Every finding on record at Good Samaritan Ambassador

Based on observation, interview and document review, the facility failed to use proper personal protective equipment (PPE) for 1 of 1 residents (R17) reviewed for droplet precautions. Findings include: R17's annual Minimum Data Set (MDS) dated [DATE], included R17 was severely cognitively impaired and required substantial assistance for toilet hygiene, dressing, and transfers. R17's electronic medical record (EMR) included a facility form titled Good Samaritan Society - Ambassador COVID - 19 Test dated 12/30/24, indicated a positive test result for COVID-19. R17's EMR entry dated 12/30/24, included R17 tested positive for COVID-19 and droplet precautions were initiated. On 1/7/25 at 8:43 a.m., nursing assistant (NA)-A was observed entering R17's room with a food tray. NA-A donned a gown, glove and a N95 mask prior to entering room. Eye protection was not donned. R17's room had a sign posted with the title droplet precautions and included instructions to make sure eyes, nose and mouth are fully covered before room entry. On 1/7/25 at 9:09 a.m., NA-A was observed exiting R17's room and utilizing alcohol-based hand sanitizer. During interview on 1/7/25 at 9:12 a.m., NA-A stated she was aware R17 was on precautions for a COVID-19 infection, and she was supposed to wear eye protection when entering the room. NA-A stated she had not worn eye protection because there was not any in the precautions cart outside of R17's room. During interview on 1/7/25 at 9:56 a.m., registered nurse (RN)-A confirmed R17 was on precautions for a COVID-19 infection and all staff should have been trained on what PPE was necessary when caring for a resident with an infection. RN-A stated the nurses usually stock the precautions carts on the units, but all PPE supplies were available to any staff. On 1/7/25 at 12:46 p.m., trained medical assistant (TMA)-A was observed entering R17's room. TMA-A was wearing gown, gloves, and mask without eye protection. During interview on 1/7/25 at 2:09 p.m., TMA-A confirmed he gave R17 medication earlier in the day. TMA-A stated he wore a gown, gloves and N95 mask. TMA-A stated he did not wear a face shield because none were available in the precautions cart. TMA-A stated they have received training and was aware he was supposed to wear a face shield. During interview on 1/9/25 at 10:25 a.m., infection preventionist (IP) confirmed staff were trained to wear a gown, N95 mask, face shield and gloves when working with a resident who is positive for COVID-19. IP stated everyone was able to stock the precautions cart and did have access to PPE. The IP stated she would have expected the staff to get a face shield if none were available in the precautions cart prior to entering the room to care for a resident who was on precautions. This was important to prevent spread to vulnerable residents. During interview on 1/9/25 at 10:25 a.m., director of nursing (DON) stated all staff were educated on proper use of PPE. Facility policy for infection prevention dated 12/2/24, included the facility would utilize transmission based precautions in addition to standard precautions, to prevent and control known and suspected infections.

Based on interview and document review, the facility failed to ensure the Skilled Nursing Facility Advanced Beneficiary Notice-Centers for Medicare and Medicaid-10055 (SNFABN-CMS-10055) was provided for 1 of 3 residents (R126) reviewed for beneficiary notices. Findings include: R126's Part A discharge Minimum Data Set (MDS) dated [DATE], indicated R126 was admitted [DATE]. R126's was cognitively intact. R126's Notice of Medicare non-coverage form CMS-10123 (NOMNC-CMS-10123), signed and dated 7/29/24, indicated R126's services would end 7/31/24 although Medicare coverage days remaining. R126 remained in the facility. R126's discharge MDS dated [DATE], included R126 was discharged from the facility on 11/17/24. R126's medical record lacked evidence the SNFABN-CMS-10055 was provided to R126. During interview on 1/8/24 at 3:36 p.m., Medicare case manager (CM)-A confirmed R126 did not receive a SNFABN-CMS-10055 prior to his Medicare coverage ending. CM-A confirmed R126 should have received this form since he was staying in the facility with coverage days remaining. CM-A stated the form was not completed because there was confusion on who was responsible for completing this form. Facility policy titled Advance Beneficiary Notice of Non-Coverage dated 2/14/23, included the SNFABN-CMS-10055 was to be issued prior to providing a service that is usually paid for by Medicare but may not be because it was not considered medially necessary.

Based on interview, observation, and document review the facility failed to ensure 1 of 1 resident (R327) who had a significant weight loss received assistance with eating. Findings include: R327's admission Minimum Data Set (MDS) dated [DATE], indicated severe cognitive impairment and required extensive physical assistance of one person for eating. R327's care plan dated 2/21/23, indicated resident required supervision and eating assistance as needed. R327's Mini-Nutritional assessment dated [DATE], indicated no weight loss or decrease in food intake in the prior 3 months, but scored at risk of malnutrition. R327's Food and Nutrition Data Collection dated 2/20/23, indicated R327's hospital admission weight was 180#. R327's Dietician assessment dated [DATE], indicated weight was not stable, and resident had greater than 5% weight loss in 30 days. Additionally, R327 required feeding assistance, food intake varied 0-100% at meals, and was at risk of malnutrition. Interventions included weekly weights and feeding assistance. R327's occupational therapy (OT) assessment dated [DATE], indicated R327 required cueing to eat. R327's progress notes and weight documentation indicated the following: On 2/17/23, admitted to the facility. No weight was recorded this date. On 2/18/23, was fed at breakfast and had 25% intake, a poor appetite, and required cues with eating. 173.1#. On 2/20/23, had a poor appetite and required moderate assistance with eating. 169.6 #. On 2/21/23, had a poor appetite and ate 25% of his meal. 167#. On 2/22/23, fed himself with cueing and some hands-on assistance. On 2/24/23, ate about 40% of meals with cues. On 2/24/23, the care conference progress note lacked information in the nutritional section of the note. On 2/25/23, had low appetite and required encouragement to eat, with a diagnosis of gastrointestinal (GI) cancer, which was not previously mentioned in progress notes, nor on the diagnosis list or nutritional assessment. On 2/27/23, lacked mention of appetite, intake, or level of assistance required for eating. 164#. On 2/28/23, required cues for eating, and had poor appetite. 163.4#. On 3/2/23, the nutritional status note indicated a significant weight loss of 6.4%/-11 pounds, Likely due to disease progression and sub-optimal intake. R327 required supervision and prompting to improve intake. 162#. On 3/4/23, had eaten less than 50% of meals. Level of assistance required to eat was not documented. On 3/6/23, had eaten less than 50% of meals, and had fed self after set-up. On 3/8/23, fed self and needed, Lots of help with eating and drinking. On 3/93/23, the care conference note indicated intake greater than 50% of meals, required feeding supervision, food intake varied 0-100% at meals, weight 162# with a significant weight loss of 6.1%, and was at risk of malnutrition. On 3/9/23, the skilled care progress note indicated staff was monitoring needs related to GI cancer. 159.6#. On 3/10/23, appetite remained poor to fair. Level of assistance required to eat was not documented. Required cues for drinking fluids. On 3/11/23, appetite fair to poor. 159#. On 3/12/23, was able to feed self after set-up, but required prompts to participate. On 3/14/23, had good appetite for breakfast, but not the rest of the days. On 3/14/23, had red flags for significant weight loss based on weight recorded 3/11/23, 159#, which was a 8/1% loss or -14 # since admission, Likely due to progression of dementia, advanced age, and sub-optimal intake. R327 required supervision and prompting to improve intake. No additional weights were recorded prior to discharge on 3/15/23. R327's Discharge Summary dated 3/12/23, lacked mention of weight loss or level of assistance required for eating. When interviewed on 3/13/23 at 6:04 p.m., family member (FM)-C stated, He's lost his appetite, and he eats better when we feed him. He was worse after surgery. They set him up and pretty much expect him to eat on his own. During observation on 3/14/23 at 8:54 a.m., staff provided meal set-up, but did not provide additional physical help or cueing for the meal. R327 ate his cold cereal but mostly poked at the scrambled eggs, sliced banana, and French Toast with the fork. By the end of the meal, R327 had eaten a couple of bites of eggs and the sliced banana. Staff removed him from the dining room without encouraging or assisting the resident to eat. During observation on 3/14/23 at 1:12 p.m., staff provided meal set-up, but did not provide additional physical assistance or cueing for the meal. R327 was served beef tips, green beans, mashed potatoes, and a chocolate magic cup (nutritional supplement for extra calories). R327 ate a few bites of his beef tips and his magic cup. Occupational therapist (OT)-D was also observing the meal. When interviewed on 3/14/23 at 1:40 p.m., OT-D stated R327 ate about 50% of the meal and the purpose of that OT observation and assessment was about the functionality of eating with the adaptive utensil, not intake. When interviewed on 3/14/23 at 1:50 p.m., the registered dietician (RD) stated it was part of R327's dementia diagnosis to push food around on the plate. Additionally, the RD stated staff should provide feeding assistance if the MDS assessment and care plan indicated feeding assistance was required and was unsure if staff was providing feeding assistance. The RD stated the medical record indicated R327 was eating greater than 50% of his meals, but the medical record progress notes lacked documentation to support R327 was eating greater than 50% of his meals. When interviewed on 3/15/23 at 7:58 a.m., speech therapist (ST)-E stated the RD the role of ST is to ensure food and liquid textures for the resident ensure low risk for aspiration, and the RD oversaw oral intake and monitoring weights. When interviewed on 3/16/23 at 9:43 a.m. the director of nursing (DON) stated if staff is offering to assist a resident to eat, but the resident refuses the assistance, the refusals should have been documented. The DON stated she did not know if staff was offering to feed R327. The Activities of Daily Living Policy Dated 11/29/22, indicated any resident who is unable to carry out activities of daily living will receive necessary services to maintain good nutrition.

