one inch round of brown substance. - walk in freezer inner side of door was observed to have ice build up on edge of door approximately one quarter inch thick from the top of the door to the bottom. Inner door surface was observed to have thin layer of ice. Plastic slates at entrance observed to have two missing slats, one slat with crack approximately two inches long, one slat was broken off about three inches from the floor, one broken off approximately four inches from the floor and one broken off approximately five inches from the floor. Light fixture at the back of the walk in freezer was observed to have an abject approximately one inch long and a quarter inch wide. On 7/20/21, at 4:20 p.m. walk in cooler was observed to have several small areas of black fuzzy debris on ceiling from the back of the cooler to half way to the door. There was a crevasse that ran from the front of the cooler to the back where the two halves of the ceiling met, the length of the crevasse was observed to have black debris the entire length. Cooler floor continued to have food debris and plastic items on floor. When interviewed on 7/20/21, at 4:25 p.m. cook-A stated the cleaning in the kitchen was done on a schedule with the cooler having one area of shelving cleaned according to a numbered diagram. Cook-A stated that cooler light fixture looked dirty, it should have been cleaned awhile ago' the ceiling looks nasty. Cook-A was unsure of who cleaned the floors, ceiling and light fixtures in the cooler and freezer. During interviewed and observation on 7/22/21, at 8:07 a.m. dietary director (DD) stated kitchen cleaning was completed according to the weekly cleaning schedule. DD stated the schedule is laid out for a different area to be cleaned each day and shift. Day shift sweeps at the end of their shift, evening shift sweeps and mops. Environmental services does deep cleaning monthly, this did not include the walk in cooler or freezer. If the kitchen staff noticed the light fixtures need cleaning they were to notify DD for a work order to be completed as maintenance cleaned light fixtures. Cooler floor continued to have food debris and plastic items on the floor, debris on light fixture and ceiling, walk in freezer continued to have ice build up and debris remained in light fixture. During interview on 7/22/21, at 10:37 a.m. the administrator stated the expectation was to ensure cleaning was done not only according to the paper schedule but also if staff notice something was not clean they were to clean it or report it. Administrator further stated cleaning of cooler and freezer was not up to standards Dietary Cleaning Schedule identified a week schedule and contained 8 columns and 9 rows of boxes, top row identified days of the week with first box blank. first column indicated which kitchen staff member was responsible for cleaning, remaining boxes identified which area of the kitchen was to be cleaned. Schedule identified Wednesdays cooler and freezer were to be swept and mopped. Facility Sanitation Monitoring Standards Nutrition Services policy dated as reviewed 7/2020, indicated food service supervisor and dietetic tech maintained the cleaning schedule, cleaning schedule was posted and reviewed weekly. Environmental services team cleaned and sanitized walls, floor and ceiling annually and as needed. Facility policy and cleaning schedule failed to identify when light fixtures, walk in cooler and walk in freezer wall and ceiling cleaning were scheduled.

Based on observation, interview and record review the facility failed to follow assessment results for self-administration of oral medications when medications were left in 1 of 1 resident's (R54) room. Findings include: R54's quarterly Minimum Data Set (MDS) dated [DATE], indicated R54 was able to make herself understood and was able to understand others. R54's vision was adequate and had no cognitive impairment. R54 did not have problems swallowing. R54's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R54's assessment for self-administration of medications dated 12/7/16, indicated R54 was safe to self-administer medications after set up by a nurse only in the dining room, Do Not Leave in Room. Assessment signed by R54 and by registered nurse completing the assessment. R54's care plan with revision date 12/6/19, indicated R54 can self-administer medications after set up by nurse in dining room only. No medications set up in room. On 7/19/21 at 6:18 p.m. a medication cup was noted on the tray table in R54's room with two pills in it. R54 stated the medications were left in her room by the nurse currently working. R54 indicated the current nurse always left medications in her room for her to take. On 7/21/21, at 2:24 p.m. licensed practical nurse (LPN)-A stated she has set up R54's medications and left them with R54 in the dining room, but watched her to ensure she took them. LPN-A stated instructions for self-administration of medication were found at the top of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/22/21, at 11:26 a.m. director of nursing (DON) confirmed instructions at the top of R54's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . DON stated she expected these instructions were followed. If medications are left for R54 in her room, it could result in missed dose of medications. Facility policy, Self Administration of Meds revision date 6/1998, did not identify how specific instructions related to self-administration would be communicated.