Based on observation, interview and document review, the facility failed to assess the ability of 2 of 2 residents (R38 and R32) to self-administer medications observed to be left at bedside, or without a nurse present during administration. Findings include: R38's quarterly Minimum Data Set (MDS) dated [DATE], identified R38 was cognitively intact, and able to express needs. R38 was identified as receiving limited assistance to complete activities of daily living (ADLs). R38's diagnoses included, dementia, anxiety, depression, chronic obstructive pulmonary disease (COPD) and coronary artery disease. During interview on 3/13/23, at 2:28 p.m. it was noted R38 had the following medications on her bedside stand: 1. a 30 milliliter bottle of artificial tears 2. a 180 count bottle of vitamin C Gummies - approximately 1/2 full 3. a bottle of TUMS 160 count - approximately 1/2 full R38 stated she had been arguing with a nurse who took her artificial tears from her, stating she could not keep them bedside. R38 would not state where she obtained the vitamin C and TUMS. R38's physicians orders, identified on 2/17/23, OK to self administer eye drops every shift. There was another order, dated 3/14/23, OK to keep at bedside and self administer eye drops every shift. R38's medical record had a Self-Administration of Medications assessment, dated 2/15/23, which found R38 was able to self administer her artificial tears, keeping them at bedside. There was no assessment for TUMS or Vitamin C. During interview on 3/15/23, 1:30 p.m. registered nurse (RN)-A verified R38 was assessed to have the capability to self administer and keep at bedside her eye drops, however she was unaware of the vitamin C and TUMS in R38's room. RN-A stated staff should report any medications noted in resident rooms, while R38 did not have orders for either of the other two medications in her room. 40938 R32's significant change MDS dated [DATE], identified R32 was cognitively intact, was able to express needs and required limited assistance with activities of daily living (ADL's). The MDS identified the following diagnoses: hypertension, asthma/chronic obstructive pulmonary disease or chronic lung disease and respiratory failure. R32's orders directed staff to administer ipratropium 0.5 milligrams (mg)/3 milliliters 1 vial (medication to open airways, and treat air flow blockage) via nebulizer every 6 hours with albuterol sulfate 1.25mg/3ml 1 applicator via nebulizer every 6 hours. During observation on 3/13/23, at 7:10 p.m. RN-B placed both medications into medication chamber and placed nebulizer chamber into holder of machine, administered R32's oral medications, then left room reminding R32 to complete nebulizer treatment. On 3/16/23, at 8:48 a.m. RN-C stated an assessment to self-administer medications with education provided to resident and return demonstration was needed to self-administer in addition to an order from the provider. RN-C stated R32 was able to self-administer nebulizer medications after set up by nursing. RN-C reviewed R32's orders, stated no order was in medical record for OK to self-administer nebulizer's, R32 had a resident self-administer of medications dated 3/7/23, which indicated R32 was able to self-administer albuterol inhaler. On 3/16/23, at 9:00 a.m. RN-D stated R32 had a quarterly self-administration of medications assessment completed on 3/7/23. Prior self-administration assessment was completed on 8/30/22, which indicated R32 was able to self-administer albuterol inhaler, assessment had been completed during prior admission to facility, R32 had discharged from facility on 11/9/22. R32 admitted back facility on 11/15/22 however no self-administration of medication was completed during admission. RN-D stated R32 was cognitively intact and was able to recall information so R32 was safe to self-administer nebulizer. R32's medical record lacked any assessment indicating she was safe to self administer nebulizer medications after nurse set up, record lacked any order from provider that indicated R32 was ok to self-administer nebulizer medications. The Resident Self-Administration of Medication policy, last reviewed 10/21/22, indicted the purpose of the policy was the following: - To determine if the resident can safely self-administer medications - To identify which medications may be safely self-administered - To assist the resident who is self-administering medications to manage his or her prescribed medications in a safe manner - To provide residents who can do so safely with the opportunity to self-administer medications

Based on interview and document review, the facility failed to comprehensively assess and implement individualized interventions to reduce the risk of falls for 2 of 3 residents (R1, R2) reviewed for accidents. This resulted in actual harm for R1 and R2 who both fell multiple times and obtained fractures which required emergency medical care. Findings include: A hospital Discharge Summary for R1 dated 6/30/22, identified the resident had sustained fractures of both hands and right foot due to trauma and [CONDITION(S)]. On 7/23/22, at 5:43 a.m. a progress note identified R1 was admitted to the hospital with intercranial hemorrhage and r (right) femoral neck fracture following a fall 7/22/22 at the facility. R1's nursing note indicated an admitted [DATE]. R1's discharge return anticipated Minimum Data Set (MDS) dated [DATE], identified R1 required extensive physical assist of one staff for mobility and toileting cares. R1 was free of range of motion limitations in her upper and lower extremities, was occasionally incontinent of bowel and bladder, experienced a fall with injury in the month prior to admission and a fall with major injury since admission, and was diagnosed with a right hand fracture, Alzheimer's Disease, dementia, and COVID-19. Upon hospital return, R1's admission MDS dated [DATE], identified R1 was severely cognitively impaired and required extensive physical assist of two staff for mobility and toileting cares. R1 experienced range of motion limitations to both upper extremities and to one lower extremity, was frequently incontinence of bowel and bladder, and was diagnosed with a right foot fracture and continued discharge return anticipated identified diagnosis. R1's hospital Discharge Summary dated 6/21/22, identified R1 was diagnosed with a right hand third metacarpal bone fracture related to a fall. The summary directed orders for R1 to be non-weight bearing to her right upper extremity and for physical and occupational therapy. R1's initial Fall Tool completed 6/21/22, identified R1 scored 20.0 indicating a high risk for falls. The tool identified its purpose was To identify risk for potential falls, possible causes for actual falls, and to provide guidance for proper interventions and reviewed several factors including history of falls, medication usage, psychological and cognitive status, automatic high risk status(s), a check list for additional risk factors and an action plan. The tool identified R1 experienced one or more falls prior to admission, received one higher risk medication, was affected by one or more psychological factors, was moderately impaired and recently had a change in condition affecting safe mobility. In addition, the tool identified R1 was at risk for falls related to confusion, poor memory, disorientation, difficulty following instructions and incontinence. The risk factors for mobility/transfers and medical remained unchecked. R1's action plan was a referral to therapy. The action plan to update the care plan remained unchecked. R1's subsequent Fall Tools identified the following information: -6/26/22: Score of 13.0 (medium fall risk) with additional identified risk factors (forgets to use equipment, dementia, impulsive/risk-taking behavior, impaired balance or coordination). The tools Action Plan section was unchecked for interventions. -7/1/22: Score of 20 (high fall risk) with additional identified risk factors (weight bearing restrictions, difficulties in orientation). The Action Plan indicated a referral to therapy intervention. The Action Plan to update the care plan remained unchecked. R1's baseline care plan initiated 6/21/22 through 6/22/22, identified R1 was cognitively impaired with impaired thought process related to Alzheimer's Disease, demonstrated limited physical mobility with inability to transfer, ambulate or do self-cares without assistance related to a right hand fracture, was incontinent of bladder, was diagnosed with COVID-19, required use of antidepressant medication, and was at risk for falls related to confusion, history of falls, incontinence. In addition, her care plan identified R1's desire to return to her private condo with her spouse. The care plan listed several interventions for R1 which included R1 required contact guard for mobility and toileting and fall prevention intervention to educate resident about safety reminders and what to do if a fall occurs, educate resident as to fall causes, and review and modify environmental hazards that could cause or contribute to falls. R1's medical record identified the following information: On 6/22/22, a progress note indicated R1 required frequent safety checks to prevent falls as R1 continually transfer[s] without asking for help after education. On 6/23/22, a progress note indicated[R1] is able to ambulate but needs reminders to have someone with her to do so . An occupational therapy (OT) progress note dated 6/23/22, identified R1 was assessed for safety awareness and received extensive training on call light use during the session; however, when asked what she should do if she needed to use the bathroom R1 stated, get up and go. The OT note indicated R1 required max cues to locate and use call light this date. On 6/24/22, a progress note indicated R1 was able to make needs known, but needs frequent checks due to high fall risk related to Alzheimer's diagnosis. On 6/25/11, a progress note indicated Nursing staff needs to do frequent checks on [R1] due to high fall risk r/t (related to) confusion from late onset Alzheimer's. A Found on Floor event report, dated 6/26/22, at 8:25 a.m. identified R1 was found in her room in front of door with blood covering her face, lips, and tongue with an abrasion noted on her left elbow. R1 stated she heard something and thus looked for someone to come get her. R1 was sent to the hospital for evaluation. At the time of the fall, R1 was oriented only to herself with the following predisposing physiological factors: confused, impaired memory, gait imbalance, weakness/fainted, and recent illness. The event report lacked evidence a fall intervention was initiated immediately after R1's fall. A progress note on 6/27/22, indicated the IDT (interdisciplinary team) met and reviewed R1's fall. The note indicated R1 stated she heard something and looked for someone to get her in which R1 failed to use her call light to ask for assistance. IDT reviewed reason for admission, diagnosis, medication use, age and R1's high risk for falls. IDT's plan was to re-evaluate patient fall risk status upon return from hospital. R1's hospital Discharge Summary, dated 6/30/22, identified R1 was diagnosed with COVID-19, anxiety, hypertension, late onset Alzheimer's dementia and traumatic fractures of both hands and right foot due to trauma and [CONDITION(S)]. Associated discharge orders identified R1's activity level to consist of non-weight bearing to right lower extremity and partial weight bearing of one to two pounds for left and right upper extremities, along with orders for physical and occupational therapy. On 6/30/22, a progress note indicated R1 returned to the facility. She required assist of one staff for transfers, to be monitored closely d/t (due to) fall risk, was disoriented to time and place, needed direction, required oxygen which she was noted to remove at times, her right arm/hand and right lower leg were ace wrapped, she was oriented to her call light and was on COVID precautions. On 7/1/22, a progress note indicated R1 changed rooms d/t safety. An OT progress note dated 7/1/22, identified per nursing staff, R 1 continued to attempt self-transfers. On 7/4/22, a progress note indicated R1 was attempting to self transfer and required a full mechanical lift for all transfers. A physical therapy (PT) progress note dated 7/7/22, indicated when the PT entered R1's room, R1 was seated on the toilet. The note indicated R1 self-transferred based on call light not triggered and wheelchair not by bathroom. There was not evidence the PT updated nursing staff related to R1's self-transfer. On 7/9/22, a progress note indicated R1 was noted to self transfer in room; safety checks every 2 hours to prevent injury. An OT progress note dated 7/14/22, indicated when the OT entered R1's room, R1 was noted on the toilet without her CAM (control ankle movement) specialty boot for protection, and neither the wheelchair or walker was in the bathroom. The note included, R1 reports walking there on her own. There was not evidence the OT updated nursing staff related to R1's self transfer. A Found on Floor event report dated 7/22/22, at 6:38 p.m. identified R1 was found on her bathroom floor covered in blood and fecal matter. The report indicated R1 stated she tried to go to the bathroom and slipped. She sustained a skin tear on her right forearm. At the time of the fall, R1 was oriented only to herself with the following predisposing physiological factors: confused, impaired memory, gait imbalance, weakness/fainted, and incontinent. In addition, the event noted she had a CAM boot on her right foot. A subsequent progress note on 7/22/22, at 7:40 p.m. indicated R1 was noted by the nurse trying to get out of bed by herself. Staff reminded her to use her call light to get staff to be with her before she moved. The progress note identified R1 failed to remember she fell at 6:38 p.m. On 7/23/22, at 5:43 a.m. a progress note identified R1 was admitted to the hospital with intercranial hemorrhage and r (right) femoral neck fracture. From 6/22/22 to 7/22/22, prior to her 7/22/22 fall, R1's care plan lacked documented evidence to support R1's baseline fall interventions having been assessed/adjusted, or new individualized fall interventions implemented to decrease R1's fall risk after R1's attempted/performed self-transfer attempts, after her initial fall within the facility, and after she was determined to be at a higher risk for falls based on her multiple Fall Tool risk factors. R2's progress notes and Fall Event report indicated the resident had fallen on 5/31/22 during the night and was subsequently admitted to the hospital with a left hip fracture. A progress note indicated R2 was admitted to the facility 5/13/22. R2's admission MDS dated [DATE], indicated R2 was severely cognitively impaired. She was able to usually express herself and sometimes understood others. She required limited to extensive assist with her mobility and extensive assist for toileting. She was deemed not steady and required staff assist to stabilize her during walking and transfers. Diagnosis included acute [CONDITION(S)] and pneumonia. R1 was free of falls prior to admission; however, sustained at least one fall without injury after admission. R2's initial Fall Tool completed 5/13/22, identified R2 scored 20.0 indicating R2 was at a high risk for falls. The tool identified R2 was free of fall history; but took two or more higher risk medications, was moderately psychologically affected and moderately cognitively impaired. Check marked risk factors identified R2 experienced muscle weakness or strength, fatigue, reduced insight, confusion, and poor memory. The action plan indicated a referral to therapy. The action plan to update the care plan remained unchecked. R2's subsequent Fall Tools identified the following information: -5/15/22: Score of 17.0 (high fall risk) with additional identified risk factors (impulsiveness, incontinence). Mobility/Transfers status remained unchecked. The Action Plan to update the care plan was checked. -5/31/22: Score of 17.0 (high fall risk) with additional identified risk factors (impulsive/risk-taking behavior, disorientation, difficulty following instructions, impaired balance and coordination). No other Action Plan interventions were identified. -6/3/22: Score of 20.0 (high fall risk) with additional identified risk factors (pain, fatigue, change in weight bearing ability, incontinence). The Action Plan intervention was a referral to therapy. The Action Plan to update the care plan remained unchecked. R2's baseline care plan initiated 5/13/22, identified R2 experienced communication impairments related to dementia and [CONDITION(S)] (difficulty expressing self), a limitation in physical mobility and deficits in self-care performance related to weakness and deconditioning, and a diagnosis of congestive heart failure where she required oxygen. R2's fall risk care plan identified a fall risk related to weakness, deconditioning, dementia, [CONDITION(S)] (decreased oxygen level in tissues), impaired balance, activity intolerance and shortness of breath. R2's fall risk goal was to remain free of falls with interventions to remind R2 to use a grabber to pick things up off of the floor, encourage therapy with exercise activity promotion, and ensure she wore appropriate footwear during transfers. R2's fall risk care plan lacked individualized fall interventions to decrease R2's risk of falls based on R2's fall risks. R2's medical record identified the following information: R2's hospital Acute Physical Therapy Evaluation dated 5/4/22, identified R2 demonstrated impaired cognition with short term memory recall around 20 seconds, impaired judgement with decreased safety awareness, along with decreased balance, strength and activity tolerance. The evaluation indicated R2 was at risk for falls and identified the following interventions: standard interventions, Posey sitter (alarm), seated positioning system, call light in hand, all needs within reach. On 5/12/22, at 5:05 a.m. a hospital nursing progress note indicated R2 utilized a bed alarm at all times for safety. On 5/12/22, at 10:22 a.m. a hospital nursing progress note indicated [R2] experienced a near fall, very unsteady on feet . A nursing home Found on Floor event report dated 5/15/22, at 6:26 a.m. identified R2 was found on the floor with her trash can tipped over under her back, her pants and incontinence product were pulled down to her ankle and stool (feces) was found in the trash can. The report indicated at the time of the fall, R2 was oriented only to herself with the following predisposing physiological factors: confused gait imbalance, incontinence. The event report lacked evidence a fall intervention was initiated immediately after R2's fall. On 5/15/22, at 7:00 a.m. R2's fall progress note lacked evidence a fall intervention was initiated immediately after her fall. On 5/15/22, at 10: 20 p.m. a progress note indicated R2 was observed standing between her bed and the window. R2 informed staff she stood there for a long time. A safety check every 30 minutes to one hour for prevention of falls/injury was initiated. On 5/16/22, at 1:49 p.m. a Mood/Behavior progress note indicated R2 kept trying to stand up during lunch while she made comments she needed to use the bathroom. Staff brought R2 to her bathroom; however, the nurse found R2 standing up with her pants by her ankles, crying and she stated she did not know what to do. The nurse was uncomfortable leaving R2 alone in her room and brought her out to the dining room. The progress note identified All nursing staff was made aware that [R2] cannot be left alone on toilet as she is a high fall risk and is very forgetful. A progress note on 5/16/22, at 3:54 p.m. indicated the IDT met and reviewed R2's fall. The note identified R2 was found on the floor and impaired cognition contributed to poor safety awareness and judgement with lack of insight into her current physical limitations. The IDT discussed a bedside commode; however, due to R2's dementia severity and inability to recognize what a commode was or its purpose this approach was not implemented. IDT's plan was to perform frequent checks on R2. On 5/16/22, at 8:39 p.m., on 5/18/22, and 5/20/22 progress notes indicated R2 self-transport[ed] in and out of her room and needs to be monitored every hour for risk of falls. R2's care plan identified on 5/16/22 the intervention frequent checks was initiated due to her high fall risk; however, R2's care plan lacked a care plan approach that R2 was not to be left alone on the toilet or specific details on how often staff were to check on R2. On 5/25/22 a Care Conference progress note identified R2's fall risk was a barrier to her discharge; however, R2's anticipated transition date for therapy was documented as 5/31/22 with a plan for her to discharge back to her memory care assisted living facility on 6/1/22. The progress note lacked additional fall risk information or intervention discussion related to fall risk. On 5/29/22, a progress note indicated R2 did not use her call light or make her needs known and thus staff conducted frequent safety checks on R2 as she has fallen numerous times during current stay and is a high fall risk. A Found on Floor event report dated 5/31/22, at 1:30 a.m. identified R2 was found lying on the bathroom floor. R2 stated she walked back from the bathroom and lost her balance. R2 appeared to have walked to the bathroom without a device. R2 displayed a goose egg on the side of her head, complained of severe left hip pain with movement, and her left foot was rotated out. At the time of the fall, R2 was oriented only to herself with the following predisposing physiological factors: confused and gait imbalance. The event report lacked evidence a fall intervention was initiated immediately after her fall. On 5/31/22, at 2:34 a.m. a progress note identified R2's fall at 1:30 a.m. On 5/31/22, at 6:56 a.m. a progress note indicated R2 was admitted to the hospital with a left hip fracture, pneumonia, and low magnesium. A hospital shift to shift summary progress note, dated 6/1/22, indicated R2 participated better with cares when she was instructed it was time for the cares versus if R2 was asked if she was ready for the cares. A hospital Care Plan note dated 6/2/22, identified R2 was at risk for falls in which the following interventions were in place: fall risk light on outside of room, fall risk sticker on door, fall prevention reminders to R2, frequent re-orientation and repetitive reminders to ask for assistance, high risk armband on, hi-lo bed, keep assistive device close at all times, bed alarm on, fall prevention slippers, stay within arm's reach and offer/assist with toileting every two hours, review prescribed medications that could predispose falling, and physical therapy. A hospital Discharge Summary, dated 6/3/22, identified R2 required surgery for a left inter trenchant femur fracture On 6/3/22, a progress note indicated a review of R2's status before and after her 5/31/22 fall. The note identified R2 was cognitively impaired secondary to dementia with a SLUMS (cognitive test) of 5/30, she was incontinent of bladder, call light use was inconsistent, she displayed a pattern of self-transfers to the bathroom, therefore she is frequently checked due to confusion and risk for falls. In addition, the note confirmed R2's walker and wheelchair remained next to her bed and she did not activate her call light before she self-toileted. The care plan was reviewed and followed prior to and during time of the incident. The progress note lacked evidence a fall intervention was initiated immediately after her fall or with the 6/3/22 fall review. On 6/3/22, a new care plan was initiated for R2. The care plan indicated R2 experienced a self-care performance deficit related to recent fall and femur fracture with interventions R2 required assist with mobility. R2's fall risk care plan identified a fall risk related to dementia, impaired decision making, weakness and deconditioning, history of falls, admission to the facility for therapies, and a Falls Tool score of 20. R2's fall risk goal was to remain free of falls with interventions to remind R2 to use a grabber to pick things up off of the floor, encourage therapy with exercise activity promotion, and ensure she wore appropriate footwear during transfers. The care plan lacked evidence of R2's self-transfer attempts or any additional fall risk interventions. On 6/10/22, a progress note indicated R2 required daily monitoring due to .safety concerns. In addition, the note indicated R2 was forgetful, restless and called out for help. R2 attempted to self-transfer when she needed the bathroom and as she was a high fall risk staff performed frequent checks on her to ensure safety. R2's care plan lacked evidence of her self-transfer attempts or any additional fall risk interventions. On 6/16/22, a progress note indicated R2's discharge plans were to discharge on 6/17/22 to her assisted living facility with hospice (end of life) services. On 6/17/22, a progress note indicated R2 discharged to her assisted living facility. When interviewed on 7/29/22, at 1:56 p.m. registered nurse (RN)-B stated after a resident fell staff were expected to develop or revise fall interventions immediately and these were to be followed until the fall committee reviewed the fall and either adjusted the intervention(s) or implemented new ones. RN-B indicated a frequent check fall intervention meant purposefully, once every hour, and every time I walk down the hall I look in. We try to keep the door open if we can if they are a fall risk. RN-B acknowledged if a frequent check intervention lacked a specific time frame for the checks staff could check as much as they wanted. RN-B indicated R1 experienced at least two falls in the facility and stated the first one is what caused the foot fracture. She stated R1 was on an every two hour toileting plan and those [staff] that knew [R1] knew to check on her and there was an undocumented understanding that we needed to keep our eyes on her. She was unable to explain why such approach(es) were not initiated into R1's care plan prior to R1's fall on 7/22/22. She confirmed, on 7/22/22 before R1's fall, she witnessed R1 attempting self-transfers during her shift. She explained only after R1's 7/22/22, fall she initiated a care plan approach to perform hourly safety checks on R1 as she was a fall risk. RN-B stated R2 was a huge fall risk in which staff were keeping an eye on her. She indicated she was unsure of any other interventions R1 utilized to help prevent falls. During interview on 7/29/22, at 2:25 p.m. nursing assistant (NA)-B stated she referenced the resident's care plan to know resident needs and fall interventions. NA-B confirmed she could be scheduled wherever the needs were and sometimes worked with residents she was not initially familiar with. She confirmed she did not remember details related to R2 based on length of time since worked with her however, she stated R1 was kind of hard to take care of as she was a demanding resident who would just get up and walk and who presented with sundowning symptoms. NA-B explained R1 required a toileting plan and frequent checks however, was unable to remember any additional individualized interventions for fall prevention. NA-B stated a frequent check fall intervention meant she checked on those residents usually every hour to make sure they are okay .some are every 15 minutes, some are more or less. She indicated a resident's care plan, or their charting, indicated the time frame for checks. She explained she checked on R1 as frequently as she could while she helped others, and stated the frequency fluctuated based on how busy she was on the unit that shift. When interviewed on 7/29/22, at 2:41 p.m. NA-A stated she referenced the resident care plans to know resident needs and fall interventions. NA-A explained an intervention for frequent checks meant she was to check on that resident every 15 to 30 minutes. She stated R1 was a high fall risk due to past falls and her cognitive status. She was unable to identify specific care planned interventions for R1; however, she indicated she was instructed by nurses to keep an eye on [R1] due to her high fall risk as R1 self-transferred every day: [R1] could be taking a nap and then 10 to 15 minutes later she would be standing at the window .not sure how she does things so quick. Each time you pass [R1] you have to peek on her .if you do not see her seated in the chair you have to go in there to see about her whereabouts. When interviewed per telephone on 7/29/22, at 3:45 p.m. R1's family member (FM-A) stated he was aware of R1's two falls in the facility and verbalized she sustained hand and foot fractures with the first fall and a hip fracture with the second fall. He denied knowledge of interventions staff conducted to decrease R1's fall risk. He stated during a care conference staff mainly talked about her needing memory care. He indicated R1's biggest issue was she did not remember she was not supposed to self-transfer and explained the only intervention to stop her from self-transfers was to strap her to a chair. FM-A stated R1 transitioned to hospice (end of life) services on 7/28/22, after hip surgery for pain management. He explained R1's falls did not help her status; however, he did not think the recent fall caused her current status. During a telephone interview on 8/1/22, at 11:36 a.m. RN-A stated after each fall staff performed a fall huddle and attempted to come up with a fall intervention as a team which they care planned. This intervention would then be reviewed by the fall committee who either adjusted the intervention or came up with a stronger one. RN-A stated she failed to remember if interventions were initiated after R1 fell on [DATE] however, commented the priority was getting her to the hospital. RN-A stated R1 self-transferred which was a frequent behavior for her. RN-A explained R1 required constantly peeking in on her and encouraging toileting to help prevent falls. RN-A verbalized the intervention for frequent checks meant every time anyone passed that residents room they peeked into the room as they attempted to keep those resident doors open. She followed up with usually we put a number [time frame] on it as just an intervention which stated frequent checks was pretty vague. RN-A identified the care plan was the main place staff went to locate interventions for resident care and acknowledged the facility attempted to schedule staff on the same units; however, staff were scheduled where they were needed with the potential to work with residents they were unfamiliar with. When interviewed via telephone on 8/1/22, at 11:57 a.m. RN-C stated after a fall staff were expected to implement or adjust fall care plan intervention(s) on the shift the fall occurred and she expected all interventions which assisted with fall risk reduction/prevention to be care planned, especially given staff were scheduled where they were needed and may not know the resident. She expected staff reviewed the care plan and group sheets for fall interventions. RN-C identified a frequent check fall intervention meant every hour or two checking on them, especially if they are a high fall risk. She stated at times the care plan indicated a time frame for the checks or the care plan just indicated frequent checks. She stated basically interventions fall around the reason of the fall and safety of the resident. She explained R1 tend[ed] to self-transfer and followed up: She has a history of falls, that is why we had her on frequent checks. RN-C thought she recollected, on 7/22/22 after R1's fall, she updated R1's care plan to toilet her right after supper to decrease falls. During interview on 8/1/22, at 12:30 p.m. physical therapy aide (PTA)-A stated R1 was a fall risk based on her CAM boot and her cognition: [R1] was so mobile and with her cognition she just thought she could do it. PTA-A explained R1 was doing really well until she fell and showed progress with her mobility despite her weight bearing restrictions. PTA-A stated therapy makes recommendations for fall risk; however, she lacked recollection of involvement in R1's fall risk interventions despite her having been one of R1's primary therapists. When interviewed on 8/1/22, at 12:57 p.m. care manager RN-D stated she expected after a resident fall some sort of intervention was to be initiated right away within that [fall] time period and care planned. Care planned interventions were important so that it [intervention] is carried over shift to shift and it is part of their plan of care. She explained if interventions were not care planned information would not be relayed to staff and confirmed staff were overall scheduled where they were needed and there was a risk they worked with unfamiliar residents. RN-D stated she was involved in the fall committee which met Monday through Friday and involved the interdisciplinary team (IDT). The review process involved a review of the electronic medical record's system Risk Management which tracked facility events (falls). The review process was based on the fall circumstances; however, overall after a residents first fall the committee reviewed the risk management report only which encompassed the fall details, the nurses fall note and follow-up, and conducted notifications and in general did not review the resident's progress notes section or care plan. If the resident fell frequently the committee reviewed risk management and the resident's progress notes section and the care plan in order to continue with approaches or adjust them. She denied the committee re-reviewed falls and fall risk after a resident returned from the hospital and explained she expected a Fall Tool to be completed upon admission/return and after a fall and based on the score and fall history the careplan was initiated or updated with fall interventions. She stated a committee review of a residents fall after a hospital return was important to ensure associated fall risk interventions were care planned and implemented. RN-D confirmed the committee had not met after R1 and R2's hospital returns to re-evaluate their falls prior to hospitalization and to ensure the care plan encompassed individualized fall risk interventions. She stated a frequent check fall intervention meant when [staff] are walking down the hall just peeking in the room to see what the person is doing .making sure they are not on the floor or doing all those things they should not be doing. She denied she educated staff on what she expected when a care plan indicated frequent checks without a specific time frame despite her comment that a frequent check intervention was not specific enough to ensure safety. RN-D confirmed R1 and R2 were at risk for falls based on their Fall Tool scores and both were observed to self-transfer during their stay(s). She stated R1's and R2's care plans lacked individualized fall interventions to decrease their fall risk based on their risk factors and observed self-transferring behavior. When interviewed on 8/1/22, at 1:54 p.m. the administrator stated she expected staff to follow their fall policy and expected a fall intervention to be put into place immediately after a fall which was documented/reflected in the care plan. This action helped with staff communication of resident needs and assisted to decrease fall risk. The goal was to prevent falls. The administrator confirmed she was involved in the fall committee and explained the committee should be re-reviewing the fall once a resident returned from the hospital to ensure appropriate interventions and she expected the re-review to be documented in the resident's chart: if we know someone is a fall risk we really should have a conversation on how to prevent a fall . She stated a frequent check intervention meant a pop in when walking by [a resident room] .more than usual checks. The administrator stated R1 and R2 were fall risk residents. During interview on 8/1/22, at 2:19 p.m. the director of nursing (DON) stated she expected after a resident fell that the care plan was reviewed and then adjusted or a new intervention implemented and documented within the care plan. Care planned interventions were important as the care plan directed resident care and safety. She confirmed s[TRUNCATED]