Based on observation and interview, the facility failed to ensure 1 of 1 resident (R34) was free of restraints, when staff locked the wheelchair brakes to keep R34 confined to an area in her wheelchair. Findings include: R34's quarterly Minimum Data Set (MDS) dated [DATE], indicated R34 had moderate cognitive impairment and no restraints were used. R34's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R34's care plan failed to include use of wheelchair brakes as a fall intervention. On 7/19/21 at 6:28 p.m., R34 was seated in her wheelchair in the day room. The back brakes on the wheelchair were locked. The back brakes were out of R34's reach. R34's wheelchair was pushed up to a table with a variety of items placed on it. There were no staff present in the area at the time of this observation. R34 placed her hands against the table and pushed until her wheelchair was tipping back, the front wheels where completely off the floor. When the front wheels were back on the floor, R34 pushed against the table again. The table moved approximately six inches away from R34. On 7/20/21 at 8:46 a.m., R34 was seated in her wheelchair at the dining room table. The back brakes on her the wheelchair were locked. On 7/20/21 at 9:39 a.m., R34 was still at the dining room table in her wheelchair with the back brakes locked. R34 looked around and stated, Is someone going to come help me? as she was attempting to move her wheelchair away from the table, but was unable to. Staff responded by releasing the brakes and moving R34 out of the dining room. On 7/19/21 at 6:39 p.m., nursing assistant (NA)-A stated R34's wheelchair back brakes are always locked to prevent her from moving away from the table. NA-A indicated the back brakes were locked so R34 was not able to release them. On 7/21/21 at 12:53 p.m., NA-B stated they locked R34's wheelchair back brakes when no staff were around because she tries to stand up. On 7/21/21 at 2:17 p.m., licensed practical nurse (LPN)-A stated if a resident was not able to release the wheelchair brakes, then it would be considered a restraint. LPN-A indicated R34 was at risk for falls, R34's fall interventions did not include locking the wheelchair brakes. She is not able to release them, so it would be considered a restraint. On 7/22/21 at 10:03 a.m., registered nurse (RN)-A stated R34 is at risk for falls. RN-A indicated R34's fall interventions did not include locking her wheelchair brakes because it would be considered a restraint because R34 is not able to release the brakes. Locked wheelchair brakes could result in R34 tipping her wheelchair over resulting in an injury. On 7/22/21 at 11:31 a.m., director of nursing (DON) stated the facility was free from use of restraints. If a R34's wheelchair brakes were locked and R34 was not able to release them, then the brakes would be considered a restraint. DON stated the risks of using wheelchair brakes as a restraint included a potential for injury. Facility restraint policy dated 2/4/21, indicated use of restraints required an assessment, reassessment, documentation, communication with family, and the resident's personal physician be updated. The resident's care plan would include information regarding use of the restraint. These requirements were not found in R34's record.