Based on observation, interview and document review the facility failed to secure medications from unauthorized access on the TCU (transitional care unit) for 3 of 21 medication cupboards located in the xhallway of the TCU. This had the potential to affect all 21 residents on the TCU unit. Findings include: During an observation on 3/30/21, at 2:00 p.m. room [ROOM NUMBER]'s medication cupboard was unsecured with R122's medications inside. The unlocked cupboard contained several medications included but not limited to; [MEDICATION(S)] 5mg (used for hypertension), [MEDICATION(S)] 50 mg (used for hypertension), [MEDICATION(S)] PO 300mg at bed time (Antipsychotic). During an observation on 3/30/21, at 2:00 p.m. room [ROOM NUMBER]'s medication cupboard was unsecured with R126's medications inside. The unlocked cupboard contained several medications included but not limited to; Potassium chloride ER 20meq dly (used to treat low potassium), [MEDICATION(S)] 150mg PO BID (used as a blood thinner) . During an observation on 330/22, at 2:01 p.m. room [ROOM NUMBER]'s medication cupboard was unsecured with R127's medication inside. The unlocked cupboard contained several medications included but not limited to; [MEDICATION(S)] 80 mg dly (used to treat [CONDITION(S)] fibrilation), [MEDICATION(S)] 20mg po dly (used for hypertension), trazadone 50mg po qd (used to treat [CONDITION(S)]), [MEDICATION(S)] 20 mg dly ( used to treat blood clots). During an observation and interview on 3/30/22, at 2:05 p.m. registered nurse (RN)-A checked medication cupboards for rooms 404, 406 and 415 and confirmed the medication cupboards were opened, not secured, and she locked them. RN-A state they should not be open. RN-A stated there were no narcotics stored in the medication cupboards and they were secured elsewhere on the unit. During an interview on 3/30/22, at 2:10 p.m. licensed practical nurse (LPN)-A stated she should have secured the medication cupboard for R126. LPN-A stated we know the medication cupboards need to be locked, I do not know what happened. During an interview on 3/30/22, at 2:16 p.m. LPN-C stated the medication cupboards should be locked. LPN-C stated I thought I locked R137's medication cupboard, it was a mistake. LPN-C stated the medication cupboards should be locked at all times. During an interview on 3/30/22, at 2:26 p.m. RN-D stated the medication cupboard for R122 should have been locked. RN-D stated the medication cupboards contained over the counter medications and scheduled medications but no narcotic medications. RN-D stated they needed to push in and turn the key to make sure it was locked. The facility policy medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . Only the person passing medications and the director of nursing services and/or designee will be permitted to have access to the keys to the medication storage areas.

Based on observation, interview, and document review the facility failed to ensure nursing staff had necessary competencies and skill set for indwelling catheters for 1 of 1 resident (R20). whom had an indwelling catheter. Findings include: R20's Minimum Data Set (MDS) dated [DATE], identified R20 was cognitively impaired and had an indwelling catheter. R20's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R20's care plan revised on 3/1/22, identified R20 had an indwelling catheter. He was to wear a leg bag during the day and catheter drainage bag at night. The care plan further identified catheter care done by CNA (certified nursing assistant) with daily peri care (cleaning the private areas of a resident) and as needed. During an observation on 3/30/22, at 7:37 a.m. nursing assistant (NA)-C washed hands and put on clean gloves. NA-C gathered the supplies from the bathroom to switch from a catheter drainage bag to a leg bag. R20 was sitting on the edge of the bed and NA-C knelt to the catheter drainage bag and emptied the urine into a gradate (measuring devise). NA-C then put the drain spout in the holder without cleaning with an alcohol wipe. NA-C hooked the catheter drainage bag on the bed. NA-C then measured, emptied the graduate into the toilet and rinsed the graduate out. NA-C went back to R20, unhooked the catheter drainage bag from the side of the bed, disconnected the catheter drainage bag from the indwelling foley catheter tube, however, NA-C failed to use an alcohol wipe prior to disconnecting the catheter drainage bag from the indwelling foley catheter tubing. NA-C placed the catheter drainage bag on the floor with no cap on the open-ended tube. NA-C took the uncleaned leg bag with no cap on, attached it to the indwelling foley catheter tube and attached the leg bag to R20's leg. NA-C took off her gloves and finished getting R20 dressed and brought him to the bathroom where R20 washed his face and brushed his teeth. NA-C put on clean gloves, picked up the catheter drainage bag and brought it to the bathroom to place in a plastic bag hanging on a grab bar. NA-C straightened up R20's bed. NA-C went back into the bathroom, got the catheter drainage bag out of the plastic bag, uncapped a 60 cc (cubic centimeter) syringe out of a basin and an opened bottle of sterile water from a bathroom cabinet. During an interview on 3/30/22, at 7:57 a.m. NA-C stated there was 25 cc of sterile water in the opened container. NA-C stated she could not find any vinegar to clean the catheter drainage bag with so I will use the sterile water and warm water from the tap. Then NA-C took the 60 cc syringe, filled it with sterile water and put it in the catheter drainage bag tube and allowed the sterile water to go down the tubing to the catheter drainage bag, then swished it around and then drained it into the toilet. NA-C then got the graduate and put warm tap water into it and used the 60 cc syringe to get the warm tap water and put 60 cc of warm tap water into the catheter drainage bag and swished it around and then drained into the toilet. NA-A hung the drainage bag on the grab bar to allow to dry, there was no cap placed on the tubing that connected to the indwelling foley catheter. NA-C threw the plastic bag into the trash then tied up the garbage and linen bags and took gloves off. NA-C then brought them to the soiled utility room and washed her hands. During an interview on 3/30/22, at 8:03 a.m. NA-C stated this was her first NA job and was just off orientation. NA-C stated she was working independently but could ask questions of coworkers if she needed to. NA-C stated she had no orientation check list that needed to be completed for her to work independently. NA-C stated no one had shown her how to properly clean the catheter drainage bags, so I do what is best for me. NA-C stated she would have used 40 cc to 50 cc of vinegar if she could have found the vinegar to clean out the catheter drainage bag. NA-C stated she should wash her hands and changed her gloves before and after cares. NA-C did not indicate any other times to wash hands and change gloves. During an interview on 3/30/22, at 8:52 a.m. the director of nursing services (DNS) stated NA's have clinical instruction with an instructor, when done with clinical the NA students have orientation to the floor with a mentor. The DNS stated she was informed when the NA students were ready to go on the floor for training until they took their examination. The DNS stated the instructor updated her weekly and the NAs had eight to ten days of orientation on the floor with a mentor to learn the floor skills. During an interview on 3/30/22, at 9:46 a.m. registered nurse (RN)-C visualized the catheter drainage bag in a plastic bag hanging on the grab bar in R20's room and stated there was no cap on the tip of the catheter drainage bag. RN-C stated the tip of the catheter drainage bag should be wiped with an alcohol wipe and the spout should be wiped with an alcohol wipe before placing in the holder. RN-C stated the catheter drainage bag should have been cleaned with a vinegar solution not just sterile water or tap water. During an interview on 3/30/22, at 11:36 a.m. the state nursing assistant coordinator (SNAC) stated new NAs had training in the lab and on the computer before they were able to be on the floor with a mentor. During an interview on 3/30/22, at 11:58 a.m. DNS stated NA-C did not have an orientation packet completed, nor was there any indication she was trained in changing from a catheter drainage bag to a leg bag. During an interview on 3/30/22, at 12:09 p.m. DNS stated NA-C should have used vinegar to clean the catheter drainage bag. DNS stated the catheter drainage bag should not have been on the floor, there should have been a cap on the end of the catheter drainage bag tubing, and NA-C should have changed gloves more frequently during the procedure. DNS stated R20 will need a new drainage system. During an interview on 3/30/22, at 1:13 p.m. the director of nursing services (DNS) stated she had no idea how NA-C slipped through the cracks for orientation. DNS stated NA-C had a mentor assigned to her for orientation, however, staffing did change at times and the facility would have more consistent mentors with orientees. During an interview on 3/31/22, at 8:30 a.m. staffing coordinator (SC) stated she put new employees on the schedule with a mentor. SC stated typically NA's have six to eight shifts with a mentor. SC stated my main goal was to make them comfortable before putting them on the floor. A review of the facility General Unlicensed Pathway, Certified Nursing Assistant, Nursing Assistant-Certified revised 2/12/21, indicated competency was the ability to perform the skill safely, correctly, and effectively. Validation means the individual has demonstrated competence in the skill. -provides pericare and catheter care, handling and placing tubing appropriately to minimize infection. -for emptying catheter drainage bag/ leg bag appropriately to minimize infection/cross contamination. Document review revealed NA-C did not have this orientation check list completed. The facility policy Orientation dated 1/3/20, indicated the department/clinic was expected to provide learning options for employee competency/orientation achievement. The supervisor coordinates competency checklists in collaboration with the assigned preceptor. Completion of department /clinic orientation checklists were documented in the employee's department record.

Based on observation and interview, the facility failed to ensure nails were trimmed and clean when a brown substance was under identiifed under the nails for 1 of 3 residents (R17) who were dependent on staff for activities of daily living (ADLs). Findings include: R17's annual Minimum Data Set (MDS) identified R17 required physical assistance from staff with ADLs including personal hygiene and did not refuse cares. R17's care plan printed 3/31/22, indicated he required maximum assist from another person to complete personal hygiene. R17's face sheet printed 3/31/22, included diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] On 3/28/22, at 2:35 p.m. R17 was observed to have ½ inch long fingernails, with dark brown, unknown substance under each nail on both hands. R17 stated, they're pretty long and messy. It'd be nice to have them trimmed and cleaned. On 3/30/22, at 8:13 a.m. R17 was observed with ½ inch long fingernails, dark brown, unknown substance under each nail on both hands. R17 was using his left hand to pick up pieces of fruit and place them in his mouth. On 3/30/22, at 11:44 a.m. licensed practical nurse (LPN)-B stated R17 required a nurse to cut and clean his fingernails because he had DM. Nurses cut and cleaned fingernails on bath day and as needed when they became soiled or were noted to be long. Further, aides were not allowed to clean fingernails of residents with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] On 3/30/22, at 1:40 p.m. registered nurse (RN)-B confirmed R17's fingernails, on both hands, were approximately ½ inch long with dark brown, unknown substance under each nail. RN-B stated she was aware R17 occasionally used his hands to bring food to his mouth. RN-B expected a nurse to cut and clean fingernails for residents with DM on their bath day and as needed, especially if a resident sometimes used their hand to bring food to their mouth. RN-B stated cut and clean nails prevented injury, possible infection and promoted dignity. On 3/31/22, at 9:55 p.m. director of nursing (DON) stated she expected nail care for residents with DM was completed by a nurse and was done weekly and as needed. She expected nails were observed daily for cleanliness, especially if we know they put their hands in their mouths. DON expected hand hygiene was provided before meals. Facility policy, Nail Care-Rehab/Skilled, Assisted Living, revised 3/8/2022, instructed licensed nurse should be notified to do nail care as needed for residents who are diabetic.

Based on observation and interview, the facility failed to ensure resident wheelchairs were in good repair for 1 of 1 residents (R27) whose wheelchair were observed to need repair. Findings include: R27's Face Sheet, undated, documented resident was readmitted [DATE] with the diagnoses of fracture of left femur neck with joint replacement surgery and fractures of lumbosacral spine and pelvis. R27's Admission minimum data set (MDS) dated [DATE], indicated R27 required extensive assistance with bed mobility, transfers, and dressing of 2-3 staff. He received occupational, physical and speech therapies. R27 was allowed minimal ambulation in room with the assist of one. The MDS indicated R27 was cognitively impaired. During observation on 3/28/22, at 5:00 p.m. R27's wheelchair had the following issues: > both WC arm rests soft pads had rippled cracked vinyl with the vinyl covering missing where the pad met the hard surface attached to the hard surface. The nylon webbing was exposed all the way around. > the left arm rest had approximately 4 inches wrapped in orange duct tape. > the sling back of the WC had two tears, one in the middle top and 1 next to the resident's right shoulder handle, each being approximately 1/2 inch each. During an interview on 3/28/22, at 5:00 p.m. R27 confirmed his wheelchair was provided by the facility. R27 stated he had been readmitted to the facility on [DATE], after being discharged to home two weeks earlier. While he was home, he fell and fractured his left hip. R27 stated this was the wheelchair he was provided upon admission, and was already in this condition. During interview on 3/30/22, at 1:20 p.m. licensed practical nurse (LPN)-A verified R27's wheelchair was provided upon admission. However, LPN-A stated she had not noticed the disrepair of both arms rests, the back rest nor the orange duct tape. LPN-A stated and had shown the log where resident equipment repair needs were logged by staff for maintenance to review and remove for repair. R27's wheelchair repair needs was not on the log. LPN-A stated that each day, maintenance rounded and collected the lists of things needing repair. In an interview on 3/30/22, at 1:34 p.m. maintenance director (MD) stated the maintenance department was unaware of R27's WC repair needs. MD verified the procedure facility staff were to follow, that of placing repair needs the repair logs found at each nurse's station, which maintenance reviews each day. MD stated that the facility did not have a specific policy for reporting repairs. MD stated the repair logs were the system the facility used for that purpose.

Based on observation, interview and document review the facility failed to ensure the process to determine self-administration and safe storage of medications was followed for 1 of 1 residents (R30), who was self-administering and storing medication. Findings include: R30's annual Minimum Data Set (MDS) indicated R30 had no cognitive impairment. R30's face sheet printed on 3/31/22, indicated diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Facility assessment, Self-Administration of Medications (SAM) completed 2/9/22, noted R30 was able to continue to self-administer medication, but failed to indicate which medications R30 was able to self-administer. The assessment also failed to indicate if and how medications were stored in R30's room and if teaching or instruction was provided to R30. R30's care plan, printed on 3/31/22, noted R30 was able to safely administer nebulizers, nasal sprays, medicated shampoos and inhalers. R30's physician orders signed 3/3/22, included [MEDICATION(S)] sodium 1% gel (a non-steroidal anti-[CONDITION(S)] medication), apply to hips and lower back three times daily for chronic pain, however, did not include orders for self-administration. On 3/28/22, at 5:03 p.m. [MEDICATION(S)] sodium 1% gel was observed on a bay windowsill behind a recliner in R30's room. R30 stated she self-administered the medication to her hips as needed. R30 indicated staff assisted her to apply the medication to her back and were aware she kept the medication in her room. On 3/30/22, at 11:39 a.m. licensed practical nurse (LPN)-B stated R30 self-administered [MEDICATION(S)] gel and stored the medication in her room. Further, LPN-B stated a physician order was needed for residents to self-administer medications and confirmed there was none for R30. On 3/30/21, at 1:17 p.m. registered nurse (RN)-B reviewed R30's SAM and physician's orders. RN-B stated R30's SAM was incomplete and failed to indicate which medications R30 was able to self-administer or how they be securely stored in R30's room. Further, RN-B confirmed physician's orders did not include an order for [MEDICAL RECORD OR PHYSICIAN ORDER] On 3/31/22, at 9:51 a.m. director of nursing (DON) stated self-administration of medication required a completed assessment and physician's order. Storage of medication in a resident's room required a lock box or another way for the medication to be securely stored. Facility policy, Resident Self-Administration of Medication- Rehab/Skilled reviewed/revised 10/15/21, directed prior to self-administration a SAM was completed and reviewed by the interdisciplinary team. A physician's order required a signature. Storage of medication in a resident's room required them to be secured.