Based on interview and document review, the facility failed to ensure the State agency (SA) was notified within 2 hours of allegations of verbal abuse for 1 or 1 incidents reviewed for reporting. Findings include: R1's annual Minimal Data Set (MDS) dated [DATE], indicated R1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 required extensive assistance for activities of daily living (ADLs) which included two staff members for transfers and dressing, and one staff member for bed mobility and toileting. R1's care plan indicated that R1 is resistive to care with episodes of kicking/hitting, grabbing, unresponsive to staff and wandering related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, care plan indicated R1 has impaired cognitive and thought process and directed staff to use simply structured activities that avoid demanding tasks and to keep routine consistent as much as possible. On 2/8/21, at 1:01 p.m. nursing assistant (NA)-C stated while working with NA-A, NA-A mentioned an incident of NA-B calling R1 derogatory names while assisting with cares. NA-C directed NA-A to tell NA-D about the incident due to all residents being vulnerable adults. However, NA-C was unable to give an exact date that NA-C was made aware of the incident, but stated approximately 1/26/21. In addition, NA-C did contact RN-A on 2/3/21 to report the incident of verbal abuse. NA-C indicated NA-C did not report the incident due to not witnessing it and was not sure what my duty would be to report that, but stated it is important to notify someone because you don't want someone like that working with vulnerable adults. During interview on 2/8/21, at 1:42 p.m. NA-B denied allegation of calling R1 any names or swearing at resident, however did state if she were to call a resident a name it is usually sweetheart or honey. When asked why someone would allege she swore at a resident, NA-B replied, I don't swear in general so I don't know where that is coming from. On 2/8/21, at 2:39 p.m. NA-A stated she was assisting R1 with evening cares along with NA-B. NA-A stated NA-B was hurrying R1 to stand up from the recliner and NA-B stated we don't have all day. Further, NA-A stated R1 then was punching at NA-A and NA-B and R1 punch NA-B in the chest. NA-A then indicated she heard NA-B call R1 a derogatory name. In addition, NA-A confirmed what NA-A witnessed was verbal abuse and should have been reported to management immediately within the two hour window. Further, NA-A stated she did not report the incident due to being scared. However, NA-A was unable to provide an exact date of when the incident NA-A witnessed occurred, but stated approximately around 1/10/21. On 2/9/21, at 9:52 a.m. NA-D indicated NA-D was made aware of the incident on 2/3/21 by a text message that NA-D received from NA-C. NA-D then indicated she notified the director of nursing (DON) immediately. On 2/9/21, at 10:33 a.m. DON indicated DON was made aware of the incident on the morning of 2/3/21 by NA-D. DON then called and spoke with NA-A to verify and confirm details of the allegation. Further, DON stated NA-A indicated she witnessed NA-B call R1 a derogatory name. In addition, DON stated she expected staff to provide resident safety and remove the alleged perpetrator immediately and report to a nurse who will then follow the facility VA policy. Further, DON stated we have an obligation to keep residents safe from harm and that (reporting timely) is part of keeping them safe. On 2/9/21, at 11:27 a.m. Administrator indicated she was made aware of the incident on 2/3/21, from the DON. Administrator indicated NA-B was removed from schedule pending investigation. In addition, Administrator stated she expected staff to report to their supervisor immediately as it is their responsibility and obligation. Further, Administrator confirmed that incident was considered verbal abuse and should have been reported immediately to keep the resident's safe. The facility policy titled LTC (long term care) Vulnerable Adult Policy, not dated, indicated each resident will be free from abuse and abuse can include verbal, mental, sexual or physical abuse. Further review of facility policy, indicated it is the policy of this facility that abuse allegations are reported per Federal and State Law. In addition, policy indicated the facility to ensure that all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made to the administrator of the facility and to other officials (including to the State Survey Agency).

Based on observation, interview and document review, the facility failed to appropriately implement interventions to provide supervision and protect residents from potential sexual abuse for 3 of 3 residents (R4, R1, R3), reviewed for allegations of resident to resident sexual abuse. This deficient practice had the potential to affect all 12 (R1, R2, R3, R5, R6, R7, R8, R9, R10, R11, R12, R13) female residents residing on the memory care unit. Findings include: R4 R4's quarterly Minimum Data Set ((MDS) dated [DATE], identified R4 had moderate cognitive impairment and had [DIAGNOSES REDACTED]. The MDS indicated R4 required extensive assistance with most activities of daily living (ADL's). Further, the MDS identified R4 had behavioral symptoms not directed towards others one to three days during the assessment reference period. R4's annual Care Area Assessments (CAA) dated 8/15/19, identified R4 had anxiety and dementia and had displayed behaviors of yelling out at others. Further, the CAA identified R4 had made inappropriate comments or actions at times towards staff. The CAA identified R4 required extensive assistance for most ADL's. Additionally, the CAA identified R4 had one episode of sexually inappropriate behavior towards staff during the seven day assessment reference period. R4's care plan, revised 2/10/20, identified R4 must be supervised around vulnerable female residents and redirected away if attempting to make physical contact with them. Further, R4's care plan listed to intervene as necessary to protect the right and safety of others, approach/speak in a calm manner, divert attention, and remove from situation and take to alternate location as needed. R4's care plan identified R4 had impaired cognition and had been prescribed [MEDICAL CONDITION] medications for depression and increased sexual behaviors. R3 R3's admission MDS dated [DATE], identified R3 had severe cognitive impairment and had [DIAGNOSES REDACTED]. The MDS indicated R3 required extensive assistance with most ADL's and identified R3 had displayed physical behavior directed towards others, rejected cares and wandered one to three days during the assessment reference period. R3's admission CAA dated 1/10/20, identified R3 required extensive assistance with most ADL's and had impaired cognition. Further, the CAA indicated R3 had refused cares, had episodes of kicking/hitting and wandered. R3's care plan revised 1/10/20, identified R3 had impaired cognition and thought processes due to Alzheimer's and dementia. The care plan identified R3 required extensive assistance with most ADL's and identified R3 required cueing, reorientation and supervision as needed. During observation of 2/19/20, at 5:00 p.m. R4 wheeled his wheelchair to the dining room table and stopped right next to R3 who was seated at a table. R4 grabbed R3's left hand with his right hand and stroked her left arm up to her elbow a few times. R3 removed his hand and repeated this action two more times. There were seven residents present in the dining room at that time, with licensed practical nurse (LPN)-A was present. At 2/19/20, at 5:04 p.m. LPN-A stated R4 and R3 frequently held hands and she felt they both liked it. Further, LPN-A made no attempt to redirect R4 or attempt to relocate him to a different location. On 2/19/20, at 5:05 p.m. DON stated R4 had experienced an increase in hyper-sexual behaviors in the past few weeks and he frequently had touched other female residents on the hand or arm. The DON stated the facility had provided one to one supervision on the day and evening shift for R4 and made attempts to transfer R4 to a geriatric psychiatric facility which had been unsuccessful thus far. Further, the DON stated medication adjustments had been made and a psychiatric evaluation had been scheduled for the end of March. The DON stated the facility had also enlisted assistance from the activites staff, the homemakers and the therapy staff to assist with one to one supervision of R4. DON stated when R4 was seen touching a female resident, staff were to redirect R4. DON stated she considered a female resident who had been flirtatious and positively responded to R4's advances a resident who was able to give consent. The DON stated she had been aware of R4's touchy, feely behaviors and felt the facility had done everything within their power to prevent them. Review of R4's facility incident report dated 2/10/20, identified R4 entered R1's room while she had been seated in her chair with a blanket covering her. Staff noticed R4's hand was underneath the blanket resting on R1's groin area. The staff removed R4 from R1's room and reported the incident to the director of nursing (DON). DON questioned R4 and R4 stated he remembered the incident, however, he had touched R1's belly button. The immediate action taken was for staff to supervise R4 when he was near female residents and was to be re-directed away from female residents. Review of the internal investigation of the incident with R4 and R1 on 2/10/10, included a written note by staff who witnessed the incident, which indicated R4's hand was underneath the blanket and had cupped R1's private area. Review of R4's progress notes