Based on observation, interview and document review the facility failed to ensure proper catheter drainage bag care, hand hygiene, and glove use were followed for 1 of 1 resident (R20) observed during personal cares. Findings include: R20's Minimum Data Set (MDS) dated [DATE], identified R20 was cognitively impaired and had an indwelling catheter. R20's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R20's care plan revised on 3/1/22, identified R20 had an indwelling catheter, was to wear a leg bag during the day and catheter drainage bag at night. The care plan further identified catheter care done by CNA (certified nursing assistant) with daily peri care (cleaning the private areas of a resident) and as needed. During an observation on 3/30/22, at 7:37 a.m. NA (nursing assistant)-C washed hands and put on clean gloves. NA-C gathered the supplies from the bathroom to switch from a catheter drainage bag to a leg bag. R20 was sitting on the edge of the bed, NA-C knelt to the catheter drainage bag and emptied the urine into a gradate (measuring devise). NA-C put the drain spout in the holder without cleaning with an alcohol wipe. NA-C hooked the catheter drainage bag on the bed. NA-C then measured, emptied the graduate into the toilet, and rinsed the graduate out. NA-C did not change her gloves or do hand hygiene. NA-C went back to R20, unhooked the catheter drainage bag from the side of the bed, disconnected the catheter drainage bag from the indwelling foley catheter tube. NA-C failed to use an alcohol wipe prior to disconnecting the catheter drainage bag from the indwelling foley catheter tubing. NA-C then place the catheter drainage bag on the floor with no cap on the open-ended tube. NA-C took the leg bag tubing tip, with no cap on, and no alcohol wipe used and attached the leg bag drainage system to the indwelling foley catheter tube. She attached the leg bag to R20's leg. NA-C removed her gloves, however, did not wash or sanitize her hands, and finished getting R20 dressed. NA-C brought R20 to the bathroom where he washed his face and brushed his teeth. NA-C put on clean gloves picked up the catheter drainage bag, brought it to the bathroom and placed in a plastic bag hanging on a grab bar. NA-C straightened R20's bed. NA-C went into the bathroom. NA-C did not change her gloves or do hand hygiene, and got the catheter drainage bag out of the plastic bag. Then NA-C got an uncapped 60cc (cubic centimeter) syringe out of a basin and an opened bottle of sterile water from a bathroom cabinet. During an interview on 3/30/22, at 7:57 a.m. NA-C stated there was 25 cc of sterile water in the opened container. NA-C stated she could not find any vinegar to clean the catheter drainage bag, and would use the sterile water and warm water from the tap. NA-C took the 60cc syringe, filled it with the sterile water and put it in the catheter drainage bag tube and allowed the sterile water to go down the tubing to the catheter drainage bag. She swished it around and then drained it into the toilet. NA-C put warm tap water into the graduate, used the 60cc syringe to get the warm tap water to put into the catheter drainage bag and swished it around. She then drained into the toilet. NA-A hung the drainage bag on the grab bar to allow to dry, there was no cap placed on the tubing that connected to the indwelling foley catheter. NA-C threw the plastic bag into the trash then tied up the garbage and linen bags. She removed her gloves. NA-C then brought the bags to the soiled utility room and washed her hands. During an interview on 3/30/22, at 8:03 a.m. NA-C stated she was working independently but could ask questions of coworkers if she needed to. NA-C stated no one had shown her how to properly clean the catheter drainage bags, so I do what is best for me. NA-C stated she would have used 40cc to 50cc of vinegar if she could have found the vinegar to clean out the catheter drainage bag-remove. NA-C did not look or ask where the vinegar was located. NA-C stated she should wash her hands and changed her gloves before and after cares. NA-C did not indicate any other times to wash hands and change gloves. During an interview on 3/30/22, at 8:52 a.m. the director of nursing services (DNS) stated NA's have clinical instruction and then orientation to the floor with a mentor. The DNS stated she was informed when the NA students were ready to go on the floor for training until they took their examination. The DNS stated the instructor updated her weekly and the NAs had eight to ten days of orientation on the floor with a mentor to learn the floor skills. DNS stated NA-C was orientated on a different unit that did not have urinary catheters. During an interview on 3/30/22, at 9:46 a.m. registered nurse (RN)-C visualized the catheter drainage bag in a plastic bag hanging on the grab bar in R20's room and stated there was no cap on the tip of the catheter drainage bag. RN-C stated the tip of the catheter drainage bag should be wiped with an alcohol wipe and the spout of the catheter drainage bag should be wiped with an alcohol wipe before placing in the holder. RN-C stated the catheter drainage bags were cleaned with a vinegar solution, not just sterile water or tap water. RN-C stated there are caps for the catheter tubing at the nurse's station. During an interview on 3/30/22, at 11:36 a.m. the state nursing assistant coordinator (SNAC) stated new NAs had training in the lab and on the computer before they were able to be on the floor with a mentor. During an interview on 3/30/22, at 12:09 p.m. DNS stated NA-C should have used vinegar to clean the catheter drainage bag. DNS stated the catheter drainage bag should not have been on the floor, and there should have been a cap on the end of the catheter drainage bag tubing. DNS stated NA-C should have changed gloves more frequently during the procedure, R20 required a new drainage system. The Catheter Bag Cleaning section of the policy directed staff to assemble equipment. Knock on the door. Identify the resident. Explain the procedure and proved privacy. Perform hand hygiene and apply gloves. Empty the large drainage bag. Clamp the catheter tubing. Disconnect the urinary catheter tube from the large bag. Do not pull on catheter. Place the large bag on a towel or in a basin. Clean the tip of the leg bag with an alcohol pad, wiping away from the opening. Attach the leg bag to the catheter tubing. Store tubing caps in designated bag or container when not in use and clean tubing inside and out with alcohol pad before recapping tubing. To clean the bag not in use: Rinse the bag with warn soapy water or [MEDICATION(S)] solution such as one part vinegar and three parts water solution or an appropriate commercial solution. Pour solution into the bag. Swish the solution around being sure to get the corners of the bag. Hint: 60cc syringe may be used to get solution into bag, be sure to clean the tip of the syringe with alcohol wipe before use and store in clean dry place. Soak the bag for 30 minutes. Open the bottom drainage port and drain the solution from the bag. Rinse the bag with warm water and hang to dry in the resident's restroom covered with a clean towel. Cover/cap the tubing one the bag is dry. Remove gloves if applicable. Perform hand hygiene. Leave resident comfortable. Place call light within reach. Document where/when appropriate.

Based on observation, interview, and document review, the facility failed to ensure proper gloving and hand hygiene was implemented during incontinent cares for 1 of 1 residents (R4) reviewed. Findings include: R4's annual Minimum Data Set ((MDS) dated [DATE], indicated R4 was cognitively intact. R4 required extensive assistance with bed mobility, personal hygiene and with toileting. R4 was always incontinent of bowel and bladder. R4's Care Plan dated 2/24/20 directed staff to check and change R4 every 2 hours, assist with changing incontinent brief, and assist with cleansing. During observations of morning cares on 3/4/20, at 7:07 a.m. nursing assistant (NA)-C filled up a basin with soap and water, gloved, and brought the basin of water to R4's bedside. NA-C removed the blanket covering R4. NA-C looked at R4's incontinent brief and stated R4 was very wet. NA-C unfastened the brief and put a washcloth in the soapy water basin. NA-C cleaned R4's perineal area with the washcloth and used another towel to dry the area. NA-C cued and assisted R4 to roll to his right side. Stool was observed on R4's buttocks. NA-C removed the soiled incontinent brief. NA-C did not removed her gloves or perform hand hygiene. With the same gloved hands, NA-C put a new towel in the soapy water and washed R4's back. NA-C then used the soapy towel to clean the stool from R4's buttocks. NA-C dried R4's back and buttocks with a new dry towel. NA-C, did not remove her gloves and perform hand hygiene. With the same gloved hands, NA-C pulled down R4's clean shirt, placed a lift sling under R4, placed and secured a new incontinent brief on R4, and pulled up R4's pants. NA-C then removed her gloves, dumped the soapy water filled basin into the toilet and washed her hands with soap and water. During an interview on 3/4/20, at 7:37 a.m. NA-C stated gloves are to be removed and hands washed after performing perineal care. NA-C stated she did not do this and did not know why she did not. During an interview on 3/5/20, at 2:46 p.m. the director of nursing (DON) stated staff are to remove gloves after providing perineal care where urine and stool are present, wash hands and glove again before continuing with cares. The facility's policy Hand Washing and Glove Use dated 7/18, directed hands are washed thoroughly before putting gloves on and after taking gloves off. The use of gloves does not eliminate the need for proper hand washing or good hygiene. Gloves are to be worn when contact with bodily fluid is expected. Gloves are changed after coming in contact with body fluids. Staff are to wash hands before and after using gloves.

Based on observation, interview, and document review, the facility failed to ensure medication was labeled with the current physician orders [REDACTED]. Findings include: R60's Order Recap Report, printed on 3/5/20 revealed the following route order changes. -A 2/7/20 order for Eliquis 5 mg by mouth two times a day changed to 5 mg via pe[DEVICE] 2 times a day on 2/20/20. -A 2/7/20 order for folic acid 1 mg by mouth daily changed to 1 mg via pe[DEVICE] daily on 2/20/20. -A 2/7/20 order for [MEDICATION NAME] 20 mg by mouth daily changed to 20 mg via peg tube daily on 2/20/20. -A 2/7/20 order for [MEDICATION NAME] 25 mg by mouth 2 times a day changed to 25 mg via pe[DEVICE] on 2/20/20. During observations of a medication administration pass on 3/5/20, at 8:28 a.m., registered nurse (RN)-F stated R60 receives some medication via a pe[DEVICE] and some medication orally. RN-F stated she would administer the medication R60 receives via the pe[DEVICE] now and R60's oral medication later, as R60 was sleeping. -RN-F removed a bubble pack of Eliquis 5 mg tablets from R60's medication cupboard. The Eliquis label directed to administer 1 tablet by mouth twice daily. RN-A placed 1 tablet in a medication cup. -RN-F removed a bubble pack of folic acid 1 mg tablets from R60's medication cupboard. The folic acid label directed to administer 10mg by mouth daily. RN-F placed the medication in a separate medication cup. -RN-F removed a bubble pack of [MEDICATION NAME] 20 mg tablets from R60's medication cupboard. The [MEDICATION NAME] label directed to administer 20 mg by mouth daily. RN-F placed the medication in a separate medication cup. -RN-F removed a bubble pack of [MEDICATION NAME] 25 mg tablets from R60's medication cupboard. The [MEDICATION NAME] label directed to administer 25 mg by mouth twice daily. RN-F placed the medication in a separate medication cup. RN-F crushed each medication separately and stated all the medication will be administered via R60's pe[DEVICE]. When asked about the medication labels identifying to administer medication by mouth, RN-F reviewed R60's medication orders and stated R60's Eliquis, Folic acid, [MEDICATION NAME] and [MEDICATION NAME] are ordered to be administered via R60's pe[DEVICE]. RN-F stated a change of direction sticker to refer to the chart should have been placed on the medication when the medication route direction changed, but this was not done. During an interview on 3/5/20, at 8:28 a.m. the director of nursing (DON) stated when a physician changes the direction of a medication, staff are to place a change of direction sticker on the medication label and refer to the resident's orders for directions. The facility's policy Acquisition, Receiving, Dispensing and Storage of Medications, dated 12/19, directed All medication are packaged in accordance with the location dispensing system and state pharmacy rules. these medications must be labeled according to state pharmacy regulations. Cautionary and accessory instructions, as well as expiration date, will be included. New labels will be applied by the pharmacist or the pharmacist's agent as needed. The policy lacked directions related to change of direction stickers.

Based on observation, interview, and document review, the facility failed to ensure oxygen therapy was provided as ordered for 1 of 1 residents (R47) reviewed for respiratory care. Findings include: R47's quarterly Minimum Data Set ((MDS) dated [DATE], identified R47 as moderately cognitively impaired. R47 required extensive staff assistance with transfers, dressing, and personal hygiene. R47 had shortness of breath with exertion and received oxygen. A provider note, dated 2/6/20, identified R47 as oxygen dependent. The note indicated R47 gets short of breath when off oxygen and oxygen saturations are good when R47 is on 2 liters/per/min (LPM) of oxygen. R47's Order Summary Report, printed 3/5/20, included an order initiated on 9/23/19 for Oxygen 2 LPM scheduled every shift for [MEDICAL CONDITION] (below normal oxygen in blood). During observation and interview with R47 on 3/3/20, at 3:02 p.m. R47 was sitting in a wheelchair in his room. R47 had an oxygen nasal cannula in his nose. The nasal cannula tubing was attached to an oxygen tank secured to the back of R47's wheelchair. R47 stated he is always on oxygen which is set at 2 (LPM). R47 did not appear to be laboring with breathing and had even respirations; however, R47 stated it feels like I'm fighting for a breath. The oxygen tank was observed to be set at 0 (off). On 3/3/20, at 3:04 p.m. registered nurse RN-(D) and registered nurse (RN)-E were informed of R47 complaints of shortness of breath and that R47's oxygen tank was observed to be turned off. RN-E immediately went to R47's room. RN-E stated R47 was to receive oxygen at 2 LPM continuously, but R47's oxygen tank was turned off. RN-E turned R47's oxygen tank to 2 LPM. RN-E asked R47 if he was short of breath. R47 stated yeah, I'm breathing harder. R47 denied dizziness. RN-E checked R47's oxygen saturation level at the surveyor's request. R47's oxygen saturation level was normal at 99% on 2 LPM of oxygen. RN-E stated he had just started his shift and RN-D had worked with R47 during the day. On 3/3/20, at 3:10 p.m. RN-D stated she had filled R47's tank at 12:30 p.m. RN-D stated at that time R47's oxygen tank was on and set at 2 LPM. RN-D stated she did not know how the oxygen tank got turned off. RN-D added the nursing assistants do not adjust the flow rate on the oxygen tanks. During an interview on 3/5/20, at 2:46 p.m. the director of nursing (DON) stated residents who have orders for continuous oxygen are to receive oxygen as ordered unless it is the resident's preference not to use oxygen. The facility's policy Oxygen Administration dated 1/20, directed Oxygen administration carried out only with a medical provider order. A licensed nurse or other employee trained according to state regulations in the use of oxygen will be on duty and is responsible for the proper administration of oxygen to the resident.

Based on interview and document review, the facility failed to implement restorative therapy to maintain or prevent physical decline after discharge from physical therapy and prior to discharge from the facility for resident (R214) reviewed for restorative services. Findings include: R214's minimum data set (MDS) indicated a BIMS score (brief interview for cognitive mental status) was 13, which indicated cognition was intact, and R214 required limited to extensive assistance with all activities of daily living (ADL's). R214's [DIAGNOSES REDACTED]. R214's progress note dated 12/31/19, indicated a care conference was held and discharge plans were discussed. R214 was to be discharged from physical therapy on 1/3/20, and discharged home on[DATE]. R214's family member (FM)-A expressed concerns for discharge and wished to appeal. Further, the note indicated R214 would remain in the facility until the appeal process was completed. R214's Notice of Medicare Non-coverage indicated services would end 1/3/20, and was signed by FM-A on 12/31/19. R214's BFCC-QIO (Beneficiary and Family Centered Care-Quality Improvement Organizations) Determination letter dated 1/2/2020, indicated Livanta LLC was authorized by Medicare to review the services received by R214 and determined that R214 no longer required skilled nursing facility services. Further, it directed to contact MAXIMUS Federal Services, Inc if FM-A disagreed with this determination. A letter addressed to R214 dated 1/8/2020, indicated an Expedited Appeal Request had been completed and the decision was unfavorable. Occupational Therapy (OT) Patient Instructions dated 1/3/2020, indicated R214 was discharging home with 24/7 supervision and assistance from caregivers. OT recommended long term care however, family declined the recommendation. Further, OT note indicated R214 required use of extended tub bench for all bathing transfers with assist of 1 for self-cares and a HEP (home exercise program) was provided in visual aid format with instructions for caregivers. Physical Therapy (PT) discharge instructions dated 1/3/2020, indicated R214 was discharging facility to home and recommended a four wheeled walker for short distance ambulation and a wheelchair for longer distance mobility. Patient was given HEP for lower extremity strengthening exercises. Therapist recommends home care PT. PT orders dated 1/10/20, indicated R214 start a restorative exercise program offering options for strengthening exercises. R214's care plan indicated restorative therapy was initiated on 1/14/20 and canceled on 1/14/20. During an interview on 3/4/20, at 3:07 p.m. FM-A stated R214 did not receive restorative therapy after discharge from physical therapy (PT) and prior to discharge home. During an interview on 3/5/20, at 1:56 p.m. social worker (SW)-A indicated R214's discharge plans had changed due to the appeal to Medicare coverage of skilled services. Further, SW-A stated typically PT would have known prior to discharge from Medicare PT the status of a resident's plan to go home or stay in the facility. However, R214's plan was changed when FM-A requested an appeal on behalf of R214 and she remain in the facility until the appeal was completed. Further, SW-A confirmed the record lacked evidence of communication with therapy related to change in discharge plans. SW-A stated we should have recognized before the 10th (1/10/20) that R214 was not receiving restorative therapy. During an interview on 3/5/20, at 2:07 p.m. registered nurse (RN)-A stated restorative therapy would have been set up prior to discharge from PT unless PT thought R214 was discharging home. Further, RN-A stated she was not aware why there was no communication with therapy between 1/3/20 and 1/10/20 in regards to restorative therapy for R214. During an interview on 3/5/2020, at 3:17 p.m. director of nursing (DON) stated there should have been communication with PT that R214's discharge plans had changed. A facility policy on discharge planning revised 9/17, indicated the resident and resident representative be involved in the development of the discharge plan.

Based on observation, interview and document review, the facility failed to develop and implement a baseline care plan that included interventions for positioning to decrease pain and [MEDICAL CONDITION] for 1 of 1 residents (R266) reviewed for baseline care planning. Findings include: R266's face sheet indicated R266 was admitted to the facility on [DATE], was cognitively intact and needed limited assistance with activities of daily living (ADL's). R266 had medical [DIAGNOSES REDACTED]. R266's care plan dated 2/26/2020, indicated R266 has an ADL self care performance deficit related [MEDICAL CONDITION] left [MEDICAL CONDITION], weakness, deconditioned evidenced by inability to perform transfers without mechanical lift and has decreased ability to participate with self cares, had a potential impairment to skin integrity related [MEDICAL CONDITION] by left sided weakness, had chronic pain/discomfort related to weakness, required extensive assist of 1 staff with all repositioning, 2 staff present for transfers, had a limited physical mobility related [MEDICAL CONDITION] left [MEDICAL CONDITION], weakness, deconditioned evidenced by WC is primary mode of locomotion at baseline, unable to ambulate, is receiving physical therapy and occupational therapy. The care plan interventions lacked evidence of a positioning device for R266's left arm. R266's progress note dated 3/3/2020, at 12:42 p.m. licensed practical nurse, (LPN)-A documented R266 was grimacing and holding her left hand, that R266 stated her fingers hurt. The progress note identified that LPN-A massaged R266's fingers and hand with a muscle rub, and put R266's left arm up on a pillow. The note further indicated joints were puffy looking and that R266 stated that was helpful. R266 progress note dated 3/5/2020, at 10:02 a.m. indicated LPN-A massaged R266's left shoulder, hand and wrist and left knee with muscle rub before breakfast and put R266's hand up on a pillow. No further notes identified of a positioning device use for R266's left hand. During observation on 3/3/2020, at 10:32 a.m. R266 was sitting in wheelchair (WC) with left arm on lap and left hand resting in her lap. left hand and fingers were [MEDICAL CONDITION] (swelling). No positioning device noted. During observation on 3/4/2020, at 8:02 a.m. R266 was in the dining room in WC. R266's left hand was in lap with noticeable [MEDICAL CONDITION] in hand and fingers. No positioning device noted. During observation on 3/4/2020, at 12:48 p.m. R266 was in WC, eating lunch. R266's left arm and hand were [MEDICAL CONDITION]. No positioning device noted. During interview on 3/4/2020, at 1:15 p.m. nursing assistant (NA)-B stated R266's care sheet lacked documentation for positioning devices used on R266's left arm. During observation on 3/5/2020, at 8:17 a.m. R266 was sitting in WC in dining room eating breakfast. R266's left hand was resting on leg and was noted to have [MEDICAL CONDITION] in hands and fingers. R266 left hand did not have a positioning device in place. During observation on 3/5/2020, at 9:15 a.m. R266 was working with occupational therapy. (OT)-A was assisting R266 with balance bars. OT-A then had R266 sit down in WC R266's left hand and fingers were [MEDICAL CONDITION] and R266 was not wearing a positioning device. During interview on 3/5/2020, at 9:23 a.m. OT-A stated on admission OT-A reviewed the medical record, and completed an assessment with the focus on functional goals. OT-A stated R266 had an order for [REDACTED]. OT-A stated she had not discussed the use of a pillow or other device with R266 that could be used to support R266's left arm. Further, OT-A stated she would provide education on the plan of care, the goals of therapy and the frequency of therapy. During interview on 3/5/2020, at 9:43 a.m. R266 stated she had a lot of pain in her left arm and hand and when R266 was in bed the staff put a pillow under R266's left arm and hand and that helped with the pain. Further, R266 stated the staff every once in awhile put a pillow under R266's left arm and hand when in the WC. Additionally, added she liked to be in her WC for most of the day and liked having a pillow under her left hand because it feels lots better. During interview on 3/5/2020, at 10:05 a.m. LPN-A stated R266 did have a swollen left hand and fingers and that LPN-A used muscle rub and had spoken to therapy and ordered a sling for R266. LPN-A stated R266's left arm is positioned with the use of a pillow. During observation on 3/5/2020, at 10:44 a.m. R266 was in the WC in her room with R266's left arm/hand positioned on a pillow. During interview on 3/5/2020, at 11:26 a.m. nursing assistant (NA)-A stated LPN-A just recently requested NA-A find a tray in R266's room and that NA-A positioned R266's left arm on the tray and it was painful for R266. NA-A further stated NA-A then placed a pillow under R266's left arm which was per LPN-A's request. A policy titled Mobility Support and Positioning dated 10/2013, with a revision date of 12/2019, indicated the purpose of the policy was to position those residents unable to position/reposition independently on a manner which prevents formation of contractures, provides comfort and maintains skin integrity and to provide proper body alignment for residents in wheelchairs. The section of this policy titled positioning of the affected side: upper extremity: · Resident's arm is supported with a surface such as pillow, or hemi tray. · Resident's wrist and hand are properly positioned in a functional position (wrist is in neutral and fingers are slightly flexed with thumb at side). · Shoulders are level ( not elevated or depressed). · Elbow of affected arm is slightly forward of the shoulder. · The forearm rests perpendicular to the back of the wheelchair. During an interview on 3/5/2020, at 2:29 p.m. the director of nursing (DON) stated if the resident had dependant [MEDICAL CONDITION] the staff should be elevating or supporting the arm to decrease swelling. Further, the DON stated the expectation was the resident's affected extremity should be supported with a pillow or another device to help with positioning and to reduce the swelling.