from the electronic health record (EHR) from 2/10/20, through 2/20/20, revealed the following: - 2/10/20, at 11:44 a.m. R4 had kissed another resident on the lips and rested his hand on her lap. - 2/10/20, at 5:13 p.m. R4 had been found in another resident's room sitting next to the female resident with his hand noted to be underneath the blanket resting on the female resident's groin area. Staff removed R4 from the room and when questioned, R4 stated he had been touching the female resident's belly button. R4 further stated it had been inappropriate to touch female residents on the chest or 'down below. - 2/11/20, at 11:40 a.m. R4 grabbed female resident's head with both hands and pulled her down and kissed her on the lips. Staff removed the female from the situation and R4 wheeled himself to his room. - 2/11/20, at 1:17 p.m. R4 was found to be holding hands with a female resident. R4 brought to an activity after the incident. - 2/11/20, at 3:04 p.m. R4 repeatedly attempted to hold female resident's hands during an activity. R4 had been redirected multiple times. R4 wheeled himself to his room afterwards. - 2/11/20, at 3:28 p.m. R4 held hands with female residents once staff walked away from the area. - 2/11/20, at 3:44 p.m. R4 made multiple attempts to get close to a female resident and touch her. Afterwards, staff removed the female resident from the situation and monitored R4. - 2/11/20, at 9:16 p.m. R4 kissed a female resident twice. Resident had been monitored throughout the shift. - 2/12/20, at 3:26 p.m. R4 made multiple attempts to get close to female resident and touch her. Female resident held up her finger and stated no, no, no when R4 would get too close. R4 went back to his room afterwards. - 2/12/20, at 5:55 p.m. R4 was noted to be holding a female resident's hand and started to move his hand up her arm and attempted to pull female resident towards him. Staff intervened and R4 returned to his room afterwards. - 2/13/20, at 3:56 p.m. R4 had made multiple attempts throughout the shift to touch female residents' hands or legs after placing his wheelchair next to female residents. R4 had grabbed two female residents' hands on that shift. R4 had been removed from situations. One of the female residents had stated no when he got too close to her. - 2/13/20, at 10:10 p.m. R4 attempted to grab a female resident during supper. - 2/14/20, at 2:18 p.m. R4 had been found in the morning rubbing and grabbing female resident's leg. R4 had been redirected and went to his room after the incident. - 2/16/20, at 10:37 p.m. R4 had three episodes of physical contact with female residents which consisted of holding a female resident's hands and rubbing her leg, kissing a female resident and holding another resident's hands. R4 had been redirected or removed from the situations. - 2/17/20, at 3:00 p.m. R4 repeatedly grabbed a female resident's arm and face. R4 was moved away from the female resident. - 2/18/20, at 10:00 a.m. dietary staff observed R4 holding female resident's hand, stroking her hand and arm and kissed female resident four times. R4 returned to his room after the incidents. - 2/18/20, at 1:15 p.m. R4 was noted to be holding a female resident's hand. Staff turned their back and when they turned around, R4 was kissing female resident. R4 was asked to keep to himself and he returned to his room. - 2/18/20, at 6:15 p.m. R4 attempted to kiss female resident and was stopped by staff. R4 then attempted to kiss female visitor and she was able to avoid the kiss. - 2/19/20, at 8:44 a.m. R4 was found to be touching a female resident on her hand and arm. R4 did remove his hand and remained seated right next to female resident. R4's physician progress notes [REDACTED]. The progress note indicated medication adjustments had been made and requested another contact be made for potential admission to a geriatric psychiatric facility. R1 R1's quarterly MDS dated [DATE], identified R1 had severe cognitive impairment and had [DIAGNOSES REDACTED]. The MDS identified R1 had unclear speech, sometimes understood others and indicated R1 required extensive assistance with most ADL's which included bed mobility, transfers, locomotion, dressing, toileting, personal hygiene and bathing. R1's admission CAA dated 5/19/19, indicated R1 had [MEDICAL CONDITION] and a decreased ability to make herself understood or to understand others. The CAA identified staff provided cues, reminders and supervision to R1 to maintain her daily routine. R1's CAA indicated R1 was most often non-verbal which required staff to interpret R1's non-verbal cues. R1's care plan revised 8/20/19, identified R1 required extensive assistance with most ADL's which included bathing, showering, bed mobility, dressing, personal hygiene, toileting and transfers. The care plan identified R1 had impaired cognitive function from [MEDICAL CONDITION]. On 2/20/20, at 8:08 a.m. nursing assistant (NA)-B indicated R4 had at least twice a day attempted to hold female residents' hands and tried to kiss them. NA-B indicated she had witnessed R4 display these behaviors with three different female residents. NA-B stated the facility had utilized the current scheduled staff to provide more one to one supervision of R4. NA-B stated R4 was routinely unsupervised when the staff providing the one to one supervision had been needed to assist with a transfer of another resident or to assist other staff with resident cares. On 2/20/20, at 8:32 a.m. NA-C stated she had observed R4 kiss a female resident and touch female residents within the past couple of weeks. NA-C stated she was not aware R4 required one to one supervision and stated the facility routinely scheduled three NA's on the memory care unit. On 2/20/20, at 9:11 a.m. NA-A stated R4 approached female residents at least once or twice a shift, kissed them and placed his hand on their arm or leg and rubbed them. NA-A stated she had observed R4 display this behavior to four different female residents residing on the unit. NA-A stated for the past two weeks the facility had attempted to provide one to one supervision of R4 while using the existing three NA's they usually scheduled on the memory unit. NA-A stated it had been challenging as the other two NA's needed assistance with cares and the third NA who had been tasked to provide one to one supervision would be pulled from that duty to assist and then R4 would be unsupervised. During a follow up interview on 2/20/20, at 11:07 a.m. NA-C stated she felt physical contact meant when R4 touched another resident on any part of her body. NA-C indicated she had witnessed R4 touch three female residents and the touching included hand holding and kissing. NA-C she had seen one of the female residents become visibly upset with the touching and had stated, No, No. On 2/20/20, at 12:02 p.m. licensed social worker (LSW) stated staff had noted increased hyper-sexual behavior with R4 within the past few weeks. LSW stated attempts had been made to admit R4 to a geriatric psychiatric unit and had been unsuccessful up until that day (2/20/20), when the facility had been notified a geriatric psychiatric unit would accept him and he had been transferred there on 2/20/20. LSW stated there had been 12 female residents who resided on the memory care unit and all of them had been considered vulnerable to abuse. LSW stated she had considered the ability to consent when a resident was able to verbalize no or wheel themselves away. LSW stated the facility had attempted to provide one to one supervision as much as possible. LSW stated staff had been instructed to remind R4 to keep his hands to himself when he had been observed approaching female residents. During a follow up interview on 2/20/20, at 12:15 p.m. the DON confirmed the facility had not added extra staff to provide one to one supervision for R4, and indicated the facility had attempted to provide one to one supervision with their existing staff. After review of the daily assignment sheets, the DON verified there had been 13 shifts as indicated on the daily assignment sheets in which less than three NA's had been staffed for the memory care unit. The DON stated she felt the facility had done their best at replacing staff to ensure there had been three NA's scheduled. Further, the DON stated activities staff, the care coordinators, homemakers and therapy staff assisted as well when they were available. She indicated the incident with R4 and R1 had been reported to the State agency. The DON confirmed R4's current care plan and stated she felt the physical contact related more to boundaries and resident non-verbal signs. The DON stated there were female residents on the memory care unit who had the ability to say no and move away from R4 and stated she felt some female residents initiated the physical contact themselves. Review of the daily assignment sheets from 2/10/20, through 2/19/20, revealed the following: - 2/10/20, two NA's scheduled for day and pm shift. - 2/11/20, two NA's scheduled for day and pm shift. - 2/12/20, two NA's scheduled for day shift and two and a half NA's scheduled for pm shift. - 2/13/20, two NA's scheduled for day shift and three NA's scheduled for pm shift. - 2/14/20, two NA's scheduled for day and pm shift. - 2/15/20, three NA's scheduled for day and pm shift. - 2/16/20, two NA's scheduled for day shift and three NA's scheduled for pm shift. - 2/17/20, three NA's scheduled for days and two and a half NA's scheduled for pm shift. - 2/18/20, three NA's scheduled for day shift and two NA's scheduled for pm shift. - 2/19/20, three NA's scheduled for day shift and two NA's scheduled for pm shift. The assignment sheets identified 13 different shifts in which less than three NA's had been staffed for the memory care unit, and were responsible to provide the 1:1 supervision of R4. Review of the undated facility policy titled LTC/TCU/Swing Bed Vulnerable Adult Policy indicated each resident would have been free from abuse. The policy stated no abuse of any type would have been tolerated and residents and staff would have been monitored for protection. The policy defined sexual abuse as non-consensual sexual contact of any kind with a resident. Review of current resident census sheet of the facility dated 2/19/20, revealed the following female residents resided on the memory care unit, and had cognitive impairment (R1, R2, R3, R5, R6, R7, R8, R9, R10, R11, R12, R13).