Based on interview and document review, the facility failed to ensure the required nurse staffing information was posted daily. This had the potential to affect all 77 residents residing in the facility and/or their visitors who may wish to view this information. Findings include: When reviewing the facility's daily nursing hour postings for 3/2/20-3/5/20, the daily postings were noted to be displayed on the wall at eye level on 3/2/20, 3/3/20, and 3/4/20. However, on 3/5/20 the posting was not updated. When interviewed on 3/5/20, at 12:11 p. m. director of nursing (DON) stated the posting had not been updated for the day. Further, DON indicated the staff person in charge of posting had called in for the day. It was DON's responsibility to make sure it was updated and it had been an oversight.

Based on interview and document review, the facility failed to ensure allegations were thoroughly investigated for 1 of 3 (R3) who reported allegations of abuse against facility staff. Findings include: R3's admission Minimum Data Set ((MDS) dated [DATE], identified R3 had moderate cognitive impairment and required extensive assistance with cares. R3 discharged from facility 9/18/19. An incident report summary was reported to the state agency (SA) on 9/15/19, R3 had reported that on 9/14/19, a nursing assistant (NA) had directed R3 to take a shower, when they refused NA had thrown towels at R3. A review of the facility investigation included an interview with the alleged perpetrator on [DATE], identified NA-A had entered the room, informed R3 verbally and by writing a note that they had a shower scheduled. NA-A stated he had showed towels to R3 and placed them in the bathroom. NA-A denied throwing towels at R3. The investigation did not include supporting documentation that staff from other shifts or other residents on the unit or units NA-A had worked on had been interviewed. During interview on 2/26/20, at 3:11 p.m. director of nursing (DON) stated the investigation file should have included interviews with other residents and staff on the unit. DON was not aware that R3's file did not contain interviews with other residents to determine if there was other concerns from residents and to ensure they felt safe in the facility. The facility's Abuse and Neglect Policy revised 10/2018, identified investigation may include interviewing employees, residents or other witnesses.

Based on observation, interview and document review, the facility failed to ensure a residents gastrostomy tube feeding (R47) was properly labeled. Findings include: R47's quarterly Minimum Data Seta ((MDS) dated [DATE], indicated R47 had Dysphagia (difficulty swallowing), abnormal weight loss, [MEDICAL CONDITIONS], and had a gastrostomy (a surgical opening from the abdominal wall into the stomach). R47 had physician orders [REDACTED]. R47's care plan dated 11/5/18, indicated R47 required all nutrition and hydration per his gastrostomy tube. R47 was not to have anything by mouth except ice chips to keep his mouth moist. R47's gastrostomy physician orders [REDACTED]. During observation on 2/26/19, at 3:05 p.m. R47 was sitting on edge of his bed and had a clear bag hanging on his tube feeding pole. There was 300 cc of a milky colored substance in the unlabeled clear bag. It was not infusing at this time. There is a bottle of [MEDICATION NAME] 1.5 sitting on his night stand which was dated 2/25/19. During observation on 2/27/19, at 8:43 a.m. R47 was sitting on the edge of his bed trying to get his socks on. There was a clear unlabeled bag with 300 cc of a milky colored substance hanging on his tube feeding pole. During interview on 2/27/19, at 9:25 a.m. registered nurse (RN)-A stated the clear unlabeled bag was from last night and was not running now as it was shut off at 7 a.m. RN-A stated she could not tell what the milky substance was hanging in the bag, as it was not labeled. RN-A stated there is no way of knowing what was in the bag and she would have to go to the Medication Administration Record [REDACTED]. During interview on 2/27/19, at 10:11 a.m. the director of nursing (DON) stated the clear unlabeled bag should be labeled with the tube feeding name, the date and the initial of the nurse who hung it. The DON stated she knew what happened and explained that the spikes for the labeled tube feeding bottles ran out, so the nurses pored the tube feeding solution into the clear unlabeled bags to hang on the tube feeding poles. The DON also added they should have labeled the bag. The DON stated this was just being done temporally until the new spikes arrived. A policy on gastrostomy tube feeding was requested and not received.

Based on observation, interview, and document review, the facility failed to ensure the oxygen delivery system of oxygen tubing was changed in a timely manner for 1 of 1 residents (R60) reviewed for respiratory care. Finding include: R60's admission Minimum Data Set (MDS), dated [DATE], indicated and admission date of [DATE]. R60 required extensive staff assist for dressing and personal hygiene. [DIAGNOSES REDACTED]. R60 received oxygen. R60's physician orders [REDACTED]. (MONTH) use 4 liters to maintain oxygen saturation above 90%. R60's care plan, dated 1/25/19, identified R60 received oxygen via nasal cannula continuously. During observations on 2/26/19, at 9:03 a.m. R60 was laying in bed. The oxygen was on and set at 3 liters per minute (lpm). R60 was receiving oxygen via nasal cannula. The nasal cannula/oxygen tubing was not dated. R60 stated she received oxygen 24 hours a day and could not recall the oxygen tubing being changed since admission. R60's medical record lacked directions for frequency of oxygen tubing changes and lacked documentation of oxygen tubing changes since admission. During observations and interview on 2/27/19 at 7:29 a.m., R60 was in her room. R60 was receiving oxygen via nasal cannula at 3 lpm. The oxygen tubing remained undated. Licensed practical nurse (LPN)-A stated R60 has been receiving oxygen continuously since admission. LPN-A stated the oxygen tubing is changed weekly and if there is a problem. LPN-A stated she changed the oxygen tubing 1 week ago. LPN-A stated there is no place to document the oxygen tubing change. LPN-A stated the tubing should be dated when changed, but it is not done all the time. LPN-A stated R60's current oxygen tubing is undated. LPN-A stated there is no schedule for tubing changes We should have a list for that. During an interview on 2/28/19 at 10:57 a.m. the director or nursing (DON) stated when oxygen is in use, staff are to initial on the medication/treatment administration record directions for weekly oxygen tubing changes. If this is not done, the tubing needs to be dated and checked daily. Oxygen tubing is to be changed weekly. The facility's policy Oxygen Administration with Nasal Cannula, Face Mask or Face Tent, revised 10/17, directed Disposable equipment should be changed weekly or according to manufacturer's instruction and marked with date and initials. Document on TAR or eAdmin note when these items are changed. The manufacturer's instruction, revised 10/17, direct Once a day, use a clean damp cloth to wipe off the nasal prongs and headset tubing. Discard and replace your nasal cannula when it becomes soiled, discolored or the prongs become stiff. Recommend replacing nasal cannula at least once every 14 days. Do not use you nasal cannula for more than 30 days.

Based on interviews and record review the facility failed to assure that one of one resident (R1) received the necessary care and services in the event of an emergency. The facility did not immediately provide Cardio [MEDICAL CONDITION] Resuscitation (CPR) for R1 who requested CPR to be completed if his heart stopped. Findings include: R1 ' s medical record was reviewed and indicated that he was admitted to the facility on [DATE], from an acute care facility. R1 ' s [DIAGNOSES REDACTED]. Discharge instruction form from the acute care facility dated [DATE], identified R1 as a full code status meaning he wanted to receive CPR in the event he stopped breathing and had no pulse. Review of the facility ' s internal investigation revealed that on [DATE], between 6:00 p.m. and 6:15 p.m. R1 was in the dining room eating supper. Nursing assistant (E) was alerted by another resident that R1 was unresponsive. Two nursing assistants removed R1 from the dining room and started towards his room. In the hallway R1 was assessed by registered nurse (RN) (C) to have a pulse and was breathing when she was summoned by staff to assist R1. RN (C) told Licensed Practical Nurse (LPN) (D) to get the oxygen. R1 was brought to his room. LPN (D) brought the oxygen to R1 ' s room where he was observed by LPN (D) to have stopped breathing and had no pulse. LPN (D) checked R1 ' s vital signs and there was no blood pressure or pulse and R1 was not breathing. LPN (D) stated that they could not do CPR due to R1 having a pacemaker. RN (C) stated that they should start CPR. CPR was not initiated. LPN (D) and RN (C) went to the nursing station where LPN (D) called RN (B) to inquire if CPR should be initiated on R1. RN (B) told LPN (D) to initiate CPR. LPN (D) initiated CPR as emergency services arrived. The documentation lacked what time CPR was initiated. Emergency medical services (EMS) took over resuscitation. On [DATE], at 6:53 p.m., EMS ceased CPR. R1 ' s death certificate indicated he died from natural causes. On [DATE], at 12:00 p.m. LPN (D) was interviewed and stated that when she checked R1 ' s vital signs on [DATE], at approximately 6:00 p.m. there was no pulse and he was not breathing. LPN (D) stated that she did not immediately initiate CPR because R1 had a pacemaker and she thought that CPR could not be performed if the person had a pacemaker. LPN (D) called RN (B) to find out if she should initiate CPR. RN (B) instructed LPN (D) to initiate CPR. LPN (D) returned to R1 ' s room to initiate CPR as EMS arrived. On [DATE], at 9:10 a.m., RN (C) was interviewed and stated that she told LPN (D) that they needed to start CPR after LPN (D) checked R1 ' s vital signs and there was not pulse. RN (C) stated that she did not start CPR because LPN (D) was the primary nurse and she said R1 had a pacemaker and could not do CPR. RN (C) did not initiate CPR for R1. On [DATE], at 1:10 p.m. RN (B) was interviewed and stated that she had received a telephone call on [DATE], between 6:00 p.m. and 6:15 p.m. from LPN (D) asking if CPR should be done on someone with a pacemaker. RN (B) stated that LPN (D) needed to start CPR on R1. An ambulance service Patient Care Report document dated [DATE], indicated that no CPR had been initiated on R1 when they had arrived on scene at 6:12 p.m. CPR was initiated at 6:13 p.m. The facility ' s policy on Automated External Defibrillator, dated [DATE], indicated staff are to confirm a resident ' s advanced directive. The nurse will determine if there are apparent signs of life. CPR will be initiated or not initiated based on that nurse ' s determination and its medical efficacy.