Based on observation, interview, and document review, the facility failed to ensure oxygen tubing was changed in a timely manner for 1 of 2 residents (R59) reviewed for respiratory care. Findings include: R59's Order Summary Report printed 5/8/19, indicated [DIAGNOSES REDACTED]. R59's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R59 was cognitively intact, and received oxygen. R59's Active Orders dated 5/8/19, included an order to replace and date oxygen tubing on both portable tank and concentrator every Sunday. The order also indicated to administer oxygen at 2-5 liters per minute (LPM) to keep oxygen saturations greater than 85%. R59's treatment administration record (TAR) for (MONTH) 2019, indicated R59's tubing was changed on 5/5/19, box was initialed. On 5/8/19, at 10:32 a.m. R59 was observed sitting in a chair in his room with portable oxygen on 2.5 LPM. Oxygen tubing for portable tank was dated 4/28/19. Tubing on oxygen concentrator and bubbler was dated 4/28/19. On 5/8/19, at 10:58 a.m. registered nurse (RN)-A confirmed the date on R59's oxygen tubing for his portable tank and concentrator was dated 4/28/19. RN-A stated the tubing should have been changed on 5/5/19. RN-A reviewed the TAR for (MONTH) and stated it was signed off, but had not been completed. On 5/8/19, at 11:48 a.m. director of nursing (DON) stated changing oxygen tubing should be done weekly per the order set in point click care, this is something we have implemented for any resident receiving oxygen. DON stated the tubing should have been changed. LTC Policy/Procedure for Oxygen Administration undated, lacked any direction of when oxygen tubing should be changed.

Based on observation, interview, and document review, the facility failed to ensure the most recent state agency survey results were readily accessible to all residents. This had the potential to affect 62 of 84 residents who required a wheelchair for locomotion off the unit. Findings include: During an observation on 5/7/19, at 8:59 a.m. a mesh type basket was affixed to the wall near the entrance of the facility. The basket was at eye level when standing next to it. In the basket was a three-ring binder indicating State Survey results were enclosed. R15's quarterly Minimum Data Set (MDS), dated [DATE], indicated R15 was cognitively intact. R15 utilized a walker or a wheelchair for locomotion and was independent with locomotion off the unit. During observation and interview on 5/8/19, at 10:22 a.m. R15 independently wheeled her wheelchair to the mesh basket. While sitting in the wheelchair, R15 reached up to remove the binder. The basket was too high for R15 to reach the binder. R15 stated she was unable to reach and remove the binder from the basket. During an interview on 5/8/19, at 2:52 p.m. the director of maintenance (MNT) measured the distance from the top of the basket to the floor at 58.5 inches. MNT stated a resident sitting in a wheelchair could not reach something out of the basket at the basket's current height. During an interview on 5/9/19, at 1:08 p.m. the administrator stated she was made aware the basket containing the survey results was too high for some residents to access by MNT on 5/8/19. A policy was requested, but not provided.